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For one patient the facility failed to ensure that an informed consent had been completed prior to a lumbar puncture. The findings are based on review of the clinical record, interview and review of the facility policy and include the following:

Review of the clinical record for Patient #39 indicated that the patient presented to the (Emergency Department) ED on 2/4/09 with mental status changes. Review of the ED record indicated that the patient had a lumbar puncture performed. Review of the clinical record failed to identify an informed consent had been completed. Interview on11/18/10 with the Director of regulatory compliance indicated that an informed consent should have been completed and that she was unable to locate one in the record. Review of the facility policy indicated that an informed consent must be obtained and placed in the medical record.

1. For three (3) of nine (9) clinical records reviewed (Patients # 38, #40 and #44) the facility failed to ensure the restraints were applied based on a physicians or licensed independent practioner (LIP) order. The findings are based on review of the clinical record, interview and review of facility policy and include the following:

a. Review of the clinical record with the ED Manager for Patient # 38 indicated that the presented to the ED on 2/26/08 at 2:23 PM with change of mental status. The clinical record indicated that the patient was placed in four point restraints at 5:20 PM due violent and aggressive behaviors. Review of the clinical record, including the restraint order sheet, failed to identify an order for four point restraints. The restraint order sheet identified an order for constant observation only.
b. Review of the clinical record with the EDl Manager for Patient #40 indicated that the police brought the patient to the ED on 9/16/10 at 7:15 PM. The record indicated that the patient arrived to the ED in four point restraints and was placed in four points in the ED. Review of the clinical record failed to identify an order for four point restraints.
c. Review of the clinical record with the ED Manager for Patient #44 indicated that the patient presented to the ED on 7/7/10 at 10:11 AM. The clinical record indicated that on arrival the patient was placed in four point restraints. Review of the clinical record failed to identify an order for four point restraints.
Review of the facility policy indicated that all restraints will be applied and continued pursuant to an order by the LIP.

For four (4) of nine (9) clinical records (Patients # 39, #41, #42 and #44) reviewed the facility failed to ensure that restraints were discontinued at the earliest possible to time. The findings are based on review of the clinical record, interview and review of the policy and include the following:
a. Review of the clinical record for Patient # 39 indicated that the patient presented to the ED on 2/4/09 with acute psychosis. The clinical record indicated that the patient was placed in four point restraints at 7:40 AM secondary to yelling and threatening behaviors. Review of the restraint monitoring flow sheet indicated that during the period of 8:45 AM through 10:15 AM the patient was lying down and sleeping. The flow sheet indicated that the patient was maintained in four point restraints during that time and was released from four point restraints at 10:15 AM. The flow sheet and/or the progress notes failed to indicate that the restraints were discontinued at the earliest possible time.
b. Review of the clinical record for Patient # 41 indicated that the patient presented to the ED on 7/8/09 with homicidal ideation, agitation, and violent threats. The clinical record indicated that the patient was placed in four point restraints at 4:00PM secondary to yelling, spitting, biting and kicking. Review of the restraint monitoring flow sheet indicated that during the period of 5:45 PM through 2:00 AM the patient was lying down and sleeping. The flow sheet indicated that the patient was maintained in four point restraints for the period of 5:45 PM -8:30 PM and at 8:45 PM was decreased to 2 point restraints and was released from restraints at 2:00 AM. The flow sheet and/or the progress notes failed to indicate that the restraints were discontinued at the earliest possible time.
c. Review of the clinical record with the ED Manager for Patient #44 indicated that the patient presented to the ED on 7/7/10 at 10:11 AM. The clinical record indicated that on arrival the patient was placed in four point restraints secondary to confusion and homicidal ideation. Review of the restraint monitoring flow sheet dated 7/7/10 indicated that during the period of 11:00AM through 5:00 PM the patient was quiet, calm and sleeping. The flow sheet indicated that the patient was maintained in four point restraints during that period of time (six hours). The flow sheet and/or the progress notes failed to indicate that the restraints were discontinued at the earliest possible time.
d. Review of the clinical record for Patient # 42 indicated that the police brought Patient #42 to the ED on 5/22/10 at 3:06 PM for evaluation after voicing suicidal thoughts. Review of the clinical record indicated that the patient was placed in four point restraints for " aggressive or violent behavior " . Review of the restraint monitoring flow sheet dated 5/22/10 indicated that at 3:00 PM when the patient was initially restrained the patient was calm. The flow sheet indicated that during the period of 3:00 PM through 9:45 PM the patient was quiet, calm and sleeping. The flow sheet indicated that the patient was maintained in four point restraints during that period of time (six hours and forty five minutes). The flow sheet and/or the progress notes failed to indicate that the restraints were discontinued at the earliest possible time.
Review of the facility policy indicated that all restraints should be discontinued at the earliest possible time.

The facility failed to ensure that staff had the appropriate education and training. The findings are based on review of facility documentation, interview and review of the facility policy and include the following:

Interview with the Assistant Police Chief indicated that the Building and Grounds (B&G) officers assist the clinical staff when required. The Assistant Police Chief indicated that if clinical staff requires assistance with restraint application and/or assistance with a patient the B&G officers are utilized. Review of the personnel files for the B&G officers indicated that the staff had attended basic hospital orientation on hire and in August of 2009 all B&G officers attended crisis training. Review of the personnel files failed to reflect that the officers had received hospital specific education related to restraint application. Interview with the Director of Regulatory Compliance indicated that the hospital was unable to locate hospital specific education and/or crisis training prior to 2009. Review of the B&G officer's standard operating procedure policy indicated that B&G officers would assist the medical staff with restraining patients and assist in holding patients for medication administration. The policy further indicated that the B&G officers would be provided with the necessary and appropriate training in order to assist the ED staff.