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Based on interview and record review, the facility failed to 1) have physician orders present for restraint application for 2 (#1, 11) of 3 patients whose charts were reviewed for restraint; 2) failed to provide a one hour face-to-face evaluation for 1 (#10) of 3 patients whose charts were reviewed for restraint; and 3) failed to develop and implement policy relating to a hospital employee accused of assault resulting in the potential for less than optimal outcomes for all patients served by the facility. Findings include:

See Specific Tags:

A-145 Failure to develop and implement policies regarding a hospital employee accused of abuse
A-168 Failure to provide a physician order for restraint application
A-178 Failure to conduct a face-to-face within 1 hour of restraint application

Based on interview and record review, the facility failed to develop and implement policies relating to the protection of patients from an alleged employee abuser resulting in the potential for less than optimal outcomes for all patients served by the facility. Findings include:

On 11/9/2021 at 1020, review of the medical record for Patient #1, the patient of concern, revealed she was a 42-year-old female who arrived via private vehicle on 9/29/2021 at 1354 with a chief complaint of "hearing God" and "seeing Jesus" for the past five days. Past medical history included: gastritis (inflammation of the stomach), chronic back pain status post motor vehicle accident in 2003, ovarian cyst, pancreatitis (inflammation of the pancreas), diabetes (high blood sugar), hypertension (high blood pressure), and pelvic inflammatory disease (pelvic infection). A petition (a report of observations and/or witness statements forming a basis to request a mental health examination) and clinical certificate (written conclusions and statements of a physician or licensed psychologist stating a person needs treatment for their mental health), both dated 9/29/2021, were present in the medical record. The patient did also sign a consent for voluntary admission on 9/30/2021.

During her evaluation in the emergency department (ED), Patient #1 repeated told the provider and nursing staff that she had pancreatic cancer, was experiencing discomfort, and she wanted to be placed on hospice. Laboratory and radiologic testing revealed the patient had no cancer present on any structures in her abdomen; however, a cyst was present on the pancreas.

Patient #1 attempted to leave the ED on multiple occasions, was yelling and verbally abusive toward ED staff, and attempted to hit a nurse while being escorted back to her room following an elopement attempt. Patient #1 was placed in 4-point restraints for her safety and the safety of others on 9/29/2021 at 2259. The restraints were removed on 9/30/2021 at 0007.

She was admitted to the Behavioral Health unit on 9/30 at 1409 with the following diagnoses: mood disorder, affective, unspecified; rule out bipolar disorder, currently manic, severe, with psychosis; and cannabis use disorder.

On 11/9/2021 at 1152, Behavioral Health Manager Staff B stated Patient #1 had stated "she had passed out on the (behavioral health) unit 50+ times and staff did nothing for her. That did not happen."

As a result of the above findings, facility policy "Abuse and Neglect" dated 4/2021 was reviewed on 11/9/2021. It was noted there was a lack of policy/procedure on what should occur if a hospital employee/contracted employee was accused of assault of any type including removal of the alleged perpetrator from all patient care until the investigation was complete.

On 11/9/2021 at 0921, Director of Risk Management Staff A was queried as to what steps were taken if a hospital or contracted employee was identified as an alleged abuser to which she stated, "The staff member would be removed immediately and placed on paid leave until the investigation was completed." When queried as to if there was another policy that addressed what she had just described, Staff A stated, "There are two abuse and neglect policies, one is for the long term care unit. I think it is their policy that states the abuser will be removed from patient care. I will be looking at that and combine it into one policy for all."

Based on interview and record review, the facility failed to have a physician order for each application of a behavioral restraint for 2 (#1, 11) of 3 patients with behavioral restraints who were reviewed and/or failed to renew an order for restraint lasting longer than 4 hours for 1 (#11) of 3 patients reviewed for behavioral restraint resulting in the violation of the patient's rights and potential for adverse patient outcomes. Findings include:

On 11/9/2021 at 1020, review of the medical record for Patient #1 revealed she was a 42 year old female that had been placed in restraints on 9/29/2021 at 2259 for multiple incidences of attempted elopement, high agitation, and attempting to hit a nurse. She remained in restraint until 9/30/2021 at 0007. Further review of the medical record revealed there was no order present for the patient to be placed in restraint.

On 11/9/2021 at 1420, Emergency Department (ED) Physician Staff K stated he recalled Patient #1 and stated he had given a verbal order while being present in Patient #1's room for restraint application. He stated, "I believe it was busy that night. I must have forgotten to put it in the computer."

On 11/9/2021 at 1433, Risk Manager Staff A stated, "It is not a fluke that there is no order for restraint from the ED. We have a problem there. They give a verbal order and it never gets put into the medical record."

On 11/9/2021 at 1437, review of the medical record for Patient #11 revealed he was a 59 year old male who had been placed in behavioral restraints multiple times during his ED admission. Dates and times of restraint application and discontinuation were as follows:

Date/Time Applied Date/Time Discontinued
11/3/2021 0610 11/3/2021 0805
11/3/2021 1315 11/3/2021 1400 left wrist; 1414 all restraint removed
11/3/2021 2026 11/3/2021 2152 right arm; 2215 all restraint removed
11/3/2021 2327 11/3/2021 2355 left ankle; 11/4/2021 0100 all restraint
removed
Undated/ Not timed 11/6/2021 2240 right wrist, left ankle removed
(nurse documentation time, which
was not dated, occurred at 1155)
11/6/2021 2255 right wrist 11/6/2021 2347 all restraints removed
left ankle reapplied
11/9/2021 0633 11/9/2021 0800 all restraints removed

Review of physician orders revealed orders for the following dates and times:
11/3/2021 at 1325
11/6/2021 at 2245
11/9/2021 at 0641

On 11/9/2021 at 1445, Risk Manager Staff A, who was conducting review of the medical record, stated the undated restraint application "must be from 11/6..." It was noted on 11/6/2021 that Patient #11 was in restraint from approximately 1155 until 2347 (a total of 11 hours and 52 minutes) with the order given 1 hour and 2 minutes prior to release. There was no order initially on 11/6/2021 and no renewal of an order every 4 hours on 11/6/2021.

Review of facility policy titled "Restraints and Seclusion" revised 3/2021 states, "An order for restraint must be placed in the patient chart either before or within a few minutes after application in emergent situations... In some situations , the need for a restraint or seclusion intervention may occur so quickly that an order cannot be obtained prior to the application of restraints. RN (registered nurse) nursing staff may initiate & apply restraints in this emergency situation. The order must be obtained either during the emergency application of the restraint/seclusion or immediately after the restraint has been applied. A patient may be temporarily restrained without an order or authorization in an emergency. Immediately after the imposition of the temporary restraint/seclusion, a physician must be contacted. If, after being contacted, the physician does not order or authorize the restraint/seclusion, or the physician is unable to be contacted, the restraint shall be removed... A specific order is required for each episode of restraint (or) seclusion. Each patient must be assessed, and interventions should be tailored to meet the individual patient's needs... an RN may initiate use of a protocol for restraint use and obtain a Physician order... Time limited orders... Each order must include reason for restraint, type of restraint, start time of restraint and duration. The restraint order sticker must be utilized... After the original order expires, that patient receives a face-to-face reassessment by a physician. The physician writes a new order if restraint is going to be continued."

Based on interview and record review, the facility failed to perform a 1-hour face-to-face evaluation for 1 (#11) of 3 patients whose charts were reviewed for restraint application resulting in the potential for adverse patient outcomes. Findings include:

On 11/9/2021 at 1624 review of the medical record for Patient #11 revealed she was a 23 year old female who was admitted to the behavioral health unit on 5/14/2021. Review of restraint documentation revealed no face to face was done on this patient when she was restrained on 5/15/2021 at 1425.

On 11/9/2021 at 1630 Staff A agreed a face to face should have been conducted on Patient #11.

Review of facility policy titled, "Restraints and Seclusion" last revised 3/2021 states, "When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hours after the initiation of the intervention."