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Based on interview, review of documentation in 2 of 2 medical records of inpatients who experienced restraint or seclusion (Patients 1 and 3) and review of policies and procedures and training content it was determined that the hospital failed to ensure that the use of restraint or seclusion was in accordance with a written modification to the patient's plan of care.

Findings include:

1. a. The review of the policy titled "Restraint and Seclusion for Violent Self-Destructive Behavior" with policy number NSG-2505 and effective date of 08/27/2015 was reviewed. The policy included the following direction: "The use of restraint or seclusion constitutes a change in a patient's plan of care and will be documented in the patient's plan of care."

b. The review of the policy titled "Restraint for Non-Violent Non-Self-Destructive Behavior" with policy number NSG-3919 and effective date of 10/30/2017 was reviewed. The policy included the following direction: "The use of restraint constitutes a change in a patient's plan of care and will be documented in the patient's plan of care."

c. The review of the policy titled "Restraint for Non-Violent Non-Self-Destructive Behavior" with policy number 400.3.126 and effective date of 08/31/2018 was reviewed. The policy included the following direction: "The use of restraint constitutes a change in a patient's plan of care and will be documented in the patient's plan of care."

d. The content of the "Rapid Regulatory Reference Module 2018 Patient Services" training provided to all patient services staff in 2018 was reviewed. It contained a section for "Restraint and Seclusion: Safely Using Restraint" that included "Safe techniques for restraint and seclusion must be implemented following: Hospital policy and procedure; Written modification to the patient's plan of care."

2. The review of the medical record of Patient 1 reflected he/she was admitted to the ICU from the ED on 12/04/2018 with toxic encephalopathy and agitated delirium. Physician orders and restraint documentation reflected that bilateral soft wrist restraints were ordered and applied beginning on 12/04/2018 at 0556. However, the patient's care plan did not identify the use of those restraints as a patient treatment intervention.

3. The review of the medical record of Patient 3 reflected he/she was admitted to the pediatric unit from the ED on 02/18/2019 with an intentional drug overdose and disruptive mood dysregulation. Physician orders and restraint documentation reflected that bilateral soft wrist restraints were ordered and applied beginning on 02/22/2019 at 2033. However, the patient's care plan did not identify the use of those restraints as a patient treatment intervention.

4. During interviews at the time of the record reviews on 03/14/2019 beginning at 1300 the DON-M/S, PMA and other staff present confirmed that the care plans for Patients 1 and 3 had not been modified to include the use of restraints.

Based on interview, review of training documentation for 6 of 6 staff who participate in patient restraint or seclusion (Staff 1, 2, 3, 4, 5 and 6) and review of policies and procedures and training content it was determined that the hospital failed to ensure that appropriate staff were trained in the use of immediate interventions and first aid to be rendered to a restrained or secluded patient who is in distress or injured, such as a restrained patient who is found to have positional asphyxiation, a patient who is found hanging from the bed with a tangled vest restraint tightened around the neck, a secluded patient who is found with a ligature tied around their neck, etc.

Findings include:

1. a. The review of the policy titled "Restraint and Seclusion for Violent Self-Destructive Behavior" with policy number NSG-2505 and effective date of 08/27/2015 was reviewed. The policy contained a section for "Training Requirements" that included "Education, training, and demonstrated knowledge will include...training in how to recognize and respond to signs of physical and psychological distress." However, it did not clearly stipulate the "first aide" training required in this regulation.

b. The review of the policy titled "Restraint for Non-Violent Non-Self-Destructive Behavior" with policy number NSG-3919 and effective date of 10/30/2017 was reviewed. The policy contained a section for "Training Requirements" that included "Education, training, and demonstrated knowledge will include...training in how to recognize and respond to signs of physical and psychological distress." However, it did not clearly stipulate the "first aide" training required in this regulation.

c. The review of the policy titled "Restraint for Non-Violent Non-Self-Destructive Behavior" with policy number 400.3.126 and effective date of 08/31/2018 was reviewed. The policy contained a section for "Training Requirements" that included "Education, training, and demonstrated knowledge will include...training in how to recognize and respond to signs of physical and psychological distress." However, it did not clearly stipulate the "first aide" training required in this regulation.

d. The content of the "Rapid Regulatory Reference Module 2018 Patient Services" training provided to all patient services staff in 2018 was reviewed. It contained a section for "Restraint and Seclusion: Staff Training" that included "Staff must be trained and competent in the following...Use of first aid techniques and certification in the use of cardiopulmonary resuscitation." However, there was no content or other information to reflect that restraint and seclusion first aid technique training was provided.

e. The content of the "Rapid Regulatory Reference Module 2018 Nursing Services" training provided to all nursing services staff in 2018 was reviewed. It contained a section for "Restraints and Seclusion." However, there was no content or other information to reflect that restraint and seclusion first aid technique training was provided.

2. The review of training documentation for Staff 1, a Neurology Unit RN, reflected he/she started in his/her current position on 03/20/2017. The records reflected he/she completed the "Rapid Regulatory Reference Module 2018 Patient Services" training and the "Rapid Regulatory Reference Module 2018 Nursing Services" training on 04/25/2018. In addition, he/she completed the "Restraints FY18" electronic learning program and applications skills demonstration on 05/24/2018. There was no documentation to reflect that Staff 1 had received restraint and seclusion first aid technique training.

3. The review of training documentation for Staff 3, an ED Tech II, reflected he/she started in his/her current position on 08/05/2018. The records reflected he/she completed the "Rapid Regulatory Reference Module 2018 Patient Services" training on 03/22/2018. In addition, he/she completed the "Restraints FY18" electronic learning program and application skills demonstration on 03/16/2018. There was no documentation to reflect that Staff 3 had received restraint and seclusion first aid technique training.

4. The review of training documentation for Staff 6, a Medical Unit CNA, reflected he/she started in his/her current position on 10/28/2018. The records reflected he/she completed the "Rapid Regulatory Reference Module 2018 Patient Services" training on 02/08/2018. In addition, he/she completed the "Restraints FY18" electronic learning program and application skills demonstration on 03/25/2018. There was no documentation to reflect that Staff 6 had received restraint and seclusion first aid technique training.

5. Similar findings that reflected a lack of restraint and seclusion first aid technique training were identified in the 2018 training records for Staff 2, an ED RN; Staff 4, an ICU RN; and Staff 5, an ED RN.

6. During interview on 03/15/2019 beginning at 1130 with the CEM, HRD and other education staff they stated that first aid is a part of an RNs skills and therefore restraint and seclusion first aid technique training had not been provided to staff.