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DENVER HEALTH & HOSPITAL AUTHORITY 777 BANNOCK ST DENVER, CO 80204 Sept. 11, 2019
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on interviews and document review, the facility failed to ensure patients who were placed in physical restraints were monitored and assessed to ensure their physical and emotional safety in 2 of 4 restraint records reviewed (Patient #7 and Patient #11).

Findings include:

Facility Policy

The policy, Restraint and Seclusion, read the purpose was to provide for the evaluation, treatment and monitoring of patients who required restraint and/or seclusion. Non-violent/Non-self destructive restraints were used to prevent the patient from disrupting necessary medical care. Restraints were only used to ensure the immediate physical safety of the patient was met. The decision to use restraints was based on and individual assessment, not diagnosis. The procedure for the use included completing a comprehensive clinical assessment prior to implementation of restraints for safety and an evaluation of alternative methods, other than restraints, to maintain patient safety. Immediately following the application, the patient's skin integrity and circulation, movement and sensation were to be assessed. Throughout the duration of the use of the restraint the patient's general care needs were to be monitored a minimum of every two hours which included airway checks and circulation checks. If the patient were awake, the patient's skin integrity, mental status, nourishment/hydration needs, elimination needs, hygiene and comfort and safety were to be assessed every two hours. The policy read staff were to document the initial assessment, changes to the plan of care, the use of least restrictive measures, date/time of application, the type of restraint used, the rationale for use, ongoing assessments, monitoring and general care needs, interventions and patient care actions completed, education provided, and date/time of removal of the restraint.

1. The facility failed to ensure staff monitored and assessed Patient #11 while in restraints to ensure the patient's emotional and physical needs were met.

a. Medical record review of Patient #11 revealed he received treatment in the emergency department (ED) on 8/4/19 at 10:02 a.m. following a seizure and head injury. While in the ED Patient #11 was placed in two point (bilateral upper extremity) restraints after he threatened to elbow a nurse who was trying to assist him back to bed and not following instructions from staff to remain in bed for safety.

The record revealed an order on 8/4/19 at 12:46 p.m. to place the patient in non-violent restraints due to the patient inability to follow safety instructions to include climbing over the side rails of the bed and was grabbing at tubes and dressings.

Review of the nursing flow sheets revealed, Patient #11's restraint application was initiated on 8/4/19 at 12:46 p.m., the medical doctor (MD) was notified, there were attempts at increased observation/monitoring and modification of the environment/safety prior to the application of the restraints. It was further documented the patient's condition was evaluated at the time of application including assessment of the airway, skin integrity and circulation.

There was no evidence in the medical record, after the application of the restraints on 8/4/19 at 12:46 p.m., the patient's general care needs were monitored every two hours which included airway checks, circulation checks or assessment of the patient's skin integrity, mental status, nourishment/hydration needs, elimination needs, hygiene and comfort and safety.

On 8/4/19 at 7:00 p.m. there was a note entered into the ED Non-Provider note section of the record which read the patient's care was assumed by a different nurse and Patient #11 was no longer in restraints. There was no evidence of the time in which the restraints were discontinued.

b. An interview was conducted with Registered Nurse (RN) #5 on 9/11/19 at 8:37 a.m. RN #5 stated patients who were in restraints were monitored every two hours to ensure their safety, ensure the patient had not experienced additional impairments and to reassess their readiness to have the restraints removed. RN #5 confirmed she initiated the restraints for Patient #11 on 8/4/19 at 12:46 p.m. and completed the initial restraint assessment. However, RN #5 was unable to identify, in the medical record, evidence the patient was monitored and assessed every two hours following the restraint application.

Additionally, RN #5 was unable to identify the time in which Patient #11 was removed from the restraints.

c. An interview was conducted with RN #4 on 9/11/19 at 7:51 a.m. RN #4 verified she assumed care of Patient #11 on 8/4/19 at 1:03 p.m. RN #4 stated she was unable to recall if Patient #11 was in restraints while under her care.

Upon review of the medical record with RN #4 she stated there was a gap in the record in regards to monitoring and assessing the patient's status while in restraints. She was able to identify the patient received an Occupational and Physical Therapy (OT and PT) evaluation at 5:00 p.m., in which she stated, could not have been completed if Patient #11 was in restraints. However, she was unable to identify the time when the restraints were discontinued. Furthermore, she was unable to identify an assessment of the patient's ability to follow instructions, circulation and breathing status, safety of the patient or the readiness of the patient to have the restraints discontinued.

d. An interview was conducted with Emergency Department Nurse Manager (RN Manager) #6 on 9/11/19 at 11:12 a.m. RN Manager #6 stated nurses were expected to document every 2 hours, in order to stay current with the patient's status, to verify the patients were not harming themselves and the patients remained in a safe setting.

2. The facility failed to ensure Patient #7 was assessed at the time of application of restraints to ensure the patient's emotional and physical needs were met.

a. Medical record review of Patient #7 revealed he received treatment in the emergency department (ED) on 8/22/19 at 11:19 a.m. for angioedema (a condition where there is rapid swelling of the mucosal tissues within the face). At the time of arrival to the ED the patient was alert and oriented. The medical record revealed in order to protect the patient's airway, the facility attempted to intubate (place a tube in the patient's throat to maintain an open airway) while the patient was awake. Per the physician's notes, the patient became agitated and caused the tube to be displaced and the procedure was converted to intubation under anesthesia.

The record revealed, in the physician's orders, an order to place the patient in non-violent or non-self destructive restraints on 8/22/19 at 12:57 p.m. to prevent disruption of treatment/therapy. Additionally, the physician's order identified Patient #7 was grabbing at tubes and dressings and the use of restraints was indicated as the least restrictive intervention to protect the patient and others from harm.

Review of the Nursing Flowsheet Restraint Summary section, revealed at 3:00 p.m., when the patient was transported to the Intensive Care Unit (ICU), the restraints were continued and remained monitored. There was no evidence, other than the physician's order on 8/22/19 at 12:57 p.m., of when the patient was placed in restraints or that the patient was assessed with the application of the restraints.

b. An interview was conducted with Senior Quality Nurse (RN) #7 on 9/11/19 at 1:46 p.m. Upon review of the medical record, RN #7 confirmed there was no evidence of the time of application of the restraints for Patient #7. RN #7 stated documentation of the patient assessment and use of restraints was expected by the nursing staff at the time of initiation as well as every shift.

c. An interview was conducted with Emergency Department Nurse Manager (RN Manager) #6 on 9/11/19 at 11:12 a.m. RN Manager #6 stated nurses were expected to document upon initiation of any type of restraint and the rationale for use.