HospitalInspections.org

Based on review of records and staff interviews, it was determined the Hospital failed to report a patient death associated with restraints within 24 hours. This failure poses the risk of an incomplete evaluation as to contributory factors in the death due to passage of time.

Findings include:

Policy titled, "Death of a Patient", revealed: "...When a patient dies, the attending physician or designee shall notify the patient's family that their family member has died...Notify House Supervisor: If death is considered unanticipated, House Supervisor will notify administrator on-call and will discuss any further actions needed including but not limited to Event Reporting, Family Communication, Medical Examiner and Hospital Provided Autopsy...."

Policy titled' "Restraint", revealed: "...Non-violent Restraint (NVR)- NVR is used to limit mobility or temporarily immobilize an acute care patient related to providing safe medical care...Non-violent behavior justifying the use of restraints (Non-violent Restraint NVR): Movements which threaten to disrupt medically necessary dressings or invasive medical equipment such as endotracheal tubes, enteral tubes, urinary catheters, intravascular catheters, ventricular catheters, drainage tubes, chest tubes, and similar devices if such disruption could result in immediate harm...Lack of understanding to comply with safety directions (Examples: Attempts to get out of bed if such actions would potentially harm a patient or behavior resulting from traumatic brain injury)...Requirements for Orders for Non-violent Restraint: 1. A telephone or written order must be obtained from a Practitioner as soon as possible following the initiation of restraint/seclusion. 2. Reorder: Restraint/seclusion reorder to continue restraint beyond the initial application must be accompanied by an order from a practitioner. A written order clinically justifying continuing the restraint must be obtained no less often than once daily...Application of Physical Restraint: The type and size of restraint device will be selected as appropriate to the patient's condition and/or assessed need. Restraints will be applied with safe and appropriate techniques, evaluated frequently for continuation and ended at the earliest possible time...Assessment and Reassessment of the Patient in Restraint/Seclusion: The condition of the patient must be continually assessed, monitored and evaluated...Patients in Non-Violent Restraint will be re-assessed at least every two hours or more frequently if necessary...Non-violent restraints will be terminated when the individual is able to: safely engage in necessary medical treatment, follow directions, demonstrate compliance with safety instructions...Death Reporting Requirements: The hospital adheres to the CMS regulation on documenting and reporting deaths in restraints...."

Document titled, "CMS Report of a Hospital Death Associated with the Use of Restraint or Seclusion", revealed the facility had submitted two (2) reports on Patient #1. One report indicated Patient #1 had died on 10/20/2023 while in 4 point hard restraints for violent behavior. One report indicated Patient #1 had died on 10/20/2023 while in 4 point soft restraints for non-violent behavior.

Review of Patient #1 medical record identified an ED History and Physical dated 10/17/2023 which revealed: "...Patient presented to the ED due to fall and RLE (right lower extremity) pain. The patient was here 10/6/23-10/10/23. (Patient) was treated for anemia, PNA (pneumonia) and electrolyte abnormalities...recommended SNF but the patient went home...back due to fall today...states needs more help...lives alone...states s/he is a DNR/DNI...Assessment/Plan: Congestive Heart Failure: start Lasix 20 mg IV BID, Consult cardiology and nephrology to assist; acute kidney injury (AKI): nephrology; anemia: monitor; CKD (chronic kidney disease); Fall: PT/OT, case management to assist in DC planning, wound care; ischemic cardiomyopathy: EKG, trop-I, IV diurese; PVT (paroxysmal ventricular tachycardia): Amiodarone...DNR, no intubation (BiPAP ok)...."

Review of Patient #1 medical record Physician note dated 10/18/2023 revealed: "...Metabolic encephalopathy: does have an underlying element of dementia...has happened when dehydrated however does appear to be euvolemic at the bedside...Later this morning became agitated and was swinging at nursing staff and wandering down the hallways...was placed in mechanical restraints and given 2 mg of IM Haldol...may need psychiatric evaluation down the line...The patient was seen and examined at the bedside this morning...when prompted seems to be alert and oriented X 4 answering correctly to correct date, president, year, and place however goes off on tangents and makes nonsensical comments which suggest to me that s/he is not oriented at baseline...."

Review of Patient #1 medical record Physician note dated 10/19/2023 revealed: "...Metabolic encephalopathy/delirium: The patient does have an underlying element of dementia...Yesterday the patient became delirious and agitated and was combative with nursing staff. We tried administering IM Haldol with little effect...subsequently received Ativan which resulted in significant sedation and respiratory suppression...Oxygen requirements went up to 10L...this morning remained agitated and aggressive pulling at [his] restraints...This resulted in skin sloughing from [his] chronic arm wounds...reached out to [son] and discussed palliative care...decision was made to transition to comfort measures with possible inpatient hospice over the next couple of days...There is a high likelihood that the patient passes away from aspiration as s/he is having a hard time keeping oxygen mask on...Family is aware of this...will control [his] symptoms and keep [him] comfortable...This hospitalization may be [his] last...If we are able to calm [him] down and get [him] out of restraints hopefully we will be able to discharge [him] to home with home hospice or inpatient hospice at a facility however s/he might not survive that long...For now we will discontinue labs. We will stop vital checks at night so s/he can get some rest...We will slowly make the transition to comfort care and hospice...."

Review of Patient #1 medical record nursing progress note dated 10/19/2023 at 0226 revealed: "...went into room to assess patient. Patient became increasingly agitated, combative and trying to get out of bed. NP was notified, Seroquel and Melatonin ordered and given. Progressively getting more agitated and combative, trying to get out of [his] restraints. NP was notified again and Ativan was ordered and given. Excessive skin tears noted on bilateral wrists and hands from trying to get out of restraints. Additional Ativan given per NP. Dressings applied to multiple skin tears sloughing...."

Review of Patient #1 medical record nursing progress note dated 10/20/2023 at 0137 revealed: "...This RN and day shift RN in at 1900 to provide skin care, peri care and linen change after patient removed [male] purewick. Patient disoriented and combative, in two point restraints on this RN's arrival. Patient repositioned, resting comfortably. Throughout the shift this RN was notified on multiple occasions that patient was restless and removing wound dressings, as well as combative and kicking at staff. Charge RN placed patient in 4 point restraints at 2200. Patient still restless. Charge RN administered 1 mg IV Lorazepam at 23:24 for restlessness and agitation. Received call from monitor room at approximately 0028 regarding patient reading asystole but still showing a rhythm. In to assess patient at approximately 0030. Patient found without a pulse, not breathing, and pupils fixed. Patient pronounced deceased by this RN and by Charge RN. Patient in 4 point restraints at time of death. Notified on-call hospitalist at 0034 of patient's passing. Attempted to notify family at 0036, left voicemail with callback number. Notified second emergency contact of patient passing at 0038...Review of telemetry alarms revealed patient in asystole at 0026...."

Review of physician restraint orders revealed the following orders:
*10/18/2023 at 1000 Restraints Non-Violent/Non-Destructive q2hr interval 24 hour, soft limb, all four extremities. Climbing out of bed/chair risking safety.
*10/19/2023 at 1000 Restraints Non-Violent/Non-Destructive q2hr interval 24 hr, soft limb, bilateral wrists, pulling at lines, tubes or dressings, physician face to face assessment done at 1000 10/19/2023.
*10/19/2023 at 2216 Restraints Non-Violent/Non-Destructive q2hr interval 24 hr, soft limb, All four extremities, pulling at lines, tubes or dressings, physician face to face assessment done at 2216 10/19/2023.

Employee #4 confirmed on 10/31/2023 that Patient #1 was placed in soft bilateral wrists restraints due to behaviors that were interfering with medical treatment and nursing cares. Employee #4 confirmed that Patient #1 remained uncooperative and was then placed in four point soft restraints. Employee #4 confirmed that Patient #1 was at no time in 4 point hard restraints.

Employee #1 confirmed on 10/31/2023 that the hospital had submitted two death reports on 10/24/2023 to CMS for Patient #1. Employee #1 confirmed that the first report submitted was completed incorrectly by a new staff member and was submitted before it could be reviewed for accuracy. Employee #1 confirmed that a second report was submitted on 10/24/2023 with the inaccurate information corrected, which resulted in conflicting reports being filed with CMS. Employee #1 acknowledged that the death report was submitted four days after the patient's death but thought that it was within the allowable timeframe as the patient had died on a weekend.