HospitalInspections.org

Based on review of Medical Records (MR), Emergency Department (ED) Video, Facility Death in Restraint report to CMS (Centers for Medicare and Medicaid Services), facility policies and procedure and staff interview, it was determined the facility failed to obtain and/or document a physician's order with the use of restraints.

This deficient practice did affected two of ten MR's reviewed with a restraint, including Patient Identifier (PI) # 10 and PI # 2. This deficient practice had the potential to affect all patients served by the facility.

Findings Include:

Facility Policy: Workplace Violence
Policy Number: 4.01.33
Effective Date: 1/3/22

Scope: The scope of this policy includes potential or actual violent acts committed...by or against...associates...patients.

Purpose: To identify, prevent and consistently respond to potential or actual acts of workplace violence to promote a safe environment...

Definitions:

Workplace violence: A threat or act of violent behavior, against oneself, another person....that either results in or has a high likelihood of resulting injury, death, or psychological harm. These events may involve patients...associates. Examples include...hostility...use of physical force...

...Violent act: Any physical or verbal act intended to inflict physical or emotional harm or suffering on another person...

...Physical Assault: The infliction of unwanted physical contact that is intended to harass...cause pain, injury... Physical assault includes but is not limited to beating, kicking...touching...

Facility Policy: Restraints
Policy Number: 2.01.51
Effective Date: 10/7/21

Policy:

...6. The assessment of: (a) behavioral changes caused by medical conditions or symptoms or (b) the incidence of violent or self-destructive (V/SD) behavior which threatens the patient's best interest should determine the types of restraints or processes attempted...

Definitions:

...2. Restraints for Acute Medical and Surgical Care...In acute medical and post surgical care, a restraint may be necessary to support patient well being and medical healing....

3. Emergency Use of Restraints in Situations of Violence or Self-Destructive Behavior...A restraint may be necessary in emergency or crisis situations if a patient's behavior becomes violent or self-destructive, presenting an immediate, serious danger to his/her safety or that of others...

....Procedure:

A. Implementation of restraints for acute medical/surgical care

...4. A physician's order is required for application of restraints...

5. If a physician is not available to issue an order, emergency restraint use may be initiated by an RN (Registered Nurse) based on an appropriate assessment of the patient.

6. If an RN initiates the use of restraints, a physician order must be obtained promptly...

...C. Implementation of restraints in patients with violent or self-destructive behaviors that threaten themselves or others.

...2. Following assessment, the RN may initiate the emergency use of restraints and must promptly notify the attending physician.

a. Orders for restraints are never written as standing or PRN (as needed) orders...

1. PI # 10 presented to the facility Emergency Department on 7/12/22 with a chief complaint of "pt (patient) states (he/she) is homicidal and suicidal...".

Review of the Restraint nursing notes revealed PI # 10 was in four point leather restraints from 7/12/22 at 4:00 PM until 7/13/22 at 8:30 AM.

Review of the MR from 7/12/22 to 7/15/22 revealed no documentation of a physician's order for the use of restraints.

An interview was conducted on 9/9/22 at 3:05 PM with Employee Identifier (EI) # 1, Vice President of Patient Care, who confirmed there was no documentation of a physician order for the use of restraints on PI # 10.



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2. PI # 2 presented to the facility ED on 8/24/22 at 1:58 AM with a chief complaint of, "Brought in per Mobile Fire and Rescue (MFR) found in a field brought in by Mobile Police Department (PD) custody, combative and shouting".

Review of the ED video dated 8/24/22 at 2:03 AM revealed ED Patient Care Technician entered PI # 2's room with soft restraints.

Review of the CMS report submitted by the facility to CMS on 8/25/22 at 5:00 PM revealed, "The patient was transferred to the hospital's stretcher and handcuffed by external law enforcement to the stretcher side rails at each wrist. The law enforcement applied shackles remained on the patient's ankles. Due to continued attempts to get up by the patient, hospital clinical staff also applied soft restraints to the patient's ankles."

Review of the ED medical record dated 8/24/22 revealed no documentation of a physician's order for the restraints.

An interview conducted on 9/7/22 at 5:20 PM with EI # 1 confirmed there was no documentation of a physician order for soft restraints.

Based on Medical Record (MR) review, facility policies and procedure and staff interview, it was determined the facility failed to obtain and/or document an appropriate physician's order every four hours for the use of restraints used for the management of violent or self-destructive behavior in an adult above the age of 18.

This deficient practice did affected two of ten MR's reviewed with a restraint, including Patient Identifier (PI) # 10 and PI # 1. This deficient practice had the potential to affect all patients served by the facility.

Findings Include:

Facility Policy: Workplace Violence
Policy Number: 4.01.33
Effective Date: 1/3/22

Scope: The scope of this policy includes potential or actual violent acts committed...by or against...associates...patients.

Purpose: To identify, prevent and consistently respond to potential or actual acts of workplace violence to promote a safe environment...

Definitions:

Workplace violence: A threat or act of violent behavior, against oneself, another person....that either results in or has a high likelihood of resulting injury, death, or psychological harm. These events may involve patients...associates. Examples include...hostility...use of physical force...

...Violent act: Any physical or verbal act intended to inflict physical or emotional harm or suffering on another person...

...Physical Assault: The infliction of unwanted physical contact that is intended to harass...cause pain, injury... Physical assault includes but is not limited to beating, kicking...touching...

Facility Policy: Restraints
Policy Number: 2.01.51
Effective Date: 10/7/21

Policy:

...6. The assessment of: (a) behavioral changes caused by medical conditions or symptoms or (b) the incidence of violent or self-destructive (V/SD) behavior which threatens the patient's best interest should determine the types of restraints or processes attempted...

Definitions:

...2. Restraints for Acute Medical and Surgical Care...In acute medical and post surgical care, a restraint may be necessary to support patient well being and medical healing....

3. Emergency Use of Restraints in Situations of Violence or Self-Destructive Behavior...A restraint may be necessary in emergency or crisis situations if a patient's behavior becomes violent or self-destructive, presenting an immediate, serious danger to his/her safety or that of others...

....Procedure:

...C. Implementation of restraints in patients with violent or self-destructive behaviors that threaten themselves or others.

...2. Following assessment, the RN (Registered Nurse) may initiate the emergency use of restraints and must promptly notify the attending physician.

a. Orders for restraints are never written as standing or PRN (as needed) orders...
...e. Initial written order is time limited to:
1. Four hours for adults...

...3. The condition of the patient who is in restraint must continually be assessed, monitored and evaluated.
...d. The RN, after reassessing need for continuation of restraints, must review need with the physician and obtain an order (as above) for continuation of the restraint prior to the end of the time limit.

1. PI # 10 presented to the facility Emergency Department on 7/12/22 with a chief complaint of "pt (patient) states (he/she) is homicidal and suicidal...".

Review of the facility face sheet revealed PI # 10 was 34 years.

Review of the Restraint nursing notes revealed PI # 10 was placed in four point leather restraints for "violent behavior requiring restraint" from 7/12/22 at 4:00 PM until 7/13/22 at 8:30 AM which was 16.5 hours, due to "imminent risk to harm self or others."

Review of the MR from 7/12/22 to 7/15/22 revealed no documentation of a physician's order for the use of restraints. The facility staff failed to obtain and document a physician order every 4 hours for the use of restraints used for the management of violent or self-destructive behavior in an adult above the age of 18.

An interview was conducted on 9/9/22 at 3:05 PM with Employee Identifier (EI) # 1, Vice President of Patient Care, who confirmed there was no documentation of a physician order for the use of restraints on PI # 10.

2. PI # 1 was admitted to the facility on 8/30/22 with the diagnoses including Elevated Troponin, Hypotension, Dementia with aggressive behavior/agitation and Acute Psychosis.

Review of the facility face sheet revealed PI # 1 was 77 years old.

Review of the Patient Care Orders dated 8/31/22 revealed a physician's order at 8:42 PM entered by the RN for "Restraint Initiate Non-Violent Behavior" interfering with medical care devices.

Review of the Violence Aggression Assessment Checklist (VAAC) dated 8/31/22 at 8:47 PM revealed documentation PI # 1 was a high workplace violence risk with known risk factors of "kicking, biting, swinging, cussing" and "yes" documented for history of violence, uncooperative, verbal abuse, hostile attacking objects, threats and assaultive/combative.

Review of the Restraint nursing notes dated 8/31/22 at 9:04 PM revealed 4 point leather restraints were initiated on PI # 1 due to "pt (patient) kicking, biting, punching at nurse and tech (technician)".

Further review of the Restraint nursing notes revealed PI # 1 remained in four point restraints until discontinuation on 9/1/22 at 6:02 AM, a total of 8 hours and 58 minutes.

Further review of the Patient Care Orders revealed no documentation of a physician order for the use of restraint for violent behavior from 8/31/22 to 9/1/22. The facility staff failed to obtain and document a physician order every four hours for the use of restraints used for the management of violent or self-destructive behavior in an adult above the age of 18.

An interview was conducted on 9/7/22 at 3:50 PM with Employee Identifier (EI) # 7, RN, to determine if PI # 1 was placed in a restraint on 8/31/22 for violent or nonviolent behavior. During the interview, EI # 7 verbalized she/he was out of work for two days due to being hit in the throat by PI # 1 and the restraint was initiated for "Behavioral issues impeding care. (PI # 1) was being violent." EI # 7 verbalized "...I just chose the one we always use..." when asked if there was a reason the order was put in for nonviolent versus violent behavior restraint.

Review of the Patient Care Orders dated 9/5/22 revealed a physician's order at 8:37 AM entered by the RN for "Restraint Initiate Non-Violent Behavior" interfering with medical care devices.

Review of the Restraint nursing notes dated 9/5/22 at 8:38 AM revealed four point restraints were initiated on PI # 1 due to "pt physically and verbally abusive to staff."

Review of the Nursing Progress Note dated 9/5/22 at 8:55 AM revealed documentation of "this RN was called into patient's room by...CNA (Certified Nursing Assistant). Patient was sitting on the edge of the bed attempting to get out of bed and began swinging at CNA... Patient reoriented and asked politely to get back in the bed. Patient still refused and became verbally abusive. This RN put the patient back in the bed and 4 point soft wrist restraints applied. While initiating restraints the patient pinched this RN and attempted to bite..."

Further review of the Restraint nursing notes revealed PI # 1 remained in four point restraints until discontinuation on 9/6/22 at 12:00 AM. A total of 15 hours and 22 minutes.

Further review of the Patient Care Orders revealed no documentation of a physician order for the use of restraint for violent behavior from 9/5/22 to 9/6/22. The facility staff failed to obtain and document a physician order every four hours for the use of restraints used for the management of violent or self-destructive behavior in an adult above the age of 18.

An interview was conducted on 9/7/22 at 12:03 PM with EI # 8, RN to determine if PI #1 was placed in a restraint on 9/5/22 for violent or nonviolent behavior. EI # 8 verbalized she/he would consider a restraint to be for violent behavior "if they are swinging at staff, grabbing at them. If they are trying to hurt the staff" and for nonviolent behavior, "if they are pulling at their lines or tubes." EI # 8 verbalized the restraint was initated on PI # 1 due to the CNA (Certified Nursing Assistant) called EI # 8 into the patient's room. EI # 8 verbalized, PI # 1 had swung at the CNA then swung at her/him. EI # 8 verbalized, following PI # 1 swinging at her/him, PI # 1 was placed in the bed and restraints initiated. When asked if the patient was placed in the restraint for violent or nonviolent behavior? EI # 8 stated, "violent, (she/he) was violent."

Based on Medical Record (MR) review, facility policy and procedure and staff interview, it was determined the facility staff failed to document behavior requiring need for continued restraint and failed to discontinue restraints at earliest possible time.

This deficient practice did affected two of ten MR's reviewed with restraints, including Patient Identifier (PI) # 10 and PI # 1. This deficient practice had the potential to affect all patients served by the facility.

Findings Include:

Facility Policy: Restraints
Policy Number: 2.01.51
Effective Date: 10/7/21

Policy:

...6. The assessment of: (a) behavioral changes caused by medical conditions or symptoms or (b) the incidence of violent or self-destructive (V/SD) behavior which threatens the patient's best interest should determine the types of restraints or processes attempted...


Definitions:

...2. Restraints for Acute Medical and Surgical Care...In acute medical and post surgical care, a restraint may be necessary to support patient well being and medical healing....

3. Emergency Use of Restraints in Situations of Violence or Self-Destructive Behavior...A restraint may be necessary in emergency or crisis situations if a patient's behavior becomes violent or self-destructive, presenting an immediate, serious danger to his/her safety or that of others...

....Procedure:

A. Implementation of restraints for acute medical/surgical care

...11. Patient condition is re-assessed every two hours to determine if early removal of restraint is possible.

12. Restraints should be discontinued at the earliest possible time, based on a readiness assessment by the RN (Registered Nurse) or physician, regardless of the time identified by the physician order. Factors to consider include: the patient exhibits safe behavior with orientation to location, time, person, and can follow instructions easily.

...16. Documentation...Monitoring documentation

a. Patient assessment should include the patient's behavior, frequency of behavior, level of distress or mental status or agitation, as well as that the risks of using a restraint method outweigh the risk of not using the restraint method...

...f. Patient observations and interventions should be documented every 2 hours to include:

...6. Readiness for discontinuation of restraint...

...C. Implementation of restraints in patients with violent or self-destructive behaviors that threaten themselves or others.

1. The RN performs an assessment of the patient's behavior and determines that danger exists to the patient or others and less restrictive alternatives are ineffective. Lease restrictive methods include but are not limited to:

Verbal interventions (reality orientation, clarification)
Diversion activities (soothing music, activity box)
Ask family/friends to stay with patient and participate in care
Allow patient to stand/move at side of bed

...3. The condition of the patient who is in restraint must continually be assessed, monitored and evaluated.
a. Assessments should be documented at a minimum of every 15 minutes...

...8. Documentation...Monitoring documentation

1. Patient assessment should include the patient's behavior, frequency of behavior, level of distress or mental status or agitation, as well as that the risks of using a restraint method outweigh the risk of not using the restraint method...

...2....i. Readiness for discontinuation of restraint.

1. PI # 10 presented to the facility Emergency Department (ED) on 7/12/22 at 11:53 AM with a chief complaint of "pt (patient) states (he/she) is homicidal and suicidal...".

Review of the ED documentation on 7/12/22 from 11:53 through 3:59 PM revealed no documentation of the use of restraints.

Review of the ED Physician documentation dated 7/12/22 at 1:01 PM, PI # 10 "...presented to the ED for evaluation of suicidal and homicidal ideation. Patient was initially evaluated out in triage was reporting suicidal and homicidal ideation. Patient then started pacing around the room and left the ED. (He/She) was followed by security out into the middle of...a major road. Patient states (he/she) was attempting to get hit by a car...wants to die. Patient also states...was having homicidal ideation but states...not having...at this time....followed this by stating (he/she) beat some murder charges. Patient is currently cooperating but has a very aggressive demeanor...states...having auditory and visual hallucinations who are telling...to kill (himself/herself)... Patient is aggressive and agitated. With suicidal (SI) and homicidal ideation (HI)..."

Further review of the Medication Orders and MAR (Medication Administration Record) revealed a physician's order dated 7/12/22 at 1:22 PM for a now dose of Haldol 5 mg IM, which was administered on 7/12/22 at 1:25 PM.

Review of the Restraint notes dated 7/12/22 at 4:00 PM, revealed documentation of a "continue episode" of restraints for "...violent behavior requiring restraint...imminent risk to harm self or others. There was no documentation of the date and time the restraint "episode" was initiated, a physician's order for the restraint or the patient's behavior which presented an imminent risk to self or others and less restrictive alternatives currently in place, one to one observation with sitter at bedside and medication administration, were no longer effective.

Further review of the Restraint notes revealed PI # 10 remained in restraints for "violent behavior requiring restraint" from 7/12/22 at 4:00 PM until 7/13/22 at 8:30 AM due to "imminent risk to harm self or others" with the restraint type documented as four point leather restraints from 7/12/22 at 6:00 PM until 7/13/22 at 6:00 AM. PI # 10 was documented as "Calm. No SI or HI. Cooperative and polite..." with a "sitter/caregiver/staff at bedside" for the behavior description and reason for release of the restratint on 7/13/22 at 8:30 AM.

Review of the Psychosocial assessment and Visit Information notes revealed the following documentation:

On 7/12/22 at 4:00 PM to 4:45 PM, PI # 10 was documented every 15 minutes in the patient room with eyes closed, lying down, sleeping with affect/behavior appropriate, calm.
On 7/12/22 at 4:58 PM, PI # 10 was documented in the patient room awake, visiting calmly.
On 7/12/22 at 5:00 PM to 5:30 PM, PI # 10 was documented every 15 minutes in the patient room with eyes closed, lying down, sleeping with affect/behavior appropriate, calm.
On 7/12/22 at 5:45 PM, PI # 10 was documented in the patient room awake, eyes closed, lying down, visiting calmly.
On 7/12/22 at 6:00 PM to 6:45 PM, PI # 10 was documented every 15 minutes in the patient room with eyes closed, lying down, sleeping with affect/behavior appropriate, calm.
On 7/12/22 at 7:00 PM, PI # 10 was documented in the patient room with eyes closed, lying down with affect/behavior documented as appropriate, calm.
On 7/12/22 at 7:20 PM and 8:00 PM, PI # 10 was documented in the patient room with eyes closed, lying down, sleeping with affect/behavior appropriate.
On 7/12/22 at 9:00 PM, PI # 10 was documented in the patient room with eyes closed, lying down with affect/behavior appropriate, calm, cooperative.
On 7/12/22 at 10:00 PM to 7/13/22 at 12:00 AM, PI # 10 was documented every hour in the patient room with eyes closed, lying down, sleeping with affect/behavior appropriate, calm.
On 7/13/22 at 1:00 AM, PI # 10 was documented in the patient room awake, lying down with affect/behavior appropriate, calm, cooperative.
On 7/13/22 at 2:00 AM to 6:00 AM, PI # 10 was documented every hour in the patient room with eyes closed, lying down, sleeping with affect/behavior appropriate, calm.
On 7/13/22 at 7:15 AM, 7:30 AM and 7:31 AM, PI # 10 was documented in the patient room with eyes closed with affect/behavior appropriate, calm.
On 7/13/22 at 7:45 AM and 8:00 AM, PI # 10 was documented in the patient room with eyes closed, sleeping with affect/behavior appropriate, calm.

An interview was conducted on 9/9/22 at 3:05 PM with Employee Identifier (EI) # 1, Vice President of Patient Care, who confirmed there was no documentation why restraints were not discontinued when the patient's behavior was documented as was calm, appropriate and sleeping.

2. PI # 1 was admitted to the facility on 8/30/22 with the diagnoses including Elevated Troponin, Hypotension, Dementia with aggressive behavior/agitation and Acute Psychosis.

Review of the Patient Care Orders dated 9/5/22 revealed a physician's order at 8:37 AM entered by the RN for "Restraint Initiate Non-Violent Behavior" interfering with medical care devices.

Review of the Restraint notes dated 9/5/22 at 8:38 AM revealed four point restraints were initiated on PI # 1 due to "pt physically and verbally abusive to staff."

Review of the Nursing Progress Note dated 9/5/22 at 8:55 AM revealed documentation of "this RN was called into patient's room by...CNA (Certified Nursing Assistant). Patient was sitting on the edge of the bed attempting to get out of bed and began swinging at CNA... Patient reoriented and asked politely to get back in the bed. Patient still refused and became verbally abusive. This RN put the patient back in the bed and four point soft wrist restraints applied. While initiating restraints the patient pinched this RN and attempted to bite..."

Further review of the Restraint notes revealed PI # 1 remained in four point restraints for "behavior interfering with medical care, devices, tubes/drain" from 9/5/22 at 8:37 AM until 9/6/22 at 12:00 AM .

Review of the Physical Therapy Treatment note dated 9/5/22 at 11:05 AM the patient was "pleasant and cooperative" and participated in treatment.

Review of the Psychosocial notes dated 9/5/22 revealed documentation at 11:05 AM, PI # 1's affect/behavior was "appropriate" and at 9:00 PM, PI # 1's affect/behavior was "appropriate, calm, cooperative".

Review of the MR revealed PI # 1 remained in 4 point restraints from 9/5/22 11:05 AM to 9/6/22 at 12:00 AM, which was 12 hours and 55 minutes.

An interview was conducted on 9/9/22 at 2:22 PM with EI # 1, who confirmed there was no documentation why restraints were not discontinued when the patient's behavior was documented as calm, appropriate and cooperative.

Based on review of Medical Records (MR), Emergency Department (ED) Video, facility Death in Restraint report to CMS (Centers for Medicare and Medicaid Services), facility policies and procedure and staff interviews the facility failed to monitor a patient in restraints.

This deficient practice affected two of ten MR reviewed with restraints and did affect Patient Identifier (PI) # 1 and PI # 2. This deficient practice had the potential to affect all patients admitted to the hospital.

Findings include:

Facility Policy: Workplace Violence
Policy Number: 4.01.33
Effective Date: 1/3/22

Scope: The scope of this policy includes potential or actual violent acts committed...by or against...associates...patients.

Purpose: To identify, prevent and consistently respond to potential or actual acts of workplace violence to promote a safe environment...

Definitions:

Workplace violence: A threat or act of violent behavior, against oneself, another person....that either results in or has a high likelihood of resulting injury, death, or psychological harm. These events may involve patients...associates. Examples include...hostility...use of physical force...

...Violent act: Any physical or verbal act intended to inflict physical or emotional harm or suffering on another person...

...Physicial Assault: The infliction of unwanted physical contact that is intended to harass...cause pain, injury... Physical assault includes but is not limited to beating, kicking...touching...

Facility Policy: Restraints
Policy Number: 2.01.51
Effective Date: 10/7/21

Policy

6. The assessment of: (a) behavior changes caused by medical conditions or symptoms or (b) the incidence of violent or self-destructive behavior which threatens the patient's best interest should determine the types of restrains or processes attempted.

Procedure

C. Implementation of restraints in patients with violent or self-destructive behaviors that threaten themselves or others.

3. The condition of the patient who is in restraint must continually be assessed, monitored and evaluated.

a. Assessments should be documented at a minimum of every 15 minutes, or more frequently based on the needs of the patient.

8. Documentation

Monitoring documentation

1. Patient Assessment should include...

b. Type of restraint

d. Time of initial application

2. Patient observations and interventions as appropriate should be documented every 15 minutes or more frequently based on needs of (the) patient.

d. Vital signs with each observation

g. Loosening of restraints, circulation/skin checks and repositioning

h. Skin care provided and skin integrity evaluated, especially with the confused patient who may be very active.

1. PI # 1 was admitted to the facility on 8/30/22 with the diagnoses including Elevated Troponin, Hypotension, Dementia with aggressive behavior/agitation and Acute Psychosis.

Review of the Violence Aggression Assessment Checklist (VAAC) dated 8/31/22 at 8:47 PM revealed documentation PI # 1 was a high workplace violence risk with known risk factors of "kicking, biting, swinging, cussing" and "yes" documented for history of violence, uncooperative, verbal abuse, hostile attacking objects, threats and assaultive/combative.

Review of the Restraint nursing notes dated 8/31/22 at 9:04 PM revealed four point restraints were initiated on PI # 1 due to "pt (patient) kicking, biting, punching at nurse and tech (technician)" and PI # 1 remained in four point restraints until discontinuation on 9/1/22 at 6:02 AM, a total of 8 hours and 58 miniutes.

Review of the MR revealed the patient was monitored every two hours for a nonviolent behavior restraint instead of the every 15 minutes per the facility policy for a violent behavior restraint.

Review of the Restraint nursing notes dated 9/5/22 at 8:38 AM revealed four point leather restraints were initiated on PI # 1 due to "pt physically and verbally abusive to staff."

Review of the Nursing Progress Note dated 9/5/22 at 8:55 AM revealed documentation of "this RN (Registered Nurse) was called into patient's room by...CNA (Certified Nursing Assistant). Patient was sitting on the edge of the bed attempting to get out of bed and began swinging at CNA... Patient reoriented and asked politely to get back in the bed. Patient still refused and became verbally abusive. This RN put the patient back in the bed and 4 point soft wrist restraints applied. While initiating restraints the patient pinched this RN and attempted to bite..."

Further review of the Restraint nursing notes revealed PI # 1 remained in four point restraints until discontinuation on 9/6/22 at 12:00 AM, a total of 15 hours and 22 minutes.

Review of the MR revealed the patient was monitored every two hours for a nonviolent behavior restraint instead of the every 15 minutes per the facility policy for a violent behavior restraint.

An interview was conducted on 9/9/22 at 2:22 PM with EI # 1, Vice President of Patient Care, who confirmed monitoring was not documented every 15 minutes due to the restraint being ordered as a nonviolent behavior restraint.



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2. PI # 2 presented to the facility ED on 8/24/22 at 1:58 AM with a chief complaint of, "Brought in per Mobile Fire and Rescue (MFR) found in a field brought in by Mobile Police Department (PD) custody, combative and shouting".

Review of the ED video dated 8/24/22 at 2:03 AM revealed ED Tech entered PI # 2's room with soft restraints.

Review of the Death in Restraint report submitted by the facility to CMS on 8/25/22 at 5:00 PM revealed, "The patient was transferred to the hospital's stretcher and handcuffed by external law enforcement to the stretcher side rails at each wrist. The law enforcement applied shackles remained on the patient's ankles. Due to continued attempts to get up by the patient, hospital clinical staff also applied soft restraints to the patient's ankles."

Review of the ED Documentation: Patient Status Rounding report dated 8/24/22 at 2:45 AM revealed, "received patient to room 8. Patient in police custody. Patient is cuffed and shackled, is fighting cuffs and will not follow commands. Will not talk to staff, ambulance crew or police. Flings himself/herself around on (the) stretcher."

Review of the ED medical record dated 8/24/22 revealed no documentation of monitoring of the patient including no documentation of the time the restraints were applied, type of restraints applied and no documentation of monitoring every 15 minutes including circulation, skin evaluation and vital signs.

An interview conducted on 9/7/22 at 5:20 PM with Employee Identifier # 1 confirmed there was no documentation of every 15 minute checks per policy.

Based on Medical Record (MR) review, facility policy and procedure and staff interview the facility failed to document a one hour face to face evaluation for the use of restraints initiated for violent behavior.

This deficient practice did affected one of 10 MR's reviewed with a restraint, including Patient Identifier (PI) # 10. This deficient practice had the potential to affect all patients served by the facility.

Findings Include:

Facility Policy: Restraints
Policy Number: 2.01.51
Effective Date: 10/7/21

Policy:

...6. The assessment of: (a) behavioral changes caused by medical conditions or symptoms or (b) the incidence of violent or self-destructive (V/SD) behavior which threatens the patient's best interest should determine the types of restraints or processes attempted...

....Procedure:

...C. Implementation of restraints in patients with violent or self-destructive behaviors that threaten themselves or others.

...2. Following assessment, the RN (Registered Nurse) may initiate the emergency use of restraints and must promptly notify the attending physician.

...b. A physician or a RN or physician assistant...must see the patient and evaluate the need for restraint as soon as possible but no later than one (1) hour after the initiation of restraint.

1. PI # 10 presented to the facility Emergency Department on 7/12/22 with a chief complaint of "pt (patient) states (he/she) is homicidal and suicidal...".

Review of the Restraint nursing notes revealed PI # 10 was in four point leather restraints from 7/12/22 at 4:00 PM until 7/13/22 at 8:30 AM.

Review of the MR from 7/12/22 to 7/15/22 revealed no documentation of a one hour face to face evaluation.

An interview was conducted on 9/9/22 at 3:05 PM with Employee Identifier (EI) # 1, Vice President of Patient Care, who confirmed there was no documentation of a one hour face to face evaluation.

Based on Medical Record (MR) review, Emergency Department (ED) Video review, facility Death in Restraint report to CMS (Centers for Medicare and Medicaid Services), facility policy and procedure and staff interview the facility staff failed to document a description of the patient's behavior which required a restraint.

This deficient practice did affected two of ten MR's reviewed with a restraints, including Patient Identifier (PI) # 10 and PI # 2. This deficient practice had the potential to affect all patients served by the facility.

Findings Include:

Facility Policy: Restraints
Policy Number: 2.01.51
Effective Date: 10/7/21

Policy:

...6. The assessment of: (a) behavioral changes caused by medical conditions or symptoms or (b) the incidence of violent or self-destructive (V/SD) behavior which threatens the patient's best interest should determine the types of restraints or processes attempted...

Definitions:

3. Emergency Use of Restraints in Situations of Violence or Self-Destructive Behavior...A restraint may be necessary in emergency or crisis situations if a patient's behavior becomes violent or self-destructive, presenting an immediate, serious danger to his/her safety or that of others...

....Procedure:

...C. Implementation of restraints in patients with violent or self-destructive behaviors that threaten themselves or others.

1. The RN (Registered Nurse) performs an assessment of the patient's behavior and determines that danger exists to the patient or others and less restrictive alternatives are ineffective....

...8. Documentation...Monitoring documentation

1. Patient assessment should include the patient's behavior, frequency of behavior, level of distress or mental status or agitation, as well as that the risks of using a restraint method outweigh the risk of not using the restraint method...

1. PI # 10 presented to the facility Emergency Department (ED) on 7/12/22 at 11:53 AM with a chief complaint of "pt (patient) states (he/she) is homicidal and suicidal...".

Review of the ED documentation on 7/12/22 from 11:53 through 3:59 PM revealed no documentation of the use of restraints.

Review of the Physician Assistant Note dated 7/12/22 at "immediately upon arrival" to the ED revealed documentation "...patient pacing and appears very anxious. Refusing triage vital signs. States (he/she) is suicidal and homicidal and ready to die right now. Security notified and trying to search patient in (and) his belongings..."

Review of the ED Triage Note dated 7/12/22 at 12:04 PM revealed documentation "pt states (he/she) is homicidal and suicidal, refuses vitals, ripped off wristband, appears aggressive and agitated..."

Review of the ED Note-Nursing dated 7/12/22 at 12:09 PM revealed documentation of "pt pacing...waiting room and speaking to (himself/herself). Security present. Refuses to answer triage questions other than stating SI (Suicidal Ideation) and HI (Homicidal Ideation). Police was (were) contacted."

Review of the Psychosocial assessment dated 7/12/22 at 12:29 PM revealed documentation of PI # 10's affect/behavior as "agitated, anxious, hostile, impulsive, inappropriate."

Review of the Patient Status Rounding documentation from 7/12/22 at 12:29 PM revealed documentation PI # 10 was on one to one observation with a sitter at bedside, the patient's room was cleared, the patient was medicated per MAR (Medication Administration Record), and the patient's belongings had been locked up.

Further review of the Patient Status Rounding documentation revealed documentation PI # 10 remained on one to one observation with a sitter at bedside until 7/14/22 at 2:00 PM.

Review of the Medication Orders and MAR revealed a physician's order dated 7/12/22 at 12:31 PM for a now dose (immediate one time dose) of Valium 10 mg (milligrams) intravenous (IV) and at 1:22 PM for a now dose of Diphenhydramine 50 mg Intramuscular (IM). Both the Valium and Diphenhydramine were documented as administered on 7/12/22 on at 12:40 PM. There was no documentation of the reason the Diphenhydramine was administered prior to the documented time of the physician's order.

Review of the ED Physician documentation dated 7/12/22 at 1:01 PM, PI # 10 "...presented to the ED for evaluation of suicidal and homicidal ideation. Patient was initially evaluated out in triage was reporting suicidal and homicidal ideation. Patient then started pacing around the room and left the ED. (He/She) was followed by security out into the middle of...a major road. Patient states (he/she) was attempting to get hit by a car...wants to die. Patient also states...was having homicidal ideation but states...not having...at this time....followed this by stating (he/she) beat some murder charges. Patient is currently cooperating but has a very aggressive demeanor...states...having auditory and visual hallucinations who are telling...to kill (himself/herself)... Patient is aggressive and agitated. With suicidal and homicidal ideation..."

Further review of the Medication Orders and MAR revealed a physician's order dated 7/12/22 at 1:22 PM for a now dose of Haldol 5 mg IM, which was administered on 7/12/22 at 1:25 PM.

Review of the Restraint notes dated 7/12/22 at 4:00 PM, revealed documentation of a "continue episode" of restraints for "...violent behavior requiring restraint...imminent risk to harm self or others. There was no documentation of the date and time the restraint "episode" was initiated and the patient's behavior which presented an imminent risk to self or others and less restrictive alternatives currently in place, one to one observation with sitter at bedside and medication administration, were no longer effective.

Review of the Environmental Safety Management dated 7/12/22 at 4:17 PM revealed documentation of the use of leather restraints.

An interview was conducted on 9/9/22 at 3:05 PM with Employee Identifier (EI) # 1, Vice President of Patient Care, who confirmed there was no documentation of the patient's behavior leading to less restrictive interventions in use being no longer effective and the patient's behavior required a restraint, except what was documented upon arrival at the triage and provider assessments.



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2. PI # 2 presented to the facility ED on 8/24/22 at 1:58 AM with a chief complaint of, "Brought in per Mobile Fire and Rescue (MFR) found in a field brought in by Mobile Police Department (PD) custody, combative and shouting".

Review of the ED video dated 8/24/22 at 2:03 AM revealed ED Tech entered PI # 2's room with soft restraints.

Review of the 8/24/22 Death in Restraint report submitted by the facility to CMS on 8/25/22 at 5:00 PM revealed, "The patient was transferred to the hospital's stretcher and handcuffed by external law enforcement to the stretcher side rails at each wrist. The law enforcement applied shackles remained on the patient's ankles. Due to continued attempts to get up by the patient, hospital clinical staff also applied soft restraints to the patient's ankles."

Review of the ED medical record dated 8/24/22 revealed no documentation in the MR that the soft restraints were applied to the patient's ankles and no documentation of the patient's behavior that prompted the use of the restraints.

An interview conducted on 9/7/22 at 5:20 PM with Employee Identifier # 1 confirmed there was no documentation of the patients behavior that led to the soft restraints in the MR.

Based on review of medical records (MR), Emergency Department (ED) Video review, facility self reported Death in Restraint report, staff interviews and policy and procedure, the facility failed to provide documentation of the condition or symptom that warrented the use of restraints.

This deficient practice affected one of one MR reviewed with death in restraints presenting to the ED for treatment and did affect Patient Identifier (PI) # 2 and had the potential to affect all patients admitted to the hospital.

Findings include:

Facility Policy: Assessment of Patients
Policy Number: 2.01.132
Effective Date: 3/12/21

Policy

Patients who receive care at Providence Hospital are assessed and reassessed by qualified individuals to determine the patient's initial needs, continuing needs, and the outcomes of care and interventions. Patient assessment is a multidisciplinary process that involves a continuous, collaborative effort by each discipline within their scope of practice, licensure laws, applicable regulations and certifications.

The assessment process across disciplines includes the following:

Collection of data through mechanisms such as: observation, interview, measurement, and diagnostic tests.

Data collected is analyzed to determine pertinent information to make decisions necessary to provide care for the patient.

Procedure

...Information generated via the patient's assessment should be integrated with other disciplines to identify and prioritize the patient's needs for care and treatment...

G. Emergency Department

Individuals presenting to the ED seeking care will receive a medical screening exam (MSE) upon arrival, conducted by physicians or qualified registered Nurses...

An assessment for each patient will be performed by the registered nurse...

Reassessments are performed by RN's (Registered Nurse) and physicians when:

There is a change in the patient's status

There is a change in the patient's vital signs

As indicated by the patient's condition and/or treatment

The ED physician assesses and evaluates each patient prior to making any referrals or decisions regarding disposition.

Prior to disposition/discharge/or transfer

1. PI # 2 presented to the facility ED on 8/24/22 at 1:58 AM with a chief complaint of, "Brought in per EMS (Emergency Medical Services) found in a field, brought in by ...PD (Police Department) custody, combative and shouting."

Review of the ED video dated 8/24/22 at 2:03 AM revealed ED Tech entered PI # 2's room with soft restraints.

Review of the Death in Restraint report submitted by the facility to CMS on 8/25/22 at 5:00 PM revealed, "The patient was transferred to the hospital's stretcher and handcuffed by external law enforcement to the stretcher side rails at each wrist. The law enforcement applied shackles remained on the patient's ankles. Due to continued attempts to get up by the patient, hospital clinical staff also applied soft restraints to the patient's ankles."

Review of the MR and interview with staff revealed PI # 2 did not receive a thorough assessment to determine his/her care needs. This deficient practice led to PI # 2 loss of vital signs, CPR and subsequent death.

An interview conducted on 9/7/22 at 5:20 PM with Employee Identifier (EI) # 1, Vice President of Patient Care confirmed there was no documentation of a thorough assessment to identify the patient's needs.

Based on review of medical records (MR), Emergency Department (ED) video, staff interviews and policy and procedure, the facility failed to provide a complete assessment of a severely injured patient complaining of gun shot wound (GSW).

This deficient practice affected one of one MR reviewed with death in restraints presenting to the ED for treatment and did affect Patient Identifier (PI) # 2 and had the potential to affect all patients admitted to the hospital.

Findings include:

Facility Policy: Assessment of Patients
Policy Number: 2.01.132
Effective Date: 3/12/21

Policy

Patients who receive care at Providence Hospital are assessed and reassessed by qualified individuals to determine the patient's initial needs, continuing needs, and the outcomes of care and interventions. Patient assessment is a multidisciplinary process that involves a continuous, collaborative effort by each discipline within their scope of practice, licensure laws, applicable regulations and certifications.

The assessment process across disciplines includes the following:

Collection of data through mechanisms such as: observation, interview, measurement, and diagnostic tests.

Data collected is analyzed to determine pertinent information to make decisions necessary to provide care for the patient.

Procedure

...Information generated via the patient's assessment should be integrated with other disciplines to identify and prioritize the patient's needs for care and treatment...

G. Emergency Department

An assessment for each patient will be performed by the registered nurse. The assessment recorded in the ED record will include, but not be limited to:

Patient complaint...

1. PI # 2 presented to the facility ED on 8/24/22 at 1:58 AM with a chief complaint of, "Brought in per (EMS) found in a field, brought in by ...PD (Police Department) custody, combative and shouting."

Review of the ED Triage Note dated 8/24/22 at 2:38 AM revealed, "...Temp 97.9...Blood Pressure 94/67...Respirations 32...Oxygen Saturation 97%...Faces Pain Scale: 2."

Review of the Patient Status Rounding report by the nurse dated 8/24/22 at 2:45 AM revealed, "received patient to room 8. Patient in police custody. Patient is cuffed and shackled, is fighting cuffs and will not follow commands. Will not talk to staff, ambulance crew or police. Flings himself/herself around on (the) stretcher."

Review of the 8/24/22 Death in Restraint report submitted by the facility to CMS revealed, "The patient was transferred to the hospital's stretcher and handcuffed by external law enforcement to the stretcher side rails at each wrist. The law enforcement applied shackles remained on the patient's ankles. Due to continued attempts to get up by the patient, hospital clinical staff also applied soft restraints to the patient's ankles."

Review of the ED medical record dated 8/24/22 revealed no documentation of monitoring of the patient including no documentation of the time the restraints were applied, type of restraints applied and no documentation of monitoring every 15 minutes including circulation, skin evaluation and vital signs.

An interview was conducted on 9/7/22 at 5:44 PM with EI # 6, RN who was asked about PI # 2's ED visit on 8/24/22. EI # 6 verbalized she/he documented the quick triage report from the report called by the EMS. EI # 6 verbalized EMS said the patient was combative, was found in a field, thrashing about, and had told them he/she had been shot but the patient hadn't, the patient just had an abrasion on the knee. EI # 6 verbalized when the patient arrived at the facility ED he/she was covered in sand and sweaty. EI # 6 verbalized she/he stayed in the patient's room until vital signs had been obtained then left the room to put the triage note in (the computer) then EI # 12, ED Physician, said the patient's labs haven't been drawn and she/he noticed the patient had calmed down so, EI # 6 and a coworker would go in and the draw blood. EI # 6 verbalized when she/he entered the patient's room, the patient didn't have any monitoring equipment on, which the patient had a BP cuff and Oxygen probe on prior, and the patient wasn't breathing so a code was called. EI # 6 verbalized she/he didn't know who took the monitoring equipment off.

Further review of the ED record revealed the patient remained in the ED from arrival time of 1:58 AM until time of death at 3:29 AM which was one hour and 31 minutes and there was no documentation of a complete nursing assessment.

An interview conducted on 9/8/22 at 8:50 AM with EI # 1, Vice President of Patient Care confirmed there was no documentation of a complete nursing assessment.

Based on review of medical records (MR), Emergency Department (ED) video, staff interviews and policy and procedure, the facility failed to provide rapid treatment of a severely injured patient complaining of gun shot wound (GSW).

This deficient practice affected one of one MR reviewed with death in restraints presenting to the ED for treatment and did affect Patient Identifier (PI) # 2 and had the potential to affect all patients admitted to the hospital.

Findings include:

Facility Policy: Major Trauma/Trauma Alerts
Policy Number: 2.01.58
Policy Effective: 7/11/22

Purpose

Rapid treatment of severely injured and/or unstable trauma patients.

Policy

Trauma alert notification to team members for trauma arrival via hospital operator to page an overhead Trauma Alert.

Definition

Major Trauma will be as defined by the Alabama Trauma System:

3. Head Trauma:

a. Glasgow Coma Scale score of 13 or less.

Procedure

1. Upon notification by EMS (Emergency Medical Services), the nurse accepting the call will immediately notify the ED (Emergency Department) physician on duty of the impending trauma arrival.

2. The hospital operator will be notified to page a "Trauma Alert." This page will notify Radiology and Respiratory Therapy they will be needed in the ED. This alert will also notify the OR (Operating Room) personnel after hours to contact the appropriate on call team for the "Trauma Alert". This will also alert Lab (Laboratory) personnel that there will be lab specimens which will need STAT turnaround times. CT (Computed Tomography) will also be alerted to expect the patient for imaging.

4. Radiology staff responding to the Trauma Alert should bring a portable X-Ray unit to the ED for immediate bedside films...

5. Administrative Nursing Supervisor should respond to all Trauma Alerts and should, after making an assessment of ED volume...assist with the trauma in order to maintain flow in the ED.

6. ED Physician will decide on additional imaging and labs as appropriate for patient care.

7. Once patient is stabilized, ED Physician will make decision to send patient to surgery, admit to unit or floor, or transfer patient as appropriate.

1. PI # 2 presented to the facility ED on 8/24/22 at 1:58 AM with a chief complaint of, "Brought in per MFR (Mobile Fire and Rescue) found in a field brought in by Mobile PD (Police Department) custody, combative and shouting.

Review of the ED physician's documentation dated 8/24/22 at 2:27 AM revealed, "EMS reports that patient was found in a field on Cody Road. The patient was screaming that he had been shot..."

Review of the Glasgow Coma Assessment by the nurse dated 8/24/22 at 2:50 AM revealed a Glasgow Coma Score of 8.

Review of the ED video dated 8/24/22 from 1:58 AM to 3:00 AM revealed a portable X-Ray machine at the entrance to PI # 2's room at 2:51 AM which was 53 minutes after the patient arrival at the ED.

Further review of the ED video dated 8/24/22 from 1:58 AM to 3:00 AM revealed at 2:55 AM, Employee Identifier (EI) # 6, Charge Nurse ED entered PI # 2's room to obtain lab specimens which was 57 minutes after the patient arrived at the ED.

Review of the ED record revealed the patient remained in the ED from arrival time of 1:58 AM until time of death at 3:29 AM and no documentation that a Trauma Alert was activated.

An interview conducted on 9/8/22 at 8:50 AM with EI # 1, Vice President of Patient Care confirmed the Trauma Alert Policy Number 2.01.58 is the policy that should have been activated and followed and a Trauma Alert was not activated per policy.