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METHODIST HOSPITAL 7700 FLOYD CURL DR SAN ANTONIO, TX 78229 March 21, 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.

Findings Include:

1. Review of the hospital policy entitled, "Patient Restraint/Seclusion (includes Mental Health Service Units)," on 03/21/18 at 12:45 p.m. with S#1 in the office of the Chief Medical Officer 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 may 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.

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. In an interview of S#1 on 03/20/18 at 2:18 p.m. in the office of the Chief Medical Officer, a review of the medical record for restraint documentation with S#1 revealed the following in part and was confirmed by S#1 at that time:

There was no restraint documentation in the medical record on 07/01/17 after 0004 until 0109, no documentation from 0109 until 2000 and no documentation that the restraint had been removed between 0109 and 2000.

The medical record contained a physician order for soft limb holders dated 07/01/17 at 9 p.m. There was no restraint documentation from 07/01/17 2000 until 07/05/17 when a second tier review was recorded at 1242.

It could not be determined whether the restraint order on 07/01/17 at 9 p.m. was an initial order or a renewal order for an ongoing need for the restraints.

2. b. In an interview of S#1 on 03/21/18 at 9:20 a.m. in the office of the Chief Medical Officer, a review of the medical record with S#1 revealed the following in part and was confirmed by S#1 at that time:

The restraint documentation for 06/30/17 at 2340 did not include a second tier review, the date and time the restraint was applied, the type of restraint, restraint device, safe application and least restrictive verified. A second tier review was not performed until 07/05/17. S#1 confirmed this should have been performed within a couple of hours after the restraint assessment on 06/30/17.

The restraint documentation for 07/01/17 at 0004, for 07/01/17 at 0109, and for 07/01/17 at 2000 did not include a second tier review, the date and time the restraint was applied, the type of restraint, restraint device, safe application and least restrictive verified, safety/rights/dignity was maintained or when criteria for restraint release was met and the date and time the restraint was discontinued.

The restraint documentation for 07/01/17 at 0004 and at 0109 noted "Alternatives Successful: Yes" but there was no documentation that the restraints were discontinued.

Safety/risk regulatory documentation for 07/01/17 at 2000 recorded at 2014 noted the following:

"Patient grabbed breakfast knife and tried to cut her wrists,"
"Recent self harm/suicide attempt: Yes"
"Method of self harm: Cutter"
"Warning signs of acute risk: Severe anxiety/agitation"
"Additional warning signs: Helpless/feeling trapped"

According to S#1, there was no electronic or paper documentation at the time the patient was admitted for any patient with restraints regarding safety checks by a sitter and sitters could not document in EBCD (Evidence Based Clinical Documentation).

2. c. In an interview of S#1 on 03/21/18 at 12:45 p.m. in the office of the Chief Medical Officer, a review of the medical record and the hospital's policy and procedure on restraints with S#1 revealed the following in part and was confirmed by S#1 at that time:

The facility did not follow their own policy and procedures regarding restraints because the medical record:

Did not include documentation by a nurse that a second tier review was done until 07/05/17 (5 days after a restraint assessment on 06/30/17 indicated alternatives were not successful and the patient would be safer in restraints than not)

Did not include documentation by a nurse of the date and time and restraint device applied/initiated

Did not include documentation that family were notified of restraint use

Did not include documentation that patient and family were educated regarding restraint use
Did not include documentation 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 patient's rights and dignity were maintained

Did not include modifications of the plan of care

Did not include physician notification of changes in the patient's condition

Did not include documentation by a nurse of the date and time the restraint was removed/terminated

The exact date and time that the restraints were applied/initiated and removed could not be determined due to lack of nursing documentation.

The provider's telephone/verbal order dated 6/30/17 at 2338 for "2 point BUE restraints," and signed by a physician on 7/2/17 did not specify whether it was a telephone order or a verbal order or that it was read back to the physician as per hospital policy. The order did not include the clinical justification, did not specify the restraint device, did not include the duration of use, did not include the type of restraint, did not include behavior-based criteria for release and was not noted by the nurse.

The physician order titled, "Restraint for Non-violent/Non-self Destructive Behavior dated 7/1/17 at 9 p.m. for "soft limb holders right left" and signed by a physician did not include the clinical justification, did not specify whether it was an initial order or renewal order, did not include the duration of use, did not include behavior-based criteria for release and was not noted by the nurse.