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Based on facility policy review, medical record review, video review, and staff and physician interviews, facility staff failed to ensure a timely restraint order was obtained and documented for each restraint episode for 1 of 6 restraint records reviewed (#5).

Findings included:

Review of the policy titled "Patient Incidents/Occurrences" last reviewed 09/25/2017 revealed, "Purpose: To establish policy and procedures to ensure that appropriate action is taken, accurate records are kept and preventative strategies are identified in the event of a patient incident/occurrences at (Named Facility). The overall purpose of event reporting is to improve safety ...Definitions: ...5. All observations/assessments and treatments will be documented by the nurse and/or physician/physician extender in the patient's medical record. Documentation will occur as quickly as possible, but no later than the end of the shift in which the incident occurred or was discovered."

Review of the policy titled "Restrictive Interventions-Behavioral" last reviewed 06/03/2019 revealed, "Purpose: To establish guidelines for the use of restrictive interventions for behavioral purposes ...Policy: ... J. Documentation is required for each use of restrictive interventions ...Z. Any injuries that result from a restrictive intervention ...will be reported ...Definitions: ...D. Restraint: Any manual method ...that immobilizes or reduces the ability of a patient to freely move his or her arms, body or head ...This could involve moving ...the patient from one location to another or it could involve stopping a patient from doing something ...When patient care unit staff members are presented with a situation requiring emergency use of restrictions and it is not possible to involve other team members, they may place the patient in the appropriate restrictive intervention for up to 15 minutes and must notify the Charge Nurse immediately ...A Registered Nurse must begin an assessment of the patient within 15 minutes...Receipt of a verbal or written physician order."

Review of the medical record revealed Patient #5 was a 6 year old male admitted to the facility on 07/12/2019 with a history of oppositional defiance disorder (ODD) and post-traumatic stress disorder (PTSD) admitted for increased violent behaviors in his foster home environment. Review of the admission "Medical History and Physical Exam" dated 07/12/2019 at 1234 revealed no history of medical problems were noted during the review of systems. The physical exam noted no physical abnormalities except for a "very superficial abrasion across left cheek," mildly elevated heart rate, and a "heart murmur" which, after a call to the guardian, was determined to have been evaluated and considered benign. Review of the facility record revealed Patient #5 was placed in brief manual restrictive interventions twice during the morning of 07/31/2019, at approximately 0841 and 0845. Review of the record revealed existence of a "Brief Manual Hold Order Number: 1449190," and a second "Brief Manual Hold Order Number:1446972." Review revealed intervention 1449190 was noted to have begun on 07/31/2019 at 0841 and was created in the record on 08/02/2019 at 1203 (51 hours and 42 minutes after the time of the intervention). Review revealed intervention 1446972 was noted to have begun on 07/31/2019 at 0930 and was created in the record on 07/31/2019 at 1015. Further review revealed of intervention 1446972 revealed a correction addendum stating, "The timing of this manual hold was 8:33 AM - 8:34 AM on 7/31/19 ..." Review revealed a post interventions assessment was completed by a registered nurse, RN #3, on 07/31/2019 at 1015, and by the Pyschiatric (sic) Fellow, MD #1, on 07/31/2019 at 1024. Review of a "Medical Progress Note" dated 07/31/2019 at 1041 revealed Patient #5 was seen by an Internal Medicine physician, MD #2, after slipping and falling on a wet floor created by Patient #5 the previous night, and also injuring his right foot that same evening after kicking a door. Review of the note revealed Patient #5 had reported right elbow pain during the encounter which she assessed as having normal range of motion in the right elbow, but also noted Patient #5 "initially holding it straight, cried when I touched it, but then it loosened up when pt (patient) distracted. No bony abnormalities." Review of the record revealed Patient #5 was sent to an outside facility on 07/31/2019 at 2000 after reporting ongoing right elbow pain, and medical reassessment noted swelling and coolness of the affected limb. After stabilization of behavioral health concerns, Patient #5 was discharged back to the care of his foster family with continued outpatient therapy on 09/04/2019.

Review with facility staff of the facility's video records of patient common areas for 07/31/2019 revealed two young males seated on a hallway bench interacting at 0840:00. At 0840:50 staff, identified as youth program education assistant (YPEA) #1 entered the area and approached the patients, one identified as Patient #5. At 0841:00 as YPEA #1 stretched out her hand toward Patient #5, he stood and placed his right arm in her hand as they began to walk toward the doors at the far end of the hall. At 0841:12 Patient #5 began to pull left and resisted going down the hall. Both stop at 0841:17. At 0841:22 staff identified YPEA #2 entered camera view, reached YPEA #1 and Patient #5 at 0841:33, and took Patient #5's left arm as they walked into the dayroom and toward the bedroom hall. At 0842:01 all three arrive at Patient #5's bedroom door which YPEA #2 unlocked while Patient #5 kicks at the door. Patient #5 is released from the hold and entered the room alone at 0842:18. At 0842:20 YPEA #2 entered the room followed by YPEA #1. YPEA #1 left the room at 0842:32 followed by YPEA #2 at 0842:43 and YPEA #2 continued to stand at the doorway with YPEA #1. At 0843:24 staff identified as RN #3 stopped and talks with YPEA #2 at the doorway to Patient #5's room before YPEA #2 reentered the room at 0843:52, returned to the hall. At 0843:59 YPEA #1 exited the hall, and RN #3 exited the hall at 0844:51. At 0845:08 YPEA #2 entered Patient #5's room for the third time, RN #3 reentered the area and entered the room at 0845:39. At 0849:14 YPEA #2 exited Patient #5's room carrying a dripping wet stuffed animal and RN #3 exited at 0849:14. At 0850:21 YPEA #2 reentered Patient #5's room for the fourth time and exited at 0851:05. At 0858:58 Patient #5 looked out of his doorway, was standing in the hall at 0858:58, and was talking with an unnamed staff member at 0859:59. At 0901:50 Patient #5 exited the hallway into the day room.

Telephone interview on 09/12/2019 at 1024 with YPEA #1 revealed she recalled the incident on 07/31/2019. Interview revealed Patient #5 had been "sent out of the class room for a five minute break" after becoming disruptive. Interview revealed both patients were given the choice of returning to class or going to their rooms, and Patient #5 had refused to return to class. Interview revealed YPEA #1 attempted to "transport" Patient #5 who was "resistant and tugging and trying to get away" from her hold and YPEA #2 had offered to help. YPEA #1 revealed at the time she was not aware that transport was a restrictive intervention, but "I did find out later ...any time you lay hands on a child it's a restrictive intervention." Interview revealed she had notified RN #3 of the "transport" that day.

Telephone interview on 09/11/2019 at 1130 with YPEA #2 revealed YPEA #1 had been "attempting to escort the patient (#5) and seemed to be having trouble. I asked if she needed some help and she said 'Yes'." Interview revealed, after escorting Patient #5 to his room, "he became more irate after we got into the room, he was kicking the door, yelling, screaming ...struck me on my arm. I proceeded to give him our therapeutic wrap ...talked with him and explained he could not hit staff or me."

Interview on 09/11/2019 at 0950 with RN #3 revealed Patient # 5 had been sent out of his classroom because he had been "disrespectful," and he had been placed in two, one minute manual holds. RN #3 had been alerted to the hold when a YPEA "blew a whistle, and I came in." RN #3 revealed when he arrived at the room "he (YPEA #2) was just about done with the hold (and Patient #5) was compliant." Interview with RN #3 revealed the hold had been appropriately applied by YPEA #2, and once released Patient #5 had sat on his bed. RN #3 stated he had contacted the psychiatry fellow and notified him of the holds and had "debriefed" Patient #5. RN #3 indicated he had not seen the first hold, and RN #3 stated during the debriefing, Patient #5 indicated he had right arm pain and he notified MD #2 who "happened to be on the floor," she assessed the arm, and noted no redness or swelling. RN #3 stated his assessment had been similar, but he provided some acetaminophen for the pain. RN #3 stated he did not know about the injury until he returned to work, and he had also been instructed to correct documentation time errors for the interventions.

Interview on 09/11/2019 at 1015 with MD #2 revealed she had arrived on the unit to see Patient #5 "about something totally different" than the arm pain. Interview revealed when MD #2 met with the patient he had been back in the classroom, she had met him at the door and took him to an exam room where he "jumped up on the table (and) took off his shoes" when she asked about his hip and toe injuries. MD #2 stated Patient #5 informed her his toe did not hurt, and his hip "itched." Interview revealed as MD #2 was "walking out the door and the nurse (RN #3) said do you want to tell her about your arm? Then he said it hurt. I moved it up and down and it was OK, but the underlying problem was that he couldn't move it" because of the type of injury it was. MD #2 stated she had not been informed Patient #5 had been in a hold earlier in the morning.

Interview on 09/11/2019 at 1100 with a psychiatry fellow, MD #1 revealed he had seen Patient #5 after the holds on 07/31/2019. MD #1 revealed he had given orders for the holds, had done the face to face assessment after the holds, and had also seen Patient #5 during a treatment team meeting later in the afternoon. MD #1 stated Patient #5 had been "irritable" but "reasonable" during the team meeting, and he did not learn of the injury that day. Interview revealed documentation discrepancies had been noted as a result of the incident review, and the chart errors had been amended.

Interview on 09/12/2019 at 1011 with RN #5 revealed "each time a restrictive intervention order is entered, a face to face is generated by the system for the MD to complete." Interview revealed MD face to face assessments had been completed for orders 1449190 and 1446972.

Interview on 09/12/2019 at 1350 with the interim chief executive officer (CEO) and interim assistant director of nursing (ADON) revealed during administrative review of Patient #5's injury on 08/01/2019 documentation timing of the interventions was not consistent with review of video recordings. Documentation revealed one telephone order entry had been created by RN #3 for the two, one minute holds on 07/31/2019 which occurred between 0841 and 0846, and timing documentation of the interventions was incorrect (0841 and 0930). Interview revealed the time of the physician assessment after the interventions had also been incorrectly documented but could not be corrected by the involved staff until their return to work on 08/02/2019. Interview revealed RN #3 "received verbal re-education regarding the need to ensure all restrictive interventions are documented accurately in a timely manner." During interview the CEO agreed the time documentation was not fully consistent with times on the video record, but the observable time differences were small, and the sequence of events was accurate.

NC00154425