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Based on interviews and record review the facility failed to ensure a patient transported to an outside facility would meet the criteria for admission after a change in condition occurred in 1 of 1 transfers reviewed (Patient #1).

The failure resulted in the patient denial for admission upon arrival to the outside facility.

FINDINGS

POLICY

According to Emergency Medical Treatment and Active Labor Act, one purpose of the policy is to describe the procedures for transfer of individuals in need of specialized emergency medical services not available at the initiating facility.

When the hospital transfers an individual with an unstabilized emergency medical condition to another facility the transfer will be carried out in accordance with the following procedures: A representative of the receiving facility must confirm that the receiving facility has available space and qualified personnel to treat the individual; and the receiving facility agrees to accept transfer of the individual and to provide appropriate medical treatment.

Additionally, the hospital will send the receiving facility copies of all pertinent medical records available at the time of transfer.

1. The facility failed to ensure the receiving hospital was provided with information pertinent to the care of Patient #1.

a) Patient #1 presented to the emergency department (ED) on 06/07/16 for evaluation and medical clearance. Patient #1 was found to be in need of psychiatric care unavailable at the ED. On 06/09/16 at 1:50 p.m. an outside facility agreed to accept the transfer of Patient #1 for specialized care of an emergency medical condition (EMC). Further review of the ED record of Patient #1 revealed a change in the patient's condition at 3:20 p.m., specifically, the patient suddenly became violent and required the use of leather restraints on 4 limbs (point) and sedation.

The patient was transported by ambulance to the outside facility sedated and in 4-point restraints. Documentation within the Progress Note section of the medical record stated the patient had been denied admission to the outside facility after s/he arrived because the patient had been restrained and sedated during transport.

b) An interview was conducted with the Medical Social Worker (MSW #2) on 10/04/16 at 2:48 p.m. According to MSW #2, the pertinent medical records of Patient #1 were faxed to the outside facility and acceptance for admission occurred at 1:50 p.m. On 06/09/16. MSW #2 confirmed a nurse to nurse report was provided but no physician to physician contact was made. MSW #2 stated s/he was unaware the outside facility did not accept patients who required restraints or sedation during transport. According to MSW #2, s/he believed the RN was instructed by the outside facility to sedate the patient prior to transport and when the RN entered the room to administer the medication Patient #1 then became violent.

MSW #2 stated s/he did contact the outside facility after Patient #1 was placed in restraints and medicated. Documentation in the ED Behavioral Health Evaluation form revealed MSW #2 spoke with a staff member of the outside facility on 06/09/16 at 11:43 a.m., which was before the patient was medicated and restrained.

A progress note written by MSW #2 on 06/09/16 at 6:53 p.m. (approximately 3 hours after the patient was transferred) revealed Patient #1 was refused admission to the outside facility due to the use of 4-point restraints and sedation during transport.

During a second interview with MSW #2 on 10/05/16 at 10:30 a.m., s/he stated the Electronic Health Record was left unsigned for several hours and the note was continued after the change in the patient's condition on the day of transfer. As there was no documented time the notification occurred, MSW #2 stated s/he could not prove the documentation of notification to the receiving facility occurred prior to notification the receiving facility would not accept Patient #1.

c) Review of the documentation by the discharging Registered Nurse, on 10/05/16 at 4:33 p.m., revealed a note which stated the receiving facility was notified the patient had to be restrained and was willing to still accept the patient. There was no documentation to show whom at the receiving facility the RN spoke with.

d) During an interview with the Director of the ED (Director #3) on 10/05/16 at 10:30 a.m. Director #3 stated s/he was sure the ED staff did their due diligence in communicating the condition of Patient #1 to the outside facility prior to transport. Director #3 confirmed the documentation was lacking and could be improved.

e) An interview was conducted with the Medical Director of the ED (Physician #4) on 10/05/16 at 1:21 p.m. According to Physician #4 in all ED transfers there is communication between the sending and receiving physician except in the case of psychiatric transfers due to the continuous change of physician care throughout the patient's stay. Physician #4 stated the receiving physician at the outside psychiatric facility was informed by psychiatric staff of the patient's condition and it was then up to the receiving physician to contact the ED sending physician with any questions.

Physician #4 was unaware Patient #1 had been transported in 4-point restraints and sedated and such a process would not be typical when transferring a patient. According to Physician #4 there would be an expectation for communication to occur between the sending ED staff and the receiving outside facility when a change in the condition of the patient occurred.

There is no documentation to support the outside facility was informed of the condition change of Patient #1. The safety of Patient #1 was placed at risk when Patient #1 had to be restrained and sedated for an approximate 3-hour transport then again transported to another ED after the accepting facility refused the patient.

Based on interviews and record reviews the facility failed to ensure orders for restraints were completed according to facility policy. Specifically, 2 out of 5 restraint records reviewed revealed a lack of, or inaccurate documentation of the restraint documentation (Patients #8 and #9).

The failure created the potential for patient safety to be placed at risk due to incomplete monitoring of patient in restraints.

FINDINGS

POLICY

According to Restraint or Seclusion: Behavioral restraints, behavioral or seclusion is limited to the Psychiatric Emergency Department (ED) and treatment area. The purpose of the policy is to provide a systematic and safe approach to restraint and seclusion while protecting the patient's health and safety and preserving their rights. Each episode of restraint requires an order which is time-limited and written prior to the restraint placement or within minutes of restraint placement.

Assessment, observation and documentation required for behavioral restraint include:
a. every 15-minute observation and documentation of restraint type;
b. location of properly applied restraint;
c. psychological status;
d. behaviors demonstrated, including criteria for release;
e. orientation and level of consciousness;
f. circulation and airway;
g. restraint assessment;
h. activity and position;
i. comfort care provided.

Restraint: Non-Behavioral maintain the same documentation and ordering requirements except assessment, observation and documentation requirements are every 2 hours.

1. The facility failed to ensure timely orders for restraints.

a) The medical record of Patient #8 revealed admission to the facility on 9/29/16 for intoxication with changes in consciousness and aggressive behavior. According to the Restraint Ongoing Assessment flowsheet, behavioral (BH) restraints were applied on 9/29/16 at 4:45 p.m. with an order written at 4:49 p.m. for soft limb restraints to all four limbs for a duration of 4 hours, which expired at 8:49 p.m.

Continued review of the Restraint Ongoing Assessment flowsheet revealed the patient was assessed as asleep on 9/29/16 beginning at 9:45 p.m. until 10:10 p.m. at which time the Justification for Removal of restraints was documented as the patient was no longer threat to self or others, was calm and sleeping. In the Orientation section of the flowsheet the patient was documented to be sedated beginning at 9:45 p.m. At 10:31 p.m. on 9/29/16 there was a Free Text note from the ordering physician which stated the patient was out of restraints, more than 90 minutes after the restraint order expired.

There were no additional orders written to maintain the patient in restraints beyond the 4-hour time limit in contrast to facility policy.

b) Patient #9 was admitted to the facility on 10/01/16 for injuries from a motor vehicle accident and emergency surgical intervention was necessary. During the post-operative period when the patient was still sedated the patient was documented on the Restraints Ongoing Assessment flowsheet to have been involuntarily attempting to remove medical equipment critical to continued safe care. According to Patient #9's medical record soft wrist restraints were applied on 10/01/16 at 8:00 p.m. and discontinued on 10/02/16 at 7:50 a.m.

Review of the order section of the medical record revealed Non-Behavioral restraints were not ordered until 10/02/16 at 8:03 a.m., a full 12 hours after placement of the restraints in contrast to facility policy.

c) An interview was conducted on 10/03/16 at 9:22 a.m. with the psychiatric ED registered nurse (RN #1). RN #1 verified the facility used BH restraints for patients who become violent and a danger to themselves and staff. According to RN #1 BH restraints have a strict time limit of 4-hours for adults (> 18 years old) and a 2-hour limit for pediatric patients (9-17 years old). RN #1 further confirmed a new restraint order was required for each new time-frame.

d) RN #6 was interviewed on 10/03/16 at 3:03 p.m. According to RN #6, non-behavioral restraints were used primarily for patient safety on the medical unit. RN #6 confirmed non-behavioral restraints were required to be reviewed every 24 hours for evaluation of continued necessity or discontinuation by the physician. RN #6 stated there was a section within the electronic health record (EHR) to record the care and monitoring of patients in restraints along with an automatic pop up feature when an order was near expiration to alert the physician a renewal or cancellation order must be written.

e) In an interview conducted with the Assistant ED Manager (RN #6) on 10/05/16 at 10:30 a.m. a review of restraint documentation for Patient #8 was completed. According to RN #6 the documentation for removal of restraints from Patient #8 was correctly documented except the nurse inaccurately documented the restraints were continued.

f) On 10/05/16 at 2:06 p.m. a review of the restraint record of Patient #9 was reviewed with the Regulatory Manager (Manager #5). Manager #5 stated s/he performed monthly audits of a sample of restraint records in addition to the daily restraint audits which were performed by nurse managers, assistant nurse managers or charge nurse of each unit.

Manager #5 confirmed restraints were placed on Patient #9 at 8:00 p.m. on 10/01/16 and the order for restraints was not written until 10/02/16 at 8:03 a.m. Manager #5 stated the restraint order was supposed to be written within minutes of restraint placement, not 12 hours later.