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PSYCHIATRIC INSTITUTE OF WASHINGTON DC 4228 WISCONSIN AVENUE, NW WASHINGTON, DC July 12, 2013
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0187
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on the review of 10 medical records, hospital policy, staff interviews and the review of the video surveillance tape dated September 30, 2012, it was determined that facility staff failed to follow hospital policy # NSG.081 entitled " Restraint and Seclusion " , as it pertains to documentation of Patient #1 ' s behaviors that required the physical hold of an extremity during the administration of an intramuscular medication in an isolated incident.

The findings include:

Policy Number: NSG.081 entitled Restraint and Seclusion, revised September 12, 2012
Section three (3) Definitions, Items three (3) and five (5); Section six (6) item one (1) stipulates:
" ...PHYSICAL HOLD FOR ADMINISTRATION OF IM MEDICATION is when a patient behaviorally demonstrates the need for a IM medication and is not willing to have the injection administered. In order to determine if the injection should be in the arm or hip, the patient is to be asked for his/her preference. The patient's physical condition or limitations must be taken into account. Injections may be given in a standing or seated position as long as the site is briefly immobilized...

CHEMICAL RESTRAINT is a drug administered intramuscularly and used to control behavior or to restrict the patient's freedom of movement. Chemical restraint is not a standard treatment for the patient's medical or psychiatric condition and cannot be ordered PRN ....

PROCEDURE FOR INITIATION OF RESTRAINT AND/OR SECLUSION

Item 1. When the use of mechanical restraints, chemical restraints, physical holding, or seclusion is needed, the attending physician, an LIP, or the Nursing Supervisor must document a face-to-face assessment prior to applying restraints and/or initiating seclusion, document the rationale, and write the order.


DOCUMENTATION OF PHYSICAL HOLD, SECLUSION AND/OR RESTRAINT-
Item 2. Each episode of physical hold, restraint and/or seclusion use is to be recorded in the medical record. Documentation by a nurse at the times of restraint/seclusion will include:
Physical Hold/Seclusion/Restraint blue packet form. Nurse ' s initial assessment and conditions for release. Followed by nurse ' s assessment every 15 minutes until procedure is terminated.
Justification for Restraint/Seclusion Section of packet. Nurse documentation will include: The circumstances that led to the use of Justification for physical hold/restraint/seclusion (patient harm to self or others) ... "

Patient #1 was admitted on [DATE] with diagnoses of Major Depressive Disorder with Psychotic Features, Suicide Ideations, Poly-substance Dependence and Human Immunodeficiency Virus.

Review of the medical record starting July 12, 2013 revealed Employee #4 transcribed a telephone (verbal) " Injection Order " for Thorazine 100 milligrams from the physician on September 30, 2012 at 10:03 AM. The order was entitled " Physician ' s Emergent Order " .

Review of the Routine Medication Administration reflected that the medication was administered at 10:15 AM. Employee # 4 documented the reason for the medication " severe agitation. "

The Emergent Injection form reflected interventions attempted for the patient prior to obtaining an order for the Thorazine injection.

Review of the surveillance video dated September 30, 2012, PIW 3-3 Quite Room (QR) between 10:14 AM and 10:18 AM revealed, that four (4) employees to include Employee #9 who initially entered the Quite Room to assist Employee # 4 with the injection for Patient #1.
When Employee # 4 administered the injection at 10:17:04 there were five (5) employees around the patient who was prone on the mattress; one (1) of the five (5) employees was holding the patient ' s left lower extremity (ankle). According to the documented time on the surveillance video the encounter lasted until 10:17:21, a total of seventeen seconds.

The medical record lacked documented evidence of how the patient ' s behavior was a significant threat of imminent danger to self or others. The medical record lacked documented evidence of the signs and symptoms of the agitation and threatening behavior the patient was said to be exhibiting.

The nursing staff failed to document in the medical record, the justification for the physical hold to the left lower extremity and signs and symptoms of behavior exhibited.

A face to face interview with Employee # 4 that administered the injection was conducted on July 12, 2013 at approximately 11:45 AM. Employee # 4 stated that the encounter was not a physical hold; " it was for an emergent injection. The staff hands were over the patient, they did not hold the patient down " .

Employee # 4 further stated, " The patient started acting up early that morning, not following directions, agitated threatening staff and peers, threatened to harm [his/her] roommate. Patient #1 could not be redirected and she would not listen to me and other staff. The staff tried to de-escalate the situation and attempted conflict resolution, but the patient would not listen " . The aforementioned information was not documented in Patient #1 ' s medical record.
On July 15, 2013 at 1:26 PM and 2:46 PM, telephone interviews were conducted with two (2) Psychiatric Technicians (Employees #7 and #8). Both technicians response was the encounter " was not a physical hold " . The technicians stated, " hands were laid over and on the patient without gripping, holding or force " . Employee #7 stated she/he " did not touch the patient " and Employee #8 stated about five (5) staff gently touched the patient.

In summary observation of the surveillance video, provided by the hospital, confirms that Employee #9 held Patient #1 ' s lower extremity during the administration of an intramuscular injection. The record failed to detail the behavior that warranted the physical hold.