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Based on review of the hospital's policy and procedures, Health Care Power of Attorney (HCPOA) documentation, medical record review, and staff interviews, the hospital staff failed to notify a patient's Health Care Power of Attorney (HCPOA) of the need for restraint for 1 of 1 patient requiring the use of non-violent restraints with a designated HCPOA (Patient #2).

The findings included:

Review of the hospital's policy, "Restraint Use - Non-Violent", Number IRI.ADM.0004, revised 12/14/2016, on 03/10/2020 revealed "...Nonviolent, non-self-destructive behavior are those behaviors resulting from confusion, disorientation.... that the patient is not responsible for safe decision-making and may cause accidental harm self or others. The patient may be interfering with medical interventions or may be compromising their safety/wellbeing. ... Documentation ... e. When appropriate, notification of family/legally responsible representative. ..."

Review on 03/11/2020 of Patient #2's Health Care Power of Attorney document provided by the hospital's accreditation team revealed it was signed by the patient and witnessed by a Notary Public on 05/19/2005.

Closed medical record review on 03/10/2020 revealed a 70-year-old presented to the hospital's Emergency Room (ER) via Emergency Medical Services (EMS) on 12/11/2019 at 1726 with altered mental status (Patient #2) and transferred to another hospital, per the family's request, on 12/12/2019 at 2233. Review of the ER provider note by MD #1 revealed that when upon arrival to the ER, the patient "seemed to have some confusion." She also reported, "...that the left side of her head is [sic] hurt all day today ... Head CT (computed tomography) is negative. Labs reassuring. No evidence of infection on her urine ... (Family member) is here and think [sic] she is slightly confused which seems to come and go as well. ..." Review revealed Continuous Cardiac Monitoring was initiated at 2206 by a Registered Nurse (RN #1), prior to the patient's transfer to the Acute Care Medical Surgical Unit. Review of the "Cardiac Monitor Event Log", dated 12/12/2019 at 0129, revealed a note by the Cardiac Monitor Unit Technician (CMUT) stating, "called (RN) about leads off in 213 (Patient #2's room). pt ripping leads off." Review of a nursing note by RN #2 on 12/12/2019 at 0145 revealed, "pt (Patient) is agitated and won't keep gown or leads [cardiac monitor] on. needing something for anxiety." Review revealed MD #2 was notified and ordered Ativan [sedative used to treat anxiety] 0.5 mg IV push [administered in the vein] at 0145. Review of the "Non-Violent Restraints" note at 0200 by RN #2 revealed, the patient became "agitated" and attempted to hit staff. MD #2 was notified at 0200, and the patient was placed in Non-violent, bilateral soft wrist and ankle restraints at 0200. Review revealed the patient remained in Non-violent restraints until 0858, when the HCPOA arrived. Review of a Physical Therapy (PT) note by PT #1, on 12/12/2019 at 1153, revealed "... Per RN, pt's family very upset due to pt being placed in restraints overnight without family's acknowledgement. ..." Review failed to reveal documented notification of the HCPOA of the need for Non-Violent Restraint per hospital's policy.

Interview with the Director of Accreditation (DA), on 03/11/2020 at 1000, revealed RN #2 (RN who initiated the Non-Violent restraints) was no longer an employee of the hospital and was not available for interview.

Interview with RN #3, on 03/11/2020 at 1143, revealed she was Patient #2's primary nurse on 12/12/2019 during the 7a-7p shift. Interview revealed the patient's HCPOA was "very upset" when she came in and found the patient in restraints without her knowledge. Interview revealed, "She wanted to know what was going on, why she wasn't notified (of the need for restraints) and wanted to speak with the doctor." Interview revealed RN #3 was not aware the patient's HCPOA had not been notified of the need for Non-Violent restraint use and that according to the hospital policy, the HCPOA should have been notified.

Interview with MD #3, on 03/11/2020 at 1349, revealed the HCPOA was upset because she was not aware the patient had been placed in restraints during the night and wanted to know why she had not been notified. Interview revealed the hospital staff failed to notify the patient's guardian of the need for Non-Violent restraint per policy.

Based on review of hospital policy and procedure, medical record review, and staff interview, the hospital's medical staff failed to document elements of the face-to-face assessment for 2 of 2 patients (Patient #3 and #10) following initiation of violent restraints per policy.

The findings included:

Review on 03/12/2020 of the hospital's policy, "Restrain/Seclusion," CSG.CSG.001, effective 01/29/2020, revealed "... 9. Face-to face assessment by a Physician or LIP: a. A face-to-face assessment by a physician or LIP (Licensed Independent Practitioner), RN or physician assistant with demonstrated competence, must be done within one (1) hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN/PA will: 1) Work with the staff and patient to identify ways to help the patient regain control 2) Evaluate the patient's immediate situation 3) Evaluated the patient's reaction to the intervention 4) Evaluate the patient's medical and behavioral condition 5) Evaluate the need to continue or terminate the restraint or seclusion 6) Revise the plan of care, treatment and services as needed. ..."

Review om 03/12/2020 of the hospital's "PROVIDER RESTRAINT EDUCATION: NEW POLICY JANUARY 29, 2020" training revealed, "... FACE TO FACE EVALUATION - DOCUMENTATION A physician face to face assessment within one hour of violent behavior restraint placement must be completed and documented. An AP (Advanced Practitioner) can complete the face to face assessment in place of the physician ... The physician or AP documentation for the Face to Face Assessment occurs in the Violent Restraint Powerplan in the Face to Face phase. ..."

1. Open medical record review for Patient #3, on 03/12/2020 revealed a 23-year-old male who presented to the ER on 02/29/2020 at 1349 via law enforcement (LE) under Involuntary Commitment (court order). Review of the ER Report revealed, "Per per [sic] staff who talked to alone for cement [sic] (law enforcement), patient reports that he did methamphetamine today, was at a drugstore that he was banned from and was seen attempting to pleasure himself in the area. He also reportedly threatened to rob the store. Law enforcement placed him on IVC stating that he was a harm to himself or others. ..." Review of the nursing notes revealed on 02/29/2020 at 1627 the patient was "Agitated, Threatening to leave, Suspicious, Threatening" and was ordered Haldol (antipsychotic) 10 mg IM, Benadryl (antihistamine) 50 mg IM, and Ativan (Benzodiazepine) 2mg IM and a physical hold was utilized to administer the medications. Review of the restraint documentation by RN #4, on 02/29/2020 at 1754, revealed "... Restraints Violent Face to Face - Face to Face Completed within one hour by: MD/LIP/AP Face to Face completed by: (MD #6 name). Review failed to reveal documented evaluation of the patient's immediate situation, evaluation of the patient's reaction to the intervention, and evaluation the patient's medical and behavioral condition per policy.

Interview with RN #4, on 03/13/2020 at 1300, revealed that the patient became upset and wanted to leave the ER. A Behavioral Emergency Response Team (BERT) call (consists of staff members from behavioral health services who have experience in caring for patients with acute psychiatric disorders as well as competence in management of assaultive or escalating behavior) was made when the patient's behavior began to escalate. The patient was held while the medications were administered. Interview revealed, "the he (MD #4) was right there, assessing the patient while we administered the meds." Interview revealed nursing staff in the ER have historically documented that the Face to Face assessment was completed by the doctor as part of the restraint documentation. Interview revealed MD #4 did not document the Face to Face assessment per policy.

Interview with the ER Medical Director (MD #5), on 03/13/2020 at 1400, revealed the physician is in the ER when a violent restraint is initiated. When a manual restraint is required for the administration of medication, "It is conducted under the supervision of the physician. Once the patient is safe and stabilized, the face to face evaluation should be documented in the medical record by the physician." Interview revealed on 01/23/2020, during a Medical Staff meeting, the Chief of Staff informed physicians that the one-hour face to face assessment had been built into the medical record for physicians to complete and a mandatory training module was sent out for physicians to complete. Interview revealed physician's or APs are expected to document the one-hour face to face assessment for initiation of all violent restraints.

Interview with the Director of Accreditation, on 03/13/2020 at 1600, revealed nursing staff in the ED note that the one-hour face to face assessment has been completed as a "safety net" to assure documentation of completion. Interview revealed training was disseminated in January to all providers regarding changes to the "Restraint/Seclusion" policy, with the expectation that physicians would document the face to face assessment in the medical record. Interview revealed elements of the face to face assessment was not documented per policy.

2. Closed medical record review for Patient #10, on 03/13/2020, a 23-year-old with a history of methamphetamine abuse who presented to the ER via EMS with law enforcement (LE) on 02/12/2020 at 1923 due to "substance abuse and combative and psychotic (disconnection from reality) behavior." Review of the ER report by MD #6, on 02/12/2020 at 2000, revealed "...According to EMS who received a report from the patient's girlfriend, the patient has been combative all day long hitting his face and head on the floor, rolling around, and has not been able to be redirected. His girlfriend states he has used cocaine and methamphetamines today ... He is asleep on ED arrival due to combative behavior with EMS he was given 2.5 mg of versed (used for sedation). Review of the Restraint documentation by RN #5, on 02/12/2020 at 2147, revealed the patient was placed in bilateral lower and upper limb restraints at 1950 for "Combative, Danger to self and/or others, Destructive, Physical aggression, Violent" behavior. Further review of the restraint documentation by RN #5 "... Restraints Violent Face to Face - Face to Face Completed within one hour by: MD/LIP/AP Face to Face completed by: (MD #6 name). Review revealed elements of the face-to-face assessment were not documented by the physician per policy.

Interview with RN #4, on 03/13/2020 at 1300, revealed nursing staff in the ER have historically documented that the Face to Face assessment was completed by the doctor as part of the restraint documentation. Interview revealed MD #4 did not document the Face to Face assessment per policy.

Interview with the ER Medical Director (MD #5), on 03/13/2020 at 1400, revealed the physician is in the ER when a violent restraint is initiated. When a manual restraint is required for the administration of medication, "It is conducted under the supervision of the physician. Once the patient is safe and stabilized, the face to face evaluation should be documented in the medical record by the physician." Interview revealed on 01/23/2020, during a Medical Staff meeting, the Chief of Staff informed physicians that the one-hour face to face assessment had been built into the medical record for physicians to complete and a mandatory training module was sent out for physicians to complete. Interview revealed physician's or APs are expected to document the one-hour face to face assessment for initiation of all violent restraints.

Interview with the Director of Accreditation, on 03/13/2020 at 1600, revealed nursing staff in the ED note that the one-hour face to face assessment has been completed as a "safety net" to assure documentation of completion. Interview revealed training was disseminated in January to all providers regarding changes to the "Restraint/Seclusion" policy, with the expectation that physicians would document the face to face assessment in the medical record. Interview revealed elements of the face to face assessment was not documented per policy.


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