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.

NEW HANOVER REGIONAL MEDICAL CENTER 2131 S 17TH ST BOX 9000 WILMINGTON, NC 28402 Feb. 1, 2012
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on hospital policy and procedure review, grievance file review and staff interview, the hospital staff failed to provide written notice of the resolution of a grievance in 1 of 2 grievances reviewed (#1).

The findings include:

Review of the hospital's policy, "Patient Complaints/Grievances", revised 01/2009, revealed, "...IV. Procedure...C. Timeframes for addressing and responding to grievances are as follows: ...2. Completion of investigation - within forty-five (45) calendar days from receipt of complaint or sooner when possible; if the investigation cannot be completed within 45 days, the status of the investigation will be communicated. 3. Written response- within 45-60 calendar days or sooner when possible. ...".

Review of grievance file for Patient #1 revealed the patient presented to the hospital's emergency services department 09/26/2011 for involuntary commitment. Record review revealed after a medical screening examination Patient #1 was discharged with a same day appointment for outpatient therapy. Grievance file review revealed a grievance was filed by the patient's mother on 09/30/2011. Grievance file review on 02/01/2012 revealed a written notice of the resolution of the grievance had not been completed (4 months, 3 days later).

Interview on 02/01/2012 at 1405 with risk management staff confirmed the grievance related to Patient #1 was received on 09/30/2011. Further interview confirmed a written notice of the resolution of the grievance had not been completed. Interview confirmed the hospital staff failed to follow the hospital's grievance policy and procedure.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on restraint policy review, medical record review, police report review and staff and physician interviews, the nursing staff failed to ensure the least restrictive type/technique of restraint was used for 1 of 5 restrained patients reviewed (#3).

The findings include:

Review of the "Restraint Use for Adults and Children" policy revised August 2011 revealed "Handcuffs" applied by the hospital's "Special Police" are considered restraints. Further review revealed "... C.4. In an emergency situation, if the physician or designee is not available to issue the order, the initial decision to use the restraints is based on a comprehensive assessment of the patient by a RN (registered nurse), and an order will be obtained. ... D.1. Assessment - Restraints are an exceptional event and are only used when alternatives have been exhausted. They are to be applied by trained personnel based on assessment and the individualized need of the patient, using the least restrictive means possible. ..."

Closed record review on 01/31/2012 of Patient #3 revealed a [AGE] year-old male that was (MDS) dated [DATE] with a subdural hematoma and subarachnoid hemorrhage after the patient's bicycle collided with a truck. The patient had a history of traumatic brain injury in 1999. Review of the record revealed the patient was admitted to an Intensive Care Unit (ICU) on 06/07/2011, transferred to a neurology floor on 06/09/2011, transferred to a rehabilitation unit on 06/14/2011 and discharged to a nursing facility on 08/15/2011. Record review revealed the patient returned to the hospital on [DATE] after breaking out a window and eloping from the nursing facility. The patient was readmitted to a neurology unit on 08/18/2011 and discharged to another facility on 12/11/2011. Review of the patient's medical record revealed outbursts of violent behavior that included destruction of property, entering other patient rooms and throwing items causing the other patients and nurse to barricade themselves in the bathroom for protection, and cursing, threatening and attacking staff. Record review revealed repeated use of restraints necessary for safety during the six month hospitalization . Further review revealed psychiatric consults and ongoing medication adjustments to attempt to control the patient's agitation and combativeness. Review of nursing notes dated 08/25/2011 at 1959 revealed the physician was paged to notify him of increasing agitation and the patient was not responding to the medication (Haldol). Notes at 2128 recorded "Patient intermittently belligerent. Becomes agitated and uncooperative and then becomes cooperative again quickly." Nursing notes at 2152 recorded the physician was notified that the Ativan (medication for agitation) was ineffective and new orders were received. Notes at 2312 recorded that the physician was notified of the patient's increasing agitation and that the physician would be up to see the patient. Review of nursing notes at 2335 revealed "MD called to notify Special Police place patient in handcuffs to bed due to violence." Review of nursing restraint documentation dated 08/26/2011 at 0003 revealed "Restraints applied by Special Police." Further review revealed "leather restraints" were applied at 0003 due to violent behavior described as "altered level of consciousness, confused, threatened physical harm and unable to comprehend." Review of physician's orders dated 08/25/2011 at 1145 revealed "Patient was being unruly after 4mg (milligrams) IM (intramuscular) Ativan (medication for agitation) and 5mg Haldol (medication for behavior) x2 (times two). He was running halls and disrupting hospital. Special Police were called and patient handcuffed to bed after getting aggressive with officer. I am changing the handcuffs to leather restraints so the patient won't hurt himself and won't be able to break them such as with cotton or neoprene restraints."

Review of a Special Police Report revealed a call was received on 08/25/2011 at 2326 and officers arrived at 2328 and completed the response on 08/26/2011 at 0003. The report recorded four officers responded to a disruptive patient call in room #638 (Patient #3's room). Notes stated the patient was "attempting to get out of bed and resisting any attempt by the nursing staff to be placed back in it. Patient was very confused and using abusive language. The patient after many attempts to be re-directed to bed, began to physically struggle with both officers and nursing staff. Due to the patient's violent behavior the patient's doctor placed a restraint order on the patient. He was then placed in four-point leather restraints."

Telephone interview on 02/01/2012 at 1355 with the registered nurse assigned to Patient #3 on 08/25/2011 revealed she remembered the restraint episode on 08/25/2011. The nurse stated the patient got "violent" with the sitter and was grabbing her arm and threatening her. The nurse stated "I wanted restraints and was told that he had broke out of soft limb restraints in the past. We had to get him into leather restraints. We had to get a supervisor to get the leather restraints. I had never used them before. I went out to call the charge nurse, police and physician. When I returned to the room the handcuffs were on." The nurse stated she could not remember how long the handcuffs were on the patient. Interview revealed the nurse had not been trained in the use of handcuffs and had never seen them used before or after this episode. The nurse stated "We would not have needed handcuffs if we had leathers available. The police would have held the patient and we would have applied the leather restraints."

Telephone interview with a Special Police Officer involved in the restraint of Patient #3 on 08/25/2011 revealed he remembered the patient, but was unable to remember the specific restraint episode on 08/25/2011. Interview revealed the officer did not recall handcuffs ever being used on Patient #3. The officer stated "We don't do handcuffs unless it is a last resort and the patient is out of control and it is the only option for safety." The officer stated nursing staff used leather restraints with this patient and he was unaware of the use of handcuffs.

Interview on 02/01/2012 at 1210 with the physician that wrote the order for restraints on 08/25/2011 revealed he was the resident on call and received a call about Patient #3 needing restraints. The physician stated he went to evaluate the patient and saw the patient in handcuffs. The physician stated "The officers stated the patient took a swing at them so they used cuffs. Police and nursing staff were in the room. A large police officer had grabbed (the patient) after (the patient) tried to hit him." The physician stated he wrote the order for leather restraints and stated "He didn't need cuffs. He could hurt himself with cuffs. Leather restraints are stronger that the nylon restraints but less abrasive that the metal cuffs."

Interview on 01/31/2012 at 1440 with the hospital Chief of Police revealed he was very familiar with Patient #3 as there were several incidents involving this patient and the hospital police. Interview revealed the patient was combative, wouldn't take direction, wandered and threw things. Interview revealed sitters were placed with the patient due to his behavior. The officer stated the patient responded better with males than females and that the patient usually responded well and would cooperate with police presence. The officer stated he was not aware of Patient #3 being placed in handcuffs while in the hospital. Interview revealed Patient #3 was not under arrest or in police custody during the patient's hospitalization .

Interview on 02/01/2011 at 1120 with the Director of Patient Safety revealed handcuffs are used for forensic reasons and applied by the hospital's Special Police. Interview revealed nursing staff do not apply handcuffs. Interview revealed the hospital's policy identified handcuffs as a restraint but did not address when handcuffs are appropriate for use. The staff member stated "It is not standard to use handcuffs outside of forensics." Interview revealed restraint training is focused on the "clinical application" and does not address the use of handcuffs as restraints. Interview revealed handcuffs should only be used when a patient is under arrest or in the custody of law enforcement. Interview further revealed handcuffs should only be used when all other least restrictive measures have been attempted.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review and staff interview the hospital failed to ensure restraints were not ordered on an as needed basis (prn) for 1 of 5 sampled restraint patients (#3).

The findings include:

Review of the "Restraint Use for Adults and Children" policy revised August 2011 revealed "... C.5. PRN (as needed) restraint orders will not be accepted, transcribed nor implemented. If a "PRN" order is recorded in the medical record by the LIP (licensed independent practioner) the nurse is responsible for contacting the physician or designee to obtain a time limited order. An entry is made to disregard the incorrect order and a correct order is immediately obtained from the LIP. ..."

Closed record review on 01/31/2012 of Patient #3 revealed a [AGE] year-old male that was (MDS) dated [DATE] with a subdural hematoma and subarachnoid hemorrhage after the patient's bicycle collided with a truck. The patient had a history of traumatic brain injury in 1999. Review of the record revealed the patient was admitted to an Intensive Care Unit (ICU) on 06/07/2011, then transferred to a neurology floor on 06/09/2011, then transferred to a rehabilitation unit on 06/14/2011 and discharged to a nursing facility on 08/15/2011. Record review revealed the patient returned to the hospital on [DATE] after breaking out a window and eloping from the nursing facility. The patient was readmitted to a neurology unit on 08/18/2011 and discharged to another facility on 12/11/2011. Review of the patient's medical record revealed outbursts of violent behavior that included destruction of property, entering other patient rooms and throwing items causing the patient and nurse to barricade themselves in the bathroom for protection, and cursing, threatening and attacking staff. Further review revealed psychiatric consults and ongoing medication adjustments to attempt to control the patient's agitation and combativeness. Record review revealed repeated use of restraints necessary for safety during the six month hospitalization . Review of a physician's order dated 11/11/2011 at 1155 revealed "Hold restraint for today unless needed." Further review of physician's orders revealed no entry was made to disregard the incorrect prn order and a correct order obtained.

Interview on 02/01/2012 at 1120 with the Director of Patient Safety revealed the physician's order on 11/11/2011 was an order to use restraints as needed and was inappropriate. Interview revealed nursing staff should have called the physician and obtained a correct order that was time limited. Interview revealed prn or as needed restraint orders are not acceptable.

NC 680, NC 705 and NC 293