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MEDICAL CITY DENTON 3535 SOUTH I35 EAST DENTON, TX 76210 July 2, 2012
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
Based on review of documents and interview with staff, the facility did not ensure that the orders for physical restraint were in accordance with the required limits for 2 of 5 patients whose records were reviewed. Patient #1 and Patient #2, both adults, were physically restrained for combative behavior requiring an order renewal every 4 hours; these orders were not obtained.

Findings were:

The hospital's restraint policy, entitled PATIENT RESTRAINT/SECLUSION, last approved in February 2012, states under the section entitled PROCEDURE, the RN assessment of a patient who may need restraints includes whether the patient understands that he/she should not remove medical devices, and/or whether or not the patient understands the need to remain immobile. The RN assessment also includes determining if a patient is exhibiting aggressive, combative, or destructive behavior that places the patient or staff in immediate danger. Section 5A outlines the requirements for physician orders for restraint needed for non-violent behavior, such as the need to remain immobile or to leave medical devices undisturbed. In these cases, the physician orders are required at least every 24 hours. To continue restraint beyond the initial order duration, the physician or Licensed Independent Practitioner (LIP) must see the patient and perform a clinical assessment to determine if continuation of restraint is necessary at least each calendar day. Section 5B outlines the requirements for physician orders for restraint for violent or self-destructive behavior; the order must not exceed 4 hours for adults, aged 18 years and older. To continue restraint or seclusion beyond the initial order duration, the RN determines that the patient is not ready for release and calls the ordering physician to obtain a renewal order that does not exceed 4 hours for adults.

Review of the medical record for Patient #1 revealed that the patient required the use of restraints for combative behavior from 5/13/2012 - 5/15/2012. Beginning at 2:40 pm on 5/13/12, nursing notes indicated that the patient was getting out of bed and wanting to leave. Patient #1 ripped all the EKG monitoring leads off and began to punch the sitter. Soft restraints were applied to arms and legs, and the physician was notified. Nursing notes for 5/14/12 state that the patient " continuously moves self in bed even in restraints ....attempted to bite me while administering medication ....patient physically abusive. " On 5/14/2012, an order for non-violent restraints was written by the physician at 8:15 am. The 2nd restraint order for non-violent behavior was obtained the next morning, 5/15/12. The facility considered Patient #1 as a " non-violent " patient who needed restraints for " non-violent " behavior every 24 hours; therefore, orders for violent behavioral restraints were not obtained per facility policy: There was no initial order at the time of initiation of restraints the afternoon of 5/13/12, nor were there renewal orders every 4 hours based on nursing assessments of the need to continue the restraints.

Review of the medical record for Patient #2 revealed that the patient required restraints for combative behavior 4/28/2012 between the hours of 6:20 pm and 2:00 am, 4/29/12. Nursing notes indicate that at 6:20 pm on 4/28/2012, the patient was combative with physical aggression, and attempting to remove medical devices. At 7:20 pm, a " code yellow " was called because the patient was combative during nursing intervention and they required additional security staff. An initial physician order for non-violent restraint was obtained at the initiation of restraints for the duration of 24 hours, not the required 4 hours per combative behavioral restraint requirements.

These findings were acknowledged by the facility Vice President of Human Affairs and the Director of ICU in a joint in-person interview conducted the afternoon of 7/2/2012.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0205
Based on review of documentation and interview with staff, the facility failed to ensure that staff monitored the physical and psychological well-being of 2 of 5 patients placed in restraints for combative behavior. Patient #1 and Patient #2 were placed in restraints and were not monitored every 20 minutes according to facility procedure.

Findings were:

The hospital's restraint policy, entitled PATIENT RESTRAINT/SECLUSION, last approved in February 2012, states that restraints used for non-violent behavior, such as a patient who pulls at tubes and devices, must be monitored at least every 2 hours. For those patients in restraints for violent behavior, the policy does not specify the timeframe required for monitoring. The staff training documents state that that patients should be monitored three times an hour (every 20 minutes) if in behavioral restraints, including documenting any changes in behavior, signs of injury, the alternatives attempted, and the patient's readiness for release from restraint.

Review of the medical record for Patient #1 revealed that the patient required the use of restraints for combative behavior from 5/13/2012 - 5/15/2012. Beginning at 2:40 pm on 5/13/12, nursing notes indicated that the patient was getting out of bed and wanting to leave. Patient #1 ripped all the EKG monitoring leads off and began to punch the sitter. Soft restraints were applied to arms and legs, and the physician was notified. Nursing notes for 5/14/12 state that the patient " continuously moves self in bed even in restraints ....attempted to bite me while administering medication ....patient physically abusive. " Review of restraint documentation indicates that Patient #1's restraint status was monitored every 2 hours while the patient was restrained 5/13/12-5/15/12, not every 20 minutes as required by facility procedure for patients placed in restraints due to combative or violent behavior.

Review of the medical record for Patient #2 revealed that the patient required restraints for combative behavior 4/28/2012 between the hours of 6:20 pm and 2:00 am, 4/29/12. Nursing notes indicate that at 6:20 pm on 4/28/2012, the patient was combative with physical aggression, and attempting to remove medical devices. At 7:20 pm, a " code yellow " was called because the patient was combative during nursing intervention and they required additional security staff. Review of restraint documentation indicates that Patient #2's restraint status was monitored every 2 hours while the patient was restrained for combative behavior, not every 20 minutes as required by facility procedure.

These findings were acknowledged by the facility Vice President of Human Affairs and the Director of ICU in a joint in-person interview conducted the afternoon of 7/2/2012.