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Based on record review, document review, and interview, the facility failed to ensure the safety of patients requiring restraints. Specifically, the facility failed to ensure that staff who apply restraints received education for CPR (Cardiopulmonary Resuscitation), First Aid Techniques, and monitoring of the restrained patient and had demonstrated competency for restraint application

These failures place all restrained patients at risk for harm.

Findings:

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Based on medical record review, document review and interview, in one (1) of four (4) medical records reviewed, the facility failed to ensure a Supervisor was immediately notified of an allegation of patient abuse and failed to follow the facility's policy.

This failure places all patients at risk for potential abuse.

Findings:

A grievance, dated 09/30/16 at 10:30AM, for Patient #1, stated "they were trying to draw his blood from his right arm and were forcing his arm to straighten out but they could not and the individual punched him in his arm". The complainant indicated his arm is bruised and he has pain.

The facility's Allegation of Abuse / Neglect Checklist dated 09/30/16 at 11:10AM for Patient #1, stated that at "approximately 11:15AM I spoke to Staff D and Staff E separately who report that at approximately 8:00AM Staff F requested assistance to draw blood (from Patient #1). Staff D said he held the patient's right wrist in an attempt to extend if for the Phlebotomist. The patient pulled away so Staff D exited the room to tell the Staff E that the patient was refusing (to have his blood drawn.) ... When Staff E entered the room she reports that the patient was saying "they are punching me".

The report further noted that at 11:15AM Staff D was removed from duty ... and Staff D and Staff F "have been assigned to a non-patient contact assignment until the investigations completed".

On 09/30/16 at 8:00AM when Patient #1 complained to Staff E that Staff D and Staff F were punching him, she did not immediately notify a Supervisor of the allegation of abuse as required by policy. As a result Staff D and Staff F were not immediately removed from direct patient contact. They remained in direct patient contact until Patient #1's wife filed a grievance and Staff H removed the staff from direct patient care at 11:15AM, approximately three (3) hours and fifteen (15) minutes after the patient complained.

Patient #1's MR indicated that there was a right humerus x-ray dated 09/30/16 at 1:30PM, which documented an impression of "displaced spiral fracture involving the midshaft of the right humerus."

During an interview with Staff I on 11/02/16 at 10:30AM, the staff member confirmed the finding.

On 09/30/16 at 10:30AM a grievance was filed regarding an employee punching Patient #1. At 1:30 PM Patient #1's wife was "given an opportunity to file a report with the University Police and ... they ... agreed to do this". There was no documented evidence that Staff F was interviewed during this three (3) hour period as required by facility policy.

During an interview with Staff G on 11/02/16 at 2:20PM, the staff member stated "I did not interview Staff F (Phlebotomist) before the Police came. I was the only witness Police allowed to sit for the interview of Staff F." Staff G did not document the Police interview he witnessed.

The facility Policy and Procedure titled "Patient Allegations of Abuse / Neglect by a Staff Member" last revised 07/20/16 noted the following statements: "Any employee who becomes aware of an allegation of patient abuse or neglect immediately notifies a supervisor. If an allegation of abuse or neglect has been made, appropriate care shall include separating the caregiver from the alleged victim. If the employee has direct patient contact, he / she will be immediately removed from direct patient care by the supervisor or anyone in the supervisor's chain of command. All involved staff are interviewed ... and interviews are documented."
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Based on medical record review, document review, and interview, in five (5) of eight (8) medical records reviewed, the facility failed to renew Physician Orders timely for patients in restraints.

This failure places all patients at risk for remaining in restraints longer than required.

Findings:

The facility's Policy and Procedure titled "Restraint and Seclusion Provision of Care, Treatment, and Services" published on 08/17/16 stated the following: for violent / self-destructive patient restraint use "The duration of time for adults may not exceed 2 hours."

Patient #6's MR identified that on 10/11/16 at 8:24PM an Order was placed for 4-Point Violent Restraints for the patient while in the ED. The next Order for 4-Point Restraints was placed at 12:18AM on 10/12/16, one (1) hour and six (6) minutes after the facility two (2) hour re-order requirement.

Another Restraint Order for Patient #6 was noted at 4:44AM on 10/12/16, two (2) hours and forty-six (46) minutes after the facility two (2) hour re-order requirement.

Similar findings were noted regarding the lack of Restraint Orders within the two (2) hour re-order requirement in the medical records of Patients #4, #5, #7 and #8.

These findings were confirmed with Staff H on the afternoon of 11/02/16 .
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Based on medical record review, document review, and interview, in six (6) of eight (8) medical records reviewed, the facility staff failed to follow their policy to ensure that patients in restraints were offered hydration every fifteen (15) minutes.

This failure places all patients in restraints at risk for dehydration.

Findings:

The facility's Policy and Procedure titled "Restraint and Seclusion Provision of Care, Treatment, and Services" published on 08/17/16 stated the following: "Patients in restraints are monitored as often as necessary to assure safety, dignity, and attend to comfort needs", and "Every 15 minutes" restraint documentation should include "hydration".

Patient #7's medical record identified that on 10/16/16 at 7:36PM, the patient was placed in 4-Point Violent Restraints while in the Emergency Department (ED). The medical record lacks evidence of the Nursing Restraint Flow Sheet, the documentation used by the Registered Nurse for patients in restraint, to determine if the patient was properly monitored during his time in restraints, including offering hydration.

Patient #2's medical record identified that on 10/31/16 at 9:12PM, the patient was placed in 4-Point Violent Restraints while in the ED. Review of the Nursing Restraint Flow Sheet lacks evidence that the patient was offered hydration every fifteen (15) minutes while in restraints.

Further medical record review revealed that Patient #2's Restraint Order was changed to Bilateral Wrist Restraints on 10/31/16 at 10:51PM. However, there continued to be no evidence that the patient was offered hydration until he was transferred to the Medical Unit on 11/01/16 at 8:30AM, more than eleven (11) hours after the initial implementation of restraints.

Similar findings were noted regarding the lack of evidence that the restrained patients patients were offered hydration in the medical records of Patients #4, #5, #6 and #8.

These findings were confirmed with Staff H on the afternoon of 11/03/16.
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Based on medical record review, document review, and interview, the facility failed to ensure that Resident Physicians were trained on the reqirement for timely Restraint Orders.

This failure places all patients at risk for being placed in restraints without a correct Order.

Findings:

Patient #7's medical record identified that an Order for 4-Point Violent Restraints with a documented "start time" of the restraint as 10/16/16 at 7:30PM. The computer time-stamp indicated the restrait was not ordered until 10/16/16 at 11:21PM. More than three (3) hours after the documented Order Time.

Patient #6's MR identified that an Order for 4-Point Violent Restraints with a documented "start time" of the restriant as 10/11/16 at 10:15PM. The computer time-stamp indicated the restraint was not ordered until 10/12/16 at 12:18AM. More than two (2) hours after the documented Order Time. A duplicate Order was also placed by the same Practitioner, a Resident Physician, on 10/12/16 at 12:19AM. There was no explanation for the repeat Order.

Another Restraint Order for Patient #6 was noted with a documented "start time" of the restraint as 4:15AM on 10/12/16, but the time-stamp indicated the restraint was not ordered until 10/12/16 at 6:55AM. More than two and one-half (2½) hours later.

Similar findings were noted in the medical records of Patients #8 and #9.

Per interview with Staff J on the morning of 11/07/16, Restraint Orders should be discontinued before new Orders are placed. She also stated "I didn't know Orders could be modified".

Per interview with Staff I on the morning of 11/07/16, she also stated she was unaware that the computer system allowed Orders to be modified.

The facility's Policy and Procedure titled "Restraint and Seclusion Provision of Care, Treatment, and Services" published on 08/17/16 stated the following: "Physicians who order restraint or seclusion are educated in the requirements of this policy and demonstrate a working knowledge of this policy through ongoing compliance."

Review of the facility's "Electronic Medical Record" (EMR) education, "Use of Restraint Required Education for Providers", and "Patient Safety" education provided to the Physicians, Interns and Residents at orientation upon hire, and annually, none of the education provided instructions for placing Restraint Orders, or discussed back-timing or modifying Orders.

Per interview on 11/04/16 at 9:05AM, this was confirmed with Staff Members R, S and T.
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Based on medical record review, document review, and interview, in one (1) of eight (8) medical records reviewed, the facility failed to ensure a Physician face-to-face was completed for a patient in 4-Point Violent Restraints.

This failure places all patients at risk for being placed in 4-Point Violent Restraints unnecessarily.

Findings:

Patient #8's MR identified the patient was placed in 4-Point Violent Restraints documented as 10/26/16 at 12:42AM until 8:31AM, however the required face-to-face within one (1) hour of the initial restraint placement was not completed until 6:45AM, more than five (5) hours later.

The facility's Policy and Procedure titled "Restraint and Seclusion Provision of Care, Treatment, and Services" published on 08/17/16 states the following: for violent / self-destructive patient restraint use "Authorized Provider is summoned immediately and must see and evaluate the patient".

The facility Physician education titled "Use of Restraints Required Education for Providers, undated, states under "Non-Violent Restraints" that the "Patient must be on one to one observation as well as restraint until the LIP (Licensed Individual Practitioner) evaluation within one hour is done."

The education does not include the same requirements for an evaluation for patients in Violent Restraints.

Neither the Policy, nor the Physician Education, instructs a Physician or LIP to complete a face-to-face evaluation within one (1) hour for patients placed in Violent Restraints.

An interview with Staff H on the afternoon of 11/3/16 confirmed these findings.
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Based on personnel file review, documentation review, and interview, the facility failed to ensure that staff demonstrated competencies for restraint application.

This failure places all patients at risk for harm when in restraints.

Findings:

The facility's Policy and Procedure titled "Restraint and Seclusion Provision of Care, Treatment, and Services" published on 08/17/16 stated the following: "All staff assigned to apply or monitor restraints will demonstrate corresponding competency, which will be assessed initially and annually."

Review of the Personnel File for Staff L hired on 05/20/99 lacked evidence of demonstrated Restraint Competencies.

Interview with Staff II on the afternoon of 11/07/16 confirmed that all forty-four (44) Security Officers lacked demonstrated Restraint Competencies.

Review of the Personnel File for Staff N hired on 06/15/89 lacked evidence of demonstrated Restraint Competencies.

Interview with Staff JJ on 11/07/16 at 1:45PM confirmed that all sixty-four (64) Nursing Assistants did not demonstrate Restraint Competencies.

Further interview revealed that the facility Nursing Staff also did not demonstrate Restraint Competencies.

Interview with Staff H on 11/08/16 at 10:08AM, both Security Officers and Nursing Assistants participate in the application of restraints.

The facility failed to follow its own Policy regarding their Staff Education Requirement for Restraint Application.
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Based on documentation review and interview, the facility failed to ensure that Staff Restraint Education included training to recognize and respond to signs and symptoms of distress for patients in restraints.

This failure places all patients at risk while in restraints.

Findings:

The facility Staff Restraint Education Materials titled "Restraints and Seclusion", undated, lacks education on identifying signs and symptoms of physical and psychological symptoms of distress for patients in restraints.

The facility Staff Restraint Education Materials titled "Patient Safety Interventions", last revised 10/01/14, lacks education on identifying signs and symptoms of physical and psychological symptoms of distress for patients in restraints.

The education lacks instructions on what to do for a patient in distress while in restraints.

This was confirmed with Staff JJ on 11/07/16 at 1:45PM.
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Based on documentation review and interview, the facility failed to ensure that staff received training and competency for the monitoring of the physical and psychological well-being of patients in restraints.

This failure places all patients at risk for harm when in restraints.

Findings:

Review of the Personnel File for Staff L hired on 05/20/99 lacked training and competency for the monitoring of the physical and psychological well-being of patients in restraints.

An interview with Staff II on the afternoon of 11/17/16 confirmed that all forty-four (44) Security Officers lacked training and competency for the monitoring of the physical and psychological well-being of patients in restraints.

Review of the Personnel File for Staff N hired on 06/15/89, lacked training and competency for the monitoring of the physical and psychological well-being of patients in restraints.

An interview with Staff JJ on 11/07/16 at 1:45PM confirmed that all sixty-four (64) Nursing Assistants lacked training and competency for the monitoring of the physical and psychological well-being of patients in restraints.

Further interview revealed that the facility Nursing Staff also did not receive training and competency for the monitoring of the physical and psychological well-being of patients in restraints.

Per interview with Staff H on 11/08/16 at 10:08AM, both Security Officers and Nursing Assistants participate in the application of restraints.

This was confirmed with Staff JJ on 11/07/16 at 1:45PM.
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Based on document review and interview, the facility failed to ensure that staff who participate in violent crisis interventions and place patients in restraints received the required: (A) First Aid Training in nineteen (19) of nineteen (19) Clinical and Security Personnel Records, and (B) CPR (Cardiopulmonary Resuscitation) Training in four (4) of thirteen (13) Clinical Personnel Records.

This places all patients in restraints at risk for potential harm.

Findings pertinent to A include:

Review of the Personnel File for Staff L hired on 05/20/99 lacked evidence that the staff member received training in First Aid Techniques.

Review of the Personnel File for Staff M hired on 02/22/07 lacked evidence that the staff member received training in First Aid Techniques.

Review of the Personnel File for Staff N hired on 06/15/89 lacked evidence that the staff member received training in First Aid Techniques.

Similar findings were found in the Personnel Files of Staff Members O, P, Q, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF and GG.

Per interview with Staff K on the morning of 11/07/16, the staff member stated "My Security Guards have not received any First Aid Training". Staff K also stated "I knew [the Regulations] said First Aid, and I have asked, but no one could tell me what type of First Aid they needed".

Per interview with Staff H on 11/08/16 at 10:20AM, when questioned about the training and certifications for Nurses' Aides stated "the Nurses' Aides have not received First Aid Training".

Findings pertinent to B include:

Review of the Personnel File for Staff A on 11/08/16 at 12:15PM revealed that the staff member did not have a Cardiopulmonary Resuscitation (CPR) Training Certificate on file.

This was reviewed in the presence of Staff J who confirmed the findings. Staff J stated that "the Registered Nurse should have a current CPR Training Certificate on file".

Similar findings were found in the Personnel Files of Staff Members C and D.

During an interview with Staff H on 11/08/16 at 12:15PM, the staff member stated that "Nurses' Aides in the Emergency Department (ED) are not required to have CPR Training".

The facility's Policy and Procedure titled "Restraint and Seclusion" last revised 08/17/16 lacked the requirement that staff receive First Aid and CPR Training.
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Based on document review and interview, the Quality Assurance Program did not identify and address the problems identified in the "Quality Assurance Referral" document regarding Patient #1 and implement corrective measures to prevent a reoccurrence.

This failure places all patients at risk for poor quality care.

Findings:

Review of the Safety / Security Event (15989) documents on 10/05/16 that Staff HH did a Quality / Risk Management Review of Patient #1's care (which began on 09/30/16) and will send the case "for Emergency Department and Nursing Quality Assurance Reviews".

Review of the facility's undated "Quality Assurance Referral" documents to review Patient #1's "Emergency Department course and Medical Unit stay from a medical and nursing perspective for possible deviations in the standard of care surrounding timeliness and accuracy of assessments and treatments ........ and the etiology of spiral humeral fracture and make suggestion for improvement."

During an interview with Staff HH on 11/04/16 at 8:50AM the staff member stated that "I did the Quality Review of the patient care. If any issues are identified the case is sent to the Clinical Departments for review. I'm sending this case to the Emergency Department, Medicine, and Nursing for review. It would have already have gone to the Departments for review but I was told to wait. (The case) is under Police investigation."

During an interview with Staff I on 11/04/16 at 8:50AM the staff member stated that "any case Risk Management is involved in is a priority. It would have been a priority review. I would want it done right away. I agree the Medical and Nursing Reviews should have been separated from the Police section and performed."