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METHODIST HOSPITAL 7700 FLOYD CURL DR SAN ANTONIO, TX 78229 March 23, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on record review and interviews the hospital failed to ensure the use of restraints were implemented in accordance with safe and appropriate restraint techniques determined by hospital policy to ensure patients' rights for 1 of 1 patient (Patient #1) reviewed with a patient rights complaint after the implementation of restraints used for the management of a danger to self/others.

Findings Include:

1. Review of the hospital policy entitled, "Patient Restraint/Seclusion (includes Mental Health Service Units)," on 03/07/18 at 3:35 p.m. in the conference room revealed the following in part:

PROCEDURE:
1. a. The Registered Nurse (RN) performs an assessment for risk for restraint or seclusion when a patient exhibits behavior that my place the patient at risk for restraint or seclusion.

3. The RN determines that alternatives to restraint or seclusion have failed and that the patient will be safer in restraints than continuing without restraint.

4. A member of nursing administration/management (e.g., nursing supervisor, manager/director, CNO, etc.) will review the need for restraint or seclusion with the RN who has determined that the patient requires restraint or seclusion. The second tier of review will occur with the initial application of restraint or seclusion.

Note: In an emergency application of the restraint or seclusion, the above review will be done immediately after the application of restraint.

5. Order for Restraint or Seclusion
a. An order for restraint or seclusion must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release.

5B. Order for Restraint with Violent or Self Destructive Behavior
a. Physician orders for restraint or seclusion must be time limited, and must specify clinical justification for the restraint or seclusion, the date and time ordered, duration of restraint or seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint or seclusion must not exceed:
1. 4 hours for adults, aged 18 and older

6. Application of Restraints
b. The patient is informed of the purpose of the restraint or seclusion and the criteria for removal.
c. The patient's family is informed of restraint or seclusion use, the purpose of the restraint or seclusion and the criteria for removal.

7. Monitoring the Patient in Restraints or Seclusion
a. Patients are assessed by an RN immediately after restraints or seclusion are initiated to assure safe application/initiation of the restraint or seclusion.
b. An RN will assess the patient at least every 2 hours.
d. A trained staff member monitors each patient in restraint or seclusion at least 3 times an hour for safety, and to confirm that the patient's rights and dignity are maintained. This check will be documented in either electronic record or on paper.

10. Care of the Patient/Plan of Care.
a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications.

11. Discontinuation of Restraint or Seclusion:
c. Once restraints or seclusion are discontinued, a new order for restraint or seclusion is required to reapply or reinitiate.

12. Documentation Requirements:
The medical record contains documentation of:
a. Assessment for risk for restraint or seclusion
b. Restraint or seclusion alternatives employed
c. Determination of effectiveness/ineffectiveness of restraint or seclusion alternatives
d. Second tier review of need for restraint or seclusion
e. Order for restraint or seclusion and any renewal orders for restraint or seclusion
f. Restraint or seclusion application/initiation
g. Family notification of restraint or seclusion use
h. Patient and family education regarding restraint or seclusion use
i. Assessment of the patient in restraint or seclusion
j. Monitoring of the patient in restraint or seclusion
k. Medical and behavioral evaluation for restraint or seclusion management of violent or self-destructive behavior
l. Modifications of the plan of care
m. Physician notification of changes in patient condition
n. Restraint or seclusion removal/termination

2. a. Review of the medical record on 03/07/18 beginning at 3:00 p.m. in the conference room revealed that the medical record did not contain documentation:

That an RN performed an assessment for the risk for restraint or seclusion
Of restraint or seclusion alternatives employed
That an RN determined alternatives to restraint or seclusion failed and the patient would be safer in restraints than continuing without a restraint
That a second tier review was done
That restraint or seclusion was applied/initiated
That family were notified of restraint or seclusion use
That patient and family were educated regarding restraint or seclusion use
That the patient was assessed by an RN immediately after restraints were initiated to assure safe application/initiation of the restraints or that a trained staff member monitored the patient in a restraint at least 3 times an hour for safety and to confirm the patients rights and dignity were maintained
Of modifications of the plan of care
Of physician notification of changes in the patient's condition
Of restraint or seclusion removal/termination.

2. b. The medical record did not contain any documentation by a nurse after an Admission/Shift Assessment that occurred on 10/10/17 at 0000 and recorded at 0035. The last assessment by a nurse documented "Cardiac monitor: Present/Exists, Monitored heart rhythm: Normal sinus rhythm" and Abdomen: Tenderness: with palpation: Location: epigastric, Bowel sounds normal-active in all 4 quadrants, Nausea: None, and Vomiting/Dry heaving: None." There was no documentation in the medical record by a nurse regarding the use of restraints. The exact time that the restraints were applied/initiated and removed could not be determined due to lack of nursing documentation.

The physician order dated 10/10/17 at 0345 listed the restraint device as "seclusion restraint," and not "4 pts" as noted under A/P of the physician's consult note dated 10/10/17 at 0346.

3. a. In an interview on 03/08/18 at 9:42 a.m. in the conference room, the restraint order given at 0345 was reviewed with S#7. S#7 was asked about restraint documentation by a nurse. S#7 agreed that there should have been documentation by a nurse regarding the order for restraint at 0345 and stated, "If the order was at 0345, there should be something that they initiated a restraint." S#7 confirmed there was no restraint assessment on 10/10/17.

3. b. In a telephone interview on 03/22/18 at 3:06 p.m., S#2 stated, "The patient is not on the restraint log," and confirmed that following S#2's own review of the medical record that there was no documentation in the medical record as to the time restraints were applied or the time the restraints were released and no documentation by a nurse in the medical record about restraints.

3. c. During the exit conference on 03/23/18 at 8:20 a.m. in the conference room, S#2 confirmed the following:

The patient was not on the hospital's restraint log.

The medical record did not contain documentation by a nurse after the shift assessment on 10/10/17 that occurred at 0000 and recorded at 0035, did not contain documentation by a nurse regarding restraints.

The medical record did not contain documentation as to when the patient's IV was removed and by whom.

The medical record did not contain documentation according to the hospital's restraint policy and procedure including an assessment for risk for restraint or seclusion, restraint or seclusion alternatives employed, determination of effectiveness/ineffectiveness of restraint or seclusion alternatives, a second tier review of the need for restraint or seclusion, restraint or seclusion application/initiation, family notification of restraint or seclusion use, patient and family education regarding restraint or seclusion use, assessment by an RN of the patient in restraint or seclusion, monitoring of the patient in restraint or seclusion, modifications of the plan of care, physician notification of changes in patient condition and restraint or seclusion removal/termination.

The physician restraint order listed the restraint device as "seclusion restraint," and not "4 pts" as noted in the physician's consult note.

S#2 agreed that the nurse should have put a note in the medical record regarding restraints.