HospitalInspections.org

Intakes: TX00155679

Based upon record review and interview, the facility failed to follow their own policy regarding the use of restraints. The facility failed to properly assess 1 of 1 patient's behavior for the use of restraints. The facility failed to document on the physician's order the attempts at less restrictive interventions. The facility failed to obtain a time limited order for restraints. The facility failed to discontinue the restraints when the unsafe situation had ended. The facility also failed to obtain physician's orders for restraints for a second episode that restraints were utilized.

Record review of the facility's policy #80 titled "RESTRAINTS" revealed the following: The intent of this policy is to provide guidance in the use of restraints to all members of the patient care team who assess and/or provide care to patients.

1. ASSESS PATIENT'S BEHAVIOR
Assess patient's behavior to determine the need for the use of restraints.
A. Violent or Self Destructive Behavior:
a. Harmful to self, others and the environment. This includes hitting, hair pulling, throwing objects, striking at or biting staff, other patients and/or visitors and self mutilation.
B. Non-violent or Non Self Destructive Behavior:
a. Interferes with life-saving and/or necessary medical treatment. This includes, but is not limited to; pulling, tugging, grabbing at lines, catheters and tubes, picking at an open wound, interfering with complex dressings drains and traction..
b. Indicative that the patient is unable to follow directions to avoid self-injury. This may include climbing out of bed or wandering without the strength or cognition to safely do so.

2. CONSIDER THE USE OF LESS RESTRICTIVE INTERVENTIONS AS ALTERNATIVES TO RESTRAINTS: Less restrictive measures are to be considered prior to application of restraint devices. Such alternatives may include, but are not necessarily limited to: REORIENTATION, DE-ESCALATION, LIMIT SETTING, INCREASED OBSERVATION AND MONITORING, USE OF A SITTER, CHANGE IN THE PATIENT'S PHYSICAL ENVIRONMENT, REVIEW AND MODIFICATION OF MEDICATION REGIMENS. Less restrictive measures attempted must be documented on the physician order form.

3. ORDERING THE USE OF RESTRAINT FOR BOTH VIOLENT/SELF-DESTRUCTIVE BEHAVIOR AND NON-VIOLENT/NON-SELF DESTRUCTIVE BEHAVIOR. If less restrictive measures prove unsuccessful and the patient remains at risk to self, notify the Licensed Individual Practitioner and obtain a TIME LIMITED order for restraints before application. If there is an emergency situation where the need for a restraint or seclusion occurs so quickly that an order cannot be obtained prior to application, the order must be obtained immediately afterwards.

8. DISCONTINUATION OF RESTRAINT OR SECLUSION - Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Restraint or seclusion may only be employed while the unsafe situation continues. Once the unsafe situation ends, the use of restraint or seclusion must be discontinued.


Review of the medical record revealed patient #1 was brought to the facility by ambulance involuntarily on 1/20/12 at approximately 4:50 am after a suicide attempt in which patient took approximately 30 Xanax (Anti-Anxiety Medication). Patient also reported to have been drinking beer, vodka, and gin and also took some Vicodin (prescription narcotic pain medication). Emergency Medical Staff and Police reported that patient admitted she wanted to hurt herself. Patient had slurred speech upon arrival and vital signs were stable. Nursing assessment revealed "patient appeared to be intoxicated. Patient cooperative, patient alert, oriented to person, place, and time. Patient's affect agitated, alcohol on breath, depressed, judgement impaired, visual hallucinations present, patient states she sees "black figures", no auditory hallucinations reported". Review of physician's evaluation revealed no additional information about patient's condition. Physician re-evaluation documented at 6:01 am on 1/20/12 revealed the following: "Discussed results and findings with patient. Informed patient of plan to admit to hospital. Patient with intact gag reflex, slurred speech , wacing and waning mental status." There was no documentation that patient was psychotic, aggressive, violent, uncooperative, disoriented or requiring any emergency intervention while in the emergency department.

Review of nurses' notes for Critical Care Unit dated 1/20/12 at 6:45am revealed the following: "Received from ED (emergency department) per stretcher. Awake agitated. Pulling off IV's and monitoring devices and screaming. Placed in soft wrist restraints x2. 7:24am - Severely agitated, screaming and cursing. Refuses oxygen. Indwelling catheter with clear yellow urine. Redness to neck. Denies pain. Psychosocial - Cognitive Impairment: Delirium; Level of Anxiety: Panic; Behaviors observed: Agitated, screaming. States she will kill herself. Restraint: Yes, Type: Non-Violent. Comment Self Harm Risk.
8:19 am - Physician paged at 6:55 am. Returned call at 7:45 am. Reported to physician that patient was agitated, pulling at and refusing monitors and IV. Response from Physician - Geodon and Restraints ordered.

Review of physician's orders written as telephone orders at 7:48 am revealed: 1. Med Surg (Medical Surgical) restraints per policy. 2. Geodon (anti-psychotic medication) 20 mg IM STAT (Now). Further review of physician's orders revealed a pre-printed restraint order form that contained the following information that required writing in or making a check mark to define the order: Date: 1/20/12; Time: From___ to _____. The date (1/20/12) was re-written in the time area but there was no time limit. There was a section for Restraint Type with a check mark beside Soft Wrist x2 points and a check mark by Soft Ankle x2 points. The order contained a section titled Clinical Justification for Restraints (Non-violent or non-self destructive behavior) a check mark was made in front of "Interfering with life-saving and/or necessary equipment". The section for Clinical Justification for Restraints of Violent or Self destructive behavior (Agressive, violent, with potential for harm to self or others) was left blank. There was no documentation in the physician's orders for the least restrictive interventions attempted.

Further review of physcian's orders revealed orders dated 1/20/12 at 8:20am. The orders were as follows: MHMR (Mental Health Mental Retardation) Consult once patient is fully oriented for a period of 2 hours and respiratory rate equal to or greater than 16. Geodon 20 mg. IM every 12 hours as needed for severe agitation. Suicide Precautions. Social work consult.

Further review of nursing notes revealed the following: 8:35am - Sedated. Sleeping - respirations 18 and regular. 8:36am - Physician visit - patient exam, chart reviewed, orders.
9:25am - Restraint assessment completed. The following less restrictive measures were tried prior to restraining patient: Re-orientation, Comfort measures addressed, Increased observatioin/monitoring, diversional activities. Removal of restraints, position change, range of motion (ROM), skin care, circulation check, comfort measures addressed, Fluid/Nourishment, Elimination, Call bell in reach - Yes to all the above. Restraints discontinued - NO. There was no documentation of attempt to release patient from restraint. 10:30 am - Sedated, sleeping soundly, respirations 18 and regular. 10:54 am - 2 hour restraint assessment done. Restraints discontinued - No. No documentation of attempt to release patient from restraint. 12:51 pm - 2 hour restraint assessment done. Restraints discontinued - No. No documentation of attempt to release patient from restraint. Nursing note for the same time: "Sedated, sleeping soundly. Respirations regular and non-labored." 2:28 pm - 2 hour restraint assessment done. Restraints discontinued - No. No documentation of attempt to release patient from restraints. 3:37 pm - Nursing note - "Awake. Interacting x 2 hours. Respirations regular. Calm and interacting at this time. Have requested notification of MHMR per admission orders. 4:08 pm - 2 hour restraint assessment done. Restraints discontinued.

The afore mentioned nursing notes documented that patient remained in restraints from approximately 6:45 am until approximately 4:08 pm. During that time period, there was no documentation of attempts to release patient from restraints. From approximately 8:35 am - 12:51 pm, the documentation revealed patient was sedated and sleeping soundly. The unsafe situation no longer existed when patient was sedated and sleeping soundly and restraints could have been discontinued.

A telephone interview was conducted with staff #5 on 1/26/2012 at 11:00 am. Staff #5 reported to have been assigned to care for patient #1 on 1/20/2012. Staff #5 reported patient was screaming, cursing and severely agitated when arrived on the unit. Staff #5 reported patient #1 was the most hostile patient seen in the Intensive Care Unit. Staff #5 reported there were no attempts to release patient from restraints except when providing range of motion one extremity at a time. When patient was awake, coherent, and interacting calmly for 2 hours, patient was released from restraints.

Further review of nurses' notes for 1/20/12 at 5:40 pm revealed "Mental Health Screener to Bedside". 7:15pm - "Patient wondering what is going on and plans for tonight. Informed patient will check into it." 9:49pm - "State Hospital supervisor called Critical Care Unit and report given. Their physician on call will call for doctor to doctor report. State Hospital requires IVs and Foley out before transfer and patient needs to void." 10:00pm - Foley discontinued (dc'd) Bedside Commode (BSC) placed at bedside due to patient wobbly when out of bed." 10:18pm - Voided 100milliliters per BSC. 1/21/12 at 00:15am - "Attending Physician called confirming physician to physician report with state hospital. Gave order to transfer to State Hospital for psychiatric treatment." 00:45am - "Patient's IV out. Getting dressed. States she is leaving. Informed she is to go to state hospital tonight. States she will not do it and is leaving. Security paged to help detain patient until sheriff's department arrives to transfer to state hospital." 1:30 am - "Patient yelling and refusing to go to state hospital. Became violent, hitting and throwing furniture in room. Patient placed in bed and in four point restraints." 1:54am - Two officers from sheriff's department placed patient in handcuffs to wrist and ankle. Patient calmed down. Placed in wheelchair and pushed out by officer."

Review of physician's orders revealed no order written for the use of restraints.

Review of the medical record on 1/26/2012 at 11:00am with the Critical Care Unit Director and the Critical Care Unit Clinical Coordinator confirmed there were no orders written for the use of restraints, no documentation of least restrictive interventions attempted prior to application of restraints, and there was no further documentation regarding the restraints after they were applied.

Based upon record review and interview, the facility failed to obtain a physician's order for the use of restraint for 1 of 1 (#1)patient.

Review of the medical record revealed patient #1 was brought to the facility by ambulance involuntarily on an emergency detention warrant on 1/20/12 at approximately 4:50 am after a suicide attempt in which patient took approximately 30 Xanax (Anti-Anxiety Medication). Patient also reported to have been drinking beer, vodka, and gin and also took some Vicodin (prescription narcotic pain medication). Emergency Medical Staff and Police reported that patient admitted she wanted to hurt herself. Patient had slurred speech upon arrival and vital signs were stable. Nursing assessment revealed "patient appeared to be intoxicated. Patient cooperative, patient alert, oriented to person, place, and time. Patient's affect agitated, alcohol on breath, depressed, judgement impaired, visual hallucinations present, patient states she sees "black figures", no auditory hallucinations reported". Review of physician's evaluation revealed no additional information about patient's condition. Physician re-evaluation documented at 6:01 am on 1/20/12 revealed the following: "Discussed results and findings with patient. Informed patient of plan to admit to hospital. Patient with intact gag reflex, slurred speech , wacing and waning mental status."

Review of nurses' notes for 1/20/12 at 5:40 pm revealed "Mental Health Screener to Bedside". 7:15pm - "Patient wondering what is going on and plans for tonight. Informed patient will check into it." 9:49pm - "State Hospital supervisor called Critical Care Unit and report given. Their physician on call will call for doctor to doctor report. State Hospital requires IVs and Foley out before transfer and patient needs to void." 10:00pm - Foley discontinued (dc'd) Bedside Commode (BSC) placed at bedside due to patient wobbly when out of bed." 10:18pm - Voided 100milliliters per BSC. 1/21/12 at 00:15am - "Attending Physician called confirming physician to physician report with state hospital. Gave order to transfer to State Hospital for psychiatric treatment." 00:45am - "Patient's IV out. Getting dressed. States she is leaving. Informed she is to go to state hospital tonight. States she will not do it and is leaving. Security paged to help detain patient until sheriff's department arrives to transfer to state hospital." 1:30 am - "Patient yelling and refusing to go to state hospital. Became violent, hitting and throwing furniture in room. Patient placed in bed and in four point restraints." 1:54am - Two officers from sheriff's department placed patient in handcuffs to wrist and ankle. Patient calmed down. Placed in wheelchair and pushed out by officer."

Review of physician's orders revealed no order written for the use of restraints.

Record review of the facility's policy #80 titled "RESTRAINTS" revealed the following: The intent of this policy is to provide guidance in the use of restraints to all members of the patient care team who assess and/or provide care to patients.

1. ASSESS PATIENT'S BEHAVIOR
Assess patient's behavior to determine the need for the use of restraints.
A. Violent or Self Destructive Behavior:
a. Harmful to self, others and the environment. This includes hitting, hair pulling, throwing objects, striking at or biting staff, other patients and/or visitors and self mutilation.
B. Non-violent or Non Self Destructive Behavior:
a. Interferes with life-saving and/or necessary medical treatment. This includes, but is not limited to; pulling, tugging, grabbing at lines, catheters and tubes, picking at an open wound, interfering with complex dressings drains and traction..
b. Indicative that the patient is unable to follow directions to avoid self-injury. This may include climbing out of bed or wandering without the strength or cognition to safely do so.

3. ORDERING THE USE OF RESTRAINT FOR BOTH VIOLENT/SELF-DESTRUCTIVE BEHAVIOR AND NON-VIOLENT/NON-SELF DESTRUCTIVE BEHAVIOR. If less restrictive measures prove unsuccessful and the patient remains at risk to self, notify the Licensed Individual Practitioner and obtain a TIME LIMITED order for restraints before application. If there is an emergency situation where the need for a restraint or seclusion occurs so quickly that an order cannot be obtained prior to application, the order must be obtained immediately afterwards.


Review of the medical record on 1/26/2012 at 11:00am with the Critical Care Unit Director and the Critical Care Unit Clinical Coordinator confirmed there were no orders written for the use of restraints and there was no further documentation regarding the restraints after they were applied.