HospitalInspections.org

Based on review of one (1) of four (4) medical records reviewed for patients in restraints (Medical Record #1), staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure staff notify the patient's family or guardian when a patient is placed in restraints.

Findings include:

Reference: Facility policy, "Restraints and Seclusion" states, "... General Guidelines... 4. Staff will notify the family or guardian identified on the Patient Contact List of the reasons for the use of restraints. When clinically feasible, the staff will obtain the patient's consent. ... ."

1. Review of Medical Record #1 on 9/8/21 revealed the following:

a. The patient arrived to the Emergency Department (ED) on 6/8/21 at 3:03 PM with a chief complaint of a possible stroke.

b. ED notes dated 6/8/21 at 3:43 PM state, "Patient reports mother's contact information is [name and telephone number of mother]."

c. Review of the Patient Care Timeline indicated that an order for non-violent restraints was entered on 6/8/21 at 5:01 PM.

(i) The Non-Violent Restraint order states, "Clinical Justification: Attempting to disrupt treatment; Pulling tubes/drains... Education... Patient's Response to Intervention: Uncooperative/Unable to follow directions; Extremely Restless/Agitated; Confused/Disoriented... Family Notification: Patient declined notification."

d. Documentation on the nursing flowsheet at 5:01 PM and 7:02 PM states, "Family Notification: Patient declined notification."

(i) Documentation in the medical record indicated the patient was confused, disoriented, and unable to follow direction. There was no evidence the patient was capable of giving consent to decline family notification.

(ii) There was no evidence the patient's mother, identified as a person of contact, or any other family member, was notified regarding the use of restraints for Patient #1.

2. On 9/8/21 at 2:33 PM, Staff #24 confirmed there was no evidence in the medical record the family was notified that Patient #1 was placed in restraints, at the time of restraint application.

3. Upon interview, Staff #1 confirmed the family was not made aware of the use of restraints for Patient #1 until 8:00 PM, when a family member arrived to the patient's bedside.

Based on review of one (1) of three (3) medical records reviewed for patients with suicidal ideation (#6), staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure patients assessed to be at moderate risk for suicide, are placed on one-to-one (1:1) observation for safety.

Findings include:

Reference: Facility policy, "Care of the Patient Assessed to be at Risk for Suicide" states, "... 3. Any patient assessed as at-risk for suicide will be placed under an appropriate level of interventions... Moderate Risk... Order 1:1 sitter and maintain direct visual eye contact at all times at arm's length distance from the patient with consideration of staff's safety, including while patient is toileting... ."

1. Review of Medical Record #6, on 9/9/21, revealed the following:

a. The patient arrived to the ED on 8/31/21 at 9:58 AM with complaints of intentionally putting his/her arm through a glass window in anger.

b. The patient had a crisis evaluation performed on 8/31/21 at 3:00 PM. Crisis evaluation notes state, "Clinical Summary: This patient is a 22 year old male who presents as extremely impulsive and reckless, with no regard for the consequences of harm to himself when he put his hand and arm through a glass window, causing extensive injury to himself. ... Patient denies current suicidal thoughts, but hospital records indicate patient has a history of once [sic] suicide attempt via intention MVA. At this time, patient presents as a current danger to himself and others. If medically cleared, patient will requires [sic] a psychiatric admission for safety and stabilization. ... ."

(i) A Columbia Suicide Severity Rating Scale (C-SSRS) conducted on 8/31/21 at 2:00 PM indicated the patient was a moderate risk for suicide.

c. Review of physician orders indicated the patient was placed on 1:1 observation on 9/4/21 at 4:58 PM, four (4) days after the patient was initially identified as a moderate risk for suicide.

d. There was no evidence of physician documentation indicating the patient did not require 1:1 observation after being assessed as a moderate risk for suicide.

2. Staff #1, Staff #2, and Staff #5 confirmed the above finding on 9/9/21 at 2:45 PM.

Based on medical record review, staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure orders for restraints, to manage violent or self-destructive behaviors, are renewed a minimum of every four (4) hours for patients 18 years of age and older.

Findings include:

Reference: Facility policy, "Restraints and Seclusion" states, "... Patients Demonstrating Violent/Self-Destructive Behavior... 4. Each order for restraint or seclusion for management of the Violent/Self-destructive behavioral management... a. 4 hours for adults 18 years of age or older... ."

1. Review of Medical Record #10, on 9/9/21, revealed the following:

a. The patient was admitted to the facility on 7/2/21 at 9:54 PM. An initial physician order for restraints for violent or self-destructive behavior was entered on 7/5/21 at 6:37 PM.

(i) An order for restraints for violent or self-destructive behavior was entered on 7/5/21 at 10:38 PM. The order for restraints for violent or self-destructive behavior was renewed on 7/6/21 at 8:10 AM, nine (9) hours and thirty-two (32) minutes after the previous restraint order was entered.

(ii) An order for restraints for violent or self-destructive behavior was entered on 7/6/21 at 11:04 AM. The order for restraints for violent or self-destructive behavior was renewed on 7/6/21 at 4:29 PM, five (5) hours and twenty-five (25) minutes after the previous restraint order was entered.

2. Staff #1, Staff #2, and Staff #5 confirmed the above findings on 9/9/21 at 2:45 PM.

Based on observation, staff interviews, and review of facility documents, it was determined the facility failed to screen all visitors for COVID-19, in accordance with facility policy and procedures.

Findings include:

Reference: Facility document, "Visitor Information" states, "... All visitors/support persons will be screened to determined if they have tested positive for COVID-19 within the past 14 days, have a pending COVID-19 test or have someone within their household who tested positive for COVID-19 within the past 14 days. Hospital visitors/support persons will be required to complete temperature and symptom screening upon entering the facility. If the individual does not pass any element of the screening, they will not be permitted to visit. ... ."

1. Upon entry into the facility at 9:45 AM, this surveyor was greeted by Staff #7, who asked this surveyor to hand sanitize and proceed to the Patient Liaison's desk for assistance. Staff #7 did not ask this surveyor COVID-19 screening questions.

a. At the Patient Liaison's desk, this surveyor was greeted by Staff #8. This surveyor indicated the reason for the visit and Staff #8 stated he/she would notify facility staff. Staff #8 did not ask this surveyor COVID-19 screening questions.

b. While waiting for facility staff, multiple visitors were observed entering the facility and being assisted by Patient Liaisons without being asked COVID-19 screening questions.

2. Upon interview on 9/8/21 at 10:55 AM, Staff #1 confirmed staff were required to ask COVID-19 screening questions to all visitors entering the facility.

3. On 9/8/21 at 11:05 AM, Staff #8 confirmed he/she did not ask this surveyor COVID-19 screening questions.