HospitalInspections.org

Based on a review of 8 open and 2 closed patient records, the hospital Seclusion/Restraint (S/R) policy (revised 2/2018) and the record of patient #1, it was revealed that, patient #1 (P1), who was secluded for 31 hours, was not released at the earliest possible time; and, staff secluded P1 without behavioral justification.

Review of the hospital S/R policy revealed in part, "G. Once the patient has been restrained or secluded, the RN or physician must discuss with the patient the criteria for discontinuation. The restraint/seclusion will be discontinued as soon as it is safe to do so based on an individualized assessment and re-evaluation.

Other pre-printed documentation on the "Early Release/15 Minute Check Report" revealed the directive under "Criteria for Discontinuation," "Criteria for discontinuation is to be written by the physician." This directive was not also found in the S/R policy.

Further S/R policy provisions included "IX. Discontinuing Seclusion/Restraint
"A. As soon as the patient appears to demonstrate criteria for release, the assigned staff monitoring the patient must inform the RN. The RN must immediately assess and confirm the patient's readiness for release. The RN will immediately notify the physician of the assessment and based on their clinical assessments that the patient can be safely released, the restraint/seclusion event will be terminated per order of the physician. The physician will provide an order for release from restraint/seclusion and document the rationale for release.
B. At a minimum, the criteria for discontinuation are:
1. Patient is calm or quiet, i.e. not severely aggressive, violent, or destructive in behavior or otherwise demonstrating behaviors that represent serious and imminent risk of physical harm to self or other, OR
2. Patient is asleep.
3. The patient is able to demonstrate capacity for self-control."

According to policy, a nurse was constrained from the release of a patient from S/R without a discussion with the physician and an order to do so. Determining when to release a patient from seclusion or restraint is within a nurse's scope of practice. This policy provision failed to meet requirements for release at the earliest possible time where a patient had to meet criterion and wait for physician availability and agreement.

1) Patient #1 (P1) was a forensic patient admitted to the psychiatric hospital in October 2018. P1 was frequently irritable and argumentative at a baseline. In November 2018, P1 hit a peer, and broke the nose of the peer, resulting in a 4 hour seclusion event. The following day, P1 was secluded at 0945 due threats to harm staff. P1 remained in seclusion through the following day at 1700 for an approximate total of 31 hours.

Review of documentation during the seclusion period revealed in part, that nursing initially informed P1, "Patient was made aware that (P1) was secluded due to behavior that was threatening to others. (P1) was made aware that once (P1) was calm and no longer exhibited threatening behaviors such as banging on the seclusion room door and not threatening staff, seclusion would be re-evaluated." Per policy, physicians set criteria for release. However, the RN stated multiple criterion which when met, would only result in re-evaluation, not a release.

A face to face timed at 0945 by the Physician Clinical Specialist revealed " ...criterion necessary for release ..." in part, "(P1) will need to demonstrate ability to control (P1) behavior for an extended period of time so that (P1) is not a threat to the safety of others." This meant that once P1 met criteria, P1 would remain in seclusion for "an extended period of time" while maintaining control. P1 was not given a criterion which once met, would actually result in release.

Review of 15-minute documentation revealed that at 1215, P1 was offered the bathroom and was able to eat lunch without incident. An "Hourly RN note" stated at 1215, "Pt received lunch and ...juice and medications. Pt did urinate in toilet and provided a urine specimen that was ordered. Pt has been noted pacing back and fourth (sic) with fists balled up with an angry affect." According to all documentation at 1215, P1 had met criteria for release, yet was not released. Neither pacing, nor angry affect, nor balled fists justified continued seclusion, though these behavioral elements were documented extensively over the course of 31 hours to attempt justification of ongoing seclusion.

At 2145, an Hourly RN note revealed "Patient reassessed by doctor__, and patient said (P1) did not remember why (P1) was placed in seclusion, but did not want to be reminded. Doctor determined that patient is still unpredictable ..." Actual physician criteria for the assessment was documented as, "To remain calm, to verbalize will not harm anyone, to be able to discuss the assaulting event." While discussion of the event was desirable, refusing discussion was not justification for continued restraint, nor was P1 required to verbalize P1 would not harm anyone where the only criterion for cessation of restraints should be to cease dangerous behavior. Further, P1's behaviors since being secluded revealed that P1 was not then attempting to harm anyone.

A Physician Clinical Specialist assessment of 1741 revealed new criteria of, "(P1) needs to be less hostile to staff and agree to safe monitoring." Neither of these new criterion were appropriate where only a cessation of imminently dangerous behaviors was required. According to documentation, during this assessment, P1 stated in part, "You all keep changing the rules ..."

At 2230, P1 was documented on the 15 Minute Check Report (15MCR) as "Pt is monitored via cam, (P1) is lying on (P1) side with eyes closed with easy respirations," and at 2245, "Pt monitored _ cam, resting on right side with eyes closed remains quiet." No attempts to release P2 were made though P2 was in a state of sleep.

A physician assessment the following morning at 0527 revealed criterion of, "To cooperate with mental status evaluation, to verbalize will not harm anyone." This represented another new criterion. Whether P1 was in seclusion or not, P1 retained the right to refuse treatment, including a mental status evaluation.

P1 met criteria for release multiple times over 31 hours, though P1 was not released from seclusion. Additionally, P1 was subject to arbitrary and changing release criterion which often had no behavioral basis, and was not based on imminently dangerous behaviors. Finally, S/R policy directives for releasing P2 were not implemented and ultimately failed to meet the right of P1 to be free of seclusion.

2) Patient #2 (P2) was admitted in March 2019. An RN note of 1056 revealed in part, "Patient had been pacing the unit sizing up staff ...Patient looked at (direct care assistant) and stated, "I'm gonna get you" ...Patient was asked to go to the quiet room for de-escalation which (P2) then walked on (P2)'s own into the quiet room. (P2) was asked to stay in there until (P2) calmed down, which (P2) kept walking in and out of the doorway. (P2) was informed that (P2) would needed to stay in on (P2)'s own or (P2) would be secluded and the door would be locked. The patient would not follow direction to stay in the quiet room so at 0955 the door was locked and seclusion was put into place." This note described a voluntary process which staff mandated for P2. When P2 did not comply with the mandate, the door was locked, and P2 received intramuscular (IM) medications as well.

Additionally, a disparity existed between Physician Clinical Specialist face to face documentation of 1000 which revealed in part, "(P2) was bumping into patients in the hallway," and "patient was agitated and threatening." Nursing documentation did not state that P2 was bumping into others, nor was there nursing documentation of imminently dangerous behaviors when coerced to stay in the seclusion room. P2 was inappropriately secluded, and continued in seclusion until 1335.

Based on a review of patient #1's record, it was determined that criteria for termination of seclusion failed to describe appropriate and consistent criterion, and was not completed within one hour of seclusion initiation.

Per tag A-0154, multiple face to face assessments revealed arbitrary and changing release criterion. A face to face at the initiation of a 0945 seclusion revealed face to face documentation was actually completed at 1409 which was the approximate time of the order renewal. Therefore, it could not be confirmed that the face to face with completed within one hour of the initiation of seclusion. Another face to face note of 1328 for the same seclusion episode was documented within 3 minutes of the first face to face at 1412.