HospitalInspections.org

Based on medical record review, staff/physician interviews and review of medical staff bylaws/rules and regulations and other facility documents, the governing body failed to ensure that hospital organization structure did not interfere with timely implementation of an attending psychiatrist's clinical decision to transfer sample patient #1 to a higher level of care.

The hospital's clinical structure required the attending psychiatrist to obtain approval for transfer from several layers of hospital directors that had no direct clinical responsibility for the patient. The last person to be consulted and notified was the receiving attending psychiatric nurse practitioner, who was the primary psychiatric provider for the receiving unit, since the unit's psychiatrist was on vacation. By the time the sending psychiatrist had completed the extensive, multi-layer approval process, it was after hours and the receiving psychiatric nurse practitioner was already off duty for the day. The sending psychiatrist left a hand-off message for the receiving psychiatric nurse practitioner, along with the transfer note summary in the chart. Allegedly, the sending psychiatrist spent six hours attempting to clear all of the administrative approvals to get approval to transfer the care. Although the decision to transfer the patient was made earlier in the day, by the time all of the approvals were obtained, the key people, such as the receiving psychiatric nurse practitioner and the unit lead nurse were not available to coordinate the patient's care. The transfer approval process delays also contributed to a delay in the transfer, so the patient did not arrive on the receiving unit until approximately 7 p.m., when the patient was accompanied by three security guards and admitted directly to a locked seclusion room because of very disorganized and combative behavior. The patient was given a PRN dose of Ativan and was able to go to his/her assigned room at approximately 10:15 p. m., per medical record review.

The transfer sign-off did not include coordination with the receiving unit. There was no prior contact with either the receiving unit lead nurse or the psychiatric nurse practitioner to discuss the rational for transfer, the patient's care needs and the capacity of the receiving unit to manage the patient's needs and behaviors. When the patient was refusing medication, appearing potentially dangerous to self or others and a telephone call was made to the psychiatric nurse practitioner for a PRN (as needed) medication the next morning, the nurse practitioner knew nothing about the patient and had to come to the unit to review the chart and familiarize him/herself with the patient before making a decision about medication.

The failure to ensure that the patient transfer process focused on the receiving unit that was accepting accountability for the patient created a situation in which the provider and staff receiving the patient were unclear about the reason for transfer, the needs of the patients, and the patient's recent medical issues (very elevated Clozapine level, possible Clozapine/Ativan drug interaction and rule out of possible meningitis). The failure to have a system that allowed the priority to be coordination of care with the receiving provider/unit, created the potential for a negative patient outcome.

The findings were:

1. Medical Staff Bylaws/Rules and Regulations:

Review of the medical staff bylaws/rules and regulations on 8/17/10 revealed the following findings, in pertinent parts:

"Medical Staff Bylaws"
"...Article III Roles and Responsibilities of the Medical Staff
The Medical Staff shall have the following responsibilities:
3.1 Direction of Patient Care
To direct the medical and psychiatric care of patients at (the facility), including the supervision of Allied Health Professionals (HPS's), as well as all ancillary and paramedical care and treatment...
3.9 Relationship with (the facility) and its departments may be provided by individuals who are not members of the Medical Staff (E.g. Division Directors or Assistant Superintendents). In those circumstances, the Members of the Medical Staff continue to have ultimate responsibility for clinical direction and satisfactory implementation of clinical care..."

"Medical Staff Rules & Regulations"
"...2. Principal Provider of Care & Admitting Physician Duties
2.1 Definition
The "Principal Provider of Care" is the Member of the Medical Staff responsible for the diagnostic formulation for each patient and the development and implementation of the individual patient's plan of care at (the facility). Unless otherwise specified, the Principal Provider of Care is the Medical Staff Member who is responsible for the patient on the (facility) Unit where he is located...
2.6 Assuring Essential Treatment Services
Within the context of available resources, it shall be the responsibility of the Principal Provider of Care to ensure that patients receive all essential treatment services appropriate to their assessed needs. When patient have needs that cannot be met by their current treatment unit or can be better met by a different unit, the Principal Provider of Care shall be responsible for ensuring that such care is arranged. If there is a dispute among the physicians that cannot be resolved, the Chief of Medical Staff or his designee shall be consulted...
2.10 Transfer of Patients Between Units
In all transfers of patient between units, in advance of the transfer, the Principal Provider of Care shall contact the Medical Staff Member who will be the Principal Provider of Care on the receiving unit...The receiving Member of the Medical Staff becomes the Principal Provider of Care upon the patient's arrival on the receiving unit..."

2. Review of Medical Record for Sample Patient #1:

Review of the medical record of sample patient #1 on 8/17/10, revealed the following findings:

A transfer note by the sending psychiatrist, dated 8/9/10 at 3:10 p.m., contained the following information:
The note documented that the psychiatrist consulted with the following staff/physicians to get approval for the transfer of sample patient #1: 1) chief of psychiatry, 2) assistant director of forensics division, 3) clinical team leader for forensics division, 4) clinical team leader of sending unit, 5) lead nurse of sending unit. There was no indication that the receiving psychiatric nurse practitioner or the receiving unit lead nurse were notified or included in the transfer discussions. The only evidence of notification and coordination of care with the receiving unit was the documentation of the nurse-to-nurse transfer call by the sending and receiving charge nurses just prior to the transfer of the patient at approximately 6:30 p.m. and the completion of the nurse transfer sheet ("Patient Handoff Communication Form," #140-I).

3. Staff/Physician Interviews:

Staff members #1 and #8 were interviewed with the organizational chart and revealed that the following staff were involved in the approval of the transfer sample patient #1: 1) chief of psychiatry, 2) assistant director of forensics division, 3) clinical team leader for forensics division, 4) clinical team leader of sending unit, 5) lead nurse of sending unit. They clarified that the clinical team leaders essentially function as the director or manager of the unit. They clarified that the assigned attending psychiatrist does not have the leadership role/authority on the unit, in their current reporting model. The clinical team leader (who is usually a psychiatric clinician, but does not provide direct care) represents the unit. Although in the case of the transfer of sample patient #1, even the clinical team leader for the receiving unit was not included in the transfer process.

Based on the nature and number of deficiencies cited, the hospital failed to comply with the Condition of Patient Rights. The facility failed to ensure that patients were safely positioned and monitored while in restraints and seclusion. The facility also failed to ensure that staff were adequately trained to employ leather shears as an emergency restraint release device when a patient was determined to be in respiratory arrest and requiring cardiopulmonary resuscitation and advanced life support measures. These failures created the potential for negative patient outcomes and were determined to constitute an Immediate Jeopardy to the health and safety of all patients placed in restraints in the prone position and then monitored by staff through a locked seclusion room door viewing window. Sample patient #1 was restrained on 8/10/2010 and was pronounced deceased 22 minutes after being placed in restraints. Since the autopsy results and coroner's report for the patient that died in restraints was not available at the time of the survey exit, the failures were not identified or ruled out as contributory factors in the patient's death.

On 8/17/10 at 2:40 p.m., an Immediate Jeopardy situation was declared under the Condition of Patient Rights. Specifically, it was determined that the facility failed to ensure that patients were safely positioned and monitored while in restraints and seclusion. The facility also failed to ensure that staff were adequately trained to employ leather shears as an emergency restraint release device when a patient was determined to be in respiratory arrest and requiring cardiopulmonary resuscitation and advanced life support measures. These failures created the potential for negative patient outcomes and were determined to constitute an Immediate Jeopardy to the health and safety of all patients placed in restraints in the prone position and then monitored by staff through a locked seclusion room door viewing window. The Director of Quality Support Services and the Manager of Liaison Functions were notified in a meeting that an IJ (Immediate Jeopardy) had been declared and directed to begin to formulate an immediate plan to correct the situation. The administrative team provided and began to implement an acceptable plan to correct the IJ situation, prior to the survey team's exit of the facility at the end of Survey Day 4 (8/19/2010 at 12:30 p.m.).

The facility failed to meet the following standards under the Condition of Patient Rights:

A 0167 Restraint or Seclusion:
The facility failed to ensure that the use of restraints and seclusion was implemented in accordance with safe and appropriate techniques. Specifically, it was determined that the hospital failed to ensure that patients were safely positioned and monitored while in restraints and seclusion. The facility also failed to ensure that staff were adequately trained to employ leather shears as an emergency restraint release device when a patient was determined to be in respiratory arrest and requiring cardiopulmonary resuscitation and advanced life support measures. These failures created the potential for negative patient outcomes and were determined to constitute an Immediate Jeopardy to the health and safety of all patients placed in restraints in the prone position and then monitored by staff through a locked seclusion room door viewing window. Sample patient #1 was restrained on 8/10/2010 and was pronounced deceased 22 minutes after being placed in restraints. Since the autopsy results and coroner's report for the patient that died in restraints was not available at the time of the survey exit, the failures were not identified or ruled out as contributory factors in the patient's death.

A 0183 Restraint or Seclusion:
The hospital failed to ensure that patients that were simultaneously restrained and in seclusion were continually monitored face-to-face by an assigned, trained staff member. This failure led to the potential for a negative patient outcome and may have contributed to the death of sample patient #1.

A 0194 Restraint or Seclusion:
The hospital failed to ensure that trained staff were implementing restraint and seclusion in a safe manner; specifically, staff were not aware that leather cutting shears were available for removal of restraints in an emergency.

A 0196 Restraint or Seclusion:
The hospital failed to ensure that all staff received a periodic training review regarding restraint/seclusion policies and procedures.

A 0202 Restraint or Seclusion:
The hospital failed to ensure that staff were trained in responding to signs of physical distress. Specifically, staff were not aware of the availability of leather cutting shears that were to be used to remove restraints in an emergency.

A 0205 Restraint or Seclusion:
The hospital failed to ensure that staff were trained in the appropriate monitoring of patients in restraints by directing staff to place restrained patients in locked seclusion while in restraints.

A 0206 Restraint or Seclusion:
The hospital failed to ensure that staff were trained to respond to medical emergencies during restraint episodes. Specifically, staff were not aware of the availability of leather cutting shears that were to be used to remove restraints in an emergency.

Based on Medical Record review, staff interviews, review of hospital policies/procedures and facility documents, the facility failed to ensure that the use of restraints and seclusion was implemented in accordance with safe and appropriate techniques. Specifically, it was determined that the hospital failed to ensure that patients were safely positioned and monitored while in restraints and seclusion. The facility also failed to ensure that staff were adequately trained to employ leather shears as an emergency restraint release device when a patient (sample patient #1) was determined to be in respiratory arrest and requiring cardiopulmonary resuscitation and advanced life support measures. These failures created the potential for negative patient outcomes and were determined to constitute an Immediate Jeopardy to the health and safety of all patients placed in restraints in the prone position and then monitored by staff through a locked seclusion room door viewing window. Sample patient #1 was restrained on 8/10/2010 and was pronounced deceased 22 minutes after being placed in restraints. Since the autopsy results and coroner's report for the patient that died in restraints was not available at the time of the survey exit, the failures were not identified or ruled out as contributory factors in the patient's death.

The findings were:

The review of the medical record of sample patient #1 revealed the following, in pertinent parts:

The patient was admitted to the hospital on 7/16/2010 for significant mental decompensation after presenting to a mental health center. The patient had been under the care of multiple providers and was having his/her psychiatric medications adjusted as well as had undergone testing to determine any medical issues that may have been contributing to the decompensation. On 8/10/2010 at approximately 9:45 a.m., the patient was described to have an increase in agitation and was documented to attempt to push staff out of his/her way in order to go to areas where the patient was not allowed. Staff offered the patient PRN (as needed) medication for agitation, which s/he refused. The staff notified the patient's attending psychiatric provider regarding the situation and the provider stated that s/he would come to the unit to assess the patient.

At approximately 10:00 a.m., the patient was documented to be lunging at staff with his/her fists clenched. The patient was escorted to the seclusion room by five staff members to "prevent harm to the patient, staff, or peers." Once the patient arrived to the seclusion room, the patient continued to be "threatening and resistive."

At approximately 10:02 a.m., the patient was placed in the prone position on the bed in the seclusion room and was restrained with keyed-leather restraints to all four extremities. The "Behavioral Emergency Record" stated that the beginning restraint position was "prone (face down)". In the area where the form requires a reason for the position "if prone or side-lying" the form indicated "other medical condition (describe) fighting will release ASAP when safety achieved, will observe closely."

At approximately 10:12 a.m., the patient was found to be not breathing and cyanotic and was taken out of restraints with CPR (cardiopulmonary resuscitation) being initiated and a "Code 0" (respiratory arrest emergency code) was called to the hospital operator.

At approximately 10:15 a.m., EMTs (Emergency Medical Technicians) arrived and continued efforts to provide advanced life support measures. The patient was pronounced dead at 10:22 a.m., "per ER protocol" and the coroner was notified.

A review of the facility's policies/procedures and training documents was conducted during the survey and revealed the following:

A policy titled "Seclusion and Restraint/Medical Protective Restraint" was reviewed on 8/16/2010 and revealed that the policy was updated on 8/12/2010. The policy that was in place on 8/10/2010 was also reviewed and stated the following in pertinent part:
"...D. Safety Procedures...
...3. No physical or mechanical restraint or body positioning of a patient shall place excessive pressure on the chest or back of the patient or inhibit or impeded the patient's ability to breathe or otherwise obstruct the airway, nor impede circulation to extremities..." the amended policy added "therefore, prone position shall not be used when restraining the patient to the bed."

The policy did not specify what positioning would be standard, instead the policy stated, "Positioning patients during restraint must take into consideration pre-existing medical conditions...or physical disabilities and limitations that might place the patient at greater risk for injury during the episode..." the amended policy stated that patients may request repositioning "except for prone position." The amended policy did not mention the use of leather cutting shears in the case of an emergency.

The policy in place on 8/10/2010 stated the following, in pertinent part:
"...C. Nursing Responsibilities...
...4. Nursing staff are responsible for providing the level of monitoring that will protect the patient's safety. Patients in simultaneous seclusion and restraint shall be continuously monitored face-to-face by trained staff at all times."

A copy of the "Seclusion and Restraint 2010" education handout that is provided during orientation was provided to the surveyors on 8/19/2010 at approximately 10:20 a.m. The education handout stated in pertinent part:
"...Begin with the supine or side-lying position, especially if the patient has a seizure disorder, impaired gag reflex, hyper-salivation related to medications, obesity, or late pregnancy to name a few.
If it becomes necessary to revert to the PRONE position, the reason must be clearly documented on the Behavioral Emergency Record (206sr)...
...No one position is considered routine for seclusion and restraint episodes..."

An interview with staff member #3 on 8/17/2010 at approximately 9:05 a.m., revealed that s/he was one of the personnel responsible for the 1:1 observation of sample patient #1 on 8/10/2010. S/he stated that it was standard operating procedure that after a patient was placed in restraints, the door would be closed and locked. S/he also stated that it was standard practice to place all patients in the prone (stomach and chest down) position when restrained unless there was a medical reason for another position. S/he stated that initially staff member #5 was monitoring the patient through the window until staff member #3 relieved staff member #5 so that staff member #5 could go complete paperwork. Staff member #3 stated that s/he was then relieved by staff member #4 and s/he went into the nurses' station to express to the charge nurse his/her concern that the patient was going to wear him/herself out and that the patient needed to be changed to the supine position. Staff member #3 stated at that point staff member #6 went to the seclusion area to check on the patient. Shortly after that, staff member #4 came to the nurses' station and stated that a Code 0 (respiratory arrest emergency code) needed to be called. Staff member #3 responded to the seclusion room and aided in removing the restraints with a key and helped turn the patient onto his/her back. S/he stated that the patient was noted to have a blue coloring around his/her mouth and cheeks. When asked if staff sat in the seclusion room with patients when they were restrained, s/he stated that staff did not for safety reasons. S/he also stated that s/he was not aware of any scissors for the cutting of leather restraints and had never seen such shears.

An interview with staff member #4 on 8/17/2010 at approximately 10:00 a.m., revealed that s/he was one of the personnel responsible for the 1:1 observation of sample patient #1 on 8/10/2010. S/he confirmed that the door was closed and locked after the patient was restrained and that it was the standard operating procedure to do so. S/he stated that s/he was unable to see the patient's head or face during the 1:1 observation from the hallway through the door. S/he stated that s/he took over from staff member #3 and was told by staff member #3 to "keep an eye on his breathing" and had noted that it had "drastically slowed" while he was observing the patient. S/he stated that within approximately 30 seconds, staff member #6 had come to the seclusion area and that staff member #4 told him/her that they should go in to the room to check the patient's breathing. S/he stated that when they entered the room, they noticed the patient's head was turned to the left and was light blue in color. S/he then ran to the nurses' station to retrieve the emergency bag and notify staff to call a Code 0. Staff member #4 stated that s/he had never seen scissors used or knew of anyone cutting restraints. S/he stated that scissors were used for cutting down someone who would have been hanging in a suicidal attempt. S/he stated that the training did not include any education on the use of leather cutting shears in the removal of restraints. S/he stated that "99% of the time patient's are restrained face down."

An interview with staff member #2 on 8/17/2010 at approximately 11:10 a.m., revealed that s/he was one of the staff present during the restraint and seclusion of sample patient #1 on 8/10/2010. S/he stated that the door was closed and locked after the patient was placed in restraints and that it was the standard operating procedure to do so. S/he recalled the events of that morning and confirmed the recounting of events that was provided by staff members #3 and #4. S/he stated that s/he was aware of some kind of leather cutters that s/he thought might have been locked in the medication room, which was locked with keys in the possession of the medication nurse and charge nurse. S/he stated that s/he recalled hearing of the cutters in training.

An interview with staff member #1 on 8/17/2010 at approximately 12:45 p.m., revealed that staff member #6 had stated that the use of keys for removal of restraints from sample patient #1 on 8/10/2010 was difficult.

Based on staff interviews, review of policies/procedures and facility tour, the hospital failed to ensure that patients simultaneously restrained and in seclusion were continually monitored face-to-face by an assigned, trained staff member. The failure led to the potential for a negative patient outcome and may have contributed to the death of sample patient #1.

The findings were:

A review of the hospital's policies/procedures on 8/16/2010 revealed the following:
A policy titled Seclusion and Restraint/Medical Protective Restraint (that was in place on 8/10/2010 - the policy was changed on 8/12/2010) revealed the following in pertinent part:
"...C. Nursing Responsibilities...
...4. Nursing Staff are responsible for providing the level of monitoring that will protect the patient's safety. Patients in simultaneous seclusion and restraint shall be continuously monitored face-to-face by trained staff at all times..."

An interview with staff member #3 on 8/17/2010 at approximately 9:05 a.m., revealed that s/he was one of the personnel responsible for the 1:1 observation of sample patient #1 on 8/10/2010. S/he stated that it was standard operating procedure to that after a patient was placed in restraints, the door would be closed and locked.

An interview with staff member #4 on 8/17/2010 at approximately 10:00 a.m., revealed that s/he was one of the personnel responsible for the 1:1 observation of sample patient #1 on 8/10/2010. S/he confirmed that the door was closed and locked after the patient was restrained and that it was the standard operating procedure to do so. S/he stated that s/he was unable to see the patient's head or face during the 1:1 observation from the hallway through the door.

An interview with staff member #2 on 8/17/2010 at approximately 11:10 a.m., revealed that s/he was one of the staff present during the restraint and seclusion of sample patient #1 on 8/10/2010. S/he stated that the door was closed and locked after the patient was placed in restraints and that it was the standard operating procedure to do so.

A tour of the restraint/seclusion room where patient #1 was restrained was viewed with facility staff on 8/16/2010 at approximately 2:20 p.m. The seclusion area was separated from the main common room by a secured door requiring badge access. Within the seclusion area, there were two rooms that contained a bed secured to the floor and a heavy metal door that had a large window that was used for viewing patients that were placed in seclusion with or without restraints. The Director of Nursing stepped into the seclusion room and shut the door to demonstrate the sounds of a patient that was in seclusion through the door. It was acknowledged by the staff present (the Chief Psychiatrist, Lead Nurse of the unit, Manager of Liaison Functions, and Director of Quality Support Services) and the surveyors that it would have been difficult, if not impossible, to hear a patient's breathing pattern or other low pitched sounds as it was difficult to discern normal speaking through the closed door.

An interview with the Superintendent of the hospital on 8/16/2010 at approximately 11:45 a.m., revealed that staff do not sit in the restraint/seclusion room with patients while they are restrained and that it was hospital policy and staff were trained to have doors closed and locked at all times when patients are restrained.

Based on staff interview, review of hospital policies/procedures and review of personnel records the hospital failed to ensure that trained staff were implementing restraint and seclusion in a safe manner. Specifically, staff were not aware of the availability of leather cutting shears that were to be used to remove restraints in an emergency.

The findings were:

Review of staff personnel records was conducted on 8/18/2010. It was revealed that in five (#1, #2, #3, #4, & #5) of five personnel records that staff received explicit seclusion and restraint education upon orientation. Any subsequent training was sporadic and was not required at any specific interval.

Personnel record #1 revealed a document titled "CMHIP Orientation & Training Requirements." A section on the record titled "Seclusion and Restraint" indicated that it was a "one-time" requirement and was completed on 6/2/2004. No other entries for this section existed. The form also indicated that it was reviewed by the "Department/Discipline Supervisor" on 3/23/2009. The record did not contain a "Competency Screen" for Restraint/Seclusion that was found in other personnel files.

Personnel record #2 revealed a document titled "CMHIP Orientation & Training Requirements." A section on the record titled "Seclusion and Restraint" indicated that it was a "one-time" requirement. However, the record indicated that the education was completed on 4/24/2001, 10/31/2002, & 3/24/2009. The form also indicated that it was reviewed by the employee's Supervisor on 9/30/2009. The record also contained a form titled "RN Seclusion/Restraint Competency Screen" that indicated completion on 10/2/2009.

Personnel record #3 revealed a document titled "CMHIP Orientation & Training Requirements." A section on the record titled "Seclusion and Restraint" indicated that it was a "one-time" requirement and was completed on 10/13/2004. No other entries for this section existed. The form also indicated that it was reviewed by the "Department/Discipline Supervisor" on 4/20/2010. The record also contained a form titled "Seclusion/Restraint Competency Screen (Nursing Staff - Non RN)" that indicated completion on 4/20/2010.

Personnel record #4 revealed a document titled "CMHIP Orientation & Training Requirements." A section on the record titled "Seclusion and Restraint" indicated that it was a "one-time" requirement and was completed on 8/24/2006. No other entries for this section existed. The record also contained a form titled "Seclusion/Restraint Competency Screen" that indicated completion on 5/10/2006, 6/2008, 3/2009, and 7/2009.

Personnel record #5 revealed a document titled "CMHIP Orientation & Training Requirements." A section on the record titled "Seclusion and Restraint" indicated that it was a "one-time" requirement and was completed on 1/7/2010. No other entries for this section existed. The form also indicated that it was reviewed by the employee's supervisor on 1/15/2010. The record also contained a form titled "Seclusion/Restraint Competency Screen (Nursing Staff - Non RN" that indicated completion on 1/13/2010.

A review of hospital policies/procedures on 8/16/2010 revealed the following in pertinent part:
A policy titled "Seclusion and Restraint/Medical Protective Restraint" stated the following, in pertinent part:
"...E. Performance Improvement:...
...4. Clinical staff are regularly trained in areas that assess competency and enhance their ability to utilize realistic alternatives to external control and safely and humanely implement use of seclusion and/or restraint and MPR when it becomes necessary to do so."

Interviews with staff present on 8/10/2010 during a restraint episode requiring emergency medical care and removal of restraints were performed on 8/17/2010 from approximately 9:05 a.m. through 1:00 p.m. The interviews revealed that staff members #3 and #4 were unaware of leather cutting shears and did not recall of being trained in their use. Staff member #2 did recall being notified of the leather cutting shears in his/her training, but thought that the shears were kept in the medication room, not in the emergency kit. Staff member #3 stated that s/he was not aware of any scissors for restraints and stated that s/he had never seen shears for releasing restraints and that a key was used to remove restraints. Staff member #4 stated that s/he had never seen scissors used or knew of anyone cutting restraints. S/he stated that scissors were used for cutting down someone who would have been hanging in a suicidal attempt. S/he stated that the training did not include any education on the use of leather cutting shears for the removal of restraints. Staff member #3, #4, and #2 stated that prone positioning was the preferred and standard position unless there was a medical reason contraindicating that position at the time of the restraint episode on 8/10/2010.

An interview with staff member #1 on 8/17/2010 at approximately 12:45 p.m., revealed that staff member #6 had stated that the use of keys for removal of restraints from sample patient #1 on 8/10/2010 was difficult.

An interview with staff member #7 was conducted on 8/19/2010 at approximately 10:20 a.m. and revealed that all staff received education on Restraint/Seclusion policy/procedure as a part of Hospital Orientation upon hire. S/he stated that staff received education on restraint application as a part of the biannual CTI (Continuum of Therapeutic Intervention) training. A copy of the Instructor's Manual was provided to the surveyors during the interview. The manual indicated that the course was a six hour class that covered many aspects of verbal and physical means to control aggression. There was no mention in the instructor's manual of emergency removal of restraints or of leather cutting shears. A copy of the "Seclusion and Restraint 2010" education handout that was provided during orientation was given to the surveyors after the interview.

The education handout stated in pertinent part:
"...Begin with the supine or side-lying position, especially if the patient has a seizure disorder, impaired gag reflex, hyper-salivation related to medications, obesity, or late pregnancy to name a few.
If it becomes necessary to revert to the PRONE position, the reason must be clearly documented on the Behavioral Emergency Record (206sr)...
...No one position is considered routine for seclusion and restraint episodes..."

Staff member #7 stated that each nursing unit was expected to perform a CTI drill on each shift for each quarter, which would include an opportunity to familiarize staff with appropriate techniques for controlling aggressive behaviors and the application of restraints. Each unit was expected to send reports of the drills to staff member #7 each quarter, which would include all three shifts for each unit. When requested, s/he later provided a report listing the drills completed over the last year for the facility. The report showed that there were no drills completed on the unit where sample patient #1 was restrained on 8/10/2010 within the last year. That was confirmed by staff member #7. When asked if s/he had the authority to enforce the standard for drills, s/he stated s/he had no authority over the units to gain compliance in the performance of the CTI drills. S/he stated that reports were made to the Restraint/Seclusion committee on compliance with CTI drills and s/he stated that e-mail notifications of laoc of compliance with drills were sent to the division director(s).

An interview with staff member #8 was conducted on 8/19/2010 at approximately 10:30 a.m. and revealed that documentation of staff competency in restraint/seclusion policies and methods was not uniform throughout the personnel files. S/he stated that the documentation of competence was being changed. S/he stated that staff received education initially and then would receive additional training as problems were identified or when policies had been changed.

S/he stated that education could be performed annually to ensure that staff had training on a periodic basis. S/he also stated that in the education that was provided to staff, the staff would have been educated about the leather cutting shears that were available in the emergency response kit. S/he identified that in drills there should have been more emphasis on the availability of the shears and allowance of staff familiarity with the shears. S/he stated that his/her expectations would be for staff to handle all of the pieces of an emergency kit when drilling and that s/he would ensure that it would occur immediately.

Based on staff interview, review of hospital policies/procedures and review of personnel records, the hospital failed to ensure that staff was trained in implementing restraint and seclusion after orientation subsequently on a periodic basis.

Reference A0194 - Restraint or Seclusion: Staff Education - for findings regarding failure to consistently implement seclusion/restraint policies and procedures training on a periodic basis.

Based on staff interview, review of hospital policies/procedures and review of personnel records, the hospital failed to ensure that staff were trained to respond to signs of physical distress. Specifically, the facility failed to train staff in the use of leather cutting shears for the expeditious removal of restraints when emergency medical treatment was required for a patient in restraints. This failure created the potential for patient harm.

Reference A0194 - Restraint or Seclusion: Staff Education - for findings regarding failure to adequately train staff in the use and availability of leather cutting shears for emergency release of patients in restraints.

Based on staff interview, review of hospital policies/procedures and review of personnel records, the hospital failed to ensure that staff were trained in the appropriate monitoring of patients in restraints by directing staff to place restrained patients in simultaneous locked door seclusion while in restraints. This failure led to the potential for patient harm.

Reference A0167 - Restraint or Seclusion: Safe and Appropriate Techniques - for findings regarding failure to ensure that patients were safely positioned and monitored while in restraints and seclusion.


Reference A0183 - Restraint or Seclusion: Monitoring of Patients in Restraint and/or Seclusion - for findings regarding failure to ensure that patients simultaneously restrained and in seclusion were continually monitored face-to-face by an assigned, trained staff member.

Reference A0194 - Restrain or Seclusion: Staff Education - for findings regarding failure to adequately train staff in the use and availability of leather cutting shears for emergency release of patients in restraints.

Based on staff interview, review of hospital policies/procedures and review of personnel records, the hospital failed to ensure that staff was trained in responding to medical emergencies during restraint episodes. Specifically, the facility failed to train staff in the use of leather cutting shears for the expeditious removal of restraints when emergency medical treatment was required for a patient in restraints. This failure created the potential for patient harm.

Reference A0194 - Restraint or Seclusion: Staff Education - for findings regarding failure to adequately train staff in the use and availability of leather cutting shears for emergency release of patients in restraints.