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A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined, that for 1 of 7 clinical records reviewed (Pt. #1) for patients placed in restraints, the Hospital failed to ensure restraints were discontinued at the earliest possible time.

Findings include:

1. Hospital policy titled, "Utilization of Restraint and Seclusion," was reviewed on 3/2/11 at 9:05 AM. The policy required, "D. Restraint and Seclusion for Violent or Self-destructive behavior... 4. Discontinuation of Restraint a. Restraints will be discontinued at the earliest possible time, regardless of the duration of the physician order."

2. On 3/2/11 between 9:55 AM and 11:45 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 28 year old female, who arrived in the Emergency Department on 9/5/10 at 11:39 AM, with diagnoses of Acute Mania, Psychiatric Disorder, and Bipolar Disorder. The ED notes dated 9/5/10, included Pt. #1 was " Restless/ agitated ... Inappropriate to content, Angry/ Irritable ... Impaired attention ... Paranoid ... " Pt. #1 was transported on 9/5/10 at 2:53 PM, via wheelchair from the ED to the Psychiatric Intensive Treatment Unit (3 North) by security and psychiatric staff.

A physician's order dated 9/7/10 at 9:15 AM, included 4 hours of full leather restraints due to "Immediate danger to others. Immediate danger to self." The order was renewed every 4 hours from 9/7/10 at 1:15 PM to 9/9/10 at 9:15 AM. Pt. #1's restraints were removed on 9/9/10 at 12:30 PM, before Pt. #1 was transferred to Elgin Mental Health Center.

During 51 hours of continuous full leather restraints, with breaks for range of motion, toileting, and meals, Pt. #1's suicide/safety precaution check lists, face to face evaluation sheets, flow sheets, problem intervention evaluation plan notes, and progress notes, included several periods when Pt. #1 was calm or asleep:

- On 9/8/10 - 3:00 PM to 5:00 PM
- On 9/8/10 - 5:45 PM to 7:15 PM
- On 9/8/10 - 9:15 PM to 11:45 PM
- On 9/9/10 - 3:00 AM to 6:00 AM
- On 9/9/10 - 6:15 AM to 9:45 AM
- On 9/9/10 - 9:45 AM to 12:30 PM

Restraints were not removed at the earliest possible time.

3. These findings were confirmed by the Director of Behavioral Health and Professional Services on 3/3/11 at 11:45 PM, during an interview.

A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined, that for 1 of 7 clinical records reviewed (Pt. #10) for patients placed in restraints, the Hospital failed to ensure the frequency of monitoring, assessment, and intervention were provided to restrained patients, in accordance with policy.

Findings include:

1. Hospital policy titled, "Utilization of Restraint and Seclusion," was reviewed on 3/2/11 at 9:05 AM. The policy required, " C. Restraint for Non-Violent or Non-Self-Destructive... 2. Assessment and Monitoring a. Ongoing RN assessments 1) RN reassessment of the patient will occur no less than every two hours... 2) The monitoring and assessment may include, but is not limited to, the following elements: a) Signs of any injury associated with the restraint... b) Nutrition and hydration, c) Circulation and range of motion in the extremities, d) Vital signs, e) Hygiene and elimination, f) Physical and psychological status and comfort, g) Environmental Safety Check ... "

2. On 3/3/11 between 1:00 PM and 2:30 PM, the clinical record of Pt. #10 was reviewed. Pt. #10 was an 83 year old male, admitted on 1/28/11 at 5:46 PM, with a diagnosis of Dementia. Restraint records dated from 1/28/11 through 2/21/11, included documentation that Pt. #10 was frequently confined by a waist restraint due to "cognitive impairment with inability to remember or follow directions". During this period, there was no documentation that monitoring, assessments, and interventions were provided every 2 hours while Pt. #10 was restrained:

- 1/29/11 - 8:00 AM to 11:35 AM
- 1/29/11 - 11:35 AM to 8:44 PM
- 2/08/11 - 2:00 AM to 8:00 AM
- 2/10/11 - 10:00 AM to 3:33 PM
- 2/16/11 - 8:00 AM to 12:16 PM
- 2/16/11 - 12:16 PM to 7:22 PM
- 2/17/11 - 3:00 AM to 11:12 AM
- 2/17/11 - 11:12 AM to 2/18/11 12:00 AM
- 2/21/11 - 1:19 PM to 5:46 PM
- 2/21/11 - 5:46 PM to 11:00 PM

3. These findings were confirmed by the Director of Behavioral Health and Professional Services on 3/3/11 at 2:30 PM, during an interview.