HospitalInspections.org

Based on document review, medical record review, and interview, in 1 of 5 medical records reviewed (Patient #3) of patients placed in restraints, staff secured a patient's wrist restraints to the wheelchair handles (used to push the
wheelchair) resulting in the patient's hands being restrained over their head. This could potentially injure a patient and cause untoward patient outcomes.

Findings include:

-- Review of the facility's policy and procedure titled, "Restraints: Application & Removal Standard Precautions Exposure Category 1," last revised 10/2022, indicated staff should never restrain a patient with their arms positioned over their head.

-- Per medical record review, Patient #3 presented to the emergency department (ED) on 3/21/2024 accompanied by law enforcement with chief complaint of homicidal statements and need for a psychiatric health evaluation. Medical screening exam was completed and revealed patient had bipolar affective disorder with severely manic psychotic features. Patient was very agitated and had to be physically and chemically restrained. The psychiatrist on the comprehensive psychiatric emergency program (CPEP) unit was consulted and Patient #3 was accepted for evaluation.

Patient was transported to CPEP on 3/21/2024 at 5:55 am.

A late entry in the medical record on 3/21/2024 at 9:31 pm, documented that a security officer and a patient care technician wrapped bilateral wrist restraint straps around the wheelchair handles (used to push the wheelchair) to restrain Patient #3. This resulted in his hands being positioned above his head after he slid down in the wheelchair.

--Per interview of Staff A, Security Guard on 4/18/2024 at 7:00 am, after Patient #3 was assisted into a wheelchair for transport from the ED to the CPEP unit, he became very agitated, was kicking, and yelling. Staff A decided to wrap the bilateral wrist restraint straps around the wheelchair handles (used to push the wheelchair) to try and prevent Patient #3 from flailing and potentially hitting staff.

-- Per interview of Staff B, Patient Care Technician on 4/17/2024 at 11:30 am, once Patient #3 was placed in a wheelchair for transport from the ED to the CPEP unit, he became combative and was grabbing at staff. Staff B wrapped the straps from the wrist restraints around the handles (used to push the wheelchair) in order to prevent staff from getting hit by Patient #3.

-- Per interview of Staff C, Registered Nurse on 4/19/2024 at 12:20 pm, nursing does not have input into the decision regarding the patient's transfer from the ED to the CPEP unit; this is controlled by the doctors. Patient #3 was medically cleared and in need of a behavioral health assessment.

-- During interview of Staff D, Registered Nurse Coordinator on 4/16/2024 at 1:05 pm, he/she/they acknowledged the above findings.

Based on document review and interview, in 2 of 3 investigations reviewed the facility failed to thoroughly investigate the events and failed to implement corrective actions (Patient #1 and Patient #3). These failures could put patients at risk for injury and lead to poor patient outcomes.

Findings pertinent to Patient #1 include:

-- Review of a facility investigation report entered on 3/12/2024 revealed a patient (Patient #1) fell during a transfer. It was stated in the report that Patient #1 did not have a fall bracelet (armband) on. (A fall bracelet is placed on a patient who is identified as a high risk for falling) The report was reviewed by the manager of the department where the fall occurred. He/she/they closed the investigation with the status documented as "No further follow-up necessary."

-- The facility's investigation did not address the concern that the patient, who was at high risk for falls, was not wearing a fall bracelet (armband). No corrective actions were implemented.

Findings pertinent to Patient #2 include:

-- Review of a facility investigation report entered on 3/21/2024 revealed a patient (Patient #3) was inappropriately restrained while being transported in a wheelchair.

-- The facility's investigation identified concerns related to this event. The investigation did not address all the concerns identified or implement corrective actions for all the concerns identified.

-- Per interview of Staff G, Regional Director Clinical Risk on 5/10/2024 at 9:00 am, he/she/they acknowledged the above findings.