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Based on a review of hospital policy, restraint and seclusion (R/S) educational content, two medical records along with staff interviews on 6/21/17, it was determined that the hospital failed to use restraints and seclusion safely, failed to adequately train staff, and failed to have a policy in place of sufficient detail to allow the safe use of restraints and seclusion.

A review of two records of patient who had been restrained identified one patient who was restrained with a non-approved device and was secluded for two hours without an order and without documented justification.

Review of the hospital R/S policy identified a lack of definitions of specific restraints, and lacked specific behaviors that would indicate the need for violent vs. non-violent restraints. The policy also lacked documentation requirements for physicians and LIPs.

Review of the educational content given to staff about R/S identified that the training lacked definitions of restraint type, lacked examples of violent vs non-violent behavior and responses to same, lacked means of safe application, lacked time frames for assessments, lacked content of the required face to face physician assessment, and contained erroneous information regarding the use of seclusion.

The failure of the hospital to ensure safe application of restraints or seclusion by failing to appropriately train staff placed all patients needing restraint or seclusion for violent or non-violent reasons at risk of injury.

Based on a review of three grievance files received by the hospital since January 2017, it was determined that two of the grievances lacked any resolution. One was opened in January and the other was opened in April.

Based on a review of pt. #2's medical record, it was determined that the patient was placed in a seclusion room upon arrival on the behavioral health unit without any documented violent or destructive behavior. Pt. #2 was kept in the seclusion room for two hours, again, without documented violent or destructive behavior and without a physician order. (See Tag A-0168)

Pt. #2 was transferred from a medical unit to the BHU (Behavioral Health Unit) in two-point wrist restraints. The nurse's note stated "Pt arrived on the unit at approximately 1715 with security escorts in a stretcher. Pt was received in restraints. Pt. was spitting on arrival but that behavior subsided shortly thereafter. Pt was in NAD (no acute distress). [Patient] was alert. [Patient] was transferred to LDS (locked door seclusion) upon arrival and restraints discontinued. Pt was monitored per policy with a 1:1 sitter. No aggressive behavior noted ..."

A physician face to face occurred at 1815 and revealed that patient #2 was calm and cooperative, and could be released from seclusion. There was no order found to either initiate or discontinue seclusion and patient #2 was continued in seclusion until 1900.

Documentation in pt. #2's medical record did not justify placing the patient in a seclusion room immediately upon arrival to the BHU, prior to any assessment. Nor did the documentation justify keeping pt. #2 in seclusion for two hours.

Based on a review of hospital restraint and seclusion policy and the medical record for pt. #2, it was determined that the patient was restrained in a non-approved restraint while on a medical floor.

According to the medical record, pt. #2 had at least two 24 hour orders for restraint with a draw sheet while on the medical unit. Hospital policy no. BAL.PCS.Rest.010, Restraint and Seclusion, last updated 8/2015 did not include any description of specific restraint types or information on application or use. The policy contained a statement saying that "Only restraint type devices approved by the leadership may be utilized." In addition, the education for Restraint and Seclusion did not include any information on the application of specific restraint types. (See Tag A-0202)

Patient #2 was restrained in an unsafe and inappropriate manner when the physician ordered, and staff used, a draw sheet to keep the patient in bed and to prevent interference with medical treatment. There is no safe standard of application or use for a draw sheet restraint.

Based on a review of two restraint records on 6/21/17, it was determined that the hospital staff restrained and secluded one patient without obtaining a physician or licensed independent practitioner (LIP) order. In February 2017, Patient #2 (Pt# 2) was transferred in two-point wrist restraints from a medical unit to the behavioral health unit. No physician order was found for the restraint transfer or subsequent seclusion episode. Further review of the medical record revealed Pt. # 2 was placed in seclusion upon arrival to the behavioral unit at 1715, described by the RN as locked door seclusion (LDS). Additionally, nursing flowsheet documentation revealed P# 2 remained in LDS from 1715 to 1900 without an order.

In addition, while pt. #2 was on the medical unit, a physician wrote two orders for seclusion with a belt restraint with the reason given to prevent patient interference with medical treatment. There is no evidence that pt. #2 was secluded while on the medical unit.

Based on a review of hospital policy, the educational content for restraint and seclusion (R/S) use, pt. #2's medical record, and interviews with staff on 6/21/17, it was determined that the hospital's restraint and seclusion training did not include information on the safe use of specific restraints and seclusion, and lacked information about recognizing and responding to signs of patient distress.

According to the medical record, pt. #2 had at least two 24 hour orders for restraint with a draw sheet and/or belt while on the medical unit. The education for R/S did not include any information on the application of specific restraint types. In addition, hospital policy no. BAL.PCS.Rest.010, Restraint and Seclusion, last updated 8/2015 did not include any description of specific restraint types or information on application or use. The policy contained a statement saying that "Only restraint type devices approved by the leadership may be utilized."

The educational content also lacked discussion of specific time frames for monitoring and the content of that monitoring. In an interview during the survey, a staff RN on the behavioral health unit (BHU) could not give the correct timeframes for the face-to-face requirement for a secluded patient.

Because the R/S education and policy lacked definitions of safe restraints, examples of restraints, and content for application, pt. #2 was unsafely restrained with a draw sheet.