Patient left in full leather restraints for over 2 hours with no circulation, hygiene, or comfort assessments

Fairmount Behavioral Health System was cited during an unannounced onsite complaint investigation by the Pennsylvania Department of Health (DOH) for deficiencies related to patient rights: restraint or seclusion. DOH found that the facility “failed to monitor and assess a patient during the use of physical restraints.” Standard patient rights: restraint and seclusion regulations state, “the condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner or trained staff…at an interval determined by hospital policy.” According to the DOH inspection report, Fairmount Behavioral Health System has a facility policy titled “Restraints and Seclusion” dated April 2010 that “the patient shall be assessed every 15 minutes while in restraints by a Registered Nurse or Psych Technician.” Another facility policy titled “Use of Restraints When Taking Patients to Off-Site Civil Commitment Hearings (“Mental Health Court”) stipulate that “An RN or physician must assess the patient no less than once an hour for physical and psychological status and any signs of injury.” A review of medical record revealed a “physician order for full leather restraints dated November 28, 2012, at 9:45AM, which were released at 12:05PM.” However, further review of the medical record “revealed no documented evidence that the patient’s “Circulation,” “Hygiene,” and “Comfort” were assessed.” DOH found a physician order for wrist restraints for the same patient on November 30, 2012 at 9:00AM “related to the patient going to court” and was discontinued the same day at 3:30PM. Further review of the patient’s medical record again “revealed no documented evidence that a registered nurse or physician assessed the patient no less than once an hour for physical and psychological status and any signs of injury.” In the plan of correction, the facility’s Chief Nursing Officer and Service Line Directors re-educated all nursing and psychiatric technician staff on the need for 15-minute interval assessments of patients in mechanical restraints at the annual Safety Fair.