HospitalInspections.org

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Based on record review, video review, and interviews the facility failed to ensure a physician's order was obtained for two physical restraints used for 1 patient (#2) out of 5 patients reviewed for restraints and seclusions. This failed practice denied the patient's practitioner information about interventions used for dangerous behaviors and the potential of psychological and/or physical harm to the patient. Findings:


Record review on 2/8/23 revealed Patient #2 had diagnoses that included Post Traumatic Stress Disorder.
Review of a "North Star Behavioral Health -ACUTE Seclusion/Restraint Order" dated 1/31/23 at 9:23 AM revealed "Date/Time of Intervention" was 1/31/23 at 9:20 AM. The "Type of Intervention" was marked "Seclusion" and the "Duration of Order" was marked "Youth ages 9- 17 years up to 2 hours." The practitioner had signed off on the order 1/31/23 at 9:23 AM.


Video review on 2/07/23 at 12:30 PM, with the Assistant Administrator and the Risk Manager, of Resident #2's seclusion event revealed Mental Health Staff (MHS) #3 was in the anteroom, (adjacent to the four seclusion rooms) with Patient #2. The Patient was sitting on the floor near a corner of the anteroom. At 9:41 Registered Nurse (RN) #1 and MHS #2 were observed entering the anteroom. The RN unlocked one of the seclusion rooms and held the door open as MHS #2 and #3 grabbed Patient #2 under his/her arms and moved the patient forcefully into the seclusion room. Patient #2 was physically forced into the room, falling towards the opposite wall. The RN then closed the door.


During the video review it was noted that not all corners of the seclusion room or the anteroom could be observed on camera. The Assistant Administrator stated the time stamps on the video were off by an hour.


Review of a second "North Star Behavioral Health -ACUTE Seclusion/Restraint Order", dated 1/31/23 at 12:39 PM, revealed "Date/Time of Intervention" was 1/31/23 at 12:59 PM. The "Type of Intervention" was marked "Seclusion" and the "Duration of Order" was marked "Youth ages 9- 17 years up to 2 hours." Further review revealed the practitioner signed off the order on 2/01/23 at 4:30 PM.


Video review on 2/7/23 at 12:17 PM, of the second seclusion event, revealed MHS #1 and #4, and RN #1 in a doorway to a seclusion room with Patient #2. Patient #2 was again restrained on each arm by the MHS staff and forced into the seclusion room, the door to the locked seclusion room was then closed.


During the video review it was noted the entire seclusion room and the anteroom was not observed on camera. The Assistant Administrator stated all the time stamps on the video were off by an hour.


During a telephone interview on 2/09/23 at 12:55 PM, RN #1 was asked about the definition of a brief manual hold (BMH), the RN stated it was a manual escort with a closed hand. The RN stated if the patient cannot get away from the hold, it was considered a restraint. When asked about Patient #2's seclusions and if the Patient had been put in a BMH, RN #1 replied with the 1st event he/she didn't see the event because the Patient was suddenly in the seclusion room. With the second event, it took 5 staff to get the Patient in the seclusion room.

Review of the facility policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion - RTC,PC112", last revised 8/2020 and approved 2/2022, revealed the following definitions:

-Physical Escort: Using a "light" grasp to escort a resident to a desired location. If the resident can easily remove or escape the grasp, it is not a physical restraint. If the resident cannot easily remove or escape the grasp this would be a physical restraint.

-Physical Restraints: The application of any manual method that immobilizes or reduces the ability of the resident to move his or her arms, legs, body, or head freely (also named therapeutic hold, protective hold, or manual restraint)

Further review of the policy revealed under "Initial Resident Assessment" ..."2. The LIP/physician's order for use of restraint or seclusion will be recorded in the medical record ..." and "3. 1)An order is required for each separate restraint and seclusion episode that is not considered one continuous episode, i.e., a resident at some later time is determined to require the use of a restraint or seclusion to ensure his/her safety or the safety of others.