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Based on interview and document review, the hospital failed to protect and promote a patient's rights when hospital staff failed to ensure restraints were removed at the earliest time possible for one of eleven patients, P1, reviewed for restraint use.

See A-0174 - Based on interview and record review, the hospital failed to ensure restraints were removed at the earliest possible time for one of eleven patients, P1, reviewed for restraint use.

Based on interview and record review, the hospital failed to ensure restraints were removed at the earliest possible time for one of eleven patients, P1, reviewed for restraint use.

Findings include:

P1's medical record was reviewed and indicated the patient had a diagnosis of Schizophrenia and was admitted on a court hold to the inpatient adult mental health unit on 7/17/17, for hallucinations.

P1's nursing note dated 8/18/17, at 3:59 p.m. indicated P1's left eye was bleeding and P1 stated, "The bible told me to gouge my eye out. So I stuck it in and tried to pluck it out." P1 used a ball point pen as a tool to try to remove his eye. The nursing staff notified Psychiatrist (P)-E who ordered four point restraints (a restraint on both wrists and both ankles) to protect the patient from further self harm.

P1's physician order on 8/18/17, at 1:58 p.m. directed double Velcro four point restraints on all four extremities for self injurious behavior.

P1's nursing progress notes dated 8/18/17, indicated P1 was placed in double Velcro four point restraints from 8/18/17, at 1:58 p.m. to 8/19/17, at 12:59 p.m., a total of approximately 21 hours. Staff documented on a electronic restraint flowsheet located in the P1's medical record every 15 minutes on patient response, readiness for release, and reinforcing discontinuation criteria. The discontinuation criteria identified for P1 was, "Patient no longer exhibits behavior that could result in serious injury to self or others."

P1's condition on the restraint flowsheet indicated on 8/18/17, at 4:00 p.m. P1 was "Subdued/ Calming.

P1's condition on the restraint flowsheet indicated on 8/18/17, at 4:30 p.m. P1 was "Agitated/ restless, and "Subdued/ Calming." P1 had a hand released to use the urinal.

P1's condition on the restraint flowsheet indicated on 8/18/17, at 5:30 p.m. P1 was "Subdued/ Calming."

P1's progress notes dated 8/18/17, at 5:52 p.m. indicated the patient was seen by the ophthalmologist for blunt trauma to the left eye with a pen. The patient had no signs of rupture or laceration to the cornea and was prescribed eye ointment nightly and was directed to follow up with the eye clinic after discharge.

P1's physician order dated 8/18/17, at 6:00 p.m. directed double Velcro four point restraints on all four extremities for self injurious behavior. There was no corresponding assessment or documentation regarding justification of continuing the restraints.

P1's condition on the restraint flowsheet indicated on 8/18/17, at 6:30 p.m. P1 was "Delusional; Subdued/ Calming."

P1's Nursing note dated 8/18/17, at 7:18 p.m. indicated P1 was preoccupied with showing staff a verse in the bible. P1 required frequent reorientation of why his eye hurt and the reason for the restraints. The note indicated P1 would remain in restraints until the physician was able to assess the patient in the morning to prevent further damage to his eye.

P1's condition on the restraint flowsheet indicated on 8/18/17, from 7:30 p.m. to 9:15 p.m. P1 was "Delusional; Subdued/ Calming."

P1's physician order dated 8/18/17, at 10:00 p.m. directed double Velcro four point restraints on all four extremities for self injurious behavior. There was no corresponding assessment or documentation regarding justification of continuing the restraints.

P1's Nursing note dated 8/18/17, at 10:23 p.m. indicated the patient was calm and appropriate. P1 made several repeated requests to use the restroom and to be released from restraints. P1 took all medications and continued to request to be released from restraints until the patient fell asleep.

P1's condition on the restraint flowsheet indicated from 8/18/17, at 9:30 p.m. to 8/19/17, at 3:15 a.m. P1 was described as either "Subdued/ Calming," or the patient was sleeping. The restraint flowsheet indicated P1 was sleeping on 8/18/17, at 10:00 p.m., 10:15 p.m., 10:45 p.m., 11:30 p.m., and 11:45 p.m. On 8/19/17, P1 was sleeping from 12:00 a.m. to 1:00 a.m., at 1:30 a.m., and from 2:15 a.m. to 3:00 a.m. The facility did not attempt to release the restraints.

P1's physician order dated 8/19/17, at 2:00 a.m. directed double Velcro four point restraints on all four extremities for self injurious behavior. There was no corresponding assessment or documentation regarding justification of continuing the restraints.

P1's Nursing note dated 8/19/17, at 5:42 a.m. indicated the patient was attempting to purge to rid himself of poison he believed he ingested.

P1's physician order dated 8/19/17, at 6:00 a.m. directed double Velcro four point restraints on all four extremities for high risk to inflict self harm. There was no corresponding assessment or documentation regarding justification of continuing the restraints.

P1's Nursing note dated 8/19/17, at 6:02 a.m. indicated the patient had a short attention span, was impulsive, restless, and lacked insight. P1 was in four point restraints and was released for range of motion and to use the urinal. P1 slept a few hours and woke up demanding food and medications. Patient continued to attempt to purge and was irritable at times threatening to spit on staff.

P1's physician orders dated 8/19/17, at 10:00 a.m. directed double Velcro four point restraints on all four extremities for high risk to inflict self harm. There was no corresponding assessment or documentation regarding justification of continuing the restraints.

P1's physician order dated 8/19/17, at 12:42 p.m. directed double Velcro two point restraints on left arm and right ankle for self harm. There was no corresponding assessment or documentation regarding justification of continuing the restraints.

On 8/19/17, at 12:59 p.m. nursing progress note indicated P1 was switched to two point restraints (a restraint on the right wrist and left ankle).

P1's Nursing note dated 8/19/17, at 2:21 p.m. indicated nursing staff spoke with the physician and the patient was switched to two point restraints with the plan to remove all restraints if the patients behavior was appropriate. The nursing note did not specify what behavior was considered "appropriate" for P1. P1 was aware and agreeable to the plan. P1 was cooperative after two of the restraints were removed, and the restraints were discontinued at 2:20 p.m. on 8/19/17.

During interview on 8/31/17, at 12:50 p.m. Registered Nurse (RN)-N stated P1 was in restraints on 8/18/17, and 8/19/17, to prevent further self injury. RN-N stated P1 was impulsive and would strike staff or injure himself without any warning. RN-N stated several days prior to 8/18/17, P1 was calm and talking with staff and suddenly struck a staff member in the head without warning or change in behavior. RN-N stated when a patient is in restraints nursing staff should be reassessing to ensure restraints are discontinued as early as possible. The assessment would include asking the patient if they felt they were at risk for self injury or injuring others, and the patients response to being restrained. RN-N stated there was no indication staff asked P1 about feelings of further self injury and it could not be determined from the documentation if P1 was still a danger to himself or others. RN-N stated purging and/ or delusions or hallucinations would not be a reason to continue restraints on P1 as these are behaviors the patient had demonstrated in the past.

During interview on 8/31/17, at 4:30 p.m. RN-O stated P1 was placed in four point restraints on 8/18/17, to prevent further self injury. RN-O stated he contacted P1's psychiatrist after the patient stuck the pen in his eye, and the plan was to ensure the patient was safe and medication was given to calm the patient. RN-O stated the psychiatrist spoke about ensuring P1 was safe for the next 24 hours while attempting to stabilize P1 on medication. RN-O stated the restraint order was active for four hours, at which time the nurse who was responsible for the patient needed to contact the physician or psychiatrist for a new restraint order, or discontinue the restraints when nursing felt the patient was no longer a danger to himself or others. RN-O was aware of the facility policy on restraints and all training and education was up to date.

During interview on 9/1/17, at 9:00 a.m. RN-F stated on 8/18/17, P1 had been placed in four point restraints earlier that day prior to her arrival at the hospital. RN-F stated when she arrived at the hospital and received patient report from the nurse, she understood the psychiatrist wanted P1 to continue in restraints until the next morning (8/19/17), to prevent further self injury due to P1's impulsiveness. RN-F stated P1's antipsychotic medications were adjusted and staff wanted to ensure the patient was safe until the medication was administered and had time to take effect to decrease the patient's impulsivity and risk of further self injury. RN-F stated the restraint order was renewed every four hours per facility policy because of P1's extreme behavior of stabbing himself in the eye with a pen and impulsiveness prior to being placed in restraints. RN-F stated the restraint order for P1 was renewed with the weekend on call physician who was aware of P1's condition and impulsiveness. RN-F was aware of the facility policy on restraints and all training and education was up to date.

During interview on 9/1/17, at 11:45 a.m. Psychiatrist (P)-E stated P1 was impulsive and at high risk for injuring himself or others. P-E stated he wrote the initial restraint order for P1 on 8/18/17, after P1 stabbed himself in the eye with the pen. P-E stated he spoke with nursing staff and informed them P1 may need to remain in restraints for a period of time to prevent further self injury. P-E stated medication adjustments were implemented for P1 and he spoke to staff about allowing some time for the medication to take effect with decreasing the patient's impulsiveness. P-E stated nursing staff were responsible for obtaining a new restraint order every four hours and reassessing the patient to ensure restraints were removed as soon as P1 no longer had thoughts of self harm or harm to others.

The facility policy titled, Restraints and Seclusion, dated 2/2017, indicated restraints may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others, and must be discontinued at the earliest time possible. The use of restraints must be limited to the duration of the emergency situation. The restraint type was determined by the patients behavior and physician order, and directed to apply a minimum of two restraints which must be applied to alternating limbs (i.e. right wrist and left ankle). The clinical nurse must reassess the patient for discontinuation of restraints. The criteria for discontinuation may include the patient no longer exhibits behavior that could result in injury to self or others, the patient was able to commit to safe behavior, and threats have ceased.