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Based on document review, policies and procedures, and interviews on 10/25 and 10/26/2016, it was determined that the hospital was not incompliance with the Condition of Participation of Patient Rights as a result of the severe brain injury suffered by patient #1 who was held face down on the floor of the Emergency Department in September 2016.

In late September 2016, patient #1 presented to the Emergency Department (ED) on Emergency Petition via police, and in handcuffs. Patient #1 's handcuffs were removed after he stated his intent to cooperate. A triage was done at 2034 which revealed a Chief complaint of homicidal ideation and that patient #1 was brought in for manic behaviors.

There was limited nursing documentation by the Charge nurse (RN#1) at 2035. However, it was not entered documented until the following morning at 0244 which noted " Patient in room 10. (Alert/Oriented x 3). Yelling at staff. Refusing to answer questions. "

A RN#1 note performed at 2115 and entered the following morning at 0309, stated " At approximately 2045, pt began fighting with security and ran out of the room into the hall. Security quickly secured patient and Geodon was administered per orders. "

Documentation from the assigned RN#2 performed at 0935, and entered as a late entry two days later stated "I went to the room to administer the IM Geodon as ordered by (physician), the client became aggressive, agitated, kicking, swinging his arms, hitting and pushing security personnel. Run out of his room and security run after the client. tooked (sic) 3 personnel to hold the client to the floor, medication given as ordered."

During an interview with the ED Manager on 10/25 at approximately 0930 it was stated that two security guards and a transport person restrained patient #1 on the floor of the ED between two medical patient rooms #7 and #8 that held a critically ill patient.

In an interview on 10/25/2016 at approximately 1230 with the ED physician who was present for the incident it was revealed that he witnessed security guard #1 and patient #1 on the floor in a prone position (on their stomachs) with their feet in polar opposite directions, and that security guard #1 was positioned over patient #1's upper shoulders and head. The physician consented to demonstrate this positioning to the surveyor to further define the hold security had on patient #1. Other documentation revealed the physician description of this position as " ...Security guard (#1) appeared to have right arm holding torso under patient ' s left neck/upper shoulder running toward and locking with the left arm around torso under patient's right axilla. Patient's head situated under (security guard #1 ' s) upper torso, looking to right. Face and mouth visible me. Patient was yelling to be released and clearly struggling to free himself ... "

Other documentation from the physician revealed in part that he asked staff if there were other security available to which the Charge Nurse replied that " Police had already been called. " The physician then went to room #8 to reassure the critically ill patient and family members that they were safe, and then walked to the computer area intending to write the face-to-face and restraint orders as well as follow up on other patients pending results. Other physician documentation revealed at that time patient #1, " ...was yelling for security to get off of him. He was also yelling that he couldn 't breathe, though loudly and clearly."

Other documentation from security #1 revealed in part, " ...After meds was rendred (sic) we were told by (the physician) to keep him restrain (sic) til the meds take effect (patient #1) were still kicking and punching. "

Other documentation from security guard #2 revealed in part, " ...(security guard #1) had the patient in a bear hug position. I (security guard #2) had the patient right and left arm held down. The patient was being secured on his stomach. At all times the patient was continuously asked if he could breath (sic) because he did say, " I can ' t breath ... "

Other documentation from witnessing RN #3 revealed in part, " ...Patient ran toward exit in the back of the emergency department. I reached for phone and called security requesting further back up. When I came around the corner I witnessed 2 security officers holding patient to floor in front of ED 7 in the hallway. One person was holding patient by the feet and the second was positioned across patients top half ...Security states they were waiting on police to arrive before they attempt to relocate patient ... "

Other documentation from the RN#1 stated, in part, " ...At approximately 2055, the county police arrived and a stretcher was brought out to place the patient on. When the patient was rolled over, it was noted that he wasn't breathing and that he had vomited ..."

Other documentation from the Dayshift Administrative Coordinator stated, in part, " we discussed the plan to move the patient to the stretcher, which had restraints on it, but not used at current time ... "

Other documentation from a PA-C (Physician Assistant - Certified) revealed in part, " ...I saw two security guards (did not see who) physical restraining patient on the ground in the hallway between rooms ED7 and ED8, and patient yelled, "I can't breathe." He continued to struggle against the security guards and (the physician) came to his side. I continued seeing other patients and after some time I heard the charge nurse yelling for the physician as a patient had become unresponsive. I later learned it was the same patient. "

Because of the findings of this investigation, an immediate jeopardy was called which the hospital took immediate action to abate. However, because of this unapproved, poorly supervised hands-on restraint, patient #1 suffered a severe brain injury due to a lack of oxygen which resulted in patient #1 ' s death 2 weeks later.

Based on review of 5 closed medical records, including 4 medical records of patients eligible for Medicare, the hospital failed to provide the first Medicare Important Message (IM) to patient #15, and failed to provide a second IM to patients # 12, #13, #14 and #15.
Patient #12 was admitted 9/21/2016. An initial Important Message from Medicare was presented to the patient 9/21/2016 at 2030. No second Important Message from Medicare was presented to the patient #12 within 2 days of discharge.
Patient #13 was admitted 9/21/2016. An initial Important Message from Medicare was presented to the patient 9/24/2016 at 2000. No second Important Message from Medicare was presented to the patient #13 within 2 days of discharge.
Patient #14 was admitted 8/11/2016. An initial Important Message from Medicare was presented to the patient 8/11/2016 at 0105. No second Important Message from Medicare was presented to the patient #14 within 2 days of discharge.
Patient #15 was admitted 9/25/2016 no initial Important Message from Medicare was presented to the patient within 2 days of admission. No second Important Message from Medicare was presented to the patient #15 within 2 days of discharge.
In summary, the hospital failed to provide the Medicare Important Message notice to 4 of 4 eligible patients informing them of rights prior to the discharge.

Based on a review of the hospital policy " Complaints and Grievances: Patients (approved 2/28/2014), and the Rights and Responsibility information given to patients on admission, and review of grievance files, no specific grievance timelines are conveyed to patients.

The hospital policy Complaints and Grievance: Patients states in part, " A grievance received from a patient or patient's representative is responded to in writing on average within 7 days. " However, the Rights and Responsibility information given to admission patients states in part, " 18 ...Our grievance process provides you the right to a timely response... " No actual timelines are described as required by regulation.

Based on a tour of the video monitored behavioral health beds in the Emergency Department (ED), it is revealed that the hospital has no definitive way to inform behavioral health patients that they are under constant observation.

Tour of the ED on 10/25/2016 revealed two behavioral health beds areas with video monitoring ,which feed into nursing station monitors. Interview with the ED Manager on 10/25/2016 at approximately 0930 revealed that staff tell patients of the video monitoring, but that staff do not document this information. Additionally, no other method of informing patients of continuous monitoring such as signage was found. Based on this information, the hospital failed to meet privacy requirements for patients who are receiving mental health services in the hospital ED.

Based on a review of hospital Policy Restraint: Patient, (approved 8/22/2014) it was revealed that the restraint policy has a provision allowing staff to restrain patients undergoing mental health evaluations without regard to restraint regulatory requirements.

The hospital policy Restraint, Patient (approved 8/22/2014) stated in part, " Special Considerations: Restraint standards do not apply when; 5. Retaining physical custody of a patient to enable an emergency mental health evaluation. "

This statement under Special considerations allows for patients who are emergency petitioned to the hospital, to be restrained without regard for orders, assessments or other restraint regulatory requirements solely based on the emergency petition.

During an interview with the Risk Managers #1 and #2 on 10/26/2016 at 0900 there was no apparent awareness of this statement in the policy on their part . They also believed that it was not implemented affording all patients who must be restrained during mental health evaluations the right to have restraint orders, assessments and all other regulatory requirements met. When it was discussed that the provision was stated in the policy and that staff could act on the policy as written, they reiterated that restraint regulatory processes were followed. However, having this provision in the restraint policy represents a possible risk to the rights and safety of patients undergoing mental health evaluations.

Based on a review of hospital training materials, patient #1's record and interview with staff it was revealed that the hospital staff failed to implement safe restraint positioning per hospital training, resulting in patient #1 ' s positional asphyxiation.

A review of hospital training materials under Dangers of Restraints, stated in part, illustrational examples of positional asphyxia and stated in part, " ...It is also important to understand that in some cases, restrained individuals have gone from a state of no distress to death in a matter of moments ..., " and " Restraint-related positional asphyxia occurs when the person being restrained is placed in a position which he cannot breathe properly and is not able to take in enough oxygen. Death can result from this lack of oxygen and consequent disturbance in the rhythm of the heart. Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breathe. This includes sitting or lying across a person's back or stomach. When someone is lying facedown, even pressure to the arms and legs can impact that person's ability to breathe effectively."

During an interview with the Director of Security on 10/25/2016 at 1120 it was revealed that security guards receive Crisis Prevention training to conduct de-escalation and manual holds. Review of the training materials revealed unsafe restraining techniques such as prone (on stomach) positioning and positions which apply pressure to the patient back and chest. When asked if security could have utilized mechanical restraints, he stated that security staff have not yet been trained on mechanical restraints. Further, he stated that while trained in Crisis Prevention (CPI), nursing does not generally participate in manual restraints occurring in the ED.

As a result of an prone restraint by security patient #1 suffered an anoxic brain injury. Refer to the details under tag A-115 regarding the fact that no attempts were made to turn patient #1 to a safer supine (back-lying) position.

Based on a review of patient #1's record, no order for the restraint of patient #1 was found.

In late September 2016, patient #1 presented to the Emergency Department (ED) on Emergency Petition via police, and in handcuffs. Patient #1 's handcuffs were removed after he stated his intent to cooperate. The police left the patient in the ED for the evaluation. A triage was done at 2034 which revealed a Chief complaint of homicidal ideation and that patient #1 was brought in for manic behaviors.

Per the medical record the nurse went to the room to administer the IM Geodon as ordered by physician, the patient became aggressive, agitated, kicking, swinging his arms, hitting and pushing security personnel. He ran out of his room and security ran after the client. Security personnel held the patient to the floor and the medication was given as ordered.

In an interview on 10/25/2016 at approximately 1230 with the ED physician who was present for the incident it was revealed that he witnessed security guard #1 and patient #1 on the floor in a prone position (on their stomachs) with their feet in polar opposite directions, and that security guard #1 was positioned over patient #1's upper shoulders and head.

Documentation from the physician revealed in part that he asked staff if there were other security available to which the Charge Nurse replied that " Police had already been called. " The physician then went to room #8 to reassure the critically ill patient and family members that they were safe, and then walked to the computer area intending to write the face-to-face and restraint orders as well as follow up on other patients pending results. Other physician documentation revealed at that time patient #1, " ...was yelling for security to get off of him. He was also yelling that he couldn 't breathe, though loudly and clearly."

Other documentation from security #1 revealed in part, " ...After meds was rendred (sic) we were told by (the physician) to keep him restrain (sic) til the meds take effect (patient #1) were still kicking and punching. "


Review of patient #1 ' s record by the surveyor revealed that no restraint order was written as required. Based on this, patient #1 was restrained for approximately 10 minutes without an order. Refer to additional details under tag A-0115 .

Based on a review of patient #1's record and other documentation, clinical staff, failed to provide effective ongoing assessments of patient #1's status while in a face down manual restraint.
In late September 2016, patient #1 presented to the Emergency Department (ED) on Emergency Petition via police, and in handcuffs. Patient #1 's handcuffs were removed after he stated his intent to cooperate. A triage was done at 2034 which revealed a Chief complaint of homicidal ideation and that patient #1 was brought in for manic behaviors.

According to documentation, a nurse entered the patient's room to administer IM Geodon as ordered by physician. The patient became aggressive, agitated, kicking, swinging his arms, hitting and pushing security personnel. He ran out of his room and security ran after him . Two security staff and a transport staff held the patient on the floor in a prone position and the medication was given as ordered.

In an interview on 10/25/2016 at approximately 1230 with the ED physician who was present for the incident it was revealed that he witnessed security guard #1 and patient #1 on the floor in a prone position (on their stomachs) with their feet in polar opposite directions, and that security guard #1 was positioned over patient #1's upper shoulders and head. The physician consented to demonstrate this positioning to the surveyor to further define the hold security had on patient #1. Other documentation revealed the physician description of this position as " ...Security guard (#1) appeared to have right arm holding torso under patient ' s left neck/upper shoulder running toward and locking with the left arm around torso under patient's right axilla. Patient's head situated under (security guard #1 ' s) upper torso, looking to right. Face and mouth visible me. Patient was yelling to be released and clearly struggling to free himself ... "

Other documentation from the physician revealed in part that he asked staff if there were other security available to which the Charge Nurse replied that " Police had already been called. " The physician then went to room #8 to reassure the critically ill patient and family members that they were safe, and then walked to the computer area intending to write the face-to-face and restraint orders as well as follow up on other patients pending results. Other physician documentation revealed at that time patient #1, " ...was yelling for security to get off of him. He was also yelling that he couldn 't breathe, though loudly and clearly."

Other documentation from security #1 revealed in part, " ...After meds was rendred (sic) we were told by (the physician) to keep him restrain (sic) til the meds take effect (patient #1) were still kicking and punching. "

Other documentation from security guard #2 revealed in part, " ...(security guard #1) had the patient in a bear hug position. I (security guard #2) had the patient right and left arm held down. The patient was being secured on his stomach. At all times the patient was continuously asked if he could breath (sic) because he did say, " I can't breath ... "

Other documentation from the RN#1 stated, in part, " ...At approximately 2055, the county police arrived and a stretcher was brought out to place the patient on. When the patient was rolled over, it was noted that he wasn't breathing and that he had vomited ..."

Other documentation from a PA-C (Physician Assistant - Certified) revealed in part, " ...I saw two security guards (did not see who) physical restraining patient on the ground in the hallway between rooms ED7 and ED8, and patient yelled, "I can't breathe." He continued to struggle against the security guards and (the physician) came to his side. I continued seeing other patients and after some time I heard the charge nurse yelling for the physician as a patient had become unresponsive. I later learned it was the same patient. "

Despite the fact that patient #1 was restrained in a prone position and that the patient had stated that he was having difficulty breathing, clinical staff failed to effectively monitor patient #1 who suffered an aspiration event during restraint. Staff were unaware until the restraint was ended and the patient was turned over that the patient had aspirated and was now unresponsive.

Refer to tag A-0115 for a detailed account of the incident .