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Based on review of hospital policy and procedure, medical record review and staff interviews, facility staff failed to ensure new time limited 4 point restraint orders were obtained for a patient after transition from rigid to soft restraints for violent behaviors for 1 of 2 restraint records reviewed (Patient #10).

The findings included:

Review of the policy titled "Restraints Seclusion and Safety Devices" effective date 08/02/2019 revealed, "Purpose: To guide appropriate safe management of patients who are restrained and/or in seclusion ...Definitions: ...3. Restraints for violent/self-destructive behaviors are used when the patient's behavior jeopardizes the immediate physical safety of the patient, staff or others and when alternative/least restrictive methods have been considered. These restraints are intended to be a brief intervention to allow time for calming the patient and advancing them toward less restrictive alternatives and preventative strategies ... Procedural Guidelines: ...H. Orders for Violent/Self Destructive restraints are time limited and not to exceed 4 hours for patients 18 years or older ...If the need for restraints continues beyond the above time frames, a new order is required. I. Orders for Violent/Self Destructive restraints may be renewed according to the time limits listed above for a maximum of 24 hours ..."

Review of the medical record revealed Patient #10 was a 33 year old male who arrived at the facility emergency department (ED) on 08/17/2019 at 0600 accompanied by law enforcement officers (LEO). Patient #10 was noted to have become agitated and was "walking down the street around his neighborhood naked," subsequently became combative and threatening, barricaded himself in his home and was admitted to the facility under involuntary commitment (IVC) orders. Review of the medical record revealed Patient #10's medical history consisted of Bipolar 1 disorder and Schizophrenia, and in addition to exacerbation of his behavioral health conditions, Patient #10 was diagnosed with three acute medical conditions requiring intravenous fluid therapy. Review of Patient #10's record revealed he was placed in "rigid" 4 point restraints (both wrists and both ankles) for violent behavior after less restrictive measures had been unsuccessful on 08/17/2019 from 1808 to 2145 (3 hours and 37 minutes), and again on 08/19/2019 from 0842 until 0949 (1 hour and 7 minutes). Review revealed, after an initial soft four point restraint order for violent behaviors on 08/19/2019 at 0950, a restraint renewal order was not entered until 08/20/2019 at 0944 (23 hours and 6 minutes). Subsequent restraint renewal orders were obtained on 08/20/2019 at 1425 (4 hours and 41minutes); on 08/20/2019 at 1733 (3 hours and 8 minutes); on 08/20/2019 at 2040 (3 hours and 7 minutes); and the orders were changed to non-violent soft four point restraints on 08/21/2019 at 0208 (5 hours and 28 minutes). Review revealed violent restraint orders were not obtained according to policy.

Request for interview on 08/22/2019 at 1515 with a registered nurse, RN #3, revealed she was not available for interview.

Interview on 08/22/2019 with RN #4 during chart review at 1500 confirmed there were not renewal orders for four point restraints for Patient #10 between 08/19/2019 at 0950 and 08/20/2019 at 0941.

Interview on 08/22/2019 at 1658 with RN #1 revealed he worked on an inpatient medical unit and had been the primary nurse for Patient #10 during the day shift (0700 - 1900) on 08/20/2019. Interview revealed Patient #10 had been in 4 point restraints and had been "trying to swing at staff" and "spitting so he (Patient #10) had a mask on." RN #1 revealed, because Patient #10 had violent restraint orders, the order was to be renewed every four hours and Patient #10 "had it pretty much renewed every four hours the day I took care of him." Interview with RN #1 revealed the facility had a nurse who monitored restraint use, RN #5, and she had spoken with him to ensure renewal orders were being obtained since it had not been done the previous day.

Interview on 08/22/2019 at 1710 with RN #2 revealed she worked in the ED and had taken care of Patient #10 on 08/19/2019 when rigid restraints were applied the second time, and then switched for soft restraints. RN #2 stated "he was in four point and needed an IV (intravenous line) but had ripped two out already." Interview revealed after a third IV line had been obtained, Patient #10 was taken "upstairs after that" to an inpatient unit. Interview revealed the restraint orders at the time of transfer to the inpatient unit had been for "violent" behaviors.

Interview on 08/22/2019 at 1615 with RN #5 revealed she provided ongoing education to staff on restraint policy and procedure and monitored staff compliance. Interview revealed RN #5 had become aware of the gap in orders for use of Patient #10's violent restraints and had called RN #1 to ensure renewal orders were obtained. Interview revealed the violent restraint orders were not completed according to policy.

NC00153041