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Based on a review of documentation and staff interview, it was determined that the hospital was out of compliance with the Condition of Governing Body. In October of 2018, the hospital was cited for failing to train a contracted police officer on safe and therapeutic restraint techniques. The hospital provided an acceptable plan of correction (POC) promising to train the officer by January 1, 2019. Review of the training, personnel file, and interview with the Director of Security on July 16, 2019 identified that the officer has not been trained as called for in the POC.

See tag A0196.

Based on a review of 2 open surgical medical records, the hospital consent policy and other pertinent documents, it was determined that the hospital failed to ensure that consents for patient #10 (P10) were signed by P10 who had decision making capacity rather than various surrogate decision makers.

The hospital "Informed Consent" policy (revised August 2018) revealed in part, "Informed Consent: The giving and discussion of information with the patient (or person authorized to consent for the patient) ...," and,

"Capacity: ...Incapacity is present if a mental status defect renders the individual unable to understand and knowingly and intelligently act upon consent information using rational processes."

Patient #10 (P10) was an oriented 70+ year old who presented to the emergency department (ED) after a fall at home. ED assessment and imaging found that P10 had a fracture to the right upper extremity. P10 was admitted for further evaluation by the orthopedic service and was deemed to required surgical intervention. Review of the medical record found that, while P10 signed some consents and documentation, others were signed by various family members including the adult child and spouse.

Signatures in P10's medical record appeared as follows:
1. The adult child signed the Important Message from Medicare day one of admission.
2. Spouse signed the Blood or Blood Components Transfusion on day two of admission.
3. Twenty minutes later, P10 signed Anesthesia Services on day two of admission.
4. P10 and spouse both signed the Medical and Surgical Procedure consent on evening of day two of admission.
5. P10 signed discharge instructions on day four.

P10's medical record gave no indication that P10 was unable to sign all consents nor provided reason such as lacking capacity for deferring to family members to sign consents. P10 was documented as oriented throughout the hospitalization and did not have a capacity examination. Nor was there notation in the record that P10's dominant hand was affected by the injury. Therefore, the hospital failed to ensure that consents were reviewed, understood, and signed by P10, who had decision making capacity to do so.

Based on interview and a request for hospital training and oversight of restraint practices for hospital police (PO), it was revealed that elements of a previous plan of correction (POC) submitted by the hospital following a deficiency of 10/23/2018 for police training on hospital restraints were never implemented.

The hospital had a number of employed security staff. Interview with the Security Director on July 16, 2019 at approximately 1000 revealed that security staff receive training for hospital restraints, as do nursing staff. This allowed for clinical oversight for safe restraint practices by security.

The hospital had a formal agreement with the town police barracks since September 2017 to pay for stationing a PO in the hospital. Inquiry to the Security Director regarding the PO stationed at the hospital revealed that the PO would, on occasion, help to restrain patients. A request for hospital restraint training for the PO revealed no hospital restraint training had been implemented which per the former Plan of Correction, was to be completed by January 1, 2019.

A request for the job description of the PO revealed only the PO barracks job description. The lack of a hospital job description indicated that the hospital had no expectation of managing the PO's interaction with patients. Therefore, the PO had free agency to restrain patients without training in safe and therapeutic clinical restraint techniques, and without clinical oversight for safe restraint practices.