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Based on interview, clinical record review, and policy review, the facility failed to involve Patient #31 in the planning and treatment as a victim of domestic violence. The hospital's total census was 250 patients.
Findings:
The clinical record review for Patient #31 was completed on 07/14/11. The clinical record review revealed 35-year-old patient came to the emergency room on 06/05/11 at 6:56 A.M. with a chief complaint of altercation with spouse, and has a laceration behind the right ear. A review of the physician documentation stated he/she claimed his/her spouse attempted to stab him/her and hit him/her all over. The document stated he/she had a two centimeter laceration over the left mastoid area, and a three centimeter laceration over his/her shoulder. The document stated the shoulder laceration was closed with three sutures, and the scalp was closed with two stitches.
A review of the triage assessment revealed the patient stated he/she did not feel safe at home, and affirmed that someone at home had hit him/her or injured him/her in any way. The remainder of the emergency room documentation did not reveal in any way how the facility involved the patient in the planning and care as a victim of domestic violence.
Review of the facility's policy entitled " Domestic Violence " as revised on 05/10/11 was completed on 07/14/11. The review revealed: " If upon routine screening domestic abuse is identified or suspected, additional assessment is performed. " The additional assessment includes, according to the policy, behavioral and psychological signs.
On 07/14/11 at 10:30 A.M. in an interview, Staff P confirmed no additional assessment or care was provided to involve the patient in his/her care as a victim of domestic violence. He/she said a police report was made and the patient went home with his/her mother. He/she said social services was not involved and did not meet with the patient. He/she said the additional assessments for behavioral and psychological signs were usually done by the social worker.

Based on interview, policy review, and clinical record review, the facility failed to use the least restrictive interventions that would be effective to treat Patient #24 and #30. The total census of restrained patients was census, the hospital's total census was 250 patients.
Findings:
The clinical record review for Patient #30 was completed on 07/14/11. The clinical record review revealed the 49-year-old patient was admitted to the facility on 07/05/11 with a chief complaint of high blood glucose, nausea, and coffee-ground emesis. The clinical record review revealed a history and physical dictated on 07/05/11 that stated the patient had severe diabetic acidosis with a blood glucose level of 982 milligrams/deciliter and a pH of 7.25 (normal 7.35 to 7.45). The history and physical said the patient had a history of alcohol, tobacco, marijuana, and cocaine abuse.
The clinical record review revealed a restraint assessment flow sheet that stated on 07/05/11 at 6:30 A.M., the patient was placed in four point restraints for removal of intravenous or other tubing thereby slowing the healing processes, unable to follow directions, movements that may re-injure a treated condition, and attempting to get out of bed. The flow sheet listed options for less restrictive devices that included bed alarm, chair alarm, and constant observation (i.e. a sitter). The flow sheet did not indicate those devices were attempted, but that re-orientation and verbal re-direction were.
On 07/13/11 at 10:20 A.M. in an interview, Staff N confirmed that less restrictive devices such as bed alarms, chair alarms, or a sitter had not been attempted prior to using the four-point restraints. He/she said he/she was too restless for a sitter to keep him/her in bed.
The clinical record review for Patient #24 was completed on 07/13/11. The clinical record review revealed a history and physical dated 07/09/11 at 3:50 P.M. The history and physical stated the 79-year-old patient fell down approximately 12 stairs while changing a light bulb. The history and physical stated the patient had displaced right rib fractures, and was admitted to intensive care.
The clinical record review revealed a nursing note dated 07/11/11 at 10:30 P.M. that stated the patient was found sitting in chair with both intravenous lines pulled out. The note stated the patient was placed back into bed. The clinical record review revealed a nursing note dated 07/12/11 at 12:20 A.M. that stated the patient was yelling "help" and found out of bed with intravenous line pulled out. The note stated the patient attempted to punch and spit at staff. The note stated the patient was placed in bilateral wrist and ankle restraints.
The clinical record review revealed a restraint flow sheet dated 07/12/11 at 12:30 A.M. that listed as less restrictive alternatives reorientation, verbal re-direction, covering intravenous sites, and defining clear expectations to patient as attempted without success. The flow sheet did not indicate a bed alarm had been used between 07/11/11 at 10:30 P.M. and 07/12/11 at 12:20 A.M. The flow sheet did not indicate a bed alarm, bilateral upper extremity restraints, a sitter, or some combination of all three had been attempted before using four point restraints.
The clinical record review revealed a nursing note dated 07/12/11 at 1:30 A.M. that stated the patient was sedated.
The clinical record review revealed a nursing note dated 07/12/11 at 2:00 A.M. that stated the patient was sleeping, eyes closed.
The clinical record review revealed a nursing note dated 07/12/11 at 4:00 A.M. that stated the patient was resting quietly.
The clinical record review revealed nursing note dated 07/12/11 at 5:20 A.M. that stated the patient was becoming very restless.
Review of the facility's policy entitled "Restraints, use of for medical or surgical reasons," as revised on 03/10 was completed on 07/14/11. The review revealed: "Restraint is only used when less restrictive interventions have been determined to be ineffective to protect the patient from harm."
On 07/13/11 at 10:30 A.M. in an interview Staff O was unable to show where less restrictive devices were used before placing the patient four-point restraints.
A review of the facility's documentation of restraint usage throughout the facility was completed on 07/14/11. The review revealed in each of the hospital's units, the individual unit is significantly below the measurement benchmark, including the surgical intensive care unit where Patient #24 stayed, and the medical intensive care unit where Patient #30 stayed.