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BROOKWOOD BAPTIST MEDICAL CENTER 2010 BROOKWOOD MEDICAL CENTER DRIVE BIRMINGHAM, AL 35209 Sept. 20, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy and procedure, medical records and interviews with facility staff, it was determined the facility staff failed to conduct a debriefing with 2 of 3 patients after having been released from restraint and/or seclusion.

This affected Patient Identifier (PI) # 2 and # 4 and has the potential to negatively affect all patients admitted to facility and exhibit aggressive, destructive behavior requiring restraint and/or seclusion.

Findings include:

Facility Policy:
Policy and Procedure Directive
Subject: Restraint & Seclusion
Date: 5/16
Reviewed: 05/16, 07/17

I. Scope: This policy applies to Brookwood Baptist Medical Center. It is a hospital-wide policy that would apply to any department providing patient care.

II. Purpose:

The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety, and preserves his or her dignity, rights and well-being.

III. Definitions:
A. "Restraint" means any method, physical or chemical, or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...

B. "Seclusion" is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving...

IV. Policy:

It is the policy of this organization to limit the use of restraint and seclusion to those situations where it is necessary to ensure the immediate physical safety of the patient, staff members, or others with appropriate and adequate clinical justification and to facilitate the discontinuation of restraint or seclusion as soon as possible based on an individual patient assessment and re-evaluation.

V. Procedure:
A. Methodology:

... 4. As early as feasible in the restraint process, make the patient aware of the rational for the intervention...

6. Once the patient meets the criteria for release, the restraint is discontinued. The decision to discontinue the intervention must include a determination that the patient's behavior is no longer a threat to himself/herself...

C. Documentation:

1. Each episode of restraint use shall be documented in the patient's medical records and shall include but not limited to:

... e) Discontinuation of restraint at earliest possible time.

1. Decision based on the determination that the medical need for restraint is no longer present or that the patient's needs can be met with less restrictive methods...

3. Monitoring and Reassessment:

a) The restrained patient is assessed, monitored and reassessed...

f) Monitoring determines the following:

... Assessment of patient's condition to determine if the current restraint should be continued or if less restrictive methods could be used or restraints could be discontinued...

g) Assessment and Reassessment must include, but are not limited to:

... Patient safety and comfort, during and after restraint is removed.

Other criteria based on the type of intervention used and the patient's condition...

Definitions and Information Points

Definitions:

... Seclusion:

Seclusion is different from timeout. "Timeout" means the restriction of a patient for any period of time to a designated area from which the patient is not physically prevented from leaving and for the purpose of providing the patient an opportunity to regain self control. In "timeout", the staff and patient collaboratively determine when the patient has regained self control and is able to return to the treatment milieu. In seclusion, this determination is made by the staff...

Information Points:

Management of Violent or Self-destructive Behavioral Restraint:

Is the use of restraint for demonstrated outburst of severely aggressive behavior that poses an imminent danger to the patient or others. In such cases, the management of violent or self-destructive behavior restraint requirements must be followed...

1. PI # 2 was admitted to the facility on [DATE] with diagnosis including Schizoaffective Disorder, Bipolar Type.

Review of the medical record revealed a physician order dated 9/17/17 at 11:45 PM for 4 point soft wrist and ankle restraints for four hours due to the patient hitting the seclusion door and becoming verbally aggressive.

An evaluation of the patient's status was completed by the Registered Nurse (RN) on 9/18/17 at 3:45 AM, at which time a physician order was received for soft right wrist, right and left ankle restraints. The patient was verbally threatening to self and others and the restraints were being discontinued one at a time to allow the patient to regain control of self. All restraint were discontinued on 9/18/17 at 6:30 AM.

There was no documentation the patient was debriefed after removal of all restraints.

An interview was conducted on 9/20/17 at 2:55 PM with Employee Identifier (EI) # 2, Nurse Manager, who verified the above findings.






2. PI # 4 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type with Psychosis.

Medical record review included a physician's order dated 9/2/17 at 7:30 PM for seclusion due to patient agitation, physical and verbal aggression. PI # 4 was released from seclusion at 8:40 PM.

Further review of the staff documentation revealed staff documented "pt (patient) asleep" at the time seclusion ended. There was no documentation a patient debriefing was completed and no documentation a patient debriefing was completed when PI # 4 was able to participate.

Record review revealed on 9/4/17 from 1:20 PM to 1:35 PM PI # 4 became agitated and combative and required a physical (manual) hold. At 1:35 PM, PI # 4 was released from the manual hold. Staff documented the patient was uncooperative with nurse assessment, patient unable to participate in the debriefing.

The medical record did not include documentation PI # 4 was debriefed at a later time, when cooperative with a debriefing assessment.

In an interview on 9/20/17 at 2:10 PM, EI # 3, RN, Charge Nurse reported no patient debriefings were documented. EI # 3 reported once alert/cooperative, a re-assessment is usually completed. EI # 3 confirmed staff failed to complete and document patient debriefing at the earliest available time.

Review of the facility medical record audit tool titled 2017 Audit Tool POC (plan of correction) revealed PI # 4's record was audited from 9/1/17 to 9/3/17 and 9/4/17 to 9/7/17. There was no documentation the above record deficiencies were identified.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records and interview with staff, it was determined the nursing staff failed to administer intravenous (IV) fluids according to physician orders for 1 of 1 patient record reviewed who received IV fluids. This affected Patient Identifier (PI) # 2 and has the potential to affect all patients admitted to this facility.

Findings include:

1. PI # 2 was admitted to the facility on [DATE] with diagnoses including Alzheimer-Type Dementia and Behavioral Disturbance.

Review of the Physician order dated 8/31/17 revealed orders for sodium chloride (NS) 0.45%, 1000 milli-liters (ml) at 75 ml/hour (hr) to be infused over 13.3 hours and discontinued after (1) one bag.

Review of the Nursing Note dated 9/1/17 at 9:34 AM revealed the nurse documented having inserted a 23 G (gauge) IV to the left upper arm and began infusing 1/2 NS IV fluids at 75 ml/hr. This infusion was through 9/3/17 at 7:05 PM.

Review of the Nursing Note dated 9/3/17 at 7:05 PM revealed the nurse documented IV 1/2 NS infusing at 125 cc (cubic centimeters)/ hr.

Review of the Nursing Note dated 9/5/17 at 11:01 AM revealed the nurse documented, "... Report from PM shift patient removed (his/her) IV. Will ask MD (medical doctor) on rounds what he want to do about IV..." There was no documentation the nurse talked with the physician in regards to the patient's IV fluids, nor was there documentation of additional physician orders for IV fluids.

Review of the Nursing Note dated 9/7/17 at 4:46 AM revealed the nurse documented having placed a 22 G angiocath to left upper forearm and "IV fluids began." The nurse further documented the patient was attempting to remove IV, pulling at tubes and the patient was difficult to redirect. There was no documentation of the infusion rate, nor was there documentation of a physician's order for the IV fluids.

Review of the Nursing Note dated 9/7/17 at 4:47 AM revealed the nurse documented having spoken with the physician concerning the assessment of the patient after restraint placement. The patient remained restless and continued to received IV fluids "as ordered". There was no documentation of physician orders for IV fluids.

Review of the Nursing Note dated 9/7/17 at 12:18 PM revealed the nurse documented, "... IV fluids normal saline infusing to right upper arm w/o (without) any s/sx (signs/symptoms) of infiltration noted... Soft restraints was d/c (discontinued) at 0930 (9:30 AM) this AM after the completion of (his/her) IV fluids... heplock remains intact and secure..."

An interview was conducted on 9/20/17 at 2:30 PM with Employee Identifier # 1, Director (sister facility) who verified the above findings.