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BLOUNT MEMORIAL HOSPITAL 907 E LAMAR ALEXANDER PARKWAY MARYVILLE, TN 37804 Aug. 6, 2014
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
Based on medical record review, review of facility policy, and interview, the facility failed to ensure a restraint was monitored and renewed according to facility policy for one patient (#7) of eight patients reviewed.

The findings included:

Patient #7 was admitted to the Emergency Department (ED) on May 12, 2014, at 12:06 p.m., with a chief complaint of depression and was suicidal. Further review revealed the patient was transferred to a Psychiatric facility on May 13, 2014, at 2:50 a.m.

Medical record review of the Orders for Violent Self Destructive Patient Restraint (Behaviors) form dated May 12, 2014, at 12:00 p.m., revealed the ED physician signed the seclusion order sheet for the first application of the seclusion room. Continued review of the Orders revealed "...Administrative Supervisor/ED RN (Registered Nurse) reports and renews orders within specified time frames...this documentation will cover 24 hours for an adult..." Further review revealed the documentation required every 4 hour interval assessments and documentation while the patient was in the restraint/seclusion room.

Review of the facility policy Emergency Department Care of Patient at Risk for Harm to Self and Other (Suicidal/Homicidal Patient) Restraint/Seclusion, revised November 11, 2009, revealed "...patients who have communicated by act or work a desire harm themselves or others in any way are designated as a potential suicide/homicide risk...the patient will be placed in special observation (seclusion) or restraint as a means of protecting the patient and insuring the safety of others...continuous observation is appropriate for patients who have verbalized or acted out serious intentions of self-harm, ending their lives, or a flight risk...the ED physician must evaluate the patient within one hour of the initiation of restraint seclusion...the patient is re-evaluated in person for continued need for restraint/seclusion by the ED physician...every 4 hours for patients aged 18 and older..."

Medical record review of the Documentation of Restraint/Seclusion for Violent/Self Destructive Behavior form revealed the patient was monitored every 15 minutes by the ED staff beginning on May 12, 2014, at 12:00 p.m., through May 13, 2014, at 4:20 a.m.

Medical record review of a Daily Focus Assessment Report dated May 12, 2014, at 12:45 p.m., written by RN #5, revealed the physician signed the seclusion order and the patient was placed in the seclusion room.

Medical record review of an ED Physicians Worksheet dated May 12, 2014, at 8:47 p.m., revealed "...history of neuropathy and CVA (Cerebral Vascular Accident, stroke) and was brought in for further evaluation of suicidal ideation...made statement to (named hospital) staff indicating...is considering suicide as a solution to...health problems..."

Medical record review of the Orders for Violent Self Destructive Patient Restraint (Behaviors) form dated May 13, 2014, at 3:00 a.m. (15 hours after the first application order was signed) revealed the RN and the physician signed to continue the 4 hour order for the restraint. Continued review revealed no orders or signatures after 12:00 p.m., through 3:00 a.m., on May 13, 2014.

Interview with RN #1 on August 5, 2014, at 10:50 a.m., in the EDrevealed "...when a patient is placed in the secure room the physician signs the order sheet for the behavioral restraint...the see the patient very fast...they patient will show up on the tracking board for the physician to see the patient..." Further interview revealed "...if the physician is delayed in coming to see the patient the nurses will take the order sheet and the chart to the physician, review the complaint and the need for the seclusion with the physician and they will sign the sheet...they will see the patient as soon as they can but within the hour..."

Interview with the ED physician #1 on August 5, 2014, at 11:00 a.m., in the ED nurses station, revealed "...we have a tracking board and as soon as the patient comes into the seclusion rooms we are notified...we try to see the patient very soon after admission and perform an assessment to ensure the patient's safety..." Further interview revealed "...the physician signs the behavior seclusion order sheet when the patient comes in and once the patient is ready for the seclusion to be discontinued..." Continued interview revealed "...if we cannot see the patient immediately the nurse will let us know why the patient is here and why they are placed in the seclusion room...the physician will sign the order but as soon as possible the physician goes into the patient's room for evaluation..."

Interview with RN #2 on August 5, 2014, at 11:25 a.m., in the ED, revealed "...if we place a patient in the seclusion room the physician will see the patient shortly after...the patient shows up on the tracking board for the physician to see..." Further interview revealed "...the patients are monitored every 15 minutes and every 4 hours we document on the restraint order sheet the need for the continued seclusion..."

Interview with RN #3 on August 5, 2014, at 11:30 a.m., in the ED, revealed "...the physician signs the order sheet for any patient who is placed in the seclusion room or any type of restraint...they will see the patient face to face and perform an examination..." Further interview revealed "...we monitor the patient's every 15 minutes and every four hours the patient is evaluated for the need for continued seclusion..."

Interview with Quality Management Director on August 5, 2014, at 1:05 p.m., in the conference room, revealed the physician signed the order on May 12, 2014, at 12:00 p.m., and there was no documentation regarding the continued need for the restraints until 3:00 a.m., on May 13, 2014. Continued interview revealed "...there should be documentation at 4:00 p.m., 8:00 p.m., and 12 a.m.,(May 13, 2014) regarding the continued use of the restraint..." Further interview confirmed the documentation for patient #7 did not follow the facility's policy related to monitoring the patient every four hours for the use and renewal of behavioral restraints.

C/O # 3