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.

DELL SETON MED CENTER AT THE UNIVERSITY OF TX 601 E 15TH STREET AUSTIN, TX 78701 Nov. 18, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on a review of documentation and interview, the facility failed to protect and promote each patient's rights, as evidenced by issues with restraints at the facility. There was risk of patient harm due to inconsistency in documentation, monitoring, order renewals, and utilization of restraints at the facility.

* The facility failed to ensure that restraints were discontinued at the earliest possible time. Failing to discontinue the restraint episode at the earliest possible time increases the potential risk of sustaining possible injury or negative health outcomes for patients while in restraints longer than clinically necessary. Please refer to A0154.

* The facility failed to ensure that restraints orders were renewed after 4 hours for adults 18 years of age or older. Patients require an order renewal for any restraint lasting longer than 4 hours. Please refer to A0171

* The facility failed to ensure that the condition of the patient who is restrained or secluded must be monitored at an interval determined by hospital policy. Failing to monitor patients appropriately while in restraints, increases the potential risk of sustaining possible injury or negative health outcomes while in restraints. Please refer to A0175.

* The facility failed to ensure that the rationale for continued use of the restraint intervention was reflected in patient medical records. Please refer to A0188.

* The facility failed to ensure that staff must be trained and able to demonstrate competency in the application of restraints, subsequently on a periodic basis consistent with hospital policy. Hands on training should be reflected for all staff members that could be involved in the application and use of restraints in order to ensure safe and correct technique, which minimizes any potential for patient injury. Please refer to A0196.

An immediate jeopardy was identified at the facility on 11/17/20, related to the issues noted above. The facility was able to enact plans of correction which included the immediate education of staff and development of audit tools for restraints. The facility abated the immediate jeopardy on 11/18/20, however, the condition level finding remained.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on a review of documentation and interview, the facility failed to ensure that restraints must be discontinued at the earliest possible time.

Findings included:

Facility based policy entitled,
"Restraints and Safety Alternative-Use of- Medical/Surgical Acute Care Facilities" stated in part,

"Registered Nurses:
1. Responsible for all aspects of care of the patient in restraints, to include:
o Perform the initial assessment for the need for restraint
o Receive orders from the attending physician or other licensed independent practitioner
o Perform re-assessments for restraint order renewal within required time frames and to assure restraint is discontinued as soon as possible
o Apply, monitor, discontinue and/or remove restraints
o Document according to Procedure C ...

PROCEDURES:
A. Assessing the need for restraint:
1. The registered nurse is collecting assessment criteria, interpreting their relevance to the patient's physical safety; and, based on the interpretation, recognizing the need to contact the physician for a medical evaluation and/or treatment of the patient.
2. The RN immediately notifies the patient's physician of the assessed need for restraint.
3. The RN, utilizing clinical judgment, assesses the patient's ongoing requirement of restraints. Upon finding that the patient no longer requires restraints (for example, the behavior/condition that, required application of the restraints no longer exist, alternatives begin to be effective, etc), the RN shall discontinue restraints ....

C. Documentation in the medical records includes at a minimum: ...
o The patient's condition or symptom(s) that warranted the use of the restraint and the intervention used....
o The patient's response to the restraint(s) used, including the rationale for continued use of the intervention ..."

Facility based "Ascension Texas Restraints and Safety Alternatives ATTACHMENT Summary of Restraint Required Elements 10.2020" stated in part,

"Violent Restraint Use ...
Minimum Monitoring Requirements(Documentation) ...
RN Re-assessment to assure restraint is discontinued as soon as possible ..."

Review of medical records revealed issues involving patients not being released and/or the restraint discontinued at the earliest possible time in 8 of 13 restraint records reviewed. Patients #2, 5, 6, 7, 8, 9 12, and 14 did not have clear behaviors documented to justify the continued use of the restraint. Patient #2 was kept in restraints with a note that "pt to stay in restraints-until taken to jail per MD" this does not indicate any aggression or behavioral justification for continued use of restraint. Patient #5 appeared to be sleeping and was kept in restraints. Some patients had calm and/or cooperative behavior documented but were kept in restraints and not released. Others had "uncooperative" documented but there was no evidence of aggression or injurious behavior being exhibited.

Patient #2 had a physician order on 09/03/20 at 2145 for the restraint chair due to "Significant danger to others, tried to strangle RN". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "Calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:
* This restraint was initiated at 2050 related to "Physical Abuse to others" and "pt lunged at CA and tried to strangle RN" .
* The "Release Criteria for Restraint" at 2100 included "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others". The "Restraint Release Status" noted "Criteria not met" from 1100-1245.
* The Behavior Description-Restraint area at 2105 indicated, "cont rocking restraint & threatening staff". At 2121 "pt contd threatening staff". At 2140 "pt drowsy awaiting UTPD arrest-pt to stay in restraints-until taken to jail per MD. "At 2155 "pt drowsy". At 2210 "pt drowsy". At 2225 "pt drowsy".
* This patient was released from the restraint chair at 2225, a note stated, "The patient was released from restraint at this time. A note indicated, "UTPD here to arrest pt-pt placed in cuffs for transport to jail".
Based on the above review, Patient #2 did not have clear behavior documented to justify the continued use of the restraint. At 2140, a note stated, "pt drowsy awaiting UTPD arrest-pt to stay in restraints-until taken to jail per MD", this did not indicate any aggression or behavioral justification for continued use of restraint. Also, waiting for police to pick up the patient is not a valid reason to continue the restraint with no accompanying behavior of aggression. This patient was kept in restraint while noted to be drowsy from 2140-2225. There was no documented aggressive behavior after the note at 2121.

Patient #5 had a physician order on 09/18/19 at 1919 for a restraint chair due to "agitated, threatening, posturing at cops, agitated." This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "Verbal contract-no harm to self/others". Review of the Restraint Monitoring documentation for this incident revealed the following:
* This restraint was initiated at 1913 related to "Verbal aggression with potential harm to self or others".
* The "Release Criteria for Restraint" at 1913 stated "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others". The "Restraint Release Status" noted "Criteria not met" from 1913 to 2115.
* The Behavior Description- Restraint portion of the monitoring had the following documented. 1915 "yelling, bargaining, threatening to spit on staff". 1930 "yelling, cursing, bargaining". 1945 "yelling, cursing, attempting to get out of chair, moving chair around". 2000 "yelling, cursing, bargaining to get out of chair". 2015 "Asking to get out of chair, yelling". 2030 "talking loudly at times, starting to slow down". 2045 "sitting in restraint chair". 2100 "Patient calm, appeared to be sleeping." 2115 "Patient appears to be sleeping".
* This patient was released from the restraint chair at 2121.
Based on the above review Patient #5 stopped exhibiting agitated behavior at 2045 and appeared to be sleeping at 2100 and 2115, however was not released from restraint until 2121. Sleeping and calm would meet the indicated release criteria. Due to lack of documentation, it cannot be established if the patient was asked about verbal contracting, and a patient cannot verbally contract to safety when asleep.

Patient #6 had a physician order on 10/11/19 at 1746 for soft limb restraints due to being "combative". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:
* This restraint was initiated at 1324 related to "Physical abuse to others, self-injurious behavior, verbal aggression and potential harm to self or others".
* The "Release Criteria for Restraint" stated "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others, No longer exhibits physical abuse to self". The "Restraint Release Status" noted "Criteria not met" with no other details from 1324 to 1730.
* The Physical/Mental State portion of the monitoring only had "Yes" with no other details documented from 1324 to 1730.
* There was no Behavior Description- Restraint portion entered for this patient.
* This patient was not released from restraints until 1745 on 10/11/19, the restraint activity was listed as "discontinue episode".
Based on the above review Patient #6 did not have behavior documented to justify the continued use of the restraint. Without documented behaviors, it is unknown how the patient was not meeting release criteria. There was no documentation that the patient was actively continuing to engage in threatening, or aggressive/abusive behavior to self or others.

Patient #7 had a physician order on 11/21/19 at 1055 for the restraint chair due to "Patient attempted to suffocate self with hands". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "verbal contract-no harm to self/others". Review of the Restraint Monitoring documentation for this incident revealed the following:
* This restraint was initiated at 1050 related to "Self-injurious behavior".
* The "Release Criteria for Restraint" at 1050 included "No longer exhibits behavior threatening harm to self, others". The "Restraint Release Status" noted "Criteria not met" from 1100-1245.
* The Physical/Mental State area at 1105 and 1120 indicated, "Calm, Cooperative". At 1135 "Cooperative". Nothing noted in that area at 1145. At 1150 "Cooperative". At 1205, 1220, and 1245 "Calm, Cooperative".
* This patient was released from the restraint chair at 1300.
Based on the above review, Patient #7 did not have clear behavior documented to justify the continued use of the restraint. From 1105-1245 calm and/or calm, cooperative was noted for Physical Mental State, this does not indicate any self-harm or behavioral justification for continued use of restraint. This patient was kept in restraint for an hour and half with repeated notation they were calm. It is unknown if they were asked to verbally contract to safety while calm, however no clear danger to self is noted in the restraint documentation after 1105.

Patient #8 had a physician order on 12/03/19 at 0151 for side rails X 4 or Full due to "aggressive and violent behavior toward staff". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:
* This restraint was initiated at 0200 related to "Physical abuse to others, Verbal aggression with potential harm to self or others".
* No "Release Criteria for Restraint" or "Restraint Release Status" were present for 0230, 0300, 0330, or 0400.
* At 0230, Physical/mental State indicated, "Uncooperative". There was nothing documented under Physical/Mental State at 0300. At 0330 and 0400 "Appears emotionally distressed".
* This patient was released from the restraint chair at 0430.
Based on the above review, Patient #8 did not have clear behavior documented to justify the continued use of the restraint. "Appears emotionally distressed" does not clearly indicate aggressive behaviors. It is unclear what "appears emotionally distressed" actually means. The patient could have just been upset about being restrained and not necessarily agitated or aggressive. Without clearly documented behaviors, it is unknown if the patient was meeting release criteria or not. From 0300-0400, there was no clear documentation that the patient was continuing to engage in or threaten aggression towards self or others that would justify the continued use of the restraint.

Patient #9 had a physician order on 12/16/19 at 2010 for a restraint chair due to "hitting yelling threatening;" this order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:
* This restraint was initiated at 2011 related to "Physical abuse to others, Verbal aggression with potential harm to self or others".
* The "Release Criteria for Restraint" at 2015 included "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others". The "Restraint Release Status" noted "Criteria not met" from 2011-2030.
* At 2011, Physical/mental State indicated, "Uncooperative, appears emotionally distressed, Other: threatening" There was nothing documented under Physical/Mental State at 2015. The Physical/Mental State tab was not present for 2030.
* This patient was released from the restraint chair at 2045.
Based on the above review, Patient #9 did not have behavior documented to justify the continued use of the restraint. Without documented behaviors, it is unknown how the patient was not meeting release criteria. From 2015-2030 there was no documentation that the patient was continuing to engage in or threaten aggression towards self or others.

Patient #12 had a physician order on 10/02/20 at 1827 for a restraint chair due to "combativeness;" this order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:
* This restraint was initiated at 1819 related to "Physical abuse to others, Self-Injurious behavior, Verbal aggression with potential harm to self or others".
* No "Release Criteria for Restraint" was indicated on this form.
* Physical/mental State portion at 1910, 1940, 2010, 2040, 2110, and 2130 stated "calm".
* This patient was released from the restraint chair at 2137.
Based on the above review, Patient #12 did not have behavior documented to justify the continued use of the restraint. Without documented behaviors, it is unknown how the patient was not meeting release criteria. From 1940-2130, it was documented that this patient was calm; there was no documentation that the patient was continuing to engage in or threaten aggression towards self or others.

Patient #14 had a physician order on 10/26/20 at 0133 for soft limb restraints due to "attempted to strike staff;" this order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "verbal contract-no harm to self/others Calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:
* This restraint was initiated at 0100 related to "Physical abuse to others, self-injurious behavior, verbal aggression and potential harm to self or others".
* The "Release Criteria for Restraint" stated "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others, No longer exhibits physical abuse to self". The "Restraint Release Status" noted "Criteria not met" with no other details from 0130 to 0630.
* The Physical/Mental State portion of the monitoring had the following documented. At 0200, 0230, and 0300 "Appears emotionally distressed". At 0330, 0400, 0430, 0500, 0530, 0600, and 0630 "No apparent distress. Uncooperative."
* This patient was not released from restraints until 0700 on 10/26/20.
Based on the above review, Patient #14 did not have specific behavior documented to justify the continued use of the restraint. It is unclear how the patient was "uncooperative". Without documented behaviors, it is unknown how the patient was not meeting release criteria. There was no documentation that the patient was actively continuing to engage in aggressive behavior. Due to lack of documentation, it cannot be established if the patient was asked about verbal contracting to meet ordered release criteria.

The above findings indicate that the facility failed to ensure that restraints were discontinued at the earliest possible time. Failing to discontinue the restraint episode at the earliest possible time increases the potential risk of sustaining possible injury or negative health outcomes for patients while in restraints longer than clinically necessary. The above findings were confirmed on 11/17/20 and 11/18/20 with staff members # 3 and 53, along with other administrative staff members.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on a review of documentation and interview, the facility failed to ensure that each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours:
(A) 4 hours for adults 18 years of age or older.

Findings:

Facility based policy entitled, "Restraints and Safety Alternative-Use of- Medical/Surgical Acute Care Facilities" stated in part,

"Key Points ...

D. PRN or "as needed" restraint orders are not allowed. Should a restraint order occur, within 60 minutes either 1) restraints must be applied, or 2) documentation be entered in the medical record that restraints are not initiated and rationale ...

o All usage of restraints, non-violent or violent, requires a written order ...

RESPONSIBILITIES:

Physicians (including residents) and other licensed independent practitioners

1. Responsible to have a working knowledge of and comply with restraint policy and procedure:

2. Provide verbal and written orders for the appropriate use of restraints."


Facility based "Ascension Texas Restraints and Safety Alternatives ATTACHMENT Summary of Restraint Required Elements 10.2020" stated in part,

"Violent Restraint Use ...

The original restraint order may only be renewed within the required time limits** below for up to a total of 24 hours.

Prior to obtaining a renewal order (in accordance with the required renewal time frames): ...

o The physician is contacted and report given. If indicated, a renewal order is obtained ....

o**Renewal time frames are:

o every 4 hours for adults [AGE] and older;

o every 2 hours for ages 9 to 17;

o every 1 hour for children under age 9 ..."


Review of medical records revealed 2 of 13 patients were in restraints lasting longer than 4 hours with no order renewal noted.

Patient #6 had a physician order on 10/11/19 at 1746 for soft limb restraints due to being "combative". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 1324 related to "Physical abuse to others, self-injurious behavior, verbal aggression and potential harm to self or others".

* The "Release Criteria for Restraint" stated "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others, No longer exhibits physical abuse to self". The "Restraint Release Status" noted "Criteria not met" with no other details from 1324 to 1730.

* The Physical/Mental State portion of the monitoring only had "Yes" with no other details documented from 1324 to 1730.

* There was no Behavior Description- Restraint portion entered for this patient.

* This patient was not released from restraints until 1745 on 10/11/19, the restraint activity was listed as "discontinue episode".

* Based on this documentation, this patient was in restraint from 1324-1746, which was 4 hours and 22 minutes. There was no second order present to extend the restraint past 4 hours as required by regulations and policy.

Based on the above review, Patient #6 did not have behavior documented to justify the continued use of the restraint. Without documented behaviors, it is unknown how the patient was not meeting release criteria. There was no documentation that the patient was actively continuing to engage in threatening, or aggressive/abusive behavior to self or others. Patient #6 also was restrained beyond 4 hours with no restraint renewal order present.


Patient #14 had a physician order on 10/26/20 at 0133 for soft limb restraints due to "attempted to strike staff;" this order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "verbal contract-no harm to self/others Calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 0100 related to "Physical abuse to others, self-injurious behavior, verbal aggression and potential harm to self or others".

* The "Release Criteria for Restraint" stated "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others, No longer exhibits physical abuse to self". The "Restraint Release Status" noted "Criteria not met" with no other details from 0130 to 0630.

* The Physical/Mental State portion of the monitoring had the following documented. At 0200, 0230, and 0300 "Appears emotionally distressed". At 0330, 0400, 0430, 0500, 0530, 0600, and 0630 "No apparent distress. Uncooperative."

* This patient was not released from restraints until 0700 on 10/26/20.

* Based on this documentation, this patient was in restraint from 0100-0600, which was 5 hours. There was no second order present to extend the restraint past 4 hours as required by regulations and policy.

Based on the above review, Patient #14 did not have specific behavior documented to justify the continued use of the restraint. It is unclear how the patient was "uncooperative". Without documented behaviors, it is unknown how the patient was not meeting release criteria. There was no documentation that the patient was actively continuing to engage in aggressive behavior. Due to lack of documentation, it cannot be established if patient was asked about verbal contracting to meet ordered release criteria. Patient #14 also was restrained beyond 4 hours with no restraint renewal order present.


On 11/17/20, staff member #56 was asked if they could locate a second restraint order for patients (#6 and 14) that had restraints lasting longer than 4 hours. This staff member was unable to find an order to continue or renew the restraint for either of these patients.

The above findings indicate that the facility failed to ensure that restraints orders were renewed after 4 hours for adults 18 years of age or older. Patients require an order renewal for any restraint lasting longer than 4 hours. The above findings were confirmed on 11/17/20 and 11/18/20 with staff members # 3 and 53, along with other administrative staff members.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on a review of documentation and interview, the facility failed to ensure that the condition of the patient who was restrained was monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy.

Findings:

Facility based policy entitled, "Restraints and Safety Alternative-Use of- Medical/Surgical Acute Care Facilities" stated in part,

"Restraint Monitoring: includes visual check, assisting with range of motion, elimination, nutrition and hydration, and hygiene needs along with physical and mental comfort status ...

* For violent restraint, monitoring occurs through direct visual contact at a minimum of every 30 minutes or more frequently as determined by the patient's condition ..."

C. Documentation in the medical records includes at a minimum: ...

o The patient's condition or symptom(s) that warranted the use of the restraint and the intervention used.

o The intervals and results of the monitoring of the patient ..."


Facility based "Ascension Texas Restraints and Safety Alternatives ATTACHMENT Summary of Restraint Required Elements 10.2020" stated in part,

"Violent Restraint Use ...

Minimum Monitoring Requirements(Documentation) ...

* Visual checks occur minimally q 30 minutes, unless otherwise indicated based on the patient's medical and psychological condition ..."


Review of the medical record revealed that the following patient was in restraints without monitoring every 30 minutes documented, per policy.

Patient #13 had a physician order on 10/08/20 at 2049 for soft limb restraints due to "POED". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 2049 related to "Physical abuse to others".

* The "Release Criteria for Restraint" at 2049 included "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others, No longer exhibits physical abuse to self". The "Restraint Release Status" noted "Criteria not met" from 2049-2200.

* At 2145, nothing was noted under Physical/Mental State. The Physical/Mental State tab was not present for 2200 or 2300.

* This patient was released from the restraint chair at 2300.

Based on the above review, Patient #13 was not monitored every 30 minutes or more frequently per policy. There should have been monitoring around 2120 and 2230. This indicated there were 2 hours without proper monitoring of this patient.


The above findings indicated the facility failed to ensure that the condition of the patient who was restrained was monitored at an interval determined by hospital policy. Failing to monitor patients appropriately while in restraints, increases the potential risk of sustaining possible injury or negative health outcomes while in restraints. The above findings were confirmed on 11/17/20 and 11/18/20 with staff members # 3 and 53, along with other administrative staff members.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
Based on a review of documentation and interview, the facility failed to ensure that medical records included the following documentation: the rationale for continued use of the intervention.

Findings:

Facility based policy entitled, "Restraints and Safety Alternative-Use of- Medical/Surgical Acute Care Facilities" stated in part,

"Registered Nurses:...

o Document according to Procedure C ...

PROCEDURES:

A. Assessing the need for restraint:...

3. The RN, utilizing clinical judgment, assesses the patient's ongoing requirement of restraints. Upon finding that the patient no longer requires restraints (for example, the behavior/condition that, required application of the restraints no longer exist, alternatives begin to be effective, etc), the RN shall discontinue restraints ....

C. Documentation in the medical records includes at a minimum: ...

o The patient's response to the restraint(s) used, including the rationale for continued use of the intervention ..."


Review of medical records revealed issues involving patients not having the rationale for continued use of restraint documented in 8 of 13 restraint records reviewed. Patients #2, 5, 6, 7, 8, 9, 12, and 14 did not have clear behaviors documented to justify the continued use of the restraint. Patient #2 was kept in restraints with a note that "pt to stay in restraints-until taken to jail per MD;" this does not indicate any aggression or behavioral justification for continued use of restraint. Patient #5 appeared to be sleeping and was kept in restraints. Some patients had calm and/or cooperative behavior documented but were kept in restraints and not released. Others had "uncooperative" documented but there was no evidence of aggression or injurious behavior being exhibited.


Patient #2 had a physician order on 09/03/20 at 2145 for the restraint chair due to "Significant danger to others, tried to strangle RN". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "Calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 2050 related to "Physical Abuse to others" and "pt lunged at CA and tried to strangle RN" .

* The "Release Criteria for Restraint" at 2100 included "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others". The "Restraint Release Status" noted "Criteria not met" from 1100-1245.

* The Behavior Description-Restraint area at 2105 indicated, "cont rocking restraint & threatening staff". At 2121 "pt contd threatening staff". At 2140 "pt drowsy awaiting UTPD arrest-pt to stay in restraints-until taken to jail per MD. "At 2155 "pt drowsy". At 2210 "pt drowsy". At 2225 "pt drowsy".

* This patient was released from the restraints chair at 2225, a note stated, "The patient was released from restraint at this time. A note indicated, "UTPD here to arrest pt-pt placed in cuffs for transport to jail".

Based on the above review, Patient #2 did not have clear behavior documented to justify the continued use of the restraint. At 2140, a note stated, "pt drowsy awaiting UTPD arrest-pt to stay in restraints-until taken to jail per MD;" this does not indicate any aggression or behavioral justification for continued use of restraint. Also, waiting for police to pick up the patient is not a valid reason to continue the restraint with no accompanying behavior of aggression. This patient was kept in restraint while noted to be drowsy from 2140-2225. There was no documented aggressive behavior after the note at 2121.


Patient #5 had a physician order on 09/18/19 at 1919 for a restraint chair due to "agitated, threatening, posturing at cops, agitated." This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "Verbal contract-no harm to self/others". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 1913 related to "Verbal aggression with potential harm to self or others".

* The "Release Criteria for Restraint" at 1913 stated "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others". The "Restraint Release Status" noted "Criteria not met" from 1913 to 2115.

* The Behavior Description- Restraint portion of the monitoring had the following documented. 1915 "yelling, bargaining, threatening to spit on staff". 1930 "yelling, cursing, bargaining". 1945 "yelling, cursing, attempting to get out of chair, moving chair around". 2000 "yelling, cursing, bargaining to get out of chair". 2015 "Asking to get out of chair, yelling". 2030 "talking loudly at times, starting to slow down". 2045 "sitting in restraint chair". 2100 "Patient calm, appeared to be sleeping." 2115 "Patient appears to be sleeping".

* This patient was released from the restraint chair at 2121.

Based on the above review, Patient #5 stopped exhibiting agitated behavior at 2045 and appeared to be sleeping at 2100 and 2115, however was not released from restraint until 2121. Sleeping and calm would meet the indicated release criteria. Due to lack of documentation, it cannot be established if the patient was asked about verbal contracting, and a patient cannot verbally contract to safety when asleep.


Patient #6 had a physician order on 10/11/19 at 1746 for soft limb restraints due to being "combative". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 1324 related to "Physical abuse to others, self-injurious behavior, verbal aggression and potential harm to self or others".

* The "Release Criteria for Restraint" stated "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others, No longer exhibits physical abuse to self". The "Restraint Release Status" noted "Criteria not met" with no other details from 1324 to 1730.

* The Physical/Mental State portion of the monitoring only had "Yes" with no other details documented from 1324 to 1730.

* There was no Behavior Description- Restraint portion entered for this patient.

* This patient was not released from restraints until 1745 on 10/11/19, the restraint activity was listed as "discontinue episode".

Based on the above review Patient #6 did not have behavior documented to justify the continued use of the restraint. Without documented behaviors, it is unknown how the patient was not meeting release criteria. There was no documentation that the patient was actively continuing to engage in threatening, or aggressive/abusive behavior to self or others.


Patient #7 had a physician order on 11/21/19 at 1055 for the restraint chair due to "Patient attempted to suffocate self with hands". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "verbal contract-no harm to self/others". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 1050 related to "Self-injurious behavior".

* The "Release Criteria for Restraint" at 1050 included "No longer exhibits behavior threatening harm to self, others". The "Restraint Release Status" noted "Criteria not met" from 1100-1245.

* The Physical/Mental State area at 1105 and 1120 indicated, "Calm, Cooperative". At 1135 "Cooperative". Nothing noted in that area at 1145. At 1150 "Cooperative". At 1205, 1220, and 1245 "Calm, Cooperative".

* This patient was released from the restraint chair at 1300.

Based on the above review, Patient #7 did not have clear behavior documented to justify the continued use of the restraint. From 1105-1245, calm and/or calm, cooperative was noted for Physical Mental State, this does not indicate any self-harm or behavioral justification for continued use of restraint. This patient was kept in restraint for an hour and half with repeated notation they were calm. It is unknown if they were asked to verbally contract to safety while calm, however no clear danger to self is noted in the restraint documentation after 1105.


Patient #8 had a physician order on 12/03/19 at 0151 for side rails X 4 or Full due to "aggressive and violent behavior toward staff". This order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 0200 related to "Physical abuse to others, Verbal aggression with potential harm to self or others".

* No "Release Criteria for Restraint" or "Restraint Release Status" were present for 0230, 0300, 0330, or 0400.

* At 0230 Physical/mental State indicated, "Uncooperative". There was nothing documented under Physical/Mental State at 0300. At 0330 and 0400 "Appears emotionally distressed".

* This patient was released from the restraints chair 0430.

Based on the above review, Patient #8 did not have clear behavior documented to justify the continued use of the restraint. "Appears emotionally distressed" does not clearly indicate aggressive behaviors. It is unclear what "appears emotionally distressed" actually means. The patient could have just been upset about being restrained and not necessarily agitated or aggressive. Without clearly documented behaviors, it is unknown if the patient was meeting release criteria or not. From 0300-0400 there was no clear documentation that the patient was continuing to engage in or threaten aggression towards self or others that would justify the continued use of the restraint.


Patient #9 had a physician order on 12/16/19 at 2010 for a restraint chair due to "hitting yelling threatening;" this order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 2011 related to "Physical abuse to others, Verbal aggression with potential harm to self or others".

* The "Release Criteria for Restraint" at 2015 included "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others". The "Restraint Release Status" noted "Criteria not met" from 2011-2030.

* At 2011, Physical/mental State indicated, "Uncooperative, appears emotionally distressed, Other: threatening." There was nothing documented under Physical/Mental State at 2015. The Physical/Mental State tab was not present for 2030.

* This patient was released from the restraint chair at 2045.

Based on the above review, Patient #9 did not have behavior documented to justify the continued use of the restraint. Without documented behaviors, it is unknown how the patient was not meeting release criteria. From 2015-2030, there was no documentation that the patient was continuing to engage in or threaten aggression towards self or others.


Patient #12 had a physician order on 10/02/20 at 1827 for a restraint chair due to "combativeness;" this order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 1819 related to "Physical abuse to others, Self-Injurious behavior, Verbal aggression with potential harm to self or others".

* No "Release Criteria for Restraint" was indicated on this form.

* Physical/mental State portion at 1910, 1940, 2010, 2040, 2110, and 2130 stated "calm".

* This patient was released from the restraint chair at 2137.

Based on the above review, Patient #12 did not have behavior documented to justify the continued use of the restraint. Without documented behaviors, it is unknown how the patient was not meeting release criteria. From 1940-2130, it was documented that this patient was calm, there was no documentation that the patient was continuing to engage in or threaten aggression towards self or others.


Patient #14 had a physician order on 10/26/20 at 0133 for soft limb restraints due to "attempted to strike staff;" this order was "Not to exceed 4 hours (Age 18+ yrs). Per the physician order, the behavior for release was "verbal contract-no harm to self/others Calm/in control". Review of the Restraint Monitoring documentation for this incident revealed the following:

* This restraint was initiated at 0100 related to "Physical abuse to others, self-injurious behavior, verbal aggression and potential harm to self or others".

* The "Release Criteria for Restraint" stated "No longer exhibits behavior threatening harm to self, others, No longer exhibits physical abuse to others, No longer exhibits physical abuse to self". The "Restraint Release Status" noted "Criteria not met" with no other details from 0130 to 0630.

* The Physical/Mental State portion of the monitoring had the following documented. At 0200, 0230, and 0300 "Appears emotionally distressed". At 0330, 0400, 0430, 0500, 0530, 0600, and 0630 "No apparent distress. Uncooperative."

* This patient was not released from restraints until 0700 on 10/26/20.

Based on the above review, Patient #14 did not have specific behavior documented to justify the continued use of the restraint. It is unclear how the patient was "uncooperative". Without documented behaviors, it is unknown how the patient was not meeting release criteria. There was no documentation that the patient was actively continuing to engage in aggressive behavior. Due to lack of documentation, it cannot be established if patient was asked about verbal contracting to meet ordered release criteria.


The above findings indicate that the facility failed to ensure the above patients had the rationale for continued use of the restraint intervention reflected in their medical records. The above findings were confirmed on 11/17/20 and 11/18/20 with staff members # 3 and 53 along with other administrative staff members.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on a review of documents and interview, the facility failed to ensure that staff must be trained and able to demonstrate competency in the application of restraints subsequently on a periodic basis consistent with hospital policy.

Findings:

Facility based policy entitled, "Restraints and Safety Alternative-Use of- Medical/Surgical Acute Care Facilities" stated in part,

"REQUIRED COMPETENCE:

The assessment, initiation, application (physical), administration (drugs), evaluation, and monitoring associated with restraint use are limited to those direct care staff who demonstrate evidence of training and the completion of identified competence requirements on an annual basis, in compliance with this policy.

o New AT and contract/agency staffs are provided initial orientation and training on those aspects of the restraint process identified as responsibilities for their positions for both violent and non-violent restraint.

o See Restraints and Safety Alternatives ATTACHMENT-Orientation and Training requirements.docx ...."


Review of personnel records revealed staff did not all have documented competency in restraint application for 2019. Per facility policy, "The assessment, initiation, application (physical), administration (drugs), evaluation, and monitoring associated with restraint use are limited to those direct care staff who demonstrate evidence of training and the completion of identified competence requirements on an annual basis".

A sample of nursing staff members were selected to review their prior restraint training. One of 3 nursing staff employed prior to 2020 (staff member #7) did not have documented hands on demonstration or competency of restraint application and use for 2019.

Staff member #7

* 9-2018 - Restraint chair training (skills fair)

* 5-17-19 - web-based training: restraint education

* 5-10-20 - web-based training: restraints education

* 8-28-20 - web-based training: other: CPI nonviolent crisis intervention FLEX 2020

* 10-6-20 - Instructor-led course: CPI non-violent crisis intervention 2020

This staff member only had web based restraint training in 2019 with no hands on demonstration or competency in restraint application noted.


Review of the Management of Aggressive Behavior (MOAB) training for a sample of facility employed security officers revealed the following:

* Staff member #35 had training certificates for 05/19/16, 09/20/17, 07/20/19 and 11/05/20.

* Staff member #38 had training certificates for 04/04/16, 09/20/17, 08/28/19, and 11/05/20.

* Staff member #45 had training certificates for 04/04/16, 08/19/20, and 11/02/20.


One of 3 security staff members (#45) did not have restraint training documented for 2019. In an interview on 11/18/20, staff member
#45 reported that starting in July 2020, the facility had enough staff to offer annual updates to MOAB beyond the 2-year recertification, however this had not occurred annually prior to 2020.


2 of 6 staff members did not have evidence of the "completion of identified competence requirements on an annual basis" for 2019 which would included documented hands on demonstration or competency of restraint application and use. Hands on training should be reflected for all staff members that could be involved in the application and use of restraints, to ensure safe and correct technique to minimize any potential for patient injury. The above findings were confirmed on 11/17/20 and 11/18/20 with staff members # 3 and 53 along with other administrative staff members.