HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to ensure:
*Physician's restraint orders for destructive behavior included the type of restraint the staff member should have implemented for one of one sampled patient (8) requiring a physical restraint and seclusion.
*The protocol of open seclusion/open safety was identified in the provider's policy and procedures.
Findings include:

1. Review of patient 8's medical record revealed:
*She had been admitted on 9/9/17.
*Diagnoses included suicidal ideation, aggression, self-harm, depression, and anxiety disorder.

a. Review of patient 8's medical record revealed a physician's orders for a violent restraint had been ordered on 9/10/17 at 8:40 a.m. for being a danger to others and self. The order did not indicate what type of restraint should have been implemented by the staff.

Review of patient 8's Violent or Self Destructive Behavior - Seclusion/Restraint RN (registered nurse) Documentation form revealed:
*On 9/10/17 at 8:40 a.m. the patient had been upset with another patient, left the dining room, began throwing chairs, and tipping tables.
*She was transported to open safety.
*She refused to have her vital signs assessed during the Face to Face Evaluation.
*She had punched herself repeatedly causing a swollen lip.

Review of patient 8's Violent or Self Destructive Behavior - Restraint/Seclusion Flow Sheet for the above incident revealed:
*The restraint type was a transport maneuver.
*The intervention had begun on 9/10/17 at 8:40 a.m. and ended on 9/10/17 at 8:41 a.m.

b. Review of patient 8's medical record revealed a physician's order for a violent restraint had been ordered on 9/10/17 at 10:30 a.m. for being a danger to others and self. The order did not indicate what type of restraint should have been implemented by the staff.

Review of patient 8's Violent or Self Destructive Behavior - Seclusion/Restraint RN Documentation form on 9/10/17 revealed:
*The seclusion/restraint intervention had begun at 10:30 a.m. and ended at 10:45 a.m.
*The justification for the seclusion/restraint indicated she was a danger to self and others.
*The patient was trying to escape out of the emergency exit, tipping tables, and climbing on furniture.
*The patient was walked to open safety and was verbally threatening staff.
*"When in open safety when given a direction to not slam doors she punched staff x 2 [twice] then the door was closed." There was no indication what door had been closed.
*She had purposely punched herself in the face, bit her lip until it bled, and had given herself a swollen lip during the seclusion/restraint. The form had not indicated if the injury had occurred during the restraint or seclusion.

Review of patient 8's Violent or Self Destructive Behavior - Restraint/Seclusion Flow Sheet for the above incident revealed:
*The incident had occurred on 9/10/17 at 10:30 a.m. and ended on 9/10/17 at 10:45 a.m.
*The restraint level/type was listed as seclusion.
*There was no documentation when seclusion had begun.
*The transport restraint and seclusion had been identified as one event.

Interview and review of the above incidents on 9/12/17 at 1:53 p.m. with the nurse manager and quality manager revealed:
*The physician's orders included the reason for the violent restraint, the date and start time of the restraint, and the stop date and time of the restraint.
*It was the practice of the behavioral health department to not put the type of restraint or seclusion in the physician's orders.
*The type of restraint ordered by physicians at the main hospital campus was included in the physician's order.
*During a restrictive intervention the patient might transition many times between one restraint hold to seclusion.
*The staff participating in the incident determined which restraint position to use or when seclusion was appropriate.

Interview on 9/13/17 at 2:34 p.m. with the nurse manager revealed open seclusion/open safety meant the patient was no longer restrained or secluded. The patient was watched by staff but had no restrictions on their movement or mobility.

Review of the provider's August 2016 Seclusion and Restraint policy revealed:
*"Seclusion/Restraint must be in accordance with the order of a physician or other licensed independent practitioner (LIP - resident, nurse practitioner, physician's assistant) who is responsible for the care of the patient."
*"In emergency application situations when a physician or LIP is not available to write the order, seclusion/restraints may be applied with an RN immediately calling physician/LIP to obtain this order."
*The policy had not identified the type of seclusion/restraint should have been identified in the physician's order.
*The purpose of the policy was to provide guidance for the use of seclusion/restraints for violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, staff members, or others.
*Restraints were defined "as any manual method, physical or mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body or head freely. (may include CPI [Crisis Prevention Intervention] techniques, soft wrist restraints, Velcro restraints, or Restraint Chair)."
*Seclusion was defined as "the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. May only be used for the management of violent or self-destructive behavior."
*There was no information in the policy defining open seclusion/open safety.

Review of the provider's July 2017 Safety Precautions Level System revealed there was no information describing open seclusion/open safety.