HospitalInspections.org

Based on the review of 7 closed medical records, 4 open medical records, and video surveillance, it was determined for 2 of 3 restrained patients (#10 and 11) the hospital failed to ensure that patients were not restrained based on staff convenience.

Patient #10 was a late twenties year old individual who was brought to the emergency department (ED). The patient during examination endorsed suicidal ideation and displayed symptoms of mania. Patient #10 was transferred to the ED psychiatric area. While in this area the patient was held to receive an intramuscular anti-psychotic and anti-anxiety medication at 0226. The medical record lacked documentation or objective descriptors of violent/ self-destructive behaviors that warranted the patient being given the emergency medications and being held by security staff during the administration of the medication.

Per the medical record, the registered nurse (RN) documented the patient's behavior over the hour prior to medications administration as "not following directions, disruptive, pacing in the halls, verbal, and not respecting BHU limits." There was no documentation that the patient was violent or posing a imminent threat to self, other patients, or staff. Behaviors were intrusive but not violent.

The physician's progress note leading up to the patient being medicated stated that at 0151 "per the RN [pt] was growing increasingly agitated and combative with staff as well as not following directions."

Video surveillance of this area consisted of visual observation without audio but did not confirm that the patient was combative with staff. This observation of events included visuals of nursing station, the hall, and in the patient's room from midnight until 0315. There was no evidence to support that patient #10 presented a physical threat to other patients, staff, or himself.

The face-to-face for this restraint episode also lacked objective descriptors of behaviors by patient #10 that justified the restraint. Per the face-to-face, documented at 0305, the patient's behaviors leading up to the restraint episode were increased agitation, shouting, refusing to follow instructions. These documented behaviors did not describe a violent or self-destructive patient, nor did they describe a patient in need of emergency interventions.

Pt #11 presented to the emergency department (ED) in late March with complaints of depression and feeling suicidal, without a plan. The patient was transferred to the Behavioral Health Unit (BHU) within the ED. Over the 48+ hours that followed, nursing documentation on multiple occasions stated "Patient trying to come out of the room and walk around", "Patient is agitated, walking out of room" and "Patient awake and wondering around the room, very drugged and staggering around the room." The ED physician was notified by nursing and medication orders were entered. The patient was medicated with antipsychotics and other sedating medications multiple times as emergency interventions for dangerous behaviors during this time frame.

During this timeframe, the patient was also placed in violent restraints on 2 occasions and in locked door seclusion on 3 occasions. Nursing notes state patient #11 was "unable to stay in room after medication" and "Doctor ordered seclusion until medication given earlier takes effect." Documentation prior to placement of restraints/seclusion for violent behavior failed to reveal dangerous behaviors that justified the need for restraints and seclusion. Review of the 1:1 sitter flowsheets revealed documentation over the time period of three 12 hour shifts that over half of the time the patient was asleep and/or cooperative. During the time the patient was awake, the sitter documented "agitated/getting out of bed".

Further medical record review revealed a physician note that stated "Patient is not violent but RN would like some medication." On the day of discharge, the nurse documented that the transportation team "is requesting restraints for transport ...I explained that patient's current behavior, which is not aggressive, does not legally support restraints." However the physician placed an order at that time for the patient to receive another dose of antipsychotic medication.

Video of patient #11 also failed to support that the patient posed a threat to anyone. Patient #11 was intrusive and pacing/walking in the halls, but at no time appeared to pose a physical threat to anyone.

In neither patient did documentation support or explain the need for continued medication and restraint use. In summary the documentation of these restraint episodes lacked descriptive behaviors exhibited by the patients that warranted or supported that the patients required restraint interventions, emergency medications, or physical holds, especially in the face of contradictory video evidence.

Based on review of 4 open and 7 closed records and pertinent documentation, it was determined that the hospital failed to obtain an order for seclusion for 1 of 3 patients reviewed for restraints/seclusion.

Findings include:
Patient #11 presented to the emergency department (ED) in late March with complaints of depression and feeling suicidal, without a plan. The patient was moved to the Behavioral Health Unit (BHU) within the ED. Nursing documentation revealed the patient was agitated on multiple occasions and kept 'coming out of (the) room' and 'pacing the hallway'. During this time, nursing notes were found that stated "Patient was secluded in isolation under doctor's orders," "seclusion commenced" and 30 minutes later "Patient is still in Locked Door Seclusion (LDS)".

However, Patient #11's medical record did not contain an order from the physician for the patient to be placed in locked door seclusion at that time.

Based on review of 4 closed and 7 open medical records it was determined that providers in the emergency department's behavioral health unit were writing standing restraint orders.

Per record review of patient #4 record, it was revealed there were 2 orders by two different physicians that had PRN restraint instructions. Per "Medication Administration Record," (MAR) orders for an anti-psychotic and anti-anxiety medication at 03:14 and 15:42 had administration instructions that stated, "Initiate physical holding for forced medication to limit patient's movement in order to administer medication. Discontinue the physical hold on patient once the medication administration is completed." The brief hold order was part of the medication order on the MAR. It was not needed for patient #4, who willing took the intramuscular medications, and thus constituted a PRN (as needed) order for a restraint.

Based on the review of 7 closed medical records, 4 open medical records, and video surveillance, it was determined in 2 of 3 restraint records a complete face-to-face evaluation was not completed.

Patient #10 a 20+ year old who was brought to the emergency department (ED) for evaluation. Patient #10 was medically cleared and transferred the ED psychiatric area for treatment. While in this area patient #10 had a Violent /Self Destructive Restraints episode at 0233, which required a face-to- face evaluation. Per the medical record, the physician's progress note documented the face-to-face was completed at 0305. Reviewed of the video surveillance of the unit show that the physician came on to the unit to evaluated the patient; however, the physician never entered the patient's room. The physician was seen on recording entering the unit, speaking with the RN, the RN and physician walked towards the patient's room, the physician looked in the patient's room for less than a minute, never coming to the door frame, and then walked back towards the nurse's station. Per video, the patient during this time was lying prone on the bed. Evidence of completion of a face-to-face evaluation is not supported by the proximity and time elapsed witnessed from the video.

Based on review of 4 open and 7 closed medical records along with quality assurance data, it was determined that 1 of 11 records lacked dates on the behavioral observation flowsheets in one patient's (#11) medical record.

Findings include:
The medical record for Patient #11 included handoff flowsheets for documentation of behaviors while the patient was in the behavioral health unit that were not filled out in entirety. One form lacked a date. Multiple sheets lacked times as well as signatures. The lack of dates, times and signatures on the flowsheets eliminated the Quality Assurance Department's (QA) ability to review care during this patients restraint/seclusion episodes.