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Based on document review and interview, it was determined for 1 of 11 (Pt. #1) clinical records reviewed of psychiatric patients in the Emergency Department, the hospital failed to ensure patients were free from physical abuse, per policy.
Findings include:
1. Hospital policy titled, "Patient Rights and Responsibilities" lacking an effective date, was reviewed on 1/8/14 at 11:15 AM and required, " IV Patient Rights - All patients (or family when appropriate) have the right to... Be free from... mental, physical... abuse."
2 On 1/7/14 at 9:50 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was an 85 year old female, treated in the ED on 8/5/13, with diagnoses of disequilibrium, disease and disorder of ear, nose, mouth, and throat, dementia, hypertension, and urinary tract infection (UTI). A physician ' s note dated 8/5/13 at 7:58 PM, included, " ...While waiting [for admission] in the ER, another patient [Pt. #2] attached... [Pt. #1] repeatedly hitting her in the head. The assaulter [Pt. #2] was removed by ED staff. Afterwards patient [Pt. #1] was crying but consolable and on repeat exam PEERL [pupils equal and equally reactive to light] with a hematoma on the left posterior scalp, no ttp [tender to pressure] of neck, and no other apparent abrasions at this time. Head CT was repeated which demonstrated interval hematoma but no intracranial pathology.
3. Pt. #1 ' s history and physical dated 8/6/13 at 11:26 AM, included, Pt. #1 was observed in the intensive care unit during the night (8/5/13). A nursing note dated 8/6/13 at 10:24 AM, included, " Discharged home accompanied by family. Condition stable. Discharge instructions given including follow-up appointment. "
4. On 1/8/14 at 9:40 AM, an interview was conducted with the Director of Emergency Services (E #3). E #3 stated that Pt. #2 was one to one while in restraints but the sitter was discontinued after restraints were removed because Pt. #2 was calm and cooperative.

Based on document review and interview, it was determined for 5 of 7 (Pt #s 2, 6, 7, 8 and 9) clinical records reviewed of patients in restraints, the hospital failed to ensure a physician ' s order was obtained for restraints as per policy.
Findings include:
1. Hospital policy titled, " Restraint and Seclusion for Violent/Self-Destructive Patient (revised 9/13) " included, " Orders for Restraints: The initial and all subsequent restraint orders shall expire: 4 hours or less for patients 18 years of age and older. Each order must be provided by a physician ... "
2. The clinical record of Pt. #2 was reviewed on 1/7/14. Pt. #2 was a 26 year old male, treated in the ED on 8/5/13 with the diagnosis of schizophrenia. Pt. #2 ' s Restraint and Seclusion Observation Flow Sheet dated 8/5/13, indicated Pt. #2 was placed in restraints at 5:30 PM through 6:15 PM, when he was transferred to another hospital. The clinical record lacked documentation of a physician's order for the restraints.
3. The clinical record of Pt. #6 was reviewed on 1/8/14. Pt. #6 was a 32 year old male admitted on 10/7/13 with the diagnosis of psychosis. The nursing progress notes included Pt. #6 was placed in behavioral restraints due to aggression on 10/7/13 at 3:00 PM and removed from restraints on 10/8/13 at 2:45 PM. The clinical record included a physician ' s orders for behavioral restraints dated 10/7/13 at 3:00 PM, 10/8/13 at 1:00 AM and 10/8/13 at 5:00 AM. The clinical record lacked documentation of a physician ' s order every 4 hours as per policy.
4. The clinical record of Pt. #7 was reviewed on 1/8/14. Pt. #7 was a 35 year old male admitted on 10/31/13 with the diagnosis of suicide attempt. The nursing progress notes included Pt. #7 was placed in behavioral restraints due to patient becoming aggravated on 10/31/13 at 12:30 PM and removed from restraints on 10/31/13 at 7:40 PM. The clinical record lacked documentation of a physician's order for restraints.
5. The clinical record of Pt. #8 was reviewed on 1/8/14. Pt. #8 was a 32 year old female admitted on 9/3/13 with the diagnosis of overdose of heroin. The nursing progress notes included Pt. #8 was placed in behavioral restraints by security due to " emergency physician states that patient is a deserter and needs to be restrained " on 9/3/13 at 5:16 PM and removed from restraints on 9/3/13 at 5:17 PM (RN felt restraints not needed). The clinical record lacked documentation of a physician ' s order for restraints.
6. The clinical record of Pt. #9 was reviewed on 1/8/14. Pt. #9 was a 38 year old male admitted on 9/18/13 with the diagnosis of alcohol intoxication. The nursing progress notes included Pt. #9 was placed in behavioral restraints due to patient becoming aggressive on 9/18/13 at 5:00 AM and removed from restraints on 9/18/13 at 9:00 AM. The clinical record lacked documentation of a signed physician ' s order for restraints.
7. During an interview on 1/8/14 at 1:30 PM the Director of Emergency Services stated, " there should be a physician orders for restraints on all of the reviewed records."

Based on document review and interview, it was determined for 1 of 7 (Pt. #4) clinical records reviewed of patients in restraints, the hospital failed to discontinue the restraints at the earliest possible time.
Findings include:
1. Hospital policy titled, " Restraint and Seclusion for Violent/Self -Destructive Patient (revised 9/13) " included, " A trained staff member provides continuous monitoring, needs assessment and comfort measures that include the following: Readiness for discontinuation of restraint. "
2. The clinical record of Pt. #4 was reviewed on 1/8/14. Pt. #4 was a 25 year old male admitted on 10/29/13 with the diagnosis of drug abuse. The nursing progress notes included Pt. #4 was placed in behavioral restraints due to agitation on 10/29/13 at 3:57 PM and removed from restraints on 10/29/13 at 8:04 PM. The nursing assessment dated 10/29/13 at 5:06 PM included, " Patient is alert and oriented times 3 (person, place and time).
The " Restraint and Seclusion Observation Flow Sheet " included that Pt. #4 was calm and cooperative during the entire restraint occurrence. Pt. #4 remained in restraints for 4 hours and was discharged home when the restraints were removed.
3. During an interview on 1/8/14 at 1:30 PM the Director of Emergency Services stated she could not find documentation of why Pt. #4 remained in restraints for that period of time or if an assessment was completed to remove the restraints earlier.

A. Based on document review and interview it was determined for 1 of 7 (Pt. # 2) clinical records of patients in restraints, the hospital failed to ensure the patients in restraints were monitored every 15 minutes, as required by policy.
Findings include:
1. Hospital policy titled, " Restraint and Seclusion for Violent/Self-Destructive Patient (revised 9/13)" was reviewed on 1/9/13 at 11:00 AM. The policy included, " [Physical Restraint] Documentation... Continuous monitoring and documentation every 15 minutes of the patient's status... Chemical Restraint (drug used as a restraint)... 6. Monitor the patient at 15 minute intervals for the first two (2) hours for behavioral status and effects(s) of medication administered."
2. The clinical record of Pt. #2 was reviewed on 1/7/14. Pt. #2 was a 26 year old male, treated in the ED on 8/5/13 with the diagnosis of schizophrenia. The nursing progress notes dated 8/5/13 at 1:16 PM, included, "On arrival [9:30 AM] patient is violent striking out at staff placed in 4 point restraint." Nursing notes dated 10:00 AM; included Pt. #2 was administered Ativan 1 mg and Haldol 5 mg "for therapeutic reasons." Pt. #2's "Restraint and Seclusion Observation Flow Sheet" included documentation of 30 minute monitoring, not 15 minute monitoring, during restraint, from 9:30 AM to 1:30 PM.
3. On 1/8/14 at 9:40 AM, an interview was conducted with the ED Manager (E #3). E #3 stated that there should have been documentation of 15 minute monitoring for Pt. #2 while in restraints. The reassessment for Ativan and Haldol was documented at 11:30, 1 1/2 hours after administration. The nurse responsible for Pt. #2's 15 minute monitoring has resigned.
B. Based on document review and interview it was determined for 5 of 7 (Pt. #s 2, 4, 5, 6 and 7) clinical records of patients in restraints, the hospital failed to ensure extremity circulation was monitored while the patient was in restraints.
Findings include:
1. Hospital policy titled, " Restraint and Seclusion for Violent/Self -Destructive Patient (revised 9/13) " included, " A trained staff member provides continuous monitoring, needs assessment and comfort measures that include the following: ... Circulation and range of motion of the extremities. "
2. The hospital " Restraint and Seclusion Observation Flow Sheet (revised 10/11) " required, " The following are continuously monitored and recorded at a minimum of every: 1 hour - circulation check. "
3. The clinical record of Pt. #2 was reviewed on 1/7/14. Pt. #2 was a 26 year old male, treated in the ED on 8/5/13 with the diagnosis of schizophrenia. The nursing progress notes dated 8/5/13 at 1:16 PM, included, "On arrival patient is violent striking out at staff placed in 4 point restraint." Pt. #2's "Restraint and Seclusion Observation Flow Sheet" lacked documentation of hourly circulation being monitored, while Pt. #2 was in restraints from 9:30 AM to 1:30 PM.
4. The clinical record of Pt. #4 was reviewed on 1/8/14. Pt. #4 was a 25 year old male admitted on 10/29/13 with the diagnosis of drug abuse. The nursing progress notes included Pt. #4 was placed in behavioral restraints due to agitation on 10/29/13 at 3:57 PM and removed from restraints on 10/29/13 at 8:04 PM. The " Restraint and Seclusion Observation Flow Sheet " lacked documentation of circulation being monitored.
5. The clinical record of Pt. #5 was reviewed on 1/8/14. Pt. #5 was a 41 year old male admitted on 9/4/13 with the diagnosis of drug abuse. The nursing progress notes included Pt. #5 was placed in behavioral restraints due to agitation on 9/4/13 at 3:39 PM and removed from restraints on 9/4/13 at 7:22 PM. The " Restraint and Seclusion Observation Flow Sheet " lacked documentation of circulation being monitored.
6. The clinical record of Pt. #6 was reviewed on 1/8/14. Pt. #6 was a 32 year old male admitted on 10/7/13 with the diagnosis of psychosis. The nursing progress notes included Pt. #6 was placed in behavioral restraints due to aggression on 10/7/13 at 3:00 PM and removed from restraints on 10/8/13 at 2:45 PM. The " Restraint and Seclusion Observation Flow Sheet " lacked documentation of circulation being monitored.
7. The clinical record of Pt. #7 was reviewed on 1/8/14. Pt. #7 was a 35 year old male admitted on 10/31/13 with the diagnosis of suicide attempt. The nursing progress notes included Pt. #7 was placed in behavioral restraints due to patient becoming aggravated on 10/31/13 at 12:30 PM and removed from restraints on 10/31/13 at 7:40 PM. The " Restraint and Seclusion Observation Flow Sheet " lacked documentation of circulation being monitored.
8. During an interview on 1/8/14 at 1:30 PM the Director of Emergency Services stated, " There seems to be a pattern of not documenting circulation, all these patients do not have it documented."
C. Based on document review and interview, it was determined for 2 of 2 (Pts. #2 & 7) clinical records reviewed of patients on suicide precautions, the hospital failed to ensure visual monitoring by a support person, occurred per policy.
Findings include:
1. Hospital policy titled, "Suicide Risk Assessment and Interventions in Acute Care Setting (revised 8/13)", was reviewed on 1/8/14 at 11:10 AM and required, " Interventions relative to level of suicide risk: Immediate Risk Patients: ... including actual suicide attempt. Level of Supervision: Continuous visual surveillance (line of sight) with 1:1 observation. "
The policy also required, (pg 5) " Moderate Risk Patients (level 3): Close Observation ... (pg 2) Levels of Supervision ... C. Close Observation: Patients may not be left alone without support person (may be reliable family/friend). "
2. The clinical record of Pt. #2 was reviewed on 1/7/14. Pt. #2 was a 26 year old male, treated in the ED on 8/5/13 with the diagnosis of schizophrenia. A nursing assessment on 8/5/13 at 1:16 PM included a " suicide lethality assessment " which placed Pt. #2 at " suicide risk moderate". "Suicide interventions done include... continuous 1:1 direct observation..."
3. On 8/5/13 at 1:30 PM, when restraints were removed, one to one care provided for suicidal protection and during restraint was removed and Pt. #1 was cared for and monitored by a registered nurse (E #7) every 15 minutes, not constantly, as required by policy.
4. During a phone interview with E #7 on 1/8/14 at 2:00 PM, E #7 stated on 8/5/13 on the 11:00 AM to 11:00 PM shift, he was assigned to 4 patient rooms, including Pt. #2's, and Pt. #2 was not one to one after the restraints were removed. Pt. #2 attacked and injured another patient when E #7 was out of the room.
5. On 1/8/14 at 9:40 AM, an interview was conducted with the Director of Emergency Services (E #3). E #3 stated that Pt. #2 was one to one while in restraints but the sitter was discontinued after restraints were removed because Pt. #2 was calm and cooperative.
6. The clinical record of Pt. #7 was reviewed on 1/8/14. Pt. #7 was a 35 year old male admitted on 10/31/13 with the diagnosis of suicide attempt. Pt. #7 was assessed as a high suicide risk per " overall suicide lethality score. " The nursing progress note dated 11/1/13 at 12:56 AM included, " patient was reassessed at 11:30 PM, sitter leaves at this time. " The nursing progress note dated 11/1/13 at 7:49 AM included, " The patient was reassessed at 7:30 AM, and sitter arrives at this time. " Every 15 minute safety checks were documented throughout the night by the RN caring for the patient.
7. During another interview on 1/8/14 at 1:30 PM with E #3, E #3 stated, " I cannot explain why a sitter was not present for the night shift [for Pt. #7], but there definitely should have been one."