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Based on policy and procedure review, security documentation review, medical record reviews and staff interviews the staff failed to obtain a physician's order for the use of restraints in 3 of 4 restrained patients reviewed (#5, #2, #6).

The findings include:

Review of hospital policy 300.024 titled Restraints: Behavioral revised March 9, 2009 revealed "2. Licensed Independent Practitioners (LIPs) or physician assistants and nurse practitioners as delegated by LIP, may order restraints...The order is to be time limited for four hours for adults, two hours for adolescents (ages 9-17)...The order must be written and completed on the preprinted order set "Restraint/Seclusion Order Set for Behavioral/Psychiatric Health Diagnosis". "

1. Review of "Security Department Use of Force Incident Form" (event #1) revealed on 10-5-2010 at 1200 Security was notified to assist with patient #5 in the (Pediatric Intensive Care Unit) Peds ICU. Review of the documentation revealed "to assist with medication. we were there for approx 20 minutes with no serious problems". Review of the "Security Department Use of Force Incident Form" (event #2) dated 10/8/2010 at 1645 revealed "Security was called by dispatch for officers to respond to a call in Peds ICU. As we were responding dispatch changed to Code Gray. My self and C-7 were the first to respond and the nurses were trying to talk the patient down but talking was not working. The patient became more violent and began kicking".

Medical record review of patient #5 revealed an 11 year old admitted on 9/27/2010. Record review revealed on 10/5/2010 at 1200 (event #1)documentation the patient was having disruptive behavior in the Peds ICU. Review of the nursing documentation revealed "at 1200 pt (patient) became very belligerent and combative. Began pulling off monitors, trying to pull out PICC ( intravenous line to supply fluids). Kicking and hitting staff, trying to bite and spit. Attempted to reason with pt, pt just getting more agitated. Dr XXX notified. Given 2 mg ativan (antianxiety medication) IV (intravenous). dose repeated at 1220. At 1240 IM haldol (antipsychotic medication)". Record review did not reveal documentation of a physician's order for the usage of a restraint in the form of a therapeutic hold. Record review did not reveal how long the patient was in the therapeutic hold. Further record review revealed documentation by the nurse dated 10/8/2010 at 1630 (event #2) revealed "Pt violent and having uncontrolled behavior, unable to redirect pt. and security called. 4 nurses and 3 security guards were called and arrived to room. To maintain pt and staff safety, Ativan Iv given the 15 minutes later Haldol 3mg/Im given. Pt placed in 4 point restraints for approximately 15 minutes. Pt stated he needed to go to bathroom, pt was released from restraints at that time and was not re restrained. Pt calmed down...". Record review revealed no documentation of a physician's order for the use of restraints.

Interview with administrative staff on 10/15/2010 at 1045 revealed there was no documentation of a physician's order for the usage of restraint or therapeutic holds for patient #5 on 10/5/2010 or 10/8/2010. The interview revealed the hospital policy requires a physician's order for restraint usage. The interview did not reveal why the nursing staff did not obtain an order for restraint usage.

2. Review of "Security Department Use of Force Incident Form" dated 10/4/2010 at 2350 revealed "Patient came in by (name of ambulance service). Combative. Security assist medical staff with escorting (patient #2) to ER #40 and applied restraints".

Medical record review of patient #2 revealed an 51 year old presenting to the Emergency Department on 10/4/2010 for overdose and involuntary commitment. Record review revealed documentation by the physician "He did require restraints because of rather marked agitation when he was awake...and the fact that he is in restraints". Record review did not reveal any documentation of a physician's order for restraints.

Interview with administrative staff on 10/15/2010 at 1045 revealed there was no documentation of a physician's order for the usage of restraint for patient #2 on 10/4/2010. The interview revealed the hospital policy requires a physician's order for restraint usage. The interview did not reveal why the nursing staff did not obtain an order for restraint usage.

3. Review of "Security Department Use of Force Incident Form" dated 8/17/2010 at 0445 revealed Security staff responded to request for assistance to room 39 for patient #6. Review of the report revealed patient #6 "became combative with medical staff. Security Officer (name of officer) and (name of officer) were requested to assist medical staff (name of nurse) to administer medication. (name of patient #6) became more combative and (name of nurse) order restraints". Further review revealed four officers assisted patient #6 'back to the bed so medical staff could apply restraint".

Medical record review of patient #6 revealed a 54 year old presenting to the Emergency Department on 8/17/2010 for a Psychiatric evaluation. Record review revealed documentation by the nurse on 8/17/2010 at 0531 "Patient becoming steadily more agitated since 4:30. Attempted to redirect, reduce stimuli and use de escalation techniques. Patient did not respond to attempts to calm patient and advised that chemical and possibly physical restraint might be necessary if patient did not cooperate". Further record review revealed on 8/17/2010 at 0538 documentation by the nurse "Patient became steadily louder, aggressive and violent. Per MD order, patient sedated with 5 mg of Haldol and 2 mg of Ativan and placed in 4 point restraints...". Record review revealed the patient was restrained until 0730 (3 hours 45 minutes restrained). Record review did not reveal any documentation of a physician's order for restraints.

Interview with administrative staff on 10/15/2010 at 1045 revealed there was no documentation of a physician's order for the usage of restraint for patient #6 on 8/17/2010. The interview revealed the hospital policy requires a physician's order for restraint usage. The interview did not reveal why the nursing staff did not obtain an order for restraint usage.

Based on policy and procedure review, Hospital Security documentation review, medical record review and staff interview the staff failed to document the monitoring of a patient restrained in 1 of 4 patients reviewed (#2, #4).

The findings include:

Review of hospital policy 300.024 titled "Restraints: Behavioral" revised March 9, 2009 revealed "The patient will be assessed at least every 15 minutes."

1. Review of "Security Department Use of Force Incident Form" dated 10/4/2010 at 2350 revealed "Patient came in by (name of ambulance service). Combative. Security assist medical staff with escorting (patient #2) to ER #40 and applied restraints".

Medical record review of patient #2 revealed an 51 year old presenting to the Emergency Department on 10/4/2010 for overdose and involuntary commitment. Record review revealed documentation by the physician "He did require restraints because of rather marked agitation when he was awake...and the fact that he is in restraints". Record review did not reveal any documentation of the monitoring of the patient while the patient was restrained.

Interview with administrative staff on 10/15/2010 at 1045 revealed there was no documentation of assessment or monitoring of patient #2 on 10/4/2010 while the patient was restrained. The interview revealed the hospital policy requires documentation every 15 minutes of the patient while the patient is restrained for behavioral reasons. The interview did not reveal why the nursing staff did not document the monitoring of the patient. The interview indicated the nursing staff had not viewed the usage of the restraint episode as a behavioral restraint

NC00068358