HospitalInspections.org

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that the facility failed to allow a patient the right to refuse treatment for one of one patients (MR1).

Findings include:

Review of "Patients' Notice and Bill of Rights and Responsibilities Date: September 28, 2010" revealed "I. Policy It is the policy of the UPMC to promote the interests and well-being of patients served in its domestic locations. It has been, and continues to be, the policy to protect the interests of patients by the adoption of a Patients' Notice and Bill of Rights and Patient Responsibilities. II. Scope This policy applies to all UPMC domestic acute care hospitals ... and behavioral health programs. ... IV. Patients' Notice And Bill Of Rights ... Plan of Care You have a right to: ... i. able to refuse any drugs, treatments, or procedures offered by the facility, to the extent permitted by law, and a physician shall inform you of medical consequences of this refusal. ... Staff and Environment You have a right to: 1. Receive respectful care given by competent personnel in a setting that: ... d. will assure that you will be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff;"

Review of "Patients and Visitors Request to leave from the DEC ... Revised ... 6/10" revealed "Purpose: It is the procedure of the Diagnostic Evaluation Center (DEC) to provide comprehensive, multidisciplinary discharge planning services to all patients in need of such services and to ensure that patients have individualized plans for continuing care and/or services following psychiatric evaluation in the DEC. Every patient who presents to the DEC must be seen by a physician. ... Procedure: ... 3. If a patient requests to leave the DEC prior to the evaluation, clinical staff will be notified. The DEC Physician will see the patient briefly to determine if the patient is safe for discharge. If the patient is safe for discharge, every effort will be made to complete the DEC visit with and outpatient appointment. If the patient is not safe for discharge, the Physician will need to assess for 302 grounds and pursue accordingly."

1) Review of a grievance letter sent to the facility by a patient (MR1), dated October 12, 2010, revealed that the patient presented to the facility on September 28, 2010, for a request for medication management. Further review of the patient's grievance revealed that the patient waited for approximately four hours without seeing a physician. Additional review revealed that the patient stated they were "forcibly detained against [their] will," that the patient had come to the facility "voluntarily and had clearly, calmly, and repeatedly requested to leave," and that the facility "violated my rights to make informed decision regarding my care; refuse treatment; receive care in a safe setting, free from verbal or physical harassment; and be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience, or retaliation by staff ..."

2) Review of MR1 and staff interviews, conducted on November 22 and 23, 2010, revealed that the patient was physically held and physically escorted to a seclusion room on September 28, 2010, at 11:30 PM, after requesting to refuse treatment. Further investigation revealed that the patient remained in the seclusion room until September 29, 2010, at 3:30 AM, a total of four hours.

3) Review of MR1 revealed a "DEC Triage Assessment," initiated at 8:50 PM and concluded at 9:34 PM. Review of this assessment revealed "STOP STATUS: If the patient required to be on a STOP in the DEC? No (A STOP status indicates that the patient will be stopped and assessed by clinical staff prior to allowing him/her to leave the DEC)." Further review of MR1 revealed no documented evidence that the facility pursued a 302 (involuntarily commitment) for the patient.

4) Review of MR1 and staff interviews, conducted on November 22 and 23, 2010 revealed that the patient was not permitted to leave the facility after requesting to leave the facility and refusing treatment. You will have to include info from interviews and the record since this is not the condition and even though you cross reference.

During a telephone interview with EMP5, on November 22, 2010, at approximately 1:00 PM, EMP5 was asked if patients are allowed to leave the DEC area of the facility and EMP5 stated "They are not allowed to leave unless the doctor or nurses tell us."

During an interview with EMP9, on November 23, 2010, at approximately 7:45 AM, EMP9 was asked if patients are allowed to leave the DEC area of the facility and EMP9 stated "We are not allowed to let patients out of the DEC until a doctor or nurse says it is OK."

During a telephone interview with EMP10, on November 23, 2010, at approximately 7:50 AM, EMP10 was asked if patients are allowed to leave the DEC area of the facility and EMP10 stated "If a patient wants to leave, the safety officer calls back to alert the physician ... It is ultimately the physician's decision wether to let the patient leave." During further interview, EMP10 was asked what the facility's "STOP" procedure entailed and EMP10 stated "When a patient is triaged and has lethality, suicidal or homicidal, a STOP is placed on them ... If a patient cannot make informed consent, we pursue a 302." During additional interview, EMP10 was asked about patients that are not placed on a "STOP" and EMP10 stated "A doctor still needs to see the patient before they leave ... It really does not matter if they are on a 'STOP' or not, they still need to be seen by a physician before they can leave."

5) An interview was conducted with EMP2, on November 23, 2010, at approximately 11:15 AM. EMP2 was asked about the process when a patient requests to leave the DEC and EMP2 stated "The safety officer will call ... Usually within a minute, we go out and see the patient ... The patients are usually frustrated ... Yes, we try other alternatives to get them to stay ... If they are insistent on wanting to go, we go through some standard questions to determine what would necessitate and involuntary commitment ... At that point, we would discharge the patient, try to convince them to stay or 302 [involuntarily commit] them." During further interview, EMP2 was asked if it was ultimately the physician who makes the decision if a patient is allowed to leave the DEC, regardless if the patient has been put on a "STOP" and EMP2 stated "Yes."

6) During interview on November 23, 2010, at approximately 12:00 PM, EMP1 was asked in relation to patients not being able to leave the DEC until a physician says it is allowable, is there any legal or regulatory basis for this practice and EMP1 stated "It was a clinical decision [to develop policies] ... It was in response to events that happened previously ... I instituted that policy ... The DEC used to have Left-Without-Being-Seens, like other hospitals ... If anyone really wants to leave, you are running the risk of them getting hurt ... We have never been sued for someone saying that they were illegally detained ... We need to ensure that the patient is safe before being discharged."

Cross reference:

482.13(e) Use Of Restraint Or Seclusion
482.13(e)(5) Patient Rights: Restraint Or Seclusion
482.13(e)(16)(ii) Patient Rights: Restraint Or Seclusion
482.13(e)(16)(iv) Patient Rights: Restraint Or Seclusion

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that a patient was physically restrained and placed in seclusion against their will for one of one medical records reviewed (MR1) and that patients are detained in the Diagnostic Evaluation Center (DEC) against their will.

Findings include:

Review of "Patients and Visitors Request to leave from the DEC ... Revised ... 6/10" revealed "Purpose: It is the procedure of the Diagnostic Evaluation Center (DEC) to provide comprehensive, multidisciplinary discharge planning services to all patients in need of such services and to ensure that patients have individualized plans for continuing care and/or services following psychiatric evaluation in the DEC. Every patient who presents to the DEC must be seen by a physician. ... Procedure: ... 3. If a patient requests to leave the DEC prior to the evaluation, clinical staff will be notified. The DEC Physician will see the patient briefly to determine if the patient is safe for discharge. If the patient is safe for discharge, every effort will be made to complete the DEC visit with and outpatient appointment. If the patient is not safe for discharge, the Physician will need to assess for 302 grounds and pursue accordingly."

Review of "Discharge From The DEC ... Revised ... 4/10" revealed "Procedure: 1. The Diagnostic Evaluation Center Physician, in consultation with the Physician of Record (POR) when appropriate, determines when a patient may be discharged after evaluation and level of care decision has been made. ... 3. Patients asking to leave the DEC will be assessed upon request by the Physician. The Physician will need to make a determination if the patient is safe to be discharged from the DEC. Appropriate documentation will be completed."

Review of "Patients' Notice and Bill of Rights and Responsibilities Date: September 28, 2010" revealed "I. Policy It is the policy of the UPMC to promote the interests and well-being of patients served in its domestic locations. It has been, and continues to be, the policy to protect the interests of patients by the adoption of a Patients' Notice and Bill of Rights and Patient Responsibilities. II. Scope This policy applies to all UPMC domestic acute care hospitals ... and behavioral health programs. ... IV. Patients' Notice And Bill Of Rights ... Plan of Care You have a right to: ... i. able to refuse any drugs, treatments, or procedures offered by the facility, to the extent permitted by law, and a physician shall inform you of medical consequences of this refusal. ... Staff and Environment You have a right to: 1. Receive respectful care given by competent personnel in a setting that: ... d. will assure that you will be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff;"

Review of "Restraint and Seclusion Date: April 15, 2010" revealed I. Policy ... A. Scope: There are two types of restraints and seclusion recognized at UPMC: ... restraints and seclusion for Violent or Self-Destructive Behavior ... This restraint and seclusion policy applies to: All hospitals ... All locations within the hospital ... All hospital patients ... A written time limited order from a physician and documentation of the reason must accompany all episodes of restraint or seclusion. ... Violent or Self-Destructive Restraint ... used when protective interventions are necessary due to behavior changes caused by an emotional or behavioral disorder. This behavior jeopardizes the immediate physical safety of the patient, staff or others. ... Seclusion - Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of Violent or Self-Destructive behavior. Timeout - An intervention in which the patient consents to b being alone in a designated area for an agreed-upon timeframe which the patient is not physically prevented from leaving. Time out is not to exceed 30 minutes at a time. Emergency - a situation when the patient's behavior is Violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff and others. ... C. Exceptions: A restraint does not include devices such as: ... 4. Other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). ... IV. Use Of Restraint Or Seclusion For Violent Or Self-Destructive Behavior ... A. At times, a patient may need to be restrained for Violent or Self-Destructive behavior. Restraint or seclusion use in these situations is limited to emergencies in which there is an imminent risk of a patient physically harming himself/herself, staff or others and Non-physical interventions have been viable or effective. Use of restraints or seclusion can not be solely based on a patient's history, diagnosis, or on a history of dangerous/self destructive behavior, but on the individual patient assessment. B. The use of restraint or seclusion must be in accordance with the order of a physician who is responsible for the care of the patient and authorized to order restraint or seclusion. C. Written Orders A written order by a physician is required for restraint or seclusion use. ... 6. In an emergency, an RN or staff authorized by the institution may place the patient in restraint or seclusion before and order is obtained from a physician. An ordered should be obtained for the restraint or seclusion with a few minutes after the restraint or seclusion has been implemented. In a few minutes is defined as the conclusion of the restraint or seclusion and when it is safe for the nurse to leave the patient to obtain the order. 7. The physician must see the patient and evaluate the need for restraint or seclusion within one hour of initiation of restraint or seclusion and write an order or sign a verbal order for the restraint or seclusion. The findings of the evaluation are to include the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. The findings are to be documented in the patient record. ... V. Documentation A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. B. For each episode of restraint or seclusion use, all assessments and all interventions are to be documented. C. Any type of variation from the norm should be accompanied by a narrative note.

1) Review of MR1 revealed a "DEC Triage Assessment," initiated at 8:50 PM and concluded at 9:34 PM. Review of this assessment revealed "STOP STATUS: If the patient required to be on a STOP in the DEC? No (A STOP status indicates that the patient will be stopped and assessed by clinical staff prior to allowing him/her to leave the DEC) ... Chief Complaint / Patient Expectations For Treatment: Pt 'angry' as [they have] been dealing with restless leg syndrome for long time. [The patient] just found out after numerous attempts to control (sic) the symptoms that it might be akathisia related to lamictal. [The patient] is mad that [they have] been telling [their] doctor about it but was never told it might be due to the medication. Very frustrated as [the patient] had been doing so well and is stable. ... Risk Assessment: Suicidal Ideation: Denies ... Homicidal Ideation: Denies ... Hallucinations: Denies ... Delusionatlity: Denies ... Other Concerns: ... Of note - pt wants to know how to get off lamictal. Has gone to chiropractor for advice on supplements to replace lamictal, not interested in new psychiatrist."

2) Review of MR1 revealed a physician progress note, written by EMP8, "09/29/2010 12:10 AM ... Pt became upset about being in the DEC and having to wait for evaluation. [The patient] began to kick the door and required restraint briefly to help [them] maintain calm. [The patient] was taken to the seclusion room where [they] calmed further. Reported feeling akathisia that [the patient] attributes to Lamictal and is upset that [their] outpt psychiatrist does not change the medication. [The patient] was offered ativan to help [them] calm down and to help with akathisia but pt asked for Motrin 800mg as [they] reports this has helped [them] in the past. Will dispense Motrin and continue to monitor. Pt is stable for continued evaluation in the DEC."

3) Review of MR1 revealed a "DEC Observation Sheet." Further review of this form revealed that the patient was located in Room 192 (a Seclusion room) from September 28, 2010, at 11:30 PM until September 29, 2010, at 3:30 AM, a total of four hours.

4) Review of documentation, from EMP5, concerning a grievance filed by the patient (MR1) revealed that the patient was physically restrained by staff and was escorted to a seclusion room.

A telephone interview was conducted with EMP5, on November 22, 2010, at approximately 1:00 PM. Interview with EMP5 confirmed the above findings and revealed "I came down to the DEC and came in through the front door ... As soon as I entered the door, the patient tried running through the door and run me over. I had to grab him. We pulled the patient back into the DEC ... We told [the patient] that all you have to do is do the evaluation ... We walked [the patient] down to the interview room holding [their] arms the majority of the way ... [The patient] walked back into the open room ... There were two people on each side of him, I was on is right, there was someone on his left, and [EMP11] was behind his back ... Yes, [the patient] was trying to resist."

5) Review of documentation, from EMP8, concerning a grievance filed by the patient (MR1) revealed that the patient was physically restrained by staff and was escorted to a seclusion room.

A telephone interview was conducted with EMP8 on November 22, 2010, at approximately 2:10 PM. Interview with EMP8 confirmed the above findings and revealed "There was some sort of outburst in the front area ... It escalated after the patient wanted to leave and was threatening staff ... He became more and more agitated ... The security officers had to hold him and restrain him ... He continued to have verbal outbursts ... He stayed in the seclusion room and remained calm ... He was not in locked seclusion ... I think someone was outside the door ... I believe someone stayed back there with him ... there was someone outside the room." During further interview EMP8 was asked if they filled out any paperwork or wrote an order for the manual restraint or seclusion of the patient and EMP8 stated "I did not fill out any restraint paperwork ... I did not write an order." During additional interview, EMP8 was asked if restraint orders are typically written for patients that are physically held or need to be physically escorted to a seclusion room and EMP8 stated "Not typically with a patient that needs to be escorted."

6) Review of documentation, from EMP9, concerning a grievance filed by the patient (MR1) revealed that the patient was physically restrained by staff and was escorted to a seclusion room.

An interview was conducted with EMP9, on November 23, 2010, at approximately 7:45 AM. Interview with EMP9 confirmed the above findings and revealed "The patient was stating that [they] wanted to leave and kept getting louder ... I told [the patient] that [they] had to wait ... About one minute later, [the patient] began kicking the door ... Another officer opened the front door and the patient tried to push out ... We walked him back to the seclusion room ... We had to grab his arms ... He was fighting us ... He was trying to flex out ... He was trying to get away from us and out the door."

7) Review of documentation, from EMP11, concerning a grievance filed by the patient (MR1) revealed that the patient was physically restrained by staff and was escorted to a seclusion room.

A telephone interview was conducted with EMP11, on November 23, 2010, at approximately 8:05 AM. Interview with EMP11 confirmed the above findings and revealed "I heard a lot of yelling and loud banging ... Someone called for a Level II ... The patient was pushing and kicking the doors ... The patient was talking and pretty upset ... When an officer unlocked the front door, the patient tried to push past [them] to get out of the DEC ... We ended up putting [the patient] in arm restraints ... one officer was on one arm and one on the other arm ... [The patient] would tighten up and resist ... I had my hands on [the patient's] back ... Eventually we walked [the patient] to the back."

8) Interviews with EMP1, EMP2, EMP4, EMP5, EMP6, EMP8, EMP9, EMP10, and EMP11 on November 22 and 23, 2010, confirmed the findings in the facility policies "Patients and Visitors Request to leave from the DEC" and "Discharge From The DEC" and revealed that the DEC doors are locked at all times and all patients are prevented from leaving the DEC until they are assessed by a physician, regardless of the patients' reason for request for a medical screening exam or the patient's assessed mental state.

9) An interview was conducted with EMP2, on November 23, 2010, at approximately 11:15 AM. EMP2 was asked about the process when a patient requests to leave the DEC and EMP2 stated "The safety officer will call ... Usually within a minute, we go out and see the patient ... The patients are usually frustrated ... Yes, we try other alternatives to get them to stay ... If they are insistent on wanting to go, we go through some standard questions to determine what would necessitate and involuntary commitment ... At that point, we would discharge the patient, try to convince them to stay or 302 [involuntarily commit] them." During further interview, EMP2 was asked if it was ultimately the physician who makes the decision if a patient is allowed to leave the DEC, regardless if the patient has been put on a "STOP" and EMP2 stated "Yes."

10) During interview on November 23, 2010, at approximately 12:00 PM, EMP1 was asked in relation to patients not being able to leave the DEC until a physician says it is allowable, is there any legal or regulatory basis for this practice and EMP1 stated "It was a clinical decision [to develop policies] ... It was in response to events that happened previously ... I instituted that policy ... The DEC used to have Left-Without-Being-Seens, like other hospitals ... If anyone really wants to leave, you are running the risk of them getting hurt ... We have never been sued for someone saying that they were illegally detained ... We need to ensure that the patient is safe before being discharged."

Cross reference:

482.13(b)(2) Patient Rights: Informed Consent
482.13(e)(5) Patient Rights: Restraint Or Seclusion
482.13(e)(16)(ii) Patient Rights: Restraint Or Seclusion
482.13(e)(16)(iv) Patient Rights: Restraint Or Seclusion

Based on review of facility documents, review of medical records (MR), and staff interviews (EMP), it was determined that a patient was physically restrained and secluded without a physician's order for one of one medical records reviewed (MR1).

Findings include:

Review of "Restraint and Seclusion Date: April 15, 2010" revealed I. Policy ... A. Scope: There are two types of restraints and seclusion recognized at UPMC: ... restraints and seclusion for Violent or Self-Destructive Behavior ... This restraint and seclusion policy applies to: All hospitals ... All locations within the hospital ... All hospital patients ... A written time limited order from a physician and documentation of the reason must accompany all episodes of restraint or seclusion. ... Violent or Self-Destructive Restraint ... used when protective interventions are necessary due to behavior changes caused by an emotional or behavioral disorder. This behavior jeopardizes the immediate physical safety of the patient, staff or others. ... Seclusion - Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of Violent or Self-Destructive behavior. Timeout - An intervention in which the patient consents to b being alone in a designated area for an agreed-upon timeframe which the patient is not physically prevented from leaving. Time out is not to exceed 30 minutes at a time. Emergency - a situation when the patient's behavior is Violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff and others. ... C. Exceptions: A restraint does not include devices such as: ... 4. Other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). ... IV. Use Of Restraint Or Seclusion For Violent Or Self-Destructive Behavior ... A. At times, a patient may need to be restrained for Violent or Self-Destructive behavior. Restraint or seclusion use in these situations is limited to emergencies in which there is an imminent risk of a patient physically harming himself/herself, staff or others and Non-physical interventions have been viable or effective. Use of restraints or seclusion can not be solely based on a patient's history, diagnosis, or on a history of dangerous/self destructive behavior, but on the individual patient assessment. B. The use of restraint or seclusion must be in accordance with the order of a physician who is responsible for the care of the patient and authorized to order restraint or seclusion. C. Written Orders A written order by a physician is required for restraint or seclusion use. ... 6. In an emergency, an RN or staff authorized by the institution may place the patient in restraint or seclusion before and order is obtained from a physician. An ordered should be obtained for the restraint or seclusion with a few minutes after the restraint or seclusion has been implemented. In a few minutes is defined as the conclusion of the restraint or seclusion and when it is safe for the nurse to leave the patient to obtain the order. 7. The physician must see the patient and evaluate the need for restraint or seclusion within one hour of initiation of restraint or seclusion and write an order or sign a verbal order for the restraint or seclusion. The findings of the evaluation are to include the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. The findings are to be documented in the patient record. ... V. Documentation A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. B. For each episode of restraint or seclusion use, all assessments and all interventions are to be documented. C. Any type of variation from the norm should be accompanied by a narrative note.

1) Review of MR1 revealed a physician progress note, written by EMP8, "09/29/2010 12:10 AM ... Pt became upset about being in the DEC and having to wait for evaluation. [The patient] began to kick the door and required restraint briefly to help [them] maintain calm. [The patient] was taken to the seclusion room where [they] calmed further. ..."

2) Review of MR1 and staff interviews, conducted on November 22 and 23, 2010, revealed that the patient was physically held and physically escorted to a seclusion room on September 28, 2010, at 11:30 PM. Further investigation revealed that the patient remained in the seclusion room until September 29, 2010, at 3:30 AM, a total of four hours.

3) Review of MR1 revealed no documented evidence of a a physician's order for restraint or seclusion for September 28 or 29, 2010.

4) A telephone interview was conducted with EMP8 on November 22, 2010, at approximately 2:10 PM. During interview, EMP8 was asked if they filled out any paperwork or wrote an order for the manual restraint or seclusion of the patient and EMP8 stated "I did not fill out any restraint paperwork ... I did not write an order."

Cross reference:

482.13(b)(2) Patient Rights: Informed Consent
482.13(e) Use Of Restraint Or Seclusion
482.13(e)(16)(ii) Patient Rights: Restraint Or Seclusion
482.13(e)(16)(iv) Patient Rights: Restraint Or Seclusion

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure documentation of a description of a patient's behavior when physical restraint and seclusion were implemented for one of one patients (MR1).

Findings include:

Review of "Restraint and Seclusion Date: April 15, 2010" revealed I. Policy ... A. Scope: There are two types of restraints and seclusion recognized at UPMC: ... restraints and seclusion for Violent or Self-Destructive Behavior ... This restraint and seclusion policy applies to: All hospitals ... All locations within the hospital ... All hospital patients ... A written time limited order from a physician and documentation of the reason must accompany all episodes of restraint or seclusion. ... Violent or Self-Destructive Restraint ... used when protective interventions are necessary due to behavior changes caused by an emotional or behavioral disorder. This behavior jeopardizes the immediate physical safety of the patient, staff or others. ... Seclusion - Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of Violent or Self-Destructive behavior. Timeout - An intervention in which the patient consents to b being alone in a designated area for an agreed-upon timeframe which the patient is not physically prevented from leaving. Time out is not to exceed 30 minutes at a time. Emergency - a situation when the patient's behavior is Violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff and others. ... C. Exceptions: A restraint does not include devices such as: ... 4. Other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). ... IV. Use Of Restraint Or Seclusion For Violent Or Self-Destructive Behavior ... A. At times, a patient may need to be restrained for Violent or Self-Destructive behavior. Restraint or seclusion use in these situations is limited to emergencies in which there is an imminent risk of a patient physically harming himself/herself, staff or others and Non-physical interventions have been viable or effective. Use of restraints or seclusion can not be solely based on a patient's history, diagnosis, or on a history of dangerous/self destructive behavior, but on the individual patient assessment. B. The use of restraint or seclusion must be in accordance with the order of a physician who is responsible for the care of the patient and authorized to order restraint or seclusion. C. Written Orders A written order by a physician is required for restraint or seclusion use. ... 6. In an emergency, an RN or staff authorized by the institution may place the patient in restraint or seclusion before and order is obtained from a physician. An ordered should be obtained for the restraint or seclusion with a few minutes after the restraint or seclusion has been implemented. In a few minutes is defined as the conclusion of the restraint or seclusion and when it is safe for the nurse to leave the patient to obtain the order. 7. The physician must see the patient and evaluate the need for restraint or seclusion within one hour of initiation of restraint or seclusion and write an order or sign a verbal order for the restraint or seclusion. The findings of the evaluation are to include the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. The findings are to be documented in the patient record. ... V. Documentation A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. B. For each episode of restraint or seclusion use, all assessments and all interventions are to be documented. C. Any type of variation from the norm should be accompanied by a narrative note.

1) Review of MR1 revealed a physician progress note, written by EMP8, "09/29/2010 12:10 AM ... Pt became upset about being in the DEC and having to wait for evaluation. [The patient] began to kick the door and required restraint briefly to help [them] maintain calm. [The patient] was taken to the seclusion room where [they] calmed further. Reported feeling akathisia that [the patient] attributes to Lamictal and is upset that [their] outpt psychiatrist does not change the medication. [The patient] was offered ativan to help [them] calm down and to help with akathisia but pt asked for Motrin 800mg as [they] reports this has helped [them] in the past. Will dispense Motrin and continue to monitor. Pt is stable for continued evaluation in the DEC."

2) Review of MR1 and staff interviews, conducted on November 22 and 23, 2010, revealed that the patient was physically held and physically escorted to a seclusion room on September 28, 2010, at 11:30 PM. Further investigation revealed that the patient remained in the seclusion room until September 29, 2010, at 3:30 AM, a total of four hours.

3) Review of MR1 revealed no documented evidence of a detailed description of a physical or mental status assessment of the patient, or any environmental factors that may have contributed to the situation at the time of the physical restraint and seclusion.

Cross reference:

482.13(b)(2) Patient Rights: Informed Consent
482.13(e) Use Of Restraint Or Seclusion
482.13(e)(5) Patient Rights: Restraint Or Seclusion
482.13(e)(16)(iv) Patient Rights: Restraint Or Seclusion

Based on review of facility documents and medical records (MR), and staff interviews (EMP) it was determined that the facility failed to ensure documentation of the patient's condition or symptom(s) that warranted the use of physical restraint and seclusion for one of one patients (MR1).

Findings include:

Review of "Restraint and Seclusion Date: April 15, 2010" revealed I. Policy ... A. Scope: There are two types of restraints and seclusion recognized at UPMC: ... restraints and seclusion for Violent or Self-Destructive Behavior ... This restraint and seclusion policy applies to: All hospitals ... All locations within the hospital ... All hospital patients ... A written time limited order from a physician and documentation of the reason must accompany all episodes of restraint or seclusion. ... Violent or Self-Destructive Restraint ... used when protective interventions are necessary due to behavior changes caused by an emotional or behavioral disorder. This behavior jeopardizes the immediate physical safety of the patient, staff or others. ... Seclusion - Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of Violent or Self-Destructive behavior. Timeout - An intervention in which the patient consents to b being alone in a designated area for an agreed-upon timeframe which the patient is not physically prevented from leaving. Time out is not to exceed 30 minutes at a time. Emergency - a situation when the patient's behavior is Violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff and others. ... C. Exceptions: A restraint does not include devices such as: ... 4. Other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). ... IV. Use Of Restraint Or Seclusion For Violent Or Self-Destructive Behavior ... A. At times, a patient may need to be restrained for Violent or Self-Destructive behavior. Restraint or seclusion use in these situations is limited to emergencies in which there is an imminent risk of a patient physically harming himself/herself, staff or others and Non-physical interventions have been viable or effective. Use of restraints or seclusion can not be solely based on a patient's history, diagnosis, or on a history of dangerous/self destructive behavior, but on the individual patient assessment. B. The use of restraint or seclusion must be in accordance with the order of a physician who is responsible for the care of the patient and authorized to order restraint or seclusion. C. Written Orders A written order by a physician is required for restraint or seclusion use. ... 6. In an emergency, an RN or staff authorized by the institution may place the patient in restraint or seclusion before and order is obtained from a physician. An ordered should be obtained for the restraint or seclusion with a few minutes after the restraint or seclusion has been implemented. In a few minutes is defined as the conclusion of the restraint or seclusion and when it is safe for the nurse to leave the patient to obtain the order. 7. The physician must see the patient and evaluate the need for restraint or seclusion within one hour of initiation of restraint or seclusion and write an order or sign a verbal order for the restraint or seclusion. The findings of the evaluation are to include the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. The findings are to be documented in the patient record. ... V. Documentation A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. B. For each episode of restraint or seclusion use, all assessments and all interventions are to be documented. C. Any type of variation from the norm should be accompanied by a narrative note.

1) Review of MR1 revealed a physician progress note, written by EMP8, "09/29/2010 12:10 AM ... Pt became upset about being in the DEC and having to wait for evaluation. [The patient] began to kick the door and required restraint briefly to help [them] maintain calm. [The patient] was taken to the seclusion room where [they] calmed further. Reported feeling akathisia that [the patient] attributes to Lamictal and is upset that [their] outpt psychiatrist does not change the medication. [The patient] was offered ativan to help [them] calm down and to help with akathisia but pt asked for Motrin 800mg as [they] reports this has helped [them] in the past. Will dispense Motrin and continue to monitor. Pt is stable for continued evaluation in the DEC."

2) Review of MR1 and staff interviews, conducted on November 22 and 23, 2010, revealed that the patient was physically held and physically escorted to a seclusion room on September 28, 2010, at 11:30 PM. Further investigation revealed that the patient remained in the seclusion room until September 29, 2010, at 3:30 AM, a total of four hours.

3) Review of MR1 revealed no documented evidence of descriptions of the patient's condition or symptom(s) that warranted the use of physical restraint and seclusion for a total of four hours.

Cross reference:

482.13(b)(2) Patient Rights: Informed Consent
482.13(e) Use Of Restraint Or Seclusion
482.13(e)(5) Patient Rights: Restraint Or Seclusion
482.13(e)(16)(ii) Patient Rights: Restraint Or Seclusion