HospitalInspections.org

Based on medical record review, document review and interview, in 1 of 15 (Patient #13) medical records reviewed, a chemical restraint was ordered to be given on a PRN basis (as needed) and administered on a PRN basis.

Findings include:

-- Per medical record review, Patient #13 was admitted for management of severe constipation and anemia. Patient #13 had a past medical history of intellectual disability and schizoaffective/bipolar disorder.

A physician documented on 7/12/2024 at 9:56 pm, that the patient has been agitated and interfering with care, and received multiple doses of sedatives and antipsychotics to calm them down with little to no improvement. On 7/13/2024 at 2:41 am, the physician ordered a chemical restraint, Versed 2 milligrams (mg) given intravenously, every 2 hours PRN for agitation.

Registered nursing staff administered Versed, at 3:07 am, 5:07 am, 7:29 am, and 9:31 am.

-- Per interview of Staff N, Quality Manager, on 9/5/2024 at 11:15 am, they acknowledged the above findings.

Based on document review and interview, the hospital has put in place, through its policy and procedure and supporting education, the option for a specially trained registered nurse (RN) to conduct face-to-face evaluations, in lieu of a physician or other qualified licensed provider, when restraints are applied in an emergency.

The hospital did not comply with New York Codes, Rules, and Regulations, Title 10 § 405.7 - Patients' rights, which requires the hospital to ensure that all patients including inpatients, outpatients and emergency service patients, are afforded their rights as set forth in subdivision (b) of this section. Specifically, section (5) limits the use of physical restraints to those patient restraints authorized in writing by a physician after a personal examination of the patient, for a specified and limited period of time to protect the patient from injury to himself or to others. In an emergency, the restraint may be applied only by or under the supervision of and at the direction of a registered professional nurse who shall set forth in writing the circumstances requiring the use of restraints. In such emergencies, a physician shall be immediately summoned and pending the arrival of the physician, the patient shall be kept under continuous supervision as warranted by the patient's physical condition and emotional state.

When state regulations are more restrictive regarding the types of practitioners who may conduct the 1-hour face-to-face evaluation, hospitals are required to comply with these state regulations.

Findings include:

-- Per review of the hospital's policy and procedure titled, "Restraints for Behavior Management (Violent Behavior)," last approved 4/23/2024, "in an emergency/violent situation that jeopardizes the immediate physical safety of the patient, a staff member, or others: a qualified RN may identify the need for and initiate the use of physical restraint prior to obtaining an order...

a. The physician, other qualified licensed provider (QLP), or trained nursing supervisor must see the patient face-to-face within one hour after the initiation of restraints to evaluate:
- the patient's immediate situation
- the patient's reaction to the intervention
- the patient's medical and behavioral condition; and
- the need to continue or terminate the restraint.

b. The goal of the face-to face evaluation if to determine if there is a medical cause for the behavior and correct it so the restraints can be discontinued.

c. If the evaluation is conducted by a trained nursing supervisor, the supervisor shall consult the physician or other QLP responsible for the care of the patient as soon as possible after completion of the evaluation. Telephone consultation is acceptable and the physician/QLP is not required to come to the hospital to see and evaluate the patient."

-- Per review of the hospital's annual education titled, "Restraint Policies: Medically Necessary and Behavioral Restraints, Annual Education," dated March 2024, "the decision to use a restraint should only be implemented following a comprehensive individual assessment by the RN and/or physician or other QLP ... If the RN completes the assessment, they shall consult the physician or other QLP ... A 1 hour face-to-face assessment must be completed by the physician, other QLP, or trained nursing supervisor. The physician, other QLP, or trained nursing supervisor must see the patient face to face within 1 hour. If the evaluation is conducted by a trained nursing supervisor, the supervisor shall consult the physician or other QLP responsible for the care of the patient as soon as possible after completion of the evaluation. Telephone consultation is acceptable and the physician/QLP is not required to come to the hospital to see and evaluate the patient.

-- During interview of Staff N, Quality Manager, on 9/5/2024 at 11:15 am, they acknowledged the above findings.