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.

VIRGINIA MASON MEMORIAL 2811 TIETON DRIVE YAKIMA, WA 98902 June 17, 2019
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure staff modified the patient's plan of care when patients were placed in restraints, as demonstrated by the medical records of 1 of 4 patients reviewed (Patient #3).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included :

1. Review of the hospital's policy and procedure titled, "Non-Violent/Self-destructive Restraint/Restraint and Seclusion Policy - Medical," reviewed 09/28/18, showed that the patient's care plan would be revised immediately following initiation of restraints and would be updated on an ongoing basis.

2. On 06/11/19, the investigator reviewed the medical records for four patients currently being treated in the hospital who had been placed in restraints during their stay. The review showed that Patient #3 was a [AGE] year-old patient who was admitted to the hospital's medical/surgical unit on 04/27/19 for treatment of gastrointestinal bleeding. The patient was autistic and developmentally delayed and had a history of violent, aggressive behavior. The patient was placed in a vest and bilateral leg restraints for his safety and the safety of his caregivers. The patient's plan for care included interventions for de-escalation of the patient's behavior and less restrictive alternatives to restraints, but it did not include a long-term plan for behavior management and discontinuing the restraints prior to the patient's discharge to the community.

3. During an interview with the investigator on 06/17/19 at 9:55 AM, the medical/surgical unit's nurse manager (Staff #5) and the Senior Director for Medical/Surgical Services confirmed there was no long-term plan for discontinuation of the patient's restraints.



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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, record review, and review of hospital policies and procedures, the hospital failed to ensure that restraints were utilized in accordance with a physician's order, as demonstrated by 1 of 4 patients reviewed (Patient #2).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included :

1. Review of the hospital's policy and procedure titled, "Non-Violent/Self-destructive Restraint/Restraint and Seclusion Policy - Medical," reviewed 09/28/18, showed that restraints would only be initiated in accordance with a physician's order.

2. On 06/11/19, the investigator reviewed the medical records for three patients currently being treated in the hospital who had been placed in restraints during their stay. The review showed that Patient #2 was a [AGE] year-old patient who was admitted to the hospital's critical care unit (CCU) on 05/25/19 for treatment of liver failure and respiratory failure. On 06/06/19, a tube was inserted into the patient's airway and attached to a machine to help him breath. On 06/06/19 at 3:00 AM, the patient was placed in wrist restraints to prevent him from pulling out the tube. The patient was still in restraints on 06/12/19 at 9:00 AM. Review of the patient's records showed a physician order dated 06/11/19 authorizing use of the restraints.

3. During an interview with the investigator on 06/12/19 at 9:00 AM, the CCU nurse manager (Staff #4) confirmed that the restraint order had not been written at the time the restraints were applied on 06/06/19.
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that hospital staff members assessed and monitored patients while in restraints as directed by the hospital's restraint policy, as demonstrated by the records of 1 of 4 patients (Patient #4).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included :

1. Review of the hospital's policy and procedure titled, "Non-Violent/Self-destructive Restraint/Restraint and Seclusion Policy - Medical," reviewed 09/28/18, showed that patients would be assessed at least every four hours for circulation and skin integrity; the need for fluids, food, and elimination; and the patient's activity, comfort, restraint type, and environment.

2. On 06/11/19, the investigator reviewed the medical records for three patients currently being treated in the hospital who had been placed in restraints during their stay. The review showed that Patient #4 was a [AGE] year-old developmentally delayed patient who was admitted on [DATE] for treatment of aspiration pneumonia that included insertion of drainage tubes in the patient's chest. The patient was placed in restraints on 06/03/19 at 1:21 PM and remained in restraints until the chest tubes were removed on 06/11/19 at 11:12 AM. The patient's record lacked evidence that he was assessed every four hours on five occasions between 06/02/19 at 10:00 PM and 06/08/19 at 10:33 AM. Intervals between assessments ranged from 5 hours and 17 minutes to 9 hours and 5 minutes.

3. During an interview with the investigator on 06/12/19 at 10:15 AM, the Senior Director for Medical/Surgical Services confirmed that the record lacked evidence that the patient had been assessed every four hours as directed by hospital policy.
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to develop a policy that specified the interval for education, training, and assessment of competency of hospital staff members and healthcare providers who utilized restraints, as demonstrated by the training records of 1 of 2 staff members reviewed (Staff #7).

Failure to train staff to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included :

1. On 06/12/19 at 8:45 AM, the investigator interviewed a registered nurse (Staff #7) who was caring for Patient #2. During the interview, the nurse stated she was "not sure" when she last participated in education and training for the use of restraints during patient care. Review of Staff #7's training records showed she had completed computerized on-line restraint training in June of 2019, but there was no evidence of return demonstration of competency in the use of restraints since 2013.

2. Review of the hospital's policy and procedure titled, "Non-Violent/Self-destructive Restraint/Restraint and Seclusion Policy - Medical," reviewed 09/28/18, showed that all physicians, allied health professionals, and nursing staff with direct patient contact would have "ongoing" education and training for use of restraints and seclusion. The policy did not specify how often the education and training would occur or how staff would demonstrate competency in the use of restraints.

3. On 06/17/19 at 9:20 AM, the investigator interviewed the Senior Director for Medical/Surgical Services. The director confirmed the hospital's restraint policy did not specify how often the education and training would occur or how staff would demonstrate competency in the use of restraints
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