HospitalInspections.org

Based on record review and document review, it was determined that the facility failed to show evidence that the use of physical restraints in 1 (Patient #9) of 21 sampled patients was authorized and authenticated by a physician in accordance to hospital policy and state law, resulting in the violation of patient rights and the potential for emotional and physical harm for Patient #1. Findings include:

Review of Patient #9's medical record, revealed she was a 37-year-old female who presented the emergency department on 01/18/2022 at 0347 with Left lower abdominal pain. Her blood pressure was documented as 167/107 (elevated) and pulse of 110 (elevated). Review of initial Emergency Department provider note at 0413 revealed Patient #9 presented tachycardic (high heart rate) with left lower abdominal pain with tenderness to palpation (to touch), awake and alert with no negative neurological findings. Ultrasound does not demonstrate left ovary, Pending CT (Computerized tomography - Radiological exam of the abdominal cavity) of abdomen/pelvis. Concerning for possible ovarian mass. Turn over care to next physician. Review of next provider note at 1415 on 1/18/2022 revealed Patient #9's abdominal pain is likely secondary to constipation. On re-evaluation patient stated she wants to record nurses giving her milk molasses enema. Nursing staff refused; nurse manager involved after patient requested to speak to management. The note indicated Patient #9 was offered to perform the enema herself, offered medication to take home for constipation and she refused, stating she was in pain and could not walk. The note indicated the patient was able to previously walk independently to the bathroom for fleets(fluid in a small bottle with a tip applicator to be inserted into the rectum for dispensing fluid into the colon). Patient did have diffuse abdominal tenderness, known constipation, chronic dermoid ovarian cyst, stable vital signs and cleared for discharge. The note indicated at 1410 the physician was notified by nursing that patient became combative when trying to remove IV's (intravenous lines to deliver fluids and medications), Security called and at bedside. The note indicated the physician immediately went to bedside to see if restraints were necessary, patient gathered her items while yelling at staff, walked out of the room and out of the hospital without assistance.
Nursing note dated 1/18/2022 indicated Patient #9 attempted to use her phone to record while nursing staff gave her an enema. The note indicated that nursing staff refused to give enema while Patient #9 was recording. Staff J (House Supervisor) spoke with Patient #9 and gave her the option to turn off her phone or be discharged with medication for constipation. Patient was discharged, but did not want her current nursing staff to touch her to remove her IV's (intravenous catheter to deliver medication and fluids). The note indicated security was called and Patient #9 was restrained by staff and security to have IV's removed. Patient was escorted out of the department by security.
Review of physician orders for Patient #9 revealed one order for an enema, which documented "soap suds enema" (large bag of soapy water hanging next to the patient, to be administered slowly via gravity through a tube into the rectum), on 01/18/2022 at 1152, orders for laboratory studies, intravenous fluids, intravenous pain medication, ultrasound of abdomen, CT scan (radiological scan) of the abdomen and pelvis and a urinalysis. Review of the physician orders did not reveal an order for restraints for Patient #9.

In an interview on 03/15/2022 at 1615, Staff J, (RN House Supervisor) said Staff K (Emergency Department RN) came to his office and reported there was a patient in the emergency department (ED) with an enema ordered and the patient wanted to record on her phone while the enema was given. Staff J said he went to Patient #9's treating physician and explained the situation. Staff J told the physician the patient's options were "enema and phone off or mag citrate (medication for constipation) and discharge". Staff J stated he then went in and told this to the patient of concern. Staff J said he told Patient #9, "I don't think I really need to explain to you why, or the inappropriateness of your recording the nurses." Staff J said the patient stated she couldn't walk and needed a bed pan, and he told the patient, "Well you walked in here. There's a bedside commode right there." Staff J stated Patient #9 didn't like that. Staff J said the physician walked in to explain that she (Patient #9) was being discharged. Staff J said Patient #9 became upset and jumped up and ran out. Staff J stated he wasn't present to observe if Security was involved or not. Staff J stated Security did call and state Patient #9 was on the ground outside. Staff J said, "She was going on and on out there. The local police came, and I told them she had been discharged, they could take her."

In an interview with Staff K (ED RN) on 3/16/2022 at 0830 she stated she was Patient #9's nurse on 1/18/2022. The doctor had ordered an enema, so she (Staff K) walked Patient #9 to the bathroom where the patient gave herself a fleets(fluid in a small bottle with a tip applicator to be inserted into the rectum for dispensing fluid into the colon). Staff K stated she saw Patient #9 come out of the bathroom after an unknown amount of time and stated it didn't work. Staff K stated the doctor then ordered a milk and molasses enema. Staff K said they set everything up, including a bedside commode, but when she and another nurse attempted to start the patient told us what we were doing was wrong and attempted to record them. Staff K stated she told Patient #9, "We're just doing an enema". Patient #9 asked to speak to a manager. At that time Staff K went to get Staff J (House Supervisor). Staff K said the patient of concern got dressed and said she was leaving. Security was in the room, who ended up restraining Patient #9. Staff K stated there were four security staff and three nursing staff restraining the patient of concern and removing her IV's (intravenous lines). Once the IV's were removed, Patient #9 walked out, knocking some things off the desk on her way out.

In an interview with Staff P (ED RN) on 3/16/2022 at 0940, she sated a soap suds enema was ordered for Patient #9. Staff P said she told Patient #9 she would take her to the bathroom and the patient was upset stating she couldn't walk to the bathroom due to pain. Staff P stated the patient had walked to the bathroom previously. The patient was on the phone with a family member via FaceTime. Staff P offered a bedside commode, but the Patient #9 wanted a bedpan. Staff P told Patient #9 the bedpan was too messy. When Staff K entered the room the patient of concern refused to turn off the FaceTime with her family. Staff P told Patient #9 she (Staff P) would not do the enema unless she turned off the phone. Patient #9 escalated at that point, so the doctor wrote discharge orders for medication at home. Staff P went in to discharge the patient, but Patient #9 refused to go home and refused to have her IV's removed. Staff P said she called security, who came to help remove the Patient #9's IV's.

In an interview with Staff Q, (Emergency Room Resident), She stated she ordered a soap suds enema, then a milk and molasses enema for Patient #9. She (Staff Q) was notified Patient #9 didn't want to have the enema done, and wanted to record the nurses doing the enema. Staff Q stated when she went in to speak with Patient #9 about taking medication at home and educate her on doing an enema at home, she was talking on her phone. Staff Q stated she asked the patient to call the person back, walked away and then a few minutes later heard a loud commotion. Staff Q stated there were many people in Patient #9's room, including security, without her (Staff Q) being notified. Staff Q said she didn't think the patient was ever given the enema and she (staff Q) was never able to give her the guidance on how to do it at home.

In an interview on 03/16/2022 at 0900, Staff L (Security Manager) said security was called to the emergency department on 1/18/2022 for a panic alarm. Patient #9 was leaving and refused to have her IV's (intravenous line) removed. We explained to her several times that she couldn't leave until her IV's were removed. Staff M (Security Lieutenant) and another security officer put Patient #9 on the bed, and she started kicking and screaming, so Staff L helped hold her arms and Staff M held her legs while nursing staff removed her IV lines. Once nursing was done, she was given her personal belongings bag and she left.

In an interview on 3/16/2022 at 0910, Staff M (Security Lieutenant) stated that he was called to the ED by a panic alarm. Patient #9 wanted to leave but needed to have her IV lines removed. She refused, so another security staff member and Staff M placed Patient #9 on the bed while she was kicking and screaming. Staff L assisted with holding her arms with another security officer, while Staff M held her legs. Nursing removed her IV lines. Staff M said he then gave the patient her personal belongings bag and she took off running out of the department.

Review of facility incident report dated 01/18/2022 from 1401 to 1455 revealed Staff L and Staff M, along with two other security personnel responded to the emergency room for a panic alarm where Patient #9 was trying to leave with her IV (intravenous line) in. Patient #9 was escorted to her bed by security staff where she started swinging her arms and kicking. Security staff held Patient #9's arms, legs, and head while nursing staff removed her IVs. Patient #9 then ran out of the emergency room on her own.

Review of facility Restraint Usage Policy dated 04/2021 revealed in section A.1. the definition of a restraint to be "Any method of involuntarily restricting a person's freedom of movement, physical activity or normal access to his body." Also, the policy documented "Only Licensed Independent Practitioners, Nurse Practitioners, and Physician Assistants can authorize restraint orders. This excludes residents, nurse anesthetist, and clinical nurse specialists." "Clinical justification must be documented on the restraint order." "An RN can initiate a restraint and must call to obtain a verbal order. If restraint is initiated with a verbal order, a physician must enter a restraint order electronically within 24 hours to capture face-to-face evaluation." "PRN (as needed) restraint orders are not permitted."