HospitalInspections.org

Based on staff interview and record review, during the provision of care and services in the Emergency Department (ED) staff failed to maintain patient rights in accordance with State statute, Title 18, Chapter 42; Bill of Rights for Hospital Patients; ? 1852. 1) The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of his or her personal dignity, for 2 of 10 applicable patients. (Patients #1, #2). Findings include:
Per record review the policy, titled Restraint and Seclusion Policy last approved on 1/10/2013 states "....that all patients have the right to the least restrictive alternative for restraint and seclusion and support the fundamental patient right to be free from physical restraint, chemical restraint, and seclusion. Restraint alternatives will be considered prior to restraint and/or seclusion......It is our responsibility to facilitate the discontinuation of restraint or seclusion as soon as possible......are committed to preserve the patient's safety and dignity when restraint or seclusion is used."

Per record review staff failed to provide care in a respectful and dignified manner by failing to adhere to the CAH's policy for restraint use for Patients #1 and #2, both of whom were phyically restrained during their respective individual treatment in the ED (Emergency Department). Each of the patients had an extended length of stay in the ED, exceeding 24 hours, while awaiting available bed placement for involuntary admission to an inpatient psychiatric unit.

Patient #1 was brought to the ED on 10/23/12, in custody of the Sheriff's department with behavioral changes, suicidal thoughts, delusional, paranoid and aggressive, homicidal thoughts. The patient, age 33, was in need of medical clearance to facilitate a involuntary inpatient psychiatric unit admission. Patient #1 remained in the ED for 11 days, during which time restraints were utilized on multiple occasions, with limited documentation to ensure least restrictive alternatives were attempted or evidence of appropriate medical staff orders for the use of restraints and reassessment for continuation or discontinuation of restraints. During a period of restraint use, staff failed to preserve Patient #1's dignity. On 10/24/12 at 15:44 a nurses note states the patient requested to stand to void (a bladder scan confirmed 662 ML of urine), however the patient was not permitted to stand and remained restrained on a stretcher. At 16:13 Patient #1 became incontinent of urine and was then placed in disposable briefs and continued to be held in 4 point restraints. On 10/26/12 at 09:01 Patient #1 was described as "calm....restraints released for 20 minutes...Cooperative the entire time..." the patient was not kept out of restraints but provided the option of which two restraints s/he wanted applied. Later in the evening and night of 10/26/12 the patient slept while two guards remained outside Patient #1's room, yet restraints were not reduced or removed.

Per record review, Patient #2 was brought to the ED on 3/13/13 at 16:49 with a chief complaint of being anxious and depressed with a diagnosis of Schizophrenia. Although the patient was cooperative upon arrival, a nursing note timed 17:47 states " The patient was taken to room #5 s/he was cooperative and undressed putting on pt gown and pants. I discussed his/her earlier behavior and stated I wanted to put him/her into 4 pt (point) restraints. We talked about starting with 3 pt both legs and his/her left wrist. he is doing well with this." Without any evidence of immediate threat to himself/herself or others restraints were initiated. At 23:20 on 3/13/13 Patient #2 was released from restraints, walked to the bathroom and then placed back in 3 point restraints. Despite no evidence of violent behavior or threats and without an assessment for the reduction of restraint use, Patient #2 continued to be physically restrained until 08:13 on 3/14/12.

Per interview on the afternoon of 5/14/13, the ED nurse manager confirmed there was a lack of evidence to consistently warrant the need for restraints and there was no attempt by staff to utilize the least restrictive interventions.

Refer to Tag A-271

Based on record review and confirmed through staff interviews the CAH (Critical Access Hospital) failed to provide care and services in accordance with established policies for 2 of 10 applicable patients. (Patients #1 and #2 ) Findings include:

Per record review staff failed to provide care in accordance with the CAH's policy for restraint use for Patients #1 and #2 both of whom were physically restrained during the course of their respective individual treatment in the ED (Emergency Department). Each of the patients had an extended length of stay in the ED, exceeding 24 hours, while awaiting available bed placement for involuntary admission to an inpatient psychiatric unit.

Per record review the policy, titled Restraint and Seclusion Policy last approved on 1/10/2013 states "....that all patients have the right to the least restrictive alternative for restraint and seclusion and support the fundamental patient right to be free from physical restraint, chemical restraint, and seclusion. Restraint alternatives will be considered prior to restraint and/or seclusion......It is our responsibility to facilitate the discontinuation of restraint or seclusion as soon as possible......are committed to preserve the patient's safety and dignity when restraint or seclusion is used." And under Assessment for early release of the violent and self-destructive patient: " A. With each monitoring , the patient is reassessed to determine that continuation of the restraint is necessary. B. Reduction or removal of restraint will be considered when the patient demonstrates a change in the behavior that was the reason for the initial application of the restraint."

1. Per record review Patient #1 was brought to the ED on 10/23/12, in custody of the Sheriff's department with behavioral changes, suicidal thoughts, delusional, paranoid and aggressive, homicidal thoughts. The patient was in need of a medical clearance to facilitate a involuntary inpatient psychiatric unit admission. Patient #1 remained in the ED for 11 days, during which time restraints were utilized on multiple occasions, with limited documentation to ensure least restrictive alternatives were attempted or that restraints were removed as soon as possible. In addition, Sheriff's department and hospital staff also remained present outside the patient's room throughout patient's ED admission.

Staff failed to consider termination of restraint use, as per policy, as evidenced by ED Nursing notes: 10/24/12 at 23:26 "Pt released from restraints to use commode - pt very cooperative.....Pt placed back in wrist restraints...". On 10/26/12 at 09:01 (Pt calm in room.) Released from leg restraints and allowed to stand and ambulate in room...Pt released for 20 minutes, cooperative the entire time. Got back into bed and given the option of which two restraints s/he wanted applied, pt decided on leg restraints and leg restraints reapplied". 10/26/12 at 14:44 "pt. released from restraints for 15 minutes. ...pt. again cooperative....ankles placed back in restraints". 10/26/12 at 18:46 "Pt released from restraints...medications given...placed back in ankle restraints. is going to try to settle down for the night". Nursing notes further state Patient #1 slept for most of the night and was cooperative when awake. During this time period Patient #1 was not posing an imminent risk of patient harming self or others nor did staff identify why the patient was continuously being placed back in restraints after being released. Per CAH policy, removal of restraint should have been considered when Patient #1 demonstrated a change in his/her behavior that was the reason for the initial application of the restraint.

The hospital restraint policy also notes medical staff will order physical restraints for acute behavioral management to be limited to 4 hours for adults, followed by a reassessment by a member of the medical staff before issuing a new order. However, on 10/30/12 at 2030 an order was obtained to apply restraints on Patient #1 with the duration noted to be "until behavior resolves-maximum time before reassessment by physician is 12 hours with orders for continuation every 24 hours". This same incorrect order was renewed on 11/1/12 at 11:00.

Per interview on the afternoon of 5/14/13, the ED Nurse manager confirmed ED staff failed to follow hospital policy related to the use of restraints and that medical staff orders written and accepted where not in accordance to CAH policy.

2. Per record review, Patient #2 was brought to the ED on 3/13/13 at 16:49 with a chief complaint of being anxious and depressed with a diagnosis of Schizophrenia. The patient was accompanied by police and required a medical screening for involuntary inpatient psychiatric unit admission. Prior to ED admission, patient had a violent outburst and attempted assault. Although the patient was cooperative upon arrival, a nursing note timed 17:47 states " The patient was taken to room #5 s/he was cooperative and undressed putting on pt gown and pants. I discussed his/her earlier behavior and stated I wanted to put him/her into 4 pt (point) restraints. We talked about starting with 3 pt both legs and his/her left wrist. he is doing well with this." Despite not demonstrating an immediate threat to himself/herself or others, ED staff applied restraints. At 23:20 on 3/13/13 Patient #2 was released from restraints, walked to the bathroom and then placed back in 3 point restraints. Without an assessment for the reduction of restraint use or a discussion to determine the patient's ability to contract for safe behavior, Patient #2 continued to be in restraints during the night, sleeping soundly until 04:43 when patient ambulated to bathroom and once again staff reapplied restraints. At 07:59 the same process was again repeated. At 8:13 on 3/14/12 a nursing note indicates restraints were removed. A physician ordered dated 3/13/13 at 17:42 for the use of 3 point restraints provides no duration for use, which is required per CAH policy and a second order for restraints dated 3/14/13 at 02:00 describing behaviors that were a danger to self and others, however per nursing notes Patient #2 was sleeping and when awake was cooperative throughout the night and morning of 3/14/13.

Per interview on the afternoon of 5/14/13, the ED nurse manager confirmed the lack of an appropriate assessment by staff to warrant the initiation and continued use of restraints for Patient #2 and least restrictive interventions were not attempted. In addition, the physician orders for restraints did not reflect the CAH policy regarding the use of restraint for behavioral management.

Based on record review and interview, the CAH failed to assure documentation completed by staff in the ED was accurate and complete. Findings include:

During the course of record review on 5/13 - 5/14/13, the "Emergency Department Clinical Report -Nurse" and "Constant Observation flow sheets" it was noted nursing staff failed to consistently include the date when entries were made in both the patient electronic medical records (EMR) and the hand written observation flow sheet. The omissions of dates in both the EMR/Observation Flow sheet prevents a accurate review and sequence of patient care provided by nursing staff.

It was also identified the CAH medical staff utilized the incorrect restraint order sheet. The hospital restraint policy also notes medical staff will order physical restraints for acute behavioral management to be limited to 4 hours for adults, followed by a reassessment by a member of the medical staff before issuing a new order. However, on 10/30/12 at 2030 an order was obtained to apply restraints on Patient #1 with the duration for use noted to be "until behavior resolves-maximum time before reassessment by physician is 12 hours with orders for continuation every 24 hours" . Continuing to use the incorrect order form designated for non-violent patients/medical restraints , restraints were renewed on 11/1/12 at 11:00. This inaccurate charting was also noted for Patient #2. A physician order dated 3/13/13 at 17:42 for the use of 3 point restraints provides no duration for use, and a second order for restraints dated 3/14/13 at 02:00 used the same incorrect form and purpose for restraint.

The deficient practice was acknowledged by the ED nurse manager on the afternoon of 5/14/13.

Based on record review and confirmed through staff interviews the CAH failed to implement, in a timely manner, corrective actions developed as the result of a recognized deficient practice regarding the use of restraints. Findings include:

Per interview on the afternoon of 5/14/13 the ED nurse manager, Chief of Quality and Chief Nursing Officer acknowledged that the deficient practice regarding the use of restraints had been identified through an investigation conducted as a result of a complaint filed with the facility on 2/12/2013. The plan to correct included a "Checklist for Mental Health Patient" which assist both nursing and medical staff to assure all multiple tasks are completed and are incorporated in each mental health patient record. "The Violent Patient with Potential for Harm in the Emergency Department" training was also reviewed to help staff in the ED who are responsible for the safety and management of patients who present or demonstrate violent behavior. Additional interventions by the ED nurse manager also included developing a paper chart for those patients brought to the ED for medical screening during the process of a involuntary inpatient psychiatric admission. Due to the increase in ED days spent by involuntary psychiatric patients as a result placement issues, nursing staff have increased their need for documentation for medication administration and restraint use.

Despite the training and re-education of ED staff and security, the use of restraints remained a deficient practice as evidenced by the use of on going restraints on 3/13/13 when Patient #2 was brought to the ED for a medical screening for involuntary inpatient psychiatric unit admission. Although prior to this ED admission, Patient #2 had a violent outburst and attempted assault, the patient was cooperative upon arrival, however the patient was placed in 3 point restraints and even offered a choice of restraint placement. Patient #2 remained in restraints throughout the evening and night of 3/13/13 and was not released until after 8:00 AM on 3/14/13. Documentation did not substantiate Patient #2 was at imminent risk of harming self or others, however ED staff failed to follow CAH policy by not releasing Patient #2 from restraints at the earliest possible time. This incident was not identified as a Quality Assurance/Performance Improvement opportunity to assist the CAH at further corrective actions regarding the use of restraints when not warranted.

Although chart audits are being conducted to monitor specific compliance issues, nursing staff continue to not incorporate dates when documenting within the "Emergency Department Clinical Report -Nurse" and "Constant Observation flow sheets". The omissions in the charts prevents accurate assessment of compliance from staff when evaluating the timely use of restraints, reduction and ongoing monitoring of behaviors. In addition, it was also identified medical staff continue to use the incorrect restraint order form resulting in noncompliance with CAH behavioral restraint policies.

Refer to Tags A- 152, 302, 271