HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to ensure a restraint was discontinued at the earliest possible time, regardless of the length of time identified in the order for 1 of 3 patients reviewed who were applied violent restraints.

Findings are as follows:

The hospital's policy titled, "Lifespan Patient Restraint and Seclusion" effective 2/2023 states in part,

"II. Policy

...Restraint or seclusion must be discontinued at the earliest possible time, when the patient no longer exhibits violent or self-destructive behaviors (for violent restraint or seclusion) ...

...Assess need for continued use of restraint or seclusion if patient falls asleep ..."

Record review revealed that on 8/28/2023 Patient ID #1 threw a cup of urine at a staff member and became verbally aggressive at which point a decision was made with the physician to place the patient in bilateral upper and lower extremity soft restraints.

The record revealed that an order for adult violent restraints was placed on 8/28/2023 at 10:36 AM for Patient ID #1.

Further review of this order revealed that mechanical limb restraints were to be applied to Patient ID #1's upper arms and lower legs continuously for 4 hours as he was a danger to others.

Record review of restraint documentation revealed that the restraints were initiated at 10:00 AM on 8/28/2023 and were discontinued at 2:00 PM for a total of 4 hours.

Further review of restraint documentation revealed that by 11:36 AM on 8/28/2023, and subsequently at 11:51 AM, 12:00 PM, and 1:00 PM, Employee A documented that Patient ID #1 was "sleeping." The record failed to reveal evidence that the patient continued to exhibit violent or self-destructive behaviors that warranted the continuation of the restraints applied during these timeframes.
Additionally, Patient ID #1's psychological status was documented as "calm" at the following times while she/he remained restrained:

- 12:21 PM
- 12:36 PM
- 12:51 PM
- 1:06 PM
- 1:21 PM
- 1:36 PM
- 1:51 PM

The record failed to reveal evidence that the patient continued to exhibit violent or self-destructive behaviors that warranted the continuation of the restraints applied during these timeframes.

Record review of a "Consult Follow up" note entered by Employee B, Physician, dated 8/28/2023 at 12:56 PM, states in part that upon assessment Patient ID #1 was in bed, alert, pleasant and cooperative. Additionally, Employee B stated Patient ID #1 engaged thoughtfully, she/he did not have mania or psychosis, and to discontinue the restraints soon. However, the restraints applied to Patient ID #1 continues until 2:00 PM.

During a surveyor interview on 9/11/2023 at 3:20 PM with the Risk Manager in the presence of the Director of the Center for Professional Practice and Innovation and the Regulatory Readiness Specialist, no evidence was provided to the surveyor that justified the need for the continuation of the 4 limb restraints applied to Patient ID #1 on 8/28/2023 after it was documented by Employee A that the patient was "sleeping" and "calm" during consecutive assessments.