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Based on a review of hospital policy, and patient #1's record, it was determined that staff failed to release patient #1 from restraint at the earliest possible time when; 1) staff failed to establish appropriate termination criterion for patient #1 at the initiation of restraint, 2) staff applied changing, and erroneous criterion for release to patient #1; 3) staff failed to identify when patient #1 had met criteria for release.

Review of hospital Restraint/Seclusion policy (RSP) titled, "Provision OF Care Policy for Use of Seclusion or Restraint" (dated 6/2015), revealed a definition of an Emergency Situation as "Behavior poses serious and imminent danger to safety of self and/or others." The RSP further states in part, "S/R may only be used in emergency situations," ... and "S/R shall not be used solely on past history."

Patient #1 was an adult who was admitted to the psychiatric hospital for a 6 month period beginning in 2016 and ending in 2017. Patient #1 was initially on a voluntary, and not competent or responsible (NCR) for conditional release. Approximately two weeks prior to discharge, patient #1 became angry with an RN, which escalated into property destruction and an attempt to assault the RN. Patient #1 was prevented from harming the RN, and was placed into 4-point bed restraints at 8:25 AM, and then received emergency medication. Patient #1 remained in restraints for the next 5 days.

The "RN Initiation of Seclusion Restraint" form of 1/25/17 at 8:20 AM states in part, "Behavioral criteria for release explained to patient (specify, 'contract for safety' is not acceptable):___________." The RN was to fill out this portion with the behavioral criterion for release told to patient #1. However, this portion of the form was left blank. Additionally, review of the 5-day restraint revealed that the criterion told to patient #1 was not clearly or accurately documented, and appeared to change over time.
Fifteen-minute documentation was completed during the restraint on the "Care and Observation Log for Seclusion or Restraint" (COLSR). An RN note on day one at 7 PM stated in part, "Pt refused to discuss criteria for release or future coping methods that would be appropriate. Refused to discuss if he would act in a safe manner (after) restraint ...Seen by Dr. __ angry, argumentative." While education and discussion of criterion and coping methods may be beneficial to a patient, release from restraint and seclusion are based on an absence of imminently dangerous behaviors to self and others as defined in the hospital RSP and does not require that the patient discuss release criterion or coping methods.

At 10:45 PM, an RN documented in part, "Criteria of release explained to the pt. Pt is demanding to be let out of restraints and continues to have an angry affect in spite of his verbal response stating he will not act aggressively. Pt does not meet criteria for release at this time." Based on this, patient #1 was continued in restraint, justified only by an angry affect, which is insufficient by itself to justify continued restraint.

A physician face to face evaluation of 10:45 PM states "Although patient tells me he will not act aggressively if released from restraints, his voice and affect have a demanding edge. Other staff who have had a lot of contact with pt. indicate that he does not appear fully at his baseline, and that he continues to occasionally use profanity. The physician used the example of, "Pt said, "Release me now you fucker". It is unclear when patient #1 made this statement, as documentation does not support that it was made during the 10:45 PM assessment. The physician note continued "Pt still appears to be at increased risk for impulsive aggression."

The RN who documented at 10:45 PM, also documented a RN Change of Shift Assessment Progress Note at 11 PM. The 11 PM note contradicted the 10:45 PM documentation when it stated in part, " ...Pt has been unable to contract to not hurt anyone when questioned about wanting to hurt others." Patient #1 had volunteered the information to the RN and physician that he would not act with aggression. While a "contract" for safety may be discussed with a patient, the "RN Initiation of Seclusion Restraint" form explicitly stated that contracts for safety were not acceptable for use as a criterion.

Patient #1 made threats through much of day two while in restraint. While this may seem to support keeping patient #1 in restraint, behavioral assessments for release are based only in imminently dangerous behaviors during real-time assessments.

On day three at 12 AM a RN assessment for release documented "Refusing to discuss reason for restraints and remains unpredictable will continue to monitor the pt." No real-time behaviors were documented which indicated imminent dangerousness to others. Additionally, the use of the term "unpredictable" is subjective and without further description of his behavior , has no clinical value regarding a justification for continued restraint.

At 2 AM , a RN documented patient #1's quote and assessment as, "Just stop talking to me I am trying to rest." Criteria for release not met. Refusing to discuss issues and not contracting for safety. Blames others for his behaviors poor insight and judgement. Remains unpredictable and danger to others ..." It is not known why the RN disturbed patient #1 during the night where regulatory guidance allows the patient uninterrupted rest while in restraint. However, the fact that patient #1 would not discuss issues, would not contract for safety, had poor insight and judgement, or the subjective opinion that he remained unpredictable failed to justify ongoing restraint.

At 3:30 AM, a direct care associate documented "Pt nonverbal communication and restless. He raised his two hands up at intervals. Pt adjust body position to be comfortable. " It is noted that the COLSR contains no option under the listing of "Behaviors Observed" by which to document that a restrained patient is calm or sleeping. However, there is an option for "nonverbal communication." It is possible that patient #1 was nonverbal at 3:30 AM due to sleep. While a sleeping patient need not be aroused to remove restraints this documentation indicates that the patient was not a danger to self or others at that time..

At 4 AM a RN documented in part, "Patient less restless, but still upset and crying ..." Patient #1 had by now been restrained on his back for almost three days. The note continued, "Criteria for release explained to pt. Pt stated "What did I do that I have to explain myself to everyone ...remains unpredictable and criteria for release not met." No documentation in this note indicates imminent dangerousness and thus, no justification for continued restraint.

At 6 AM a RN documented "Criteria for release not met. Remains unpredictable, impulsive, irritated and angry." A physician face to face of 6 AM stated "Patient remains unchanged and unpredictable. He is unable to give contract for safety." No documentation in either note indicates imminent dangerousness, nor justification for continued restraint.

At 8 am an RN assessment documented, "When asked why he is in restraints Pt stated, "I don't want to talk about it. Pt asked "How long do I have to stay in here." Pt was educated on his behavior and criteria for release. Pt unable to state criteria for release stating, "I have never been in restraints before." Pt avoids eye contact, and when offered a prn stated "I don't need a prn so I'm not taking one fuck that ... Tolerated ROM (range of motion) but continued to insist the restraints be looser. At this time pt has a flat affect and is staring at the wall. At this time pt does not meet criteria for release ..." No element of this RN assessment described imminently dangerous behaviors which justified ongoing restraint.

At 10 AM an RN assessment documented, "Criteria for release explained to pt. Pt educated that he must be free of harm to himself or others, pt educated that he needs to remain in restraints until he is able to state his prns are effective and demonstrate appropriate behaviors and coping skills at this time pt is agreeable to the plan and will notify staff when the prn is effective ...." Based on this documentation, staff would only release patient #1 contingent on patient #1's reporting the effectiveness of prn medication. Additionally, patient #1 would not be released until he could demonstrate appropriate coping skills which is not a criterion for release from restraint, and at a baseline for an acutely hospitalized psychiatric patient, may not have been a realistic expectation for patient #1.

The note continued "Pt continues to have poor eye contact and a flat affect ...does not meet criteria for release will reassess between 1-2 hours." It is noted that poor eye contact and a flat affect might be demonstrated by much of the psychiatric hospital population, and are not criteria for restraint. Again, no clinical documentation justified a need for ongoing restraint.
A physician face to face at 12 noon stated "Pt calmer, sedated. No loud speech, uncontained anger, threats or cursing. In light of serious behavioral dyscontrol on (three days prior) caution seems prudent. Will stop 4-points, start belt-wrist-ankle. Based on this note, patient #1 was continued on restraint based on history alone which is not justification for continued restraint. Patient #1 had ceased imminently dangerous behaviors, and therefore should have been released from all restraint.

At 12 noon, an RN wrote, "Criteria for release of 4 points explained and met at this time. Pt placed in ambulatory restraints for safety of others. Although pt met criteria for release of 4 points pt continues to be unpredictable at times, pt lacks appropriate eye contact and continues to have a flat affect. Will continue to educate and encourage the use of appropriate coping skills. A criterion for release from the ambulatory restraints was documented as, "Pt must demonstrate appropriate behavior that is safe for himself and others." This is a nonspecific criterion for continuing restraint and again does not justify continued restraint use.


Based on documentation, and despite the fact that patient #1 demonstrated no imminently dangerous behaviors, staff placed patient #1 in ankle and wrist restraint based on the subjective determination that he was "unpredictable," lacked appropriate eye contact, and had a flat affect. As stated, use of the term "unpredictable" was a subjective judgement and failed to describe imminently dangerous behavior. Additionally, no patient should be restrained due to a lack of eye contact or a flat affect. Based on all documentation, clinical staff failed to identify patient #1's readiness for release from restraint.

Nursing documentation on the COLSR from 12:15 PM to 1 PM stated respectively in part, "Ambulatory restraints applied, criteria for release explained ...Pt lying in bed eyes closed ...Pt lying quietly in bedroom eyes closed ...walking slowly in dayhall ___ phone - now eating lunch." At 2 PM, a nursing COLSR note stated, "Pt continues to pace around the unit. Pt continues to make multiple phone calls to complain about his restraint episode. Pt lacks insight at this time he believes he didn't do anything wrong. Pt eye contact has improved slightly and his affect has improved slightly when asked how he was doing, he stated, "It's going." Circulation within normal limits. Pt remains unpredictable. Does not meet criteria for release at this time."
Over the following two days, patient #1 had periods of upset and cursing related to continued restraints, and the knowledge that he was to be transferred to another hospital. However, at other times he was documented as "sleeping ...quiet and watching tv and also playing cards with and interacting with peers.

Based on all documentation, staff failed to establish appropriate and objective criterion for release from restraint. Additionally, staff applied changing and inappropriate criterion through 5 days of restraint inclusive of those already mentioned and "unable to take responsibility ...is untrusted ....refuses to admit he did anything wrong." Staff failed to identify when patient #1's behaviors indicated a readiness for release. Therefore, the hospital failed to release patient #1 at the earliest possible time.

Based on a review of staff training and patient #1's record, it was revealed that when patient #1 experienced chest pain while in restraint, no physician examined patient #1 and no diagnostic testing was conducted to indicate an etiology for that pain.

Review of staff training related to seclusion and restraint was found to be appropriate in scope for the care and assessment of patients in restraint and seclusion, and is updated annually. Part of the training for nursing included competency for signs of distress. Another part of training for nursing and physicians included the face to face assessment of the patient medical status.

Patient #1 was an adult who was admitted to the psychiatric hospital for a 6 month period beginning in 2016 and ending in 2017. Patient #1 was initially a voluntary admission, and not competent or responsible (NCR) for conditional release. Patient #1 had a history of high blood cholesterol for which the patient took medication.

On an evening in late January 2017 a nursing note of 9:55 pm described in part, "(Patient #1) stated "My chest feels funny" at 6:55 pm v/s at 7 pm 97.0, 87, 16 113/74 pulse oximeter 97%. Patient denied any pain, shortness of breath, or any symptoms. Dr. __ notified. No new orders. Will continue to monitor."

Five days later, patient #1 became angry with an RN, which escalated into property destruction and an attempt to assault the RN. Patient #1 was prevented from harming the RN and was placed into 4-point limb restraints in bed at 8:25 AM, and then received emergency medication. Patient #1 remained in 4-point restraints by bed or ambulation for the next 5 days.

On the first evening of restraint at 10:15 pm, an RN note stated in part, "VS 98.2-113/78-94-96% pulse ok. Pt said that he has a dull ache in his chest. Pain level 7. Dr. ___ notified." At midnight, a nursing assistant documented "Pt wants to speak with (staff) and continue to pull the restraints. Pt complain of pain on chest." At 12:05 AM a RN wrote "Pt requested to speak with Charge nurse complained of chest pain v/s 97.2, 18, 123/71, 97% on room air. Respirations even and unlabored. No SOB or distress noted. Pt stated the pain is middle of chest. Dr. __ was notified- circulation is adequate (WNL) to all extremities, skin warm to touch ..." At 12:15 AM, an RN wrote, "Pt stated, "I will take my prn for pain. Pt took acetaminophen for pain chest discomfort ..."

No physician face to face was completed during the time of chest pain. Approximately 2 hours later at 2 am, a physician face to face note revealed the physician placed an "X" in a box labeled, "Medical status has been assessed." No specific documentation regarding patient #1's prior chest pain was noted on the face to face. An RN change of shift note of 6:15 am under "Recent PRN medication and effectiveness," documented multiple prns given to patient #1 with effectiveness. However, the RN failed to document the acetaminophen given for "Chest discomfort" and its effectiveness. No other documentation is found related to the 2 hours of chest pain experienced by patient #1.

In summary, patient #1 had a documented history of chest discomfort, five days prior to restraint, and then, over the course of two hours during a restraint episode, patient #1 described chest pain at a level 7 where 0 is no pain and 10 is the worst pain.

No physician examined patient #1 during those two hours, nor were any diagnostics such as an EKG ordered to determine a possible cardiac condition. Additionally, no further documentation or follow-up was found related to patient #1's chest pain. Based on all documentation, the hospital failed to monitor the medical condition of patient #1 while in restraints as required by regulation.