HospitalInspections.org

Based on an onsite investigation inclusive of 10 patient records, it is determined that patients #2 and #10 received no instruction as to behavioral criterion by which to terminate their restraint/seclusion events.

Patient #2 is a young adult male who presented to the emergency department (ED) via ambulance following thoughts of harming others. Following admission to the unit, patient #2 made a threatening statement that he was going to stab a staff member. Patient #2 was placed in seclusion for one hour. Review of patient #2's record reveals that no criterion for release from seclusion was given to patient #2. Therefore, patient #2 could not participate meaningfully in his care planning and treatment.

Patient #10 is an adult male who presented to the Emergency Department via police on emergency petition due to intoxication with threats to kill himself. Patient #10 was placed in 4-point restraints at the time of presentation due to combative behaviors and attempts to flip the stretcher. He remained in restraint for 3.5 hours.

Review of documentation reveals that patient #10 received no instruction regarding behavioral criteria that would release him from restraint was given. Therefore, patient #1 could not participate meaningfully in his care and treatment.

The hospital failed to inform patient's #2 and #10 of behavioral criteria for exit of seclusion and restraint respectively, therefore, failing to meet their rights to participate in their care and treatment.

Based on a review and comparison of the hospital security policy for "Use of Force" and the hospital "Patient Restraint" policy, it is revealed that the hospital, 1) allows security staff to determine the severity of patient behaviors requiring restraint; 2) allows security staff to restrain patients at their discretion, and without orders; 3) allows security to use hand cuffs and batons as they deemed appropriate, and 4) allows security to restrain without nursing or physician oversight.


The hospital has a "Use of Force Policy" (eff. 4/11) allows security staff discretion to supersede clinical interventions and evidence-based training in lieu of police-type management of aggressive patients. Per the " Use of Force" policy, the purpose is:


To establish a policy, assign responsibility and provide procedures for the use of force in controlling patients or visitors whose behavior has become aggressive, threatening or violent; to the extent that it creates safety concerns for patients, visitors, and/or staff.


This policy applies to (hospital) Security personnel and establishes a formalized process for the judicious use of force ...Certified instruction and training in the use handcuffs, pepper spray, and/or the ASP baton will be required before an individual will be allowed to carry these items. Staff interviewed indicated that pepper spray and batons have not been used even if allowed by policy.


No definitive difference between aggressive, threatening or violent behaviors that clinical staff oversee, versus aggressive, threatening or violent behaviors to which security staff may respond without clinical oversight, is found in policy. Therefore, security staff may, at their discretion, make sole determination as to when to use force consisting of non-evidence-based techniques, and police-type restraining tools (cuffs and weapons).


The hospital "Use of Force" policy attempts in part, to combine security-led restraints with clinically-led restraints where the policy states " Handcuffs, or Safe-T-cuffs, will be used as a type of patient restraint where there is an emergency need and medical order to restrain the patient or medical restraints cannot be applied quickly enough to ensure safety," and "Only staff trained in handcuffing techniques by a certified trainer and who have demonstrated competency annually are authorized to use this method." This seeming combination of police-type restraint is again at the sole discretion of the non-clinical security staff member, and neither requires no evidence-based restraint holds, nor an order to utilize.


The hospital restraint policy states in part: "Restraints will be applied in accordance with Maryland law, COMAR 10.21.12 (1994), CMS Conditions of Participation and Joint Commission Standards." All of the aforementioned regulatory bodies require clinical oversight of all restraint and seclusion processes, which would not met by a security staff decision to restrain, nor do police-type interventions meet those regulatory requirements. Therefore, the "Use of Force" policy is in direct conflict with the hospital Restraint policy.


While no records of undue force were found by the surveyor, the hospital's conflicting policies fail to consistently address safe restraint/seclusion techniques allowing non-clinical security staff to decide and act on their sole determinations of imminent dangerousness in an individual determined to be a patient, without defined guidance and oversight of clinical staff. Additionally, security staff who use police-type restraints and weapons are not using evidenced based techniques for safe restraint processes.

Based on a review of hospital restraint policy and 10 patient records, it is revealed that patients #2 and #10 received no face to face examination for respective seclusion and restraint events.

The hospital Restraint policy under violent restraints reveals "Physician/practitioner face-to-face assessment must occur within one hour of the initiation of restraints, seclusion, or physical hold ... "


Patient #2 is a young adult male who presented to the emergency department (ED) via ambulance following thoughts of harming others. Following admission to the behavioral health unit, patient #2 made a threatening statement that he was going to stab a staff member. Patient #2 was placed in seclusion for one hour. Review of patient #2's record reveals that no licensed independent practitioner (LIP) face to face examination appears in the record.


Patient #10 is an adult male who presented to the Emergency Department via police on emergency petition due to intoxication with threats to kill himself. Patient #10 was placed in 4-point restraints at the time of presentation due to combative behaviors and attempts to flip the stretcher. He remained in restraint for 3.5 hours. Review of the restraint reveals no LIP face to face in the record.


Based on policy and documentation, the hospital failed to conduct a face-to-face as required by regulation.