The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LAWNWOOD REGIONAL MEDICAL CENTER & HEART INSTITUTE 1700 S 23RD ST FORT PIERCE, FL 34950 June 10, 2013
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on clinical record review, facility record review and staff interviews, the facility failed to ensure the emotional health and well being, personal privacy, dignity and comfort for 1 of 10 sampled patients (#5) whose clinical records were reviewed.

The findings include:

The facility policy and procedure titled: Restraint and Seclusion (11/20/10), Patient Rights and Responsibilities (11/19/11) and Baker Act (12/20/12) policy specifies:

The definition applies regardless of the care setting (e.g., general medical unit, ED, pediatric unit, psychiatric unit etc.) or precipitating factors (psychiatric, medical or behavioral).

The scope of Patient Rights and Responsibilities and Baker Act is Organization Wide and Hospital Wide specifies:

The definition applies regardless of the care setting (e.g., general medical unit, ED, pediatric unit, psychiatric unit etc.) or precipitating factors (psychiatric, medical or behavioral).
Limiting the use of restraints for behavioral use to emergency or crisis situations when a patient ' s behavior becomes aggressive, presenting an immediate, serious danger to the patient ' s safety or that of others when alternatives have proven ineffective. This applies to all areas of the facility including all outpatient areas where restraints are applied.

1) On 06/11/2013 during the review of the clinical record for patient #5 it was disclosed the patient presented to the Emergency Department (ED) on 12/30/11 at 9:52 PM. The Chief Complaint per documentation on the the Encounter Record: "Psych Related."

The patient was brought to the ED by a law enforcement officer, based on the Baker Act, for involuntary psychiatric examination and evaluation.

At 11:16 PM RN #1 documents the patient's level of consciousness to be: awake , alert , agitated, and anxious; the associated signs & symptoms: depressed mood, agitated, flat affect, Suicidal Ideation's (SI) and Homicidal Ideation's (HI); the suicide precautions taken: security near patient; can see patient from nursing station; a sitter is with the patient and placed in Psych-Safe Room.

At 11:32 PM RN #1 documents a Summary Note:
"Received into room 25 from Triage; Assessments completed. "Patient stripped of all of her belongings, placed in bag, labeled and put at nursing station." Blood and urine specimens obtained and sent to lab. Patient refused to give urine specimen. "
The RN continued to write, verbal order given: mini catheter patient for urine specimen. Patient refused to follow direction and was screaming about wanting her clothes back. I tried to explain the policy about clothes but patient became hostile. The patient got out of bed and tried to grab me. Officer #1 came to my assistance. "She failed to comply with the officer's orders to return to her bed." She gritted her teeth and started talking louder, moving further away from her bed and out of her room.

At the time of clinical record review there was no physician's order found or provided for catherization of patient #5; nor was one provided up to and or at the time of the exit conference.
The facility's Investigative Reports and Contractual Agreements reviewed revealed Officer #1 is a hospital contracted security employee.

The RN wrote the patient was restrained, moved to her bed and was handcuffed for her safety and staff safety. Officer #2 spoke with the patient while assisting with placing the patient in handcuffs. House Supervisor aware of the incident.

The clinical record review for patient #5 did not disclose a physician's order for the patient to be restrained as medically determined and assessed to be necessary, per the Regulatory Requirements at 42 CFR part 482.13.

A review of the Grievance Log at approximately 12:00 PM on 6/10/13 finds patient #5 made a visit to Lawnwood Regional Medical Center & Heart Institute on 01/25/12 to file a grievance with the Risk Manager (RM) regarding Patient Rights. The patient's concerns were as follows:
RN was rude and would not allow her to keep undergarments on.
RN told police to cuff the patient.
Police officer pinned patient to the stretcher.
After police officer removed the Handcuffs patient stated she noticed the RN trying to communicate with a non English speaking family. The patient suggested the RN get an interpreter. The RN replied, "do you want to be cuffed again."

The facility's Investigative Records documents and substantiates, the patient was restrained face down on the Stretcher by two male officers. The contracted employee, officer #1, with the assistance of a second officer #2 placed handcuffs (HC) on the wrists (both) of patient #5. The handcuffs were then attached to the side rails (2).

The patient wore only a hospital gown, opened to the back, no undergarment and was in the line of site of the security / officers and all staff in the ED.

At the time of the survey the patient's medical record lacked documentation of a clinical assessment for the use of restraints / Handcuffs.
Handcuffs are law enforcement restraint devices which are not clinically considered safe, appropriate healthcare restraint intervention or for use to restrain patients, and at the time the patient was handcuffed. The facility staff failed to follow the hospital's Restraint and Seclusion policy.

The facility's Policy requires the completion of a Form titled "Observation Checklist for Suicide Precautions Patient Safety and/or Rights & Dignity", to ensure patient safety, rights, dignity, privacy, and comfort. At the time of the medical record review the medical record did not contain the required documented Checklist / Form, or evidence of an Assessment for the need to restrain the patient; nor were these documents provided up to and at the time of the exit conference.

The medical record review disclosed, the patient was catheterized by RN #1 while her wrists were in handcuffs and attached to the siderails. The medical record lacked documentation of a verbal or written order for the Mini Catheterization.

The reason documented by the nurse for the use of handcuffs, "patient refused to follow direction and was screaming about wanting her clothes back ..... ... ... ... . The patient got out of bed and tried to grab me .. .. .. .. She failed to comply with the officers orders to return to her bed. She gritted her teeth and started to talk louder moving further away from her bed and out her room".

The facility failed to provide care in a manner that promotes emotional wellbeing, with respect and dignity, privacy and comfort.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on clinical record review, facility record reviews and staff interviews, the facility failed to ensure there was adequate and appropriate clinical justification for the use of restraint, and the restraint use was not in accordance with accepted standards of practice and hospital policy Patient Rights: Restraints and Seclusion; This failure affected 1 of 1 sampled patients (#5) who was restrained.

The findings include:

The facility policy and procedure titled: Restraint and Seclusion (11/20/10), Patient Rights and Responsibilities (11/19/11) and Baker Act (12/20/12) policy specifies:

The definition applies regardless of the care setting (e.g., general medical unit, ED, pediatric unit, psychiatric unit etc.) or precipitating factors (psychiatric, medical or behavioral).
Limiting the use of restraints for behavioral use to emergency or crisis situations when a patient ' s behavior becomes aggressive, presenting an immediate, serious danger to the patient ' s safety or that of others when alternatives have proven ineffective. This applies to all areas of the facility including all outpatient areas where restraints are applied.

The scope of Patient Rights and Responsibilities and Baker Act is Organization Wide and Hospital Wide.

Scope:
This policy applies to healthcare professionals in the facility who have direct responsibility in the ordering, assessment, care planning, application/implementation of restraint, monitoring and care of the restrained patient. This policy is applicable to all age groups of patients from the neonate to the geriatric patient.

Purpose:
To provide for the safety of all patients, staff and visitors.
To identify those at risk for restraint and provide for alternatives to restraint use.
To provide guidelines for the use of restraints in the acute care setting, the circumstances under which such use shall be permitted, and the procedure to be followed when alternatives have been exhausted and proven ineffective in maintaining patient safety.
To ensure the development of a culture that understands any restraint use poses a significant threat to the patient which may include the loss of life or limb.

Responsibility:
Medical Staff, Chief Executive Officer, Department Managers, Risk Manager, Nursing Supervisors, Nursing Staff and Clinical Support Personnel.

Organization Philosophy:
Patient safety and regulatory compliance in the use of restraints depends heavily on a correct determination about whether such use is clinically justified and for what purpose (e.g. medical - surgical vs. behavioral) the restraint is being applied. To apply restraints without sufficient justification or to incorrectly deem their use to be for medical/post-surgical care and thereby implement less stringent procedures for monitoring the patient and having Licensed Independent Practitioner (LIP) oversight of the use, endangers the patient and threatens the compliance status of the hospital. Therefore, only specially trained staff (i.e. RN's, ARNPs, or PAs or physicians) should make the determination, based on a comprehensive assessment, of the purpose for which restraint is being applied and every decision should be subject to a review of its appropriateness using the most conservative criteria. Every inappropriate use of restraints (including extended use without clinical justification) should be investigated.

The policy includes but is not limited to the following: Ensuring every inappropriate use of a restraint, including extended use without clinical justification, should be subject to root cause analysis as a "near miss. "

The use of restraints within this organization is therefore limited to those situations with adequate and appropriate clinical justification and adequate human resources to meet the needs of patients requiring restraint as a therapeutic intervention. -- -- -- -- -- -- -- .
Restraints are to be used as an unusual and temporary measure when the Physician/Nursing assessment deems it necessary and other available techniques or interventions have failed. It is also the intent that whenever restraints are applied, that they be removed as soon as possible.
-- -- -- -- -- --- -- --- --- --- -- -- --.

The use of restraint to control violent behavior is governed by the behavioral management standards, even if the other medical/post surgical factors are present - when there is any doubt , the behavioral management requirements should be followed and;
> Use of less restrictive alternatives have been evaluated or were unsuccessful.
Behavioral use of restraints: Restraints used in an emergency or crisis situation when a patient's behavior becomes aggressive or violent, presenting an immediate, serious danger to the patient's safety or that of others.

The three factors that must be present when restraints are used for behavior management:
> They are used only as an emergency measure and,
> They are reserved for those occasions when severely aggressive, combative or destructive behavior places the patient, staff or others in immanent danger; and,
> The least restrictive measure that will assure the patient's or other's safety is a restraint or
seclusion.

Persons will not be restrained in a prone position. Prone containment will be used only when required by the immediate situation to prevent imminent serious harm to the person or others. To reduce the risk of positional asphyxiation, the person will be repositioned as quickly as possible.

Exceptions to the definition of restraints:

Use of handcuffs and or other restrictive devices used by law enforcement who are not employed or contracted by the hospital or custody, detention or other public safety reasons, and not for the provision of healthcare. These are not considered restraints.

Policy:
Leadership at Lawnwood Regional Medical Center and Heart Institute is dedicated to fostering an organizational culture limiting the use of restraints to clinically justified situations only and seeks to reduce, with the ultimate goal of eliminating, the use of restraints through the following mechanisms while maintaining patient safety:

The policy includes but is not limited to the following: Ensuring every inappropriate use of restraint use of restraints, including extended use without clinical justification, should be subject to root cause analysis as a "near miss "

Limiting the use of restraints for behavioral use to emergency or crisis situations when a patient ' s behavior becomes aggressive, presenting an immediate, serious danger to the patient ' s safety or that of others when alternatives have proven ineffective. This applies to all areas of the facility including all outpatient areas where restraints are applied.

Ongoing assessment and reassessment of the patient in restraint to ensure the patient ' s rights, safety well-being and dignity are protected and the patient is released from restraint at the earliest possible time.

A risk factor for restraint/seclusion includes the patient is exhibiting aggressive, combative or destructive
Behavior that places the patient/staff/ in immediate danger, alternatives are initiated to decrease the likelihood of the patient being restrained. This should be placed in the plan of care for the patient being at risk for the use of behavioral restraints.

Second Tier of Review:
Prior to the application of restraint a Second Tier of Review shall occur. A member of the nursing administration/ management will review the need for restraint with the RN who has determined that the least restrictive measures have been implemented have been ineffective and the patient requires restraint.

Types of Restraint/Safe Application per policy and procedure:
A. Interventions are arranged in ascending order of restriction as recognized by Lawnwood Regional Medical Center & Heart Institute (A to J).

A. Enclosure Bed
B Unanchored mittens.
C. Anchored mittens
D. Four Side rails.
E. One Limb Restrained
F. Two Limbs Restrained
G. Three Limbs Restrained
H. Four Limbs Restrained
I. Two point Hard
J. Four point Hard. Used for patient's exhibiting extremely violent behavior.

Medical Record Content/Documentation:
Immediately after restraints are applied, an assessment will be made by a RN, to ensure that the restraints were properly and safely applied so as not to cause the patient harm, pain or impair circulation. Documentation should include this assessment as well as the patient's response, and any adjustments made.

The RN must assess the patient 3 - 4 times per hour documentation is completed on paper, the RN documents a statement at the time the restraints are discontinued or at the end of current shift, verifying that 3-4 times per hour checks were performed throughout that time the patient was in restraint/seclusion.
If the patient is under continuous observation or other audio and video observation documentation of continuous observation for safety, rights and dignity may be entered at the end of the shift.

The patient is monitored by the assigned staff member (RN, LPN, Certified Nursing Assistants) for safety and confirm that the patient's rights and dignity are maintained. These checks will be documented either electronic record or on paper.

The fact that a patient's behavior warranted the use of Behavior Management Restraint or seclusion indicates a serious medical or psychological need for prompt assessment of the incident that led to the intervention, as well as psychological and physiological condition of the time of the assessment.

Education and Competency of Staff:
Staff members who have direct contact and any others who may become involved in the application of restraints must have education and training on hire and ongoing as applicable and training in the proper and safe use of restraints.

Education and Competency of Staff:
Includes all contract/agency personnel with direct patient care responsibilities.
Includes those who may become involved in restraint application, even if not direct care providers (i.e., security guards, Emergency Medical Technicians (EMTs) on the premises.


The Chief Nursing Officer (CNO) stated on 6/10/13 at 11:30 AM during an interview, off duty police officers from the ---- ------ ------- ------------ are contracted to provide security in the ED, however they are working as our employees while at the facility, and at this time they are part of the care team in the ED.

The CNO further stated, "the law enforcement officers are to follow the rules and regulations of Lawnwood Regional Medical Center and Heart Institute (LRMCHI); The law enforcement officers contracted provide direct observation (line of site) of patients admitted to the ED under the Baker Act (BA). The observations are made every 15 minutes and are documented on the Observation Checklist for Suicide Precautions by the law enforcement officer, (acting at the time of observation as our employees)."

The CNO further stated the RNs assess a patient in restraint every 15 minutes, and document the assessments electronically, or using the restraint packet documents Restraint Monitor for Behavioral Health Use of Restraint and the Patient Safety, Rights & Dignity Checklist; Sitters (Certified Nursing Assistants) are used upstairs on the units for the behavioral health monitoring, not in the ED. The ED Director who was present during the interview confirmed the same, stating we never use sitters in the ED.

The CNO stated, all nurses working in the ED have Crisis Intervention Prevention (CIP) training. This is an eight hour course at the time of hire. Annual updates are required.
The Director of Security stated at 11:45 AM the contracted officers have Crisis Intervention Training (CIT). Their services are paid for by Lawnwood Regional Medical Center & Heart Institute. The specialized training is designed to reduce confrontation and to calm and comfort people. The use of non-physical intervention skills as well as bodily control and physical management techniques are based on a team approach to ensure safety.

The surveyor asks if Handcuffs (HC) are used as a restraint. The CNO stated, "At no time are handcuffs to be used. They (Baker Acted patients) can be transported to the ED by a Law Enforcement Officer in Handcuffs. The Handcuffs are removed once the patient is received in the ED."

The CNO stated Handcuffs are used only when a patient is under arrest. This was also verified at the time by members of the Administrative Team present (Risk Manager (RM), Quality Assurance (QA), Director of Surgery, Director of Security and the ED Director).
RN #1 who was also present during the interview identified an intervention for the risk of suicide is to assign a sitter at the bedside.

At the time of the survey the medical record lacked documentation made by the Sitter or RN #1 (who cared for the subject patient) on the Observation Checklist for Suicide Precautions, Patient Safety and/or Rights & Dignity Checklist, used while the patient (#5) was in restraint placed while in the ED.

A review of the Grievance Log revealed patient #5 made a visit to Lawnwood Regional Medical Center on 01/25/12 to file a grievance regarding Patient Rights. The patient's concerns are as follows: RN was rude and would not allow her to keep her undergarments on; RN told police to cuff the patient; Police officer pinned patient to the stretcher; After police officer removed the Handcuff, the patient stated she noticed the RN trying to communicate with a non-English speaking family; the patient suggested the RN get an interpreter, to which The RN replied, "do you want to be cuffed again."

The facility ' s Investigative Report by the Risk Manager documents, the patient was restrained face down on the Stretcher. The hospital ' s contracted security employees placed Handcuffs on the patient's wrists. The handcuffs were then attached to the side rails (2). The risk manager wrote, "the patient was agitated and combative. No Patient Rights were found to be violated."

The QA director stated at 1:50 PM on 6/11/13 grievances/complaints, investigative reports, restraints, are reviewed by the Grievance Committee quarterly. We check for trends. The Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) will review the Grievance Log.
The QA director also stated, the last quarterly review for 2011 was April 19, 2012. The former risk manager reported the following statement to the Grievance Committee on 4/19/12: "All restraints reviewed."

On 06/11/2013 during the review of the clinical record for patient #5 it was disclosed the patient presented to the Emergency Department (ED) on 12/30/11 at 9:52 PM. The Chief Complaint per documentation on the Encounter Record: Psych Related.
Review of the Report of Law Enforcement Officer Initiating Involuntary Examination (Baker Act) revealed the law enforcement officer has reason to believe said person has a mental illness pursuant to Section 394.455 (18), F. S., and because of the mental illness: a. Patient has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination. b. There is likelihood that without care or treatment the person will cause serious bodily harm to self and others in the near future, as evidenced by recent behaviors.

The ED Encounter Record documentation reveals, the patient was triaged at 10:03 PM; the Triage Nurse documents the patient denies Suicidal Ideation's (SI); the patient admits to Homicidal Ideation (HI). The patient was moved to the Treatment Area at 10:04 PM.

The ED physician documented an Assessment at 10:00 PM, in which he wrote, the chief complaint: "I told my son- in- law that I would shoot him." The physician wrote the patient was found with a weapon. The past medical history: B...... and H......

The physician wrote orders at 10:13 PM for a Complete Metabolic Panel; Blood Alcohol Level; Urinalysis Reflex; Urine Drug Screen; and Complete Blood Count (CBC) with differential.

At 10:25 PM RN #1 documents her assessment of the patient. The patient was assessed as at High Risk for Suicide.

At 11:02 PM the RN began to record a Nursing Care Plan of an identified problem for the patient: being at Risk for Falls, and Alteration in Thought Processes.

At 11:16 PM the RN documents a description of the patient's Non Verbal behaviors as follows: Forced speech and hostile with others. The RN wrote: see the Baker Act paper as the plan for SI. The Level of Consciousness: Awake, alert, agitated, and anxious. The associated signs & symptoms: Depressed mood, agitated, flat affect SI and HI. The suicide precautions have been taken: Suicide Precautions; security near patient; can see patient from nursing station; a sitter is with the patient and placed in Psych-Safe Room.

At 11:32 PM the RN #1 documents a Summary Note: Received into room 25 from Triage. Assessments completed. Patient stripped of all of her belongings; placed in bag; labeled and put at nursing station. Blood and urine specimens obtained and sent to lab. Patient refused to give urine specimen.
" Verbal order given, mini catheter patient for urine specimen. Patient refused to follow direction and was screaming about wanting her clothes back. I tried to explain the policy about clothes but patient became hostile. The patient got out of bed and tried to grab me. Officer #1 came to my assistance. She failed to comply with the officer's orders to return to her bed. She gritted her teeth and started to talk louder moving further away from her bed and out of her room. "
The review of the patient ' s medical record did not yield evidence of a physician ' s verbal or written order for the Mini Catheterization of patient #5.


The RN wrote, the patient was restrained, moved to her bed and was handcuffed for her safety and staff safety. Officer #2 spoke with the patient while assisting with placing the patient in handcuffs. House Supervisor aware of the incident.
Medical record review for patient #5 did not yield a physician order for the patient to be restrained as medically determined to be necessary, which is required by 42 CFR Part 482. The order for the patient ' s restraint was given by the nurse, RN #1 to the security officer.

At 11:49 PM the RN recorded that she tried to give the patient Geodon, Patient states she has extrapyramidal side effects. The physician was made aware. At 02:27 AM the RN wrote the patient is refusing to sign EMTALA Form.

At 5:13 AM, RN #1 wrote an amended note which specifies the patient was restrained by police officer and handcuffed by police officer as previously recorded.

At 5:15 AM RN #1 document a second amended note, " Physically restraining patient and placing the patient in handcuffs was done by ---- ------ ------- Police and not by hospital staff. "

On 6/11/13 at 10:30 AM, an interview was conducted with two (2) officers. The two officers read the risk manager ' s Report of the incident. This surveyor asked, what were the behaviors exhibited by the patient that warranted the use of the restraint / handcuff. Officer #3 stated, " gritting teeth, yelling and agitation."

This surveyor asked if the patient was under arrest. Officer #3 stated, " the patient was being detained " and added, the nurse wrote the patient grabbed her. " Officer #3 added, the officers have 40 hours of Crisis Intervention Training.


The provisions of the aforementioned Restraint and Seclusion Policy and Procedure, as they relate to the events described in the facility were reviewed with the administrative staff (CNO, RM, QA, Directors of the ED, Surgery and Security). The Risk Manager and the Quality Assurance personnel stated, " The police officers put handcuffs on the patient, so it was not a restraint."

It was found, at the time the patient was handcuffed, she was not a prisoner, and she was handcuffed by Lawnwood Regional Medical Center contracted security officers who were not performing police duties.
The security officers are contracted employees of the hospital, are part of the care team in the ED, therefore they are expected to follow the facility's Restraint and Seclusion Policy and Procedures. The handcuffs were used as a restraint.
Handcuffs are law enforcement restraint devices and would not be considered safe, appropriate healthcare restraint intervention for use by hospital staff to restrain patients.

At the time of the survey the clinical record lacked documentation of an order by a Qualified Licensed Practitioner, as defined in the facility policy / Bylaws, and Regulatory Requirements, for the use of any restraint.

The record lacked documentation by RN #1 of an assessment, for the use of restraint, either electronically or on the facility document / Form (Restraint Monitor for Behavioral Health Use of Restraint). The restraint was not identified on a plan of care with intervention to include alternatives, starting with the least restrictive restraints.


The Policy requires a member of the nursing administrative/ management (Second Tier/second level) to review the need for the restraint with the RN. As per the Policy, the review will be made prior to applying restraints (non - emergency). In an emergency application of a restraint, the review will be done immediately after application of the restraint.

The facility did not have supporting documentation to substantiate a review was conducted as in accordance with facility policy (Second Tier of Review and documentation by RN #1.


The risk manager failed to appropriately investigate the use of Handcuffs on patient #5. Furthermore, the risk manager failed to acknowledge the inappropriate use of restraint, and subject the incident to a Root Cause Analysis (RCA) as a "Near miss" as per the Restraint/Seclusion policy. As a result it was determined the risk manager failed to provide an accurate and complete report to the Grievance Committee.

Documentation of every 15 minute observations made by the contracted security officer, on the Observation Checklist for Suicide Precautions, began at 10:15 PM and ends at 11:45 PM. The patient remained in the ED through 3:54 AM.


A subsequent call to the facility was made on 6/20/13 at approximately 9:30 AM to request the Observation Checklist for Suicide Precautions monitoring that was recorded after 11:45 PM on 12/30 - 12/31/11. The facility was unable to provide any additional documentation requested.

No evidence was found, or provided, during the course of the survey to substantiate there was adequate indication and medical necessity (clinical justification) for the use of the handcuff / restraint applied to patient #5 wrists.

There was no documentation found or provided to support, the use of handcuff / restraint was required in order to render necessary healthcare and services. Based on review of the facility ' s Policy governing the use of restraint, the actions taken by the nurse RN #1 and the security officers are not in accordance with the Policy & Procedures, established standard of practice, and Patient Rights: Restraint and Seclusion, Patient Rights & Responsibilities and the Baker Act Law.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on clinical record review, facility record review, staff interviews and observation it was determined the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program reflects the evaluation and analysis of security services furnished under contractual Agreement for direct line-of-site observation of patients who present to the Emergency Department under the Baker Act for psychiatric examination and evaluation. This failure affected 1 of 10 sampled patients (#5).

The findings include:

The facility policy and procedure titled: Restraint and Seclusion (11/20/10) Quality Assurance Performance Improvement Plan (QAPI) (1/2012) specifies: The purpose of this plan for improving Organizational performance is to provide a structure to evaluate the design and delivery of the services as planned by the Department Directors, the Medical Executive Committee, Administration, and the Board of Trustees.

The QAPI Plan - Outside Services: When patient care services are provided through a contract service or through an off - site healthcare organization, there will be mechanisms in place to evaluate the appropriateness of the referral service.

Scope:
This policy applies to healthcare professionals in the facility who have direct responsibility in the ordering, assessment, care planning, application/implementation of restraint, monitoring and care of the restrained patient. This policy is applicable to all age groups of patients from the neonate to the geriatric patient.

The use of restraint to control violent behavior is governed by the behavioral management standards, even if the other medical/post surgical factors are present - when there is any doubt , the behavioral management requirements should be followed.

The definition applies regardless of the care setting (e.g., general medical unit, ED, pediatric unit, psychiatric unit etc.) or precipitating factors (psychiatric, medical or behavioral).

Limiting the use of restraints for behavioral use to emergency or crisis situations when a patient ' s behavior becomes aggressive, presenting an immediate, serious danger to the patient ' s safety or that of others when alternatives have proven ineffective. This applies to all areas of the facility including all outpatient areas where restraints are applied.

The scope of Patient Rights and Responsibilities and Baker Act is Organization Wide and Hospital Wide.

Responsibility:
Medical Staff, Chief Executive Officer, Department Managers, Risk Manager, Nursing Supervisors, Nursing Staff and Clinical Support Personnel.

Organization Philosophy:

Patient safety and regulatory compliance in the use of restraints depends heavily on a correct determination about whether such use is clinically justified and for what purpose (e.g. medical - surgical vs. behavioral) the restraint is being applied. To apply restraints without sufficient justification or to incorrectly deem their use to be for medical/post-surgical care and thereby implement less stringent procedures for monitoring the patient and having Licensed Independent Practitioner (LIP) oversight of the use, endangers the patient and threatens the compliance status of the hospital. Therefore, only specially trained staff (i.e. RN's, ARNPs, or PAs or physicians) should make the determination, based on a comprehensive assessment, of the purpose for which restraint is being applied and every decision should be subject to a review of its appropriateness using the most conservative criteria. Every inappropriate use of restraints (including extended use without clinical justification) should be investigated.

The use of restraints within this organization is therefore limited to those situations with adequate and appropriate clinical justification and adequate human resources to meet the needs of patients requiring restraint as a therapeutic intervention. The management of the patient is intended to prevent injury to them, to other patients, to staff, and to prevent the destruction of property. Restraints are to be used as an unusual and temporary measure when the Physician/Nursing assessment deems it necessary and other available techniques or interventions have failed. It is also the intent that whenever restraints are applied, that they be removed as soon as possible.

The policy includes but is not limited to the following: Ensuring every inappropriate use of restraint use of restraints, including extended use without clinical justification, should be subject to root cause analysis as a "near miss. "

Leadership demonstrates its commitment to the aforementioned by providing and or promoting:
3. The development and promotion of preventative strategies.
4. The use of safe and effective alternatives including adequate human resources.
5. The integration of restraint/seclusion into the Performance Improvement (PI) activities of the organization, for the purpose of reducing restraint or seclusion use.

Types of Restraint/Safe Application per policy and procedure:

A. Interventions are arranged in ascending order of restriction as recognized by Lawnwood Regional Medical Center & Heart Institute (A to J).
A. Enclosure Bed
B Unanchored mittens.
C. Anchored mittens
D. Four Side rails.
E. One Limb Restrained
F. Two Limbs Restrained
G. Three Limbs Restrained
H. Four Limbs Restrained
I. Two point Hard
J. Four point Hard. Used for patient's exhibiting extremely violent behavior.

The fact that a patient's behavior warranted the use of Behavior Management Restraint or seclusion indicates a serious medical or psychological need for prompt assessment of the incident that led to the intervention, as well as psychological and physiological condition of the time of the assessment.

Education and Competency of Staff:
Staff members who have direct contact and any others who may become involved in the application of restraints must have education and training on hire and ongoing as applicable and training in the proper and safe use of restraints.

Per the policy and procedure education and competency:
Includes all contract/agency personnel with direct patient care responsibilities.
Includes those who may become involved in restraint application, even if not direct care providers (i.e., security guards, Emergency Medical Technicians (EMTs) on the premises).

One of the exceptions to the definition of restraints per facility policy:

"Use of handcuffs and or other restrictive devices used by law enforcement who are not employed or contracted by the hospital or custody, detention or other public safety reasons, and not for the provision of healthcare. These are not considered restraints. "


The Chief Nursing Officer (CNO) stated on 6/10/13 11:30 AM off duty police officers are contracted to provide security in the ED; they are our employees at this time. They are part of the care team in the ED. The CNO stated, the contracted officers are to follow the rules and regulations of Lawnwood Regional Medical Center and Heart Institute (LRMCHI). They are compensated for their services by LRMCHI.

Per the CNO, the law enforcement officers (contracted security personnel while on duty at the hospital) provide direct observation (line of site) of patients admitted to the ED under the Baker Act (BA). The observations are made every 15 minutes. The observations are documented on the Observation Checklist for Suicide Precautions by the contracted officer.

The CNO stated all nurses working in the ED have Crisis Intervention Prevention (CIP) training. This is an eight hour course at the time of hire. Annual updates are required.

The Director of Security stated at 11:45 AM on 06/10/2013, the contracted officers have 40 hours Crisis Intervention Training (CIT).

The surveyor asks if Handcuffs (HC) are used as a restraints. The CNO stated, "At no time are handcuffs to be used. They (BA patients) can be transported to the ED by a Law Enforcement Officer (LEO) in HC. The HC are removed once the patient is received in the ED. The CNO stated HC are used only when a patient is under arrest. This was also verified at the time by members of the Administrative Team present (Risk Manager (RM), Quality Assurance (QA), Director of Surgery, Director of Security and the ED Director).

The facility records documents and substantiate patient #5 was restrained face down on the stretcher. The contracted security officer placed Handcuffs to both wrist. The handcuffs were then attached to the side rails (2).

The provisions of the aforementioned Restraint and Seclusion Policy and Procedure, as they relate to the events described in the facility documentation, were reviewed with the administrative staff (CNO, RM, QA, Directors of the ED, Surgery and Security). The RM and the QA stated, " The police officers put handcuffs on the patient, so it was not a restraint."

At the time of the placement of the Handcuffs on patient #5 the contracted security officers were acting in the capacity as contracted security employees of Lawnwood Regional Medical Center & Heart Institute, held bound to the facility's Restraint Policies.
The contracted security officers are employees of the hospital and are part of the care team in the ED, therefore they are to follow the Restraint and Seclusion Policies and Procedures. Handcuffs were used to restrain patient #5 and thereby were applied as restraints. Handcuffs are not listed in the facility's Restraint & Seclusion Policy as appropriate restraint device.

At the time of survey neither the patient's medical record or facility records contained supportive evidence patient #5 was assessed for the use of restraint, starting with the least restrictive as deemed medically necessary, nor is there medical / physician's orders for the use of the restraints applied to patient #5, nor is there evidence that monitoring of the use of the restraint was performed in accordance with facility policy and regulatrory specifications.
In addition the patient was catherized for urine specimen without physician's orders; none was found in the medical record, eventhough RN #1 notes dated12/30/2011 at 11:32 PM refers to obtainig such an order; nor was one provided at the time of survey.

The facility's risk prevention analysis of the incident / occurrence failed to analyze and recognize the security officers while acting in the capacity as contracted employees of Lawnwood Regional Medical Center & Herart Institute, are bound to the facility's policy and procedures and healthcare regulatory requirements. The facility failed to recognize the contracted security employees are subject to risk prevention strategies aimed at preventing recurrent inappropriate use of restraints.

During the survey the facility was unable to provide evidence indicating the staff / employee failures were appropriately subjected to root cause analysis, and appropriate preventive measures implemented to prevent or manage the risk of future reoccurrence.

Facility staff failed to recognize handcuffs are not approved or appropriate healthcare restraint devices for patients who are not prisoners while hospitalized , and that its use is not listed in the facility's Policy under the section documenting acceptable types of hospital / healthcare restraints.