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Based on interview and record review, the hospital failed to assure restraints were discontinued at the earliest possible time for 1 of 7 applicable patients. (Patient #3) Findings include:

Per record review, Patient #3, age 55, was admitted to the hospital on 7/9/14 with diagnoses of Congested Heart Failure (CHF) with hypoxia (inadequate oxygen level), Type I Diabetes with chronic pain secondary to peripheral neuropathy. On 7/11/14 Patient #3 demonstrated increased agitation, refusing redirection from staff, pulled out IV and removed dressing from feet. Patient #3 attempted to exit room, physically grabbing and twisting an LNA's arm and attempted to break the window in his/her hospital room by repeatedly hitting the window with elbow stating this was his/her exit from the hospital.

Due to the imminent physical danger to the patient and staff and ineffective interventions, the decision was made by nursing staff to call a "Code Green". Per hospital policy Code Green: Team Intervention During Behavioral Crisis last reviewed 06/07/12, states the purpose of the Code Green is for "The management of a behavioral crisis involving aggressive, destructive, or assaultive acts by a patient or visitor.....ensures sufficient staff will be available to re-establish safety in an unsafe situation." Nursing staff determined Patient #3 required restraints. At 1530 Patient #3 was placed in 4-point restraints by nursing staff from 2 South receiving assistance from other staff who responded to the Code Green.

From 1530 on 7/11/14 through 7/12/14 at 1200 Patient #3 remained in 4 point restraints. At 1300 on 7/12/14 only the lower extremity restraints were removed. Per the "Patient Assessment/Restraint" Patient #3's behavior on 7/12/14 was repeatedly documented by nursing staff as "agitated movements" and the patient remained in bilateral upper extremity restraints. However, from 7/13/14 at 05:00 through 7/13/14 at 13:00 nursing documented the patient was sleeping for an 8 hour period. There was no evidence any attempt was made to remove the restraints or that an unsafe situation continued to exist during this period of time or that the patient demonstrated behaviors that impacted his/her safety requiring continuation of the use of restraints.

Based on interview and record review, the hospital failed to ensure that a physician or Licensed Independent Practitioner conducted a face-to-face assessment of a patient within 1 hour after the initiation of restraints for the management of violent and self-destructive behavior that had jeopardized the immediate physical safety of both patient and staff for 1 of 7 applicable patients. (Patient #3) Findings include:

Per record review, Patient #3, age 55, was admitted to the hospital on 7/9/14 with diagnoses of Congested Heart Failure (CHF) and hypoxia (inadequate oxygen level), Type I Diabetes with chronic pain secondary to peripheral neuropathy. On 7/11/14, Patient #3 demonstrated increased agitation, refused redirection from staff, pulled out the IV and removed a dressing from his/her feet. Patient #3 attempted to exit the room, physically grabbing and twisting a Licensed Nursing Assistant's (LNA) arm and attempted to break the window in his/her hospital room by repeatedly hitting window with his/her elbow stating this was how s/he would exit from the hospital.

Due to the imminent physical danger to patient and staff and ineffective interventions, the decision was made by nursing staff to call a "Code Green". Per hospital policy Code Green: Team Intervention During Behavioral Crisis last reviewed 06/07/12, states the purpose of the Code Green is for "The management of a behavioral crisis involving aggressive, destructive, or assault acts by a patient or visitor.....ensures sufficient staff will be available to re-establish safety in an unsafe situation." Nursing staff determined Patient #3 required restraints. At 1530 Patient #3 was placed in 4-point restraints by nursing staff from 2 South receiving assistance from other staff who responded to the Code Green. Per interview on 8/5/14 at 12:15 LNA #1, who assisted with the application of restraints, stated "...the patient required extra hands on.... s/he was very agitated...".

Per interview on 8/5/14 at 9:10 AM, the Interim Medical/Surgical Nurse Manager confirmed after the emergency application of 4-Point restraints on Patient #3, a discussion transpired with the day nursing supervisor and Manager of the Psychiatric Unit to determine how the event should be defined, as per hospital protocol, as "behavioral or non-behavioral ". Although Patient #3 exhibited assaultive and violent behavior and posed a risk to self and others it was determined restraints were applied for "non-behavioral" reasons. Per hospital's Restraint Orders for Non-Behavioral Purposes" a physician is required to examine the patient within 24 hours of initiation of restraints, and allows the maximum time limit of each restraint order to extend to 24 hours (for patients over the age of 18).

Staff's failure to identify the appropriate direction of care for Patient #3 prevented the 1 hour face-to-face by the physician to conduct an examination of Patient #3's immediate situation, reaction to interventions, and medical and behavioral condition. Per nursing documentation "Patient Assessment/Restraints" on 7/11/14 at 2200 Patient #3's behavior was described as "agitated, physical aggression, self-injurious and yelling". Late in the evening of 7/11/14 the patient's attending physician came to evaluate Patient #3. The physician prescribed both pain medication to manage Patient #3's significant neuropathic pain and Ativan for anxiety. After several doses, Patient #3 achieved pain relief and aggression and agitation were reduced. If staff had initially instituted the appropriate policy and protocols for restraints, it would have facilitated earlier intervention by the physician and treatment for Patient #3.

Based on staff interview and record review, the hospital failed to assure that all staff received training and demonstrated competency in the application of restraints prior to performing the action for 1 of 7 applicable patients in the targeted sample. (Patient #3). Findings include:

Per interview on 8/5/14 at 11:15 AM, Registered Nurse (RN) #1 confirmed that s/he had applied a restraint to the right wrist of Patient #3 on 7/11/14 at approximately 1530 P.M., prior to receiving hospital training on restraints. The RN stated that s/he was on his/her last day of orientation at the hospital on 7/11/14 when the RN preceptor instructed Nurse #1 to apply a soft Velcro type restraint to the right wrist of Patient #3. Since beginning work at the hospital during mid June, 2014, the RN had not yet completed the required training on restraints. The lack of training was confirmed during interview with the CNO and the Director of Quality Management at 5:30 PM on 8/5/14.