HospitalInspections.org

30984


Based on policy review, record review and interview, the hospital failed to ensure the use of restraint or seclusion was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 2 (#1, #2) of 5 sampled patients.

Findings:

Review of the hospital policy titled, Violent Restraints, revealed in part:
9. Restraint- A manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.
The use of restraint requires a written or telephone order from a physician or Licensed Independent Practitioner. The use of physical restraints can be implemented by a trained registered nurse in an emergency situation.
8. Documentation should include evidence of the inadequacy of less restrictive (alternative) interventions found to be ineffective to protect thee patient or others from harm.
B. If a LIP is not available to issue a restraint order for an emergency application, a trained Registered Nurse can initiate the use of restraints. The physician or LIP must be notified upon initiation of restraint and a telephone or written order is immediately obtained from the physician or LIP and entered into the medical record.
C. Orders for restraint must include: 1) Date and time restraint was initiated, 2) Type of restraint, 3) Length of time restraint will be utilized, 4) Reason or clinical justification for restraint.

Patient #1
Review of Patient #1's medical record revealed the following entry by S4RN:
6/18/16 at 9:31 p.m. - Pt. (patient) ripped IV out and threw the IV pole at myself. Pt. held down by staff. IV restarted and medications ordered by ER MD.

Review of the medical record for Patient #1 revealed no physician's order on 6/18/16 for the use of physical restraints.

In an interview on 9/1/16 at 7:40 a.m. with S4RN, he said he had worked in the ED. S4RN said on 6/18/16 Patient #1 pulled her IV out and threw the IV pole at him and started screaming. S4RN stated he and 4 other staff had restrained Patient #1 by holding her down so he could restart her IV in order to give her Benadryl and Ativan. S4RN said holding a patient down was not considered a restraint and did not need a physician's order.

Patient #2
Review of the Abuse/Neglect reports submitted by the hospital to DHH in the last 6 months revealed an Alleged Physical Abuse self-report had been submitted involving Patient #2.

Review of the witness statements obtained by the hospital during the investigation of the above referenced incident involving Patient #2 revealed the following, in part:
7/26/16: I walked into the room to inform the patient that the nurse had a shot to help him relax. As I was exiting the room the patient jumped off the stretcher and ran to me. He attempted to swing at me and tackled me up against the doors of the room. At that point, other staff members entered the room and attempted to control the patient. Patient continued to try to bite, scratch, and hit staff. Two staff members also tried to hold the patient's legs while the patient was on the ground. Witness statement signed by S5Tech.

Review of Patient #2's nursing notes revealed the following entry, in part: 7/26/16, 8:45 p.m.-9:00 p.m.: Patient was aggressive, yelling at staff, hitting, punching, kicking, acting out, staff attempted to subdue patient, staff instructed patient to stop. Patient given a sedative shot in his gluteus, patient continued to assault staff using hands feet, mouth and throwing staff off of him by thrusting his hips.

Further review of Patient #2's medical record revealed no physician's order for the use of physical restraint on 7/26/16.

In an interview on 9/1/16 at 7:39 a.m. with S4RN, he indicated he remembered the incident involving Patient #2. He said S5Tech had gone into Patient #2's room to ask him to calm down and he had attacked S5Tech. S4RN indicated staff had to perform a manual hold on the patient in an attempt to calm him. S4RN also indicated staff had to hold Patient #2 down so that he could administer IM injections of Ativan and Benadryl.

In an interview on 9/1/16 at 8:00 a.m. with S5Tech, he indicated he remembered the incident involving Patient #2. S5Tech said Patient #2 was fighting and kicking staff. S5Tech further indicated Patient #2 had charged at him and brought him (S5Tech) to the ground. S5Tech stated Patient #2 was then on the ground and staff was holding his legs and arms trying to keep him still. S5Tech said he had held Patient #2's his feet when nursing staff administered the shot to calm the patient. S5Tech confirmed holding down extremities is considered a manual/therapeutic hold.

In an interview on 9/1/16 at 8:20 a.m. with S3EDDir, she confirmed manual/therapeutic holds did not require a physician's order and restraint documentation was not initiated when manual holds were used.

Based on policy review, record review and interview, the hospital failed to ensure restraints were discontinued at the earliest possible time, regardless of the length of time identified in the order, for 1 (#4) of 5 sampled patients.

Findings:

Review of the document dated 5/9/16 for Patient #4 titled Behavior Management Seclusion-Restraint (Violent) Assessments and Documentation revealed in part:
Identify the immediate or serious danger to the physical safety of the patient or others: Patient paranoid, pacing, won ' t stay in assigned bed. Thinks men out to kill her.
Further review revealed Patient #4 was documented as having been restrained from 1:07 p.m. until 4:20 p.m.

Review of the Nursing Progress Note for Patient #4 revealed in part:
5/9/16 at 1:07 p.m. - Suicide precautions initiated. Nurse at bedside. Restraints applied and see restraint documentation.
2:04 p.m. - The patient is sleeping
2:28 p.m. - The patient is sleeping
4:00 p.m. - The patient is sleeping

In an interview on 9/1/16 at 8:30 a.m. with S3EDDir, she said Patient #4 was restrained from 1:07 p.m. until 4:20 p.m. because of the risk of self-destructive behavior. S3EDDir agreed Patient #4 should have been released from restraints sooner than 4:20 p.m. because she had been documented as sleeping from 2:04 p.m. until 4:00 p.m.

Based on policy review, record review and interview, the hospital failed to ensure when restraints were used for the management of violent behavior, the patient was seen face-to-face within 1 hour after the initiation of the intervention by a physician, LIP, physician assistant or trained registered nurse for 1 (#4) of 5 sampled patients.

Findings:

Review of the policy titled Violent Restraints revealed in part:
A. The physician, LIP, or RN must do a face to face within 1 hour after placing patient in restraints.

Review of the document dated 5/9/16 for Patient #4 titled, Behavior Management Seclusion-Restraint (Violent) Assessments and Documentation, revealed Patient #4 was documented as having been restrained from 1:07 p.m. until 4:20 p.m.

Review of the 1 hour face to face assessment of Patient #4 dated 5/9/16 revealed it was documented by S3EDDir at 1:05 p.m. (2 minutes before the patient was placed into restraints).

In an interview on 9/1/16 at 8:30 a.m. with S3EDDir, she said Patient #4 was restrained because of risk of self-destructive behavior. S3EDDir verified the 1 hour assessment by qualified personnel after being placed in restraints was not documented.

Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the care provided to patients. This deficient practice was evidenced by failure of the RN to initiate/maintain q 15 minute documentation of visual monitoring of a violent PEC ' d patient in the ED (emergency department) who was on close observation status for 1 (#2) of 5 patient records reviewed.
Findings:
Review of the hospital policy titled, Safety Observations in the Emergency Department, issued: 3/2013; revised: 5/2016, revealed in part: Policy: Safety observations will be determined by assessment and reassessment of patient care needs, or behaviors exhibited, by ED staff and /or physician order.
Safety Observation Levels are as follows: Close observation: Visual monitoring and documentation of patients by staff q 15 minutes. This level of observation is implemented for any patient regardless of age. Close observation will be performed on patients exhibiting, but not limited to, the following behaviors: SI/HI with a plan, elopement risks, aggressive and/or violent behavior.
Procedure: A. The level of safety observation will be determined by assessment of patient care needs and/or physician order. B. Document the safety observation level on the Safety Observation Flowsheet and visual observation of the patient q 15 minutes, unless otherwise deemed necessary for increased safety precautions. C. Document the reasons, which may include, but are not limited to: Harm to self, Harm to others, Elopement, and Behavior.
Review of Patient #2 ' s medical record revealed an arrival date to the ED on 7/26/16 with a chief complaint of Agitated, Aggressive and diagnoses of Psychotic Disorder and Drug Abuse. Further review revealed Patient #2 had been brought into the ED in police custody due to a domestic disturbance (patient had been threatening to blow up his foster mother ' s home, had stabbed a wall in the home, and had been breaking glass). The patient's legal status was PEC on 7/26/16 at 7:55 p.m. due to being dangerous to self, dangerous to others, gravely disabled, and unwilling to seek voluntary admission.
Additional review of Patient #2 ' s medical record revealed no documented evidence that a Safety Observation Flowsheet had been initiated to document q 15 minute visual monitoring of Patient #2, as required per hospital policy, for patients placed on close observation status.
In an interview 9/1/16 at 7:39 a.m. with S4RN, he confirmed Patient #2 had become close observation status after being PEC ' d by the physician. S4RN said nursing staff usually initiated observation levels and no physician ' s order was required. S4RN further indicated all patients on close observation status should have a Safety Observation Flowsheet initiated with observations documented every 15 minutes.
In an interview on 9/1/16 at 8:20 a.m. with S3EDDir, she indicated patients who had been PEC were placed on close observation status. S3EDDir confirmed Patient #2 had become close observation status after he was PEC ' d by the physician. She indicated patients on close observation status should have q 15 minute visual checks documented on the Safety Observation Flowsheet. S3EDDir confirmed, after she reviewed Patient #2 ' s medical record, that no Safety Observation Flowsheet had been initiated/maintained on Patient #2 when he was PEC on 7/26/16 at 7:55 p.m.