HospitalInspections.org

Based on review of facility policy, review of medical records and interview, the facility failed to ensure restraints were implemented in accordance with safe and appropriate techniques as determined by hospital policy in accordance with State law.

Findings included:

Facility Policy titled "Restraints, Immobilization and Seclusion - Adult/Pedi Patient Rights" stated in part, "Definitions:
1. Restraint: Use of any manual method of restricting a person's freedom of movement, physical activity or normal access to his or her body. The standards for restraint are not specific to the treatment setting but to the situation, the restraint is used to address. The decision is driven not by diagnosis, but by comprehensive patient assessment.
...b. Violent: The leadership of UMC recognizes that the use of restraint and seclusion associated with a violent or self-destructive patient who poses a risk of the physical safety and psychological well-being of both patient and staff. Therefore, at University Medical Center, use is limited to emergencies when there is imminent risk of patients harming themselves or others and safety issues demand an immediate response.
i. Examples: Severely aggressive, agitated, combative, attempting to hit/kick staff, spitting, biting using objects as weapons, etc., in which physical harm could be done to staff, other patients and or the patient themselves ...
Documenting need for ANY TYPE of restraint:
Initial documentation includes: *Restraint type & location
*Secondary restraint type & location (if any) ...
Initiation of Restraints:
...Violent Restraints: All restraint and seclusion are applied and continue according to the physician's order ...
*The physician caring for the patient will see the patient face to face within one hour after the application of restraint or initiation of seclusion in order to assess what has triggered the behavior.
The physician will evaluate and document in the progress notes:
*patient's immediate situation
*patient's reaction to the intervention
*patient's medical and behavioral condition
*need to continue or terminate the restraint or seclusion
...Time Limits:
Restraint time limits: 18 years or older - Violent - 4 Hours
Original Order expired and patient continues to need restraints?
1. Call provider
2. Report the results of the most recent assessment and request that the original order be renewed.
3. Provider determines if on-site assessment is required prior to renewing orders.
4. Orders for continuation are limited to the same time frames up to a maximum of 24 hours ...

Patient Monitoring and Periodic Assessment: The patient in restraint will be monitored appropriate to the patient's condition and be recorded in the EMR [electronic medical record] by the staff member trained in the application assessment and/or monitoring of patients in restraints.
General Monitoring ... Violent Restraints - At the initiation of restraint AND every 15 minutes thereafter.
...Non-Violent Restraints - At the initiation of restraint AND every 2 hours thereafter.
Periodic Assessment ... Violent Restraints - Every 30 min and PRN [as needed]
...Non-Violent Restraints - Every 2 hours, PRN and while awake ..."

Review of patient #1's medical record revealed an order dated 3/23/17 at 4:46 am that stated in part, "Restraint Initiation - Non-Violent: Boxing glove; Location: bilateral upper extremities; Medical pre-restraint alternatives: Comfort measures; Behavior requiring medical restraint: other: patient is MHMR [mental health mental retardation] and is currently agitated and punching self in face ..."

Nursing staff documented patient #1's behavior every 2 hours and described behavior as: "anxious, difficult to consul, agitated, combative and restless."

Nursing note dated 3/23/17 at 11:08 am stated in part, "patient got loose from soft restraints and began to punch herself in the face with the boxing glove restraints. The patinet [sic] has a bloody lip. I reaplied [sic] soft restraints and will continue to monitor the patient ..."
Although orders were written for non-violent restraints, behaviors of the patient were documented as violent and self-destructive. Although they were used, there was no order for the use of soft wrist restraints. Documentation and orders were not consistent with facility policy and Federal and State regulations related to violent restraints.

Review of the medical record for patient #10 revealed patient #10 was in restraints from 6/6/17 at 11:30 pm until 6/7/17 at 8:00 am. Periodic assessments were not documented according to facility policy of every 2 hours and as needed.

The above was confirmed in an interview with staff #1 and #3.

Based on review of facility policy, review of medical records and interview, the facility failed to ensure each restraint used for the management of violent or self-destructive behavior was in accordance with the 4 hour time limit for adults.

Findings included:

Facility Policy titled "Restraints, Immobilization and Seclusion - Adult/Pedi Patient Rights" stated in part, "Definitions:
1. Restraint: Use of any manual method of restricting a person's freedom of movement, physical activity or normal access to his or her body. The standards for restraint are not specific to the treatment setting but to the situation, the restraint is used to address. The decision is driven not by diagnosis, but by comprehensive patient assessment.
...b. Violent: The leadership of UMC recognizes that the use of restraint and seclusion associated with a violent or self-destructive patient who poses a risk of the physical safety and psychological well-being of both patient and staff. Therefore, at University Medical Center, use is limited to emergencies when there is imminent risk of patients harming themselves or others and safety issues demand an immediate response.
i. Examples: Severely aggressive, agitated, combative, attempting to hit/kick staff, spitting, biting using objects as weapons, etc., in which physical harm could be done to staff, other patients and or the patient themselves ...
...Time Limits:
Restraint time limits: 18 years or older - Violent - 4 Hours
Original Order expired and patient continues to need restraints?
1. Call provider
2. Report the results of the most recent assessment and request that the original order be renewed.
3. Provider determines if on-site assessment is required prior to renewing orders.
4. Orders for continuation are limited to the same time frames up to a maximum of 24 hours ...

Patient Monitoring and Periodic Assessment: The patient in restraint will be monitored appropriate to the patient's condition and be recorded in the EMR [electronic medical record] by the staff member trained in the application assessment and/or monitoring of patients in restraints.
General Monitoring ... Violent Restraints - At the initiation of restraint AND every 15 minutes thereafter.
...Non-Violent Restraints - At the initiation of restraint AND every 2 hours thereafter.
Periodic Assessment ... Violent Restraints - Every 30 min and PRN [as needed] ..."

Review of patient #1's medical record revealed an order dated 3/23/17 at 4:46 am that stated in part, "Restraint Initiation - Non-Violent: Boxing glove; Location: bilateral upper extremities; Medical pre-restraint alternatives: Comfort measures; Behavior requiring medical restraint: other: patient is MHMR [mental health mental retardation] and is currently agitated and punching self in face ..."

Nursing staff documented patient #1's behavior every 2 hours and described behavior as: "anxious, difficult to consul, agitated, combative and restless."
Nursing note dated 3/23/17 at 11:08 am stated in part, "patient got loose from soft restraints and began to punch herself in the face with the boxing glove restraints. The patinet [sic] has a bloody lip. I reaplied [sic] soft restraints and will continue to monitor the patient ..."
Although orders were written for non-violent restraints, behaviors of the patient were documented as violent and self-destructive. Although they were used, there was no order for the use of soft wrist restraints.
Documentation and orders were not consistent with facility policy and Federal and State regulations related to violent restraints: The order was incorrect, time frames for violent restraint were not followed, no face-to-face evaluation by a physician was completed, nursing documentation for patient monitoring and periodic assessment were not completed correctly.

The above was confirmed in an interview with staff #1 and #3.