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Based on review of medical records, policies and procedures, and interview with staff, it was determined the hospital did not require an order for restraints for 1 of 2 patients restrained for violent behavior (Pt #52).

Findings include:

The hospital policy titled Guidelines for the Use of Restraints Voluntary/Involuntary, policy number HW1132, required: "...Orders for restraint use...A verbal, telephone or written physician's order is required prior to /at the time of initiation of a restraint and is entered into the patient's medical record...."

Patient # 52 arrived in the ED on 08/09/11 at 0058 hours, with a chief complaint of suicidal thoughts documented by the triage nurse.

Nursing documented preventing the patient from leaving the ED, applying 4 point restraints, and giving Ativan, Benadryl and Haldol intramuscularly for violent behavior.

Review of the physician orders revealed a physician did not order the 4 point restraints applied to the patient.

The Director of Quality and the Director of Emergency Services confirmed the medical record did not contain an order for the 4 point restraints applied to Pt #52 on 08/25/11 at 1745 hours.

Based on review of medical records, policies and procedures, hospital training materials, and interview with staff, it was determined the hospital failed to ensure RN's /PA's conducting the one hour face-to-face assessment were trained to assess the patients' behavioral condition.

Findings include:

The hospital policy titled Guidelines for the Use of Restraints Voluntary/Involuntary, policy number HW1132, required: "...the physician, LIP, or trained RN completes a face-to-face assessment of the patient within one hour of the application of the restraint...."

Review of the training material used to train RN's to conduct the one hour face-to-face assessment revealed the educational program did not address the specific requirements for the training of RN's and PA's to assess the patients' behavioral condition, and the staff conducting the training did not have specialized training themselves in conducting an assessment of patients' behavioral conditions.

The Quality Management Specialist confirmed on 08/25/11 at 1800 hours, the education staff who perform the one hour face-to-face training for RN's do not have special training in the assessment of behavioral conditions as required by Medicare.

Based on review of medical records, policies and procedures, and interview with staff, it was determined the hospital did not require staff assessed the patients one hour after initiation of chemical or physical restraint as evidenced by, 2 of 2 patients restrained for violent behavior did not have a one hour face to face assessment documented (Pt #'s 52 and 53).

Findings include:

The hospital policy titled Guidelines for the Use of Restraints Voluntary/Involuntary, policy number HW1132, required: "...Orders for restraint use...A verbal, telephone or written physician's order is required prior to /at the time of initiation of a restraint and is entered into the patient's medical record...In addition, the physician, LIP, or trained RN completes a face-to-face assessment of the patient within one hour of the application of the restraint...If medication is being used as a restraint to address violent or aggressive patient behavior, the patient would need to be seen by the MD, DO, LIP (licensed individual practitioner), or RN within one hour of the administration of the drug...."

Patient # 52 arrived in the ED on 08/09/11 at 0058 hours, with a chief complaint of suicidal thoughts documented by the triage nurse. Social Services documented at 1339 hours, that the patient was "in the process of being titled when she assaulted a nurse (kicked her in the chest, twisted her arm, and pulled her hair)."

Nursing documented at 0741 hours that the patient "appeared agitated. The patient is combative. (security and ss (social services) have to physically keep pt from leaving, yelling and cursing, refuses to stay in room, meds ordered)...0753...The patient is combative. (pt cursing and has to be physically held in room. Pulled hair and shirt of charge nurse, assaulted staff. Medicated per order, 4 point restraints applied. Pt yelling, cursing and thrasing (sic) in bed)...0750...Ativan 2 mg (milligrams) IM (intramuscular)...Benadryl 50 mg IM...Haldol 5 mg IM...0817...police here. Handcuffed patient, arrested her and took her to jail...."

The Director of Quality and Director of Emergency Services both confirmed the following on 08/25/11 at 1730 hours:

Staff took Pt #52's vital signs at 0801 hours, which was 11 minutes after the injection and discharged the patient out of the ED at 0817 hours. A physician or nurse did not document an assessment of the patient after the chemical restraints prior to leaving in police custody.

Patient #53 arrived in the ED on 06/08/11 at 2025 hours. The ED physician documented the patient had suicidal thoughts with agitation and violent behavior.

The physician ordered 2 point restraints for violent behavior at 2044 hours. Neither the physician or nursing staff documented a one hour face-to-face assessment of the patient after the application of restraints. The patient remained in 2 point restraints for approximately 4 hours while in the ED.

The Director of Quality and the Director of Emergency Services confirmed on 08/25/11 at 1745 hours, that Pt #52 did not have a one hour face-to-face assessment documented.

Cross reference A178 for failing to ensure RN's / PA's conducting the one hour face-to-face assessment were trained to assess the patients' behavioral condition.