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.

PEACEHEALTH SOUTHWEST MEDICAL CENTER 400 NE MOTHER JOSEPH PLACE VANCOUVER, WA 98668 Sept. 6, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to ensure that the use of restraints, for violent behavior was in accordance with the order of a provider or other licensed independent practitioner (LIP) responsible for the care of Patient #1, as required by hospital policy.

Failure to obtain an order from the responsible provider before initiating restraints for violent behavior can lead to possible abuse, assault, self injury or poor patient outcome.

Findings include:

1. Review of a hospital's policy titled, "Restraint and Seclusion Procedure," dated 8/30/17, showed that the policy will ensure patient's basic rights and also protects the safety of patients, staff, and others. The policy guides staff on clinical justification, documentation, the use of less restrictive measures/documentation, plan of care, and orders/evaluations. Once a patient is determined to warrant the use of restraints, the nurse obtains an order from the licensed independent practitioner (LIP) before initiating restraints (except during an emergency, when an LIP is not available). LIP provides a time limited order for violent behavior restraints and may only be renewed in accordance with specific age criteria, 24 hours total. Patients >[AGE] years old, the order does not exceed 4 hours and for patients 9 - [AGE] years old, the order does not exceed 2 hours. Patient < 9 years old, the order does not exceed one (1) hour. For all restraint patients, after 24 hours, the primary LIP must see and assess the patient before entering a new restraint order.

2. Review of the Patient #1's medical record showed a [AGE] year old with a past medical history for autism, bipolar disorder, and developmentally delayed (functional skills appear to range from 18 mons - 3 yr. old). The patient is largely non-verbal. He has experienced recurrent ED encounters for aggressive behavior and violence towards family members. During each ED encounter, the patient was triaged, assessed, underwent diagnostic testing, and after he was medically cleared, staff switched him to observation status in the ED. Records showed that the patient's length of observation(s) varied, from 3 hours to 69 days (one encounter). The hospital discharge staff found it challenging to find permanent placement for this patient. The patient is generally transported by emergency management services (EMS), who may or may not be in 4 point restraints. The record was reviewed for violent restraint use during eight (8) separate ED encounters from 2/25/17 to 12/4/17. Documentation showed that orders entered from an ED practitioner or other licensed independent practitioner (LIP) for use of restraints during the patient's violent behavior was not in accordance with hospital policy. Records showed that the patient's violent behavior warranted restraint use during thirty - one (31) separate episodes. Review of the patient's restraint log revealed the following:
a. Orders for violent patient, restraint/seclusion, 4- point, the incorrect age criteria was entered for four (4) separate restraint episodes, which included orders for a patient >18 years and older allowing restraint use for 4 hours (Patient #1 is [AGE] year-old).

b. Orders for violent patient, restraint/seclusion, 4-point, the restraint duration was entered incorrectly for six (6) restraint episodes, which included orders for continuous restraint use greater than 2 hours (4 hours, 24 hours, 1 day, etc.).

c. Patient #1 was placed in 4-point restraints for violent behavior twice (2) without an LIP order.

d. Orders for violent patient, restraint/seclusion, 4-point, the LIP enter orders for a patient 9 - [AGE] years old, not to exceed 2 hours, however, Patient #1 remained in restraints >2 hours without an LIP assessment or new order, for two (2) separate restraint episodes.

e. During three (3) separate restraint episodes, review of nursing documentation showed the time 4-point restraints were applied on Patient #1 was not entered or discontinued (release) restraint time was also not entered.

3. During an interview on 9/5/18 at 11:25 AM, Staff A, Regulatory Accreditation Consultant, stated that she confirmed, with the hospital's clinical education department that all direct care staff receive training for restraints and seclusion upon hire, than annually. The training includes restraint documentation.

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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to ensure staff performed and documented a one hour face-to-face evaluation during use of restraints on patients displaying violent behavior, for 5 of 10 records reviewed (Patients #1, #2, #3, #4, #5).

Failure to perform or document a one hour post application, evaluation on a patient during simultaneous use of restraints for violent behavior can lead to possible abuse, assault, self injury or poor patient outcome.

Findings include:

1. Review of a hospital's policy titled, "Restraint and Seclusion Procedure," dated 8/30/17, showed that the policy will ensure patient's basic rights and also protects the safety of patients, staff, and others. The policy guides staff on clinical justification, documentation, and use of less restrictive measures/documentation. Once a patient is determined to warrant the use of restraints, the nurse obtains an order from the licensed independent practitioner (LIP) before initiating restraints. However, for violent behavior, an evaluation is conducted within one hour of initiation of restraint, even if the patient is no longer in restraints. The LIP, PA, or trained nurse will perform and document an in-person assessment to determine the continuing need for restraints and contributing factors that lead to the unsafe behavior. The policy outlines specific documentation included in the one hour assessment, which includes: the patient's immediate situation, patient's reaction to the intervention, patient's medical/behavior condition, and the need to continue or discontinue restraints. The LIP performs an in person assessment prior to entering a new order for continued use of restraints. Nursing staff also performs and documents a physical/behavioral assessment one hour of restraint initiation, for violent behavior.

2. Review of the Patient #1's medical record showed a [AGE] year old with a past medical history for autism, bipolar disorder, and developmentally delayed (functional skills appear to range from 18 mons - 3 yr. old). The patient is largely non-verbal. He has experienced recurrent ED encounters for aggressive behavior and violence towards family members. During each ED encounter, the patient was triaged, assessed, underwent diagnostic testing, and after he was medically cleared, staff switched him to observation status in the ED. Records showed that the patient's length of observation(s) varied, from 3 hours to 69 days (one encounter). The hospital discharge staff found it challenging to find permanent placement for this patient. The patient is generally transported by emergency management services (EMS), who may or may not be in 4 point restraints. The record was reviewed for violent restraint use during eight (8) separate ED encounters from 2/25/17 to 12/4/17. Documentation showed that the patient's violent behavior warranted restraint use during thirty - one (31) separate episodes. The ED practitioner's documentation describing the one hour post initiation assessment, which must include the patient's immediate situation, patient's reaction to the intervention, patient's medical/behavior condition, and the need to continue or discontinue restraints, could not be found within 29 of the 31 restraint recorded encounters, as required.

a. Similar missing one hour face to face LIP assessments were observed in the records for: Patients #2, #3, #4, #5.

3. During an interview on 9/5/18 at 1:25 PM, Staff A, Regulatory Accreditation Consultant, stated that she looked at the LIP order(s) for Patient #1's restraint use and found located within the violent restrain order, the LIPs entered "yes" to the question has the face to face been performed within one hour for each restraint episodes. However, she confirmed that the detailed restraint documentation was missing.

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