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Based on a review of documentation and interview, the facility failed to ensure the use of restraint was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law.

Findings included:

Facility based policy entitled, "Restraints and Safety Alternatives-Use of-Medical/Surgical Acute Care Facilities", stated in part,

"Physical Restraint is any manual method, physical or mechanical device or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely or a drug used as a restraint. This includes a physical hold."

"Attachment # 5 Physical Restraint Devices" referenced in the above policy stated in part, "A prone or supine hold shall not be used except to transition an individual into another position and shall not exceed one minute in duration."

Review of the documentation for Patient # 1 revealed the implementation of a prone hold, in a manner not consistent with facility based policy.

On 09/26/15 the following incident was documented:
· Nursing documentation at 0800 stated, "Pt with episode of confusion; jumped out of bed ; pulled ekg leads off and picc line out; pushed sitter at bedside against wall; ran down hallway; charge nurse; pt assisted safety to floor; code grey called."
· A security report on 09/26/15 at 0747, Narrative Description, stated in part, "Upon arrival to the sixth floor I could hear talking through double doors leading into the unit. I entered to see [Patient #1] partially nude face down on his stomach and half clothed by a patient gown with [staff member]sprawled on top, holding [Patient] to the ground ...I asked what occurred and a staff member nearby states patient knocked a nurse to the floor ...I crouched down on [Patient's] buttocks/leg in case struggle ensued and awaited additional support." According to this note the hold was discontinued at 0750.

The above documentation described the use of a prone hold on the patient for reasons other than to "transition an individual into another position" and exceeded one minute in duration, which is against facility policy. This method of restraint/personal hold, creates a risk of compromised airway for the patient.

The above findings were confirmed with staff member #1 and 2 on 02/09/16.

Based on a review of documentation, the facility failed to ensure that each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours:(A) 4 hours for adults 18 years of age or older.

Findings included:

Review of the medical record of patient #1 revealed six documented incidents of violent behavior that jeopardized the immediate physical safety of staff members, the patient himself, and other patients. However, the orders for the patient's restraints was inappropriately maintained as an ongoing order for medical restraints- nonviolent, rather than obtaining an order for behavioral restraints for these six distinct incidents. The following incidents include descriptors of aggressive and/or violent behaviors:

On 09/26/15 the following incident was documented:
· Nursing documentation included:
At 0400 stated in part, "...pt just had episode where he awoke confused and immediately tried to get out of bed and exit the room, pt was unconsolable [sic] and combative, code gray was called..."
At 0750 stated in part, "Patient got out of bed and ran down hall pulling out his PICC line in the process."
At 0800 stated, "Pt with episode of confusion; jumped out of bed ; pulled ekg leads off and picc line out; pushed sitter at bedside against wall; ran down hallway; charge nurse; pt assisted safety to floor; code grey called."
· A security report on 09/26/15 at 0747, Narrative Description, stated in part, "Upon arrival to the sixth floor I could hear talking through double doors leading into the unit. I entered to see [Patient #1] partially nude face down on his stomach and half clothed by a patient gown with [staff member]sprawled on top, holding [Patient] to the ground ...I asked what occurred and a staff member nearby states patient knocked a nurse to the floor ...I crouched down on [Patient's] buttocks/leg in case struggle ensued and awaited additional support."
This report also stated, "I spoke with [nurse] who explained saw patient running full speed and decided to try and block his path. [Patient] who was undeterred by [Nurse] ran into her knocking her down. [Nurse] mentioned the assigned sitter was standing in front of the patient room and was shoved out of the way by [Patient #1] before [patient] took off running." Security review of video footage of the incident revealed, "Upon returning nearby where [nurse] was floored [nurse] and [staff member]grabbed [patient] to prevent further injury to staff/patient and assisted him to the ground with minimal amount of force necessary."
· Physician note on 09/26/15 at 0846 stated in part, "Code Gray called again overnight d/t confusion and agitation..."
· A 24 hour physician order for a "Restraint Non-Violent" was present for 09/26/15. The restraint flowsheet for 09/26/15 indicated the patient was in 4 point soft restraints, mittens bilaterally, and a vest. At 0800 it was noted the patient displayed "behavior interfering with medical care, devices, tubes/drains, physical abuse to others".
· No physical hold was ordered or documented on this date. There was no order for or documentation of a violent restraint for 4 hours or less, on this date

On 11/17/15 the following incident was documented:
· A security report on 11/17/15 at 0855, Narrative Description, stated in part, "[Physician] was near patient when [Patient] reached out and slapped the back of her hand leading to the Code Gray page to be made."
· A nursing note at 0900 stated, "Pt very agitated and scared, pt attempting to hit staff, Haldol given".
· Physician note at 0941 stated in part, "Pt was agitated this am ...Pt then swung at me, getting me a little in the chin, grabbed my hand, scratching my hand with his nails before sitter was able to pull him away from me. Subsequently, code gray was called for his agitation/attempt to get out of bed."
· A physician order for a "Restraint Non-Violent" was present for 11/07/15. The restraint flowsheet for 11/07/15 indicated the patient was in 4 point soft restraints. A note at 0900 described the patient behavior at "pt agitated. Haldol given".
· There was no order for or documentation of a violent restraint for 4 hours or less on this date.


On 12/05/15 the following incident was documented:
· A security report on 12/05/15 at 0815, Narrative Description, stated in part, "Upon my arrival I witnessed [Patient #1] being held down by clinical staff. I stepped into the room the assist with keeping [Patient] from kicking his feet at who ever stood close enough to the bed ...Patient had become combative and verbally loud..."
· A Physician note on 12/05/15 at 8:27 stated in part, "Pt had code gray called yday 2/2 agitation in AM (12/05)."
· A physician order for a "Restraint Non-Violent" was present for 12/05/15. The restraint flowsheet for 12/05/15 indicated the patient was in 4 point soft restraints.
· There was no order for or documentation of a violent restraint for 4 hours or less on this date.

On 12/10/15 the following incident was documented:
· A security report on 12/10/15 at 1715 (documented on 12/11/15), Narrative Description, stated in part, "Upon arrival to the 9th Floor [staff member] and I arrived to find [Patient # 1] in a wheelchair by the Employee Elevators with medial Staff ...Speaking with [Nurse] [they] stated that [Patient] was able to remove his restraints and started running toward the elevator initiating the Code Gray. Medical staff was able to stop [Patient] from entering the elevators and placed him in a wheelchair. Once [Patient] was returned to his room [Nurse] notified the responding team they wanted to place [Patient] back in restraints. As security went hands on [Patient] began to become combative and attempted to kick at [staff member] not making contact."
· A physician order for a "Restraint Non-Violent" was present for 12/10/15.
· The restraint flowsheet for 12/10/15 indicated the patient was in 4 point soft restraints.
· There was no order for or documentation of a violent restraint for 4 hours or less on this date.
On 12/13/15 the following incident was documented:
· A security report on 12/13/15 at 0745, Narrative Description, stated in part, "Upon [Security] initial observation of the events that were transpiring in Room 934 were three (3) female [facility] Associate medical Staff Members and one (1) female sitter. [Patient # 1] had gotten out of [their] restraints was highly agitated, kicking, punching and trying to head-butt anyone within range.
[Security] physically placed [Patient #1] in bed. Upon placing [patient] back in bed, [Security] physically restrained [patient] to the bed, enabling the Medical Staff Members to once again, place [patient] back in four point restraints."
· A physician order for a "Restraint Non-Violent" was present for 12/13/15.
· The restraint flowsheet for 12/13/15 indicated the patient was in 2 point soft restraints (upper extremities) until 0700 when the restraints to the lower extremities were placed back on for a 4 point restraint due to "pt screaming and cussing at sitter, attempting to get out of restraints and bed. De-escalation attempts unsuccessful at this time."
· No physical hold was ordered or documented on this date. There was no order for or documentation of a violent restraint for 4 hours or less on this date.

On 12/22/15 the following incident was documented:
· A security report on 12/22/15 at 0915, Narrative Description, stated in part, "I [Security Officer] arrived and was informed by [2nd security officer] an injection of medication was to be administered to [Patient #1]. [Nurse] and [staff member] approached [patient] which caused [them] to react. [Patient] began trashing about and kicking wildly. [Patient] proceeded to kick [staff] in chest, [nurse] on [their] left side and [security officer #2] on his right side before (security officer #2] and I were able to gain control of his legs ...[Patient] then raised is upper body and attempted to head butt [Security officer #2]. With the least amount of force necessary [Security officer #2] was able to lower [patient's] lower body as I continued to hold [their] legs down as [patient] continued to violently thrash about."
· A nursing note at 2015 stated in part, "pt intermittent confusion and hostility".
· A physician order for a "Restraint Non-Violent" was present for 12/22/15.
· The restraint flowsheet for 12/22/15 indicated the patient was in a restraint vest only (upper extremities) until 0800 when 4 point restraints were re-initiated.
· There was no order for or documentation of a violent restraint for 4 hours or less on this date.

On 12/25/15 the following incident was documented:
· A security report on 12/25/15 at 1125, Narrative Description, stated in part, "I then made contact with [Nurse] who advised a [staff member] had been assaulted by [Patient #1] prior to Security personally arrival ...Upon speaking with [staff member] I learned [patient] had defeated the soft restraints that were in place prior to Security personnel arrival on event scene, then once out of restraints patient [patient] struck [staff member] with a closed fist to the left side of his head, making contact with [staff member's] left ear."
· A physician order for a "Restraint Non-Violent" was present for 12/25/15.
· The restraint flowsheet for 12/25/15 stated, "pt very agitated ...tried to punch/hit/kick RNs and took 4 people to get him down and restrained".
· No physical hold was ordered or documented on this date. There was no order for or documentation of aviolent restraint for 4 hours or less on this date.

Facility based policy entitled, " Restraints and Safety Alternatives-Use of-Medical/Surgical Acute Care Facilities " , stated in part,
"Scope:...

B. Restraint use procedures are separated into two distinct categories which are based on the reason and/or purpose for restraint use as follows:
1. Non-violent or non-self-destructive restraint is used to ensure the patient's safety and for the patient's well-being to promote healing and to ensure the continuation and effectiveness of medical, surgical, or dental treatment; or,
2. Violent or self-destructive restraint is used when a RN assessment reveals an emergency exists; and, the patient's current violent or self-destructive behavior represents physical danger to self and/or others (including staff) ...

KEY RESPONSIBILITIES

A. Physicians (including residents) and other licensed independent practitioners must have a working knowledge of and comply with restraint policy ...
1. Provide verbal and written orders for the appropriate use of restraint..

Definitions...

Physical Restraint is any manual method, physical or mechanical device or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely or a drug used as a restraint. This includes a physical hold.

C. Non-Violent or Non-Self-Destructive Restraint is used when:
· RN assessment reveals the patient is attempting to or is interfering with medical/surgical devices, treatments; and/or
· the patient is at risk for self-injury; ...

D. Violent or Self-Destructive Restraint is used when:
· RN assessment* reveals an emergency exists; and,
· the patient's current violent or self-destructive behavior represents physical danger to self and/or others (including staff) ..."

"Attachment #3 SETON Summary of Restraint Required Elements" referenced in the above policy stated in part,
· "Initial Orders" for "Violent/Non-Self Destructive Restraint Use" stated, "In an emergency situation*, if the physician is not immediately available to issue an order, as soon as possible after emergency violent/self-destructive restraint application:
* RN/designee contacts patient's attending physician to report restraint application, report medical condition and to obtain verbal order.
* By the end of 1 hour after restraint application, the attending physician performs an in-person evaluation of patient's medical condition and signs original verbal order for emergency behavior."
· "One hour face-to-face Evaluation" for "Violent/Non-Self Destructive Restraint Use" stated, "within one hour of restraint application, physician or designee:
* Performs in-person evaluation of patient's medical condition to evaluate the individual's immediate situation, reaction to the restraint, non-violent/non-self-destructive and violent/self-destructive condition and the need to continue or terminate the restraint:..."

The above 6 incidents described violent behavior that jeopardized the immediate physical safety of the patient and staff members. These restraints were ordered and documented as non-violent restraints with orders lasting 24 hours. The appropriate order for violent behavior should be limited to 4 hours or less, before renewal.

The above findings were confirmed in an interview with staff member # 1, 2, and 3 on 02/09/16.

Based on a review of documentation and interview, the facility failed to ensure each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy.

Findings included:

Facility based policy entitled, "Restraints and Safety Alternatives-Use of-Medical/Surgical Acute Care Facilities", stated in part,
"KEY RESPONSIBILITIES

A. Physicians (including residents) and other licensed independent practitioners must have a working knowledge of and comply with restraint policy ...
1. Provide verbal and written orders for the appropriate use of restraint..

J. Calendar Day is defined as the 24 hour period between 2400 to 2400."

"Attachment #3 SETON Summary of Restraint Required Elements" referenced in the above policy stated in part,

· "Initial Orders" for "Non-Violent/Non-Self Destructive Restraint Use" stated, "Duration of initial orders not to exceed 24 hours".
· "Renewal Orders" for "Non-Violent/Non-Self Destructive Restraint Use" stated, "Based on in-person physician re-evaluation a minimum of once each calendar day."

Review of restraint documentation revealed 2 out of 5 patients did not have a physician order present or order renewal every calendar day (2400 to 2400) per policy.

· Patient # 2 was in restraints for non-violent/non-self-destructive behavior on 01/16/15, 01/17/15, and 01/18/15. There was no physician order present for the use of non-violent/non-self-destructive restraints on 01/17/15.

· Patient # 5 was in restraints for non-violent/non-self-destructive behavior on 01/17/15, 01/18/15, and 01/19/15. There was no physician order present for the use of non-violent/non-self-destructive restraints on 01/18/15.

The above findings were confirmed in an interview on 02/09/16 with staff members # 4 and 5.

Based on a review of documentation, the facility failed to ensure that with restraint inerventions, inlcuding violent/ self-destructiv, the patient must be seen face-to-face within 1 hour after the initiation of the intervention to evaluate -
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.


Findings included:

Facility based policy entitled, "Restraints and Safety Alternatives-Use of-Medical/Surgical Acute Care Facilities", stated in part,
"Scope:...

B. Restraint use procedures are separated into two distinct categories which are based on the reason and/or purpose for restraint use as follows:
1. Non-violent or non-self-destructive restraint is used to ensure the patient's safety and for the patient's well-being to promote healing and to ensure the continuation and effectiveness of medical, surgical, or dental treatment; or,
2. Violent or self-destructive restraint is used when a RN assessment reveals an emergency exists; and, the patient's current violent or self-destructive behavior represents physical danger to self and/or others (including staff) ...

KEY RESPONSIBILITIES

A. Physicians (including residents) and other licensed independent practitioners must have a working knowledge of and comply with restraint policy ...
1. Provide verbal and written orders for the appropriate use of restraint..
2. Provide face-to-face patient evaluations/reevaluations to determine the need for continued restraint ...Document evidence of the medical evaluation and the findings in the medical record."

C. Non-Violent or Non-Self-Destructive Restraint is used when:
Attachment #3 SETON Summary of Restraint Required Elements" referenced in the above policy stated in part,

· "Initial Orders" for "Violent/Non-Self Destructive Restraint Use" stated,
"* By the end of 1 hour after restraint application, the attending physician performs an in-person evaluation of patient's medical condition and signs original verbal order for emergency behavior."
· "One hour face-to-face Evaluation" for "Violent/Non-Self Destructive Restraint Use" stated, "within one hour of restraint application, physician or designee:
* Performs in-person evaluation of patient's medical condition to evaluate the individual's immediate situation, reaction to the restraint, non-violent/non-self-destructive and violent/self-destructive condition and the need to continue or terminate the restraint:..."


Review of the medical record and documentation involving Patient # 1, revealed 6 incidents of violent behavior that jeopardized the immediate physical safety of staff members (09/26/15, 11/17/15,12/05/15, 12/10/15, 12/22/15, and 12/25/15) requiring physical restraint of the patient, which were not ordered as violent restraints or documented as such. There was also no documentation of a face-to-face evaluation within 1 hour after the initiation of :
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.

Lack of document the above assessments of the patient within one hour, of the 6 behavioral restraint inverventions, indicates the facility did not follow policy or regualtory requirements.


The above findings were confirmed in an interview with staff members #1 and 2 on 02/09/16.

Based on review of a patient's medical records, interviews, and observation, it was determined that the nursing staff of the facility was responding to a patient ' s underlying illness and diagnoses rather than to his displayed behaviors.

Findings included:

A 32 year old male patient (patient #1) was admitted into the facility in September of 2015, and remained on inpatient status. The nursing staff performed extraordinary care and work with this patient; however, the patient's needs and behaviors changed rapidly and unpredictably, requiring the use of violent and non-violent restraints. The nursing care plan dealt with the patient's diagnostic issues; however, nursing services and the associated plan of care for the patient need to change as rapidly as the patient's behaviors.

The need for acquiring appropriate restraint orders for the patient's behaviors rather than his disease process needed to be included in the patient's plan of care. The plans of care for this patient only addressed the use of non-violent restraint and did not include documentation addressing the patient's behaviors (including aggression) which required the use of restraints for violent behavior that jeopardized the immediate physical safety of staff.