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MT SINAI HOSPITAL MEDICAL CENTER 15TH STREET AT CALIFORNIA CHICAGO, IL 60608 Feb. 9, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined, for 4 of 4 Emergency Department (ED) registered nurses (E #8, 21, 22, & 23), the Hospital failed to ensure face to face assessments were conducted by Licensed Individual Practitioners or Registered Nurses (RN) trained in restraint face to face assessment.

Findings include:

1. On 2/7/16 at 2:00 PM, Hospital policy #MSH-CLI-C-038, titled, "Restraint Policy", revised 9/22/14, was reviewed. The policy required, VIII. Restraint and seclusion for violent or self destructive behavior (violent) ... C. Assessment of a patient in restraints or seclusion: 1. A face to face assessment [a physical and behavioral assessment including an assessment of the patient's history, drugs and medications, most recent lab results, etc. The purpose is to complete a comprehensive review of the patient's condition to determine if other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., could place the patient in danger with the use of restraints or may contribute to increased self-destructive behavior.] must be completed no longer than one (1) hour following the initial application of restraints, by an LIP [Licensed Individual Practitioner] or a Registered Nurse trained to complete this assessment ..."

2. On 2/6/17 at 1:10 PM, Pt. #1's clinical record was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE], with diagnoses of bipolar affective disorder, manic with psychosis, attention deficit disorder, obesity, chronic back pain, and hypertension. A physician order dated 6/17/16 at 8:15 PM, included 4 point locked restraints and "max duration of this order is 4 hours". This order also included the name of the individual (E #8) who conducted Pt. #1's face to face assessment. E #8 was an ED RN.

3. On 2/7/17 at 1:20 PM, an interview was conducted with E #8. E #8 stated the doctor was aware of the Pt. #1 and gave a verbal order for restraints. E #8's name was included as the individual performing Pt. #1's face to face assessment because RNs performed the 15 minute assessments while the patient was in restraints.

4. On 2/7/16 at 1:00 PM, staffing files were reviewed, including 4 ED RNs (E #8, 21, 21, & 23). The ED RN's files lacked documentation of face to face assessment training.

5. The "Emergency Department Skill Fair 2016" was reviewed and included restraint issues, but did not include face to face assessment competency.

6. On 2/8/17 at 11:25 AM, an interview was conducted with the ED Nurse Educator (E #19). E #19 stated that ED RNs are not provided face to face assessment training, other than standard restraint training.