Lutheran Medical Center
Statement of Deficiency – Tags A0168, A0175, A0194 and A0206; Event ID
YSLA11- Inspection release April 2, 2015

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT
CONFIDENTIALITY**
Based on staff interview and review of patient record, restraint policy and procedures,
and Security incident reports, the facility failed to ensure that patients are restrained in
accordance with orders of a physician or other licensed independent practitioner. This
finding was noted in one of five applicable medical records reviewed for patients where
restraints were applied.
Findings Include:
Review of MR # 1 on 4/2/2015 noted that this patient, a [AGE] year old female, with
history of COPD (chronic pulmonary disease (COPD), Asthma, HTN (hypertension), DM
(diabetes), anxiety, and borderline personality disorder, went to the facility's Emergency
Department on 2/11/2015 with presenting problem of atypical chest pain. The patient
was admitted on [DATE] and she was transferred to a medical unit.
There were two episodes of restraint application for patient #1, on 2/15/15 and again on
2/26/15.
The first episode of restraint, on 2/15/15, found the lack of timely and accurate physician
orders immediately following restraint application for patient #1. It was documented in
the record that on 2/15/2015 at 11:30 PM, the patient became very agitated and
combative, requiring physical restraint. The justification for the restraint was "to prevent
harm to self and others". It was noted that the restraint order was written on 2/16/2015
at 04:27 AM, fours after the patient was restrained. In addition, this late order obtained
for patient's restraints was inaccurate. Review on 4/2/15 of a Security Incident Report,
dated 2/16/15, indicated that security was called for assistance on 2/15/15 at 2345
(11:45 PM). This document indicated that the patient was placed on "four point
restraints". However, review of the physician's order, dated 02/16/2015 at 04:27 (4:27
AM), indicated the written order was for "soft limb both arms". It was noted that there
was no written order for four point restraints.
The second episode of restraint cited, on 2/26/15, found no evidence of any physician
orders for the application of a restraint for patient# 1. Review of the Security Incident
Report, dated 2/26/15, indicated that the security officers responded to assist nursing
staff with the patient in MR #1. This document indicated that patient was "physically
taken back to her bed and she was restrained as per MD order". Review of the medical

 record (MR#1) on 4/2/15, found there was no physician's order for the restraints applied
on 2/26/2015. The nursing staff did not document the application of the restraints in the
medical record.
Staff # 4 was interviewed on 4/2/2015. This staff stated that security applied bilateral
restraints to the patient in MR#1 on 2/26/2015. This staff stated that the patient was in
restraints for only two or three minutes and the patient broke free from the restraint. It
was also stated the restraint was not reapplied because the patient became calmer
following the arrival of her family.
The procedure titled, "Use of Restraint and Seclusion" reviewed on 4/2/15, notes "in the
emergency department and in other areas of the hospital covered by psychiatric
consultation, liaison service, licensed by NYSDOH (New York State Department of
Health), restraint is ordered by a licensed physician or licensed independent
practitioner." It further notes that in an emergency situation, the nurse may apply the
restraints, but the RN shall notify the licensed physician or licensed independent
practitioner (LIP) within 30 minutes of application. This policy also requires that "if based
on the results of the physician or LIP examination, the physician or LIP determines that
continued use of restraint or seclusion is indicated, the physician/LIP shall write an
order."
Consequently, the facility failed to follow the restraint procedures, because during the
2/15/15 restraint episode, there was no evidence of timely physician notification and
orders and in the 2/26/15 restraint event, there was no evidence of a written physician
restraint order.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT
CONFIDENTIALITY**
Based on staff interview, and review of medical record and other hospital
procedures/documents, it was determined that the facility failed to ensure: 1) the
immediate assessment by a physician or the licensed independent practitioner (LIP)
following restraint application; and 2) the ongoing assessment and monitoring of a
patient in restraints. These findings were evident in one of five applicable medical
records reviewed (MR #1).
Findings include:
Review of MR # 1 on 4/2/2015 noted that this patient, a [AGE] year old female, with
history of COPD (chronic pulmonary disease (COPD), Asthma, HTN (hypertension), DM
(diabetes), anxiety and borderline personality disorder, went to the facility's Emergency
Department on 2/11/2015 with presenting problem of atypical chest pain. The patient
was admitted on [DATE] and she was transferred to a medical unit.

 There were two incidents of restraint application for patient #1, on 2/15/15 and again on
2/26/15.
The first episode of restraint, on 2/15/15, found a lack of immediate assessment
following restraint application by a physician. It was documented in the medical record
that on 2/15/2015 at 11:30 PM, the patient became very agitated and combative,
requiring physical restraint. The justification for the restraint was "to prevent harm to self
and others". A Security report dated 2/16/2015 at 0030 (12:30AM) was reviewed on
4/2/2015. This report indicated that security was called for assistance on 2/15/2015 at
2345 (11:45 PM) and the patient (MR#1) was placed on "four point restraints " .
However, the "restraint care plan" form, which includes a restraint monitoring checklist,
noted the use of "both arms" in restraint. Therefore, the nursing staff responsible for the
care of the patient did not document in the patient ' s medical record that the patient was
placed in a four-point restraint.
The procedure titled, "Use of Restraint and Seclusion" reviewed on 4/2/15, notes "in the
emergency department and in other areas of the hospital covered by psychiatric
consultation, liaison service, licensed by NYSDOH (New York State Department of
Health), restraint is ordered by a licensed physician or licensed independent
practitioner." It further notes that in an emergency situation, the nurse may apply the
restraints, but the RN shall notify the licensed physician or licensed independent
practitioner (LIP) within 30 minutes of application.
The assessment by medical staff was not documented within 30 minutes of the restraint
application.
The second episode of restraint cited, on 2/26/15, found no evidence of ongoing
monitoring by clinical nursing staff of this patient following application of restraints. The
medical record for Patient #1 found that, on 2/25/2015 at 10:00 PM, the nurse noted,
"Informed by staff that patient had the bed all the way up. Assessed patient agitated
informed patient that bed has to be in the lowest position to prevent fall & injury. Patient
refused. Security called, patient still very agitated; MD at bedside".
Review of a Security Incident Report, dated 2/26/15, described that at 19:50 Hours
(7:50PM) that the security officers responded to assist nursing staff with patient #1, who
was aggressive and uncooperative; the patient pulled out the IV lock and was sprinkling
her blood on the face and uniform of security staff. This document indicated that patient
was "physically taken back to her bed and she was restrained as per MD order".
Staff #4 was interviewed on 4/2/2015. This staff stated that the patient referenced in MR
#1 was placed in bilateral restraints as per MD order and in the presence of nursing
staff. This staff also stated that security applied bilateral restraints to the patient in
MR#1. It was added the patient had been in restraints for only two or three minutes and

 the patient broke free from the restraint. The restraint was not reapplied because the
patient became calmer following the arrival of the family.
The nursing staff assigned to the patient did not document that the patient was placed
on restraints. The patient's medical record lacked documentation of the restraint care
plan (including monitoring flow sheet) for this restraint episode on 2/26/15. Therefore,
there was no written nursing assessment or monitoring after security staff had
restrained the patient.
-Based on interviews, review of incident report and other documents, it was determined
that the facility failed to ensure appropriate staff is trained in the safe implementation of
restraints. Specifically, the facility failed to ensure security staff members received
restraint training and are able to demonstrate competency in the application of
restraints. This finding is noted in 5 of 5 security staff credential files reviewed (Staff #1,
#2, #3, #4 and #5).
Findings include:
Facility's policy titled "Restraint Use In Non-Violent Patient", last revised in 1/2014, and
the policy titled "Restraint and Seclusion" for Psychiatric Acute Care, last revised in
6/2014, notes that staff members are trained during orientation and annually, including
demonstrating competency in the application of restraints/seclusion, monitoring,
assessment and providing care for a patient in restraint/seclusion. The restraint policies
do not describe the role of security staff in the utilization of restraints/seclusion for nonviolent and psychiatric patients.
At interview with Staff #3, Security Supervisor on 4/2/15 at 1:30 PM, she stated, security
guards may assist staff in holding patient for intervention and may apply soft wrist
restraint if ordered by a physician. Staff #3 stated she had received training in the use of
restraint once or twice since hired four years ago.
The review of the document titled "Job description for security guards", last revised on
4/30/14, notes a list of job responsibility that includes "Assist in patient restraint".
However, the review of personnel files for security staff #1, #2, #3, #4, and #5 revealed
a lack restraint training and annual competencies in the application of restraints.
Staff #4, a security guard was interviewed on 4/2/15 at 1:36 PM and was asked about
an incident involving the use of restraint on 2/26/15. Staff #4 stated he responded to a
call for help on inpatient unit 4A. Patient #1 was found in her room agitated, combative,
and threatening staff members. He stated the physician ordered the application of soft
wrist restraints, which he applied with the help of two other security guards.
At interview with Staff #6, Security Director on 4/2/15 at 1:40 PM, he stated all security
guards have annual certification in Crisis Prevention Intervention (CPI). He

 acknowledged that security staff files have no documentation of restraint training during
orientation and annually, including demonstration of competencies in the application of
restraint as prescribed by the facility policy for staff members who apply, monitor, and
provide care for patients in restraints.
The review of the CPI course description on 4/2/15 revealed the training did not include
the use of restraints.
-Based on interviews, and the review of personnel files, it was determined the facility
failed to ensure all staff who apply restraints receive education and training in the use of
first aid techniques as well as training and certification in the use of cardiopulmonary
resuscitation. This finding was noted in 5 of 5 security staff credential files reviewed.
Findings include:
Personnel files for Staff #1, #2, #3, #4 and #5 lacked education and training in the use
of first aid technique and certification in the use of cardiopulmonary resuscitation. All
staff members are security personnel.
At interview with Staff #3, Security Supervisor on 4/2/15 at 1:30 PM, she stated, security
guards may assist staff in holding patient for intervention and may apply soft wrist
restraint if ordered by a physician.
At interview Staff #6, Director of Security on 4/2/15 at 1:45 PM, he stated it was not a
requirement for security staff to have first aid training and maintain certification in
cardiopulmonary resuscitation.