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Based on hospital policy review, closed medical record reviews and staff interviews nursing staff failed to ensure an appropriate physician ' s order was obtained for a patient restrained per the hospital policy in 2 of 7 patients restrained (#11, #12).

The findings include:

Review of hospital policy "Patient Restraint Policy" effective September, 2012 revealed "... Acute medical and surgical non-psychiatric care *Restraint is used upon the order of a licensed independent practitioner *If a licensed independent practitioner is not available to issue such an order, a qualified Registered Nurse initiates restraint use based on an appropriate evaluation / assessment of the patient and following the restraint utilization guidelines. * The physician will be notified as soon as possible (no greater than 12 hours) of initiation to receive a verbal or written order which includes a clinically justifiable reason for restraints. * If the initiation of restraint use is based on a significant change in the patient ' s condition the physician will be notified immediately (within 1 hour) by the registered nurse. * A written order, based upon examination of the patient by the physician, is entered into the medical record within 24 hours of initiation of restraint. * Physician orders for restraints must be renewed every 24 hours or calendar day, whichever is greater, with the renewal being based on the physician ' s examination of the patient ...* No prn (as needed) orders can be given or received for restraints. If the reason for restraint changes, a new order must be received ... "

1. Closed medical record review of Patient # 11 revealed a 77 year old female patient admitted to the hospital on 05/26/2016 with a diagnosis of CVA (cerebral vascular accident - stroke) and expired on 06/07/2016 at 1707. Review of restraint documentation on 06/01/2016 revealed documentation of bilateral soft wrist restraints being applied on 06/01/2016 at 0800 for pulling at tubes and lines and remained on through 06/03/2016 at 1210. Review of Physician's Orders revealed a restraint order dated 06/01/2016 at 1657 with a service date/time of 06/01/2016 at 0800 (actual date/time verbal restraint order received) for " least restrictive method " every 12 hours. Further review of Physician's Orders revealed the next available documentation of a restraint order was on 06/02/2016 at 1900 (26 hours and 3 minutes since the last restraint order). Review of record revealed restraints were discontinued on 06/03/2016 at 1210. Further review of restraint documentation on 06/06/2016 revealed documentation of bilateral soft wrist restraints being re-applied on 06/06/2016 at 0800 for pulling at tubes and lines and remained on through 06/07/2016 at 0800. Review of Physician's Orders revealed a restraint order dated 06/06/2016 at 1845 (10 hours and 45 minutes after the restraint was placed on the patient at 0800) for " least restrictive method " every 12 hours. Further review of record revealed restraints were discontinued on 06/07/2016 at 0800.

Interview with nurse management staff (NM #1) on 07/21/2016 at 1530 revealed the patient was restrained on 06/01/2016 at 0800 through 06/03/2016 at 1210 and again on 06/06/2016 at 0800 through 06/07/2016 at 0800. Interview revealed there was no available documentation of a physician's order within 24 hours of the restraint initiation order on 06/01/2016 at 1657 and no available documentation of a restraint order on 06/06/2016 until 10 hours and 45 minutes after restraint was placed on the patient. Interview confirmed nursing staff failed to follow hospital policy for obtaining a physician's order for restraints.

2. Closed medical record review of Patient #12 revealed a 79 year old male patient presented to the Emergency Department on 06/21/2016 at 2001 and was admitted to the hospital on 06/22/2016 at 0804 with a diagnosis of mildly displaced left femoral neck fracture. Record review revealed Pt #12 was discharged on 06/29/2016 at 1451. Review of restraint documentation on 06/22/2016 revealed documentation of bilateral soft wrist restraints being applied on 06/22/2016 at 1619 for pulling at tubes and lines and remained on through 06/24/2016 at 0800. Review of record revealed restraints were discontinued on 06/24/2016 at 0800. Review of Physician's Orders revealed a restraint order dated 06/22/2016 at 1620 with a service date/time of 06/22/2016 at 1619 (actual date/time verbal restraint order received) for " least restrictive method ", a renewal order for restraints on 06/23/2016 at 0500, a continuation restraint order after transfer on 06/23/2016 at 1549, and a renewal order on 06/24/2016 at 0657. Review of restraint documentation on 06/24/2016 revealed documentation of bilateral soft wrist restraints re-applied on 06/24/2016 at 1400 for pulling at tubes and lines and remained on through 06/24/2016 at 2000. Review of record revealed restraints were discontinued on 06/24/2016 at 2000. Review of Physician's Orders revealed no available documentation of a restraint order on 06/24/2016 at 1400. Further review of Physician's Orders revealed the next available documentation of a restraint order was on 06/25/2016 at 0401 (14 hours and 1 minute after restraints were re-applied). Review of restraint documentation on 06/25/2016 revealed documentation of bilateral soft wrist restraints being re-applied on 06/25/2016 at 0401 for pulling at tubes and lines and remained on through 06/28/2016 at 1400. Review of record revealed restraints were discontinued on 06/28/2016 at 1400. Review of Physician's Orders revealed a restraint order dated 06/25/2016 at 0401, a restraint renewal order on 06/27/2016 at 0955 and a restraint renewal order on 06/28/2016 at 1059. Further review of Physician's Orders revealed no available documentation of a restraint order on 06/26/2016.

Interview with nurse management staff (NM #1) on 07/21/2016 at 1530 revealed the patient was restrained on 06/22/2016 at 1619 through 06/24/2016 at 0800, on 06/24/2016 at 1400 through 06/24/2016 at 2000 and again on 06/25/2016 at 0401 through 06/28/2016 at 1400. Interview revealed there was no available documentation of a new physician ' s order for restraints applied on 06/24/2016 at 1400. Further interview revealed there was no available documentation of a physician's order for renewal of restraints on 06/26/2016. Interview confirmed nursing staff failed to follow hospital policy for obtaining a physician's order for restraints.

NC00117725

Based on hospital policy review, restraint education PowerPoint, closed medical record reviews and staff interviews nursing staff failed to obtain a time-limited restraint order per the hospital policy in 1 of 1 adolescent patients restrained (#8).

The findings include:

Review of hospital policy "Patient Restraint Policy" effective September, 2012 revealed " ... Behavioral management / Violent or Self Destructive Patient ...* Restraints may be initiated by a qualified Registered Nurse in case of an emergency for behavior management. * Physicians will be notified as soon as possible (within 1 hour) after the restraints have been applied to obtain a verbal or written order ...* Physician orders will be limited to 4 hours for patient 18 years old or older, 2 hours for adolescents ages 9-17 and 1 hour for children less than 9 years old. Orders may be renewed according to the time limits for a maximum of 24 consecutive hours by communicating a re-evaluation by a qualified Registered Nurse to the physician and obtaining a verbal order for renewal."

Review of Hospital Department of Public Safety Policy titled "Use of Force" effective date 06/01/2014 revealed " ...V. PROCEDURES ...E. Patient Restraints 1. Security and sworn personnel will adhere to the Hospital ' s Patient Restraint Policy when restraining a patient unless official police custody is required for legal purposes unrelated to the patient ' s medical condition. 2. Security and/or sworn officers will assist clinical personnel with restraining patients only when clinically appropriate and requested by an authorized patient care provider. It is the responsibility of the trained patient care providers to place the restraints on the patient."

Review of Power Point Education presentation presented to Hospital Leadership on September 20, 2012 revealed "Key Concepts of Care for Patients in Shackles or Handcuffs by Law Enforcement Agencies ...4. Nursing staff should make an entry into the Daily Nursing Assessment each shift regarding the sites legally restrained, type of legal restraint and the condition of the skin at the sites ..."

Closed medical record review of Patient #8 revealed a 15 year old male patient that presented to the Emergency Department on 06/19/2016 with a chief complaint of aggressive behaviors and threatening others. Further review revealed Pt #8 was placed under IVC (involuntary commitment) after presentation to the emergency department (ED). Review of Physician's Orders revealed a written behavioral restraint order dated 06/19/2016 at 1915 which read "For continued restraint use, this order must be renewed by contacting the physician for a verbal order every ...* 2 hours for patients 9 -17 (years of age)..." Review of restraint documentation revealed documentation dated 06/19/2016 at 1915 which read " restraints for pt (patient) safety, Soft wrist restraints." Review of Hospital Police documentation revealed Pt #8 was placed in handcuffs and leg shackles on 06/19/2016 at 1923 and removed at 2009. Review of restraint documentation revealed soft wrist restraints were removed and discontinued on 06/19/2016 at 2113. Review of the nursing restraint documentation dated 06/19/2016 from 1915 to 2113 revealed documentation of soft wrist restraints monitoring with no available documentation of the handcuffs and leg shackles being applied or monitored on 06/19/2016 from 1923 to 2009. Review of Physician's Orders dated 06/20/2016 at 1611 with a service date/time of 06/20/2016 at 1330 (actual time verbal restraint order was received) revealed an order for "Restraint of Violent Patient" which read "For continued restraint use, this order must be renewed by contacting the physician for a verbal order every ...* 2 hours for patients 9 -17 (years of age)..." Further review of Physician's Orders revealed no further available documentation of a Violent Restraint order for an adolescent patient. Review of restraint documentation on 06/20/2016 revealed documentation of bilateral soft wrist restraints being applied on 06/20/2016 at 1330 for patient's behavior and monitored through 6/20/2016 at 1730, with no documented time of removal. Review of physician's orders revealed no available documentation of a time limited restraint order on 06/20/2016 at 1530 and 1730.

Interview with nurse management staff (NM #1) on 07/21/2016 at 1530 revealed there was no available documentation of a restraint order within 2 hours of restraint initiation order. Interview confirmed staff did not follow hospital policy for obtaining violent restraint orders every 2 hours for an adolescent patient. Further interview revealed there was no available documentation of monitoring of handcuffs and leg shackles by nursing staff. Further interview revealed there was no available documentation of restraints being discontinued on 06/20/2016 at 1730.

Interview with administrative staff (AS #2) on 07/20/2016 at 0920 revealed when handcuffs and/or leg shackles are placed by Hospital Police, they are considered restraints and monitoring should follow hospital policy for violent restraints.

Interview with hospital police chief (PC #3) on 07/20/2016 at 1530 revealed "handcuffs and/or leg shackles placed on a patient by hospital police would be considered a restraint."

NC00117725

Based on hospital policy review, observations during tours, restraint education PowerPoint, open and closed medical record reviews and staff interviews nursing staff failed to monitor a restrained patient per the hospital policy in 3 of 7 patients restrained (#8, #11, #12).

The findings include:

Review of hospital policy "Patient Restraint Policy" effective September, 2012 revealed " ...V. Monitors and reassess the patient during use. Patients will be observed every 30 minutes and monitored by qualified staff at least every 2 hours ...Patient will be assessed for comfort, warmth/cold, toileting and nutrition/hydration needs at least every 2 hours. Range of motion with exercise and circulation checks will be included in the assessment. This will be documented on the Restraint Flow Sheet ...Acute medical and surgical non-psychiatric care ...Behavioral management / Violent or Self Destructive Patient ...* Restraints may be initiated by a qualified Registered Nurse in case of an emergency for behavior management ...* The patient will be assessed by a competent and trained staff member every 15 minutes for signs of injury, nutrition and hydration needs, vital signs, circulation, ROM (range of motion), vital signs, hygiene elimination, physical and psychological status, comfort and readiness for discontinuation of restraints."

Review of Hospital Department of Public Safety Policy titled "Use of Force" effective date 06/01/2014 revealed "...V. PROCEDURES ...E. Patient Restraints 1. Security and sworn personnel will adhere to the Hospital ' s Patient Restraint Policy when restraining a patient unless official police custody is required for legal purposes unrelated to the patient ' s medical condition. 2. Security and/or sworn officers will assist clinical personnel with restraining patients only when clinically appropriate and requested by an authorized patient care provider. It is the responsibility of the trained patient care providers to place the restraints on the patient."

Review of Power Point Education presentation presented to Hospital Leadership on September 20, 2012 revealed "Key Concepts of Care for Patients in Shackles or Handcuffs by Law Enforcement Agencies ...4. Nursing staff should make an entry into the Daily Nursing Assessment each shift regarding the sites legally restrained, type of legal restraint and the condition of the skin at the sites ..."

1. Closed medical record review of Patient # 8 revealed a 15 year old male patient that presented to the Emergency Department on 06/19/2016 with a chief complaint of aggressive behaviors and threatening others. Further review revealed Pt #8 was placed under IVC after presentation to the ED. Review of restraint documentation revealed documentation dated 06/19/2016 at 1915 which read "restraints for pt (patient) safety, Soft wrist restraints." Review of Hospital Police documentation revealed Pt #8 was placed in handcuffs and leg shackles on 06/19/2016 at 1923 and removed at 2009. Review of restraint documentation revealed soft wrist restraints were removed and discontinued on 06/19/2016 at 2113. Review of the nursing restraint documentation dated 06/19/2016 from 1915 to 2113 revealed documentation of soft wrist restraints monitoring with no available documentation of the handcuffs and leg shackles being applied or monitored. Review of restraint documentation on 06/20/2016 revealed documentation of bilateral soft wrist restraints being applied on 06/20/2016 at 1330 for patient's behavior and monitored through 6/20/2016 at 1730, with no documented time of removal. Review of restraint monitoring revealed documentation on 06/20/2016 at 1330, 1430, 1530, 1630, and 1730. Further review of restraint monitoring documentation revealed no available documentation of restraint monitoring at 1345, 1400, 1415, 1445, 1500, 1515, 1545, 1600, 1615, 1645, 1700, and 1715.

Interview with nurse management staff (NM #1) on 07/21/2016 at 1530 revealed there was no available documentation of monitoring of handcuffs and leg shackles by nursing staff. Further interview revealed there was no further documentation available of every 15 minutes assessment and monitoring of the patient while restrained on 06/19/2016 from 1330-1730 and no available documentation of restraints being discontinued on 06/19/2016 at 1730. Interview confirmed nursing staff failed to follow hospital policy to assess and monitor patients every 15 minutes while in violent restraints.

Interview with administrative staff (AS #2) on 07/20/2016 at 0920 revealed when handcuffs and/or leg shackles are placed by Hospital Police, they are considered restraints and monitoring should follow hospital policy for violent restraints.

Interview with hospital police chief (PC #3) on 07/20/2016 at 1530 revealed "handcuffs and/or leg shackles placed on a patient by hospital police would be considered a restraint."

2. Closed medical record review of Patient #11 revealed a 77 year old female patient admitted to the hospital on 05/26/2016 with a diagnosis of CVA (cerebral vascular accident - stroke) and expired on 06/07/2016 at 1707. Review of restraint documentation on 06/01/2016 revealed documentation of bilateral soft wrist restraints being applied on 06/01/2016 at 0800 for pulling at tubes and lines and remained on through 06/03/2016 at 1210. Review of record revealed restraints were discontinued on 06/03/2016 at 1210. Review of restraint documentation on 06/01/2016 revealed documentation of restraint monitoring at 0800, 1000, 1200, 1400, 1600, 2000 (4 hours since last monitored) and 2200.

Interview with nurse management staff (NM #1) on 07/21/2016 at 1530 revealed there was no further documentation available of every two hour assessment and monitoring of the patient while restrained on 06/01/2016 from 1600-2000. Interview confirmed nursing staff failed to follow hospital policy to assess and monitor patients every two hours while in restraints.

3. Closed medical record review of Patient #12 revealed a 79 year old male patient presented to the Emergency Department on 06/21/2016 at 2001 and was admitted to the hospital on 06/22/2016 at 0804 with a diagnosis of mildly displaced left femoral neck fracture. Record review revealed Pt #12 was discharged on 06/29/2016 at 1451. Review of restraint documentation on 06/24/2016 revealed documentation of bilateral soft wrist restraints being re-applied on 06/24/2016 at 1400 for pulling at tubes and lines and remained on through 06/24/2016 at 2000. Review of nursing restraint documentation revealed documentation of restraint monitoring on 06/24/2016 at 1400, 1800 (4 hours since last monitored) and 2000. Review of record revealed restraints were discontinued on 06/24/2016 at 2000 until 06/25/2016 at 0400.

Interview with nurse management staff (NM #1) on 07/21/2016 at 1530 revealed there was no further documentation available of every two hour assessment and monitoring of the patient while restrained on 06/24/2016 from 1400-1800. Interview confirmed nursing staff failed to follow hospital policy to assess and monitor patients every two hours while in restraints.

NC00117725

Based on hospital policy review, restraint education PowerPoint, closed medical record reviews and staff interviews hospital staff failed to ensure a face-to-face assessment within 1 hour after initiation of a violent restraint intervention was completed per the hospital policy in 1 of 1 adolescent patients restrained for behavior management (#8).

The findings include:

Review of hospital policy "Patient Restraint Policy" effective September, 2012 revealed "...Behavioral management / Violent or Self Destructive Patient ...* Restraints may be initiated by a qualified Registered Nurse in case of an emergency for behavior management. * Physicians will be notified as soon as possible (within 1 hour) after the restraints have been applied to obtain a verbal or written order. * The physician must evaluate the patient (face to face) within 1 hour of the initiation of restraint (even if patient is released). A qualified Registered Nurse may conduct this evaluation of the patient with 1 hour (in lieu of the physician) provided they are trained and they consult with the physician as soon as possible (within 1 hour) after their evaluation ..."

Review of Hospital Department of Public Safety Policy titled "Use of Force" effective date 06/01/2014 revealed "...V. PROCEDURES ...E. Patient Restraints 1. Security and sworn personnel will adhere to the Hospital ' s Patient Restraint Policy when restraining a patient unless official police custody is required for legal purposes unrelated to the patient ' s medical condition. 2. Security and/or sworn officers will assist clinical personnel with restraining patients only when clinically appropriate and requested by an authorized patient care provider. It is the responsibility of the trained patient care providers to place the restraints on the patient."

Review of Power Point Education presentation presented to Hospital Leadership on September 20, 2012 revealed "Key Concepts of Care for Patients in Shackles or Handcuffs by Law Enforcement Agencies ...4. Nursing staff should make an entry into the Daily Nursing Assessment each shift regarding the sites legally restrained, type of legal restraint and the condition of the skin at the sites ..."

Closed medical record review of Patient #8 revealed a 15 year old male patient that presented to the Emergency Department on 06/19/2016 with a chief complaint of aggressive behaviors and threatening others. Further review revealed Pt #8 was placed under IVC after presentation to the ED. Review of Physician's Orders revealed a written behavioral restraint order dated 06/19/2016 at 1915 which read "For continued restraint use, this order must be renewed by contacting the physician for a verbal order every ...* 2 hours for patients 9 -17 (years of age)..." Review of restraint documentation revealed documentation dated 06/19/2016 at 1915 which read "restraints for pt (patient) safety, Soft wrist restraints." Review of Hospital Police documentation revealed Pt #8 was placed in handcuffs and leg shackles on 06/19/2016 at 1923 and removed at 2009. Review of restraint documentation revealed soft wrist restraints were removed and discontinued on 06/19/2016 at 2113. Review of the nursing restraint documentation dated 06/19/2016 from 1915 to 2113 revealed documentation of soft wrist restraints monitoring with no available documentation of the handcuffs and leg shackles being applied or monitored on 06/19/2016 from 1923 to 2009. Review of medical record revealed no available documentation of a 1 hour face-to-face assessment for the violent restraint intervention on 06/19/2016 at 1915. Review of Physician's Orders dated 06/20/2016 at 1611 with a service date/time of 06/20/2016 at 1330 (actual time verbal restraint order was received) revealed an order for "Restraint of Violent Patient" which read "For continued restraint use, this order must be renewed by contacting the physician for a verbal order every ...* 2 hours for patients 9 -17 (years of age)..." Review of restraint documentation on 06/20/2016 revealed documentation of bilateral soft wrist restraints being applied on 06/20/2016 at 1330 for patient's behavior and monitored through 6/20/2016 at 1730, with no documented time of removal. Review of medical record revealed no available documentation of a 1 hour face-to-face assessment for the violent restraint intervention on 06/20/2016 at 1330.

Interview with nurse management staff (NM #1) on 07/21/2016 at 1530 revealed there was no available documentation of a 1 hour face-to-face assessment completed after the initiation of the violent restraint intervention on 06/19/2016 at 1915 and 06/20/2016 at 1330. Interview confirmed the hospital staff did not follow the hospital policy for obtaining or conducting a 1 hour face-to-face assessment.

Interview with administrative staff (AS #2) on 07/20/2016 at 0920 revealed when handcuffs and/or leg shackles are placed by Hospital Police, they are considered restraints and monitoring should follow hospital policy for violent restraints.

Interview with hospital police chief (PC #3) on 07/20/2016 at 1530 revealed "handcuffs and/or leg shackles placed on a patient by hospital police would be considered a restraint."

NC00117725