HospitalInspections.org

I. Based on medical record review,
administrations interviews and policy review,
the hospital failed to implement a physician's
written restraint order, which was observed
in 1 of 10 records, specifically noted in P#5
record.

Failure to follow the physician's written restraint
order does not assure that nursing will safely
apply restraints, determine the type of restraints
and this will place patients at risk for harm.

Findings:

1. On 07/29/2010 at 11:00 AM, the investigator
interviewed the Nursing Clinical Educators.
The educators reported that new hired nursing
staff receive restraint training during their
orientation. They discussed when a patient
is showing violet behavior and restraints are
applied. Nursing was to obtain an order within
15 minutes after the restraints were applied.
This was documented in the guideline entitled,
"Quick Guide to Restraints." This guideline
was reviewed on 03/29/2010 by nursing staff.

2. The educators reported that all clinical
nursing staff are required to complete the
annual restraint online training. The nurse
manager receives a report explaining who
completed the training. The nurse manager
of each unit is responsible to ensure that
all staff caring for patients receive restraint
training. During the interview, a copy of
the nursing restraint annual training report
was provided for review. The restraint
report indicated that clinical nurses in the
Behavioral Unit had taken the required
annual restraint training.

3. Director of Accreditation reported that
new hired physicians are required to read the
restraint/seclusion policy during the credential
process. Physician's are then required to
review the restraint policy every 2 years.
The Medical Staff monitors the physicians
restraint training process.

4. On 08/03/2010 the investigator reviewed
P#5 restraint record. The documentation on
the history and physical dated 06/18/2010
revealed the 58 year old was admitted to
the neurology unit on the th floor.
The patient was diagnosed with a cerebral
subdural hematoma. Documentation revealed
the patient hit a nurse while attempting to
leave the unit. A Code Gray was called,
security came and patient was restrained.
The patient's physician wrote an order to
restrain the patient.

5. Review of physician's restraint order was
dated 06/18/2010 and the order was written
at 0054. The physician order read that
nurse's were to use soft cloth limb holders
and vest immobilizer restraints. The soft
restraints were ordered to prevent patient from
compromising the integrity of medical devices by
dislodging lines i.e. IV lines. The physician then
cancelled the order on 06/18/2010 at 0559.

6. Review of nursing documentation entered
on patient's Restraint Flow Sheet Record was
dated 06/18/2010 at 0054. The documentation
determined the nurses failed to enter the
physician's order on the patient's Restraint
Flow Sheet Record.

7. During the interview on 08/02/2010
with the Director of Accreditation. The Director
confirmed the order was written for medical
restraints. On 06/18/2010 at 0054 nursing
failed to complete the following:
1. Review the restraint order
2. Transcribe the order on patient's
Restraint Flow Sheet Record dated
06/18/2010 at 0054 on the Epic electronic
data base.

8. The hospital staff failed to follow the
restraint guidelines by implementing the
physicians written restraint order documented
to use soft limb restraints and use vest at chest.

I. Based on policy review, staff and
administration interviews and medical records
review, the hospital failed to follow the written
restraint policy. This was observed in 2 of 10
medical records, in P1 and P8 records.

Failure to provide the required face-to-face
1 hour evaluation when patients' are place
in restraints, does not assure that patients'
will be monitored according to written
hospital policy and violates Patient's Rights
Regulations.

Findings:

1. On 07/29/2010 at 9:30 AM, the investigator
interviewed the nurse executive. The nurse
executive explained that on this campus nurses'
contact the hospitalist to complete the required
face-to-face 1 hour assessment. The nurse
executive continued to report the hospitalist is
required to document the assessment in the
patient's Progress Notes. This was
documented in the hospital restraint policy.
.
2. On 07/29/2010 at 10:00 AM, the investigator
reviewed the hospital's restraint policy entitled,
"Clinical Restraint or Seclusion Management."
The documentation revealed the policy was
approved by administration on 11/2009.
The policy documentation entered on
page 2 of 9 included the following:
If a patient is restrained or place in seclusion
due to violent or self-destructive behavior.
The licensed independent practitioner (LIP) must
conduct the patient's face-to-face evaluation
within 1 hour after placing the patient in restraints
or seclusion.

3. The policy also documented the physician
was to document the patient's face-to-face
1 hour assessment findings in the patient's
progress notes. The physician's assessment
was to include:
A. Evaluation of the patient's immediate situation.
B. The patient's reaction to any interventions
tried before restraints or seclusion was used.
C. The patient's response to the intervention.
D. The patient's medical behavioral condition
E. The need to continue or terminate the
restraints or seclusion process.

4. On 07/29/2010 at 10:30 AM, the investigator
interviewed the Behavioral Unit Clinical Nurse
Manager. The Clinical Manager reported that
P#1 exhibited destructive violent behavior
towards the staff requiring staff to call Code
Gray/Show of Force. When a Code Gary
is called Security is contacted and comes
to the unit to assist staff and helps
in placing patient in restraints.
Documentation review determined the
patient's limbs were placed in 4 point
Velcro Cuff locked restraints. The nurse
manager explained that patient's behavior
escalated when the nurse offer the patient
a pain medication. S/he explained that it took
1 hour for pharmacy to deliver the medication
to the unit. The nurse gave the cup of water
to the patient, at which time the patient refused
the medication and threw the water into the
nurse's face. The nurse did obtain an order from
the attending after restraints were placed.
This event occurred on 03/31/2010 at 0034.

5. On 08/02/2010, the investigator reviewed
P1's medical record. Review of the
documentation entered on patient's
history and physical. The documentation
revealed the 36 year old patient was admitted
on 03/26/2010 to the Behavioral Health Unit
on 2 East. The physician noted that patient's
admitting diagnosis included depression, anxiety
with abdominal pain compliant. Review of
the patient's Restraint Flow Sheet Record
documented the nurse received a restraint
order from the attending psychiatric physician.
The nurse called Code Gray and 3 Security
Personnel and hospital nursing supervisor
came to the unit. On 03/31/2010 at 0034
the patient was placed in 4 point Velcro Cuff
locked restraints. The nurse contacted the
hospitalist about the patient being placed in
restraints to come to the unit to complete
the required face-to-face 1 hour assessment.
Review of patient's documentation on the
progress notes failed to support the
hospitalist completed the patient's
required face-to-face 1 hour restraint
assessment.

6. On 08/02/2010 at 11:00 AM, the
investigator interviewed the Director
of Accreditation. S/he confirmed the
hospitalist did come to the unit, assessed
how the patient response to the placement
of the restraints. While on the unit the
hospitalist was called away to respond
to another patient emergency and did not
return to document P1's face-to-face 1 hour
restraint assessment. The hospital failed
to follow the written restraint hospital
policy.

7. On 08/03/2010, the investigator reviewed
P#8 medical record. The documentation
on the history and physical revealed the patient
was 58 years old. The patient presented to the
Emergency Department (ED) at 1st Hill campus
on 06/01/2010 in the early morning.
The patient's diagnosis included acute
psychosis. The ED physician documented an
entry that described the patient was using
threatening language which was destructive
toward the ED staff. The ED physician wrote
orders to place the patient in 4 point
Velcro Cuff locked restraints. Review of the
ED physician's documentation determined
the initial face-to-face 1 hour evaluation
was completed. The ED physician made
made arrangements to transfer the patient to
the Behavioral Unit located on Cherry Campus
because a bed was available for this patient.
The patient was transferred by ambulance in
4 point Velcro Cuff locked restraints to the
Behavioral Unit at 2 East on 06/01/2010 at 0430.

8. Review on 08/03/2010 noted in P#8
Restraint Flow Sheet Record the nurse on
the Behavioral Unit obtained a physician's
order from the attending physician to continue
using the 4 point Velcro Cuff locked restraints.
The nurse documented on the patient's
Restraint Flow Sheet Record the ED physician
(at 1st Hill Campus) had completed the initial
face-to-face 1 hour restraint assessment.
The documentation failed to support the
hospitalist at Cherry Campus was contacted by
the nurse to complete patient's face-to-face
1 hour restraint assessment.

9. On 08/03/2010 at 2:00 PM, the investigator
interviewed the nurse executive. S/he explained
the Behavioral Unit nurse considered the ED
physician's face-to-face documented
assessment met requirement when the patient
was transferred to the Behavioral Unit at
Cherry Campus. The nurse should have
contacted the hospitalist to complete
patient's face-to-face 1 hour assessment
which is the procedure for this hospital campus.

10. The evidence determined the nurse failed to
contact the hospitalist (at Cherry Campus) to
come to the unit to complete the patient's
face-to-face 1 hour restraint assessment and
document the assessment on the record.
The hospital failed to follow the written restraint
policy and failed to follow the procedure in
contacting the hospitalist to conduct patient's
face-to-face 1 hour assessment. The nursing
executive agreed the procedure was not followed.