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METROSOUTH MEDICAL CENTER 12935 S GREGORY BLUE ISLAND, IL 60406 April 5, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined for 2 of 5 (Pts #1 and #7) clinical records reviewed for patients with restraints, the Hospital failed to ensure restraints were ordered by the physician or Licensed Independent Practitioner (LIP). The could potentially impact all patients in restraints or seclusion.

Finding include:

1. The Hospital's policy entitled, "Restraint and Seclusion Policy" (effective 2/3/15), was reviewed on 04/04/16 at approximately 11:00 am and required, "...The Physician or Licensed Independent Practitioners (LIP) responsible for the care of the patient is authorized to order a restraint...Orders should: a) Be for each use of the restraints and related to a specific episode of the patient's behavior and not for an unspecified future time or episode..."

2. The clinical record for Pt #1 was reviewed on 4/4/16 at approximately 10:00 am. Pt #1 was a [AGE] year old female who presented to the Hospital's emergency department (ED) on 3/3/16 at approximately 1:16 pm with a diagnosis of bipolar disorder. The clinical record indicated Pt #1 was combative and threatening to staff on arrival to the ED. The nurse's (E #4) note dated 3/3/16 indicated Pt #1 was placed in 4 point locked restraints for violent behavior at 1:30 pm, and restraints were removed at 2:00 pm. The clinical record lacked a physician's or LIP's order for restraints.

3. The clinical record for Pt #7 was reviewed on 4/5/16 at approximately 11:00 am. Pt #7 was a [AGE] year old male who present to the Hospital's ED on 3/3/16 at 6:19 pm for a psychiatric evaluation following a violent altercation with his girlfriend. The nurse's (E #4) note indicated Pt #7 was placed in 4 point locked restraints for violent behavior at 6:50 pm. The clinical record lacked a physician's or LIP's order for restraints.

4. The ED Manager stated, during an interview on 4/5/16 at approximately 12:00 pm, the clinical records for Pt #1 and Pt #7 did not contain an order for restraints, and an order from the physician or LIP is required for the use of restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review and interview, it was determined that the Hospital failed to ensure the restraint and seclusion policy included intervals for assessment and monitoring of patients in restraints or seclusion. This could potentially impact all patients in restraints or seclusion.

Findings included:

1. The Hospital's policy entitled, "Restraint and Seclusion Policy" (effective 2/3/15) was reviewed on 4/4/16 at approximately 11:00 am and required, "...H. Periodically Assessing, Assisting and Monitoring the Patient in Restraint or Seclusion...v) A qualified Registered Nurse must assess the patient at established timeframes. Assessment, as appropriate to the type of restraint or seclusion... Documentation...ix) All assessments and monitoring of the patient..." The policy did not include the type of monitoring or frequency of assessments required for each type of restraint or seclusion.

2. During an interview with the Chief Quality Officer (E #8) on 4/5/16 at approximately 11:30 am, E #8 stated the policy was a corporate policy which implies the ongoing assessment of the patient in restraints or seclusion but did not include requirement for monitoring or intervals for assessments.


B. Based on document review and interview, it was determined for 2 of 3 (Pt #1 and Pt #7) clinical records reviewed for patients in locked 4 point restraints for the management of violent or self-destructive behavior, the Hospital failed to ensure the patients were observed continuously while in locked restraints. The could potentially impact all patients in restraints or seclusion.

Findings include:

1. The Hospital's education course entitled, "Restraint Use The RN's Role" (2012), was reviewed on 4/5/16 at approximately 1:00 pm and included, "Violent/Self Destructive Patient...Monitoring and documentation must be done every 15 minutes while restrained...A sitter (patient observer) MUST remain at the bedside throughout restraint episode..."

2. The clinical record for Pt #1 was reviewed on 4/4/16 at approximately 10:00 am. Pt #1 was a [AGE] year old female who presented to the Hospital's emergency department (ED) on 3/3/16 at approximately 1:16 pm with a diagnosis of bipolar disorder. The clinical record indicated Pt #1 was combative and threatening to staff on arrival to the ED. The nurse's (E #4) note dated and timed indicated Pt #1 was placed in 4 point locked restraints for violent behavior at 1:30 pm, and restraints were removed at 2:00 pm. The clinical record lacked documentation that a sitter was at the bedside while restraints were in place.

3. The clinical record for Pt #7 was reviewed on 4/5/16 at approximately 11:00 am. Pt #7 was a [AGE] year old male who presented to the Hospital's ED on 3/3/16 at 6:19 pm for a psychiatric evaluation following a violent altercation with his girlfriend. The nurse's (E #4) note indicated Pt #7 was placed in 4 point locked restraints for violent behavior at 6:50 pm. The clinical record lacked documentation of the following: a sitter was at the bedside while restraints were in place; every 15 minute documentation while restrained; and the time the restraints were discontinued.

4. During an interview on 4/5/16 at approximately 12:00 pm, the ED Nurse Manager stated any patient in locked restraints requires 1:1 observation while in restraints. The presence of a sitter should be documented in the nurse's notes.

5. During an interview with the Chief Quality Officer (E #8) on 4/5/16 at approximately 11:30 am, E #8 stated the RN should have documented when the restraints were discontinued and the monitoring while in restraints.