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Based on an interview and documentation review, it was determined Emergency Department (ED) staff failed to provide appropriate restraint alternatives prior to mechanically restraining 1 of 3 selected patients mechanically restrained in the ED during the time period of 2/1-5/1/10 (Patient #1).

Findings included:

Medical record documentation indicated Patient #1; an 85+ year old who was living independently, was brought to the Hospital ED at 1:24 PM because of confusion, episodes of paranoia and irrational behavior, and an inability to care for herself. Patient #1 was not in distress and was alert and oriented to person, but not to time or place. Patient #1 denied pain, was cooperative, and was determined to weigh 110 pounds. Diagnostic interventions revealed urinary tract infection (UTI) and mild renal insufficiency and an antibiotic (ciprofloxacin) and case management consultation were ordered. A Case Manager evaluated Patient #1 at 3:44 PM and recommended a Crisis Team Evaluation for possible short-term geriatric psychiatric placement. The Crisis Team Evaluation was called for at 4:44 PM.

Documentation indicated Patient #1 remained alert, oriented to person, and cooperative, and rested quietly on a stretcher; awaiting the Crisis Team Evaluation. Documentation also indicated that just prior to 6:30 PM; Patient #1 got off of the stretcher and ED Registered Nurse (RN) #1 intervened.

ED RN #1 was interviewed in person at 11:25 AM on 6/1/10. She said Patient #1 got off the stretcher and began to walk around the ED treatment room and when she tried to verbally redirect Patient #1 back onto the stretcher; Patient #1 adamantly refused and said: "leave me alone". ED RN #1 also said: Patient #1 was confused and disoriented and there was no reasoning with Patient #1; she wanted Patient #1 back on the stretcher because Patient #1's gait was unsteady and walking around the stretcher was not safe; when she tried to redirect Patient #1 back to the stretcher with a physical escort (support at the back of 1 upper arm), Patient #1 began swinging his/her arms and then started kicking, biting and spitting all-the-while yelling "get away from me"; Patient #1 was small, but feisty, and got so out-of-control, he/she had to be restrained; she summoned help to restrain Patient #1 and; once help arrived, Patient #1 was restrained with 4-point leather restraints.

ED RN #1 did not report attempts to assist Patient #1 with ambulation and/or toileting, consideration of the use of an assistive device to improve Patient #1's ability to self-ambulate, providing Patient #1 with a chair or recliner, giving Patient #1 some space when he/she reacted to the physical escort, or attempting/providing other restraint alternatives prior to the application of the 4-point leather restraints.

Patient #1's Alternative/Restraint and Seclusion Record did not indicate restraint alternatives were considered.

The Hospital's policy/procedure titled Use of Restraints and Seclusion indicated:
1.) Restraint is a high-risk, potentially harmful procedure that is intended to be used only when less restrictive methods have not succeeded or clearly are not likely to succeed in preventing injury to a patient or others.
2.) The use of restraints to manage behavior is an emergency measure that should be reserved for those occasions when unanticipated severely aggressive or destructive behavior places the patient or others in imminent danger.
3.) In all cases of restraint use, there must be adequate and appropriate clinical justification.

Based on interview and documentation review, it was determined ED staff failed to utilize the least restrictive restraint intervention possible when restraining 1 of 3 selected patients restrained in the ED during the time period of 2/1-5/1/10 (Patient #1).

Findings included:

Please see Tag A 164 for information related to Patient #1 and the restraint intervention.

The Hospital's policy/procedure titled Use of Restraints and Seclusion indicated:
1.) The use of restraints to manage behavior is an emergency measure that should be reserved for those occasions when unanticipated severely aggressive or destructive behavior places the patient or others in imminent danger.
2.) The least restrictive, safe and effective restraint is used based on the patient's assessed needs and effectiveness of the restraint chosen. Examples of restraints from least to most restrictive include but are not limited to: siderails, mitts, lap hugger, limb holders, soft roll belt, roll sleeve jacket, gerichair, leather limb holders and chest straps.
3.) In all cases of restraint use, there must be adequate and appropriate clinical justification.

ED RN #1 said 4-point leather restraints were utilized on Patient #1 because they were readily available in the ED. ED RN #1 said less restrictive restraints such as soft roll belt and roll sleeve jacket restraints must be obtained from Central Supply/are not readily available.

Patient #1's Alternative/Restraint and Seclusion Record did not indicate the clinical indication(s) for the application of the 4-point leather restraints.

There was no evidence the use of 4-point leather restraints on Patient #1 was clinically justified.

Based on documentation review, it was determined a 1-hour face-to-face medical and behavioral evaluation was not documented following the application/administration of behavior management restraints to Patient #1.

Findings included:

Please see Tag A 164 for information related to Patient #1 and the application of the mechanical restraint.

Documentation indicated Patient #1 was also administered a chemical restraint (Haldol; 3 milligrams, intramuscularly) immediately following the application of the mechanical restraint.

Nursing documentation indicated Patient #1 was noted to have a small scratch on his/her right index finger following the application/administration of the restraints and was examined by ED Physician #1.

ED Physician #1's examination of Patient #1 or other 1-hour face-to-face medical and behavioral evaluation following the application/administration of the restraints was not documented.

The Hospital's policy/procedure titled Use of Restraints and Seclusion indicated the licensed independent practitioner or an appropriately trained registered nurse or physician assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of initiation of a behavior management restraint. The policy/procedure also indicated that if the assessment is completed by a registered nurse or physician assistant, consultation with the attending or a licensed independent practitioner needs to occur as soon as possible.

Based on documentation review, it was determined ED Staff failed to ensure Patient #1 received his/her routine medications and continued antibiotic therapy during his/her protracted ED stay.

Findings included:

Please see Tag A 164 for information related to Patient #1, Patient #1's UTI/antibiotic therapy and a Crisis Team Evaluation ordered for Patient #1.

Documentation indicated Patient #1 had a history of hypertension and was routinely taking lisinopril (an antihypertensive medication), amlodipine besylate (an antianginal medication also utilized to treat hypertension) and metoprolol tartrate (an antihypertensive medication). Documentation also indicated: Patient #1's Crisis Team Evaluation did not occur until 7:30 AM the following morning; the Crisis Team recommended a geriatric psychiatric placement; a geriatric psychiatric placement was obtained at Hospital #2 and; Patient #1 was transferred to Hospital #2 at 1:27 PM (the same day as the Crisis Team Evaluation).

Lisinopril, amlodipine besylate, metoprolol tartrate and/or continued doses of ciprofloxacin were not ordered for/administered to Patient #1 while he/she remained in the ED.