Takedowns and Security Training?

PMHNP10 · Aug 19, 2005

So glad I found this thread - anybody out there from TX? Just wondering if anybody else has been having the same problem.
I work on an acute adolescent unit of a private hospital and the rules that just came down are absolutely dangerous to follow. We cannot go hands on unless the pt is in immediate and SERIOUS danger of harming self/others. In other words, if the kid is just tearing up the unit/attempting to elope we have to let it happen... We have to try other means first, which is ok; nothing new there, but then if we DO have to go hands on, the doc has to order it and then be there face-to-face to see the pt. within some specific number of hours - I believe that that is two hours - this gives the pt. plenty of time to wreak havoc and hurt self/others before anything can be done. Since I work the night shift there is a real possibility of problems, as we have a doc that doesn't want to answer his phone when he is supposedly on call.
My question is, is this the way other psych units are run or are we just "lucky"? If anybody else operates under the same restrictions, how is the new system working for you? Is it just because we are a private hospital that the rules are so stringent?

Also keep in mind in TX (and I'm sure many other states) if you have to restrain a pt (if only for a few seconds) to give an emergency med and immediately let go, you still have to document the event as a restraint and file the packet of paperwork. In CA, when an order for an emergency medication is given, it is implied that there will have to be some sort of physical restraint, so there is no restraint documentation required (per one of our docs who says he worked for the state dept of mental health). IMHO, this is more reasonable, but what can ya do but what your required to do?

elkpark · Aug 19, 2005

Just how do you "enforce" these rules as outlined by the Fed Gov? By simply checking the facility's paperwork allows facilities to fabricate documentation. The facility I worked at were very good at producing "quality" paperwork but in reality, these union staff workers used excessive force and excessive usage of restraints without interventions because the staff were too busy attending to their own needs; eating, reading, watching tv, smoking, talking amongst themselves, sleeping to intervene early on....and re seclusions: they didn't even bother to document; just stick'em in the room and lock the door. Oh, and speak out for patient rights and you'll find yourself the target of retaliations. You want to know how to really enforce these rules: put video cams in these facilities (we did it anonymously) and you will be horrified for years to come!

Of course, I can only speak to my own experiences in my own agency. I'm certain that we weren't completely successful in identifying the kinds of abuses you describe, but we did a lot more than "checking the paperwork" -- in addition to reviewing medical records, we routinely interviewed clients about what they had observed of staff interacting with agitated clients and restraining/secluding clients, we were alert for any discrepancies or "fishy" entries in the documentation of the events surrounding an episode of seclusion or restraint (including the client's behavior leading up to the restrictive intervention) and interviewed staff members separately about any discrepancies in the seclusion/restraint documentation, we followed up on anything we heard that didn't sound right, and, if we were at all suspicious, we put the hospital in the position of proving to us that they hadn't committed any sort of infraction or abuse. My teammates and I were all experienced psych clinicians, so we were familiar with the kinds of tricks and games that can get played on psych units to cover up a lax, neglectful attitude toward restraint and seclusion -- often, we could read through a chart and just tell that the documentation didn't add up right, and, if we asked enough people enough questions, eventually, the real story came out.

Of course, there are always things that go on in psych units that you can't "catch" unless you're actually there to witness it yourself; I know that. But we tried v. hard to be vigilant and thorough and fair (to the hospital as well as the clients) about investigating whether the client's rights and applicable rules/regs were being respected and enforced, as much as we could after the fact. That was my experience -- I don't know how the surveyors in other states do things.

In CA, when an order for an emergency medication is given, it is implied that there will have to be some sort of physical restraint, so there is no restraint documentation required (per one of our docs who says he worked for the state dept of mental health). IMHO, this is more reasonable, but what can ya do but what your required to do?

That may be permissible under your state rules, but not under the CMS rules! This same issue came up with us (I'm sure it's come up in every state), the hospital where this became an issue in a survey didn't want to take our word for it, and we got an official statement from the national CMS headquarters in Baltimore: If you hold someone down, even briefly to give her/him a medication against her/his will, that is a restraint according to the CMS definition, and you are expected to follow all the CMS rules related to behavioral restraint, including a specific order and the face-to-face eval within 1 hour. There is no such thing (as far as CMS is concerned) as an "implied" restraint order (implied in the order for the emergency med -- yes, we heard that argument, too ...).

Also, if you put someone in locked seclusion and have to carry/drag them to the seclusion room (i.e., they don't walk to the seclusion room voluntarily -- and how often is that the case?), then that is an episode of restraint (physically transporting them to the seclusion room) as well as an episode of seclusion, and CMS expects you have a specific order for the restraint as well as for the seclusion (although one face-to-face eval is sufficient for both). Otherwise, you have restrained a client without an order. That's another thing a lot of hospitals are not clear on, and hospitals get cited a lot for that, too.

I'm not trying to criticize anyone or be some kind of horrible nag -- just trying to (helpfully :specs: ) provide info about how CMS interprets and enforces the rules, since there is a lot of confusion about how to implement these rules, and a lot of hospitals get cited for this stuff and get into serious trouble with CMS (which you definitely don't want ...)

PMHNP10 · Aug 19, 2005

That may be permissible under your state rules, but not under the CMS rules! This same issue came up with us (I'm sure it's come up in every state), the hospital where this became an issue in a survey didn't want to take our word for it, and we got an official statement from the national CMS headquarters in Baltimore: If you hold someone down, even briefly to give her/him a medication against her/his will, that is a restraint according to the CMS definition, and you are expected to follow all the CMS rules related to behavioral restraint, including a specific order and the face-to-face eval within 1 hour. There is no such thing (as far as CMS is concerned) as an "implied" restraint order (implied in the order for the emergency med -- yes, we heard that argument, too ...).
Also, if you put someone in locked seclusion and have to carry/drag them to the seclusion room (i.e., they don't walk to the seclusion room voluntarily -- and how often is that the case?), then that is an episode of restraint (physically transporting them to the seclusion room) as well as an episode of seclusion, and CMS expects you have a specific order for the restraint as well as for the seclusion (although one face-to-face eval is sufficient for both). Otherwise, you have restrained a client without an order. That's another thing a lot of hospitals are not clear on, and hospitals get cited a lot for that, too.

By chance is there a link to some page within the CMS website which states what you posted above about emergency meds? I'd be ever so grateful if you were able to provide one.

elkpark · Aug 19, 2005

By chance is there a link to some page within the CMS website which states what you posted above about emergency meds? I'd be ever so grateful if you were able to provide one.

No, I don't have a link and I don't have any idea, offhand, what info is available on the CMS website. I am just passing on what state surveyors responsible for enforcing the CMS rules are officially instructed by CMS regarding how they expect us to interpret and enforce the rules regarding restraint, and, when we actually cited hospitals for the situations I described (probably more often than you would imagine), nobody at CMS ever told us we were out of line for having done so ... Give that info as much or as little weight as you like.

Debba99 · Aug 21, 2005

" -- in addition to reviewing medical records, we routinely interviewed clients about what they had observed of staff interacting with agitated clients and restraining/secluding clients

1. Generally speaking, there are NO patient witnesses during restraint and seclusions....patients are instructed by staff to go to their rooms and stay there until the area is safe again.

2. These patients might be incompetent but they know "the system" and they know they'd better keep their mouths shut....remember, the system provides EVERYTHING they get, how they get it, when they get it and, (here's the kicker), IF THEY GET IT....AND, if you ever did find a patient able and willing to speak out, who would believe them? In-patient clients have a credibility problem (they're CRAZY!) Suppose you did find some "fishy" documentation (I'm sure it's not easy to come by because administration puts a great deal of time and resources ensuring the documentation you see has been screened, and combed out...and all the knots have been removed)

Suppose some "fish" did get by the "big dollar white collar" what would you do (or have you ever done in the past) to protect that patient from future retaliations? Get real! If staff can't speak out without retaliations, do you really think the patients can?

3. You and your staff may be experienced psych clinicians (probably in the "real world") but my guess is, you've never worked in a unionized, state run, in-patient, psych hospital (where "whatever happens inside, stays inside").

4. Check the workman's comp records and interview the employee that went out on comp. Find out how the employee got hurt. If it was patient related, make sure there was documentation in the patient's chart re the incident. (A unit can cut down on the number of restraints and seclusions reported if the only documentation is on the restraint/seclusion (R/S) report packets and not in the patient's nursing note). Review those restraint and seclusion packets (the ones that make it back to the charts, that is). If staff names are not on the documents identifying their role...step by step...in the R/S, suspect something "fishy" because the facility isn't looking at improving staff interactions and preventing R/S. Check to see if the injuries match the step by step roles of each participant in the R/S. (Ever wonder how a patient can sustain a knee injury if the "staff followed R/S protocol as outlined by the facility's procedures"? Now, suppose the R/S documentation packet forms don't make it back to the patient's chart.....how are you to know the R/S ever happend? Check to see how the facility follows up on their CMS training. My experience: they don't; until something goes (dead) wrong.

5. If a patient gets cut or bruised during a restraint, and if an incident report ever does get written up, what do you think happens to those reports once those cuts and bruises heal up? Do you review incident reports? If not, why not?

6. There are just too many ways to manipulate a hand written document. It's much more difficult to tamper with computer documentation; and there are more efficient methods of monitoring for this conduct. In the meantime, video monitoring and undercover staff will help the legitimate worker stay alert and interacting with patients in a therapeutic and productive manner.

7. Look at the overtime records and payroll. How can a staff member be therapeutic and productive if he/she's working double shifts 4-5 days a week; month after month, year after year. What happens to that employee after an injury? How is the trauma resolved? Does the worker feel like he/she is just a "punching bag" or does he/she feel like a contributing member of the treatment team? How many employee suicides have occured in the facility? How many patient suicides have occurred in the facility? What therapy is given (documented) to staff and patient survivors?

8. The Department of Health is really good at investigating and uncovering problems AFTER serious injuries and deaths come to their attention (not all states are required to report serious injuries and deaths; so if a patient, has no family or friends monitoring their care, these states can reasonably be assured, they won't be investigated)

9. Society, in general, doesn't want to know what goes on behind closed doors in behavioral health in-patient hospitals that care for the seriously mentally ill segment of the population; except that they be kept away from the rest of "us".

Thunderwolf, MSN, RN · Aug 22, 2005

Good posts, folks.

FeelGDRN · Sep 6, 2005

Your friend exagerated,.... just slighty. Psych nursing does have its emergencies, which require restraints for protection of safety(patient and others). This does not constitute combat. I used to joke about going to combat training. But the deal is that the training you receive to handle physical altercations is focused on safety. If you worked in the ER, there would be similar scenarios. Security is present in just about every majore US hospital. When I worked inpatient, they responded for emergencies. Usually as a show of force. If you want to work with the population, all you need to do is get past people's misunderstanding of what you do. Once your there it becomes another part of nursing.