HospitalInspections.org

Based on record review and document review the facility failed to ensure restraints were removed at the earliest possible time for one (1) patient (patient #1). (See Tags A 144, A 145, and A 174). This failure has the potential to cause great harm for all patients admitted to the facility.

A. Noncompliance: Based on medical record review the patient was placed in four (4) point mechanical restraints on 12/23/20 at 5:07 a.m. through 6:53 a.m. The documentation reveals patient was "laying quietly, hands relaxed" at 6:35 a.m., but restraints were not removed until 6:53 a.m.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: Patient restraints were not removed as soon as possible related to patient's documented condition.

C. Need for Immediate action: The Registered Nurse who did not release the restraints per policy had not had any re-education documented and was not taken out of staffing at any time.

Based on record review, document review and interview the facility failed to provide care in a safe setting by not ensuring restraints were removed at the earliest possible time for one (1) patient (patient #1). This failure has the potential to cause great harm for all patients admitted to the facility.

Findings include:

1. A record review was conducted of patient #1's medical record. The patient was placed in four (4) point mechanical restraints on 12/23/20 at 5:07 a.m. through 6:53 a.m. The documentation revealed patient was "laying quietly, hands relaxed" at 6:35 a.m., but restraints were not removed until 6:53 a.m.

2. A review was conducted of policy titled "Guidelines for Restraints and Seclusions," last revision 9/13/19. The policy states in part: "4. Discontinuation or Continuation of Seclusion/Restraint: When a patient has regained self-control, the registered nurse on duty shall authorize, in writing, release."

3. A telephone interview was conducted with Registered Nurse (RN) #1 on 1/12/21 at 9:10 a.m. She stated the following regarding patient #1, "Around 6:15 a.m. he had calmed down a lot. I asked the hall walker to get RN #2 and ask her to help me remove the restraints. The hall walker came back and said RN #2 said if you want to take him out of restraints, go ahead. The Nurse Clinical Coordinator (NCC) called me and said if I felt he needed to come out of restraints, then I should take him out. I didn't want to do it myself just in case he was playing and decided to get violent when I released him. Finally RN #2 came into the room and said if you feel he needs to come out, take him out. RN #2 finally agreed to help me and we took him out of restraints."

4. A telephone interview was conducted with RN #2 on 1/12/21 at 9:30 a.m. Regarding the incident involving patient #1 she stated, "I was at the med window and the Health Service Worker (HSW) came to me and said RN #1 wanted me to go help her remove the patient from restraints. I said I was in the middle of my med pass. The supervisor (NCC) then called me and said if she (RN #1) feels he (patient #1) can be released, then she can release him on her own. When I finished the med pass, the Safety Director and I walked back to the patient's room. Safety Director didn't feel he should be released. We asked patient #1 several questions and he answered appropriately so we released the patient from restraints."

5. A telephone interview was conducted with the NCC on 01/12/21 at 6:30 p.m. He remembered the incident and stated, "I got a call from RN #2 saying RN #1 wanted to release the patient from restraints. RN #2 said that RN #1 could release him herself. I confirmed that and said if she needed additional help since RN #2 was in the middle of her medication pass, she could call the support team to help. I did not receive any call for the support team and didn't hear from the unit after that. There was no reason why RN #1 couldn't take the patient out of restraints herself or call the support team to help."

Based on record review, document review and interview the facility failed the ensure a patient was free from all forms of abuse or harassment for one (1) patient (patient #1). This failure has the potential to cause great harm for all patients admitted to the facility.

Findings include:

1. A record review was conducted of patient #1's medical record. The patient was placed in four (4) point mechanical restraints on 12/23/20 at 5:07 a.m. through 6:53 a.m. The documentation revealed patient was "laying quietly, hands relaxed" at 6:35 a.m., but restraints were not removed until 6:53 a.m.

2. A review was conducted of policy titled "Guidelines for Restraints and Seclusions," last revision 9/13/19. The policy states in part: "4. Discontinuation or Continuation of Seclusion/Restraint: When a patient has regained self-control, the registered nurse on duty shall authorize, in writing, release."

3. A telephone interview was conducted with Registered Nurse (RN) #1 on 1/12/21 at 9:10 a.m. She stated the following regarding patient #1, "Around 6:15 a.m. he had calmed down a lot. I asked the hall walker to get RN #2 and ask her to help me remove the restraints. The hall walker came back and said RN #2 said if you want to take him out of restraints, go ahead. The Nurse Clinical Coordinator (NCC) called me and said if I felt he needed to come out of restraints, then I should take him out. I didn't want to do it myself just in case he was playing and decided to get violent when I released him. Finally RN #2 came into the room and said if you feel he needs to come out, take him out. RN #2 finally agreed to help me and we took him out of restraints."

4. A telephone interview was conducted with RN #2 on 1/12/21 at 9:30 a.m. Regarding the incident involving patient #1 she stated, "I was at the med window and the Health Service Worker (HSW) came to me and said RN #1 wanted me to go help her remove the patient from restraints. I said I was in the middle of my med pass. The supervisor (NCC) then called me and said if she (RN #1) feels he (patient #1) can be released, then she can release him on her own. When I finished the med pass, the Safety Director and I walked back to the patient's room. Safety Director didn't feel he should be released. We asked patient #1 several questions and he answered appropriately so we released the patient from restraints."

5. A telephone interview was conducted with the NCC on 01/12/21 at 6:30 p.m. He remembered the incident and stated, "I got a call from RN #2 saying RN #1 wanted to release the patient from restraints. RN #2 said that RN #1 could release him herself. I confirmed that and said if she needed additional help since RN #2 was in the middle of her medication pass, she could call the support team to help. I did not receive any call for the support team and didn't hear from the unit after that. There was no reason why RN #1 couldn't take the patient out of restraints herself or call the support team to help."

Based on record review, document review and interview the facility failed to ensure restraints were removed at the earliest possible time for one (1) patient (patient #1). This failure has the potential to cause great harm on all patients admitted to the facility.

Findings include:

1. A record review was conducted of patient #1's medical record. The patient was placed in four (4) point mechanical restraints on 12/23/20 at 5:07 a.m. through 6:53 a.m. The documentation reveals patient was "laying quietly, hands relaxed" at 6:35 a.m., but restraints were not removed until 6:53 a.m.

2. A review was conducted of the "Adult Protective Services Mandatory Reporting Form" dated 12/24/20. It states in part: "Patient was in restraints due to aggression and was ready to be released. This RN (Registered Nurse) requested the RN send someone to help remove pt (patient) from restraints for safety and she refused."

3. A review was conducted of policy titled "Guidelines for Restraints and Seclusions," last revision 9/13/19. The policy states in part: "4. Discontinuation or Continuation of Seclusion/Restraint: When a patient has regained self-control, the registered nurse on duty shall authorize, in writing, release."

4. A telephone interview was conducted with Registered Nurse (RN) #1 on 1/12/21 at 9:10 a.m. She stated the following regarding patient #1, "Around 6:15 a.m. he had calmed down a lot. I asked the hall walker to get RN #2 and ask her to help me remove the restraints. The hall walker came back and said RN #2 said if you want to take him out of restraints, go ahead. The Nurse Clinical Coordinator (NCC) called me and said if I felt he needed to come out of restraints, then I should take him out. I didn't want to do it myself just in case he was playing and decided to get violent when I released him. Finally RN #2 came into the room and said if you feel he needs to come out, take him out. RN #2 finally agreed to help me and we took him out of restraints."

5. A telephone interview was conducted with RN #2 on 1/12/21 at 9:30 a.m. Regarding the incident involving patient #1 she stated, "I was at the med window and the Health Service Worker (HSW) came to me and said RN #1 wanted me to go help her remove the patient from restraints. I said I was in the middle of my med pass. The supervisor (NCC) then called me and said if she (RN #1) feels he (patient #1) can be released, then she can release him on her own. When I finished the med pass, the Safety Director and I walked back to the patient's room. Safety Director didn't feel he should be released. We asked patient #1 several questions and he answered appropriately so we released the patient from restraints."

6. A telephone interview was conducted with the NCC on 01/12/21 at 6:30 p.m. He remembered the incident and stated, "I got a call from RN #2 saying RN #1 wanted to release the patient from restraints. RN #2 said that RN #1 could release him herself. I confirmed that and said if she needed additional help since RN #2 was in the middle of her medication pass, she could call the support team to help. I did not receive any call for the support team and didn't hear from the unit after that. There was no reason why RN #1 couldn't take the patient out of restraints herself or call the support team to help."

Based on medical record review, document review and interview it was revealed the facility failed to ensure Nursing adhered to policies and procedures in one (1) out of thirty (30) patients (patient #1). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A record review was conducted of patient #1's medical record. The patient was placed in four (4) point mechanical restraints on 12/23/20 at 5:07 a.m. through 6:53 a.m. The documentation reveals patient was "laying quietly, hands relaxed" at 6:35 a.m., but restraints were not removed until 6:53 a.m.

2. A review was conducted of policy titled "Guidelines for Restraints and Seclusions," last revision 9/13/19. The policy states in part: "4. Discontinuation or Continuation of Seclusion/Restraint: When a patient has regained self-control, the registered nurse on duty shall authorize, in writing, release."

3. A telephone interview was conducted with Registered Nurse (RN) #1 on 1/12/21 at 9:10 a.m. She stated the following regarding patient #1, "Around 6:15 a.m. he had calmed down a lot. I asked the hall walker to get RN #2 and ask her to help me remove the restraints. The hall walker came back and said RN #2 said if you want to take him out of restraints, go ahead. The Nurse Clinical Coordinator (NCC) called me and said if I felt he needed to come out of restraints, then I should take him out. I didn't want to do it myself just in case he was playing and decided to get violent when I released him. Finally RN #2 came into the room and said if you feel he needs to come out, take him out. RN #2 finally agreed to help me and we took him out of restraints."

4. A telephone interview was conducted with RN #2 on 1/12/21 at 9:30 a.m. Regarding the incident involving patient #1 she stated, "I was at the med window and the Health Service Worker (HSW) came to me and said RN #1 wanted me to go help her remove the patient from restraints. I said I was in the middle of my med pass. The supervisor (NCC) then called me and said if she (RN #1) feels he (patient #1) can be released, then she can release him on her own. When I finished the med pass, the Safety Director and I walked back to the patient's room. Safety Director didn't feel he should be released. We asked patient #1 several questions and he answered appropriately so we released the patient from restraints."

5. A telephone interview was conducted with the NCC on 01/12/21 at 6:30 p.m. He remembered the incident and stated, "I got a call from RN #2 saying RN #1 wanted to release the patient from restraints. RN #2 said that RN #1 could release him herself. I confirmed that and said if she needed additional help since RN #2 was in the middle of her medication pass, she could call the support team to help. I did not receive any call for the support team and didn't hear from the unit after that. There was no reason why RN #1 couldn't take the patient out of restraints herself or call the support team to help."