HospitalInspections.org

43881


Based on observation, record review, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation §482.13 related to Patient Rights for Patient ID# 1 who had a pillow placed over their face while his/her hands were manually restrained by a hospital employee in the emergency department.

Findings are as follows:

1. The hospital failed to provide care in a safe setting for Patient ID #1, who had a pillow placed over their face by a hospital employee while a patient in the emergency department. (Refer to A-144)

2. The hospital failed to prevent abuse from occurring for Patient ID #1, who was subjected to having their hands and arms held down preventing the removal of a pillow placed over the patients face by an employee. (Refer to A 145)

3. The hospital failed to ensure that the use of restraints is implemented in accordance with safe and appropriate restraint techniques for Patient ID# 1, related to a manual hold of their arms and hands. (Refer to A 167)

43881

Based on observation of the hospital's video surveillance, record review, and employee interview and it has been determined that the hospital failed to provide care in a safe environment for 1 of 5 patients who demonstrated aggressive behaviors (Patient ID #1).

Findings are as follows:

Review of the hospital's incident report dated 4/4/2022, revealed Patient ID# 1 was aggressive and violent and making attempts to get out of bed. EMP-A, Registered Nurse, entered the room, and requested to EMP-B, a Certified Nursing Assistant (CNA) to get additional help. When EMP-B returned to the room, Patient ID #1 had a pillow resting on her/his face.

Surveyor review of Patient ID #1's medical record revealed she/he presented to the hospital's emergency department in April of 2022 with a change in mental status with the following behaviors exhibited at home: agitation, medication refusal, attempts to leave the house, uncooperativeness, and threatened family members with a knife. His/her past medical history includes, but is not limited to, Alzheimer's disease.

Review of the hospital's policy titled, "Patient Rights" states in part,
" ...PROCEDURE...
[the hospital] shall...
4. Provide a patient with care in a safe setting..."

Surveyor observation of video surveillance in the presence of the Systems Director of Risk Management on 4/5/2022 at approximately 12:50 PM, revealed the following events that occurred on 4/4/2022 at approximately 12:26 AM:

1) Video review revealed EMP-B sitting at the enclosed nurses' station in the LSU along with EMP-A when he turns his attention to movement taking place at an adjacent room. At this time, Patient ID #1 was attempting to get out of bed, she/he had made his/her way to the edge of the foot of the bed where she/he sat with his/her legs dangling and his/her feet almost touching the floor.

During an interview with EMP-A following this observation, he stated that the concern was that the patient would fall due to the patient's unsteady gait observed on admission to the unit. Therefore, EMP-A and EMP-B discussed their concerns that the patient would fall and moved the patient back into bed resulting in aggressive and combative behavior.

2) Video review revealed EMP-B entering the room and turns on the light, at which point a white glare is reflecting off the patient and the entire bed. EMP- A enters the room and assists EMP-B in putting Patient ID #1 back to bed when she/he begins to swing his/her arms at both employees and grabs at EMP-A's forearms. EMP-B is noted on 2 occasions to leave the room leaving EMP-A alone with Patient ID# 1.

3) Video review revealed EMP-A struggling while attempting to hold the patient down when he is noted to grab a pillow from the bed and place it on top of the patient. Due to a glare in the video, it was difficult to identify where the pillow had been placed.

During a surveyor interview with EMP-A on 4/5/2022 at approximately 2:00 PM, when asked where the pillow was placed, EMP-A stated on the patient's face. When asked if the patient could remove the pillow, EMP-A stated the patient could not remove the pillow because he was holding his/her hands.

During a surveyor phone interview on 4/6/2022 at 2:07 PM with EMP-B he indicated that just before 12:30 AM on 4/4/2022, after calling for additional help to assist with Patient ID #1, he returned to the patient's room and observed a pillow over his/her face covering the entire face. He revealed that he immediately removed the pillow off the patient's face and observed his/her face red with watery eyes, and she/he appeared terrified. The patient was noted to yell in Spanish the words, "Abuser" and "get away" directed at EMP-A. EMP-B stated he speaks Spanish and could understand fully what the patient was yelling. He indicated that after the pillow was removed from the patient's face, he/she was calm. When asked if he observed EMP-A's hands holding Patient ID #1's hands in place while the pillow was covering his/her face, he replied, "Yes."

43881


Based on record review, staff interview and surveyor observation of the hospital's video surveillance it has been determined that the hospital failed to protect 1 of 6 patients from abuse (Patient ID #1).

Findings are as follows:

Review of an incident report dated 4/4/2022 revealed at 12:26 AM in the Emergency Department's Low Stimulation Unit (LSU), Patient ID #1 was aggressive, becoming violent, and attempting to get out of bed.

Surveyor review of Patient ID #1's medical record revealed she/he presented to the hospital in April of 2022, with a change in mental status with the following behaviors exhibited at home: agitation, medication refusal, attempts to leave the house, uncooperativeness, and threatened family members with a knife. His/her past medical history includes, but is not limited to, Alzheimer's disease.

Review of the hospital's policy titled, "Patient Rights" states in part,
...PROCEDURE...
[the hospital] shall...
...3. Treat a patient in a caring and polite way and ensure that a patient is free from all forms of mental, physical, sexual and verbal abuse, neglect, harassment, exploitation and corporal punishment..."

Surveyor observation of the hospital's video surveillance dated 4/4/2022, on 4/5/2022 at approximately 12:50 PM in the presence of the Systems Director of Risk Management, revealed the following events:

1) Video review revealed EMP-A entering the patient's room and assist EMP-B in putting Patient ID #1 back to bed when the patient swings his/her arms at both employees and grabs at EMP-A's forearms.

During an interview with EMP-A following this observation, he stated that the concern was that the patient would fall due to the patient's unsteady gait observed on admission the unit. Therefore, EMP-A and EMP-B discussed their concerns that the patient would fall and moved the patient back into bed resulting in aggressive and combative behavior.

2) Video review revealed that on 2 occasions EMP-B is noted to leave the room leaving EMP-A alone with Patient ID #1. EMP-A is noted visibly struggling as the patient continues to swing his/her arms and grab onto EMP-A's forearms.

3) Video review revealed EMP-A holding the patient's arms down while grabbing a pillow from the bed and then placing it over the patient. The video is not clear due to a glare where the pillow is placed. EMP-B is then noted to return to the room approximately 13 seconds after EMP-A is noted to place the pillow over the face.

During a surveyor phone interview on 4/6/2022 at 2:07 PM with EMP-B, he indicated that just before 12:30 AM on 4/4/2022, after calling for additional help to assist with Patient ID #1, he returned to the patient's room and observed a pillow over his/her face covering the entire face. He revealed that he immediately removed the pillow off the patient's face and observed his/her face red with watery eyes, and she/he appeared terrified. Since he speaks Spanish, he indicated that he understood the patient as she/he yelled the words, "Abuser" and "get away" in Spanish directed at EMP-A. He indicated that after the pillow was removed from the patient's face, he/she was calm. When asked if he observed EMP-A's hands holding Patient ID #1's hands in place while the pillow was covering his/her face, he replied, "Yes."

During a surveyor interview with EMP-A on 4/5/2022 at approximately 2:00 PM, he indicated that he held onto the patient's hands because she/he was digging his/her long fingernails into his hands and was attempting to bite him. He stated that the only thing he had as a barrier to prevent the patient from biting him was a pillow, which he laid on top of the patient's face. When asked if the patient was able to remove the pillow on his/her own, he indicated that she/he was unable because he was holding onto his/her hands.

During a surveyor interview on 4/5/2022 at 2:50 PM with the Emergency Department's Clinical Nurse Manager, she acknowledged that placing a pillow over the patient's face was not an appropriate action or an appropriate barrier even if the patient was biting or spitting.

43881


Based on record review, staff interview and surveyor observation, the hospital failed to implement safe and appropriate restraining techniques for 1 of 6 patients reviewed for restraints, (Patient ID #1).

Findings are as follows:

Review of a hospital incident report dated 4/4/2022 at 12:26 AM, in the Emergency Department's Low Stimulation Unit (LSU), Patient ID #1 was aggressive, physically violent, and attempting to get out of bed. Employee (EMP) A, a Registered Nurse, was in the room with Patient ID #1 when he asked EMP-B, a Certified Nursing Assistant (CNA), to call for additional help. When EMP-B returned, the patient was noted to have a pillow over their face.

Surveyor review of Patient ID #1's medical record revealed she/he presented to the hospital in April of 2022 with a change in mental status. His/her past medical history includes, but is not limited to, Alzheimer's disease.

Review of the hospital's policy titled, "Non-Violent and Violent Restraint" states and part,

POLICY...
...All Restraints must be applied using safe and appropriate restraining techniques...


1. Restraint: any manual method, physical or mechanical device, material or any equipment or medication that immobilizes or reduces the ability of a patient move his or her arms, legs, body, or head freely...


3. Physical Restraint: Any manual method, physical or mechanical device, material or any equipment, or drug or medication that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely in all care settings. Holding a patient in a manner that restricts his/her movement constitutes..."


Surveyor observation of the hospital's video surveillance on 4/5/2022 at approximately 12:50 PM in the presence of the Systems Director of Risk Management, revealed the following incident that occurred on 4/4/2022 at approximately 12:26 AM:

1) Video review revealed, Patient ID #1 was attempting to get out of bed, she/he had made his/her way to the edge of the foot of the bed where she/he sat with his/her legs dangling and his/her feet almost touching the floor.

During an interview with EMP-A following this observation, he stated that the concern was that the patient would fall due to the patient's unsteady gait observed on admission the unit. Therefore, EMP-A and EMP-B discussed their concerns that the patient would fall and moved the patient back into bed resulting in aggressive and combative behavior.

2) Video review revealed Patient ID# 1 was combative and was being managed by EMP-A who was noted to struggle with the patient's arms and hands. EMP-A is observed to move a pillow over the patient. A white glare on the video over the bed prevents from initially observing where the pillow was placed. This video footage revealed that EMP-A did manually hold Patient ID# 1's, hands and arms, restricting movement preventing the patient from removing the pillow for approximately 13 seconds until EMP-B enters the room.

During a surveyor interview on 4/6/2022 at 2:07 PM with EMP-B, he indicated that just before 12:30 AM on 4/4/2022 he saw the patient trying to get out of bed and assisted him/her back to bed with EMP-A. He indicated that after calling for help, he returned to the patient's room and observed a pillow over the patient's face, covering the whole face. He revealed that he immediately removed the pillow and observed the patient's face red, with watery eyes, and appeared terrified. Since he speaks Spanish, he indicated that he understood the patient as she/he yelled the words, "Abuser" and "get away" in Spanish. He indicated that after the pillow was removed from the patient's face, he/she was calm. When asked if he observed EMP-A's hands holding Patient ID #1's hands in place restricting her movement while the pillow was covering his/her face, he replied, "Yes."

During a surveyor interview with EMP-A on 4/5/2022 at approximately 2:00 PM, he indicated that he was alone with the patient, she/he was digging his/her long fingernails into his hands, and he placed the pillow as a barrier to prevent the patient from biting him. He stated that he placed the pillow on top of the patient's face so that he could maintain his hands on the patient's hands to prevent the patient from scratching. When asked if the patient was able to remove the pillow on his/her own, he indicated that she/he could not because he was holding onto his/her hands.