HospitalInspections.org

Based on observations, document review and interviews with facility staff, the governing body failed to be responsible for ensuring that hospital policies and procedures were implemented and followed by hospital staff resulting in the following deficient practices:

Findings were;

1. Patient's Rights to safety was violated according to hospital policy & procedure titled
"Patient Restraint " because staff did not initiate restraint properly as trained; Cross refer to A0194.

2. A patient was restrained without a physician's order in violation of hospital policy and procedure titled "titled"; Cross refer to A0115.

3. Medical records were not completed. Cross refer to A0168, A0185, A0186, A0187, A0188, and A0438.

Based on a review of available documentation, observations in the facility, and staff interviews, the facility failed to ensure that each patient's rights were protected and promoted.

Findings were:

The facility did not ensure that patients were cared for in a safe environment, and failed to ensure that patient restraints were properly applied per policy and ordered by a physician.

1. Based on a review of hospital policy and medical record review, the hospital failed to follow policy to ensure the safety of patients. Cross refer to A0144 and A0145.

2. Based on interviews and review of documentation the facility failed to correctly identify a restraint as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Cross refer to A0159.

3. Based on interviews and review of documentation the facility failed to properly monitor and evaluate a patient that was restrained. Cross refer to A0175, A0179.

Based on review of documentation and interviews, the facility failed to ensure the patient's right to receive care in a safe setting.

Findings were:

Patient #1 was placed in two physical restraints on 2/9/11 with no restraint orders or documentation of the restraints present in the medical record.

Staff member # 6 utilized improper restraint technique on the patient described in a written statement as " I grabbed patient from behind, around her neck and took her to the ground " and in interview as " grabbed her from behind with a choke hold. "

Staff member # 9 who was involved in the restraint had not received training in restraint technique at the time of the incident.

This lack of ensuring the patient's right to receive care in a safe setting was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

Based on review of documentation and interviews, the facility failed to ensure the patient was free from all forms of abuse or harassment.

Findings were:

Patient # 1 was placed in two physical restraints on 2/9/11 with no restraint orders or documentation of the restraints present in the medical record.

Staff member # 6 utilized improper and forceful restraint technique on the patient described in a written statement as " I grabbed patient from behind, around her neck and took her to the ground " and in interview as " grabbed her from behind with a choke hold. "

This lack of ensuring the patient's right to be free from all forms of abuse or harassment was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

Based on a review of documentation and interview the facility failed to correctly identify a restraint as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

Findings were:

Facility policy & procedure titled Patient Restraint Appendix D: Definitions stated, in part, " A. Physical restraint: Any Manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body to include immobilization or reduction of the ability of a patient to move his or her arms, legs, or head freely is considered a physical restraint ....Under this definition, many commonly used facility devices and practices could meet this definition of restraint (e.g., tucking in sheets very tightly, use of side rails, to prevent patient from voluntarily getting out of bed, holding a patient to prevent movement ...E. Physical Holds: ...Holding a patient in a manner that restricts the patient's movements against the patient's will is considered restraint. "

Review of facility paperwork revealed a written statement by staff member # 6 regarding and describing an incident between him and Patient #1 stated, in part, " Patient threw cell phone on ground and came at me. Patient ' s significant other tried to stop her and she got around him and grabbed her boots that were in the chair and threw them at me. They hit me in the face and I saw stars. I then grabbed patient and threw her to the bed so she would not come after me. Patient kicked and scratched, got away, and came after me again. I grabbed patient from behind, around her neck and took her to the ground. Security showed up and grabbed her. "

A facility Incident Report completed by staff member # 9 on 2/9/11 stated, in part, " On Wednesday, February 9th, 2011 at approximately 1145 I, (staff member # 9) responded to a radio call for security to ER room 7 stat. Upon arrival I observed ER Tech (staff member # 6) holding Patient (#1) in a restraint position with her arms plat to the floor. I took control of the situation, with a continued restraint on the Patient: (referring to patient #1 by name) because she was still being combative. "

In an interview on 5/15/12, staff member # 6 described the events of 2/9/11 involving patient # 1 as follows, "She picked her boots up and slammed them into my face. She shattered my glasses which cut my nose and my cheek. That staggered me back a little. She turned to grab something, her purse bag on the bed. I pushed him (the boyfriend) out of the way. I grabbed her wrestled her to the ground. She was kneeling on ground holding onto the bed. She reached for her purse 2nd time. I grabbed her hand and grabbed her from behind with a choke hold around her neck back down off the side of the bed to the floor. She wanted to get up and get her purse. The boyfriend pushed me off of her. She jumped up and went for the purse again. I stopped her again and we wrestled. I wrestled her back ground on the floor away from the bed and the purse. At that time security showed up. He grabbed one end and I had the other end of her. When he (Security) grabbed her I let go. "

On 5/14/12, the medical chart for Patient # 1 was reviewed and no physician order or any documentation was present for the above described physical restraint.

In an interview with staff member # 4 on 5/16/12 she acknowledged she did not obtain any physician orders for a restraint involving Patient # 1.

This inappropriate use of restraint was confirmed in an interview with Chief Nursing Officer on 5/15/12.

Based on review of documentation and interviews, the facility failed to utilize restraint in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient according to hospital policy.

Findings were:

Facility policy & procedure titled Patient Restraint stated, in part,
" 5. Order for Restraint
a. An order for restraint must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of the restraint. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release ...
d. When a LIP/physician is not available to issue a restraint order, an RN with demonstrated competency may initiate restraint use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the application or immediately (within minutes) after the restraint is applied ...
5B. Order for Restraint with Violent or Self Destructive Behavior
a. Physician orders for restraint must be time limited, must specify clinical justification for the restraint/seclusion, the date and time ordered, duration of restraint/seclusion uses, the type of restraint, and behavior-based criteria for release ... "

A written statement dated (2/9/11 at 1351) and an interview (on 5/15/12) with staff member # 6 indicate that on 2/9/11 he physically restrained Patient # 1 2- 3 times before staff member # 9 arrived to assist.

A written statement by staff member # 9 on 2/9/11 indicates he observed the restraint and assisted staff member # 6 in physically restraining patient #1 upon his arrival to Room # 7.

On 5/14/12, the medical chart for Patient # 1 was reviewed and no physician order or any documentation was present for the above described physical restraint.

In an interview with staff member # 4 on 5/16/12 she acknowledged she did not obtain any physician orders for a restraint involving Patient # 1.

This use of restraint without an order from a physician or other licensed independent practitioner was confirmed in an interview with Chief Nursing Officer on 5/15/12.

Based on review of documentation and interviews, the facility failed to ensure the condition of a patient who is restrained is monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy.

Findings were:

Facility policy & procedure titled Patient Restraint stated, in part,
" 7. Monitoring the Patients in Restraints
a. Patients are assessed by an RN immediately after restraints are applied to assure safe application of the restraint ...
9. Face-to-face assessment by a Physician or LIP:
a. A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... "

Facility policy & procedure titled Patient Restraint Appendix A: Training Requirements stated, in part, " A. Direct Care Staff Staff will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion. Training will be provided to all staff designated as having direct patient care responsibilities (the facility to list), including contract or agency personnel. In addition, if hospital security guards or other non-healthcare staff (the facility to list) assist direct care, or other non-healthcare staff (the facility to list) assist direct care staff, when requested in the application of restraint or seclusion, the security guards, or other non-healthcare staff (as defined by the facility) are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion. Training will occur:
1. Before performing restraint application, implementation of seclusion,
monitoring, assessment and providing care of patient in restrain or seclusion,
2. As part of orientation, and .... "

On 5/14/12, the medical chart for Patient # 1 was reviewed there was no documentation of the two physical restraints staff member # 6 implemented with the patient. There was also no documented monitoring of the patient while restrained in the medical chart.

A review of personnel records revealed that staff member #6 was up to date on his restraint training. Staff member # 9 who participated in restraining patient # 1 was not current in his training and had not received any restraint training at the time of the incident. Staff member # 1 confirmed staff member # 9's lack of restraint training in the date of the incident, in an interview on 5/14/12

This lack of proper monitoring of the patient and lack of up to date training for staff involved in the restraint was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

Based on review of documentation and interviews, the facility failed to ensure the patient was seen within 1 hour after the initiation of the intervention to evaluate the patient's immediate situate, reaction to the intervention and medical/behavioral condition.

Findings were:

Facility policy & procedure titled Patient Restraint stated, in part,
" 9. Face-to-face assessment by a Physician or LIP:
a. A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... "

On 5/14/12, the medical chart for Patient # 1 was reviewed there was no documentation of the two physical restraints staff member # 6 implemented with the patient. There was no documented face to face assessment of the restrained patient within 1 hour after the initiation of the intervention.

This lack of documentation was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

Based on review of documentation and interviews, the facility failed to ensure the documentation of the restrained patient s behavior and the intervention used.

Findings were:

Facility policy & procedure titled Patient Restraint stated, in part,
" 5B. Order for Restraint with Violent or Self Destructive Behavior
a. Physician orders for restraint must be time limited, must specify clinical justification for the restraint/seclusion, the date and time ordered, duration of restraint/seclusion uses, the type of restraint, and behavior-based criteria for release ...
12. Documentation Requirements:
The medical record contains documentation of: ...
b. Restraint alternatives implemented
c. Determination of effectiveness/ineffectiveness of restraint alternatives
d. Second tier review for need of restraint
e. Order for restraint and any renewal orders for restraint
f. Restraint application ... "

On 5/14/12, the medical chart for Patient # 1 was reviewed there was no documentation of the two physical restraints staff member # 6 implemented with the patient. There was no documentation describing the patient's behavior and the intervention used.

This lack of documentation was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

Based on review of documentation and interviews, the facility failed to ensure the documentation of alternatives or other less restrictive interventions attempted.

Findings were:

Facility policy & procedure titled Patient Restraint stated, in part,
" 12. Documentation Requirements:
The medical record contains documentation of:
a. Assessment for risk for restraint
b. Restraint alternatives implemented
c. Determination of effectiveness/ineffectiveness of restraint alternatives ... "

On 5/14/12, the medical chart for Patient # 1 was reviewed there was no documentation of the two physical restraints staff member # 6 implemented with the patient. There was no documentation describing the patient's behavior and the intervention used.

This lack of documentation was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

Based on review of documentation and interviews, the facility failed to ensure the documentation of the patient's condition or symptoms that warranted the use of restraint..

Findings were:

On 5/14/12, the medical chart for Patient # 1 was reviewed there was no documentation
of the patient's condition or symptoms that warranted the use of restraint.

This lack of documentation was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

Based on review of documentation and interviews, the facility failed to ensure the documentation of the patient's response to the intervention.

Findings were:

On 5/14/12, the medical chart for Patient # 1 was reviewed there was no documentation
of the patient's response to the interventions that occurred on 2/9/11.

This lack of documentation was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

Based on review of documentation and interviews, the facility failed to ensure the patient's right to safe implementation of restraint or seclusion by trained staff.

Findings were:

Facility policy & procedure titled Patient Restraint Appendix A: Training Requirements stated, in part, " A. Direct Care Staff Staff will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion. Training will be provided to all staff designated as having direct patient care responsibilities (the facility to list), including contract or agency personnel. In addition, if hospital security guards or other non-healthcare staff (the facility to list) assist direct care, or other non-healthcare staff (the facility to list) assist direct care staff, when requested in the application of restraint or seclusion, the security guards, or other non-healthcare staff (as defined by the facility) are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion. Training will occur:
1. Before performing restraint application, implementation of seclusion,
monitoring, assessment and providing care of patient in restrain or seclusion,
2. As part of orientation, and .... "


Staff member # 6 utilized improper restraint technique on the patient described in a written statement as " I grabbed patient from behind, around her neck and took her to the ground " and in interview as " grabbed her from behind with a choke hold. "

Staff member # 9 who was involved in the restraint had not received training in restraint technique at the time of the incident. Staff member # 1 confirmed staff member # 9's lack of restraint training, on the date of the incident, in an interview on 5/14/12

This lack of ensuring the patient's right to safe implementation of restraint or seclusion by trained staff was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.

Based on review of documentation and interviews, the facility failed to maintain a complete medical record for patients.

Findings were:

Patient #1 had no documentation of the two physical restraints staff member # 6 placed her in. No narratives of the restraint events, physician orders, or monitoring sheets were present in the medical record. The facility considered this chart complete at the date of review.

This lack of complete documentation in the patient's medical chart was confirmed in an interview on 5/15/12 with the Chief Nursing Officer.