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Intakes: TN 911

Based on facility policy, medical record review and interview, the facility failed to follow policy for restraints for 1 of 4 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's policy and procedure for Restraints documented, "Indications: 1. Only used when necessary for patient safety. Least restrictive measures/interventions have been determined and documented to be ineffective to protect the patient or others from harm ....General Guidelines for Violent/Self Destructive (V/SD) and Seclusion: 1. The Registered Nurse (RN) may initiate restraint/seclusion use and must be justified by an appropriate clinical assessment and/or the immediate need to sustain medical treatment and or prevent self harm. The Attending Physician must be notified within 1 hour of application ... Documentation Requirements for Violent/Self-Destructive (V/SD): Nursing: 3. Every 15 minute assessment/monitoring/ documentation by the nursing staff should include but is not limited to the following: Clinical justification-Nurse; Restraint intact/correctly applied-Nurse; Safety check of environment-Nurse or assistive personnel; Fluids offered to patient-Nurse or assistive personnel; Need for elimination assessed-Nurse or assistive personnel ..."

2. Medical record review for Patient #1 documented an admission to the Emergency Department (ED) on 11/1/11 at 1040 for medical clearance prior to admission for psychiatric care at another hospital.
Review of the Sitter Charting Check Sheet documented the session started at 1100, patient appeared restless at 1330 and 1400 and the patient was eating at 2130.
Review of the nursing "Patient Notes" dated 11/1/11 at 1040 documented the patient had a flat affect. At 1340 the patient was screaming and could not be redirected and after third attempt was successful in administering Ativan with the assistance of security. At 1818 patient was quiet and at 2030 the patient was given water. At 2104 the RN documented the patient was ambulatory in the unit and returned to stretcher without incident. The RN documented, "Cuff to bilateral wrist with leather strap behind back connecting them noted. Sitter from (named crisis center) asked if they are their cuffs. Sitter (name of sitter) stated they were and refused to remove them stating, 'He is violent'. Pt observed to be quiet and cooperative since this shifts arrival at 1900."

Further review of the medical record revealed no documentation of every 15 minute checks of the restraints or every 2 hour release of the restraints. There was no physician order for the restraints and no documentation less restrictive restraints had been attempted. There was no documentation the patient had been offered fluids or elimination from admittance until 2030.

3. On 11/14/11 at 1:10 PM the RN that admitted the patient to the trauma unit was interviewed. The RN stated the patient had restraints on that were not the typical restraints (leather belt around the waist with metal handcuffs at the sides). The RN stated a physician's order for the restraints was not obtained. The RN stated he was aware of the hospital policy to check the patient every 15 minutes and release the restraints every 2 hours, offer food/water and elimination every 2 hours. He stated this was not done.

4. During an interview in the Administration Conference Room on 11/14/11 at 12:40 PM, the Quality Manager verified there was no documentation in the medical record that the facility's policy and procedure for restraints had been followed.