HospitalInspections.org

Based on hospital restraint policy and review of 12 patient records, it is determined that on two occasions, staff failed to obtain restraint orders; once following the discontinuation and reinitiating of a vest restraint, and once to initiates 2-point soft wrist restraints.

Hospital restraint policy GNP14.6.17 Restraint /Seclusion approved 1/2014 reveals the statement " Orders are obtained for Medical /Surgical restraints from a physician or nurse practitioner. "

On 9/8 at 0906 a non-violent restraint order for "vest" was written with a rationale of "pulling at tubes/lines, and climbing OOB (out of bed) with risk of falling." No documentation of a vest application is noted until the nursing flow notes indicate a 1352 "start." According to documentation, patient #2 had the vest on until 1513 when it was removed.

Subsequent flow notes indicate a new "start" of vest use at 1800, but no new order is found in the record as required by regulation. Therefore, in practice, staff continued to use the order written at 0906 for application of a vest restraint at 1352 and 1800, without regard for obtaining orders simultaneous to the actual need for which the restraint was used.

On 9/8/14 at 2200 an order for non-violent restraints "vest" and "2-point soft wrist" were ordered. The rationale for the order was written as "pulling tubes/lines, and climbing OOB (out of bed) with risk of falling."

On 9/9 at 0400, nursing documented "Pt began attempting to hit both sitter and tech. MD paged and ordered soft wrist restraints. Pt now in posey and soft wrist restraints. RN will continue to monitor."

According to the nursing flow record patient #2 had already been in a vest and 2-point soft wrist restraint since 2200 evidenced by every-two-hour documentation on the nursing flow which stated, "Continue" for both types of restraint.

While the record reflects that patient #2 was already in a vest and 2-point soft wrist restraint, the fact that the patient was striking-out indicates that he was no longer in 2-point wrist. Further, while the RN stated that she obtained an order for soft wrist restraints, no new order was found. Therefore, patient #2 was restrained for 6 hours without a new order as required by regulation until 9/9 at 1000 when per staff, patient #2 ' s wife asked to have the restraints removed.

Based on all information, the hospital failed to obtain orders for restraint of patient #2.

Based on hospital restraint policy and review of 12 patient records, it is revealed that 1) non-violent restraint orders with up to a 24-hour duration were written for patient #2 even when patient #2 displayed no behaviors warranting a restraint order, and 2) these orders were utilized by staff on an " as needed " basis.

Hospital restraint policy GNP14.6.17 Restraint /Seclusion approved 1/2014 reveals the statement, under II. Medical Surgical Restraint: A 2. Standing orders and order written on an as-needed basis (PRN orders) are not allowed.

Patient #2 is an elder male with a history of depression and alcoholism who presented to the emergency department via emergency medical services (EMS) following a purposeful overdose in combination with alcohol. Patient #2 was intubated and admitted to critical care, due to a compromised airway secondary to aspiration and right lower lobe lung pneumonia. Patient #2 was extubated two days later.

The nursing flow record on which care is documented including restraint care reveals "no restraint summary" from 8/29/2014 at 0000 to 9/6/2014 at 2359 indicating that there were no restraint no activity/care for patient #2 during that period, as he did not require restraint.

However, a 24-hour non-violent order for vest is found written on 8/30 at 0744, and another similar order for vest is found on 8/31 at 0821. Both orders reveal rationales of: Pulling at Tubes/Lines. At that point in time, patient #2 had an IV in his arm. No documentation is found to indicate that patient #2 attempted to pull the IV from his arm. Therefore, and based on the fact that no restraints were used, the orders represent orders which staff could use as needed.

On 9/8 at 0906 another non-violent restraint vest order was written with a rationale of " pulling at tubes/lines, and climbing OOB (out of bed) with risk of falling. " No actual documentation is found which reveals patient #2 was pulling at tubes/lines (in this case his IV line), nor that he was attempting to get out of bed. Additionally, no documentation is found which reveals that a vest restraint was applied at the time the order was written. Therefore, this order also represents an order to be used as needed.

No documentation of a vest application is noted until the nursing flow notes indicate a 1352 " start. " According to documentation, patient #2 had the vest on until 1513 when it was removed. Flow notes then indicate a new " start " of vest use at 1800, but no new order is found in the record as required by regulation. Therefore, in practice, staff continued to use the initial 24-hour order written at 0906 for application of a vest restraint at 1352 and 1800, and without regard for obtaining orders simultaneous to the actual behaviors for which the restraint was used.

The vest restraint continued through 2200 when a new non-violent restraint order was written. This order was for both a vest and for 2-point soft wrist restraints with the rationale of pulling tubes/lines, and climbing OOB.

On 9/9 at 0408, nursing wrote, " Pt began attempting to hit both sitter and tech. MD paged and ordered soft wrist restraints. Pt now in posey and soft wrist restraints. RN will continue to monitor. " According to the record patient #2 was already in a vest and 2-point soft wrist restraint from the 8/9 2200 order. Based on the fact that patient #2 is documented as striking- out, it is unknown when patient #2 was taken out of the 2-point soft wrist, or why the RN continued to document a continuation of the 2-point soft wrist restraint if patient #2 was not in them.

No new order appears in the record related to the RN statement of obtaining an order. Patient #2 remained in vest and 2-point soft wrist restraints until 1000 when per staff, patient #2 ' s wife asked to have the restraints removed. The restraints were removed and at the time of survey, no untoward behaviors were noted.

Based on all documentation, patient #2 had orders for restraint during times when restraint was not identified as being necessary. This represents standing orders for restraint. Additionally, it appears that staff intermittently utilized these 24-hour non-violent restraint orders on an as-needed basis. Therefore, the hospital failed to follow their restraint policy, and failed to follow regulatory requirements for writing appropriate restraint orders.

Based on interview and review of 12 patient records, it is determined that staff in medical areas of the hospital failed to distinguish between non-violent and violent behavioral events for patient #2, which impacted the length of time patient #2 was in restraint.

Patient #2 is an elder male with a history of depression and alcoholism who presented to the emergency department via emergency medical services (EMS) following a purposeful overdose in combination with alcohol. Patient #2 was intubated and admitted to critical care, due to a compromised airway secondary to aspiration and right lower lobe lung pneumonia. Patient #2 was extubated two days later.

On 9/8/14 at 2200 an order for non-violent restraints " vest " and " 2-point soft wrist " were ordered. The rationale for the order was written as " pulling tubes/lines, and climbing OOB (out of bed) with risk of falling. " The nursing flow documentation titled " Visual check, " revealed a 2200 entry indicating patient #2 behaviors as " Agitation " and " Verbal Abuse. " No nursing progress note further describes patient #2 ' s specific behaviors.

Review of the drop down menu for " Visual Check, " reveals no behaviors which were exhibited by patient #2 for a restraint order rationale of pulling tubes/lines and climbing OOB with risk of falling. The documented criterion for release from restraint was written as the " absence " of such behavior. Based on the fact that patient #2 was not attempting to pull out his IV or climb out of bed, it is not clear why patient #2 was restrained at all.

Patient #2 had recently been identified as having developed " Sundowners Syndrome, " which is a condition characterized by increased confusion and agitation after the sun goes down in patients with some form of dementia.

On 9/9 at 0400, nursing documented, " Pt began attempting to hit both sitter and tech. MD paged and ordered soft wrist restraints. Pt now in posey and soft wrist restraints. RN will continue to monitor. "
Review of the record reveals that the RN did not write a new order for restraint (Tag A-0168). Presumably, the RN utilized the 9/8 2200 order (Tag A-0169) that was written for pulling tubes/lines and climbing OOB.

Consequently, patient #2 was restrained in a vest and 2-point soft wrist restraint for the next 6 hours until 9/9 at 1000 under a rationale that did not match his episode of violent behavior. He was restrained for those 6 hours for a behavior which was not documented to have occurred again. Further, he was restrained until his wife requested he be released from those restraints. When staff complied with the request, patient #2 had no further outbursts during the time of survey. Where the goal of restraint use is to release at the earliest possible time, the use of restraint would necessarily have to be conditioned on identifying patient behaviors which could match the criteria for discontinuation.

In summary, there is clearly staff confusion as to what constitutes non-violent and violent behaviors, the use of the appropriate orders/durations for those behaviors, and the active role staff plays for either type of restraint in helping discontinue restraint at the earliest possible time.