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AU Medical Center 1120 15TH STREET AUGUSTA, GA 30912 March 7, 2019
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record reviews, policies and procedures, and staff interviews, the facility failed to ensure that the facility protected and promoted patient's rights.

Specifically, the facility: -

Failed to renew the violent behavior restraint order every four (4) hours.
Failed to keep the patient on violent behavior restraints for no more than 24 hours.
Failed to document the type of violent restraint utilized.
Failed to monitor the patient every 15 minutes while the patient was on violent behavior restraints.
Failed to include the rationale for the continued use of violent restraints.

Findings were:

Review of Medical record #5 revealed that Patient #5 was admitted on [DATE] at 9:57 a.m. with diagnoses of seizure and altered mental status. Patient #5 had a history of lung cancer with brain metastases (the spread of cancer to other areas of the body), stroke secondary to carotid stenosis (narrowing of blood vessels in the neck). Patient #5 was transferred from the Emergency Department (ED) to the Neurological Intensive Care Unit.
On 02/22/19 at 11:56 a.m. Patient #5 was transferred to the Medical-Surgical Unit.
On 02/24/19 at 6:20 p.m. non-violent soft wrist restraints were ordered for Patient #5 for increased agitation with the bedside sitter.
On 02/24/19 at 9:44 p.m. Patient #5 was placed on violent restraints due to kicking the nurse and sending her to the ED.
On 02/25/19 at 11:57 a.m. the nurse's notes revealed that the patient was drowsy but arousable. No distress was noted and violent restraints in place.
On 02/26/19 at 12:52 p.m. the nurse's notes revealed that Patient #5 was in bed resting quietly and that the violent restraints had been discontinued.
The restraint monitoring flowsheet revealed that every 15 minutes the Patient #5 was monitored from 02/24/19 9:45 pm until 11:00 p.m. No documentation was noted again until 02/25/19 at 4:00 a.m. Another violent restraint order was placed on 02/25/19 at 4:17 a.m. and stated it was re-entered because the previous order disappeared. The flowsheet further revealed that documentation only occurred every two hours from 02/25/19 at 4:00 a.m. until 02/26/19 at 12:52 p.m. with violent restraint orders active. All documentation on the flowsheet revealed the patient was on bilateral soft wrist restraints, however, the nurse's notes indicated the patient was on four-point restraints.
Review of facility policy Acute Care Restraints and Seclusion, policy number 942, last revision date 08/26/2016, revealed the purpose of the policy was to ensure that all patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.
Restraint or seclusion will only be implemented when least restrictive methods have been employed and/or are determined ineffective for preventing patients from interfering with medical regimens (non-violent/non-self-destructive) or harming themselves or others (violent/self-destructive). The two (2) types of restraints are broken down:
--The Non-Violent/Non-Self-Destructive designation applies when the clinical justification for applying restraints is to support medical healing or protect the patient from harm. For example, the patient may try to pull out lines or tubes or has a fracture requiring restricted mobility, and less-restrictive methods haven ' t worked.
--The Violent/Self Destructive designation applies when the patient is exhibiting violent, destructive, or aggressive behavior that presents an immediate, serious danger to the patient or others, and the patient has no lines or tubes that could be pulled out nor any other health problem requiring restricted mobility. Restraints or seclusion may be used for violent/self-destructive reasons.

The policy further revealed that requirements of documentation for the time period prior to restraining or secluding the patient:
1) Description of the potential risk for the patient ' s behaviors, staff concerns for safety, risk to the patient, staff, and others that necessitated the use of restraint or seclusion
2) Identification of interventions that were implemented prior to restraining or secluding
3) An evaluation of the failed measures that were implemented.
4) All new orders for violent/ self-destructive restraint or seclusion are time limited with a maximum time period of 24 hours.
5) Adults (18 years of age or older) a renewal order is required every 4 hours.
6) Monitor and document a minimum of every 15 minutes:
--a. Patient ' s behavior, mental status, and readiness for release
--b. Reinforcement of teaching of behaviors needed for early release
as applicable and if practical and safe to do so.
--c. Check circulation, motor, and sensory function below the level of restraint as applicable and if practical and safe to do so.

An interview with the Manager of Regulatory (staff member MR GG) on 03/06/19 at 12:45 p.m. in the Quality Management conference room revealed that violent restraints are ordered for violent behavior and it did not matter what the actual type of restraint is. MR GG stated that a patient ' s behavior determines why a patient is placed in violent restraints. MR GG further stated that usually soft wrist restraints are used for non-violent behavior and nylon or leather restraints for violent behavior. MR GG confirmed the above findings and stated the documentation was sub-optimal on the physician ' s ordering of the violent restraints and nurse's documentation of monitoring of the violent restraints.