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Based on facility policy review, medical record review, and staff interviews, the facility staff failed to monitor a violent restraints patient according to facility policy for 1 of 2 physical violent restraint patients reviewed (Patient #3).

The findings included:

Review of the facility policy "(named) Restraint (Restraints) Policy" effective 09/22/2018, revealed, "Documentation of Violent Restraints/Seclusion: Violent restraint Q15 (every 15) minute documentation requirements by a registered nurse or other health care professional. - Psychological status, Clinical justification, Assessment for continued need and signs of injury, Distal pulses in restrained limb, Restraint type, Fluids, elimination and nutrition offered..."

Open medical record review of Patient #3 revealed an 84-year-old male admitted to the General Medicine and Dialysis unit of the facility on 12/13/2021 at 1918. Review of the Admission History & Physical dated 12/14/2021 at 1334 revealed, "Chief Complaint: Suicidal ideation. History of Present Illness... PMH (previous medical history) CKD (chronic kidney disease) Stage 3, HTN (hypertension), Hyperlipidemia, Cognitive Impairment..." Review of Physician Orders revealed, "Restraints violent or self-destructive adult... Electronically signed by: NP #2 on 01/21/22 2117... Frequency: Continuous x 4 hours... Restraint type... Soft restraint right wrist, soft restraint left wrist. Restraint reason: Severely aggressive behavior..." Review of Violent Restraints flowsheets revealed no monitoring documentation. Review of Non-Violent Restraints flowsheets revealed Visual Q1h Checks documented by RN #1 at 01/21/2022 at 2120, 01/21/2022 at 2300, 01/21/2022 at 2352, 01/22/2022 at 0028, and 01/22/2022 at 0121. Review of Non-Violent Restraints flowsheets dated 01/21/2022 at 2115 by RN #1 revealed, "Clinical Justification for Restraints: Prevent unsafe ambulation. Face to Face with Provider: No..." Review of Restraint Monitoring Skin Integrity, Range of Motion, Correct Application, Distal Pulses, Fluids, Food Meal, Elimination revealed documentation by RN #1 dated 01/21/2022 at 2300 and 01/22/2022 at 0028. Record review revealed Patient #3 was released from restraints 01/22/2022 at 0115. Medical record review failed to reveal documentation on a 15-minute interval for the monitoring of violent restraints.

Interview on 01/26/2022 at 1142 with RN #1 revealed she recalled providing nursing care for Patient #3. Interview revealed Patient #3 was "combative" and "kicking" during medication administration. Interview revealed RN #1 and the Charge Nurse applied wrist restraints and contacted the provider via "secure chat." Interview revealed RN #1 was aware that the order was written for violent restraints and chose not to contact the ordering provider to clarify her concerns. Interview revealed RN #1 assumed the provider meant non-violent restraints and documented the restraints according to the non-violent restraints policy. Interview revealed RN #1 monitored Patient #3 at a hourly visualization and every two hour documentation rate. Interview revealed RN #1 did not monitor Patient #3 on an every 15 minute basis while in violent restraints. Interview revealed RN #1 was aware that the monitoring of violent and non-violent restraints were performed at different intervals and acknowledged that she had received training on restraints upon hire.

Interview on 01/26/2022 at 1247 with Clinical Director #3 revealed the facility expectation was that staff follow the restraints policy. Interview revealed staff receive restraint training upon hire and annually. Interview revealed if a nurse has concerns about restraint orders, then they should activate the chain of command.

Interview on 01/26/2022 at 1401 with NP #2 revealed he was aware of the violent restraints order written for Patient #3. Interview revealed NP #2 was on "cross coverage" on the night of 01/21/2022. Interview revealed NP #2 received a secure chat message about Patient #3 acting aggressive. Interview revealed the described behavior of Patient #3 was the rationale for ordering violent restraints. Interview revealed NP #2 intended for the restraints to be violent restraints and monitored as such. Interview revealed the restraints were to be discontinued as soon as Patient #3 calmed down and was no longer acting aggressively.

Interview on 01/26/2022 at 1430 with NM #4 revealed she was unaware of the failure to monitor violent restraints according to order with Patient #6. Interview revealed violent restraints are rarely used on the General Medicine and Dialysis unit. Interview revealed the expectation that nursing staff monitor and document restraints according to policy. Interview revealed any questions or concerns about restraint orders were expected to be relayed to the ordering provider or communicated via the chain of command.

Based on facility policy review, medical record review, and staff interviews, the facility staff failed to perform a face-to-face evaluation for a violent restraint patient according to facility policy for 1 of 2 violent physical restraints patients reviewed (Patient #3).

The findings included:

Review of the facility policy "(named) Restraint (Restraints) Policy" effective 09/22/2018, revealed, "... For violent restraints, a face to face assessment by the MD/PA/NP must be documented within 1 hour of application... The face-to-face assessment includes an evaluation of the patient's immediate situation, their reaction to the restraint intervention, their medical and behavioral condition and the need to continue or terminate the restraint or seclusion..."

Open medical record review of Patient #3 revealed an 84-year-old male admitted to the General Medicine and Dialysis unit of the facility on 12/13/2021 at 1918. Review of the Admission History & Physical dated 12/14/2021 at 1334 revealed, "Chief Complaint: Suicidal ideation. History of Present Illness... PMH (previous medical history) CKD (chronic kidney disease) Stage 3, HTN (hypertension), Hyperlipidemia, Cognitive Impairment..." Review of Physician Orders revealed, "Restraints violent or self-destructive adult... Electronically signed by: NP #2 on 01/21/22 2117... Frequency: Continuous x 4 hours... Restraint type... Soft restraint right wrist, soft restraint left wrist. Restraint reason: Severely aggressive behavior..." Medical record review revealed violent restraints for Patient #3 were intitiated 01/21/2022 at 2115 by RN #1. Medical record review revealed the violent restraints for Patient #3 were discontinued by RN #1 on 01/22/2022 at 0115. Review of Physician Notes failed to reveal documentation of a face to face assessment for the 01/21/2022 violent restraint order.

Interview on 01/26/2022 at 1401 with NP #2 revealed he recalled the violent restraints order written for Patient #3. Interview revealed NP #2 was on "cross coverage" at home on the night of 01/21/2022. Interview revealed NP #2 wrote the order for the violent restraints and did not perform the face to face assessment. Interview revealed NP #2 acknowledged a communication failure with the onsite physician to perform the face to face assessment. Interview revealed NP #2 had received training on restraints and was aware of the face-to-face requirement.

Interview on 01/26/2022 at 1142 with RN #1 revealed she recalled providing nursing care for Patient #3. Interview revealed Patient #3 was "combative" and "kicking" during medication administration. Interview revealed RN #1 and the Charge Nurse applied wrist restraints and contacted the provider via "secure chat" for a restraint order. Interview revealed the provider team did not perform a face to face assessment on Patient #3 on the night shift of 01/21/2022.

Interview on 01/26/2022 at 1247 with Clinical Director #3 revealed the facility expectation was that staff follow the restraints policy. Interview revealed staff receive restraint training upon hire and annually.


NC00183404
NC00184079