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Based on review of hospital policies/procedures, medical records and interviews, it was determined that the hospital failed to protect and promote each patient's rights as evidenced by:

(A 164) failing to require that restraint be used only when less restrictive interventions are determined to be ineffective to protect the patient from harm;

(A 168) failing to require that restraint be in accordance with the order of a physician or other licensed independent practitioner (LIP);

(A 169) failing to require that an order for restraints is never written on an as needed basis;

(A 174) failing to require that restraints be discontinued at the earliest possible time;

(A 175) failing to require that staff monitor the condition of the patient in restraints as required by hospital policy/procedure; and

(A 179) failing to require that an LIP conduct and document, within 1 hour of initiation of restraint, a face-to-face evaluation of patients restrained for the management of violent or self-destructive behavior which includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.

The cumulative effect of these systemic problems resulted in the hospital's failure to protect and promote each patient's rights.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that restraint be used only when less restrictive interventions were determined to be ineffective to protect the patient from harm for 3 of 3 non-violent/non self-destructive patients (Pts #26, 27 and 33).

Findings include:

Review of the hospital policy/procedure titled Restraints revealed: "...Least Restrictive Means: a. Restraint shall not be used when less restrictive interventions should be effective...b. The decision to use a restraint is not driven by diagnosis, but by a comprehensive individual patient assessment which includes a physical assessment to identify medical problems that may be causing behavior changes in the patient...."

Review of the hospital's Medical/Surgical Restraint Order form revealed a section: "...Indication of the Need for Medical/Surgical Restraints...Potential causes of behavior: Check all that are possible:... Infection...Dehydration or electrolyte imbalance...Acute hypoxia...Change in baseline vitals...Recent trauma...Sensory deficit...Blood sugar...Reaction to medications...Other...None of the above...." The RN completing the form places a check mark next to the condition which applies to the patient.

The form also contained a section: "...Limit the use by alternative measures below: Check all that apply:...Diversion activities...Decrease stimulation...Provide comfort measures...Enlist family/significant other's support in calming and orienting the patient...De-Escalation Techniques...Medicate symptoms according to physician orders...."

Review of medical records:

Pt #26 was admitted to the facility on 5/10/12 due to "severe alcohol withdrawal." RN #26 documented, on 5/10/12 at 1815: "...Indication of the Need for Medical/Surgical Restraints...Patient's action may worsen condition or may lead to harm...Patient is pulling at tubes, lines and dressings...patient's diagnosis or condition may lead to unpredictable and sudden adverse actions to their medical plan of care...Describe patient behavior:...Climbing out of bed...." She initiated restraints at that time and a physician signed the order for the restraints on 5/10/12 at "6P" beneath the statement: "...Confirm Medical/Surgical Restraint Justification: By ordering the use of restraints, I confirm the above assessment and use of least restrictive restraint(s) is clinically justified. Alternative measures to deal with the patient's needs have been tried and found to be ineffective. The sections of the form for "...Potential causes of behavior...." and "...alternative measures...." were both blank.

On 5/11/12 at 1930, RN #26 documented the same indications for the patient to continue to be in medical/surgical restraints. She documented Physician #1's telephone order for restraints on 5/11/12 at 1945. The sections of the form for "...Potential causes of behavior...." and "...alternative measures...." were both blank.

On 5/13/12 at 0700, RN #27 documented indications for the patient to continue to be in medical/surgical restraints. A physician signed the order for restraints on 5/13/13 at 0900, beneath the same confirmation statement as described above. The form did not contain documentation of the use of alternative measures.

On 5/15/12 at 0700, RN #27 documented indications for the patient to continue to be in medical/surgical restraints. A physician signed the order for restraints on 5/15/12 at 0815, beneath the same confirmation statement as described above. The form did not contain documentation of the use of alternative measures.

Pt #27 was admitted to the facility on 5/14/12, due to "...Urosepsis...Altered mental status...Acute on chronic renal failure...Hyperkalemia...Pseudohyponatremia...Uncontrolled diabetes...." She also had a "recent intracranial bleed." On 5/15/12 at 1330, RN #26 documented indications of the need for medical/surgical restraints. She initiated restraints at that time and Physician #3 signed the order on 5/15/12 beneath the same confirmation statement as described above. The form did not contain documentation of the use of alternative measures.

Pt #33 was admitted on 4/25/12, status post code arrest. He had an "...Acute gastrointestinal bleed...Acute anemia...Aspiration pneumonia...Respiratory failure...." RN #28 initiated medical/surgical restraints on 5/4/12 at 0400. Physician #4 signed the order for restraints on 5/4/12 at 0920, beneath the same confirmation statement as described above. The form did not contain documentation of the use of alternative measures.

During interview conducted on 5/17/12, the ICU (Intensive Care Unit) Educator confirmed that the hospital policy/procedure requires that restraint be used when less restrictive interventions (alternative measures) are ineffective. The nurse is required to document on the medical/surgical restraint form the alternative measures attempted. She confirmed that the nurses had not followed the hospital policy/procedure.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that restraint be in accordance with the order of a physician for 2 of 3 non-violent/non-self-destructive patients (Pt's #27, and 33) and 1 of 3 patients restrained for the management of violent behavior (Pt #30).

Findings include:

Review of the hospital policy/procedure titled Restraints revealed: "...Orders: a. Restraints shall be ordered by a physician or other LIP (Licensed Independent Practitioner) who is responsible for the care of the patient...d. The order shall specify the method of restraint...to be used...Medical Restraint (Nonviolent/Non Self Destructive)...b. If the attending physician is not available, a registered nurse may initiate restraints in advance of a physician's order...If restraint was necessary due to a significant change in the patient's medical condition, the attending physician shall be contacted immediately for an order...Otherwise, the attending physician must be notified and a restraint order requested as soon as possible... Release and Reapplication:...If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order will be required. Staff cannot discontinue a restraint or seclusion intervention, and then re-start it under the same order...Violent/Self Destructive (Behavioral Restraint)...Physician Order: d. The initial and all subsequent restraint orders shall expire in:...2 hours for patients from 9 to 17 years...."

Review of medical records:

(Cross reference Tag A-0164 for information regarding Pts #27 and #33.)

Pt #27's medical record contained documentation that an RN initiated medical/surgical restraints on 5/15/12 at 1330. The restraints which were initiated included soft wrist restraints on both upper extremities and 4 side rails. The medical record did not contain an order for side rails.

On 5/17/12, the ICU Educator confirmed that Pt #27's medical record contained documentation that his restraints included 4 side rails and that the physician's order did not include side rails as required by policy

On 5/16/12 at 1001, Physician #5 signed an order form for medical/surgical restraints for Pt #27. The order did not specify the type or location of restraints to be applied.

On 5/17/12, the ICU Educator confirmed that the order for restraints signed on 5/16/12, by Physician #5 did not include the type or location of restraints as required by policy.

Pt #33's medical record contained documentation that RN #28 initiated medical/surgical restraints on 5/4/12 at 0400. Physician #4 signed the order for restraints on 5/4/12 at 0920. The medical record did not contain documentation that the RN notified the physician and obtained an order for the restraints as soon as possible, as required by policy/procedure.

On 5/17/12, the ICU Educator confirmed that RN #28 did not obtain a physician's order for restraints as soon as possible after she initiated the restraints as required by policy/procedure.

On 5/6/12 at 0700, an RN completed the section of the Medical/Surgical Restraint order form documenting indications of the need for restraints, potential causes of behavior, and alternative measures employed. Physician #6 signed the order on 5/6/12 at 0825, for soft restraints applied to both of the patient's upper extremities. The medical record contained nursing documentation that restraints were removed from the patient at 0800 and reapplied at 1400. An order was not obtained for the reapplication of restraints at 1400, as required by policy/procedure.

On 5/17/12, the ICU Educator confirmed that the nurse reapplied the restraints without obtaining a new order as required by policy/procedure.

Pt #30 presented to the Emergency Department (ED) on 4/15/12 at 1113 via ambulance "...with a complaint of violent behavior...the patient has history of autism and has...been violent for a while, but has just steadily worsened...." At 1115, an RN documented: "...Pt to Rm B-2 per EMS (Emergency Medical Service). Pt combative (with) EMS/PD (Police Department). Combative (with) mother. Pt remains in restraints per mothers (sic) requests...."

Pt #30's medical record contained a Behavioral/Seclusion Restraint Order form. On 4/15/12 at 1115, an RN completed the section of the form documenting indication of the need for Behavioral/Seclusion Restraints: "...aggressive/combative (at) times...." The form contained a mark next to the box indicating a 2 hour time limit for the order for restraints. The form contained the physician's printed name and the date 4/15/12 and time 1115. The physician did not sign the order form and the RN did not record a physician's telephone order for restraints.

Pt #30's medical record contained documentation that the patient's upper extremities were placed in bilateral leather restraints on 4/15/12 from 1115 until 1600, when they were discontinued.

On 5/17/12, the Chief Quality Officer confirmed that Pt #30's medical record contained documentation that he was placed in restraints for the management of violent behavior without a physician's order.

Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to require that an order for restraints is never written on an as needed basis for 1 of 3 non-violent/non-self-destructive patients (Pt #33).

Findings include:

Review of hospital policy/procedure titled Restraints revealed: "...PRN or 'if needed' restraint orders shall not be accepted and the ordering practitioner shall be contacted to clarify or discontinue the order...."

(Cross reference Tag A-0164 for information regarding Pt #33.)

Review of Pt #33's medical record:

On 5/6/12 at 0700, an RN completed the section of the Medical/Surgical Restraint order form documenting indications of the need for restraints, potential causes of behavior, and alternative measures employed. Physician #6 signed the order on 5/6/12 at 0825, for soft restraints applied to both of the patient's upper extremities. The medical record contained nursing documentation that restraints were removed from the patient at 0800 and the patient was not in restraints when the physician signed the order. An RN reapplied restraints at 1400 without obtaining a new order.

On 5/17/12, the Chief Quality Officer confirmed that Physician #6 signed the order for restraints when the patient was no longer in restraints and that this order was probably used by nursing for the reapplication of restraints at 1400. This order was also the order used to renew the restraints when the calendar day (5/17/12) began at midnight and the patient was in restraints.

Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to require that restraints be discontinued at the earliest possible time for 1 of 3 patients restrained for the management of violent behavior (Pt #30).

Findings include:

Review of hospital policy/procedure titled Restraints revealed: "...5. Release: Restraints shall be discontinued at the earliest time possible when the behavior or condition which was the basis for the restraint order is resolved, regardless of the duration of the enabling order...."

(Cross reference Tag A 0168 for information regarding Pt #30.)

Pt #30's medical record contained documentation that the patient's upper extremities were placed in bilateral leather restraints on 4/15/12 from 1115 until 1600, when they were discontinued. The Emergency Department Patient Rounding Log contained documentation every half hour from 1230 through 1600 that the patient was "sleeping."

The Administrative Director of the Emergency Department confirmed during interview conducted on 5/17/12 that the documentation revealed that the restraints were not removed at the earliest time possible as required hospital policy/procedure.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that staff monitor the patients' condition as required by hospital policy/procedure for 2 of 3 patients restrained for the management of violent behavior (Pts # 28 and 30).

Findings include:

Review of hospital policy/procedure titled Restraints revealed: "...Patient Monitoring:...b. Patient shall be assessed at the initiation of restraint...and every 15 minutes thereafter to include the following:...whether breathing is restricted due to restraints...whether circulation is restricted due to restraints...skin breakdown due to restraints...continued need for restraints...."

Pt #28 presented to the ED on 4/27/12 at 0134 for evaluation of a wound to her left forearm. Since the patient was acutely intoxicated and the circumstances of her left arm "incisions" were unknown, but "...likely to be self-inflicted as she has other well-healed scars noted to the left forearm...." she was prevented from leaving the ED and received treatment for the laceration.

The medical record contained documentation that the patient was placed in bilateral soft restraints to her upper and lower extremities on 4/27/12 from 0230 until 0330, when the restraints were discontinued. The medical record contained a Restraint Documentation Flow Sheet. The Flow Sheet contained a section for documentation of assessment "Criteria Performed," including: "...Circulation is not restricted due to restraints...No skin breakdown due to restraints...Current assessment indicates continued need for restraints...." The nurse is to place a check mark in the spaces to indicate that the assessments were completed and draw a line through numbers located below the assessment section to document that assessments were completed every 15 minutes. An LPN placed marks on the form at 0230, 0245, 0300, 0315, and 0330. A vertical line was drawn through spaces next to the assessment criteria. (No check marks were written to indicate that the assessment criteria were performed every 15 minutes as required by policy/procedure.)

(Cross reference Tag A 0168 for information regarding Pt #30).

Pt #30's medical record contained documentation that the patient was placed in bilateral leather restraints to his upper extremities on 4/15/12 from 1115 until 1600, when the restraints were discontinued. The medical record contained a Restraint Documentation Flow Sheet as described above. The section of the flow sheet for documentation of assessment "Criteria Performed," was blank.

On 5/17/12, the ICU Educator and the Chief Quality Officer confirmed that Pts #28 and 30's medical records did not contain documentation that the required assessments were completed.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that an LIP conduct and document, within 1 hour after the initiation of restraint, a face to face evaluation of patients restrained for the management of violent or self-destructive behavior which includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition; and the need to continue or terminate the restraint for 3 of 3 patients (Pts # 28, 29 and 30).

Findings include:

Review of the hospital policy/procedure titled Restraints revealed: "...Violent/Self Destructive (Behavioral Restraint) or Seclusion...2. Physician Order:...One hour face-to-face assessment: The physician shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint...." The hospital policy/procedure did not include the required elements of the face-to-face evaluation.

Review of hospital form titled Behavioral/Seclusion Restraint Order revealed that it contained a statement located above the line for the physician's signature: "...By ordering the initiation of restraints, I confirm the use of restraints is clinically indicated. Alternative methods to deal with patient's behavior have been tried and found ineffective. The body site(s) to be restrained have been determined and are the least restrictive clinically justified. A comprehensive face-to-face medical behavioral assessment is conducted within one (1) hour of the initiation of the restraint. Face-to-face reassessments will occur at the interval indicated in section C...."

Review of Section C of the form revealed: "...Confirm time limit...4 Hours for Adult...2 Hours for age 9 - 17...1 Hour for age under 9...." The physician is to place a mark by the time limit which is applicable to the patient.

Review of medical records:

(Cross reference Tag A 0175 for information regarding Pt #28.)

Pt #28's medical record contained a Behavioral/Seclusion Restraint Order form signed by physician #7 on 4/27/12 at 0230. Pt #28 was placed in bilateral soft restraints to her upper and lower extremities from 0230 until 0330, when they were discontinued. Pt #28's medical record did not contain documentation of the physician's evaluation of the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint written within one hour after the initiation of the restraints.

Pt #29 presented to the ED on 4/23/12 at 1913. He had been previously diagnosed with Bipolar Disorder and was "found...by bystander...." who called 911. The patient reported that he had not taken his medication since 4/20/12. He "...escalated and was threatening the staff...."

Pt #29's medical record contained a Behavioral/Seclusion Restraint Order form signed by a physician on 4/23/12 at 2155. He was placed in "4-point" restraints, which included bilateral restraints to his upper and lower extremities, from 2200 until 2340, when they were discontinued. Pt #29's medical record did not contain documentation of the physician's evaluation of the patient's immediate situation, reaction to the intervention, his medical and behavioral condition and the need to continue or terminate the restraint written within one hour after the initiation of the restraints. The physician documented "M.D. Eval Time" at 1950.

(Cross reference Tag A 0168 for information regarding Pt #30.)

Pt #30's medical record contained a Behavioral/Seclusion Restraint Order form which was not signed by a physician. An RN completed the top portion of the form on 4/15/12 at 1115. Pt #30 was placed in bilateral leather restraints to his upper extremities from 1115 until 1600, when they were discontinued. The physician documented "M.D. Eval Time" at 1152, however, the evaluation did not include evaluation of the patient's immediate situation, reaction to the intervention and the need to continue or terminate the restraint written within one hour after the initiation of the restraints.

Pt #30, was 15 years old at the time of the ED visit. Therefore, a physician would have been required to write a renewal order by 1315 and complete another face-to-face evaluation. The medical record did not contain any order for restraints signed by a physician. It did not contain a face-to-face evaluation by a physician after 1315.

On 5/17/12, the ICU Educator and the Chief Quality Officer confirmed that Pts #28, 29 and 30's medical records did not contain documentation of the face-to-face evaluations by the physicians within 1 hour after the initiation of restraints as required.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to analyze and track restraint data to identify variances with the use of restraints.

Findings include:

(Cross reference Tags A 0164, A 0168, A 0169, A 0174, A 0175, and A 0179 for findings related to use of restraints.)

Review of the hospital policy/procedure titled Performance Improvement Plan revealed: "...PURPOSE:...Patient care and services shall be continuously monitored and evaluated to promote optimum outcomes through an integrated interdisciplinary process...The organization has the responsibility to design, measure, assess, and improve performance and patient safety. Ultimate authority and accountability for the quality and safety of patient care and services lies with the governing Board and is delegated through the Quality Improvement Program to the Medical Staff, administration and staff of the hospital...SCOPE OF ACTIVITIES AND SERVICES: The scope of the Quality Improvement Program covers measurement and assessment activities of the Medical Staff, Nursing and ancillary of support services...FUNCTION...The Quality Improvement Council (QIC) has oversight responsibility for all performance Improvement activities conducted throughout the Organization. The Quality Improvement Council functions include: Establishing guidelines for hospital-wide monitoring and evaluation of patient care and services...."

During interviews conducted on 5/18/12 and 5/22/12, the Chief Quality Officer confirmed that the Quality Improvement Program had not identified the missing elements of the one hour LIP face-to-face evaluations, the failure to document monitoring of the patient and the failure to remove restraints at the earliest possible time for patients restrained for the management of violent or self-destructive behavior. In addition, the program had focused on measuring trends of use of restraints for the non-violent/non-self-destructive patient and had not focused on specific aspects of restraint use for individual patients. She confirmed that the Quality Improvement Program had not identified the restraint issues described in the previous Tags.

Based on review of Medical Staff Bylaws and Rules and Regulations, hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to require that the medical staff enforce bylaws to carry out its responsibilities as evidenced by:

1. failure of Physician #1 to write a complete order and failure of Physician #3 to give a complete verbal order for titrated sedation infusions administered to 2 of 2 patients;

2. failure of Physician #7 to document the condition of the patient at time of discharge, a discharge order and discharge instructions for 1 of 1 patient, discharged from the ED, who had been on suicide precautions; and

3. failure of three physicians to write orders with legible signatures or record legible printed names to identify signatures.

Findings include:

Review of hospital Medical Staff Bylaws revealed: "...PURPOSES, RESPONSIBILITIES AND ROLE OF THE MEDICAL STAFF...f. To initiate, develop, and approve Bylaws, Rules and Regulations of the Staff and other related current Hospital policies. To monitor and enforce compliance with those Bylaws, Rules and Regulations of the Staff and other related current Hospital policies...BASIC RESPONSIBILITIES OF STAFF APPOINTMENT Each appointee of the Staff shall:...Abide by the current Staff Bylaws and by all other lawful standards, current policies and rules of the Hospital...."

1. Review of MEDICAL STAFF RULES AND REGULATIONS revealed: "...D. GENERAL CONDUCT OF CARE...3. The Practitioner's orders must be written clearly, legibly and completely...."

Review of hospital policy/procedure titled Medication Administration revealed: "...A complete order documents the name of the medication, dose, frequency and route of administration...."

(Cross reference Tag A 0404 for information regarding Pts #26 and 27 and the orders for titration of Versed infusions in their respective medical records.)

The Pharmacy Director confirmed during interview conducted on 5/15/12, that the physician's order, for Pt #26, for Versed was an incomplete order and required clarification for dosage, drip rate and desired sedation level prior to the nurse administering the Versed.

The Pharmacy Director confirmed during interview conducted on 5/15/12, that the physician's order for, Pt #2, for Versed was an incomplete order and required clarification of desired sedation level prior to the nurse administering the Versed.

2. Review of MEDICAL STAFF RULES AND REGULATIONS revealed: "...ADMISSION AND DISCHARGE...8. Patients shall be discharged from the Hospital only on the order of the patient's attending practitioner...EMERGENCY DEPARTMENT...9. The Emergency Department medical record shall include:...h. Condition of the patient on discharge or transfer...

Review of medical record:

Pt #28 presented to the ED on 4/27/12 at 0134 for treatment of a laceration to her left arm. The physician evaluated the patient at 0143 and dictated an Emergency Department Note at 0355. Review of the dictated note revealed: "...EMERGENCY DEPARTMENT COURSE: The patient wanted to leave the emergency department. She attempted to leave on numerous occasions. She is felt to be incompetent and not decisional. She is acutely intoxicated on alcohol and the circumstances regarding her left forearm incisions are not known, but likely to be self-inflicted as she has other well-healed scars noted to the left forearm. Due to the inappropriateness of the patient's behavior and unclear circumstances, she was sedated for safety with an injection...After appropriate sedation, the patient was placed in the 4-point restraints...The wound was copiously irrigated...the wound margins were approximated...the skin was closed without difficulty...A dressing applied...PLAN: The patient will be sleeping in the emergency department tonight to let me know her alcohol is metabolized. We will request BEST (Behavioral Evaluation Services of Tucson) evaluation once her alcohol toxidrome has resolved...IMPRESSION:...self-inflicted left forearm laceration...Acute alcohol intoxication...."

At 0420, the physician signed an order for "Suicide Precautions."

At 1530, the BEST Evaluator documented: "...Treatment Plan: Pt is refusing to cooperate with evaluation gave little information. Pt denies now that she's sober any SI (Suicidal Ideation) or mental health needs. Discharge her to her friends...."

The sections of the medical record for physician documentation of "Discharge Rx & Plan," patient discharge or the patient's condition on discharge were blank. The physician's dictated note did not contain documentation of the patient's condition at the time of discharge.

On 5/22/12, the Chief Quality Officer confirmed that the medical record did not contain the required documentation by the physician of a discharge order, plan, or condition of the patient at the time of discharge.

3. Review of Medical Staff Bylaws revealed: "...Each appointee of the Staff shall: a. provide patients in his practice and in the hospital with continuous care at the generally recognized professional level of quality and efficiency...."

Review of the Medical Staff Rules and Regulations revealed: "...D. GENERAL CONDUCT OF CARE...3. The Practitioner's orders must be written clearly, legibly and completely and must be signed...."

At the time of the survey, Pt #26's medical record was reviewed to determine quality of care issues while the patient was in restraints and for management of the patient's alcohol detoxification.

On 5/10/12 at 1435, a physician signed an order form titled Delirium Tremens, Severe Withdrawal Orders. The orders included: "Admit or transfer patient to ICU...Lorazepam...until sedation scale 3-4 is reached...." The signature and the printed name were both illegible.

On 5/13/12 at 0900, a physician signed an order for Medical/Surgical Restraints. The signature was illegible. The space on the order form for the physician's printed name was blank.

On 5/15/12, at 0815, a physician signed an order for Medical/Surgical Restraints. The signature was illegible. The physician's printed name was illegible.

During survey, neither the Chief Quality Officer, RN #5, the Chief Medical Officer, a pharmacist, nor the Director of Health Information Management Systems were able to identify the physicians' signatures. As a result, the surveyor was unable to determine whether the physicians who ordered restraints and treatment for alcohol withdrawal had hospital privileges, ICU privileges or the necessary training to order restraints.

Based on Medical Staff Bylaws, Rules, & Regulations review, record review, credentialing file review, and interview, it was determined that the medical staff failed to follow its Bylaws, Rules & Regulations, when a physician evaluating and treating patients in the Intensive Care Unit (ICU) was not credentialed to work in the ICU (Physician #1).

Findings include:

The Northwest Medical Center "Restraint" policy revealed: "...2. Medical/Surgical restraint (Non-violent/non-self-destructive)... Used for the purpose of limiting mobility or protecting the patient from injury...Utilized only after determining less restrictive interventions are ineffective...."

Review was conducted of the medical record of Patient #26, a middle-aged male hospitalized in the ICU for Severe Alcohol Withdrawal. On 05-11-12 at 10:00 A.M., Physician #1 wrote an order for restraints for Patient #26. The field on the restraint order form was blank for "Describe patient behavior" when the physician signed the order. On 05-11-12 at 7:45 P.M., Physician #1 signed an order for restraints for Patient #26. At the time the physician wrote the order, there were no entries in the fields for potential causes of the behavior, and no checks in the field for alternative measures used before the patient was placed in restraints.

The "Medication Administration" policy and procedure for the Hospital revealed: "6.a. The physician orders medications on the physician order sheet. A complete order documents the name of the medication, dose, frequency and route of administration...."

Patient #26's record revealed that on 05-12-12 at 9:00 A.M., Physician #1 wrote orders which included: "Intubation-Airway protection... NGT (nasogastric tube) placement...Versed (benzodiazepine) drip for sedation...." There was no dosage, route, or frequency written on the Versed order, and no order to identify the level of sedation to be achieved and maintained. The orders were signed by Physician #1, a Hospitalist.

The Northwest Medical Center Bylaws, Rules, & Regulations, in Article VII Determination of Clinical Privileges 7.1 Exercise of Privileges revealed: "Every Practitioner or other professional providing clinical services at this Hospital by virtue of his Staff appointment or otherwise, shall, in connection with such practice and except as provided in section 7.4 (7.5 strike through), be entitled to exercise only those clinical privileges or specified services specifically granted to him by the Trustees...."

Physician #1, a Hospitalist, was reappointed to the medical staff of Northwest Medical Center on 08-15-11, for a two year period, expiring on 08-14-13. The "Northwest Medical Center Department of Medicine Section of General Medicine Delineation of Clinical Privileges" for Physician #1 revealed that on (markover, which appeared to be 06-13-11), Physician #1 requested "General Medicine Core Privileges." In the field for "Special Privileges in General Medicine Requested: ICU (Intensive Care Unit) Admissions," there was no documentation that Physician #1 requested, or was granted, privileges to evaluate and treat ICU patients.

The Medical Staff Director acknowledged, during interview conducted on 05-17-12 at 1:30 P.M., that Physician #1 did not request, and had not been granted ICU privileges.

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care provided as evidenced by:

1. failure to provide for required supervision and evaluation of the care of 2 of 2 patients in the Emergency Department (ED) who required suicide precautions (Pts #28 and 38); and

2. failure to provide documentation of assessment of signs and symptoms of a patient's alcohol withdrawal to determine dosage of medication to administer per Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar).

Findings include:

1. Review of hospital policy/procedure titled Patient at Risk for Harm to Self/Others revealed: "..PURPOSE: To identify patients at risk for suicide or harm to self or others and provide interventions to keep the patient and others safe from harm...POLICY: Patients who the organization identifies as being of high risk for harm to themselves or others will be provided with an environment and care to keep themselves and others safe...DEFINITIONS: Direct Visualization-the patient will be visible at all times by a member of the staff. The staff member will be within a distance which allows them to immediately react and respond should the situation require...GUIDELINES: 1. Assessment of patients with increased risk for harm to self or others may include those who exhibit:...Voicing suicidal or homicidal ideation...Recent change in stressors, loss of coping skills and/or support systems...History of suicide attempts, to include current gesture or attempt...Drug/Alcohol impairment...Drug or alcohol withdrawal symptoms...2. During the initial assessment by the RN, if any of the above conditions is identified and the patient verbalizes or demonstrates high risk behaviors, the patient will be placed immediately in a safe environment...and the physician contacted for suicide precaution orders...3.a. Emergency Department i. the patient will be moved to the Behavioral Health area...iv. The patient will remain in direct visualization of staff until precautions are no longer required according to a physician order or the patient is discharged to an appropriate facility. v. Staff members will document Risk to Self/other section of assessment form, observations and precautions implemented...Staff will remain with the patient at all times...."

(Cross reference Tags A 0175 and A 0353 #2 for information regarding Pt #28.)

Review of Pt #28's ED record:

On 4/27/12 at an undetermined time, an RN completed the "Risk for Harm to Self/Others" section of the ED Nursing Assessment form, circling several items in the "High Intensity Indicators" ratings and recording a "Total Score" of 60. The form contained a printed statement next to the space for Total Score: "...(scores greater than or equal to 21 sitter required)...Name of Sitter...." The nurse recorded a name in space (1), space (2): "...1110 no sitter...(3) 1300 (name of staff)...(4) (blank)...."

The medical record contained a form titled Emergency Department Routine Behavioral Health Continuation Orders. Physician #7 signed the form on 4/27/12 at 0425 and marked Suicide Precautions.

On 4/27/12 at 1750, a nurse documented: "...friends here to pick pt up...."

The medical record contained forms titled Emergency Department Rounding Log with half hour time intervals pre-printed from 0141 through 1800. A staff member recorded check marks and notations each half hour from 0141 through 0700 and from 1100 through 1800. The spaces from 0730 through 1030 were blank.

On 5/21/12, the Director of the ED explained that every patient's medical record in the medical center contains a rounding sheet and that all staff (including management) round on patients. The items to be addressed during rounds are listed at the bottom of the form. Review of these items revealed: "Pain...Address patient's pain...Plan of Care...Communicate the progress of treatments and diagnostic testing... Duration...Communicate the anticipated item (sic) to complete the patient's plan of care...." He clarified that the Rounding Log is not utilized as a form to document visualization of suicidal patients.

The Director of Risk Management and Regulatory provided a form titled Emergency Department Psychiatric Patient Sitter Hours. The form contained documentation that a sitter was assigned to Pt #28 on 4/27/12 from 0135 until 0330.

The medical record did not contain documentation that the patient was directly visualized from 0425 through 1750 when there was a physician's order for Suicide Precautions.

Direct observation of the ED Behavioral Health Area on 5/18/12, revealed that it contains 6 beds. 2 beds are each located in an enclosed room with a door with an observation window. The other 4 beds are located in an open area separated by privacy curtains. An open nurses' station is located in a corner visible to each of the open beds. Staff can visualize patients in the open beds, with the exception of bed #4. In order to visualize the head of bed of #4, the staff is required to move his/her chair to the far end of the desk, or move the bed. The beds in the enclosed rooms (#1 and #6) are monitored via camera, with the monitor located on the desk.

During survey, Pt #38 was a patient in the ED Behavioral Health Area. He had presented to the ED on 5/17/12, at 1453, due to Acute Alcohol Intoxication and Depression with Suicidal Ideation. He was placed in bed #6, in one of the enclosed rooms. Review of his medical record revealed that his Risk for Harm to Self/Others assessment, completed at an undetermined time was 50. A signature was written in the space for RN but the initials PCT were written after the signature. A name was recorded in the space for "Name of Sitter (1)." Spaces (2), (3), and (4) were blank. A physician ordered Suicide Precautions on 5/18/12 at 0105. The RN explained, during survey, that the patient's room was darkened to reduce stimulation and promote rest since he was beginning to "detox" from alcohol. He could be visualized on the monitor as a shadow. Pt #38 was not assigned to a specific staff member and a staff was not specifically assigned to view the monitor.

Employee #14 confirmed during interview conducted on 5/18/12, that a specific staff member is not assigned to a suicidal patient in the ED Behavioral Health Area. Staff are not specifically assigned to any of the patients in the Behavioral Health Area. The ED Behavioral Health Area is staffed with one RN and one ED Tech. The RN is responsible for the care of all of the patients. The RN and/or ED Tech attempt to remain at the desk at all times, but it is possible that there are times when both staff are away from the desk. Staff are not assigned to sit at the desk at all times or to sit at the monitor at all times. The "sitter" documented on the ED Nursing Assessment form is the ED Tech assigned to the Behavioral Health Area who observes all patients from the desk. In an emergency, staff working in the other portion of the ED and/or Security personnel are readily available.

Employee #15 confirmed during interview conducted on 5/18/12, that the name of a "sitter" recorded on the ED Nursing Assessment form is the name of the ED Tech working in the Behavioral Health Area who provides care to all of the patients in the Behavioral Health Area. S/he did not recall ever having an additional Tech or RN to function as a sitter for a suicidal patient. S/he confirmed that there have been times when all 6 beds are full. S/he confirmed that it is possible that there are times when both staff are away from the desk, but they make every effort for either the RN or ED Tech to be at the desk at all times. Neither staff are assigned to sit at the desk visualizing the patients or viewing the monitor.

During survey, the Administrative Director of the ED was asked to provide policies/procedures relevant to the care of patients in the Behavioral Health Area. On 5/21/12, the facility provided a copy of a Self-Learning Packet titled Emergency Department Care of the Patient at Risk for Self Harm/Harm to Others, Written/Last Revised: October, 2006. The Administrative Director of the ED confirmed that the packet was currently in use, although portions required revision. Review of the packet revealed: "Safety...A staff member will be assigned to monitor the at risk patient using direct visualization...." The Administrative Director of the ED stated that he believed that the staff could visualize the patients from the nursing desk and that by doing so, they met the requirement of the learning packet. He confirmed that staff are not specifically assigned to patients in the Behavioral Health Area. He was unable to proved a policy/procedure related to the use of "sitters."

The Director of Risk Management and Regulatory confirmed during interview conducted on 5/22/12, that patients in the ED Behavioral Health Area who are assessed to be at risk for harm to self and have physician orders for Suicide Precautions are not observed or supervised at a higher level than patients in the ED Behavioral Health Area who are not on Suicide Precautions.

2. Review of Pt #26's medical record revealed that it contained an order set titled Delirium Tremens, Severe Withdrawal Orders, which included: "...Diazepam 5 mg IV (Intravenous) q 15 min (every 15 minutes) PRN (as needed) until sedation scale 3-4 is reached...Monitor & record the following on the flowsheet before AND 5 min after each dose of IV medication AND at a minimum of once per hour:...CIWA-Ar score...."

Pt #26's medical record also contained a document Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). The CIWA-Ar contained 10 categories of alcohol withdrawal symptoms with rating scales for 9 categories from 0-7 (7 being the most severe symptom) and the 10th category with a rating scale of 0-4 for Orientation and Clouding of Sensorium. The category for Orientation and Clouding of Sensorium listed specific aspects of orientation and cognition: "...0 oriented and can do serial additions...1 cannot do serial additions or is uncertain about date...2 disoriented for date by no more than 2 calendar days...3 disoriented for date by more than 2 calendar days...4 disoriented for place/or person...." The category for Tactile Disturbances included: "...1 very mild itching, pins & needles, burning or numbness...7 continuous hallucinations...."

Review of the Alcohol Withdrawal/Delirium Tremens Flow Record in Pt #26's medical record, from 5/10/12 at 1805, through 5/13/12 at 0630, revealed that nurses recorded total CIWA-Ar scores "Pre-dose" and "Post dose" of medication. The medical record did not contain documentation of the actual assessments or symptoms of alcohol withdrawal exhibited by the patient.

During interview conducted on 5/15/12, RN #5 confirmed that she was assigned to provide care for Pt #26. She confirmed that nurses do not document the actual assessment of the patient's symptoms of withdrawal. She was unable to identify, from the flow record, the patient's symptoms of withdrawal. She was unable to determine whether the symptoms assessed by one nurse were the same as another nurse, or whether the symptoms assessed at one time were different from another time. She could only review the total scores.

During interview conducted on 5/15/12, the Pharmacy Director confirmed that she had identified that the current method of documenting the patient's alcohol withdrawal status did not include a record of the patient's actual withdrawal symptoms. She had identified variations in scoring between nurses and was unable to determine how the nurses had arrived at the total scores.

On 5/21/12, the Chief Quality Officer confirmed that the hospital does not have a policy/procedure for use of the CIWA-Ar in assessing a patient's alcohol withdrawal or documentation of the assessments.

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to require that an RN clarify an incomplete physician's order prior to administering medication for 2 of 2 patients in the Medical Surgical Intensive Care Unit (MSICU) who received titrated infusions for sedation (Pts #26 and 27).

Findings include:

Review of hospital policy/procedure titled Medication Administration revealed: "...Physician Order Sheet...A complete order documents the name of the medication, dose, frequency and route of administration...Questionable Orders...a. Upon review of physician orders, the nurse or pharmacist clarifies any questionable orders with the physician, prior to administration...Monitoring the Effects of the Administered Medications...a. The effects of all medications, including first doses, are monitored...b. Monitoring a medication's effect on a patient includes the following:...monitoring the patient's clinical response such as level of pain relief, blood pressure control, and sedation...."

Pt #26 was admitted to the MSICU on 5/10/12, due to "severe alcohol withdrawal." On 5/13/12 at 9 AM, Physician #1 wrote an order: "...Versed drip for sedation...." RN #28 documented the Versed infusion started on 5/13/12 at 0915, running at a dose of 5 mg/hr. At 0930, RN #28 increased the dosage to 8 mg/hr. RN #28 documented continuation of the dosage at 8 mg/hr, at 0945, 1000, 1030, 1100, 1200, 1300 and 1400. At 1415, RN #28, reduced the dosage to 6 mg/hr. The RN recorded the patient's agitation as "1" at 0915 and "0" from 0930 through 2200. She recorded his sedation as "2" at 0915 and "3" from 0930 through 2200.

Pt #26's medical record did not contain a Versed sedation protocol, sedation scale, or agitation scale. It did not contain documentation that the nurse clarified the physician's order prior to administration of the Versed.

The Pharmacy Director confirmed during interview conducted on 5/15/12, that the physician's order for Versed was an incomplete order and required clarification for dosage, drip rate and desired sedation level prior to the nurse administering the Versed.

Pt #27 was admitted to the MSICU on 5/14/12. (Cross reference Tag A 0164 for information regarding reason for admission.)

On 5/15/12 at 1350, RN #26 recorded a physician's verbal order: "...Versed gtt titrate per protocol for vent sedation...."

The patient's "bedside medical record" contained a form titled Continuous Infusion Dosing and Titration Protocols. The form contained a section for Versed dosing and maximum infusion. The form did not contain information regarding sedation level.

An RN documented, on the form titled Critical Care Physiologic Monitor, the infusion of Versed for 5/15/12 at 1530, 1600, 1700 and from 1730 through 5/16/12 at 0700. The space on the form for the patient's sedation level was blank from 5/15/12 at 1530 through 1900. An RN recorded the patient's sedation as "4" at 2000, 2400, 0230, 0400 and 0600.

Pt #27's medical record did not contain a sedation scale. It did not contain documentation that the nurse clarified the physician's order prior to administration of the Versed.

The Pharmacy Director confirmed during interview conducted on 5/15/12, that the physician's order for Versed was an incomplete order and required desired sedation level prior to the nurse administering the Versed.

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to require that a pharmacist clarify an incomplete physician's order prior to the administration of medication for 2 of 2 patients in the MSICU who received titrated infusions for sedation (Pts #26 and 27).

Findings include:

(Cross reference Tag A 0404 for information regarding hospital policy/procedure titled Medication Administration and for information regarding physician orders for titrated infusions Pts #26 and 27).

The Pharmacy Director confirmed during interview conducted on 5/15/12, that Pt #26's order for Versed "drip" was an incomplete order and required clarification for dosage, drip rate and desired sedation level prior to administration.

The Pharmacy Director confirmed during interview conducted on 5/15/12, that Pt #27's order for Versed "gtt" was an incomplete order and required desired sedation level prior to administration.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to analyze and track restraint data to identify variances with the use of restraints.

Findings include:

(Cross reference Tags A 0164, A 0168, A 0169, A 0174, A 0175, and A 0179 for findings related to use of restraints.)

Review of the hospital policy/procedure titled Performance Improvement Plan revealed: "...PURPOSE:...Patient care and services shall be continuously monitored and evaluated to promote optimum outcomes through an integrated interdisciplinary process...The organization has the responsibility to design, measure, assess, and improve performance and patient safety. Ultimate authority and accountability for the quality and safety of patient care and services lies with the governing Board and is delegated through the Quality Improvement Program to the Medical Staff, administration and staff of the hospital...SCOPE OF ACTIVITIES AND SERVICES: The scope of the Quality Improvement Program covers measurement and assessment activities of the Medical Staff, Nursing and ancillary of support services...FUNCTION...The Quality Improvement Council (QIC) has oversight responsibility for all performance Improvement activities conducted throughout the Organization. The Quality Improvement Council functions include: Establishing guidelines for hospital-wide monitoring and evaluation of patient care and services...."

During interviews conducted on 5/18/12 and 5/22/12, the Chief Quality Officer confirmed that the Quality Improvement Program had not identified the missing elements of the one hour LIP face-to-face evaluations, the failure to document monitoring of the patient and the failure to remove restraints at the earliest possible time for patients restrained for the management of violent or self-destructive behavior. In addition, the program had focused on measuring trends of use of restraints for the non-violent/non-self-destructive patient and had not focused on specific aspects of restraint use for individual patients. She confirmed that the Quality Improvement Program had not identified the restraint issues described in the previous Tags.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to analyze and track restraint data to identify variances with the use of restraints.

Findings include:

(Cross reference Tags A 0164, A 0168, A 0169, A 0174, A 0175, and A 0179 for findings related to use of restraints.)

Review of the hospital policy/procedure titled Performance Improvement Plan revealed: "...PURPOSE:...Patient care and services shall be continuously monitored and evaluated to promote optimum outcomes through an integrated interdisciplinary process...The organization has the responsibility to design, measure, assess, and improve performance and patient safety. Ultimate authority and accountability for the quality and safety of patient care and services lies with the governing Board and is delegated through the Quality Improvement Program to the Medical Staff, administration and staff of the hospital...SCOPE OF ACTIVITIES AND SERVICES: The scope of the Quality Improvement Program covers measurement and assessment activities of the Medical Staff, Nursing and ancillary of support services...FUNCTION...The Quality Improvement Council (QIC) has oversight responsibility for all performance Improvement activities conducted throughout the Organization. The Quality Improvement Council functions include: Establishing guidelines for hospital-wide monitoring and evaluation of patient care and services...."

During interviews conducted on 5/18/12 and 5/22/12, the Chief Quality Officer confirmed that the Quality Improvement Program had not identified the missing elements of the one hour LIP face-to-face evaluations, the failure to document monitoring of the patient and the failure to remove restraints at the earliest possible time for patients restrained for the management of violent or self-destructive behavior. In addition, the program had focused on measuring trends of use of restraints for the non-violent/non-self-destructive patient and had not focused on specific aspects of restraint use for individual patients. She confirmed that the Quality Improvement Program had not identified the restraint issues described in the previous Tags.

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care provided as evidenced by:

1. failure to provide for required supervision and evaluation of the care of 2 of 2 patients in the Emergency Department (ED) who required suicide precautions (Pts #28 and 38); and

2. failure to provide documentation of assessment of signs and symptoms of a patient's alcohol withdrawal to determine dosage of medication to administer per Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar).

Findings include:

1. Review of hospital policy/procedure titled Patient at Risk for Harm to Self/Others revealed: "..PURPOSE: To identify patients at risk for suicide or harm to self or others and provide interventions to keep the patient and others safe from harm...POLICY: Patients who the organization identifies as being of high risk for harm to themselves or others will be provided with an environment and care to keep themselves and others safe...DEFINITIONS: Direct Visualization-the patient will be visible at all times by a member of the staff. The staff member will be within a distance which allows them to immediately react and respond should the situation require...GUIDELINES: 1. Assessment of patients with increased risk for harm to self or others may include those who exhibit:...Voicing suicidal or homicidal ideation...Recent change in stressors, loss of coping skills and/or support systems...History of suicide attempts, to include current gesture or attempt...Drug/Alcohol impairment...Drug or alcohol withdrawal symptoms...2. During the initial assessment by the RN, if any of the above conditions is identified and the patient verbalizes or demonstrates high risk behaviors, the patient will be placed immediately in a safe environment...and the physician contacted for suicide precaution orders...3.a. Emergency Department i. the patient will be moved to the Behavioral Health area...iv. The patient will remain in direct visualization of staff until precautions are no longer required according to a physician order or the patient is discharged to an appropriate facility. v. Staff members will document Risk to Self/other section of assessment form, observations and precautions implemented...Staff will remain with the patient at all times...."

(Cross reference Tags A 0175 and A 0353 #2 for information regarding Pt #28.)

Review of Pt #28's ED record:

On 4/27/12 at an undetermined time, an RN completed the "Risk for Harm to Self/Others" section of the ED Nursing Assessment form, circling several items in the "High Intensity Indicators" ratings and recording a "Total Score" of 60. The form contained a printed statement next to the space for Total Score: "...(scores greater than or equal to 21 sitter required)...Name of Sitter...." The nurse recorded a name in space (1), space (2): "...1110 no sitter...(3) 1300 (name of staff)...(4) (blank)...."

The medical record contained a form titled Emergency Department Routine Behavioral Health Continuation Orders. Physician #7 signed the form on 4/27/12 at 0425 and marked Suicide Precautions.

On 4/27/12 at 1750, a nurse documented: "...friends here to pick pt up...."

The medical record contained forms titled Emergency Department Rounding Log with half hour time intervals pre-printed from 0141 through 1800. A staff member recorded check marks and notations each half hour from 0141 through 0700 and from 1100 through 1800. The spaces from 0730 through 1030 were blank.

On 5/21/12, the Director of the ED explained that every patient's medical record in the medical center contains a rounding sheet and that all staff (including management) round on patients. The items to be addressed during rounds are listed at the bottom of the form. Review of these items revealed: "Pain...Address patient's pain...Plan of Care...Communicate the progress of treatments and diagnostic testing... Duration...Communicate the anticipated item (sic) to complete the patient's plan of care...." He clarified that the Rounding Log is not utilized as a form to document visualization of suicidal patients.

The Director of Risk Management and Regulatory provided a form titled Emergency Department Psychiatric Patient Sitter Hours. The form contained documentation that a sitter was assigned to Pt #28 on 4/27/12 from 0135 until 0330.

The medical record did not contain documentation that the patient was directly visualized from 0425 through 1750 when there was a physician's order for Suicide Precautions.

Direct observation of the ED Behavioral Health Area on 5/18/12, revealed that it contains 6 beds. 2 beds are each located in an enclosed room with a door with an observation window. The other 4 beds are located in an open area separated by privacy curtains. An open nurses' station is located in a corner visible to each of the open beds. Staff can visualize patients in the open beds, with the exception of bed #4. In order to visualize the head of bed of #4, the staff is required to move his/her chair to the far end of the desk, or move the bed. The beds in the enclosed rooms (#1 and #6) are monitored via camera, with the monitor located on the desk.

During survey, Pt #38 was a patient in the ED Behavioral Health Area. He had presented to the ED on 5/17/12, at 1453, due to Acute Alcohol Intoxication and Depression with Suicidal Ideation. He was placed in bed #6, in one of the enclosed rooms. Review of his medical record revealed that his Risk for Harm to Self/Others assessment, completed at an undetermined time was 50. A signature was written in the space for RN but the initials PCT were written after the signature. A name was recorded in the space for "Name of Sitter (1)." Spaces (2), (3), and (4) were blank. A physician ordered Suicide Precautions on 5/18/12 at 0105. The RN explained, during survey, that the patient's room was darkened to reduce stimulation and promote rest since he was beginning to "detox" from alcohol. He could be visualized on the monitor as a shadow. Pt #38 was not assigned to a specific staff member and a staff was not specifically assigned to view the monitor.

Employee #14 confirmed during interview conducted on 5/18/12, that a specific staff member is not assigned to a suicidal patient in the ED Behavioral Health Area. Staff are not specifically assigned to any of the patients in the Behavioral Health Area. The ED Behavioral Health Area is staffed with one RN and one ED Tech. The RN is responsible for the care of all of the patients. The RN and/or ED Tech attempt to remain at the desk at all times, but it is possible that there are times when both staff are away from the desk. Staff are not assigned to sit at the desk at all times or to sit at the monitor at all times. The "sitter" documented on the ED Nursing Assessment form is the ED Tech assigned to the Behavioral Health Area who observes all patients from the desk. In an emergency, staff working in the other portion of the ED and/or Security personnel are readily available.

Employee #15 confirmed during interview conducted on 5/18/12, that the name of a "sitter" recorded on the ED Nursing Assessment form is the name of the ED Tech working in the Behavioral Health Area who provides care to all of the patients in the Behavioral Health Area. S/he did not recall ever having an additional Tech or RN to function as a sitter for a suicidal patient. S/he confirmed that there have been times when all 6 beds are full. S/he confirmed that it is possible that there are times when both staff are away from the desk, but they make every effort for either the RN or ED Tech to be at the desk at all times. Neither staff are assigned to sit at the desk visualizing the patients or viewing the monitor.

During survey, the Administrative Director of the ED was asked to provide policies/procedures relevant to the care of patients in the Behavioral Health Area. On 5/21/12, the facility provided a copy of a Self-Learning Packet titled Emergency Department Care of the Patient at Risk for Self Harm/Harm to Others, Written/Last Revised: October

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to require that an RN clarify an incomplete physician's order prior to administering medication for 2 of 2 patients in the Medical Surgical Intensive Care Unit (MSICU) who received titrated infusions for sedation (Pts #26 and 27).

Findings include:

Review of hospital policy/procedure titled Medication Administration revealed: "...Physician Order Sheet...A complete order documents the name of the medication, dose, frequency and route of administration...Questionable Orders...a. Upon review of physician orders, the nurse or pharmacist clarifies any questionable orders with the physician, prior to administration...Monitoring the Effects of the Administered Medications...a. The effects of all medications, including first doses, are monitored...b. Monitoring a medication's effect on a patient includes the following:...monitoring the patient's clinical response such as level of pain relief, blood pressure control, and sedation...."

Pt #26 was admitted to the MSICU on 5/10/12, due to "severe alcohol withdrawal." On 5/13/12 at 9 AM, Physician #1 wrote an order: "...Versed drip for sedation...." RN #28 documented the Versed infusion started on 5/13/12 at 0915, running at a dose of 5 mg/hr. At 0930, RN #28 increased the dosage to 8 mg/hr. RN #28 documented continuation of the dosage at 8 mg/hr, at 0945, 1000, 1030, 1100, 1200, 1300 and 1400. At 1415, RN #28, reduced the dosage to 6 mg/hr. The RN recorded the patient's agitation as "1" at 0915 and "0" from 0930 through 2200. She recorded his sedation as "2" at 0915 and "3" from 0930 through 2200.

Pt #26's medical record did not contain a Versed sedation protocol, sedation scale, or agitation scale. It did not contain documentation that the nurse clarified the physician's order prior to administration of the Versed.

The Pharmacy Director confirmed during interview conducted on 5/15/12, that the physician's order for Versed was an incomplete order and required clarification for dosage, drip rate and desired sedation level prior to the nurse administering the Versed.

Pt #27 was admitted to the MSICU on 5/14/12. (Cross reference Tag A 0164 for information regarding reason for admission.)

On 5/15/12 at 1350, RN #26 recorded a physician's verbal order: "...Versed gtt titrate per protocol for vent sedation...."

The patient's "bedside medical record" contained a form titled Continuous Infusion Dosing and Titration Protocols. The form contained a section for Versed dosing and maximum infusion. The form did not contain information regarding sedation level.

An RN documented, on the form titled Critical Care Physiologic Monitor, the infusion of Versed for 5/15/12 at 1530, 1600, 1700 and from 1730 through 5/16/12 at 0700. The space on the form for the patient's sedation level was blank from 5/15/12 at 1530 through 1900. An RN recorded the patient's sedation as "4" at 2000, 2400, 0230, 0400 and 0600.

Pt #27's medical record did not contain a sedation scale. It did not contain documentation that the nurse clarified the physician's order prior to administration of the Versed.

The Pharmacy Director confirmed during interview conducted on 5/15/12, that the physician's order for Versed was an incomplete order and required desired sedation level prior to the nurse administering the Versed.