HospitalInspections.org

Based upon medical record review, review of restraint policies, observations and staff interview, it was determined that the facility failed to meet the Condition of Participation for Patient Rights as evidenced by:

The facility failed to ensure that in-person assessments were performed for patients within twenty-four hours of restraint initiation of "non-violent/non-destructive restraints". (See findings at A167)

The facility failed to ensure that staff conducted restraint monitoring every thirty minutes for patients in "violent/self- destructive restraints". (See findings at A175)

The facility failed to ensure that practitioners authorized to order restraints complete yearly restraint training. (See findings at A176)

The facility failed to ensure that face to face assessments were conducted within one hour on all patients who were placed in "violent/self destructive restraints." (See findings at A178)

Failure to comply with minimum standards for restraint use can result in physical and/or psychological harm to patients.

Based on record review and interview, physician staff failed to document an in-person assessment within twenty-four (24) hours of restraint initiation to verify that the restraint is needed, and that less restrictive measures are not appropriate. This finding was observed in one (1) of fourteen (14) patients in the sample (Patient #7).


Review of medical record for Patient #7 on 4/30/2024 revealed that physician orders were written for non-violent/non self destructive behavior on 4/21/2024 at 1024, 4/22/2024 at 1855 and 4/23/2024 at 2033. The physician failed to document an in person assessment of Patient #7 within 24 hours of each restraint order to verify that restraint is needed.

Facility policy entitled "Restraint use for Non-Violent/Non-Destructive Behavior 2/16/98, revision 6/24/22" and reviewed by the SA survey staff on 5/1/2024 indicates that "The prescriber will perform an in-person assessment of the restrained patient within 24 hours of initiation to verify that the restraint is needed, and that less restrictive measures are not appropriate."

Based on record review, staff failed to monitor, per hospital policy, the conditions of patients who were restrained for violent/self-destructive behavior and non violent/non self destructive behavior. This finding was identified in 2 of 14 patients in the sample (patients #5, #7).

Findings: Medical record for patient #5 was reviewed on 4/30/2024. Survey staff noted that on 4/29/2024 from 1200 to 1305 in the Emergency Department patient #5 was restrained in five point restraints. "Restraint Monitoring Every 30 Minutes" flowsheet was not documented by nursing for that time period.

-Medical record for Patient # 5; during stay on Medical Intensive Care Stepdown unit, for application of violent restraints that began on 4/29/2024 at 1546, "Restraint Monitoring Every 30 Minutes" flowsheet was not documented between 1646-1923 and 2154-0035. There is no date or time when these restraints were removed.

-Facility policy entitled "Restraint use for Violent/Self Destructive Behavior Management 3/23/07, revised 2/20/24" and reviewed by the SA survey staff on 5/1/2024 indicates that "the physical and emotional wellbeing of the restrained/secluded patient are continually assessed, monitored, reevaluated every thirty (30) minutes by an RPN." (Registered Professional Nurse)

-Medical record for Patient #7 reviewed on 4/30/2024: patient was restrained for non-violent/non-self-destructive behavior from 4/21/2024 at 1424 to 4/22/2024 at 0738. "Restraint Monitoring Every 30 minutes" flowsheet was not documented by nursing between 1024-1200, 2100-2234 and 2254-0738.

-Facility policy entitled "Restraint use for Non-Violent/Non Destructive Behavior 2/16/98, revised 6/24/22" and reviewed by the SA survey staff on survey on 5/1/2024 indicates that "An assessment of the patient's condition shall be made at least every 30 minutes or at more frequent intervals if directed by a prescriber."

Based on record review and interview, the facility failed to conduct yearly restraint training for 2 of 5 physicians and licensed independent professionals reviewed during the survey.

Findings:

-Education files of staff members were reviewed by the State Agency (SA) during the survey on 5/2/2024. Two physicians ( X and BB ) did not complete annual mandatory training as required by the hospital.

-This was verified with the Director, Hospital Regulatory Affairs (Staff M) on 5/2/2024 at approximately 1:30 PM

-Review of the medical record of Patient # 1 completed on 5/3/2024 revealed that Staff X wrote 18 of the 53 non compliant physician orders for violent restraint.

Based on record review and interview, physician staff failed to document a "face to face" evaluation within one hour of placing patients in violent/self destructive restraints. This finding was observed in three (3) of fourteen (14) patients in the sample. (Patients #1, #5, and #7).

Findings include:

Patient 1's medical record was reviewed on 5/3/24 and revealed physician orders placing Patient 1 in restraints for violent/self-destructive behavior fifty (50) times on the following dates and times:

· On 4/11/2024 at 1438 (staff MM), 2045(staff OO), and 2341(staff NN)
· On 4/12/2024 at 0433 (staff PP), 0949 (staff QQ), 1009 (staff RR), 1546 (staff QQ), and 2055 (staff SS)
· On 4/13/2024 at 0105 (staff SS), 0534 (staff SS), 0919 (staff X), 1257 (staff X), and 1755 (staff TT)
· On 4/14/2024 at 0150 (staff SS), 0757 (staff X), and 2213 (staff PP)
· On 4/15/2024 at 0421 (staff PP), 0800 (staff X), 1240 (staff X), and 2112 (staff PP)
· On 4/16/2024 at 0359 (staff PP), 0656 (staff PP), 1041 (staff X), 1520 (staff X), and 1909 (staff X)
· On 4/17/2024 at 0011 (staff PP), 0508 (staff PP), 0952 (staff X), 1444 (staff X), and 1859 (staff X)
· On 4/18/2024 at 0035 (staff PP), 0531 (staff PP), 0928 (staff X), 1414 (staff X), 1809 (staff X), and 2233 (staff UU)
· On 4/19/2024 at 0246 (staff PP) and 2102 (staff PP)
· On 4/20/2024 at 0115 (staff PP)
· On 4/21/2024 at 0759 (staff X), 1328 (staff X), 1627 (staff XX), 2031 (staff WW)
· On 4/22/2024 at 0213 (staff QQ), 0617 (staff XX), 1011(staff YY) , and 2113 (staff QQ)
· On 4/23/ 2024 at 0251 (staff QQ) and 2336 (staff XX)
· On 4/24/2024 at 0512 (staff XX)

Patient 1 was placed in restraints fifty (50) times, however, there were only three (3) documented face to face assessments conducted by a physician as follows:

· On 4/20/2024 restraint reorder placed at 0115. At 1045, staff X conducted a face to face assessment 9.5 hours later.
· On 4/21/2024 restraint placed 0759. At 1008, staff X conducted a face to face assessment of the patient two (2) hours later.
· On 4/22/2024 restraint placed at 0213. At 0617, staff XX conducted a face to face assessment of the patient four (4) hours later.

-Staff "X" (physician) stated on interview on 5/1/2024 at 1112 that they have completed training modules on restraints but was not aware of the requirement for "face to face" documentation in the EPIC electronic medical record system until 4/20/2024. He stated he was not aware a note had to be completed when re-ordering restraints.

Patient 5's medical record was reviewed on 5/3/24 and revealed physician orders placing Patient 5 in restraints for violent/self-destructive behavior seven (7) times on the following dates and times:


· 4/28/2024 at 2336 (staff A)
· 4/29/2024 at 0339 (staff A) and 1218 (staff B)
· 4/29/2024 at 1546 (staff A), 1923 (staff C), and 2336 (staff A)
· 4/30/2024 at 0305 (staff SS)

The physician failed to document "face to face" evaluations within one hour of placing the patient in violent/self destructive restraints on the above dates/times.

Patient 7's medical record was reviewed on 5/3/24 and revealed a physician order placing Patient 7 in restraints for violent/self-destructive behavior one (1) time on the following date and time:
· 4/22/2024 at 1558 for restraint order placed by staff D.

There was no face to face assessment completed by the prescriber.

These findings were verified with Staff M (Director, Hospital Regulatory Affairs) on 5/1/2024 at 1751.

-Facility policy entitled "Restraint use for Violent/Self Destructive Behavior Management 3/23/07, rev. 2/20/24" and reviewed by the SA survey staff on 5/1/2024 indicates that the "The prescriber must complete a face to face assessment and evaluate the need for restraint within (1) hour of the initiation of the intervention."