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Based on policy review, medical record reviews, and staff interviews, the facility staff failed to perform a face-to-face evaluation within 1-hour of restraint application for 2 of 2 patients. (Patient #8 and Patient #13).

Findings included:

Review on 03/22/2023 of hospital policy, "Restrictive Interventions", approved 06/02/2022, revealed "...I. Violent/Self-destructive Restraint Orders...3. A face-to-face evaluation of the patient is to occur within one (1) hour of application of restraint (even if restraint is removed within 1 hour of application). This evaluation is to be performed by a physician who is responsible for the care of the patient; or a trained registered nurse (RN), nurse practitioner or a physician assistant. The face-to-face evaluation of the patient includes the immediate situation, patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion ..." Definitions and Exceptions A. A restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs or body or head freely; or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ..." Review revealed a face-to-face evaluation, by qualified personnel, should occur within 1-hour of initiation of a violent/self-destructive restraint and or a chemical restraint.

1. Closed medical record review on 03/23/2023 revealed Patient #13, a 25-year-old presented to the Emergency Department (ED) on 11/23/2022 at 0239 with chief complaint of Altered Mental Status-intoxicated. At 0302, ED Medical Doctor progress note revealed, the patient became aggressive and violent with any minimal stimulus as evident by, during the physical exam, the patient was alert, violent, swinging punching kicking spitting and trying to bite. At 0303, the patient was placed in 4-point restraints (restraints which immobilize both arms and legs). At 0343, the MD ordered "Restraints-Restraints violent or self-destructive adult." Review of the ED Nurses Note revealed at 0442 (1-hour and 39-minutes later), the restraints were removed because the patient "seemed more alert and more oriented," and the patient was no longer a threat to self or others. At 0520, MD Progress note revealed, the patient was re-evaluated. The patient was calm with no violent tendencies. At 0535, the patient was discharged home. Review failed to reveal documentation of a face-to-face evaluation, by qualified personnel, occurred within 1-hour of violent/self-destruction restraint initiation.

Interview on 03/23/2023 at 1615 with the Director of Nursing revealed the facility did not have any qualified or trained nurses to perform a face-to-face evaluation for restraints. The face-to-face should only be completed by qualified providers (including Medical Doctors, Physician assistants or Nurse Practitioners).

Interview on 03/23/2023 at 1715 with the Chief Nursing Officer revealed the nurses at the facility were not qualified to complete the face-to-face evaluation within 1 hour of application of restraint. The face-to-face should only be completed by qualified personnel (including Medical Doctors, Physician assistants or Nurse Practitioners).

2. Closed medical record review on 03/23/2023 revealed, Patient #8 revealed a 21-year-old presented to the ED on 03/13/2023 at 1240 for a psychiatric evaluation secondary to suicide attempt. ED Medical Doctor progress note revealed at 1839, the patient was screaming, trying to choke herself with her scrubs (?). At 1839, the MD ordered Haldol (med for mental disorder) 5-milligrams and Ativan (med for anxiety disorder) 2-milligrams administered into a muscle once for patient safety. At 1845, 2-milligrams of Ativan and 5-milligrams of Haldol were administered to the patient as ordered. At 1850, the patient was placed in a 4-point restraint. At 1919, the Medical Doctor entered an order for "Restraints-Restraints violent or self-destructive adult." Review of the ED nurses note revealed at 2100 (2-hours and 10-minutes later), the patient was assessed and was determined to be calm and cooperative. The restraints were discontinued because the criteria was met. On 3/15/2023 at 0720 (42-hours and 20-minutes later), the patient was discharged to law enforcement for transport to an inpatient psychiatric treatment unit. Review failed to reveal a face-to-face evaluation, by qualified personnel, occurred within 1 hour of a chemical restraint initiation.

Interview on 03/23/2023 at 1615 with the Director of Nursing revealed the facility did not have any qualified or trained nurses to perform face-to-face evaluations for restraints. The face-to-face should only be completed by qualified providers (including Medical Doctors, Physician assistants or Nurse Practitioners).

Interview on 03/23/2023 at 1715 with the Chief Nursing Officer revealed the nurses at the facility were not qualified to complete the face-to-face evaluation within 1 hour of application of restraint. The face-to-face should only be completed by qualified providers (including Medical Doctors, Physician assistants or Nurse Practitioners).
NC00197869