HospitalInspections.org

Based on medical chart review, facility policy review, and interviews, the facility failed to protect patients from abuse/neglect, failed to obtain a consent for treatment, and failed to provide care in a safe setting by (a) failing to report allegations of abuse/neglect to the State Survey Agency as required by the statute (refer to A 122), (b) failing to thoroughly investigate allegations of abuse (refer to A 123), (c) failing to obtain a consent for treatment (refer to A 131), and (d) failing to closely monitor a patient with documented suicidal ideation, as well as failing to have clear and clinical reasons for seclusion and restraining of patients (refer to A 144, A 145).


Based on interviews, records review, and observations, it was determined that the deficient practices found posed an immediate jeopardy to the heath and safety of patients and had the likelihood to cause harm. The Chief Executive Officer was informed of this on 01/30/15 at 10:00 am.

Based on record review and interview, the facility failed to review, investigate, and resolve each patient's grievance within 7 days of receipt of the grievance for 7 of 7 (#'s 1, 2, 3, 4, 5, 6, 7) sampled patients who filed a complaint and/or grievance with the hospital.


The findings are :


A. According to the Policy/Procedure titled "Patient Complaint/Grievance" dated 10/21/13, revealed that "The Hospital Quality Improvement Committee ensures the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within 7 days of the Hospital's receipt of the grievance, even though the hospital's resolution need not be complete within the seven-day limit. The written notice shall contain the following:
a. Name of the Hospital contact person.
b. Steps taken on behalf of the patient to investigate the grievance.
c. Results of the grievance process
d. Date of completion."


B. Review of Complaints and Grievance Log dated July 2014 - December 2014 revealed that seven complaints and/or grievances from patients were documented.


C. Review of response letters to the patients revealed that two of the seven patients were sent a written follow-up response.


1. Patient #1 reported alleged abuse and neglect on 07/30/14. A follow-up letter dated September 8, 2014 was sent to the patient, 40 days after the patient reported the incident.


2. Patient #7 reported alleged abuse and neglect after her hospital stay from November 6 - 9, 2014. A follow-up letter dated December 3, 2014 was sent to the patient, 24 days after the patient reported the incident.


3. Patient #2, #3, #4, #5, and #6 reported complaints and grievances and were not sent follow-up letters.


D. An interview was conducted with Director of Risk Management and the Interim Chief Quality Officer on 01/27/15 at 12:40 pm. The Director of Risk Management confirmed that no follow-up letters were sent to patient #2, #3, #4, #5, and #6. The Director of Risk Management and the Interim Chief Quality Officer did not have an explanation as to why the follow-up letters were not sent to those patients. The Director of Risk Management and the Interim Chief Quality Officer did not have an explanation as to why the follow-up letters to patient #1 and #7 were not sent in a reasonable time frame.

Based on record review and interview, the facility failed to submit a written response to grievances for 5 of 7 (#'s 2, 3, 4, 5, 6) patients sampled who reported a complaint and/or grievance.


The findings are:


A. According to the Policy/Procedure titled "Patient Complaint/Grievance" dated 10/21/13, revealed that "The Hospital Quality Improvement Committee ensures the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within 7 days of the Hospital's receipt of the grievance, even though the hospital's resolution need not be complete within the seven-day limit. The written notice shall contain the following:
a. Name of the Hospital contact person.
b. Steps taken on behalf of the patient to investigate the grievance.
c. Results of the grievance process
d. Date of completion."


B. Review of Complaints and Grievance Log dated July 2014 - December 2014 revealed that seven complaints and/or grievances from patients were documented.


C. Review of response letters to the patients revealed that five of the seven patients were not sent a written follow-up response.


1. Patient #2, #3, #4, #5, and #6 reported complaints and/or grievances and were not sent a written follow-up response.


D. An interview was conducted with the Director of Risk Management and the Interim Chief Quality Officer on 01/27/15 at 12:40 pm. The Director of Risk Management confirmed that no follow-up letters were sent to patient #2, #3, #4, #5, and #6. The Director of Risk Management and the Interim Chief Quality Officer did not have an explanation as to why the follow-up letters were not sent to those patients.

Based on record review, interview, and observation, the facility failed to obtain a consent for treatment. Patient #1 refused to sign a consent for treatment. After this refusal the facility proceeded to seclude, restrain, and collect urine and blood from Patient #1 over a period of five hours. The findings are:


A. Review of Patient #1 Emergency Department (ED) medical record revealed the following:

1. Review of the Facility Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment form for Patient #1 dated 07/29/14 at 5:09 pm indicated the "patient refused to sign." This form is witnessed and signed by the Director of the Emergency Department.

2. ED Physician Documentation dated 07/29/14 states "[Patient #1]presents to ED via Unassigned with complaints of Psych Problem."

3. ED Nurse Documentation's dated 07/29/14 states "Presenting complaint: Patient states: Pharmacy wouldn't give me the meds ordered from last visit."


B. Review of the Facility Security Camera Footage dated 07/29/14 from 3:15 pm until 8:15 pm indicates the following:

1. 3:15 pm, Patient #1 arrives at the ED in the company of two local law enforcement agents. The patient is handcuffed. The patient and law enforcement officers stop briefly at the ED nursing station and speak with ED Tech #1. ED Tech #1 is observed walking Patient #1 down the hall and into the "seclusion room" of the ED. Law enforcement personnel remove the handcuffs without incident. Patient #1 sits on the bed and ED Tech #1 and law enforcement leave the room. ED Tech #1 shuts the door to the room. At 3:28 pm video footage indicates the two law enforcement officers leave the facility. Patient #1 appears calm and cooperative.

2. 3:45 pm, Registered Nurse (RN) #1 is observed entering the seclusion room with a clipboard. The clipboard is given to Patient #1 and he is observed looking at it. RN #2 enters the room at this time, with her arms crossed and folded. Patient #1 appears calm and cooperative. RN#1 and #2 are observed leaving the room with clipboard in hand.

3. 3:50 pm, RN #1 and #2 enter the room. RN #2 is observed taking the patient's vital signs and giving the patient a plastic bag that appears to be the type for personal belonging/clothes. Patient #1 is cooperative and RN #1 and 2 leave the room.

4. 4:10 pm, the physician (MD) enters the room and is observed speaking with Patient #1. Neither the MD nor Patient #1 displays any type of distress or concern.

5. 4:20 pm, RN #1 and RN #2 enter the seclusion room and place what appears to be an identification band around Patient #1's wrist. Patient #1 appears cooperative and calm.

6. 4:24 pm, ED Tech #1 enters the room and conducts an electrocardiogram (EKG) on Patient #1. Patient #1 is cooperative and this procedure takes five minutes.

7. 5:00 pm, ED Tech #1 enters the seclusion room with what appears to be a butterfly needle, tubing and tubes (equipment needed to draw blood). ED Tech #1 and Patient #1 stand and talk to each other. RN #1, RN #2, RN #3 and ED Tech #2 enter the room. Patient #1 appears to be indicating with face and arm gestures that he does not want his blood drawn. Patient #1 is not aggressive with staff and they leave the room at 5:03 pm.

8. 5:05 pm, RN #1 and RN #2 enter the seclusion room as does ED Tech #1, #2, and #3, Facility Security Officer #1, and Nurse Practitioner (NP) #1. As staff approach Patient #1, the patient is observed backing up to the wall of the room and attempts to stand on the bed. Simultaneously, ED Tech #1 takes the patient's right arm, and Security Officer #1 grabs the patient's left arm, while ED Tech #3 grabs the patient by the waist and sweeps the patient's legs from underneath him and Patient #1 is forcibly taken face first onto the mattress. ED Tech #3 is observed lying across the back of Patient #1, with his left leg in between the patient's legs. RN #1 assists holding the left arm and NP #1 holds the patient's head. At this point, an unidentified, non-facility staff person wearing a black shirt and tan pants is observed to take out a pair of handcuffs and place one handcuff around the left wrist of Patient #1. The patient's left arm is placed behind his back and the unidentified person has the full weight of his left knee onto the left shoulder of Patient #1. Facility Security Officer #1 is observed holding down the left leg of Patient #1. RN #2 appears to draw blood from the patient's right antecubital vein.

9. 5:10 pm, it appears RN #2 has the requisite number of blood tubes, and staff begin to slowly release their grasps and holds on Patient #1. Staff leave the room and Patient #1 is left, in a prone position, with his arms outstretched and his back appears sweaty. Patient #1 slowly gets himself up from the mattress and begins moving around.

10. 5:22 pm, RN #4 enters the room and hands Patient #1 a plastic urinal. Patient #1 takes the urinal but appears to indicate he does not want to use it. RN #4 leaves the room and shuts the door. The Director of the Emergency Department is observed standing in the hallway outside of the seclusion room, waving and motioning to the patient through the glass.

11. 5:33 pm, seven facility staff are observed entering Patient #1's room. The staff include: ED Techs #1, #2 and #4; RN #1, #2 and #4; NP#1 and Security Guard #2. Patient #1 is observed standing near the door. Security Guard #2 goes on the left side of Patient #1 and ED Tech #1 and #2 take the right side and arm of Patient #1. Patient #1 is then forcibly taken face first, down onto the mattress. ER Tech #1 is observed with his knee in the middle of Patient #1's back. RN #4 is observed administering an injection into the the patient's right buttock, followed by RN #1 administering a second injection into the patient's right buttock. Patient #1 is then immediately flipped over on his back. NP #1 is observed forcing the patient's head down into the mattress and holding it, while ED Techs #2 and #4 begin trying to lower the patient's pants to expose the patient's genitalia. Patient #1 is observed trying to get free, and appears to be yelling. ER Tech #1 is observed placing both of his hands onto the patient's chest and applying his full body weight in an effort to keep Patient #1 from moving. ER Tech #1 then pulls the patient's left arm above the patient's head and sits on the patient's left shoulder and arm. Patient #1 is observed attempting to keep his legs together and ER Techs #2 and #4 and RN #1 and #4 are pulling and trying to open his legs. RN #2 appears in camera range with a catheter tray and bends over the patient. RN #2's back is to the camera, but over the next three minutes it appears that RN #2 is attempting to advance a urinary catheter through Patient #1's penis.

12. 5:38 pm, urine appears to have been collected and staff slowly begin releasing the patient and leave the room. Patient #1 is left on his back and alone in the room.

13. 6:00 pm, Patient #1 is asleep on the mattress in the seclusion room. There is no bedding available.

14. 7:25 pm, RN #5 and ED Tech #5 enter the seclusion room. RN #5 places a blood pressure cuff around the patient's left arm. Patient #1 moves slightly. It appears vital signs are taken and RN #5 and ED Tech #5 leave the room.

15. 7:31 pm, Patient #1 begins waking up and moving. He gets up from the bed and begins pacing around the room.

16. 7:37 pm, Patient #1 sits back down on the bed.

17. 7:42 pm, ED Tech #5, RN #4, ED Tech #1, RN #5, RN #6, and ED Tech #4 begin gathering outside the seclusion room, all putting on gloves.

18. 7:43 pm, the six staff named above enter the room. Patient #1 is observed sitting on the edge of the bed. ED Tech #1 approaches the patient and places his right hand on the patient's left shoulder. Patient #1 then stands, and bends over the bed. RN #6 hands a syringe to RN #4 and RN #4 is observed injecting the needle of the syringe into the left buttock of Patient #1. Staff then leave the room and patient #1 is left alone in the seclusion room.

19. 8:15 pm, Facility Security Guard #1 is observed pushing Patient #1 in a wheelchair for transport.

C. The Policy/Procedure titled Informed Consent dated 06/24/14 states the following:
1. Paragraph A: "A signed consent form will be obtained on procedures that the Medical Staff determines requires a specific explanation to the patient. Any doubts as to the necessity of obtaining consent from the patient for a procedure should be resolved in favor of procuring the consent."
2. Paragraph B: "Emergencies: #1 Informed consent is unnecessary when, in the physician's judgment, an emergency exists and the patient is in immediate need of medical attention and attempt to secure consent would delay treatment and increase the risk to the patient's life or health. The circumstances will be fully documented by the physician in the patient's record."

D. An interview was conducted with the Director of Risk Management and the Interim Chief Quality Officer on 01/27/15 at 12:40 pm. The Director of Risk Management and the Interim Chief Quality Officer confirmed that the incident with Patient #1 on 07/29/14 was not handled appropriately. The Interim Chief Quality Officer did not have an explanation for the manner in which Patient #1 was treated. The Interim Chief Quality Officer stated, "The video was very upsetting."

Based on record review, observation, and interview the facility failed to provide care in a safe setting by failing to:


(a) closely monitor Patient #2, who was being treated for suicidal ideation. Patient #2 was allowed to obtain and attempt to hang himself with a bed sheet.,


(b) have clear and clinical reasons for seclusion and restraining of Patient #1,


(c) have an abuse prohibition program that implements components to report and investigate allegations of abuse, and


(e) allow patients to refuse treatment.


The findings are:


A. Review of Patient #2's medical record revealed the following:


1. On 01/09/15 at 8:14 am, Patient #2 arrived in the facility Emergency Department (ED) for Crohns disease. Patient #2 states that the pain was too much to bare and he was having thoughts of hanging himself. The patient was admitted to the Medical floor with leukocytosis. (Leukocytosis is a white blood cell count above the normal range in the blood. It is frequently a sign of an inflammatory response and most commonly the result of infection.)

2. On 01/11/15 at 12:45 pm, Patient #2 is transferred to the facility Behavioral Health Unit with a diagnosis of Bipolar type 1 and Suicidal Ideation.


B. Review of the facility video recording dated 01/12/15 revealed the following:

1. 11:43 am, Patient #2 was in room 610. The patient appeared to be moving around in his room. Registered Nurse (RN) #7 was observed standing in the doorway of room 609, the room directly adjacent to room #610.

2. 11:44 am, Patient #2 appeared to be moving around in his room and removed sheets from his bed. The patient then walked toward the door of his room and pulled the bed sheet under and above the bottom door hinges. RN #7 was observed still standing in the doorway of room #609.

3. 11:45 am, Patient #2 walked into the hallway and pulled more of the sheet between the door and door frame. Patient #2 was then observed lying on the floor in the hallway, on top of the sheet and wrapped the sheet around his neck. Patient #2 then began rolling on the floor tightening the sheet around his neck. RN#7 was still standing in the doorway of room #609, approximately 18 inches away from Patient #2.

4. 11:46 am, Psych Tech #1 came into camera range and was observed running over to Patient #2 and stopped the patient from rolling. The Director of Security and Security Officer #3 came into camera range. RN #7 turned around, and RN #8 came into camera range and removed the sheet from around the patient's neck.

5. 11:46 am to 11:50 am, Patient #2 was observed lying on the hallway floor with multiple hospital staff members stood around him. At 11:50 am, RN #8 assisted Patient #2 to his room and bed.

6. 11:52 am, the Director of the Behavioral Health Unit was observed entering Patient #2's room and the video ended.

C. On 1/27/15 at 8:30 am during an interview, the Interim Chief Quality Officer and the Director of Risk Management stated that the attempt of Patient #2 to hang himself was "not really a reportable incident" and they were unaware that a comprehensive investigation, with any necessary corrective actions needed to occur within the time frame specified by the applicable State law.

D. On 01/27/15 at 9:30 am, an interview was conducted with the Director of Security. The Director of Security stated that he and Security Officer #3 were on the Behavioral Health Unit returning valuables to another patient when the incident with Patient #2 occurred. The Director of Security stated that when he and Security Officer #3 walked out of a patient room, he heard someone say "Hey." The Director of Security stated he and Security Officer #3 assisted with Patient #2 and secured the area.

E. On 01/27/15 at 10:15 am, an interview was conducted with the Director of Behavioral Health. The Director stated that staff came to her office and told her that a patient had "committed suicide" and that she went to Patient #2's room. The Director stated that she walked into Patient #2's room and the patient stated, "I don't know why I did that." The Director stated she asked the patient 'What can we do to help you?' and Patient #2 did not respond to the question. The Director stated she had Patient #2 stand up and she examined his neck. The Director stated Patient #2 appeared shaky,with a red/warm face, nervous and scared. When asked if she wrote an incident report, the Director stated, "No I did not." The Director stated she was told by the Interim Chief Quality Officer "it was not her job."

F. On 01/27/15 at 4:00 pm, an interview was conducted with RN #7. RN #7 stated she had just completed her assessment of Patient #2 prior to the incident. RN #7 stated she was in the doorway of the next room and she was unaware of what Patient #2 was doing. RN #7 stated it wasn't until she heard someone yell "Hey" and then she turned around. RN #7 stated, "I can't believe I was standing right there and this happened." RN #7 stated she was an agency nurse and had been working at this facility since 12/14, but on the Behavioral Health Unit for 10 days prior to this incident. She stated that she had received two days of training on the computer and two days shadowing another nurse on the unit. When asked why it appeared from the camera footage that she just stood over Patient #2, staring at him and not assessing for injury, she replied "We were talking to him, but he was not answering back." RN #7 stated she had not been questioned about the incident of potential hanging and was not involved in a facility investigation of the incident. When asked how abuse and neglect is reported and investigated at the facility, RN #7 stated she would report abuse/neglect to her immediate supervisor.


G. Review of Patient #1's Emergency Department (ED) medical record revealed the following:


1. The Facility Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment form for Patient #1 dated 07/29/14 at 5:09 pm indicated the "patient refused to sign." This form is witnessed and signed by the Director of the Emergency Department.


2. ED Physician Documentation dated 07/29/14 states ".....presents to ED via Unassigned with complaints of Psych Problem."


3. ED Nurse Documentation dated 07/29/14 states, "Presenting complaint: Patient states: Pharmacy wouldn't give me the meds ordered from last visit."


H. Review of the Facility Security Camera Footage dated 07/29/14 from 3:15 pm until 8:15 pm indicated the following:


1. 3:15 pm, Patient #1 arrived at the ED in the company of two local law enforcement agents. The patient was handcuffed. The patient and law enforcement officers stopped briefly at the ED nursing station and spoke with ED Tech #1. ED Tech #1 was observed walking Patient #1 down the hall and into the "seclusion room" of the ED. Law enforcement personnel remove the handcuffs without incident. Patient #1 sat on the bed and ED Tech #1 and law enforcement leave the room. ED Tech #1 closed the door to the room. At 3:28 pm, video footage indicated the two law enforcement officers left the facility. Patient #1 appeared calm and cooperative.


2. 3:45 pm, Registered Nurse (RN) #1 was observed entering the seclusion room with a clipboard. The clipboard was given to Patient #1 and he was observed looking at it. RN #2 entered the room at this time, with her arms crossed and folded. Patient #1 appeared calm and cooperative. RN#1 and #2 were observed leaving the room with clipboard in hand.


3. 3:50 pm, RN #1 and #2 entered the room. RN #2 was observed taking the patient's vital signs and giving the patient a plastic bag that appeared to be the type for personal belonging/clothes. Patient #1 was cooperative and RN #1 and 2 left the room.


4. 4:10 pm, the physician (MD) entered the room and was observed speaking with Patient #1. Neither the MD or Patient #1 displayed any type of distress or concern.


5. 4:20 pm, RN #1 and RN #2 entered the seclusion room and placed what appeared to be an identification band around Patient #1's wrist. Patient #1 appeared cooperative and calm.


6. 4:24 pm, ED Tech #1 entered the room and conducted an electrocardiogram (EKG) on Patient #1. This test involved placing 10 electrodes on the patient's chest and abdomen. Patient #1 was cooperative and this procedure took five minutes.


7. 5:00 pm, ED Tech #1 entered the seclusion room with what appeared to be a butterfly needle, tubing and tubes (equipment needed to draw blood). ED Tech #1 and Patient #1 stood and talked to each other. RN#1, RN #2, RN #3 and ED Tech #2 entered the room. Patient #1 appeared to be indicating with face and arm gestures that he does not want his blood drawn. Patient #1 was not aggressive with staff and they left the room at 5:03 pm.


8. 5:05 pm, RN #1 and RN #2 entered the seclusion room as does ED Tech #1, #2, and #3, Facility Security Officer #1, and Nurse Practitioner (NP) #1. As the staff approached Patient #1, the patient was observed backing up to the wall of the room and attempted to stand on the bed. Simultaneously, ED Tech #1 took the patient's right arm, and Security Officer #1 grabbed the patient's left arm, while ED Tech #3 grabbed the patient by the waist and sweeped the patient's legs from underneath him and Patient #1 was forcibly taken face first onto the mattress. ED Tech #3 was observed lying across the back of Patient #1, with his left leg in between the patient's legs. RN #1 assisted holding the left arm and NP #1 held the patient's head. At this point, an unidentified, non-facility staff person wearing a black shirt and tan pants was observed to take out a pair of handcuffs and placed one handcuff around the left wrist of Patient #1. The patient's left arm was placed behind his back and the unidentified person had the full weight of his left knee onto the left shoulder of Patient #1. Facility Security Officer #1 was observed holding down the left leg of Patient #1. RN #2 appeared to draw blood from the patient's right antecubital vein.


9. 5:10 pm, it appeared that RN #2 had the requisite number of blood tubes, and staff began to slowly release their grasps and holds on Patient #1. Staff left the room. Patient #1 was left, in a prone position, with his arms outstretched and his back appears sweaty. Patient #1 slowly got himself up from the mattress and began moving around.


10. 5:22 pm, RN #4 entered the room and handed Patient #1 a plastic urinal. Patient #1 took the urinal but appeared to indicate he does not want to use it. RN #4 left the room and closed the door. The Director of the Emergency Department was observed standing in the hallway outside of the seclusion room, waving and motioning to the patient through the glass.


11. 5:33 pm, seven facility staff were observed entering Patient #1's room. The staff include: ED Techs #1, #2, and #4; RN #1, #,2 , and #4; NP#1, and Security Guard #2. Patient #1 was observed standing near the door. Security Guard #2 went on the left side of Patient #1 and ED Tech #1 and #2 took the right side and arm of Patient #1. Patient #1 was then forcibly taken face first, down onto the mattress. ER Tech #1 was observed with his knee in the middle of Patient #1's back. RN #4 was observed administering an injection into the the patient's right buttock, followed by RN #1 administering a second injection into the patient's right buttock. Patient #1 was then immediately flipped over on his back. NP #1 was observed forcing the patient's head down into the mattress and holding it, while ED Techs #2 and #4 began to lower the patient's pants to expose the patient's genitalia. Patient #1 was observed trying to get free, and appeared to be yelling. ER Tech #1 was observed placing both of his hands onto the patient's chest and applied his full body weight in an effort to keep Patient #1 from moving. ER Tech #1 then pulled the patient's left arm above the patient's head and sat on the patient's left shoulder and arm. Patient #1 was observed attempting to keep his legs together and ER Techs #2 and #4 and RN #1 and #4 were pulling and trying to open his legs. RN #2 appeared in camera range with a catheter tray and bends over the patient. RN #2's back was to the camera, but over the next three minutes it appeared that RN #2 was attempting to advance a urinary catheter through Patient #1's penis.


12. 5:38 pm, urine appeared to have been collected and staff slowly began releasing the patient and left the room. Patient #1 was left on his back and alone in the room.


13. 6:00 pm, Patient #1 was asleep on the mattress in the seclusion room. There was no bedding available.


14. 7:25 pm, RN #5 and ED Tech #5 entered the seclusion room. RN#5 placed a blood pressure cuff around the patient's left arm. Patient #1 moves slightly. It appeared vital signs were taken and RN #5 and ED Tech #5 left the room.


15. 7:31 pm, Patient #1 began waking up and moving. He got up from the bed and began pacing around the room.


16. 7:37 pm, Patient #1 sat back down on the bed.


17. 7:42 pm, ED Tech #5, RN #4, ED Tech #1, RN #5, RN #6, and ED Tech #4 began gathering outside the seclusion room, all putting on gloves.


18. 7:43 pm, the six staff named above entered the room. Patient #1 was observed sitting on the edge of the bed. ED Tech #1 approached the patient and placed his right hand on the patient's left shoulder. Patient #1 then stood, and bent over the bed. RN #6 handed a syringe to RN #4 and RN #4 was observed injecting the needle of the syringe into the left buttock of Patient #1. Staff then left the room and patient #1 was left alone in the seclusion room.


19. 8:15 pm, Facility Security Guard #1 was observed pushing Patient #1 in a wheelchair out of camera range.


I. The Emergency Department Record for Patient #1 dated 07/29/14 was reviewed. No documented clinical rationale was evident in the record why the seclusion room was necessary or why Patient #1 remained in seclusion for five hours. No documented clinical rationale was evident for physically holding Patient #1 for either the blood draw or urine sample. No documented clinical rationale was evident to indicate why Patient #1 was given three intramuscular injections. No documentation was evident to indicate the patient was given food, water, or allowed to use the restroom.

Based on record review, interview and observation, the facility failed to protect patients from abuse by:


(a) failing to report allegations of abuse/neglect to the State Survey Agency as required by statute,


(b) failing to thoroughly investigate allegations of abuse,


(c) failing to obtain patient consent prior to examination and treatment,


(d) allowing an individual that was not a staff member of the facility to participate in the physical restraining of Patient #1, and


(e) allowing Emergency Department staff to seclude and restrain Patient #1 without documented clinical necessity.

These failures lead to the abuse of Patient #1. The findings are:


A. Review of the Facility Complaint and Grievance log dated 01/23/15 indicated on 07/30/14 an allegation of abuse or neglect was documented as occurring in the Emergency Department (ED) to Patient #1.


B. Review of a letter from the facility Chief Operations Officer (COO) dated 09/8/14 to Patient #1 concerning the patient's allegations of abuse and neglect while a patient in the ED on 07/29/14 indicated the following:


1. The COO stated, "I understand you complained that you were physically and verbally abused, held down against your will to have blood work drawn and raped when being held down a second time against your will to have a catheter placed."


2. The COO stated that "the investigation is complete."


3. The COO stated that "you refused treatment deemed necessary by the physician who made the decision to obtain tests to help determine your treatment. We can understand how this felt abusive to you."


4. The COO stated that "the physician determined that a blood and urine sample were necessary for your safe care. To accomplish this, several personnel did hold you down to draw your blood."


5. The COO stated that "you were indeed held to obtain the urine sample."


6. The COO stated, "We have learned from your experience and are taking steps to ensure the care given to patients is both medically appropriate and rendered in the least restrictive method possible."


C. Review of the Facility Security Camera Footage dated 07/29/14 from 3:15 pm until 8:15 pm indicated the following:


1. 3:15 pm, Patient #1 arrived at the ED in the company of two local law enforcement agents. The patient was handcuffed. The patient and law enforcement officers stopped briefly at the ED nursing station and spook with ED Tech #1. ED Tech #1 was observed walking Patient #1 down the hall and into the "seclusion room" of the ED. Law enforcement personnel removed the handcuffs without incident. Patient #1 sat on the bed and ED Tech #1 and law enforcement left the room. ED Tech #1 closed the door to the room. At 3:28 pm, video footage indicated the two law enforcement officers left the facility. Patient #1 appeared calm and cooperative.


2. 3:45 pm, Registered Nurse (RN) #1 was observed entering the seclusion room with a clipboard. The clipboard was given to Patient #1 and he was observed looking at it. RN #2 entered the room at this time, with her arms crossed and folded. Patient #1 appeared calm and cooperative. RN#1 and #2 were observed leaving the room with clipboard in hand.


3. 3:50 pm, RN #1 and #2 entered the room. RN #2 was observed taking the patient's vital signs and gave the patient a plastic bag that appeared to be the type for personal belonging/clothes. Patient #1 was cooperative and RN #1 and 2 left the room.


4. 4:10 pm, the physician (MD) entered the room and was observed speaking with Patient #1. Neither the MD or Patient #1 displayed any type of distress or concern.


5. 4:20 pm, RN #1 and RN #2 entered the seclusion room and placed what appeared to be an identification band around Patient #1's wrist. Patient #1 appeared cooperative and calm.


6. 4:24 pm, ED Tech #1 entered the room and conducted an electrocardiogram (EKG) on Patient #1. This testing involveed placing 10 electrodes on the patient's chest and abdomen. Patient #1 was cooperative and this procedure took five minutes.


7. 5:00 pm, ED Tech #1 entered the seclusion room with what appeared to be a butterfly needle, tubing and tubes (equipment needed to draw blood). ED Tech #1 and Patient #1 stood and talked to each other. RN#1, RN #2, RN #3 and ED Tech #2 entered the room. Patient #1 appeared to be indicating with face and arm gestures that he does not want his blood drawn. Patient #1 was not aggressive with staff and they left the room at 5:03 pm.


8. 5:05 pm, RN #1 and RN #2 entered the seclusion room as does ED Tech #1, #2, and #3, Facility Security Officer #1, and Nurse Practitioner (NP) #1. As the staff approached Patient #1, the patient was observed backing up to the wall of the room and attempted to stand on the bed. Simultaneously, ED Tech #1 took the patient's right arm, and Security Officer #1 grabbed the patient's left arm, while ED Tech #3 grabbed the patient by the waist and sweeped the patient's legs from underneath him and Patient #1 was forcibly taken face first onto the mattress. ED Tech #3 was observed lying across the back of Patient #1, with his left leg in between the patient's legs. RN #1 assisted holding the left arm and NP #1 held the patient's head. At this point, an unidentified, non-facility staff person wearing a black shirt and tan pants was observed to take out a pair of handcuffs and placed one handcuff around the left wrist of Patient #1. The patient's left arm was placed behind his back and the unidentified person had the full weight of his left knee onto the left shoulder of Patient #1. Facility Security Officer #1 was observed holding down the left leg of Patient #1. RN #2 appeared to draw blood from the patient's right antecubital vein.


9. 5:10 pm, it appeared RN #2 had the requisite number of blood tubes, and staff began to slowly release their grasps and holds on Patient #1. Staff left the room. Patient #1 was left, in a prone position, with his arms outstretched and his back appeared sweaty. Patient #1 slowly got himself up from the mattress and began moving around.


10. 5:22 pm, RN #4 entered the room and handed Patient #1 a plastic urinal. Patient #1 took the urinal but appeared to indicate he does not want to use it. RN #4 left the room and closed the door. The Director of the Emergency Department was observed standing in the hallway outside of the seclusion room, waving and motioning to the patient through the glass.


11. 5:33 pm, seven facility staff were observed entering Patient #1's room. The staff include: ED Techs #1, #2, and #4; RN #1, #,2 , and #4; NP#1, and Security Guard #2. Patient #1 was observed standing near the door. Security Guard #2 went on the left side of Patient #1 and ED Tech #1 and #2 took the right side and arm of Patient #1. Patient #1 was then forcibly taken face first, down onto the mattress. ER Tech #1 was observed with his knee in the middle of Patient #1's back. RN #4 was observed administering an injection into the the patient's right buttock, followed by RN #1 administering a second injection into the patient's right buttock. Patient #1 was then immediately flipped over on his back. NP #1 was observed forcing the patient's head down onto the mattress and holding it, while ED Techs #2 and #4 began to lower the patient's pants to expose the patient's genitalia. Patient #1 was observed trying to get free, and appeared to be yelling. ER Tech #1 was observed placing both of his hands onto the patient's chest and applying his full body weight in an effort to keep Patient #1 from moving. ER Tech #1 then pulled the patient's left arm above the patient's head and sat on the patient's left shoulder and arm. Patient #1 was observed attempting to keep his legs together and ER Techs #2 and #4 and RN #1 and #4 were pulling and trying to open his legs. RN #2 appeared in camera range with a catheter tray and bent over the patient. RN #2's back was to the camera, but over the next three minutes it appeared that RN #2 was attempting to advance a urinary catheter through Patient #1's penis.


12. 5:38 pm, urine appeared to have been collected and staff slowly began releasing the patient and left the room. Patient #1 was left on his back and alone in the room.


13. 6:00 pm, Patient #1 was asleep on the mattress in the seclusion room. There was no bedding available.


14. 7:25 pm, RN #5 and ED Tech #5 entered the seclusion room. RN #5 placed a blood pressure cuff around the patient's left arm. Patient #1 moved slightly. It appeared vital signs were taken and RN #5 and ED Tech #5 left the room.


15. 7:31 pm, Patient #1 began waking up and moving. He got up from the bed and began pacing around the room.


16. 7:37 pm, Patient #1 sat back down on the bed.


17. 7:42 pm, ED Tech #5, RN #4, ED Tech #1, RN #5, RN #6, and ED Tech #4 began gathering outside the seclusion room, all putting on gloves.


18. 7:43 pm, the six staff named above entered the room. Patient #1 was observed sitting on the edge of the bed. ED Tech #1 approached the patient and placed his right hand on the patient's left shoulder. Patient #1 then stood, and bent over the bed. RN #6 handed a syringe to RN #4 and RN #4 was observed injecting the needle of the syringe into the left buttock of Patient #1. Staff then left the room and Patient #1 was left alone in the seclusion room.


19. 8:15 pm, Facility Security Guard #1 was observed pushing Patient #1 in a wheelchair out of camera range.


D. Review of the Facility Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment form for Patient #1 dated 07/29/14 at 5:09 pm indicated the "patient refused to sign." This form is witnessed and signed by the Director of the Emergency Department.


E. The Emergency Department Record for Patient #1 dated 07/29/14 was reviewed. No documented clinical rationale was evident in the record why the seclusion room was necessary or why Patient #1 remained in seclusion for five hours. No documented clinical rationale was evident for physically holding Patient #1 for either the blood draw or urine sample. No documented clinical rationale was evident to indicate why Patient #1 was given three intramuscular injections. No documentation was evident to indicate the patient was given food, water, or allowed to use the restroom.


F. Review of the Facility Policy and Procedure titled, "Restraint and Seclusion," dated 03/07 and revised 05/13 reveals the following definitions:


1. Restraint: "the application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint."


2. Seclusion: "involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent of self-destructive behavior." The policy also states, "It is the policy of this facility to [limit] the use of restraints and seclusion to emergencies where there is a risk to the patient harming himself/herself or others." Staff is expected to assess and monitor the patient to ensure the patient is released from restraint or seclusion at the earliest possible time."


3. Periodically assessing, assisting and monitoring the patient in restraint or seclusion: "care is provided at least every two hours to include: offer of fluids/nourishment, hygiene care as required, toileting as required."


G. On 01/27/15 at 9:00 am during an interview, the Interim Chief Quality Officer(ICQO) and Director of Risk Management stated the allegations of abuse and neglect that Patient #1 had reported to the facility were not reported to the State Survey Agency. They stated allegations such as these were reported to the facility Corporation and Corporate offices would give guidance as to whether the allegations were reportable. The ICQO stated she had conducted a "Near Miss Intensive Analysis" of the 07/29/14 allegations. She stated this involved watching the security video footage and creating a time line. She stated this review indicated numerous discrepancies between what was recorded in Patient #1's chart and what occurred on the video. She stated the facility was unable to identify the person in the black shirt and tan pants that used a handcuff with Patient #1. When asked about the lack of consent for the assessment and treatment for Patient #1 she stated, "I know we have some problems."