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.

UNIVERSITY HEALTH SYSTEM 4502 MEDICAL DR SAN ANTONIO, TX 78229 April 5, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the facility failed to ensure specific patient rights were protected and promoted; and implement their written policy and procedures that protect and promote each patient's rights for 1 of 1 patients (Patient #1) reviewed with a patient rights violation complaint regarding restraints.


Specifically, the facility failed to ensure Patient #1's rights in accordance with the facility's restraint policy and procedures during the implementation of restraints used for the management of violent behavior.


1.) On 10/12/15, Patient #1 was placed in a 4 point restraint (soft 2 point wrist and soft 2 point ankle restraints) for a total of 5 continuous hours; which exceeded the 4 hour time limit and facility restraint policy and; the Physician Order (PO) documenting a maximum of 4 hours.


2.) On 10/12/15, Patient #1 was placed in a second restraint without a renewed order or physician face to face evaluation documented in the records for the re-implementation of a behavioral restraint.


3.) Observation documentation for Patient #1 on 10/12/15, during restraint revealed he was asleep and remained in restraints. The facility's restraint policy indicates the patient in restraints must be released from restraints once asleep and reassessed when awake.


4.) Interviews with facility Registered Nurse's (RN's) stated the use of "trial releases" during the assessment for the release of restraints. Facility policy indicates "trial release" constitutes a PRN [as needed] use of restraint and, therefore is not permitted.


Refer to A154, A168, and A171 for evidence of specific findings.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility staff failed to ensure patient rights in accordance with the facility's restraint policy and procedures during the implementation of restraints used for the management of violent behavior for 1 of 1 patients (Patient #1) reviewed with complaint allegations in the area of patient rights regarding restraints.


Specifically,


1.) On 10/12/15, Patient #1 was placed in a 4 point restraint (soft 2 point wrist and soft 2 point ankle restraints) for a total of 5 continuous hours; which exceeded the 4 hour time limit and facility restraint policy and; the Physician Order (PO) documenting a maximum of 4 hours.


2.) On 10/12/15, Patient #1 was placed in a second restraint without a renewed order or physician face to face evaluation documented in the records for the re-implementation of a behavioral restraint.


3.) Observation documentation for Patient #1 on 10/12/15, during restraint revealed he was asleep and remained in restraints. The facility's restraint policy indicates the patient in restraints must be released from restraints once asleep and reassessed when awake.


4.) Interviews with facility Registered Nurse's (RN's) stated the use of "trial releases" during the assessment for the release of restraints. Facility policy indicates "trial release" constitutes a PRN [as needed] use of restraint and, therefore is not permitted.


These deficient practices affected Patient #1's rights and resulted in this standard not being met.


Findings included:


Patient #1 filed a written complaint with the Department of State Health Services, signed 12/29/15, which indicated he was restrained physically in 4 point restraints, "with one arm pulled back over his shoulder and tied down in a very, extremely painful and uncomfortable position." Patient #1 stated he "was held this way [restrained] for approximately 5 hours." Patient #1 specifically questioned the reason he was restrained for 5 hours, "in violation of the specific statute that forbids it."


Review of Patient #1's records revealed the following two restraints implemented 10/12/15:


1.) The Registered Nurse's (RN) Assessment and Interventions documentation revealed on 10/12/15, at 02:30 AM, RN B documented patient became very aggressive and agitated. Family left patient bedside. Patient not cooperative, placed in restraints per order.

Restraints: for Behavior Management- Verbally aggressive, Physical aggressiveness/violence.
Type of restraint: soft ankle (2 point), and soft wrist (2 point).

Restraints applied at 02:30AM.


Further review revealed:

At 06:00 AM- RN C documented - Patient continues to climb out of bed and noncompliant, remains in restraints.


At 07:09 AM, RN A and RN C document change of shift report. Report given to RN A from RN C. Comments documented revealed, "seen patient in bed asleep and quiet with 4 point restraints with right arm on top of head, breathing easy, even and regular w/o [without] noted distress."


At 07:30 AM, RN A documented restraints "Removed: 07:30." (5 hours after initiation). Patient calm and cooperative with care, easy to arouse without paint to right arm, "restraints released at this time temporarily and will continue to monitor."


Review of Patient #1's PO's revealed only one restraint order dated 10/12/15, at 3:34AM, for a Behavior Management Restraint. Soft wrist 2 point and soft ankle 2 point. Restraint Duration: "Maximum of 4 hours (Adults with aggressive behavior)." Criteria for restraint discontinuation: No longer physically aggressive/violent.


2.) On 10/12/15, at 14:59, RN A documented an assessment; "patient very upset, face turned red, banging the glass door."


Further review revealed:

10/12/15, at 15:28, RN A documented "patient became very aggressive and agitated, PRN, yelling out loud with profanities." emergency room Medical Doctor (ERMD) "aware and new orders received; noted and carried out, medicated and restraints re-applied at this time." Restraints applied at "15:28." There was no documentation of the type of restraints applied.


10/12/15, at 16:07, RN A documented Patient #1 "remains to be agitated and restless, fighting restraints at this time w/o [without] noted distress, will continue to monitor and cared for."


10/12/15, at 17:15, RN A documented "patient remains restless and agitated, screaming and yelling out loud despite of redirection given, new orders received, noted and carried out, incontinent care done and kept clean and dry and made comfortable."


10/12/15, at 18:42, RN A documented "patient woke up at this time restless, anxious and agitated; fighting with restraints, screaming and yelling out loud profanities despite of efforts done by staff, will continue to monitor and needs attended to."


10/12/15, at 19:30, RN D documented "Restraints Off, Pt calm, orientated x3, agrees to be cooperative."


Review of Patient #1's PO's revealed there was not an order for the restraints "re-applied" on 10/12/15, at 15:28 and removed at 19:30. The original PO dated 10/12/15, at 3:34 AM was for a maximum of 4 hours.


3.) Review of Patient #1's Observation Record (15 minute documented checks) completed by Clerk-A dated 10/12/15, from 07:00 AM to 10/13/15, at 03:00 AM revealed the following documentation and codes:


On 10/12/15, at 15:00 Patient B6 (cursing), B11 (Combative), M1 (Anxious/Tense), M2 (Agitated), P7 (Patient Restrained), P1 (Medication given), and A13 (Interacting with LMSW or LPC).


At 17:30, there was documentation that was either a P7 (for patient restraint); or A7 (Sleeping). The documentation was altered and was unknown the accuracy of the specific code.


At 18:00, documentation revealed "A7" (Patient #1 sleeping). Patient remained in restraints according to RN-A documentation.


Further review of the observation sheet revealed A7 (sleeping) was documented continuously for 18:15, 18:30 and 18:45 (at least one hour while Patient #1 remained in restraints according to RN documentation every 15 minutes).


Review of the facility's policy regarding Restraint and Seclusion, effective 08/12/15, indicated in the area for "Ordering Restraints;" revealed restraint or seclusion may only be ordered by a Licensed Independent Practitioner (LIP).


Review of Violent or Self-Destructive Behavior, Attachment II, revealed the following, in part:

A.) This policy requires that a physician responsible for the care of the patient order restraint or seclusion prior to the application of restraint or seclusion.


B.) In some situations, however, the need for a restrain or seclusion intervention may occur so quickly that an order cannot be obtained prior to application. In these emergency applications situations, the order must be obtained either during the emergency application of the restrain or seclusion, or immediately (within a few minutes) afterwards.


C.) Each order for restraint or seclusion used for the management of violent or self-destructive behavior (behavioral restraint or seclusion) that jeopardized the immediate physical safety of the patient, a staff member, or others may only be obtained and renewed in accordance with the following limits:

1. Up to four (4) hours for adults [AGE] and older.

4. The order may be renewed one time for up to a total of 8, 4, and 2 hours respectively after which time the order expires.


D.) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN).


E.) Staff cannot discontinue a restraint or seclusion intervention, and then re-start it under the same order. This would constitute a PRN order. A "trial release" constitutes a PRN use of restraint or seclusion, and, therefore is not permitted.


F.) If restraint or seclusion is discontinued prior to the expiration of the original order, a new order must be obtained prior to re-initiating the use of restraint or seclusion.


The patient in restraints or seclusion in response to a behavioral emergency must be reassessed for the continued need for restraints or seclusion prior to the expiration of the age appropriate time limit as a specified on the physician order.


H.) A physician is required to conduct a face-to-face evaluation before issuing or renewing an order that continues the use of a behavioral restraint or seclusion.


III. Special Assessment Requirement for Patients Placed in Restraint or Seclusion for Violent or Self-Destructive Behavior:

H.) The patient in restraints or seclusion in response to a behavioral emergency must be released from restraints or have the seclusion door unlocked once asleep and reassessed when awake. If the patient in restraints or seclusion in response to a behavioral emergency appears to fall asleep while in mechanical restraint or seclusion, the RN is to assess the patient to determine if the patient is asleep. If the patient is determined to be asleep, the RN shall instruct staff members to release the patient from restraints or unlock the seclusion door. The RN will assign a staff member to maintain continuous face-to-face observation until the patient is awake and re-evaluated by the RN. If the patient exhibits behaviors requiring restraint or seclusion upon awakening, then the RN will obtain a new physician's order for any new initiation of restraint or seclusion.


Interview on 04/04/16, at 2:35 PM, RN A stated he thought a physician order for restraint was valid for "24 hours." When asked, RN A stated he was "not aware" there was a time limit of 4 hours for a behavioral/violent restraint; and stated if the patient was not cooperative then they were to stay in restraints; even if beyond 4 hours. After RN A reviewed Patient #1's Physician Order dated 10/12/15 at 3:34AM for a Behavior Management Restraint (Soft wrist 2 point and soft ankle 2 point. Restraint Duration: "Maximum of 4 hours (Adults with aggressive behavior);" he stated, "that's the first time I have seen that" and further stated he had not seen or heard of a 4 hours maximum amount of time for restraints. RN A stated he was "not sure" if he needed a new physician order to re-implement a restraint after the initial one was discontinued. RN A stated that he believed the first order would cover the restraints up to 24 hours. RN A stated if he received a verbal order from a physician that it was his responsibility to ensure the written order was obtained and evidenced in the patient's record. RN-A stated that if a patient was asleep he could leave the restraints on. RN A stated that when a patient was in restraints 15 minute documented checks/assessments were completed by the RN; along with continuous video monitoring completed by a technician who monitored live video. RN A stated it was up to the RN's assessment and judgment as to how long a patient stays in restraints. RN A stated that after he has assessed a patient for the release of restraints that he would sometimes do a "trial release" to see how the patient acted before he fully released all the restraints. RN A stated a trial release was to assess and determine if the patient was going to be cooperative and not be aggressive. RN A stated a trial release may consist of one to two points of the restraints before the release of all the points of the restraint. RN A indicated he rarely worked the psychiatric side of the Emergency Department (ED) and did not know the specific policies and procedures regarding restraints for violent/behavioral incidents.


Interview on 04/04/16, with RN-Risk Management confirmed after review of Patient #1's record that there was no Physician Order for the second 4 point restraint; 2 wrist and 2 ankle implemented on 10/12/15 at 15:28.


Interview on 04/04/16, at 3:50 PM, with RN/ED Director stated the maximum amount of time a patient can be restrained for a behavior restraint was for 4 hours and a medical (non-violent/safety) restraint was 24 hours. The RN/ED Director stated any further restraints required another Physician Order and Medical Doctor assessment. The RN/ED Director stated a verbal order is not allowed for restraints; and if a restraint is discontinued; and another (2nd) is implemented you would need another physician order to implement. RN/ED Director stated that if a patient was asleep while in restraints then it was up to the assessing RN's judgment for release. RN/ED Director indicated that if a patient was medicated along with the physical restraint that you would want to await until the patient wakes up to remove restraints; in order to complete an assessment prior to removing the restraint. RN/ED Director stated a patient was to be released once they were no longer agitated and that the RN could complete a "trial release."


Interview conducted during the exit conference on 04/05/16 at 12:25 PM with the Director of Quality Improvement (QI) and Accreditation confirmed the following findings as evident by Patient #1's record:


A.) Patient #1's first restraint implemented on 10/12/15, at 02:30 AM, was not removed until 07:30 AM; 5 total hours in duration. The PO for restraint included the time limit maximum of 4 hours.


B.) Patient #1's second restraint implemented on 10/12/15, at 15:28 to 19:30 (just over 4 hours), was implemented without a physician order and face to face evaluation documented in the record.


C.) Documentation of Patient #1's Observation records during restraint documented him being asleep and remained in restraints.


Further interview with the Director of QI and Accreditation indicated the facility had not identified these specific restraint issues as evidenced from Patient #1's complaint and record because restraints that occurred in the ED were not tracked and reported quarterly like the inpatient restraints were; which are part of the required reporting and reviews. The Director of QI and Accreditation stated "trial releases" of restraints were not allowed according to regulatory requirements and the facility's policy; which was changed/revised to reflect the regulatory requirements.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure the use of restraint was in accordance with an order of a physician or other licensed independent practitioner who was responsible for the care of Patient #1; and in accordance with the facility's policy and procedures for restraint.


Specifically, on 10/12/15, Patient #1 was placed in a second restraint without a renewed order documented in the records for the re-implementation and authorization of restraint.


This deficient practice affected Patient #1's rights.


Findings included:


Review of Patient #1's records revealed the following two restraints implemented 10/12/15:


1.) Review of the Registered Nurse's (RN) Assessment and Interventions documentation revealed on 10/12/15, at 02:30 AM, RN B documented "restraints applied."


Further review revealed:

At 06:00 AM, RN C documented - Patient continues to climb out of bed and noncompliant, remains in restraints.


At 07:09 AM, RN A and RN C document change of shift report. Report given to RN A from RN C. Comments documented revealed, "seen patient in bed asleep and quiet with 4 point restraints with right arm on top of head, breathing easy, even and regular w/o [without] noted distress."


At 07:30 AM, RN A documented restraints "Removed: 07:30." (5 hours after initiation). Patient calm and cooperative with care, easy to arouse without paint to right arm, "restraints released at this time temporarily and will continue to monitor."


Patient #1's Physician Order (PO)'s revealed only one restraint order dated 10/12/15 at 3:34AM for a Behavior Management Restraint. Soft wrist 2 point and soft ankle 2 point. Restraint Duration: "Maximum of 4 hours (Adults with aggressive behavior)."


2.) On 10/12/15, at 14:59, RN A documented an assessment "patient very upset, face turned red, banging the glass door. Further review revealed:


At 15:28, RN A documented "patient became very aggressive and agitated, PRN, yelling out loud with profanities." emergency room Medical Doctor (ERMD) "aware and new orders received; noted and carried out, medicated and restraints re-applied at this time." Restraints applied at "15:28." There was no documentation of the type of restraints applied.


At 16:07, RN A documented Patient #1 "remains to be agitated and restless, fighting restraints at this time w/o [without] noted distress, will continue to monitor and cared for."


At 17:15, RN A documented "patient remains restless and agitated, screaming and yelling out loud despite of redirection given, new orders received, noted and carried out, incontinent care done and kept clean and dry and made comfortable."


At 18:42, RN A documented "patient woke up at this time restless, anxious and agitated; fighting with restraints, screaming and yelling out loud profanities despite of efforts done by staff, will continue to monitor and needs attended to."


At 19:30, RN D documented "Restraints Off, Pt calm, orientated x3, agrees to be cooperative."


Review of Patient #1's PO's revealed there was not an order for the restraints "re-applied" on 10/12/15, at 15:28, and removed at 19:30. The original PO dated 10/12/15 at 3:34 AM was for a maximum of 4 hours and was not renewed.


Review of the facility's policy regarding Restraint and Seclusion, effective 08/12/15, indicated in the area for "Ordering Restraints;" revealed restraint or seclusion may only be ordered by a Licensed Independent Practitioner (LIP).


Violent or Self-Destructive Behavior, Attachment II revealed the following, in part:

A.) This policy requires that a physician responsible for the care of the patient order restraint or seclusion prior to the application of restraint or seclusion.


B.) In some situations, however, the need for a restrain or seclusion intervention may occur so quickly that an order cannot be obtained prior to application. In these emergency applications situations, the order must be obtained either during the emergency application of the restrain or seclusion, or immediately (within a few minutes) afterwards.


C.) Each order for restraint or seclusion used for the management of violent or self-destructive behavior (behavioral restraint or seclusion) that jeopardized the immediate physical safety of the patient, a staff member, or others may only be obtained and renewed in accordance with the following limits:

1. Up to four (4) hours for adults [AGE] and older.

4. The order may be renewed one time for up to a total of 8, 4, and 2 hours respectively after which time the order expires.


E.) Staff cannot discontinue a restraint or seclusion intervention, and then re-start it under the same order. This would constitute a PRN order. A "trial release" constitutes a PRN use of restraint or seclusion, and, therefore is not permitted.


F.) If restraint or seclusion is discontinued prior to the expiration of the original order, a new order must be obtained prior to re-initiating the use of restraint or seclusion.
The patient in restraints or seclusion in response to a behavioral emergency must be reassessed for the continued need for restraints or seclusion prior to the expiration of the age appropriate time limit as a specified on the physician order.


H.) A physician is required to conduct a face-to-face evaluation before issuing or renewing an order that continues the use of a behavioral restraint or seclusion.


Interview on 04/04/16, at 2:35 PM, RN A stated he thought a physician order for restraint was "good for 24 hours." RN A stated he was "not sure" if he needed a new physician order to re-implement a restraint after the initial one was discontinued. RN A stated that he believed the first order would cover the restraints up to 24 hours. RN A stated if he received a verbal order from a physician that it was his responsibility to ensure the written order was obtained and evidenced in the patient's record. RN A indicated he rarely worked the psychiatric side of the Emergency Department (ED) and did not know the specific policies and procedures regarding restraints for violent/behavioral incidents.


Interview on 04/04/16, with RN-Risk Management confirmed after review of Patient #1's record that there was no Physician Order for the second 4 point restraint; 2 wrist and 2 ankle implemented on 10/12/15 at 15:28.


Interview on 04/04/16, at 3:50 PM, with RN/ED Director stated the maximum amount of time a patient can be restrained for a behavior restraint was for 4 hours and a medical (non-violent/safety) restraint was 24 hours. The RN/ED Director stated any further restraints required another Physician Order and Medical Doctor assessment. The RN/ED Director stated a verbal order is not allowed for restraints; and if a restraint is discontinued; and another (2nd) is implemented you would need another physician order to implement.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that each order for restraint used for the management of violent or self-destructive behavior was implemented in accordance with the facility's policy and procedures and the following time limits: (A) 4 hours for adults 18 years of age or older; and renewed with an additional order, up to a total of 24 hours for the re-implementation of another restraint. Specifically,


1.) On 10/12/15, Patient #1 was placed in a 4 point restraint (soft 2 point wrist and soft 2 point ankle restraints) for a total of 5 continuous hours; which exceeded the 4 hour time limit and facility restraint policy and; the Physician Order (PO) documenting a maximum of 4 hours.


2.) On 10/12/15, Patient #1 was placed in a second restraint without a renewed order or physician face to face evaluation documented in the records for the re-implementation of a behavioral restraint.


This deficient practice affected Patient #1's rights.


Findings included:


Patient #1 filed a written complaint with the Department of State Health Services, signed 12/29/15 which indicated he was restrained physically in 4 point restraints, "with one arm pulled back over his shoulder and tied down in a very, extremely painful and uncomfortable position." Patient #1 stated he "was held this way [restrained] for approximately 5 hours." Patient #1 specifically questioned the reason he was restrained for 5 hours, "in violation of the specific statute that forbids it."


Review of Patient #1's records revealed the following two restraints implemented 10/12/15:


1.) The Registered Nurse's (RN) Assessment and Interventions documentation revealed on 10/12/15 at 02:30 AM, RN B documented patient became very aggressive and agitated. Family left patient bedside. Patient not cooperative, placed in restraints per order.

Restraints: for Behavior Management- Verbally aggressive, Physical aggressiveness/violence.
Type of restraint: soft ankle (2 point), and soft wrist (2 point).
Restraints applied at 02:30AM.


Further review revealed:

At 06:00 AM, RN C documented - Patient continues to climb out of bed and noncompliant, remains in restraints.


At 07:09 AM, RN A and RN C document change of shift report. Report given to RN A from RN C. Comments documented revealed, "seen patient in bed asleep and quiet with 4 point restraints with right arm on top of head, breathing easy, even and regular w/o [without] noted distress."


At 07:30 AM, RN A documented restraints "Removed: 07:30." (5 hours after initiation). Patient calm and cooperative with care, easy to arouse without paint to right arm, "restraints released at this time temporarily and will continue to monitor."


Review of Patient #1's PO's revealed only one restraint order dated 10/12/15, at 3:34AM for a Behavior Management Restraint. Soft wrist 2 point and soft ankle 2 point. Restraint Duration: "Maximum of 4 hours (Adults with aggressive behavior)."


2.) On 10/12/15, at 14:59, RN A documented an assessment; "patient very upset, face turned red, banging the glass door."


Further review revealed:


10/12/15, at 15:28, RN A documented "patient became very aggressive and agitated, PRN, yelling out loud with profanities." emergency room Medical Doctor (ERMD) "aware and new orders received; noted and carried out, medicated and restraints re-applied at this time." Restraints applied at "15:28." There was no documentation of the type of restraints applied.


10/12/15 at 16:07, RN A documented Patient #1 "remains to be agitated and restless, fighting restraints at this time w/o [without] noted distress, will continue to monitor and cared for."


10/12/15, at 17:15, RN A documented "patient remains restless and agitated, screaming and yelling out loud despite of redirection given, new orders received, noted and carried out, incontinent care done and kept clean and dry and made comfortable."


10/12/15, at 18:42, RN A documented "patient woke up at this time restless, anxious and agitated; fighting with restraints, screaming and yelling out loud profanities despite of efforts done by staff, will continue to monitor and needs attended to."


10/12/15, at 19:30, RN D documented "Restraints Off, Pt calm, orientated x3, agrees to be cooperative."


Review of Patient #1's PO's revealed there was not an order for the restraints "re-applied" on 10/12/15, at 15:28 and removed at 19:30. The original PO dated 10/12/15 at 3:34 AM was for a maximum of 4 hours.


Review of the facility's policy regarding Restraint and Seclusion, effective 08/12/15, indicated in the area for "Ordering Restraints;" revealed restraint or seclusion may only be ordered by a Licensed Independent Practitioner (LIP).


Review of Violent or Self-Destructive Behavior, Attachment II revealed the following, in part:

A.) This policy requires that a physician responsible for the care of the patient order restraint or seclusion prior to the application of restraint or seclusion.


B.) In some situations, however, the need for a restrain or seclusion intervention may occur so quickly that an order cannot be obtained prior to application. In these emergency applications situations, the order must be obtained either during the emergency application of the restrain or seclusion, or immediately (within a few minutes) afterwards.


C.) Each order for restraint or seclusion used for the management of violent or self-destructive behavior (behavioral restraint or seclusion) that jeopardized the immediate physical safety of the patient, a staff member, or others may only be obtained and renewed in accordance with the following limits:

1. Up to four (4) hours for adults [AGE] and older.

4. The order may be renewed one time for up to a total of 8, 4, and 2 hours respectively after which time the order expires.


E.) Staff cannot discontinue a restraint or seclusion intervention, and then re-start it under the same order. This would constitute a PRN order. A "trial release" constitutes a PRN use of restraint or seclusion, and, therefore is not permitted.


F.) If restraint or seclusion is discontinued prior to the expiration of the original order, a new order must be obtained prior to re-initiating the use of restraint or seclusion.


The patient in restraints or seclusion in response to a behavioral emergency must be reassessed for the continued need for restraints or seclusion prior to the expiration of the age appropriate time limit as a specified on the physician order.


H.) A physician is required to conduct a face-to-face evaluation before issuing or renewing an order that continues the use of a behavioral restraint or seclusion.


Interview on 04/04/16, at 2:35 PM, RN A stated he thought a physician order for restraint was valid for "24 hours." When asked, RN A stated he was "not aware" there was a time limit of 4 hours for a behavioral/violent restraint; and stated if the patient was not cooperative then they were to stay in restraints; even if beyond 4 hours. After RN A reviewed Patient #1's Physician Order dated 10/12/15 at 3:34AM for a Behavior Management Restraint (Soft wrist 2 point and soft ankle 2 point. Restraint Duration: "Maximum of 4 hours (Adults with aggressive behavior);" he stated, "that's the first time I have seen that" and further stated he had not seen or heard of a 4 hours maximum amount of time for restraints. RN A stated he was "not sure" if he needed a new physician order to re-implement a restraint after the initial one was discontinued. RN A stated that he believed the first order would cover the restraints up to 24 hours. RN A stated if he received a verbal order from a physician that it was his responsibility to ensure the written order was obtained and evidenced in the patient's record. RN A indicated he rarely worked the psychiatric side of the Emergency Department (ED) and did not know the specific policies and procedures regarding restraints for violent/behavioral incidents.


Interview on 04/04/16, with RN-Risk Management confirmed after review of Patient #1's record that there was no Physician Order for the second 4 point restraint; 2 wrist and 2 ankle implemented on 10/12/15, at 15:28.


Interview on 04/04/16, at 3:50 PM, with RN/ED Director stated the maximum amount of time a patient can be restrained for a behavior restraint was for 4 hours and a medical (non-violent/safety) restraint was 24 hours. The RN/ED Director stated any further restraints required another Physician Order and Medical Doctor assessment. The RN/ED Director stated a verbal order is not allowed for restraints; and if a restraint is discontinued; and another (2nd) is implemented you would need another physician order to implement.


Interview conducted during the exit conference on 04/05/16, at 12:25 PM ,with the Director of Quality Improvement (QI) and Accreditation confirmed the following findings as evident by Patient #1's record:


A.) Patient #1's first restraint implemented on 10/12/15, at 02:30 AM, was not removed until 07:30 AM; 5 total hours in duration. The PO for restraint included the time limit maximum of 4 hours.


B.) Patient #1's second restraint implemented on 10/12/15, at 15:28 to 19:30 (just over 4 hours), was implemented without a physician order documented in the record.


Further interview with the Director of QI and Accreditation indicated the facility had not identified these specific restraint issues as evidenced from Patient #1's complaint and record because restraints that occurred in the ED were not tracked and reported quarterly like the inpatient restraints were; which are part of the required reporting and reviews.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility's registered nurses failed to implement nursing care in accordance with the facility's policy and procedures for the use of restraints; and the physician's order for 1 of 1 patient (Patient #1) reviewed with complaint allegations in the area of nursing services regarding restraints. Specifically,


1.) On 10/12/15 Patient #1 was placed in a 4 point restraint (soft 2 point wrist and soft 2 point ankle restraints) for a total of 5 continuous hours; which exceeded the 4 hour time limit and facility restraint policy and; the Physician's Order (PO) documenting a maximum of 4 hours.

2.) On 10/12/15 Patient #1 was placed in a second restraint without the RN obtaining a renewed order documented in the records for the re-implementation of a behavioral restraint.

3.) Observation documentation for Patient #1 on 10/12/15 during restraint revealed he was asleep and remained in restraints. The facility's restraint policy indicates the patient in restraints must be released from restraints once asleep and reassessed when awake.

Findings included:

Patient #1 filed a written complaint with the Department of State Health Services, signed 12/29/15 which indicated he was restrained physically in 4 point restraints, "with one arm pulled back over his shoulder and tied down in a very, extremely painful and uncomfortable position." Patient #1 stated he "was held this way [restrained] for approximately 5 hours." Patient #1 specifically questioned the reason he was restrained for 5 hours, "in violation of the specific statute that forbids it."

Review of Patient #1's records revealed the following two restraints implemented 10/12/15:

1.) The Registered Nurse's (RN) Assessment and Interventions documentation revealed on 10/12/15 at 02:30 AM, RN B documented patient became very aggressive and agitated. Family left patient bedside. Patient not cooperative, placed in restraints per order.
Restraints: for Behavior Management- Verbally aggressive, Physical aggressiveness/violence.
Type of restraint: soft ankle (2 point), and soft wrist (2 point).
Restraints applied at 02:30AM.

Further review revealed:
At 06:00 AM- RN C documented - Patient continues to climb out of bed and noncompliant, remains in restraints.

At 07:09 AM- RN A and RN C document change of shift report. Report given to RN A from RN C. Comments documented revealed, "seen patient in bed asleep and quiet with 4 point restraints with right arm on top of head, breathing easy, even and regular w/o [without] noted distress."

At 07:30 AM, RN A documented restraints "Removed: 07:30." (5 hours after initiation). Patient calm and cooperative with care, easy to arouse without paint to right arm, "restraints released at this time temporarily and will continue to monitor."

Review of Patient #1's PO's revealed only one restraint order dated 10/12/15 at 3:34AM for a Behavior Management Restraint. Soft wrist 2 point and soft ankle 2 point. Restraint Duration: "Maximum of 4 hours (Adults with aggressive behavior)." Criteria for restraint discontinuation: No longer physically aggressive/violent.


2.) On 10/12/15 at 14:59, RN A documented an assessment; "patient very upset, face turned red, banging the glass door."

Further review revealed:
10/12/15 at 15:28, RN A documented "patient became very aggressive and agitated, PRN, yelling out loud with profanities." emergency room Medical Doctor (ERMD) "aware and new orders received; noted and carried out, medicated and restraints re-applied at this time." Restraints applied at "15:28." There was no documentation of the type of restraints applied.

10/12/15 at 16:07, RN A documented Patient #1 "remains to be agitated and restless, fighting restraints at this time w/o [without] noted distress, will continue to monitor and cared for."

10/12/15 at 17:15, RN A documented "patient remains restless and agitated, screaming and yelling out loud despite of redirection given, new orders received, noted and carried out, incontinent care done and kept clean and dry and made comfortable."

10/12/15 at 18:42, RN A documented "patient woke up at this time restless, anxious and agitated; fighting with restraints, screaming and yelling out loud profanities despite of efforts done by staff, will continue to monitor and needs attended to."

10/12/15 at 19:30, RN D documented "Restraints Off, Pt calm, orientated x3, agrees to be cooperative."

Review of Patient #1's PO's revealed there was not an order for the restraints "re-applied" on 10/12/15 at 15:28 and removed at 19:30. The original PO dated 10/12/15 at 3:34 AM was for a maximum of 4 hours.

Review of the facility's policy regarding Restraint and Seclusion, effective 08/12/15 indicated in the area for "Ordering Restraints;" revealed restraint or seclusion may only be ordered by a Licensed Independent Practitioner (LIP).

Review of Violent or Self-Destructive Behavior, Attachment II revealed the following, in part:
A.) This policy requires that a physician responsible for the care of the patient order restraint or seclusion prior to the application of restraint or seclusion.

B.) In some situations, however, the need for a restrain or seclusion intervention may occur so quickly that an order cannot be obtained prior to application. In these emergency applications situations, the order must be obtained either during the emergency application of the restrain or seclusion, or immediately (within a few minutes) afterwards.

C.) Each order for restraint or seclusion used for the management of violent or self-destructive behavior (behavioral restraint or seclusion) that jeopardized the immediate physical safety of the patient, a staff member, or others may only be obtained and renewed in accordance with the following limits:
1. Up to four (4) hours for adults [AGE] and older.
4. The order may be renewed one time for up to a total of 8, 4, and 2 hours respectively after which time the order expires.

E.) Staff cannot discontinue a restraint or seclusion intervention, and then re-start it under the same order. This would constitute a PRN order. A "trial release" constitutes a PRN use of restraint or seclusion, and, therefore is not permitted.

F.) If restraint or seclusion is discontinued prior to the expiration of the original order, a new order must be obtained prior to re-initiating the use of restraint or seclusion.

The patient in restraints or seclusion in response to a behavioral emergency must be reassessed for the continued need for restraints or seclusion prior to the expiration of the age appropriate time limit as a specified on the physician order.

H.) A physician is required to conduct a face-to-face evaluation before issuing or renewing an order that continues the use of a behavioral restraint or seclusion.

III. Special Assessment Requirement for Patients Placed in Restraint or Seclusion for Violent or Self-Destructive Behavior:
H.) The patient in restraints or seclusion in response to a behavioral emergency must be released from restraints or have the seclusion door unlocked once asleep and reassessed when awake. If the patient in restraints or seclusion in response to a behavioral emergency appears to fall asleep while in mechanical restraint or seclusion, the RN is to assess the patient to determine if the patient is asleep. If the patient is determined to be asleep, the RN shall instruct staff members to release the patient from restraints or unlock the seclusion door. The RN will assign a staff member to maintain continuous face-to-face observation until the patient is awake and re-evaluated by the RN. If the patient exhibits behaviors requiring restraint or seclusion upon awakening, then the RN will obtain a new physician's order for any new initiation of restraint or seclusion.

Interview on 04/04/16 at 2:35 PM RN A stated he thought a physician order for restraint was valid for "24 hours." When asked, RN A stated he was "not aware" there was a time limit of 4 hours for a behavioral/violent restraint; and stated if the patient was not cooperative then they were to stay in restraints; even if beyond 4 hours. After RN A reviewed Patient #1's Physician Order dated 10/12/15 at 3:34AM for a Behavior Management Restraint (Soft wrist 2 point and soft ankle 2 point. Restraint Duration: "Maximum of 4 hours (Adults with aggressive behavior);" he stated, "that's the first time I have seen that" and further stated he had not seen or heard of a 4 hours maximum amount of time for restraints. RN A stated he was "not sure" if he needed a new physician order to re-implement a restraint after the initial one was discontinued. RN A stated that he believed the first order would cover the restraints up to 24 hours. RN A stated if he received a verbal order from a physician that it was his responsibility to ensure the written order was obtained and evidenced in the patient's record. RN-A stated that if a patient was asleep he could leave the restraints on. RN A stated that when a patient was in restraints 15 minute documented checks/assessments were completed by the RN; along with continuous video monitoring completed by a technician who monitored live video. RN A stated it was up to the RN's assessment and judgment as to how long a patient stays in restraints. RN A indicated he rarely worked the psychiatric side of the Emergency Department (ED) and did not know the specific policies and procedures regarding restraints for violent/behavioral incidents.

Interview on 04/04/16 with RN-Risk Management confirmed after review of Patient #1's record that there was no Physician Order for the second 4 point restraint; 2 wrist and 2 ankle implemented on 10/12/15 at 15:28.

Interview on 04/04/16 at 3:50 PM with RN/ED Director stated the maximum amount of time a patient can be restrained for a behavior restraint was for 4 hours and a medical (non-violent/safety) restraint was 24 hours. The RN/ED Director stated any further restraints required another Physician Order and Medical Doctor assessment. The RN/ED Director stated a verbal order is not allowed for restraints; and if a restraint is discontinued; and another (2nd) is implemented you would need another physician order to implement. RN/ED Director stated that if a patient was asleep while in restraints then it was up to the assessing RN's judgment for release. RN/ED Director indicated that if a patient was medicated along with the physical restraint that you would want to await until the patient wakes up to remove restraints; in order to complete an assessment prior to removing the restraint.

Interview conducted during the exit conference on 04/05/16 at 12:25 PM with the Director of Quality Improvement (QI) and Accreditation confirmed the following findings as evident by Patient #1's record:

A.) Patient #1's first restraint implemented on 10/12/15 at 02:30 AM was not removed until 07:30 AM; 5 total hours in duration. The PO for restraint included the time limit maximum of 4 hours.

B.) Patient #1's second restraint implemented on 10/12/15 at 15:28 to 19:30 (just over 4 hours) was implemented without another physician order in the record.

C.) Documentation of Patient #1's Observation records during restraint documented him being asleep and remained in restraints.