HospitalInspections.org

Based on a review of hospital grievances, it was revealed that during a meeting with patient #2's family member, staff inadvertently revealed the name, age and diagnosis of patient #11.

Patient #2 was an adult admitted to the behavioral health unit in January 2017. During a family meeting to reconcile patient #2's medication, the name, age and diagnosis of patient #11 was visible on the computer used by the RN. The hospital took appropriate reporting action, however, the hospital failed to maintain confidentiality of patient #11's record.

Based on a review of patient restraint records, it is revealed that, 1) hospital restraint education failed to instruct all staff related to the identification of a patient in distress; 2) patient #10 was manually restrained by arms, head legs, torso and shoulders while in a prone position during medication administration, and 3) documentation of patient #10's 15-minute monitoring in seclusion was incomplete during the last 90 minutes prior to release.

Review of hospital training under "Using Restraints Safely" stated in part, "A Registered Nurse must be present when any type of restraining device is initially applied." Points of "While restrained, patients receive ..."Monitoring of respiratory and neurological status, skin integrity and vitals ..." This focus of the training was for RN's regarding mechanical restraints. There was no evidence of training which instructed all staff who participate in restraint events, how to recognize when a patient is in distress.


The RN focused training went on to describe in part, "Side positioning if there is a risk of vomiting or seizures." No training is found which instructed all staff who participate in restraint events that prone positioning is a known risk factor of asphyxiation or that pressure around the head, chest and back may lead to asphyxiation.


Review of the medical records revealed that Patient #10 was an adult with a history of aggression, admitted to the behavioral health unit in February 2017.


On 3/4 just prior to 0526, patient #10 became increasingly agitated and then combative with security and staff. A rapid response was initiated, and patient #10 was taken to the seclusion room by security. Documentation on the Rapid Response team record stated in part, "Forcefully placed in Quiet Room ...In quiet room - prone." Prone positioning during a restraint does not meet the standard of care due to dangers of asphyxiation.


A nursing progress note at 0615 stated in part that five staff held patient #10 in a manual restraint. The restraint included three staff who held patient #10's arms, one staff held patient #10's head, and one staff held his torso and shoulders while in a prone position. No other information was found to describe if pressure was applied to patient #10's torso and shoulders which could lead to asphyxiation, or how patient #10's head was positioned to allow for optimal ventilation during the prone restraint.


Review of fifteen minute seclusion documentation which ended at 2000 revealed that 15-minute violent documentation ended at 1830, though patient #10 remained in seclusion through 2000. Documentation of patient #10's seclusion continued on the Fifteen Minute Safety Check form which only documented patient #10's whereabouts, but not his behaviors and care while in seclusion for those 90 minutes.


Based on this, the hospital failed to provide comprehensive education to all staff who participate in restraint events regarding identification when a patient is in distress, the standard of care for avoiding prone positioning and pressure to a patient head, back and chest, and failed to appropriately document behaviors and care for the last 90 minutes of patient #10's seclusion.

Based on a review of patient #8's record, it was revealed that patient #8 was restrained for 47 minutes without an order.

Patient #8 was a young adult male who presented to the Emergency Department (ED) under police custody in March 2017 after he took drugs and was involved in a stabbing. No documentation is found that indicated if the patient presented in police restraints such as cuffs. Documentation at 0903 revealed in part, "Patient is actively on PCP ... and, PT attempting to bite his arm prior to medication." Patient #8 was placed in 4-point restraints at 0903. The initial physician order for 4-point restraint was written at 1001.

A new order for restraint was required by 1303, 4 hours from the time patient #8 was actually restrained. However, when patient #8 was released from restraint at 1350, no new order was found. Therefore, between 1303 and 1350, patient #8 was restrained without an order.

Based on a review of two closed emergency department (ED) restraint records for patients #6 and #8, and one open behavioral health unit seclusion record for patient #10 revealed that patients #6, 8 and 10 were not released from restraint and seclusion at the earliest possible time.

Patient #6 was an adult male who presented to the ED in early March 2017 on an emergency petition via police due to suicidal ideation. On presentation, patient #6 decided he wanted to leave and became combative with staff. He was placed into 4-point restraints at 0750 and received intramuscular medication for agitation. Documentation revealed a restraint documentation area for the RN to fill-in which stated, "Pt must be educated regarding behavior requiring restraints; and behaviors expected for discontinuation." This element helps patients participate in care in order to be released from restraint at the earliest possible time. There was no nursing documentation that patient #6 was educated regarding behavioral expectations.


At 0805, 0820 and 0900, patient #6 was documented as sleeping. While patient #6 was no longer demonstrating imminently dangerous behaviors and was sleeping, the nurse only released his left arm and right leg at 0805, but continued to keep him restrained in 2-point bed restraint.


Documentation revealed that patient #6 was not released from all restraints until 0928, 1 1/2 hours after he met behavioral criteria with no further combative behaviors. In summary, patient #6 was not informed of how he could demonstrate readiness for release from restraint, and was not released from restraint at the earliest possible time.


Patient #8 was a young adult who presented to the Emergency Department (ED) under police custody in March 2017 after the patient took drugs and was involved in a stabbing. There was no documentation regarding if the patient presented in police restraints such as cuffs. Documentation at 0903 revealed in part, "Patient is actively on PCP ... and, PT attempting to bite his arm prior to medication." Patient #8 was placed in 4-point restraints at 0903. At 1027, the RN released patient #8's bilateral feet. While the RN described a Richmond Agitation Sedation Scale (RASS) of +2 indicating agitation, no actual behaviors were documented to justify continued restraint. At 1200, documentation revealed patient #8 was sleeping, though patient #8 was not released from restraints until 1350. Although patient #8 was in police custody, the hospital initiated a restraint process for which they were responsible, and for which they failed to release patient #8 at the earliest possible time.


Patient #10 was an adult with a history of aggression who was admitted to the behavioral health unit in February 2017.


On 3/3/2017, patient #10 was placed into seclusion at 2126 after he became threatening to staff. Fifteen minute documentation of patient behaviors revealed that at 2230, patient #10 was documented as being "calm, cooperative." For the next hour, patient #10 was documented as "sleeping," though seclusion was not terminated until 2326.


On 3/4 just prior to 0526, patient #10 became increasingly agitated and then combative with security and staff. A rapid response was initiated, and patient #10 was secluded at 0526. Documentation of 15-minute behaviors reveals that at 0630, patient #10 was documented as "#3, Unable to follow directions, impulsive, unpredictable behavior." At a baseline, patients might not be able to follow directions, and might be impulsive. However, these behavioral descriptors did not justify continued restraint. Additionally, the terminology of "unpredictable" was subjective, and was not justification for continued restraint without further clarifiaction.


A nursing note of 0813 revealed in part, "pt in lds (locked door seclusion) laying on mat on floor and pt awake, stretching and moving arms. Per dr. __ pt is to stay in lds unitl (sic) he states to let out ..."
Fifteen minute documentation continued alternately with "#7 (calm, cooperative)" and #3 as described above. Based on this physician mandate, even though patient #10 was demonstrating an absence of imminently dangerous behaviors, he was not released from seclusion.


A physician note of 0833 revealed in part, " ...He will stay in seclusion until calm and cooperative ..."
This documentation stated an appropriate criterion, which was not implemented when patient #10 actually demonstrated calm, cooperate behavior.


A nursing note of 0958 stated in part, "med compliant with routine meds, security on standby but hands on not needed ..." Fifteen minute documentation continued with #3, "#6 (restless) and #7 (calm, cooperative) to describe behaviors. Patient #10 continued to demonstrate an absence of imminently dangerous behaviors, but was not released.


A nursing note of 1041 revealed in part, "nurse told patient that he needs to rest and be calm before we can let him out of seclusion." Patient #10 had been demonstrating calm behavior, yet was not released.


A nursing note of 1237 revealed in part, "dr.__ signed (orders) for lds at 0800 and renewal at 1200 today. Pt remains in lds per dr. __, he does not want him out of lds until reevaluated at 1600 today ..." Fifteen minute documentation continued alternately with #6, #7, and #8 (Appears to be sleeping). Again, in the absence of imminently dangerous behaviors, patient #10 was not released.


A nursing note of 1246 revealed in part, " ...he is on the mat in the lds no agitation noted. A nursing note of 1320 revealed in part, " ...pt is calm at present and appears to be resting. No aggression or agitation noted."


A nursing note of 1514 revealed in part, "remains in lds behavior unpredictable, he has injured several security guards within past 24 hrs. pt aware of need to stay in lds. He is on mat in the lds room has not hit door in room or pushed call bell for over hr. Did eat 100% of lunch today. Food fluids in pt reach. Pt pushing call bell at present and staff assisting." Neither a reiteration of the patient history or the descriptor of "unpredictable" were justification for continuing seclusion. Further, nursing failed to document by what criterion patient #10 was made " ...aware of need to stay in lds."


A nursing note of 1640 revealed in part, " ...he immediately became threatening and demanding when the door was opened. he demanded to talk to the doctor ...he did allow vital signs to be obtained with encouragement. He was given fluids and cracker, and he was cooperative with his po meds with encouragement. The longer staff were in the room, the louder and more demanding he became. dr __ was called and notified of patients status. He gave order to renew the LDS order for another 4 hrs. he has repeatedly been on the call light demanding to talk to the doctor ..." Review of fifteen minute documentation did not support that patient #10 was "threatening," and patient #10's actual documented behaviors of cooperation with medication and vitals did not support imminent dangerousness for continued seclusion.


It is not known if patient #10 who had by then been secluded an approximate 11 hours, and had complied with staff instruction that he would be released if calm and cooperative became frustrated with continued seclusion no matter how compliant he was, including periods of sleep. However, and based on fifteen minute documentation, it is known that patient #10 had demonstrated no imminently dangerous behavior since 0645 that morning. Patient #10 was ultimately secluded for approximately 15 hours when seclusion ended at 2000.


Based on a review of three patient restraint/seclusion records, the hospital failed to release patients #6, #8, and #10, at the earliest possible time.

Based on a review of emergency department patient #6 and patient #8's records, it was revealed that the face to face for a restraint events were incomplete.


Patient #6 was an adult who presented to the ED in early March 2017 on an emergency petition via police due to suicidal ideation. On presentation, patient #6 decided he wanted to leave and became combative with staff. The patient was placed into 4-point restraints at 0750.


The hospital physician face to face for restraint and seclusion was built into the physician electronic order sets. Review of patient #6's restraint order revealed only two of four elements of the face to face were addressed. The physician documented the Immediate Situation and the Medical and Behavioral Condition. However, the patient reaction to the intervention and the need to continue or terminate restraints was omitted.


Patient #8 was a young adult who presented to the ED under police custody in March 2017. No documentation is found related to police restraint, though patient #8 was placed in 4-point restraints by a physician order at 1001. The physician documented the Immediate Situation and the Medical and Behavioral Condition. However, the patient reaction to the intervention and the need to continue or terminate restraints was omitted.


Based on all documentation, the hospital documented incomplete face to face's for patient's #6 and #8.