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Based on policy and procedure review, medical record reviews and physician interview hospital staff failed to perform a face-to-face evaluation within one hour of a violent restraint for 2 of 3 restraint records reviewed for violent behavior (Patient #7, Patient #13)

The findings included:

Review of the policy "Restraint Management Program...", last revised 11/2021, revealed "...Chemical Restraint: A drug or medication when it is used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement.... is considered a restraint ....Drugs that may be used as chemical restraints include....PSYCHOTROPICS....ziprasidone (Geodon)....The patient will be monitored for Non-Violent Behavior Monitoring or Violent Behavior Monitoring in this policy.... Violent....Restraint Use: A restraint used to control aggressive, combative, or destructive behavior that places the patient or others in imminent danger....A provider must perform a face-to-face assessment of the patient within one (1) hour of the application of Violent restraints....The in-person evaluation ....includes evaluation....the patient's immediate situation....the patient's reaction to interventions....The patient's medical/ behavioral condition....The need to continue or terminate the restraint or seclusion. ..."

1. Medical record review on 04/06/2022, revealed Patient #7 was seen by an Emergency Department (ED) provider on 02/17/2022 at 1113, after being brought in by police with "...Unclear Thinking, Violence, Bizarre Behavior." ED record review revealed at 1210 Patient #7 was ordered Ativan 2 mg (milligrams) IM (intramuscular) stat (as soon as possible) and Ziprasidone 20 mg IM which were administered at 1230. A note by a Registered Nurse indicated Patient #7 became aggressive and uncooperative and medications were ordered. Review of provider notes did not reveal specific documentation of a one hour face-to-face evaluation. Review revealed documentation of the first "re-evaluation" was at 1350 (1 hour, 20 minutes later) which indicated "worsened".

Interview with MD #4 on 04/07/2022 at 1112, revealed the medications for Patient #7 were ordered for violent behavior. Interview revealed the MD "restrained chemically vs. physically. MD #8 stated face-to-face evaluations were to be conducted by the provider within one hour and, based on the medical record, the face-to-face for Patient #8 was conducted late.

2. Medical record review on 04/06-07/2022, revealed Patient #13 arrived to the ED by EMS (Emergency Medical Services) in the custody of police on 12/10/2021 at 0106 with chief complaints of psychiatric evaluation and acute alcohol intoxication. Review of an ED Nurses Note at 0108 indicated "Patient screaming, cussing, attempting to hit and bite staff and officers at bedside. ..." ED Physician Documentation noted time seen by the provider as 0111 and indicated Patient #13 was given Ativan 2 mg IM at 0111, Geodon 20 mg IM at 0115, and another Ativan 2 mg IM at 0125. Review revealed "...MDM (Medical Decision Making) Plan of Disposition for Patient: Move to Safe Zone Date of Decision: 12/10/21 Time of Decision: 01:42..." The Patient Order Summary revealed at 0153, an order for violent limb restraints was ordered and at 0208 a Restraint Flowsheet indicated the restraints were on the right and left wrist and right and left ankle. Review revealed the restraints were removed at 0310. Record review did not reveal a face-to-face evaluation conducted by a provider within one hour. The next documentation which noted Patient #13 was seen by a provider was "...Consultation: Psychiatrist...Patient seen by psych... .Call Returned: 0945."

Request to interview the ordering physician, on 04/07/2022, revealed the physician was not available for interview that day.

Interview with MD #4 on 04/07/2022 at 1112 revealed a face-to-face evaluation by a provider should be conducted within one hour for a violent restraint.

Based on policy review, medical record review and staff interview hospital staff failed to document in a patient's medical record the date and time an entry of the death was made into an internal log for 1 of 1 restraint death records reviewed (Patient #6)
The findings included:

Review of a policy titled "Restraint Management Program", last revised 11/2021, revealed "...4. Reporting of Deaths related to Restraints...F. When no seclusion has been used and when the only restraints used on the patient are wrist restraints composed solely of soft non-rigid, cloth-like material, the hospital does the following... 5. Records in a log or other system any death that occurs while a patient is in restraint.:... 9. Documents in the patient record the date and time that the death was recorded in the log or other system. ..."

Medical record review of Patient #6, on 04/06/2022, revealed the patient was admitted with diagnoses that included among others, severe sepsis (life-threatening infection), Clostridium difficile colitis (bacteria that causes severe diarrhea) and acute on chronic kidney failure. Review revealed the patient was placed in non-violent medical restraints on 03/14/2022. Review revealed the last documentation of monitoring of restraints was on 03/16/2022 at 0200 and indicated that soft limb restraints were on. Further review revealed Patient #6 expired on 03/16/2022 at 0253. Review did not reveal any documentation in the medical record that the death was recorded on the internal log.

Interview on 04/07/2022 at 1515 with Director #21 revealed deaths in restraints or within 24 hours of restraint were recorded on an internal log. Further interview revealed the date and time the death was recorded in the log was not currently being recorded in the patient's medical record. Director #7 stated they did not realize the entry in the log needed to be noted in the medical record. Interview revealed it was an "easy fix".