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Based on interviews, medical records reviewed, and other pertinent documentation, the hospital failed to protect and promote each patient's rights when (1) the hospital failed to maintain a safe environment of care when requisite suicide risk assessments were not completed in a timely manner for behavioral health patients See Tag (A144); (2) restraints were not implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law when staff relied on security staff to apply and remove restraints and no written emergency procedure was developed for emergency release form restraint, See Tag (A167); (3) restraints were not ended at the earliest possible time while staff waited for security staff to come to remove/discontinue restraints, See Tag (A174) and (4) one emergency medical screening examination of a suicidal patient was delayed for more than 3 hours See Tag (A144).

Based on interviews, medical records reviewed, and other pertinent documentation, in 3 of 20 medical records reviewed the hospital failed to ensure that care was provided in a safe setting when (1) a Medical Screening Examination was delayed for 3 hours, (2) a patient was not placed on suicide precautions for 5 hours even after a suicide attempt on the unit; (3) staff on 4 units followed a process for application and removal of restraints without any guiding policies and procedures whereby (a) security staff members to applied and removed restraints, (b) restraint keys were carried and held by security staff; (c) staff were unaware that restraint keys were also available on the unit for emergency restraint release, and (d) staff delayed patient release from restraints while awaiting response from security staff, as evidenced by:

Patient #1 was a 23 year-old female who was Emergency Petitioned with suicidal ideation to Shady Grove Adventist Hospital Emergency Department on 04/29/2010 at 1400. She went immediately to the EPTU (Emergency Psychiatric Treatment Unit) which is a separate contained area of the ED where behavioral health patient ' s emergent needs are addressed. Nursing saw patient #1 and gathered her history, home medication list, vitals, and allergy data. No suicide risk assessment was documented until 1546 when the RN documented that patient #1 was by then, denying suicidal ideation. However this assessment was not documented until an hour and 46 minutes after patient #1 ' s arrival with a presenting symptom of suicidal ideation and patient #1 was not maintained on suicidal precautions (a higher level of observation) during this time frame. Patient #1 ' s initial triage for this ED visit was also not documented until 1600, which was 2 hours after her presentation. The record indicated that patient #1 was stabilized and discharged with a 1629 physician entry revealing that patient #1 should follow up with her psychiatrist during the following week, and return to the ED for any suicidal ideation or homicidal ideation.
Patient #1 was a 23 year-old female who arrived by ambulance at Shady Grove Adventist Hospital (SGAH) Emergency Department (ED) for another ED visit on 05/01/2010 at 0649 with a complaint that was noted in the record as " psychological/psychiatric. " Patient #1 also had a very recent history of suicidal ideation as evidenced by her presenting symptoms on 04/28. The record showed that patient #1 was triaged at 0702 but the triage note focused primarily on medical assessment and failed to document sufficient assessment of patient #1 ' s psychiatric condition even though triage documentation revealed that patient #1 presented with a " psychological/psychiatric " concern. Without a suicide risk assessment, patient #1 was triaged as ESI 3 on a 5 point scale where 1 is most urgent and 5 is least urgent. (The ESI model indicates that if a patient requires immediate life-saving intervention they are triaged at ESI 1 and a patient who is suicidal with an actionable plan requires immediate life-saving intervention). Given the presenting symptom of suicidal ideation, without a suicide risk assessment, the hospital could not know if ESI 3 was or was not an appropriate triage level,.

More than 3 hours after her initial triage, at 1015, the record revealed that (1) patient #1 had still not been assessed for suicide risk; (2) had still not received a Medical Screening Examination by the emergency physician; (3) had not been placed on suicide precautions (a higher level of observation); and, (4) patient #1 had made a suicide attempt in the EPTU. A 1015 nursing note stated that patient #1 was out at the nursing station, wandering, wanting to go home, wanting to make calls, wanting to eat, " etc. " The nursing note revealed that the nurse explained to the patient that she needed to go back to her room and she indicated to the patient that the physician would be back to evaluate her. Patient #1 then became tearful and stated " will you just kill me already, this is just too much for me to bear; just let me die! " The nursing note stated that patient #1 then took hand sanitizer, unscrewed it, put it up to her lips, and tilted her head back, " but this RN removed it from her before she could swallow. " The RN guided the patient back to her room and noted that she called the physician for the third time since 0730 to request that he/she complete the Medical Screening Examination. After the attempt, the RN sat with the patient until a Physician Assistant came and saw the patient.

The Emergency Physician Record was completed by the PA and was timed 1000. There was still no indication that a suicide risk assessment was completed at this time and patient #1 was not placed on suicidal precautions (a higher level of observation). Two hours after her attempt and more than 5 hours after her arrival, at 1220 nursing completed a suicidal risk assessment for patient #1 and suicidal precautions were initiated. Lacking a suicide risk assessment, the hospital failed to document an adequate triage assessment of patient #1, failed to complete an appropriate Medical Screening Examination in a timely manner, failed to make an appropriate determination regarding whether or not patient #1 had an Emergency Medical Condition, and failed to place patient #1 on an appropriate level of observation to ensure her safety on the unit. Due to prompt intervention by the RN, patient #1 ' s attempt was not successful and she was stabilized and discharged from the EPTU into the custody of her father on 05/02 at 1104.

Patient #4 was a 44 year-old male who presented to the SGAH ED at 1919 on 06/07 with intoxication and suicidal thoughts. Patient #4 had a history that included anxiety, bipolar disease, and depression. A complete suicidal assessment was not completed, he was not placed on suicide precautions, and when triaged was triaged at ESI Level 3. The Medical Screening Examination was completed at 1720 but it too focused only on patient #4 ' s intoxication and did not assess or evaluate the suicidality that was disclosed during triage. The only psychiatric evaluation documented in the physician record, showed that patient #4 was confused, alert, oriented times 2, and that there was no evidence of acute cerebral vascular accident. Thus, nursing had not completed a suicide risk assessment and the physician had neither reviewed nor completed one. Patient #4 was discharged at 0151 on 06/08 without ever having been evaluated for suicidality after acknowledging suicidal thoughts at triage.

Regarding restraint policy and practice, based on staff interviews, and review of medical records, the hospital failed to maintain a safe environment for care by failing to ensure that the use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law when staff followed an unwritten policy. Staff followed an unwritten procedure/ practice relying on Security staff to respond to various units (ICU, IMCU, Pediatric Unit, and the ED including the EPTU) to apply and remove restraints.

Based on interview, anytime a patient has to go into restraint in the ICU, IMCU, ED, or Pediatric Unit, staff members call security to come stat because security carries the restraints and security places/applies restraints when needed. In interview, one RN in the ED reported that when security staff arrive on the unit they " take over " management of the event. It was substantiated that there was no written policy or procedure regarding this process that staff employ relying on security staff to lead the codes during application of restraint and relying on security to come and remove restraints when restraints are to be discontinued. Further, when emergency release of a patient from restraints is necessary, not all staff members were aware that restraint keys were available on the units. (This concern regarding staff awareness of keys available on the unit was addressed throughout the hospital on 07/08/2010.) This practice placed patients at significant risk for harm and failed to maintain a safe environment of care.

Based on staff interviews, and review of medical records, the hospital failed to ensure that the use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law when staff followed an unwritten policy of relying on Security staff to respond to various units (ICU, IMCU, ED, and Pediatric Unit) to apply and remove restraints which resulted in delays and placed patients at risk for harm in the event of an emergency, as evidenced by:

Based on interview, anytime a patient has to go into restraint in the ICU, IMCU, ED, or Pediatric Unit, staff members call security to come stat because security carries the restraints and security places/applies restraints when needed. In interview, one RN in the ED reported that when security staff arrive on the unit they " take over " management of the event. It was substantiated that there was no written policy or procedure regarding this process that staff employ relying on security staff to lead the codes during application of restraint and relying on security to come and remove restraints when restraints are to be discontinued. Further, when emergency release of a patient from restraints is necessary, not all staff members were aware that restraint keys were available on the unit. This concern regarding staff awareness of keys available on the unit was addressed throughout the hospital on 07/08/2010. Regarding ending restraints, in interview security staff reported that they try to come quickly when called to remove restraints, but they manage other priorities that sometimes cause delays in removing restraints.

Based on interviews and medical record review, hospital staff members on 4 units followed an unwritten procedure that failed to ensure that restraint was discontinued at the earliest possible time as evidenced by:

Based on interview, anytime a patient has to go into restraint in the ICU, IMCU, ED, or Pediatric Unit, staff members call security to come stat because security carries the restraints and security places/applies restraints when needed. In interview, one RN in the ED reported that when security staff arrive on the unit they " take over " management of the event. It was substantiated that there was no written policy or procedure regarding this process that staff employ relying on security staff to lead the codes during application of restraint and relying on security to come and remove restraints when restraints are to be discontinued. Further, when emergency release of a patient from restraints is necessary, not all staff members were aware that restraint keys were available on the unit. This concern regarding staff awareness of keys available on the unit was addressed throughout the hospital on 07/08/2010. Regarding ending restraints, in interview security staff reported that they try to come quickly when called to remove restraints, but they manage other priorities that sometimes cause delays in removing restraints. For example:

Based on medical record review, patient #1 was a 23 year-old female who arrived by ambulance at Shady Grove Adventist Hospital Emergency Department on 05/01/2010 at 0649. The Emergency Physician Record indicated chief complaint of suicidal thoughts, agitation, hallucination, and statements that her boyfriend had raped her. At 1300, patient #1 was placed into two-point restraints. Nursing notes entered at 1452, 1624, and 1625 indicated that security was called at 1445 to remove 2 point restraints from patient #1 but the nurse wrote that later she had to call security again "after realizing that restraints were still to right upper extremity and left lower extremity." The record showed that it took until 1538 to get restraints removed after patient #1 had met criteria for release. Because clinical staff relied on security, in this case there was a 53 minute delay in ending the use of restraints.

In 1 of 20 medical records reviewed, the hospital failed to ensure that patients were seen face-to-face within one hour after the initiation of restraints as evidenced by:

Patient #1 was a 23 year-old female who arrived by ambulance at Shady Grove Adventist Hospital Emergency Department on 05/01/2010 at 0649. The Emergency Physician Record indicated chief complaint of suicidal thoughts, agitation, hallucination, and statements that her boyfriend had raped her.

At 1300, patient #1 was placed into two-point restraints and she remained in restraints for 2 hours and 38 minutes. No face-to-face assessment was found documented in the medical record showing (1) the patient's immediate situation; (2) the patient ' s reaction to the intervention; (3) the patient ' s medical and behavioral condition; and (4) the need to continue or terminate the restraint or seclusion.

In 1 of 20 medical records reviewed, the hospital failed to ensure that the medical record included documentation of the patient ' s behavior when initiating restraints as evidenced by:

Patient #1 was a 23 year-old female who arrived by ambulance at Shady Grove Adventist Hospital Emergency Department on 05/01/2010 at 0649. At 1000, the Emergency Physician Record indicated chief complaint of suicidal thoughts, agitation, hallucination, and statements that her boyfriend had raped her. At 1305 a nursing note indicated that a needs assessment was underway, and patient #1 " started crying, screaming, pacing. Security called, patient continued acting out, uncooperative. Unable to calm with verbal stimulation. Security now putting patient in restraints. " Crying, screaming, pacing, acting out, and uncooperative, are insufficient justifications for the use of restraint. Actual threatening behavior (biting, hitting, throwing, threatening to harm) was not demonstrated in the record.

In 1 of 20 records reviewed, the hospital failed to ensure that all orders were dated, timed, and authenticated promptly by the ordering practitioner(s) evidenced by:

Patient #1 was a 23 year-old female who arrived by ambulance at Shady Grove Adventist Hospital Emergency Department on 05/01/2010 at 0649. The Emergency Physician Record indicated chief complaints of suicidal thoughts, agitation, hallucination, and statements that her boyfriend had raped her.

At 1300, patient #1 was placed into two-point restraints with an order written by RN and noted as a telephone order with authorization from a Physician Assistant who was in the ED on this date. (At 1312, the PA entered a medication order into the same patient's chart for Depakote 1000 mg by mouth.) The record revealed that the restraint order was never signed off by either the PA or a physician.