Based upon hospital policy and procedure reviews, observations during tours, medical record reviews, Law Enforcement Officer (LEO) interviews, staff and physician interviews, the hospital's Emergency nursing staff failed to provide ongoing assessment and monitoring of the condition of a patient during restraint or seclusion for 6 of 6 emergency department (ED) patients (#14, #16, #13, #17 #12, #9) under involuntary commitment (IVC).
The findings include:
Review of current hospital policy "Restraint of Patients, PC 17", revised 12/2014, revealed "PURPOSE: The use of restraints is a therapeutic intervention implemented to prevent the patient from injuring himself/herself or from injuring others.
Based upon hospital policy and procedure reviews, observations during tours, medical record reviews, Law Enforcement Officer (LEO) interviews, staff and physician interviews, the hospital's Emergency nursing staff failed to provide ongoing assessment and monitoring of the condition of a patient during restraint or seclusion for 6 of 6 emergency department (ED) patients (#14, #16, #13, #17 #12, #9) under involuntary commitment (IVC).
The findings include:
Review of current hospital policy "Restraint of Patients, PC 17", revised 12/2014, revealed "PURPOSE: The use of restraints is a therapeutic intervention implemented to prevent the patient from injuring himself/herself or from injuring others. The decision to use a restraint is driven by a comprehensive individual assessment. This document is used to provide consistent guidelines for the safe use of chemical and physical restraints and seclusion, if alternatives, as determined by an interdisciplinary team, have proven to be clinically ineffective to provide a safe environment for the patient. ...DEFINITIONS: Restraint - is the direct application of physical force to a patient, with or without the patient's permission, to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination thereof. Physical Restraints - any manual method or physical/mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. ...Restraint to Promote Medical Recovery (non-violent): refers to the use of restraints in those patients who require various medically essential therapies while hospitalized and who demonstrate a state of confusion or altered cognition that puts those therapies at risk OR those patients who require management of non-psychiatric behaviors that put them at risk for injury. Restraints for Violent or Self-Destructive Behavior: refers to the use of restraints in those patients who require management of violent or self-destructive behavior towards themselves or others (including caregivers or other patients) or, who require physical restraint to manage suicidal or homicidal behaviors in ANY setting. ...Restrictive Devices Applied by Law Enforcement Officials - handcuffs and other restrictive devices applied by law enforcement officials for custody, detention, and public safety reasons and is not involved in the provision of health care; no considered restraints. ...Seclusion - seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. The following interventions are not considered seclusion: 1. a patient physically restrained alone in an unlocked room. ...POLICY: It is the policy of (Hospital name) Medical Center to: 1. Prevent, reduce and eliminate the use of restraints by: a. preventing emergencies that have the potential to lead to the use of restraints, b. limiting the use of restraints to emergencies where there is a risk of the patient harming himself/herself or others. c. using the least restrictive method. 2. Protect the patient and preserve the patient's rights, dignity and well being during restraint use by: a. respecting the patient as an individual; b. maintaining a clean and safe environment; ...d. maintaining the patient's modesty, preventing visibility to others, and maintaining comfortable body temperature is maintained. 3. Provide for safe application and removal of the restraint by qualified staff. 4. Monitor and meet the patient's needs while in restraints. 5. Re-assess and encourage release of restraints as soon as possible. ...Restraints will be used only in situations where the patient is demonstrating observable behaviors that indicate he/she is at risk of injuring himself/herself or others. Restraints are not to be used for punishment, coercion, discipline, or retaliation of the patient or for staff convenience. This policy does not apply to devices....used by law enforcement officials although the standards of care stated within this document may be applicable. ...PROCEDURES: ASSESSMENT OF RISK FACTORS, INTERVENTIONS AND ALTERNATIVES TO RESTRAINT USE: A comprehensive assessment of the patient must determine that the risks associated with the use of the restraint are outweighed by the risk of not using it. ...Attempts should be made to evaluate and use the following interventions/alternatives when possible and in response to the patient's assessed needs: *Monitoring: 1. Companionship; staff or family stay with patient 2. Room near or visible from nursing station 3. Close, frequent observation ...*Environmental Measures: ...5. Room/halls clear of obstacles such as excess equipment ...Regular toileting: 1. Establish consistent toileting schedule for patient. ...CLINICAL JUSTIFICATION FOR USE OF RESTRAINT AND/OR SECLUSION: When clinically indicated, the restraint procedure is implemented by the RN who is trained in restraint and/or seclusion techniques upon a physician's/LIP's order. Unless there is an immediate and overriding concern for safety, the restraint procedure is utilized only after all alternatives, less restrictive treatment interventions have been tried without success. Prior to implementation of any restraint, care team members will confer to determine that appropriate alternative measures have been attempted. Using the decision flowcharts for patient behaviors and alternatives for use of restraint, clinical assessment and utilization of restraint should be based on patient's behavior that may place the patient or others at risk for harm. Situations in which restraints are clinically justified include: *Threatens placement and/or patiency of necessary therapeutic lines/tubs, interfering with necessary medical treatment, and appropriate alternative measures have been attempted. ...*Unable to follow directions to avoid self-injury, and appropriate protective, alternative measures have been attempted. *Vulnerable patient populations, such as Pediatrics, who are cognitively or physically limited, are at a greater risk for injury Great caution should be utilized before initiating restraint use. LEAST RESTRICTIVE RESTRAINT/SAFE APPLICATION: Assessment and reassessment processes should include the appropriateness of the choice of restraint and/or seclusion. Physical restraints will be loosened periodically to evaluate skin integrity and circulation while the patient is in restraints. The types of restraint devices available within this facility and how to apply safely is as follows: ...2. Limb Restraints 1-->2-->3-->4-point ...5. Seclusion - Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member, or others. Seclusion is not a patient physically restrained alone in an unlocked room... ALTERNATIVE THERAPY: Prior to physically restraining a patient, restraint-free interventions such as (but not limited to) the following are attempted: *Provide safe environment, i.e., bed in low position, clutter free environment ...Enhanced observation ...*Sitter... PROCEDURE FOR USE OF RESTRAINT: Initiation and Renewal of Orders Standing orders, protocols, and/or PRN orders are not permitted. When initiating the use of a restraint, the appropriate restraint physician's order form (Nonviolent or Violent/Self Destructive) must be completed and placed on the chart within 30 minutes. This original order is time-limited based on type of restraint and age of patient. When use of restraints is contemplated, a physician/LIP or RN who has been trained in restraint application must document a face-to-face assessment prior to applying restraints, and document the need for restraint within the 1 hour time frame. The physician's/LIP's order must specify: *the restraint type *the justification for the restraint *date and time ordered *duration ...The in-person evaluation, conducted within one hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff or others, includes the following: *an evaluation of the patient's immediate situation *the patient's reaction to the restraint *the patient's medical and behavioral condition *the need to continue or terminate the restraint or seclusion ...The Nonviolent Restraint Physician's Orders: Orders for nonviolent restraints must be renewed each calendar day by the patient's attending physician or other designated LIP based on his or her examination of the patient. It is not necessary for the renewal to be completed within a 24-hour time-frame as the physician can re-evaluate the patient and need for non-violent/self-destructive restraints during routine rounds. If restraints for nonviolent behavior purposes are anticipated to be continued beyond the maximum time limit of the order, a restraint renewal sticker is placed on the physician order form and must be completed by the LIP before the original order expires. Its use is based on his or her face-to-face examination of the patient. For Violent/Self-Destructive Restraints [V/SD] A physician/LIP or trained RN must document a face-to-face assessment within 1 hour of implementation of restraint or seclusion. The 1-hour face-to-face evaluation includes both a physical and behavioral assessment of the patient that must be conducted by a qualified practitioner within the scope of their practice. An evaluation of the patient's medical condition would include a complete review of systems assessment, behavioral assessment, as well as review and assessment of the patient's history, drugs and medications, most recent lab results, etc. The purpose is to complete a comprehensive review of the patient's condition to determine if other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are contributing to the patient's violent or self-destructive behavior. During the face-to-face assessment, the qualified practitioner will evaluate the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion. The time limit for Violent/Self-Destructive Restraints is: *4 hours for adults (18 years of age or older) *2 hours for children (ages 9-17) *1 hour for children under age of 9 ...All patients who are in restraints must be continuously monitored and reassessed for the need to continue restraint by a qualified registered nurse (RN). ...When the order for restraints expires, a qualified, trained individual (who has been authorized by the organization to perform this function) will conduct an in-person assessment. If the patient is not ready for release from restraints, the authorized staff member will re-evaluate the efficacy of the patient's treatment plan and revise accordingly. the physician/LIP responsible for the patient's ongoing care will then be notified and a telephone order will be obtained and a new restraint physician order form will be placed on the chart for completion by the LIP. When the authorized, qualified staff member other than the physician/LIP continues restraints based on a new telephone order by the physician/LIP, the physician/LIP will re-evaluate the patient i.e. face-to-face assessment at least every 24 hours for adults, 2 hours for ages 9-17 and after 1 hour for children under age of 9 years for nonviolent restraints. If restraints are to be continued, a new time-limited order for restraints will be obtained from the physician/LIP. For Violent/Self Destructive restraints, a face-to-face re-evaluation by the physician/LIP is required after 4 hours for adult patients, after 2 hours for children ages 9-17 and after 1 hour for children under age 9. Seclusion guidelines 1. Individuals placed in seclusion must have a protected, private observable environment that safe guards their dignity and well-being. 2. The decision to seclude may be made by a trained RN in an emergency situation in which the patient exhibits violent, self-destructive behavior, when the physician is not available, after conducting a face-to-face assessment of the individual to determine whether the behavior requires seclusion. A physician or other LIP must see and evaluate the need for seclusion within one hour after the intervention is initiated. ...4. The patient who is simultaneously restrained and secluded is continually monitored by trained staff either in-person or through the use of both video and audio equipment that is in close proximity to the patient. 5. Staff must monitor an individual placed in seclusion and document findings at a minimum of every 15 minutes. 6. Articles that might be used to inflict self-injury must be removed prior to placing in seclusion. ...8. If an individual falls asleep in seclusion, the door must be unlocked and opened within the nearest fifteen minute period monitoring. If the door is not unlocked, clinical justification must be documented in the patient's clinical record. Upon awakening, the patient must be re-evaluated by a RN or the physician upon awakening for continued release without regard to how long the individual was asleep or whether the maximum length of time prescribed in the order has expired. ...Discontinuing Restraint Once restraint is applied or initiated, the patient should be monitored and evaluated for the continued need of the intervention and the continued appropriateness of the type of intervention. ...The restraint should be discontinued as soon as the patient meets the behavior criteria for its discontinuation. The assessment of the continued need for restraint to determine early release should be documented at a minimum of every two hours or more often as the patient's condition improves. ...MONITORING, ASSESSING, AND CARE OF THE PATIENT IN RESTRAINTS: When restraints are used there is an increased need for patient monitoring and assessment to assure patient safety, that the less restrictive methods are used when possible, and that restraint is discontinued as soon as possible. Immediately after restraints are applied an assessment should be made to ensure that the restraints were properly and safely applied so as to not cause the patient harm or pain. Documentation should include this assessment as well as the patient's response, any adjustments made. The frequency of monitoring the patient must be made on an individual basis, which includes a rationale that reflects consideration of the individual patient's medical needs and health status. The assessment includes, as appropriate to the type of restraint used: *signs of injury associated with the restraints *nutrition/hydration *circulation and range of motion in the extremities *vital signs *hygiene and elimination *physical and psychological status and comfort (i.e. skin integrity, comfortable body temperature, the patient's dignity, mental status, and emotional well being) *readiness for release from restraints *patient's understanding of the reasons for restraint and requirements for release ...PATIENT/FAMILY EDUCATION: Restraint procedures should be performed in a manner that does not violate the patient's rights. ...For Non-Violent restraints, reassessment and documentation is required at least every 2 hours and for Violent/Self-Destructive restraints, it is required every 15 minutes. DOCUMENTATION: The medical record should document: *that the patient and/or family was informed of the organization's policy on the use of restraints; *any medical condition or any physical disability that would place the patient at greater risk during restraints/seclusion; *any history of sexual or physical abuse that would place the patient at grater psychological risk during restraint/seclusion. Documentation within the patient's record should indicate a clear progression in how techniques were implemented with the less intrusive restrictive intervention attempted or considered prior to the introduction of more restricted measure. When a restraint is initiated, the order must be documented immediately upon initiation. If the order for restraint is not initiated by the treating physician, the order must be followed by consultation with the patient's attending physician as soon as possible. ...Each episode of restraint/seclusion use is to be recorded in the medical record. Documentation will include: *date restraint applied *time restraint applied *type of Restraint (non-violent or violent/self destructive) *restraint device (soft, mitten, vest, geri-chair, etc.) *safe application verified *level of consciousness *safety/rights/dignity maintained verified *observed restraints appropriately intact *behavior during restraints *vital signs taken *free from injury associated with restraint *skin under/around restraint intact * range of motion done *circulation distal to restraint verified *offered nutrition/hydration *offered assistance with toileting/hygiene *offered comfort measures *the circumstances that led to restraint or seclusion use *consideration or failure of non-physical interventions including alternatives attempted and successful *the rationale for the type of physical intervention selected *notification of the patient's family/significant other, when appropriate *patient's response and any changes made as a result of the restraints *each telephone order received from a physician/LIP * debriefing of the patient with staff *any injuries that are sustained and treatment received from these injuries *any deaths. DISCONTINUING RESTRAINT DOCUMENTATION GUIDELINES *Criteria for restraint release met *Date restraint discontinued *Time restraint discontinued *Restraint debriefing when applicable for behavior (violent/self-destructive) MODIFICATION TO PATIENT'S PLAN OF CARE: The plan of care should clearly reflect a loop of assessment, intervention, evaluation and re-intervention. Restraint use must be in accordance with a written modification to the patient's plan of care..."
1. Observation during ED tour on 01/14/2015 at 1427 of exam room #17, revealed the room was located across from the nursing station. Observation revealed the room had a sliding glass door. Observation revealed a male patient (Patient #14) wearing green disposable scrubs and sitting on the end of the stretcher leaning over a bedside table. Observation revealed the stretcher's two side rails were up and in the locked position. Observation revealed the patient was alert, calm, and cooperative. Observation revealed the patient's right leg/ankle was chained to the stretcher's frame with a metal shackle/cuff (restraint). Observation revealed the patient did not exhibit any violent or self-destructive behaviors. Observation revealed the patient was in the exam room alone and without direct supervision of a LEO. At 1433, observation revealed Patient #14 stood up off the end of the stretcher and pivoted around to the side of the stretcher without difficulty or assistance. At 1434, observation revealed XYZ County Sheriff Deputy (CSD) #1 was sitting behind the nursing station in a cubical. Observation revealed the cubical was on the opposite side of the nursing station, away from exam room #17. Observation revealed CSD #1 stood up and exited the cubical and walked down the hallway on the opposite side of the nursing station, away from exam room #17 and exited the emergency department treatment area through a set of double doors. Observation revealed Patient #14 was alone in exam room #17 unsupervised by a LEO. At 1436, observation revealed CSD #1 returned to the cubical in the nursing station and sat down. Observations from 1427 to 1500 failed to observe any violent or self-destructive behaviors exhibited by Patient #14 while being restrained in exam room #17.
Open medical record review on 01/14/2015 revealed Patient #14, a [AGE] year old male presented to the hospital's ED on 01/13/2015 at 1820 accompanied by Law Enforcement under IVC petition. Review revealed the patient's chief complaint was IVC-Crisis Evaluation Referral. Review of triage nurse documentation at 1827 revealed "IVC, per caregiver pt (patient) with bizarre behavior, pt walking around showing gentials [sic], pt endorses auditory hallucinations, pt with rambling thoughts in triage, pt states he will only hurt someone if they try to hurt him." Review of triage assessment documentation revealed the patient was alert, oriented x 3 (person, place, time) and anxious. Review revealed the patient was evaluated by a physician at 1908. Review revealed a chief complaint of being agitated and exposing genitals. Review revealed the patient was assessed as no acute distress, awake and alert, slightly agitated, pressured speech, and directable. Review revealed the patient was "cooperative." Review of a "Findings and Custody Order Involuntary Commitment" revealed the order was signed on 01/13/2015 at 1541 by a Magistrate. Review revealed "The Court finds from the petition in the above matter that there are reasonable grounds to believe that the facts alleged in the petition are true and that the respondent (Patient #14) is probably: [X] 1. mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness. ..." Review of an "Examination and Recommendation to Determine Necessity for Involuntary Commitment" form dated 01/13/2015 at 2345 revealed "Description of Findings" with "...presenting for agitation, exposing himself inappropriately to others. On evaluation, pt is disorganized with pressured speech. Oriented to location but not situation. Is currently a danger to himself due to psychosis." Review of nursing documentation at 2235 revealed "Resting quietly in bed. No aggressive behaviors, no self-injurious behavior. ..." At 1215 (01/14/2015) "...Pt unshackled while bed was exchanged." At 1330 "Pt sitting at end of bed. No c/o voiced. No distress noted." At 1500 "Pt sitting on bed c (with) no distress noted." At 1845 "Pt transported to (hospital name)....ambulated to police care no distress noted." Review of "Suicide Precautions Flow sheet" documentation on 01/13/2015 from 1900 to 2300 and 01/14/2015 from 0715 to 1845 revealed the patient's behavior was documented by staff as calm or cooperative. Review revealed no documentation the patient was violent or aggressive. Review revealed on 01/14/2015 at 1430, 1445, and 1500 (corresponding timeframe to Surveyor's observation [1427-1500] of the patient cuffed/shackled to the stretcher) as being cooperative. Record review failed to reveal any available documentation Patient #14 exhibited violent or self-destructive behaviors necessitating the need for restraint use while hospitalized from [DATE] at 1820 through discharge on 01/14/2015 at 1845. Further record review failed to reveal documentation of ongoing monitoring and assessment of the patient at least every 15 minutes for violent/self-destructive restraint or every two hours for non-violent restraint (as appropriate to the type of restraint used) for one or more of the following: signs of injury associated with the restraints, nutrition/hydration, circulation and range of motion in the extremities, vital signs, hygiene and elimination, physical and psychological status and comfort (i.e. skin integrity, comfortable body temperature, the patient's dignity, mental status, and emotional well being), readiness for release from restraints, patient's understanding of the reasons for restraint and requirements for release, per hospital policy.
Interview on 01/13/2015 at 1107 during ED tour with Charge Nurse #1 revealed the only approved restraints used in the ED by nursing staff are "soft limb restraints." Interview revealed "only the Sheriff and Police Departments use handcuffs and shackles with IVC patients." Interview revealed the nurse is responsible for monitoring and assessing the patient when in handcuffs or shackles. Interview revealed the nursing staff is not responsible for applying the handcuffs or shackles.
Interview on 01/14/2015 at 1442 with CSD #1 revealed he was a Deputy Sheriff with the XYZ County Sheriff's Department. Interview revealed he was present in the ED for a "10-73" (mental subject). Interview revealed the patient (#14) in exam room #17 was under IVC. Interview revealed the patient was brought to the ED on 01/13/2015. Interview revealed he relieved the previous Deputy this morning (01/14/2015) at shift change. Interview revealed the previous Deputy placed the patient into "ankle shackles." Interview revealed the "officer makes the decision wither or not the patient needs to be handcuffed or shackled." Interview revealed Patient #14 was not going to jail and was not under arrest. Interview revealed he (CSD #1) was on standby until a mental health facility could be found for the patient. Interview revealed because the patient was in his custody, he was responsible for any of the patient's actions. Interview revealed when the patient complains the cuffs/shackles are too tight or hurting, he will use 2-3 fingers to check to see if the cuffs/shackles are too tight. Interview revealed there was no set schedule for periodically removing the cuffs/shackles or checking for tightness. Interview revealed the "patient lets me know if they are too tight." Interview revealed if the patient needed to go to the restroom, the cuffs/shackles are removed. Interview revealed he does not check pulses or skin for circulation. Interview revealed the nurse is responsible for taking care of the patient's medical needs. Interview revealed he does not document in the patients ED medical record.
Interview on 01/15/2015 at 1015 with the ED Medical Director revealed he spoke with a police officer with the ABC City Police Department while in the ED. Interview revealed the police officer stated the Chief of Police had determined that the IVC patients were in the custody of the police officer and that it was Departmental policy for all IVC patients to be placed into handcuffs or shackles while in the ED. Interview revealed "we can't control the police putting the patients in custody." Interview revealed "we can control the monitoring of the patients." The interview revealed " we have been trying to work through this for the past 9 months with Chief of Police."
Interview on 01/15/2015 at 1235 with the ED Nursing Director revealed patients brought into the ED under IVC or who are placed under IVC while in the ED were placed into "forensic" restraints (handcuffs or shackles) by the law enforcement officers. Interview revealed the ED staff did not view the placement of IVC patients in handcuffs or shackles as a restraint, because they were in the custody of law enforcement. Interview revealed there would not be any documentation of monitoring and assessment every 15 minutes (for violent self-destructive behavior) and/or 2 hours (for non-violent behavior), because the handcuffs and shackles were not considered a restrictive intervention by ED staff. Interview revealed the ED staff did not follow the hospital's Restraint of Patient policy for monitoring Patient #14 while he was restrained in the ED with metal cuffs/shackles placed by a law enforcement officer.
2. Observation during ED tour on 01/14/2015 at 1438 of exam room #5, revealed the room was located diagonally across from the nursing station. Observation revealed the room had a wood door. Observation revealed a female patient (Patient #16) wearing green disposable scrubs and laying on her left side on the stretcher, watching television. Observation revealed the stretcher's two side rails were up and in the locked position. Observation revealed the patient was alert, calm, and cooperative. Observation revealed the patient's left wrist was chained to the stretcher's frame with a metal cuff/shackle (restraint). Observation revealed the patient did not exhibit any violent or self-destructive behaviors. Observation revealed the patient was in the exam room alone and without direct supervision of a LEO. Observation revealed an ABC City Police Department officer was sitting behind the nursing station in a cubical, reading a magazine. Observations from 1438 to 1500 failed to observe any violent or self-destructive behaviors exhibited by Patient #16 while being restrained in exam room #5.
Open medical record review on 01/15/2015 for Patient #16 revealed an [AGE] year old female presented to the Hospital's ED on 01/13/2015 at 1726 for "potential drug overdose." Review revealed the patient was triaged by a RN at 1732 and was assessed by a ED Physician at 1734. Review revealed the patient was assessed at 1912 by a mobile crisis worker. Review revealed on 01/14/2015 at 0050, the patient was IVC for being mentally ill and dangerous to self and others. Review revealed at 0200 and 0400, the patient's behavior was documented as asleep with parent and LEO at bedside. Review revealed from 0600 to 01/15/2015 at 0515, the patient's behavior was documented as asleep, tearful, and resting quietly in bed, resting in bed with eyes closed and laying in bed with eyes closed. Review revealed at 0536, the patient requested the "shackle" (restraint) be loosened and the hospital staff informed the LEO. Review revealed at 0725, the patient behavior was documented as alert and oriented with right lower extremity "cuffed" (restraint) to bed frame. Review revealed at 0835, the patient was transferred to a Psychiatric hospital. Record review failed to reveal any available documentation Patient #16 exhibited violent or self-destructive behaviors necessitating the need for restraint use while hospitalized from [DATE] at 1726 through discharge on 01/15/2015 at 0835. Further record review failed to reveal documentation of ongoing monitoring and assessment of the patient at least every 15 minutes for violent/self-destructive restraint or every two hours for non-violent restraint (as appropriate to the type of restraint used).
Interview on 01/13/2015 at 1107 during ED tour with Charge Nurse #1 revealed the only approved restraints used in the ED by nursing staff are "soft limb restraints." Interview revealed "only the Sheriff and Police Departments use handcuffs and shackles with IVC patients." Interview revealed the nurse is responsible for monitoring and assessing the patient when in handcuffs or shackles. Interview revealed the nursing staff is not responsible for applying the handcuffs or shackles.
Interview with ABC Police Officer #1 on 01/14/2015 at 1435 revealed he was responsible for 3 patients under IVC in the ED at this time. The interview revealed he stations himself at an area in the corner. The interview revealed he can observe the patient in the seclusion room and the patient in room #5. The interview revealed Officer # 1 was not allowed to answer any further questions. The interview revealed a phone number to two Lieutenant at the City Police Department if further questions needed to be asked.
Interview on 01/15/2015 at 1015 with the ED Medical Director revealed he spoke with a police officer with the ABC City Police Department while in the ED. Interview revealed the police officer stated the Chief of Police had determined that the IVC patients were in the custody of the police officer and that it was Departmental policy for all IVC patients to be placed into handcuffs or shackles while in the ED. Interview revealed "we can't control the police putting the patients in custody." Interview revealed "we can control the monitoring of the patients." The interview revealed " we have been trying to work through this for the past 9 months with Chief of Police."
Interview on 01/15/2015 at 1235 with the ED Nursing Director revealed patients brought into the ED under IVC or who are placed under IVC while in the ED were placed into "forensic" restraints (handcuffs or shackles) by the law enforcement officers. Interview revealed the ED staff did not view the placement of IVC