HospitalInspections.org

Based on review of 6 patient records reviewed it was determined that in 1 of 6 patient records reviewed the patient was restrained without a check for contraband. This regulation is not met as evidenced by:

Patient #1 is a 22-year-old female admitted August 10, 2009 from a Detention Center for evaluation of competency to stand trial and criminal responsibility for 1st degree assault when she stabbed a roommate in the left elbow with a knife. Patient #1 has a history of psychiatric hospitalization from the age of 12 for cutting herself.

Patient #1 states she hears voices at times "Rosie." Patient #1 ascribes to paranoid thoughts, especially of correctional officers who she thinks are trying to get her. Her diagnoses are Schizoaffective disorder, bipolar type, a History of polysubstance abuse, and Borderline Personality disorder, Seizure disorder, Asthma, and Hypertension.

Documentation indicates that as patient #1's admission progressed, she became increasingly violent with behaviors. Per the discharge summary, she demonstrated behaviors of " Banging doors, threatening and hitting staff. Her aggressive behaviors towards others included kicking, spitting, head butting, and biting and she had necessitated emergency medications because of this. She had also been placed in restraints because of her out of control behaviors on multiple occasions."

On 9/15/2009 at 3 pm, patient #1 was placed in 5-point restraint (sitting in a restraint chair with arms and legs immobilized, and a waist restraint) following an altercation with a peer. Documentation indicates that a contraband check was not done due to "Unable to do because of patient extreme agitation. "

The hospital Seclusion/Restraint Policy states in part, " The patient shall be searched by nursing staff for potentially harmful objects, in accordance with the policy on contraband search. " This was not done, and could have presented a potential threat to patient and staff safety.

Based on review of 6 medical records it was determined that patients # 2, 5, and 6 were not released from restraint at the earliest possible time as evidenced by:

Patient #2 is a 24-year-old female transferred 3/11/201 on certificates, from psychiatric hospital #1 to psychiatric hospital #2. Patient #2 apparently assaulted 11 people while at psychiatric hospital #1. Patient #2 has a remote history of head injury and a recent history of assault, memory deficits, seizure, for some months, paranoia interspersed with confusion.

On 3/12 at 10:30 am, patient #1 was placed in 4-point leather restraint due to severe agitation, and attacking and hitting a peer and staff. A 3:30 pm nursing note states in part, " She continues to be verbally abusive, agitated, and unable to contract for safety. Staff told her what conditions she would have to meet before she gets off restraint." Contracting for safety is not a valid criteria for release of restraint, and none of the other "conditions" for release of restraint are documented in the record.

On 3/12 during a continuation of restraint, an RN writes in part, " She continues to be verbally abusive, agitated and unable to contract for safety," and at 6 pm.
"attempting to get out of the restraint, unable to contract to safety." Again, contracting for safety was being used as the criterion for release from restraint.

Patient #5 is a 28-year-old male, admitted on 5/21/2007, on a voluntary basis, but his admission was continued based on involuntary certifications. Patient #5 carries a diagnosis of Schizophrenia, paranoid type. Patient #5 has a learning disability, and he is inconsistent with taking medications.

On 2/24/2010 patient #5 had two restraining episodes following severe agitation and threats to harm staff over having to take medications. The first restraining episode was 4-point, non-ambulatory from 6:50 pm to 9:50 pm. A nursing note of 2/24 at 10 pm states in part, " ...criteria for discontinuation of restraint explained to patient but he still shows no indication for readiness for release of restraint, hence not contracted for safety." A 10:30 pm nursing note states in part, " ...patient remain in restraint & has not contracted for safety."

Patient #6 is a 29-year-old male admitted 12/7, 2009 to the hospital on certificates and violation of conditional release. Patient #6 had been living at a group home, when he became upset about his partner and either went to an acute care hospital, or was taken there by police. While in the acute care hospital, he got into a scuffle with security. Her diagnoses are Schizoaffective Disorder, Bipolar type, in remission and polysubstance dependence.

On 12/8/2009 at 8:15 pm, patient was placed in 4-point restraint after attack on peer. An RN note of 9:15 pm on the Seclusion/Restraint 15-minute Flow Sheet, states in part ... "explained behaviors needed to d/c (discontinue) restraints. Pt. (patient) admits he understands unsure if pt is able to comprehend." An RN note of initiation 11 pm states in part, " ... pt educated regarding behaviors needed to d/c restraints x 2. At 10:15 pt. demonstrated calm and cooperative behaviors so restraints d/c'd at 10:15."

On 3/11 at 2:30 pm, patient #6 was again restrained due to extremely agitated behaviors. A note written at 11:35 pm states, "Criteria for release made known to patient." Staff documented informing patient #6 of behaviors needed to exit restraint, but do not detail those expected behaviors in the record.

While it is desirable to elicit discussion of contracts for safety, such contracts are not sole criteria for release from restraint or seclusion. The only criteria for release from restraint/seclusion is the ceasing of the dangerous behavior for which the restraint/seclusion was initiated.

Based on the review of 6 patient records it was determined that 5 of 6 patient reviewed with a 21 total restraining events were not consistently monitored for range of motion (ROM), toileting, and fluids. This regulation is not met as evidenced by:

Patient #1 is a 22-year-old female admitted August 10, 2009 from a Detention Center for evaluation of competency to stand trial and criminal responsibility for 1st degree assault when she stabbed a roommate in the left elbow with a knife. Patient #1 has a history of psychiatric hospitalization from the age of 12 for cutting herself.

Patient #1 states she hears voices at times, "Rosie." Patient #1 ascribes to paranoid thoughts, especially of correctional officers who she thinks are trying to get her. Diagnoses are Schizoaffective disorder, bipolar type, a History of polysubstance abuse, and Borderline Personality disorder, Seizure disorder, Asthma, and Hypertension.

Documentation indicates that as patient #1's admission progressed, she became increasingly violent with behaviors. Per the discharge summary, she demonstrated behaviors of "Banging doors, threatening and hitting staff. Her aggressive behaviors towards others included kicking, spitting, head butting, and biting and she had necessitated emergency medications because of this. She had also been placed in restraints because of her out of control behaviors on multiple occasions."

During a 5-point restraint episode of 9/15/2009 from 3 pm to 10:30 pm, a period of 7.5 hours, patient #1 received no circulation checks.

On 12/19/2009, at 6:15 pm, a restraint event totaling 3.5 hours no ROM was performed, and no toileting was offered.

Patient #2 is a 24-year-old female transferred 3/11/201 on certificates, from psychiatric hospital #1 to psychiatric hospital #2. Patient #2 apparently assaulted 11 people while at psychiatric hospital #1. Patient #2 has a remote history of head injury and a recent history of assault, memory deficits, seizure, for some months, paranoia interspersed with confusion.

On 3/12/2010 from 10:30 am until 7:30 pm patient #2 was placed in 4-point leather restraint after becoming agitated, and hitting a peer and staff. Documentation reveals that staff offered toileting only once in 9 hours at 2:45 pm, but the documentation does not show if it was accepted. At 4:45 pm, documentation reveals "elimination is needed," but again does not indicate if patient #2 was able to complete elimination.

No ROM for patient #2 was documented for the entire 9-hour period in restraint.

Patient #3 is a 25-year-old male admitted 12/1/2008 on a court order for competency and criminal responsibility evaluation for multiple criminal charges. He was found not competent to stand trial. Patient #3 is noted to have low cognitive functioning, and was living in a developmentally disabled group home prior to arrest.

On 1/26/2010 from 4:20 am to 11:20 am, patient #3 was placed in a restraint chair using 2-point leather restraints following exposing himself, persistently attempting to fondle female staff, and making verbal threats to harm the nurse.

Review of restraining documents reveals no ROM, toileting offered only once in 6 hours, and no circulation checks.

Patient #4 is a 24-year-old male admitted on a voluntary basis as a return from a Conditional Release. Patient #4 has had 10 or more psychiatric hospitalizations. Patient #4 had been living in a group home where he decompensated and became paranoid following the death of his roommate by drug overdose.

Patient #4 has a history of auditory hallucinations, violence, destruction of property, and medication noncompliance.

On 2/1/2010 from 11am until 6 pm, patient #4 was restrained following the smashing of his fist through a nursing station window, continued threats to staff, and refusal to accept alternatives offered. Patient #4 initially refused to see the somatic physician, and then agreed. He was found to have superficial cuts.

Review of patient #4 ' s restraint documentation reveals that patient #4 had one ROM in 7 hours of restraint.

Patient #5 is a 28-year-old male, admitted on 5/21/2007, on a voluntary basis, but is continues admission on certificates. Patient #5 carries a diagnosis of Schizophrenia, paranoid type. Patient #5 has a learning disability, and he is inconsistent with taking medications.

On 2/24/2010 patient #5 had two restraining episodes following severe agitation and threats to harm staff over having to take medications. The first restraining episode was 4-point, non-ambulatory from 6:50 pm to 9:50 pm. Review of documentation reveals no ROM. Patient #5 was placed in 4-point ambulatory restraint from 10:35 pm on 2/24 until 7:40 am of 2/25. Review of restraining documents reveals no ROM until 2/25 at 12:25 am. Again on 2/25 from 1:15 pm until 5 pm, patient #5 was placed in 4-point non-ambulatory restraint. No ROM is noted in the record during this time.

Based on review of these restraint records, the hospital failed to attend to basic patient needs while those patients were in restraint.