HospitalInspections.org

Based on the review of 6 open and 9 closed records, the hospital failed to support patient #7's right to be involved in care planning, and failed to support patient #7's right to refuse medications.

Patient #7 was admitted to the medical surgical unit on 08/18/2016. Patient #7 has a diagnosis of confusion upon admission. The hospital has been using family members for medical decision making. There were no capacity statements done to determine if patient #7 was capable of making their own medical decisions

Patient #7 arrived to the ED 08/18/2015 for status post fall and confusion. Patient #7 had order written for Haldol 5mg/ml 1mg IM every 4 hours as need for agitation. The patient did not have an order for by mouth medication offered. The Haldol was given 08/23/2016 at 0019 for agitation. The patient was unable to exhibit their right to refuse by not being offered the medical by mouth initially.

Based on a review of patient #1's restraint record, it is revealed that there was no order was found for a spit sock to be applied to his head.
Patient #1 was a middle-aged male who presented to the emergency department (ED) via emergency medical services (EMS) and police in early August 2016, complaining of chest pain. Patient #1 has a history of myocardial infarction. He was triaged a priority level 2. Patient #1 was very intoxicated when picked up by EMS and was combative.
In the ED, patient #1 was placed into 4-point restraints at 1120 due to attempts to harm staff. A spit sock was applied to patient #1's head, though no order appears in the record for this restraint. Based on this, patient #1 was restrained in part, by a spit sock without orders to do so.

Review of patient #1's and #3's restraint documentation revealed that staff continued restraints though there was no justification to do so.
Patient #1 was a middle-aged male who presented to the emergency department (ED) via emergency medical services (EMS) and police in early August 2016, complaining of chest pain. Patient #1 had a history of myocardial infarction. He was triaged a priority level 2. Patient #1 was very intoxicated when picked up by EMS and was combative.
Fifteen minute monitoring revealed no real-time, objective behavioral documentation other than the behavior which initiated restraint. From 1200, through 1445, patient #1 was documented as "appears to be sleeping" for 9 of 13 fifteen minute documentations of monitoring. However, documentation between 1215 and 1445 also documented a RASS (Richmond Agitation Sedation Scale) ranging between +3 Very Agitated, to +2 Agitated, to +1 Restless, even though patient #1 was otherwise documented as being asleep. Based on this information, patient #1 was not released at the earliest possible time.
Patient #3 was an adult male who was admitted to the BHU in early August 2016. Patient #3 became threatening to staff when redirected from leaning over the nursing station desk. Patient #3 began to swing his fists at the security guards and was taken to the seclusion room where he broke the seclusion door handle. This necessitated 4-point restraints due to his ongoing attempts to harm staff. An order for seclusion for up to 4 hours for harm to self and others was written at 0006. However, a new order for 4-point restraint for up to 4 hours was written at 0032.
Patient #3 was placed in 4-point restraints at 0037, and medication was administered. Per a nursing note of 0208, regarding restraint readjustment, patient #3 " ...appeared to be sleeping ..." Staff no longer had justification to keep patient #1 restrained, but continued restraints even while noting patient #3 as sleeping, and or calm/cooperative throughout the next 8 hours, until his release at 0915.
Additionally, when the initial 4-hour order had elapsed, the physician wrote a renewal order for 4-point restraint at 0450 though there was no justification for doing so. Thus, patient #3 was not released at the earliest possible time.

Based on a review of patient #1, #2, and #3 records, it is revealed that face to face documentation was neither timely nor complete.

Patient #1 was a middle-aged male who presented to the emergency department (ED) via emergency medical services (EMS) and police in early August 2016, complaining of chest pain. Patient #1 had a history of myocardial infarction. He was triaged a priority level 2. Patient #1 was very intoxicated when picked up by EMS and was combative.

In the ED, patient #1 was placed into 4-point restraints at 1120. Documentation revealed that the physician was with patient #1 when he was placed in restraints. Face to face documentation for the order of 1214 revealed the patient's immediate situation as "hitting staff" and the medical/behavioral condition as "Delusional." The face to face assessment elements of the patient reaction to the intervention and the need to continue or terminate the restraints was not documented.

Patient #2 was an adult female who presented to the emergency department in late August 2016 for an altered mental status. Patient #2 had become increasingly agitated over some days. A nursing note of 1906 described the nurse attempted to give patient #1 intramuscular medication. However, patient #1 pulled the plunger from the syringe, spilling the medication.

Patient #2 was placed into 4-point restraints on or about 1854. Though the physician was with patient #2 at the time of restraint, no face to face appears in the record until 2019 when the physician order was entered. Face to face assessment elements were made a part of restraint orders. Documented along with the order was a statement that the patient's immediate situation of "Agitated" and the medical/behavioral condition of "Delusional." However, other assessment elements of the face to face such as, the patient's reaction, and whether to continue or terminate restraint were not found. Based on this, the hospital failed to conduct and document the face to face within one hour of the restraint, and failed to complete all assessment elements.

Patient #3 was an adult male who was admitted to the BHU in early August 2016. Patient #3 became threatening to staff when redirected from leaning over the nursing station desk. Patient #3 began to swing his fists at the security guards and was taken to the seclusion room where he broke the seclusion room door handle. This necessitated 4-point restraints due to his ongoing attempts to harm staff. An order for seclusion for up to 4 hours for harm to self and others was written at 1206. However, a new order for 4-point restraint for up to 4 hours was written at 1232.

Patient #3 was placed in 4-point restraints at 0037, and medication was administered. No face to face was noted in the record.

Based on all documentation, the physicians are not conducting and documenting face to face assessments in a timely, or thorough way, and for patient #3, no face to face was done at all.

Based on interviews, review of policy, and the job description of security staff, it is revealed that: 1) security staff have had no recent training 2) security staff restrain patients without first receiving training.


Interview with security staff #1 (SS1) on 8/29/2016 at approximately 0930 revealed no memory of restraint training as an employee of the hospital. SS1 stated that he had "Many years" of using hands-on techniques in other jobs, and described part of how he goes about putting hands on violent/threatening people in the emergency department. During the interview, SS1 made distinctions between the handling of a patient vs. a visitor, and that fact that he is directed by nursing when manually holding and/or placing restraints. When asked what he might look for to determine if a patient was in distress, SS1 answered that the nurses would know if someone was in distress during a restraint.

A review of SS1 employee file revealed his orientation to the hospital "Use of Force Policy, Patient Safety, and General Safety" but no restraint training was found. A Request for security training for restraint revealed a list of 32 security staff who had restraint training in 2013. Additionally, 5 attestations were given by the Training Officer, documenting Crisis Prevention Institute recertification every year since 2010. When employee file documentation on these trainings was requested, no documentation was forthcoming. A description of security staff duties, revealed no provision for restraining others, and no expectation of restraint training.


Review of the Use of Force policy (revised 4/16) revealed "D. When requested to restrain a patient an RN will be present during the restraining."


The policy continues with "Physical restraining methods and devices used." This part of the policy gives a cursory description of two or three officers control the patient's arms, wrists, legs, and head. No actual instructive techniques were noted, and no instruction on being able to tell when a patient is in distress was noted.

Based on interview and documentation, at least 1 security staff member restrained patients without first receiving restraint training, and no timely, on-going, or file documentation of training is noted for other security staff.

Based on an environmental tour of the emergency department (ED), and the behavioral health unit (BHU), it is revealed that 1) multiple unsecured sharps were observed in various areas of the emergency department, in addition to cup and urinal containing urine in an unoccupied room of the psychiatric ED pod, and 2) 4 oxygen tanks were stored in the clean utility of the behavioral health unit, though no signage indicating O2 storage appeared outside the door.

Observation in the ED revealed 1) a phlebotomy room near the triage area with an unsecured drawer containing 2 syringe needles; 2) the Minor care area revealed an open suture cart; 3) patient area #21 revealed an unsecured drawer containing 2 IV catheters; 4) the BHU clean utility room revealed 4 tall O2 tanks, but no signage to indicate their presence in the room. Based on these findings, the facility failed to ensure an acceptable level of safety in the ED and BHU.