HospitalInspections.org

Based on review of hospital policy, medical record review, and staff interview, hospital staff failed to renew an order for restraints used for the management of violent behavior for 1 of 1 patients in violent behavioral restraints. (Patient #5).

The findings include:

Review of hospital policy titled, "Restraints and Seclusion (NC [North Carolina] and SC [South Carolina])", last revised 03/2012, revealed, "... I. Scope / Purpose This policy applies to all (named hospital) located in North Carolina... including all departments and all hospital patients, regardless of age, who are restrained... The purpose of this policy is to comply with all laws, regulations and accreditation standards related to restraints... and to ensure that patient rights are honored. II. Policy... B. Violent or Self-Destructive Behavior... 4. Evaluations (Violent/Self-Destructive)... b. Re-evaluations - Patients must be re-evaluated for the continued need for restraint and a renewal order written as follows: -every 4 hours for adults 18 years of age or older..."

Review of hospital policy titled, "Prisoner - Care of and Orientation of Forensic Staff", last revised 11/2013, revealed, "I. SCOPE / PURPOSE To establish policies and procedures for the appropriate care, treatment, and services of patients under legal or correctional restrictions and the orientation of forensic staff having custody of patients... K. Law Enforcement or Correctional Restraints and Safety of Hospital Personnel. Law enforcement or corrections officers are required to escort patients in custody at all times and may use restraints for security... VII. Definitions... Law Enforcement or Correctional Restraints: Handcuffs..."

Review of the closed medical record of Patient #5 revealed a 44 year old male patient, who arrived to the hospital on 08/03/2015 at 1910, under involuntary commitment (a legal process through which an individual with symptoms of mental illness is court-ordered into treatment), in law enforcement custody. Review of the History of Present Illness (HPI) written on 08/03/2015 at 1921 by Nurse Practitioner (NP) #2, revealed, "...HPI Comments: Home visit by (named psychiatric service) found patient in possible psychotic state. Pt (patient) appeared agitated, with random conversation, aggressive behavior towards staff. PD (Police Department) was contacted and patient was brought to ED (Emergency Department) for further evaluation. Pt alert follows commands at times then followed by bizarre outburst of aggression and screaming..." Review of an ED Note written by Registered Nurse (RN) #7 on 08/04/2015 at 0812, revealed "Pt handcuffed to bed, (named police department) @ (at) bs (bedside). Pt yelling, thrashing around in bed..." Review of an ED Note written by RN #3 on 08/04/2015 at 1330, revealed "(Physician Assistant [PA] #2) called for restraint order for this patient, pt agressively (sic) kicking, appears trying to break the bed and can hurt himself or injure staff..." Review of an order written by PA #2 on 08/04/2015 at 1335, revealed, "RESTRAINTS VIOLENT OR SELF-DESTRUCTIVE ADULT (AGE 18 AND OLDER)." Review revealed bilateral ankle restraints were applied by RN #3 at 1342. Review revealed the "RESTRAINTS VIOLENT OR SELF-DESTRUCTIVE ADULT (AGE 18 AND OLDER)" order was renewed by NP #3 on 08/04/2015 at 1809. Review of a Restraint - Violent assessment, written on 08/04/2015 at 2215, by RN #8, revealed "...Restraint status: CONTINUED..." Review revealed no renewal order in place at this time. Review of a Restraints - Violent assessment, written on 08/05/2015 at 0200, written by RN #8, revealed "...Restraint Status: DISCONTINUED..."

Staff interview conducted on 10/14/2015 at 1310 with Director #2, revealed when a patient is brought in by law enforcement officers, the patient is considered in police custody. Interview revealed law enforcement officers stay with the patient at the bedside for the duration of time the patient remains in police custody and if handcuffs have been applied by law enforcement. Interview revealed when law enforcement officers remove handcuffs, a patient is no longer considered in police custody, and law enforcement officers are no longer required to be at the bedside.

Staff interview conducted on 10/15/2015 0920 with Manager #2, revealed an order from a provider would not be necessary for handcuffs, as that is controlled by law enforcement. Interview revealed an initial order, and order renewal every four hours is required for restraints applied by hospital staff, for a patient 18 years of age or older. Interview revealed Patient #5 was in restraints from 2209 until 0200 (3 hours, 51 minutes) without an order for bilateral ankle restraints. Interview revealed an order renewal should have been provided for Patient #5 on 08/04/2015 at 2209, and was not. Interview revealed the hospital staff failed to renew an order for the management of violent restraints.

Based upon review of hospital policy, medical record review, and staff interview, hospital nursing staff failed to supervise and evaluate the nursing care for a patient, by failing to monitor and assess 1 of 1 patients in violent behavioral restraints (Patient #5) per hospital policy.

The findings include:

Review of hospital policy titled, "Restraints and Seclusion (NC [North Carolina] and SC [South Carolina])", last revised 03/2012, revealed, "... I. Scope / Purpose This policy applies to all (named hospital) located in North Carolina... including all departments and all hospital patients, regardless of age, who are restrained... The purpose of this policy is to comply with all laws, regulations and accreditation standards related to restraints... and to ensure that patient rights are honored. II. Policy... B. Violent or Self-Destructive Behavior... 5. Monitoring and Assessment (Violent/Self-Destructive)... b. This assessment includes, as appropriate to the type of restraint... the following: -signs of any injury associated with applying restraint... -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... e. Documentation is charted every 15 minutes... VII. DEFINITIONS... Physical restraint - Any... physical or mechanical device... that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely... Examples of mechanical devices include cuffs..."

Closed medical record review of Patient #5 revealed a 44 year old male patient presented to the hospital's Emergency Department on 08/03/2015 at 1910, under involuntary commitment (a legal process through which an individual with symptoms of mental illness is court-ordered into treatment), in law enforcement custody. Review of a History of Present Illness (HPI) written at 1921 by Nurse Practitioner (NP) #2, revealed "...HPI Comments: Home visit by (named psychiatric service) found patient in possible psychotic (having or relating to a very serious mental illness that makes you act strangely or believe things that are not true) state. Pt (patient) appeared agitated, with random conversation, aggressive behavior towards staff. PD (Police Department) was contacted and patient was brought to ED (Emergency Department) for further evaluation. Pt alert follows commands at times then followed by bizarre outburst of aggression and screaming..." Review of an ED Note written by Registered Nurse (RN) #7 on 08/04/2015 at 0812, revealed "Pt handcuffed to bed, (named police department) @ (at) bs (bedside). Pt yelling, thrashing around in bed..." Review revealed Patient #5 remained in law enforcement custody handcuffed to the hospital bed, with law enforcement officers at the bedside until from 08/04/2015 at 0812 until 08/06/2015 at 1332 (2 days, 5 hours and 20 minutes). Review of an ED Note written on 08/06/2015 at 1332, written by RN #9, revealed "30 Minute Trial release of handcuffs and (named police department) per security risk assessment..." Review revealed "Restraints - Violent" assessment was not performed every 15 minutes between the dates of 08/04/2015 at 0812 through 08/04/2015 at1342 (5 hours and 30 minutes); and 08/05/2015 at 0200 through 08/06/2015 at 1332 (1 day, 11 hours and 32 minutes).

Telephone interview conducted on 10/15/2015 at 0920 with RN #10, revealed if a patient is in law enforcement custody in handcuffs, hospital staff should monitor and assess the patient no differently than if the patient was in hospital restraints.

Telephone interview conducted on 10/15/2015 at 0950 with RN #11, revealed handcuffed patients should be assessed every 15 minutes for skin integrity, circulation, safety, nutrition, and need for continued restraint. Interview revealed the hospital's policy for monitoring restraints was not followed.

Based on hospital policy and procedure review, medical record review, and staff interview, the hospital Emergency Department Behavioral Health nursing staff failed to maintain an accurate medical record for 2 of 3 (#4 and #12) patients with Quality Assessment Reports following events involving patient to patient aggression and patient to visitor aggression.

The findings include:

An unannounced onsite complaint investigation was conducted from October 13, 2015 to October 15, 2015. The investigation included hospital policy and procedure review, medical record review, Quality Assessment Report review, Quality Assessment Report Log review, and staff interviews.

Review on 10/13/2015 of the hospital's policy titled "Quality Assessment Report" effective May 2014 revealed "I. SCOPE / PURPOSE This policy/procedure is followed to report non-employee events and events involving patients..., which occur in any (named hospital)... II. POLICY To promote quality patient care and reduce events that might result in patient injuries...VII. DEFINITIONS EVENT - an event is "an unexpected occurrence or outcome involving physical or psychological injury or the risk thereof." Staff report events." Criteria for Completing a Quality Assessment Report: All events as defined on the Quality Assessment Report; Any event which caused real or potential injury to a patient or visitor..."

Review on 10/14/2015 of the hospital's policy titled "Events to be Reported to Risk Management" effective May 2014 revealed "II. POLICY The following events must be reported to Risk Management: Any event involving potential or actual moderate to severe patient harm. Sentinel Events: Ones which are serious, may be avoidable, and which cause illness or injury and result in medical intervention/treatment,...transfer to a higher level of care..."

Review on 10/14/2015 of the hospital's policy titled "Code Walker/Elopement Response Plan" last
reviewed December 19, 2011 revealed, "II. POLICY Appropriate precautions will be taken for patients
who are at risk of elopement. When a patient elopes who is believed to be missing, (named hospital
workers will take reasonable steps to find the patient ...V. PROCEDURE Elopement/Missing Patient
Response A....Behavioral Health Patients: Required to notify law enforcement if the missing behavioral
health patient is: Involuntarily committed or being detained at the facility ... "

1. Closed record review of the Medical Screening Exam summary on 10/13/2015 by Nurse Practitioner (NP) #1 for patient #4 dated and timed 08/23/2015 at 1429 revealed, "Patient #4 presented to hospital's Emergency Department (ED) at 1404 accompanied by a Mobile Crisis Unit (MCU) employee following "outbursts of anger" per the mother's report. Review revealed the patient presented with "aggressive behavior, agitation, bizarre behavior and paranoid behavior" with "worsening" progression. Review revealed the patient demonstrated "poor judgement" and non-compliance with treatment..." Review on 10/13/2015 of patient #4's medical record (MR) revealed an Emergency Department (ED) note by Registered Nurse #2 dated and timed 08/23/2015 at 1436. Review revealed "Patient was brought to the ED with mobile crisis team counselor who was contacted by his mother. Patient's mother states that the patient has not been taking his medications regularly and has been having outbursts of anger. Per mother, this morning patient shoved her and tried to light a wall on fire in their home with a lighter." Continued review revealed "Patient recalls shoving his mother and states that he did it on purpose but does not recall use of a lighter. When patient asks if he has been taking his medications regularly, pt states, "I'm just trying to get myself better". Review on 10/13/2015 of Patient #4's MR dated and timed 08/23/2015 at 1528 revealed a screening/evaluation notation by Access Coordinator #1. Review revealed, "Client states that he was trying to show his mom self defense moves today, and she became frightened of him as he pushed her...Client has been to ed several times in the past few weeks." Review revealed "3.5 weeks ago, (MCU) brought him to the ED for setting fire to his belongings out in the yard so that no one would steal them." Review revealed "Today, client reportedly had [sic] lighter up against the wall and burned it." Review revealed the patient was transferred from the ED to the hospital's Emergency Department Behavioral Health (EDBH) unit for continued treatment and stabilization at 1731. Review revealed the following notations on 08/23/2015: 1900 notation by ED RN #2 indicating the patient was transferred from EDBH to the ED and assigned a mid-level provider (Physician Assistant [PA] #1) and at 1914 orders by PA #1 for X-Ray (XR) of the shoulder; a CT (computed tomography) scan of the facial bones without contrast; and CT scan of the brain without contrast. Review revealed no EDBH nursing documentation of the cause for the need to transfer back to the hospital's ED. Review 10/13/2015 revealed an "ED Procedure Note" by PA #1 dated and timed 08/23/2015 at 1922 revealed, "Patient returned to ED from BHR (Behavioral Health) as he got into a fight with another patient. He has a small superficial lac in right eyebrown [sic]. He is refusing to have this examined with threats of violence if I touch him. He states he will only have it glued...Also complaining of left shoulder pain, but also will not let me examine...Will try to reassess after ativan..." Review revealed a notation by the same provider at 2009 stating "Patient has refused all tests and medication. Patient is not IVC (Involuntary Commitment) status and has the right to refuse. The only thing the patient has consented to it [sic] to have his lac on eye glued....Explained I would like to get a XR and CT to make sure he doesn't have injuries but he is refusing to let me examine him or conduct studies. Will send back up to BHR. A+O (Alert and Oriented) to be of sound mind." Review revealed the ED procedure note was countersigned by MD #1 on 08/24/2015 at 1238 AM agreeing with the findings and plan for the patient. Review on 10/13/2015 of the "Initial Mental Health Evaluation by Psychiatrist #1 dated and timed 08/29/2015 at 1042 revealed "History of Present Illness ...SUBJECTIVE: ...He refused EKG (electrocardiogram: heart rhythm tracing), medications, and X-ray since arrival although agreed to glue of laceration over his eye. He was apparently in a fist fight with another patient that was seen on the monitor ...Currently, the patient reports his left shoulder, arm, and skeleton are broken. He states "a black person kept staring at me and he tried to fight me and hurt me." He was punched 2-3 times ...Apparently patient and another patient were in a physical fight in ED resulting in patient sustaining dislocated shoulder. Patient refused correction and was IVC'ed (Involuntarily Committed). It was surgically corrected 8/26 ..." Review on 10/13/2015 of a Discharge Summary" by psychiatrist #2 dated and timed 10/02/2015 at 1157 revealed SUBJECTIVE: ...He refused EKG, medications, and X-ray since arrival although agreed to glue of laceration over his eye. He was apparently in a fist fight with another patient that was seen on the monitor ...Currently, the patient reports his left should [sic] (indicates the quoted matter has been transcribed exactly as found), arm, and skeleton is broken. He states "a black person kept staring at me and he tried to fight me and hurt me." He was punched 2-3 times ..." Review 10/13/2015 of the MR dated 08/23/2015 at 1845 through 08/28/15 revealed no EDBH nursing documentation regarding circumstances of the event or precipitating factors leading to his assault on 08/23/2015. Review revealed the patient was transferred from the EDBH at 1900 to the hospital's ED for treatment of a "laceration above the right eye and complaints of left shoulder pain"; however, the events surrounding the occurrence as indicated in the QAR are not included in the patient's MR.

Review on 10/13/2015 of the Quality Assessment Report (QAR) log revealed the patient was involved in an incident on 08/24/2015..Review revealed the incident occurred on the EDBH unit and involved another patient. Review of the actual QAR on 08/23/2015 revealed "Pt (aggressor) reportedly attacked this patient ...Both patients being held in EDBH area. Patient #4 was found on hands, and knees on floor in front of counselor's office, blood on floor, laceration above right eye and complained of left arm pain. Not cooperative with staff, did not want to return to the ED for assessment, did finally agree to go to ED. Incident observed on camera by monitor staff (Safety Attendant #7). Review of a second QAR dated and timed 08/25/2015 at 0825 revealed, "(Patient #4) was involved in an altercation with another patient on 08/23/2015 and was treated for a laceration but also sustained a dislocated shoulder that was not reduced in the ED prior to the patient returning to the EDBH unit on 08/23/2015."

Interview on 10/15/2015 at 1000 with the hospital's Clinical Nurse Educator revealed "The QAR would not be part of or referenced in the record; however, the expectation is that events surrounding the occurrence is documented in the medical record." Interview revealed, "There should be a progress note about the occurrence. The note would not include completion of a QAR." Interview revealed "Notation should be made the day of the occurrence." Interview revealed EDBH nursing staff did not document events of the patient's assault on 08/23/2015 in the MR. Interview revealed the EDBH nursing staff did not meet the hospital's expectation of maintaining an accurate medical record
2. Closed record review of the Medical Screening Exam summary on 10/13/2015 by NP #2 for patient #12 dated and timed 09/19/2015 at 0133 revealed the patient is a 60 year old male who presented to the ED (emergency department) for evaluation. Review revealed, "Wife presents patient to ED with concerns of SI/HI (suicidal ideation/homicidal ideation: thoughts of self harm or of harming others) states patient attempted to kill himself by stabbing himself in the chest. He also threatened his wife tonight with an iron bar. She states he has h/o (history of) manic depressive disorder. Has not been sleeping well for the last week..." Review revealed presenting symptoms as "aggressive behavior, agitation, homicidal ideas, suicidal thoughts, and suicide attempt." Review revealed, "He expresses impulsivity (acting on a thought without considering the consequences) and inappropriate judgment." Review revealed, the patient "expresses homicidal and suicidal ideation" and "suicidal plans and homicidal plans." Review on 10/13/2015 of the MR revealed notation by Access Coordinator #3 dated and timed 09/19/2015 at 0200 revealed, "The patient arrived in the ED after having an attempt to stab himself with a knife. The patient's wife was able to take the knife away from the patient. The patient believes there is a black bear in the basement, stated that they have him locked up. The patient's wife stated the patient jumped on her neck tonight to try and kill her and she had to sing 'Jesus Love Me' to get him off of her. In addition, the patient went after her with a crow bar." Review revealed, "The patient's wife reports that he is paranoid believing yellow jackets are out to get him." Review revealed the patient "hasn't slept in 7 days." Continued review of the MR revealed "15 Minutes Safety Checks" were initiated at 0230 on 09/19/201. Review revealed notation by RN #7 09/19/2015 at 0410 stating "PUBLIC SAFETY CALLED D/T PT RIPPING OUT iv AND SAYING "I'M GOING TO HURT YOU AND TURNING OVER EVERYTHING IN ROOM." Review revealed 15 minute checks continued until transfer (receiving facility) on 09/21/2015 at 0857. Review revealed the patient was transferred to the hospital EDBH unit 09/19/2015 at 0810 for continued treatment and stabilization. Review revealed "Patient broke string on bathroom alarm" at 1049. Review revealed at 1127 the "Patient continues to be invasive, intrusive, loud and demanding..." Continued review revealed notation by Licensed Practical Nurse (LPN) #1 at 1405, "Pt standing in the hallway in a fighting stance, tv remote in hand, looking at nurse yelling, "You want to fight...I'll kill you...I've done it before i'll do it again..." Review revealed notation by LPN #1 at 1415, "Pt pushed bedside table into the hallway... Nurse asked pt to return table to his room pt refused and threaten to fight with tech (technician)..." Review revealed notation by Registered Nurse (RN) #3, "Patients agitation (anxiety or nervous) increasing, pt screaming more frequently, trying to break rail off the bed and public safety responded..." Review revealed the patient was served IVC papers on 09/19/2015 at 2330. Continued review of the MR revealed notation on 09/20/2015 at 0045 by RN #6 "Pt up to nurses station yelling at staff stating, "i'm going to kill you..." Review revealed notation at 1451 by RN #6 "Pt jumped up on bed, attempting to tear camera and fire sensor off the ceiling "they are taking pictures of my...." Review revealed "pso (Patient Safety Officer) called to assist with pt, pt threatening other patient...Patient continues to act out, requires constant redirection. Engineering report that they can repair hole that patient put in wall..." Review revealed the only notation by EDBH nursing staff (RN #6) regarding patient to patient aggression was at 1730 stating, "Patient involved in altercation with other patient, public safety secured pt and returned him to his room..." Review revealed details of the event as indicated in the Quality Assessment Report (QAR) were not included in the MR. Review of the MR dated 09/20/2015 at 1845 through 09/21/2015 revealed no EDBH nursing documentation regarding the elopement, property damage, or how the patient was returned to the unit, Review revealed no documentation of interventions implemented to prevent similar occurrences. Continued review revealed no EDBH nursing documentation of precipitating (potential cause) factors leading to the "altercation with another patient" and involvement of a visitor in patient to patient aggression.
Review on 10/13/2015 of the QAR log revealed the patient was involved in two incidents on 09/20/2015. Review revealed both incidents occurred on the EDBH unit. Review of the QAR timed 1346 revealed the patient eloped (ran away) from the unit. Review revealed "Pt bent door knob on secure door (#4), opened the door and left the secured unit. Rover (staff assigned to perform monitoring and documentation every 15 minutes) alerts staff that patient left unit and staff attempted to divert (turn) patient back. PSO (Patient Safety Officer) alerted that pt left and staff unable to keep up with him. PS (Public Safety) notified, responded and shortly call received from the 9th floor that pt was on their unit. PS escorted pt. back to EDBH. CSM (Clinical Services Manager) notified engineering and fix made to door knob. Staff secured door until it was repaired and approved for secure use by Public Safety (PS)." Continued review of the QAR revealed at 1700 the patient assaulted a peer and visitor on the unit. Review revealed "Pt punched other pt, pushing him down and knocking him into his relative, whom also was pushed down on to the floor. Assaulted pt and his relative taken to the ED for assessment of injuries, assaultive pt. seen by BH MD (Behavioral Health Medical Doctor)." Review revealed, "All units were dispatched to the EDBH room 8 in reference to a person smoking in the bathroom. As we were standing by in the EDBH, a patient in room 7 Patient #12 came out of his room and started to punch patient in room 8 (victim). At this time, (victim) had to begin to fall backwards and he had fell against his grandma (visitor). Which at this time (visitor) had fell to the ground. (Visitor) was taken to the ER for further treatment. At this time I then cleared the scene at 1820 hours."
Interview on 10/15/2015 at 1000 with the hospital's Clinical Nurse Educator revealed "The QAR would not be part of or referenced in the record; however, the expectation is that events surrounding the occurrence is documented in the medical record." Interview revealed, "There should be a progress note about the occurrence. The note would not include completion of a QAR." Interview revealed "Notation should be made the day of the occurrence." Interview revealed EDBH nursing staff did not document events of the patient's elopement or patient to patient aggression involving a visitor in the MR. Interview revealed the EDBH nursing staff did not meet the hospital's expectation of maintaining an accurate medical record.
Based on the above findings; the allegation, the hospital Emergency Department Behavioral Health nursing staff failed to maintain the medical record was substantiated.












































































































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Interview revealed nursing staff did not meet the expectation of maintaining an accurate medical record.