HospitalInspections.org

Based on policy and procedure review, closed medical record review, Public Safety Department Incident Reports and staff interviews, the nursing staff failed to obtain a physician order for 1 of 2 patients restrained in the emergency department (Patient #1).

The findings include:

Review of hospital policy "TITLE: Forced Behavioral Health Treatment (NC); NUMBER:NH-RE-RI-165; Last Revised/Reviewed Effective Date: April 5, 2016" revealed "1. SCOPE/PURPOSE: In accordance with North Carolina law, ... recognizes the fundamental right of an individual to control the decision relating to his/her mental healthcare... This policy applies to the administration of treatment and medications to behavioral patients in ... hospital inpatient behavioral health units and ED's (emergency departments) located in NC (North Carolina)... 3. Physical Holds: Physical holds in order to administer a medication against the patient's wishes are considered restraints... Please see the ...Restraints and Seclusion policy for guidance on the requirements that must be followed for restraints..."

Review of hospital policy "TITLE: "Restraints and Seclusion; NUMBER: NH-PC-PS-1690; Last Revised/Reviewed Effective Date: March12" revealed"1. SCOPE/PURPOSE: ...The purpose of this policy is to comply with all laws, regulations and accreditation standards related to restraints and seclusion and to ensure that patient rights are honored. II. POLICY: ...All patients have the right to be free from restraint or seclusion of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff...2. Type of restraint/seclusion- The type or technique of restraint or seclusion must be the least restrictive intervention that will be effective to protect the patient, a staff member or others from harm... 4. Order required- The use of restraint or seclusion must be in accordance with the individual order of a Practioner who is responsible for care of the patient... B. Violent or Self- Destructive Behavior in any area-- Additional requirements -... 5. Monitoring and Assessment (Violent/Self-Destructive)- a. Monitoring must be done through continuous in-person observation by a trained staff member. b. This assessment includes, as appropriate to the type of restraint or seclusion, the following: signs of any injury associated with applying restraint or seclusion- circulation and range of motion in the extremities-vital signs-hygiene and elimination-physical and psychological status and comfort and readiness for discontinuation of restraint or seclusion. c. Trained staff will help patients meet behavior criteria for discontinuing restraint or seclusion. d. If the patient is in a physical hold, separate staff members are assigned to observe the patient. e. Documentation is charted every 15 minutes... 6. BEHAVIORAL HEALTH UNITS ONLY-... Assessment and Monitoring- ... iv. The patient is directly observed constantly for 30 minutes after the termination of the restraint/seclusion episode. Patient debriefing is completed after termination of the event. v. Vital signs are obtained upon termination of the intervention and at fifteen minute intervals times two...VI. DOCUMENTATION: Each episode of restraint or seclusion use is documented in the patient's medical record. The use of restraint or seclusion must be in accordance with a written modification to the patient's plan of care. Documentation includes the following: *All orders, assessments, observations and discontinuations * Time the restraints were initiated; * duration of use and type of restraint used; * Statements describing the behaviors/events leading to the restraints/rationale for restraint; * Alternative or less restrictive measures that were attempted and failed; * Patient's response to restraint; *Any physical and/or psychological trauma/ treatment and mental status; * Notification to family; and* Frequencies of assessment and assessment content including circulation, hydration, elimination, level of distress and agitation, mental status, cognitive functioning, skin integrity and any significant changes in patient condition; * Debriefing for BH Units Violent/ Self Destructive Restraints..."

Closed medical record review of Patient #1 revealed a 50 year old female who presented to the facility's emergency department on 05/15/2016 at 2114 for a chief complaint of "Psychiatric Evaluation". Review of ED Notes revealed at 2320 "Patient removes BH scrubs and completely naked in hallways... Pt not cooperative, hyperverbal, and aggressively hostile towards staff. Pt swung at PSO and attempted to hit staff. Patient temporarily restrained and verbal order from MD to administer anti-anxiety and anti-psychotic meds..." Review of ED Notes revealed no further documentation of physical holds. Review of record revealed no physician orders for restraints.

Review of Public Safety Department Incident Report revealed "Date and Time of Incident: 05/16/2016 12:10: 25 am.. Officers Statement: On 05/16/2016 at 0010 hours, I (name) was on A side of the ED patrolling when patient in ED 18 started escalating... I then assisted nursing staff by restraining (Patient #1) until medication was given..."

Review of Public Safety Department Incident Report revealed "Date and Time of Incident: 05/18/2016 9:38:29 am Officers Statement: On 18 May 2016 at 0938 hrs I (name) assisted RN (name) with forced meds for (Patient #1). (Patient #1) briefly jerked wildly once as if she was going to kick RN (name). (Name) and I briefly restrained (Patient #1) while RN (name) gave the medication..."

Interview on 07/27/2016 at 1430 with Clinical Shift Leader revealed the staff in the emergency department believed holding a patient was using a CPI (Nonviolent Crisis Intervention Training) technique. Interview revealed staff did not view using the trained techniques as a restraint.

Interview on 07/27/2016 at 1445 with ED Staff Nurse revealed she had previously worked on the inpatient behavioral health unit prior to working in the ED and knew a physical hold was a restraint. Interview revealed when asked why physical holds are not ordered as a restraint her response was "I was told they don't do that down here." Interview revealed nurse is aware of monitoring and documentation requirements of the restraint episode but it is not practiced in the emergency department setting.

Interview on 07/28/2016 at 0910 with 1st Sergeant of Public Safety revealed the public safety officers do have restraint training for non-clinical personnel annually as well as CPI. Interview revealed the officers also assist holding limbs but they do not apply restraints.

NC00118458, NC00118606, NC00118822, NC00119001 & NC00119200

Based on review of policy and procedure, code cart & defibrillator checklist-daily documentation and staff interview the hospital staff failed to perform daily checks of emergency resuscitation equipment on 1 of 3 inpatient units (5A Medical Surgical) for 16 days.

Findings include:

Review of policy and procedure, titled "Code Blue...NUMBER...NH-PC-EM-200...Last Revised/Reviewed...May 2014 revealed, "...I. SCOPE /PURPOSE...All (Named hospital) facilities support effective cardiopulmonary resuscitation efforts through provision of competent personnel and availability of emergency equipment....B. Emergency Cart...1. Standardized exchange crash carts are maintained by Nursing, Pharmacy and/or Materials Management depending on facility....2. Crash cart in patient care areas should be checked for availability and readiness:...a. Daily for departments open 24 hours per day and 7 days per week...."

Review of "CODE CART & DEFIBRILLATOR CHECKLIST- DAILY documentation log on, 07/26/2016 , revealed during the month of 06/2016 the emergency crash cart had not been checked for the following dates: 06/25, 06/26 and 06/30/2016. Further review revealed the emergency crash cart had not been checked for the following dates: 07/02,
07/09 and 07/15 through 07/25/2016. Review revealed emergency crash cart daily checks were not performed daily.

Interview on 07/26/215 at 1155 with the, Medical Surgical Nurse Manager, revealed she identified the problem, in the month of 06/2016, as there were only two staff members responsible for performing the crash cart daily checks. On 07/01/2016, due to the two staff members not always being available, the crash cart checks were added to the unit's daily assignment sheet. Interview revealed the emergency crash cart daily checks were not being performed per the policy.

NC00118458, NC00118606, NC00118822, NC00119001 & NC00119200