HospitalInspections.org

Based on record review, staff interviews, and policy & procedure review the facility failed to a) have an order for a physical hold; b) have a medical restraint order without an authorization of a physician/provider for 1 of 3 sampled patients (Pt 1) that had medical and/or behavioral restraints. The total sample was 10.

Findings are:


A review of the Emergency Room (ER) Physician Note (Dr B) dated 5/28/21 revealed Pt 1 arrived at 7:11 AM on 5/28/21, accompanied by the law enforcement officer under an EPC. "The patient was psychotic (disconnected from reality), agitated (troubled or nervous), delusional (fixed, false beliefs that conflict with reality) and homicidal (threatening to kill another person)." Pt 1 received Haldol (medication to treat mental disorders) 5 mg (milligrams) IM (intramuscluar-into the muscle) x (by) 2 and Ativan (medication to treat anxiousness and agitation) 2 mg x 2 IM.

A review of the Psychiatrist Consultation noted dated 5/29/21 at 5:05 PM revealed, that Pt 1 had been having assaultive towards staff and was smearing feces (stool) in room. The patient "has a history of aggressive behaviors and assaults, still considering getting a special care bed (long term mental health admission for complex mentally ill patients) in Omaha." Continue with the Haldol and Ativan 3 times a day orally, and if needed by injection. Also Thorazine (medication for treating psychotic behaviors) 50 mg IM twice a day as needed.

Review of Pt 1's Restraint Nurses Notes documentation from 5/29/21-6/1/21 revealed:
-5/29/21 at 10:10 PM, "Patient continues to be verbally abusive and violent with staff. For safety of patient and staff, SOFT RESTRAINTS APPLIED with positive CSM (circulation, sensation, and movement) x 4 (application of restraint to bilateral wrists and ankles)."
-5/29/21 at 10:45 PM, "Pt able to remove soft restraints from hands. 4 point Lock restraints applied with assistance from 5th floor (behavior health staff) staffing. CSM x 4 intact with 1-1 (one nurse with this one patient) staffing making checks every 15 minutes."
-5/29/21 (documented) at 11:34 PM, "The nurse brought down hard tat (twice as tough) restraints for patient. Pt was in a MANUAL HOLD AT THE TIME THIS NURSE AND HOUSE SUPERVISOR WALKED IN. Pt was making racial comments to security and ED (emergency department) staff. Hard tat restraints placed on bed and patient. Two finger spacing between patient extremities and the restraints were done."
-5/30/21 at 2:00 AM, "Order renewed for 4 point restraints for continued aggressive and violent behavior."
-5/30/21 at 3:30 AM, "Violent behavior starting to de escalate and right arm removed from restraint."
-5/30/21 at 5:15 AM, "Patient behavior slightly improved and left leg removed from restraint."
-5/30/21 at 5:50 AM, "Left arm left out of restraint and right arm locked. Each individual restraint removed and range of motion exercises performed on patient. CSM intact x 4. Offered water to patient who knocked it out of RN hand and spit at staff. Pt asked what (gender) prefer for breakfast and stated fruit. Food will be ordered at 0700."
-5/30/21 at 10:45 AM, "IV fluids infusing without difficulty. Pt continues to refuse scheduled po (oral) medication or offers of food/fluid. Pt agrees to administration of IV Bendaryl, Haldol and Ativan. Pt allows cardiac leads on chest, B/P (blood pressure) cuff and oximeter probe to left lower extremities for administration of IV meds. Pts left arm and left leg removed from restraints as pt becoming quiet agitated wanting to lie on right side. Pt right arm and leg remain restrained due to (gender) continued intermittent volatile behavior and risk of harm to pt/staff with medical equipment and lines."
-5/30/21 at 2:00 PM, "Pt states that (gender) doesn't want to take Ativan, Benadryl or Haldol "because they make my brain foggy and makes me rage and want to kill people. Pt then states "they better not send me back to my (family) house because I will kill (gender). Pt refuses to void (urinate). Violent restraints discontinued at this time. SOFT UPPER RESTRAINTS APPLIED TO RIGHT ARM AND RIGHT LEG AS PATIENT CONTINUES TO REQUIRE oxygen and cardiac monitoring at this time which (gender) attempts to remove without restraints."

Review of Pt 1's Restraint Orders and restraint flowsheet documentation from 5/29/21-6/1/21 revealed:
-5/29/21 LACKED AN ORDER FOR THE 10:10 PM SOFT RESTRAINTS X 4
-5/29/21 LACKED AN ORDER FOR A MANUAL HOLD (documented at 11:34 PM.)
-5/30/21 LACKED A PHYSICIAN AUTHORIZED ORDER TO CHANGE THE 'RESTRAINT VIOLENT/SELF DESTRUCTIVE BEHAVIOR' TO A "RESTRAINT NON VIOLENT" AT 1:55 PM.
-5/30/21 Restraint Flowsheet documentation changed from every 15 minute checks to every 2 hour checks when the unauthorized order to change to non violent restraint occurred at 1:55 PM.
-The Physician did reorder the RESTRAINT VIOLENT/SELF DESTRUCTIVE BEHAVIOR at 2:03 PM, but was not initiated, and staff continued with the non violent assessment.

An interview with the Director of Nurses on 6/3/21 at 10:30 AM verified the 5/29/21-6/1/21 Restraint Notes, Restraint Orders and Restraint flowsheet documentation above.

Review of the Restraint and Seclusion Policy and Procedure last revised 5/21 revealed:
-Non-Violent Restraints-may be used to protect life-saving tubes and lines from accidental dislodgement or removal by patient. A written and/or verbal orders must be documented in the Electronic Medical Record.
-Violent Restraint-used of the restraint will be limited to emergency/crisis situations when unanticipated, severely aggressive or violent/self-destructive behavior presents immediately danger to the patient or others. A written and/or verbal orders must be documented in the Electronic Medical Record.