HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure, for 1 of 5 restrained patients (Pt. #8), that the use of a restraint was in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraints by Hospital policy.

Findings include:

1. On 4/27/2022, the Hospital's policy titled, "Restraint and Seclusion Inpatient/Emergency," effective 9/14/2021, was reviewed. The policy required, "IV. Procedure... C. Provider Orders... Violent and/or Self Destructive Behaviors: 1. The RN must notify the physician, APNP or PA responsible for the care of the patient immediately after placing the patient in restraint/seclusion and obtain an order within one hour after initiation of restraint and/or seclusion..."

2. On 4/27/2022, Pt. #8's clinical record was reviewed. Pt. #8 was treated in the Emergency Department (ED) on 4/5/2022 for passive suicidal ideation. Pt. #8 became aggressive, combative, and attempted to bite ED staff. Pt. #8 was placed in restraints on 4/5/2022 at 2:35 AM, and released the same day at 3:25 AM. Pt. #8's record lacked a physician's restraint order.

3. On 4/27/2022 at 10:10 AM, an interview was conducted with the Director of Center for Mental Health (E #14). E #14 stated that a physician's order is required for the use of restraints.

Based on document review and interview, it was determined that the Hospital failed to ensure, for 1 of 5 restrained patients (Pt. #3), that when a restraint is used for the management of violent behavior, the patient must be seen face to face within 1 hour after the initiation of the restraint by a physician or other licensed practitioner.

Findings include:

1. On 4/27/2022, the Hospital's policy titled, "Restraint and Seclusion Inpatient/Emergency," effective 9/14/2021, was reviewed. The policy required, "IV. Procedure... C. Provider Orders, Notification, and Evaluation... iv. Initial Provider Evaluation... b. Violent and/or Self Destructive Behavior: 1. Any episode of restraint... for management of violent... behavior requires a documented face to face assessment by the Physician... within one hour of the initiation of restraint..."

2. On 4/25/2022, Pt. #3's clinical record was reviewed. Pt. #8 was admitted on 1/17/2022, with diagnoses, of preeclamsia (high blood pressure) and pregnancy 34 6/7 weeks. Pt. #3 exhibited worsening behavior while waiting for appropriate discharge placement for over 3 month of hospitalization (discharged to jail on 4/20/2022). Pt. #3 required restraints on multiple occasions for violent behavior (punching and kicking staff). On 2 occasions 2/17/2022 at 7:45 PM and 4/9/2022 at 4:10 AM, when violent restraints were ordered and applied, there was no documentation of face to face assessment by the physician within 1 hour of initiation of restraints.

3. On 4/27/2022 at 10:10 AM, an interview was conducted with the Director of Center for Mental Health (E #14). E #14 stated that a face to face assessment within 1 hour of apply violent restraints is required to be completed by a physician or authorized practitioner.