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Based on hospital policy review, medical record review, and staff interview, the facility failed to discontinue a restraint at the earliest possible time in 2 of 2 (Patient #18 and #19) sampled violent restraint patients.

Findings include:

Review of the policy and procedure titled "Restraint (Restraints) Policy" effective 09/22/2018 revealed " ...Initiation of Violent Restraint/Seclusion intervention (Behavioral) Restraint/Seclusion interventions are: Used to manage behavior only if there is an imminent risk of an individual harming self or others ...Used in a manner that optimally protects the patient's rights, privacy and dignity ...Discontinuation of Restraint (s): ...Restraints will be discontinued when: the patient's condition no longer justifies the use of restraint (s) ..."

1. Review on 09/29/2021 of the closed medical record for Patient #18 revealed the presented to the ED (emergency department) by EMS (emergency medical services) on 09/20/2021 at 1946. Review of the ED triage note at 1956 revealed "Pt (patient) presented to ED BIB (brought in by) EMS and police for SI (suicidal ideation)/depression/ETOH (alcohol) ...became aggressive toward EMS which led to patient being restrained in route. Pt broke restraints in route and placed in hard restraints at 1930. Pt given 10 mg (milligrams) IM (intramuscular) Versed (a sedating medication) and 10 mg Haldol (antipsychotic) in route. Pt met in ambulance bay by security and staff and given an additional 50 mg IM Benadryl (can cause drowsiness) and 2 mg IM ativan (sic) [used to treat anxiety]. Pt immediately placed in violent restraints upon arrival. Per Ems, pt had 5 bottles of wine ..." Review of the "Violent or Self-Destructive Restraints" flowsheet dated 09/20/2021 at 2000 revealed Patient #18 had Neoprene Cuff restraints applied to his bilateral wrists and ankles and documented behaviors as "violent towards staff ...Agitated/restless; Verbally abusive; Physically abusive ...Clinical Justification: Imminent risk of harm to self and others ...Discontinuation Criteria: Contracts not to harm self; Contracts not to harm others ..." Review of the "Violent or Self-Destructive Restraints" flowsheet dated 09/20/2021 at 2015 revealed Patient #18's Neoprene Cuff restraints were continued and documented behaviors as "Subdued (under control) ..." Review of the of the "Violent or Self-Destructive Restraints" flowsheet dated 09/20/2021 at 2030 through 2300 (2 hours and 30 minutes) revealed Patient #18's Neoprene Cuff restraints were "continued" and documented behaviors as "Patient asleep ... Clinical Justification: Imminent risk of harm to self and others." Review revealed RN #1 handed-off report to another RN at 2257. Review revealed the oncoming RN was assigned as Patient #18's nurse at 2306 and discontinued Patient #18's restraints at 2315.

Interview on 09/29/2021 at 1343 with RN #1 revealed she was Patient #18's primary RN until shift change at 2300. Interview revealed Patient #18 was displaying aggressive behaviors and received restraints by EMS then by hospital staff upon arrival to the ED. Interview revealed Patient #18 displayed uncooperative behaviors when she initiated his IV (intravenous-plastic catheter inserted into the vein) and performed his covid test. Interview revealed RN #1 was concerned due to his violent history and aggression, that if she released his restraints too early, he would become aggressive again. Interview revealed it was RN #1's understanding that a patient was supposed to be released from restraints when they were no longer displaying the same behaviors that caused them to be restrained.

Interview on 09/29/2021 at 1400 with the ED Manager revealed it was her expectation for nurses to discontinue a patient's restraints when the patient was calm and no longer demonstrated harmful behaviors. Interview revealed it was her expectation as well for the nurses to document the patient's behaviors that warrant restraints while the patient was restrained.

Interview on 09/30/2021 with the Director of Clinical Education revealed nurses were trained when to initiate and discontinue restraints upon hire and annually. Interview revealed a patient met criteria for discontinuation when the patient was calm, able to toilet, and follow commands. Interview revealed if a patient was asleep, the expectation was to continue the restraints.

2. Review on 09/29/2021 of the closed medical record for Patient #19 revealed she presented to the ED (emergency department) by Police on 09/09/2021 at 1806. Review of the ED triage note at 1806 revealed "Pt (patient) presented to ED in police custody with IVC (involuntary commitment) paperwork. Pt presents visibly agitated and screaming ..." Review revealed Patient #19 was administered 2mg of Ativan and 5mg of Haldol IM at 1817. Review of the "Violent or Self-Destructive Restraints" flowsheet dated 09/08/2021 at 1820 revealed Patient #19 had Neoprene Cuff restraints applied to her bilateral wrists and ankles and documented behaviors as "violent towards staff ...Agitated/restless; Verbally abusive; Confused; Delusional; Physically abusive ...Clinical Justification: Imminent risk of harm to self and others ..." Review of the "Violent or Self-Destructive Restraints" flowsheet dated 09/08/2021 at 1850 revealed Patient #19's Neoprene Cuff restraints were continued and documented behaviors as "Agitated/restless; Verbally abusive; Confused ..." Review of the "Violent or Self-Destructive Restraints" flowsheet dated 09/08/2021 at 1905 revealed Patient #19's Neoprene Cuff restraints were continued and documented behaviors as "Confused (drowsy) ..." Review of the "Violent or Self-Destructive Restraints" flowsheet dated 09/08/2021 at 1915 through 2100 (1 hour and 45 minutes) revealed Patient #19's Neoprene Cuff restraints were continued and documented behaviors as "Patient asleep ..." Review of the "Violent or Self-Destructive Restraints" flowsheet dated 09/08/2021 at 2115 revealed Patient #19's Neoprene Cuff restraints were continued and documented "Range of Motion: Patient declined ..." Review revealed RN #2 performed an "In/Out Straight Cath" (flexible tube that is inserted into the bladder to empty urine) on Patient #19 at 2119 and "Patient tolerated well." Review of the "Violent or Self-Destructive Restraints" flowsheet dated 09/08/2021 at 2130 through 2230 (1 hour) revealed Patient #19's Neoprene Cuff restraints were continued and documented behaviors as "Patient asleep ..." Review revealed Patient #19's restraints were discontinued at 2245.

Interview on 09/30/2021 at 1015 with RN #2 revealed Patient #19 was demonstrating aggressive behaviors which is why she was restrained. Interview revealed RN #2 performed her fifteen-minute checks on Patient #19 throughout her restraint episode and she was unable to contract for her (Patient #19) and staff's safety, therefore she left her in restraints despite documenting Patient #19 was asleep. RN #2 stated she was trained to discontinue a patient's restraints when they're no longer exhibiting the behaviors they were doing before getting restrained. Interview revealed Patient #19 remained "very delusional" during the duration she was restrained. Interview revealed RN #2 "could have documented better."

Interview on 09/29/2021 at 1400 with the ED Manager revealed it was her expectation for nurses to discontinue a patient's restraints when the patient was calm and no longer demonstrated harmful behaviors. Interview revealed it was her expectation as well for the nurses to document the patient's behaviors that warrant restraints while the patient was restrained.

Interview on 09/30/2021 with the Director of Clinical Education revealed nurses were trained when to initiate and discontinue restraints upon hire and annually. Interview revealed a patient met criteria for discontinuation when the patient was calm, able to toilet, and follow commands. Interview revealed if a patient was asleep, the expectation was to continue the restraints.
NC00176589, NC00175324