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Based on hospital policy review, medical record review and staff interview, the hospital staff failed to obtain a physician order for a restraint for 1 of 2 patient restraint records reviewed (#5).

The findings include:

Review of hospital policy on 05/23/2017 titled "Violent Restraint Use" last updated January, 2016 revealed "...C. Restraint Orders: 1. Initiation of Restraints: A registered nurse may initiate restraints in advance of the physician's order. As soon as possible, but no longer than one hour after initiation of restraints, the registered nurse will consult with a licensed independent practitioner (LIP) credentialed to practice...and obtain an order (verbal or written)..."

Review of the medical record on 05/22/2017 for patient #5 revealed a 34-year-old female presented to the Emergency Department via Emergency Medical Services ambulance on 03/23/2017 at 2213 with a chief complaint of intentional drug overdose. The patient was discharged to an inpatient psychiatric hospital on 03/25/2017 at 1010 via law enforcement with certified nursing assistant. Review of nursing notes dated 03/24/2017 at 1106 revealed "Pt (patient) served IVC (involuntary commitment) paperwork at 0719 by (Name) police department officer (Name)..." Review of the physician's progress note dated 03/24/2017 at 1630 revealed "Patient was attempting to come from her room and make a personal phone call to her mother. She then became loud and belligerent and attacked nursing staff. She required physical and chemical restraint. Currently being maintained in room with police escort due to repeated attempts at leaving the emergency department." Review of nursing notes dated 03/24/2017 at 1959 revealed "1600 - Pt in doorway of her room requesting to call her mother. I explained to her that she was not allowed to use the phone. I told her I would call her mother, she then tried to push past me. I told her not to touch me then she started screaming at me and push past me. I tried to block her from leaving room. She balled her fist up and swung, striking me in left lower jaw. I then took hold of her left arm and she threatened to hit me again. I then backed down and she went to the phone. (Name) attempted to unplug the telephone and pt hit (Name) in left jaw while phone was in her hand. She (patient) was then wrestled to the floor by several employees. At 1625 (Name) PD (police department) arrived. Security (hospital) was already here. Pt was handcuffed by security and escorted back to her room. At 1652 I called telepsych for them to do a reversal so she could be escorted to jail."

Review of the medical record for Patient #5 revealed no available documentation of a physician order for restraints.

Interview with MD #1 (Medical Doctor) on 05/23/2017 at 1520 revealed "I may have misspoke when I dictated she required physical and chemical restraints. I don't feel the medications were used as a restraint. My intention was not to chemically restrain her but to control her behavior." Interview revealed the nursing staff were holding the patient on the floor to protect the staff from further injury. Interview confirmed the findings.

Interview with AS #2 (Administrative Staff) on 05/23/2017 at 1645 revealed there was no available documentation in the record for patient #5 of a practitioner's order for a restraint. Interview revealed the hospital staff did not follow the hospital policy for violent restraint use. Interview confirmed the findings.

Based on hospital policy review, medical record review and staff interview, the hospital staff failed to complete a face-to-face assessment within one hour after a violent restraint intervention for 2 of 2 patient restraint records reviewed (#5 and #10).

The findings include:

Review of hospital policy on 05/23/2017 titled "Violent Restraint Use" last updated January, 2016 revealed "...C. Restraint Orders: 4. One-hour face-to-face assessment: A physician or other LIP (licensed independent practitioner) must see and evaluate the need for restraints within one hour after the initiation of the restraint intervention..."

1. Review of the medical record on 05/22/2017 for patient #5 revealed a 34-year-old female presented to the Emergency Department via Emergency Medical Services ambulance on 03/23/2017 at 2213 with a chief complaint of intentional drug overdose. The patient was discharged to an inpatient psychiatric hospital on 03/25/2017 at 1010 via law enforcement with certified nursing assistant. Review of nursing notes dated 03/24/2017 at 1106 revealed "Pt (patient) served IVC (involuntary commitment) paperwork at 0719 by (Name) police department officer (Name)..." Review of the physician's progress note dated 03/24/2017 at 1630 revealed "Patient was attempting to come from her room and make a personal phone call to her mother. She then became loud and belligerent and attacked nursing staff. She required physical and chemical restraint. Currently being maintained in room with police escort due to repeated attempts at leaving the emergency department." Review of nursing notes dated 03/24/2017 at 1959 revealed "1600 - Pt in doorway of her room requesting to call her mother. I explained to her that she was not allowed to use the phone. I told her I would call her mother, she then tried to push past me. I told her not to touch me then she started screaming at me and push past me. I tried to block her from leaving room. She balled her fist up and swung, striking me in left lower jaw. I then took hold of her left arm and she threatened to hit me again. I then backed down and she went to the phone. (Name) attempted to unplug the telephone and pt hit (Name) in left jaw while phone was in her hand. She (patient) was then wrestled to the floor by several employees. At 1625 (Name) PD (police department) arrived. Security (hospital) was already here. Pt was handcuffed by security and escorted back to her room. At 1652 I called telepsych for them to do a reversal so she could be escorted to jail."

Review of the medical record for Patient #5 revealed no available documentation of a face-to-face assessment within one hour of the restraint intervention completed by a provider.

Interview with AS #3 (Administrative Staff) on 05/24/2017 at 1430 revealed there was no available documentation in the record for patient #5 of a practitioner's face-to-face assessment within one hour of the violent restraint intervention. Interview revealed the face-to-face assessment should have been completed within one hour of the initiation of the restraint. Interview revealed the hospital staff did not follow the hospital policy for violent restraint use. Interview confirmed the findings.

2. Review of the medical record on 05/24/2017 for patient #10 revealed a 25-year-old female presented to the Emergency Department on 04/15/2017 at 0752 with a chief complaint of a motor vehicle crash. Review of the physician's orders dated 04/15/2017 at 0800 revealed a written physical restraint order for soft wrist restraints, right and left upper extremities for "confused/disoriented, combative/aggressive behavior" times 1 hour.

Review of the medical record for patient #10 revealed no available documentation of a face-to-face assessment within one hour of the restraint intervention completed by a provider.

Interview with AS #3 (Administrative Staff) on 05/24/2017 at 1430 revealed there was no available documentation in the record for patient #10 of a practitioner's face-to-face assessment within one hour of the violent restraint intervention. Interview revealed the face-to-face assessment should have been completed within one hour of the initiation of the restraint. Interview revealed the hospital staff did not follow the hospital policy for violent restraint use. Interview confirmed the findings.

Based on policy review, medical record review and staff interview, the nursing staff failed to reassess pain for 3 of 3 sampled medical records reviewed (#7, #8 and #9)

The findings include:

Review of hospital policy titled "Pain/Discomfort Management", last updated April, 2016 revealed "...Procedures...B. Reassess and document pain location, intensity and relief, utilizing the appropriate pain scale. ...- Within one hour after each pain management intervention..."

1. Review of the medical record on 05/24/2017 for Patient #7 revealed a 44-year-old female presented to the Emergency Department on 04/30/2017 at 1203 with a chief complaint of hearing voices and hallucinations. The patient was transferred to an inpatient psychiatric hospital on 05/02/2017 at 1935 via law enforcement. Review of the physician's orders revealed an order dated 05/02/2017 at 0728 for Tylenol 1000 milligrams by mouth, Motrin 600 milligrams by mouth and Zofran 4 milligrams by mouth to be given for chest pain. Review of Medication Administration Record revealed the Tylenol, Motrin and Zofran were administered by a nurse at 0808. Review of the medical record revealed no available documentation by nursing staff of a reassessment of pain after medication intervention.

Interview with AS #3 (Administrative Staff) on 05/24/2017 at 1400 revealed the nursing staff should reassess the patient's level of pain within 1 hour after a medication intervention. Interview revealed there was no available documentation in the nursing notes of a pain reassessment after Tylenol, Motrin and Zofran were administered. Interview revealed the nursing staff did not follow the hospital policy for pain management. Interview confirmed the findings.

2. Review of the medical record on 05/24/2017 for Patient #9 revealed a 38-year-old female presented to the Emergency Department on 05/22/2017 at 0858 with a chief complaint of right lower flank abdominal pain. The patient was discharged home in stable condition on 05/22/17 at 1311. Review of the physician's orders revealed an order dated 05/22/2017 at 1008 for Toradol 30 milligrams IV (intravenous), Zofran 4 milligrams IV and Flomax 0.4 milligrams by mouth to be given for abdominal pain. Review of Medication Administration Record revealed the Toradol, Zofran and Flomax were administered by a nurse at 1049. Review of the medical record revealed documentation by nursing staff of a reassessment of pain at 1311 (2 hours and 22 minutes after administered).

Interview with AS #3 (Administrative Staff) on 05/24/2017 at 1400 revealed the nursing staff should reassess the patient's level of pain within 1 hour after a medication intervention. Interview revealed the nursing staff did not follow the hospital policy for pain management. Interview confirmed the findings.

3. Review of the medical record on 05/24/2017 for Patient #8 revealed a 72-year-old female presented to the Emergency Department on 05/22/2017 at 0717 with a chief complaint of chest pain. The patient was discharged home in stable condition on 05/22/17 at 1035. Review of the physician's orders revealed an order dated 05/22/2017 at 0905 for Tylenol 650 milligrams by mouth to be given for chest pain. Review of Medication Administration Record revealed the Tylenol was administered by a nurse at 0917. Review of the medical record revealed documentation by nursing staff of a reassessment of pain at 1035 (1 hour and 18 minutes after administered).

Interview with AS #3 (Administrative Staff) on 05/24/2017 at 1400 revealed the nursing staff should reassess the patient's level of pain within 1 hour after a medication intervention. Interview revealed the nursing staff did not follow the hospital policy for pain management. Interview confirmed the findings.

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