HospitalInspections.org

Based on medical record reviews, interviews and review of policies and procedures, the hospital failed to document a physician order for
restraints, failed to monitor the patient's psychological and physical status while restrained and failed to document the time restraints were discontinued for Patient Identifier (PI ) # 1, one of ten sampled patients. The deficient practice of failing to have required nursing documentation for restraint monitoring affected PI # 3 and PI # 4, two of ten sampled patients. This deficient practice has the potential to affect all patients who are restrained.


Medical Record Review: PI # 1:

1. ED (Emergency Department) Physician Notes:
3/31/14 at 11:15 PM
Arrival Mode: Ambulance.
Chief Complaint: Patient found unresponsive with bottle of Lortab laying next to her, D (Dextrose) - stick 64 on EMS (Emergency Medical Services) arrival. 1 AMP (ampule /vial) D 50 given. BS (Blood Sugar) 128 on arrival to ED. Narcan (medication to reverse Opioid overdose) given by EMS. Patient states she only took two pills. Patient is 24 weeks pregnant. FHT (Fetal Heart Tones) on arrival 160.

History of Present Illness (HPI): Patient is a 24 year old female who is approximately 6 months pregnant who was at home when an argument took place and she then took an unknown amount of Norco 5 mm. (milligrams) pills. She denies SI (Suicidal Ideation) at this time. Per EMS, she was difficult to arouse and received 2 mg.(milligrams) Narcan on scene with an improvement of her mental status. Patient is lethargic, but will answer questions appropriately.

Impression:
SI
Narcotic Overdose
Schizophrenia
Pregnancy


Psychiatry Evaluation of PI # 1 on 9/1/14 5:12 AM:

Chief Complaint: "I took 2 lortabs. I think they were too strong."

Source: Self.

History Limitation: Inconsistent history.

HPI (History of Present Illness): 24 year old female with past psychiatric history of mood disorder and personality disorder, also 24 weeks pregnant comes to the ED via ambulance after she was found unresponsive by her fiancee with an empty bottle of lortab next to her.

The patient adamantly denies that this was a suicide attempt and states she only took two "lortabs" as prescribed for back pain. She cannot explain why she had a prescription filled on the 28th and now she was found unresponsive with an empty bottle of lortab. She does endorse depressed mood and is very tearful. She does not want to be admitted to the hospital...

Discussed the case with the ED attending. The patient is pregnant and was found unresponsive next to an empty bottle of lortab which is very concerning of a real suicide attempt. It was decided that the best route would be to admit the patient for her safety and also for the safety of the fetus. When she became aware of the decision to admit she became hostile and tried to elope.


Review of ED Nursing Notes:

Primary Nursing Assessment of PI # 1 on 8/31/14 at 11:36 PM:

Chief Complaint: Patient found unresponsive with bottle of lortab laying next to her...24 weeks pregnant. FHT (Fetal Heart Tones) on arrival 160. (Documented by EI # 4)

Nursing Assessments:

9/1/14 12:43 AM: 105/64, 80, 18. Patient sleeping. Family at bedside.
(Documented by EI # 4)

9/1/14 1:54 AM: Patient placed on continuous FHR (Fetal Heart Rate) monitor per GYN (Gynecologist) for 20 minutes. Patient sleeping unless disturbed. (Documented by EI # 4)

9/1/14 2:15 AM: 114/66, 81, 18. Patient taken off FHT monitor. GYN MD (Medical Doctor) at bedside. No signs of distress noted. (Documented by EI # 4)

9/1/14 4:37 AM: "Psych MD (first and last name) states to RN (Registered Nurse) @ (at) desk that pt. (patient/PI # 1) is about to elope. This RN entered room to find pt. up. RN states hey whats wrong. Pt. states I wanna leave. RN states you can't leave."

"Pt. then pushed this RN into door and went out started out of room around MD desk. Charge Nurse (first name) told UAB pd (police department) in ECS (radio control room) that pt. could not leave. UAB (Hospital's) PD tried to corner patient. Pt. kept walking with RN behind police. Pt. screaming I'm not...(curse word) staying, I wanna leave, ya'll can't keep me. Pt. tried to punch UAB PD. UAB PD continued to follow pt. as this RN stated she can not leave. At the entrance door to Pod 2 UAB PD tackled pt. while she tried to punch officers. Pt. was on the ground outside of registration office and lobby. Pts (patient's) husband entered area at the same time. Husband states just listen to them (first name of patient). Pt. continued to scream and kick at ...PD. More...PD responded. Pt. placed in hand cuffs for staff safety. MD (last name of Emergency Department physician) and MD (last name of Emergency Department resident physician) came to pt. side with CN (Charge Nurse), this RN, (staff RN, RN assigned to pt) and another staff RN. Pt. was lifted to bed and placed on side. Pt. was placed in four point restraints and hand cuffs removed. IM (intramuscular) ativan vorb (verbal order read back) MD (last name of ED Physician working in Pod 2) to this RN and given in right thigh. Pt. then taken back to room by this RN and RN (first name of RN assigned to pt.) in restraints, 'nadn' (no apparent distress ?). FHT (Fetal Heart Tones) obtained, rr (respiratory rate) at ease. (first name of RN assigned to pt.) remains @ bedside." Electronically signed by ED RN/ Employee Identifier (EI) # 1. (EI # 1 was caring for PI # 1 while the RN assigned to PI # 1 was at lunch).

9/1/14 5:00 AM: 110/68, 88, 20. Patient resting. Still visibly upset. No signs of distress noted, vital signs stable. Will continue to monitor. (Documented by EI # 4)

9/1/14 5:10 AM: FHT's 140-150. Patient calmer. Still anxious about being admitted to the hospital. No signs of distress noted. Family at bedside. Restraints taken "of" (off) patients hands. Will continue to monitor. (Documented by EI # 4)

9/1/14 5:17 AM: "Asked MD (last name of ED Attending - assigned to PI # 1) if he wanted to ultrasound patient's belly and said that he did not at this time." (Documented by EI # 4)

9/1/14 5:51 AM: Calm, cooperative. Admit to... Police search and transport. Pt. is high elopement risk. Attempted to elope from ED.

9/1/14 7:11 AM: Sitter watching the room. Pt. emotional about taking clothes off. Transported to "CMP" (Center for Psychiatric Medicine) by PCT (Patient Care Technician) and police.

No restraint monitoring documentation was found in the nursing notes for PI # 1. This failure was confirmed by EI # 6 / ED Manager on 10/15/14 at 10:08 AM during a review of PI # 1's medical record with the surveyor.

Review of Physician Orders:

A review of the physician orders dated 8/31/14 11:04 PM - 9/1/14 7:16 AM, revealed no restraint order for PI # 1. The lack of an order was confirmed by EI # 3, ED Manager on 10/14/14 at 4:30 PM.


2. Review of PI # 3's Medical Record:

PI # 3 was admitted to the hospital on 8/29/14 and four point soft restraints were ordered on 8/29/14. However, there was no documentation in the nursing notes for monitoring of the patient's physical and psychological response to the restraint. The lack of nursing documentation for restraints was confirmed by EI # 5/Hospital Compliance Specialist and the surveyor during medical record review on 10/15 14 at 1:45 PM.

3. Review of PI # 4's Medical Record:

A review of PI # 4's medical record revealed a physician's order for restraints was written on 9/1/14. However, there was no nursing documentation regarding restraint monitoring for PI # 4 as confirmed by EI # 5/ Hospital Compliance Specialist and the surveyor on 10/15/14 at 2:00 PM.


Interviews:

During an interview on 10/16/14 at 8:15 AM, the ED (Emergency Department) RN/ EI # 4, assigned to PI # 1 on 8/31/14 on the 7:00 PM - 7:00 AM Shift) said he was at lunch and another RN (EI # 1) was caring for PI # 1. When the RN (EI # 4) returned he heard, "They tackled her (PI # 1)in the hallway and she (PI # 1) was in restraints. EI # 4 did not see the police intervention. PI # 1 was crying. EI # 4 stated he wanted to make sure PI # 1 and her baby were okay. EI # 4 checked vital signs and Fetal Heart Tones and stated they were, "Fine." According to EI # 4, he talked with the patient and explained he would allow her boyfriend to come to her room. EI # 4 stated he was able to discontinue the restraints.

EI # 4 stated, "I don't think she was in restraints very long. I can't remember." The surveyor asked EI # 4 if he documented the restraint monitoring and he replied, "I thought whoever initiated the restraint would have initiated the monitoring."

During an interview on 10/16/14 at 9:40 AM, EI # 7, the psychiatrist who evaluated PI # 1 in the ED on 9/1/14, stated he told PI # 1 she was going to have to be admitted and could not leave after discussing the case with the ED physician. PI # 1 was "very intent" and said "I'm leaving." According to EI # 5, he left the room, closed the door and told everyone she (PI #1) was eloping."

During a telephone interview on 10/17/14 at 10:10 AM (Police Officer / Employee Identifier (EI) # 2) working in the ED on the night of 8/31/14 said he and another police officer were in the trauma bay when a charge nurse advised the officers a female patient was trying to leave. The patient "was was under doctor's orders and couldn't leave. I got up first and asked her to stop several times. I grabbed her arm and she jerked away." The patient said, "You better not touch me. I'm pregnant." The other officer was calling for backup (request for additional officers). The patient circled around the Pod (desk area located in the ED) and we followed her as we tried to avoid physical contact with the patient. As she was approaching the hallway leading to the waiting area, the other officer "grabbed" the patient and they "fell to the ground." There was a "little scuffle." EI # 2 said, "I can't describe the fall. It happened so fast." The officer was asked if he recalled if PI # 1 was on her stomach when she fell. EI # 2 answered, "Side, I think. I can't remember." The other officer (EI # 3 - assigned to the ED) had his arms wrapped around the patient's legs from the knees down. His upper body was on top of her (PI # 1) legs. The officer (EI # 3) was not laying on top of the patient. The patient was placed in handcuffs when the other officers arrived. The patient said she had the right to leave and was "very irate, cursing, kicking and trying to fight."

During an interview on 10/16/14 at 1:15 PM, with (Police Officer / EI # 3), assigned to the ED, stated on 9/1/14 around 4:20 AM someone screamed, "There's a psych (psychiatric) patient not allowed to leave. Officer (last name of EI # 2) and I responded." Someone said she's pregnant and "I called for backup." According to EI # 3, having more officers present decreases the chance of injury to the patient. The officer said, "We stepped in front of her (PI # 1) trying to block her path," but were unsuccessful. The officer said they (EI # 2 and EI # 3, police officers assigned to the ED), used verbal cues and tried to reason with the patient. The patient was screaming and cursing. EI # 3 said, "My uppermost concern was the patient and her unborn child. I don't want to put hands on anybody. To me, that is the last resort." The incident began in Pod 4 and progressed to Pod 2 (closer to waiting room and exit). The patient "became more combative- scratching, hitting, spitting and trying to bite. We were at the doors leading to the main corridor and no other officers had responded." According to EI # 3, PI # 1 was about to exit to the waiting room and the officers felt if she made it to this area it would increase the chance of PI # 1 or someone else being hurt. We had to physically restraint PI # 1 to prevent her progression to the waiting area. The other officer (EI # 2) grabbed the patient's wrist and she jerked away. "We pulled her down to the floor as gently as I could. Kind of lowered her down. Did not throw her down. Each of us had an arm. Eventually I put my arms around her and lowered her to the ground. I held her legs. I was not facing the patient. She was on her side as far as I can remember." PI # 1 remained combative-trying to bite and scratch. More staff arrived and somebody put hand cuffs on the patient. "We gently picked her up and put her on a gurney (stretcher)." The hand cuffs were removed and hospital staff placed PI # 1 in four point restraints. Hospital staff medicated her, but PI # 1 remained combative.


Policy and Procedure Review:

Restraint for Violent, Self Destructive Behavior:
Issued 6/2/14
...3.1 Definitions:

3.1.1 Restraint: any method (chemical, mechanical or manual) of restricting an individuals freedom of movement...
(1) that is not a a usual and customary part of a medical diagnostic or treatment procedure to which the individual...has consented,
(2) is not indicated to treat the individual's medical condition..., or
(3) does not promote the individual's independent functioning.

3.1.2. Restraint for violent, self destructive behavior: refers to the use of restraints for the purpose of controlling behaviors that pose an imminent risk of physical harm to the patient, staff or others, because of an emotional, behavioral disorder that is not related to a medical condition.

3.2. Restraint has the potential to produce serious psychological and physical consequences...

4.2.1.1. A physician's order shall be required for each occurrence of restraint use.
4.2.1.6. Restraint orders shall include:
4.2.1.6.1 The type of restraint device(s) authorized...
4.2.1.6.2 Device selection shall be based on the patient's diagnosis/need and, whenever possible, the patient's condition.
4.2.1.6.3 Clinical justification.
4.2.1.6.4 Time authorized.
4.2.1.6.4.1 Greater or equal to 18 years old: 4 hours maximum.

4.2.2 Reassessment/Documentation
4.2.2.1. Patients undergoing restraint for behavioral reasons shall be monitored and reassessed continuously (one-to-one) using appropriate ...form.
4.2.2.1.1. A staff member who is trained and competent, assesses the individual and documents every 15 minutes. Assessment of the individual in restraint...includes the following:
4.2.2.1.1.1. Signs of injury associated with applying restraints...
4.2.2.1.1.2. Activity and type.
4.2.2.1.1.3. Circulation/Skin.
4.2.2.1.1.4. Vital signs.
4.2.2.1.1.5. Range of Motion/Positioning.
4.2.2.1.1.6. Nutrition/Hydration.
4.4.4.1.1.7. Hygiene and Elimination.
4.4.4.1.1.8. Physical and psychological status and comfort.
4.2.2.1.1.9. Bed Safety.
4.2.2.1.1.10. Safety.
4.2.2.1.1.11. Restrain Discontinuation Readiness.

4.2.3. Discontinuation
4.2.3.4. Restraint documentation shall be documented in the patient medical record...by the RN.