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Based on record review and interview, the facility failed to follow their own policy and procedure on Restraint and Seclusion of Patients. The facility failed to obtain a physician ' s order after the use of behavioral restraints of one of one restrained patients (Patient #1)

Findings included:

a. In review on 02/08/12 of facility policy on " Restraint and Seclusion " , effective 07/11, revealed the following: " Restraint shall be ordered by a physician member of the medical staff. Restraint shall only be used for the protection of the patient, staff members or others. Such indications will be present and documented at the initiation of and throughout the episode of restraint. Initiation of Restraint: A registered nurse (RN) may initiate restraint or seclusion in advance of the physician ' s order. As soon as possible, but no later than one hour after the initiation of restraint or seclusion, the RN shall consult with a responsible physician about the patient ' s physical and psychological status and obtain an order (written or verbal). "

b. Reviewed event report on 02/08/12 of the incident, dated 01/26/12 to 01/29/12 revealed the following information: Staff #6 RN made the following statement that was placed on the events list: " At 01/26/12 at 5:10 AM, Patient #1 attempted to elope. She was admitted for psychiatric evaluation; she attempted to leave the floor and got on the elevator. Two staff including the unit secretary was behind her telling her she needed to go back to her room and she started elbowing the unit secretary. I did grab her wrists for her safety as well as ours. She started hitting, biting, scratching and kicking. During this, she lost her balance and went to the floor taking me down with her. Security showed up as we were trying to get her back to her feet. The second time she got on the elevator we again called security. I put my foot in the elevator door to prevent it from closing. She started kicking my leg and stomping my foot. Security escorted her to her room and stayed outside her door until shift change. The House Supervisor was notified twice as well " The House Supervisor #12 wrote the following on 01/29/12 at 1102 regarding the event: " In following up with staff #6, RN had read the patient had a past history of psychiatric problems and that although the emergency department physician had written being admitted for psychiatric evaluation, she was being admitted for a medical condition. I also educated staff #6, RN that although patients should not leave the floor, to never stop a patient even though concern for patient ' s safety is foremost. To allow patient to leave floor, not to stop her, call a code green, notify House Officer and to send an aide with her if possible " The following statement was documented by the unit secretary regarding this incident: " Wednesday night through Thursday morning, the patient was agitated about a number of things and wanted to leave the unit. She made several attempts to leave. First, she walked to the elevator with her oxygen tank and the nurse and I were holding the door to prevent her from going anywhere; she got upset and pushed us out the way cursing and yelling. Right after that she made her way to the stairs, where again the nurse and I tried to stop her with the help of the charge nurse by blocking the entry way. She started yelling, cursing, swinging, scratching, and biting to get us to move out of her way. The charge nurse then told me to call a code strong (green) for security while he held onto the patient with her nurse. When security came to the unit, the pt and the nurse were on the floor; they got her up and escorted her back to her room " . House Supervisor again commented about this event on 02/06/12 at 0032 by writing " this patient can be very challenging to deal with. I spoke to the nurses and unit secretary regarding this patient and explained it is best to let her go without trying to block any doors. Patient likes to leave the floor and return on her own using our hospital wheelchair, she has fallen to the ground without it as she will get up and walk, although hospital security witnessed patient running/walking in front of the library down street without the wheelchair. "

c. Reviewed on 02/08/12 of a facility Security Report, dated 01/25/12 but referring to 01/26/12 at 0510 AM revealed the following: " Duress Alarm on 4D (where patient #1 was residing). When officers arrived patient was in the hallway floor, two registered nurses were holding her down. Patient is upset and wants specific medications of which her doctor will not prescribe. Patient was lifted off the floor by techs and was taken back to her room 418. Patient is now calm enough to converse with staff " .

d. Record review on 02/08/12 of patient #1 ' s physician ' s orders, dated 01/26/12 (date of admission) to 01/29/12 (date of discharge) did not reveal a physician ' s order for restraint. Review of nursing notes for this same time period did not reveal a description of the above described altercation.

e. Interviewed staff #12 admitting physician via telephone on 02/08/12 at 2:55 PM revealed that she was not aware that patient #1 had been restrained and she did not give an order for restraint nor did she give an order for her to remain on the fourth floor.

f. Interview on 02/07/12 at 3:10 PM via telephone with RN #6, who was the charge nurse on the 4th floor at the time of the altercation with patient #1, revealed the following: " He confirmed that patient #1 wanted to leave the floor to go to the emergency room via the elevator. He stated the unit secretary got on the elevator with her asking patient #1 to return to her room. He stated he grabbed her wrists and pulled her off the elevator. He stated she then began hitting; kicking and they were pulled to the floor due to her behavior. He stated that he did not have any current training in how to prevent physical aggression in patients. He confirmed the next day he was told by an administrative nurse that if patients want to leave the floor, we need to let them leave and call a code purple (elopement) " .

g. Interviewed staff #8, unit secretary on 4D at 3:30pm on February 7, 2012 via telephone revealed the following: " She stated that she remembered the charge nurse (RN #6) standing in doorway of stairs to keep patient #1 from leaving by the stairwell. She stated he was holding her in a " bear hug " from behind and told her to go and get security. She stated she called a code strong and returned to find the charge nurse and patient #1 on the floor. She stated she also remembered the charge nurse grabbing the patient ' s arms during some of this altercation " .

h. Interviewed staff #2, Baptist Health System Regional Director for Risk Management at 3:20pm on February 8, 2012 in the administration conference room confirmed that it appeared she was restrained during this altercation and a physician ' s order should have been obtained as well as the event being documented in the nursing notes.