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Based on interview and document review, the hospital failed to protect the rights of all the patients in the hospital when patient (P1) was abused when she was restrained by a registered nurse in the ED, without attempting least restrictive measures first, this resulted in an injury and pain. The hospital was found to be out of compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

Findings include:

The hospital failed to ensure staff implemented the grievance procedure in accordance with hospital policy for 1 of 27 grievances reviewed. RN-D received a verbal grievance from P1's family member (FM)-E before leaving the emergency department (ED). FM-E alleged staff abuse P1 in the ED. Instead of documenting and forwarding the grievance to the appropriate management staff, in accordance with the hospital policy, RN-D provided FM-E a grievance form and hospital contact information to be completed by FM-E at a later time. In addition, when the hospital received the verbal grievance made by FM-E about staff abuse, hospital management failed to immediately investigate the grievance. (A118)

The hospital failed to ensure patients were free from abuse for 1 of 23 (P1) patient records reviewed. P1 was abused when an employee (RN-B) physically restrained P1's hands in an unsafe manner causing an injury to P1's right wrist and pain. (A145)

The hospital failed to ensure patients were free from unnecessary restraints for 1 of 23 (P1) patients records reviewed. RN-B physically restrained P1's wrists in an unsafe and unnecessary manner preventing movement, causing an injury to P1's right wrist and pain, and without attempting a less restrictive alternative. (A154)

Based on document review and interview, the hospital failed to ensure staff implemented the grievance procedure in accordance with hospital policy for 1 of 27 grievances reviewed. RN-D received a verbal grievance from P1's family member (FM)-E before leaving the emergency department (ED). FM-E alleged staff abuse P1 in the ED. Instead of documenting and forwarding the grievance to the appropriate management staff, in accordance with the hospital policy, RN-D provided FM-E a grievance form and hospital contact information to be completed by FM-E at a later time. In addition, when the hospital received the verbal grievance made by FM-E about staff abuse, hospital management failed to immediately investigate the grievance.

Findings include:

Review of the hospital's policy and procedure titled Grievance Process, Patient/Patient's Representative with a revision date of 7/21/2015, revealed a grievance was defined as a formal or informal written or verbal complaint by a patient/patient representative regarding patient care, abuse, and neglect. The policy indicated the Patient Relations/Risk Management Department was the hospital's delegated grievance committee. The policy stated staff who received a grievance would complete an electronic Patient Safety Event Report form to be submitted to Patient Relations/Risk Management or patient advocates by the end of their shift.

Review of the hospital's policy and procedure titled Vulnerable Adults, Reporting Maltreatment with a review/revision date of 1/2013, revealed with suspected staff maltreatment of a patient, an employee when informed of an event must inform the supervisor immediately. A patient safety report was to be completed by the staff who received the report by the end of their work shift. In addition, the supervisor was to forward the event report through the chain of command that included risk management. When appropriate, the allegation was to be reported to the appropriate state agency within 24 hours.

Interview with FM-E on 11/3/2015, at 4:37 p.m. revealed P1's ED visit was uneventful until just prior to discharge. An unidentified RN (later identified by the ED as RN-B) entered P1's room, who was sitting in a chair, quickly approached P1, and without explanation began removing P1's IV. P1 was startled and raised an arm toward RN-B. RN-B immediately grabbed P1's wrists (one wrist in each hand) and held each wrist down in P1's lap. P1's hands and arms became limp in her lap. FM-E said RN-B's knuckles on both hands were white from tightly holding P1's wrists. FM-E repeated three times for RN-B to let go "you're going to break her bones". Each time RN-B refused to release P1's wrists saying P1 would hit her. After about three minutes RN-B let go of P1's wrists. FM-E than explained to P1 the need to remove the IV and P1 allowed RN-B to remove the IV without further incident. After having her wrists held down, the FM revealed a second employee observed P1's right wrist was bleeding. FM-E said a right wrist skin tear was caused when RN-B held down P1's wrists and the hospital's identification band tore P1's skin. The unidentified employee told RN-B of the right wrist skin tear, who applied a clear adhesive dressing to P1's right wrist. No instructions were provided to FM-E about the care of the injury. FM-E indicated the injury was intentionally caused by RN-B. FM-E said she was in shock when watching RN-B's treatment of P1. P1 was discharged from the ED shortly after the incident and while in the waiting room of the ED, FM-E said she became very upset about RN-B's treatment of P1. FM-E told a security guard that P1's should not be hurt when in an ED. The security guard asked whether FM-E wanted to speak with a charge nurse. FM-E agreed and the security guard returned with RN-D. RN-D discussed RN-B's treatment of P1 and gave FM-E a grievance form to fill out at a later time. On 8/12/15 FM-E called the hospital risk management and file a grievance.

Review of the hospital's event report/grievance data form dated 8/12/2015, and not timed indicated the hospital received a verbal grievance from FM-E regarding an incident that occurred on 8/5/2015, in the ED. According to the grievance, RN-B entered P1's ED room to remove her IV prior to discharge. Without providing P1 with an explanation, RN-B approached P1 in an attempt to remove the IV. P1 responded by swinging one arm up at RN-B. RN-B grabbed and held down both of P1's wrists. Despite FM-E's repeated requests for RN-B to let go of P1's wrists, RN-B continued to hold P1's wrists. Following the third request by FM-E, the RN let go of P1's wrists. FM-E said she explained to P1 that RN-B needed to remove P1's IV. Following the explanation, P1 allowed the RN to remove the IV without incident. After having her wrists held down, P1's right wrist was bleeding and indicated the injury was intentionally caused by RN-B. The grievance revealed on 8/5/2015, FM-E discussed the concerns of RN-B's treatment toward P1 with RN-D/charge nurse. RN-D/charge nurse provided FM-E with the hospital's grievance from.

Review of P1's medical record revealed on 8/5/2015, at 12:31 p.m. P1 presented to the ED with family member (FM)-E due to increased confusion and combative behavior. P1 had a diagnoses of Alzheimer's type dementia. P1 was currently being treated for an urinary tract infection (UTI) with doxycycline (antibiotic) since 7/31/2015. P1's medical screening examination revealed P1 exhibited normal mood and affect and followed commands. At 2:33 p.m. the documentation revealed RN-B discontinued the IV from P1's left lower forearm. There was no documentation in P1's ED record about the need to use a physical restraint that caused a right wrist injury.

Interview with RN-D/charge nurse on 11/3/2015, at 11:38 a.m. revealed on 8/5/2015, around 3:00 p.m. she was informed by a security guard that FM-E wanted to report rough treatment of P1 by a RN in the ED. RN-D spoke with FM-E in the waiting room of the ED and was informed an unidentified RN held down P1's wrists too roughly causing an injury. RN-D said FM-E was able to describe RN-B. RN-D said she did not look at the right wrist injury because it was covered with a dressing. RN-D said she could have contacted a patient advocate/risk management employee to assist FM-D with her concerns of RN-B's treatment of P1. Instead, RN-D gave FM-E a grievance form and provided no further investigation or documentation of RN-B's rough treatment of P1.

Interview with the patient relations senior specialist (PRSS)-C on 11/4/2015, at 12:20 p.m. revealed a verbal grievance was received by risk management on 8/12/2015, from FM-E. The event/grievance was assigned to PRSS-C on 8/14/2015. On 8/14/2015, PRSS-C deferred the investigation to the ED leadership team after verbally discussing the grievance with the ED manager. PRSS-C e-mailed as high priority the event report/grievance to the ED manager, ED (DON), the ED physician section chair, the ED physician division chief, administrator of primary care, and the physician division chair. On 8/25/2015, after no response to the e-mail event report/grievance, PRSS-C sent a second e-mail to the same individuals. On 9/15/2015, following no response from the e-mail, PRSS-C sent an e-mail with the event report/grievance to the same staff and added the regional chief nursing officer. On 9/16/2015, the regional chief of nursing contacted the ED interim manager and ED DON who initiated the investigation by arranging an interview with RN-B on 9/17/2015.

Interview with the ED physician section chair on 11/4/2015, at 10:04 a.m. revealed he was made aware of the event report/grievance regarding staff treatment of P1 with the original e-mail sent by PRSS-C on 8/14/2015. Because the patient experience did not involve a physician in the ED, the ED physician section chair said ED nursing management should investigate the allegation.

Interview with the ED DON on 11/3/2015, at 1:54 p.m. revealed due to the nature of the grievance alleging staff abuse of P1, the grievance was considered urgent and should have immediately been investigated and documented by management. The hospital's current system of electronic notifications of event reports/grievances failed to prioritize the reports. Therefore, with numerous grievances e-mailed to management, the grievance was overlooked and not investigated until 9/17/2015, when RN-B and RN-D were interviewed. In addition, the ED DON indicated the hospital policy directed RN-B to document FM-E's grievance prior to the end of RN-D's shift on 8/5/2015, or refer the grievance to a patient advocate/risk management staff.

Based on document review and interviews, the hospital failed to ensure patients were free from abuse for 1 of 23 (P1) patient records reviewed. P1 was abused when an employee (RN-B) physically restrained P1's hands in an unsafe manner causing an injury to P1's right wrist and pain.

Findings include:

Interview with FM-E on 11/3/2015, at 4:37 p.m. revealed P1 lives with her because of her dementia and declining health. P1 has osteoarthritis, osteoarthrosis and hearing loss. She took P1 to the ED on 8/5/15, because she had concerns related to P1's urinary tract infection. P1's ED visit was uneventful until just prior to discharge. An unidentified RN (later identified by the ED as RN-B) entered P1's room. P1 was sitting in a chair and RN-B quickly approached P1, and without explanation began removing P1's IV. P1 was startled and raised an arm toward RN-B. RN-B immediately grabbed P1's wrists (one wrist in each hand) and held each wrist down in P1's lap. P1's hands and arms became limp in her lap. FM-E said RN-B's knuckles on both hands were white from tightly holding P1's wrists. FM-E repeated three times for RN-B to let go "you're going to break her bones". Each time RN-B refused to release P1's wrists saying P1 would hit her. After about three minutes RN-B let go of P1's wrists. FM-E than intervened and explained to P1 the need to remove the IV and P1 allowed RN-B to remove the IV without further incident. After having her wrists held down, FM-E said a second employee observed P1's right wrist was bleeding. The right wrist skin tear happened when RN-B held down P1's wrists and the hospital's identification band tore P1's skin. The unidentified employee told RN-B of the right wrist skin tear. RN-B then returned to the room and applied a clear adhesive dressing to P1's right wrist. No instructions were provided to FM-E about the care of the injury. FM-E indicated the injury was intentionally caused by RN-B. FM-E said she was in shock when watching RN-B's treatment of P1. P1 was discharged shortly after the incident. While in the waiting room of the ED, FM-E said she became very upset about RN-B's treatment of P1. FM-E told a security guard that P1's should not be hurt when in an ED. The security guard asked whether FM-E wanted to speak with a charge nurse. FM-E agreed and the security guard returned with RN-D. RN-D discussed RN-B's treatment of P1 and gave FM-E a grievance form to fill out at a later time. FM-E said P1 required two additional oxycodone, a narcotic pain medication during the night when P1 held her right wrist and cried. The following morning, FM-E took P1 to an urgent care clinic because of pooling blood under the Tegaderm dressing.

Review of P1's medical record revealed on 8/5/2015, at 12:31 p.m. P1, was a 91 year old, who presented to the ED with family member (FM)-E due to increased confusion and combative behavior. P1 had a diagnoses of Alzheimer's type dementia. P1 was currently being treated for an urinary tract infection (UTI) with doxycycline (antibiotic) since 7/31/2015. P1's medical screening examination revealed P1 exhibited normal mood and affect and followed commands. An intravenous (IV) saline lock was placed by RN-A, blood drawn for complete blood count (CBC) with differential, ammonia and lactic acid levels, and chemical panel. A chest x-ray was completed. All labs and chest x-ray were within normal limits and prior to P1's discharge from the ED, the treatment plan was to continue with the current antibiotic and follow-up with P1's primary provider the next day. At 2:33 p.m. the documentation revealed RN-B discontinued the IV from P1's left lower forearm. There was no documentation in P1's ED record related to RN-B's use of a physical restraint or an injury to P1's right wrist.

Review of P1's medical record revealed on 8/6/2015, at 11:10 a.m. FM-E brought P1 to urgent care for a right wrist skin tear and bruising that occurred while being restrained in the ED on 8/5/2015. P1's right wrist was covered with a Tegaderm (clear adhesive dressing) and was actively bleeding underneath the dressing. The skin tear was located on the dorsum (back) of the right wrist and was described as a small moon shaped tear surrounded by at least three centimeters of bruising. The skin tear was cleansed, four Seri-strips were applied, and the right wrist was wrapped with kling. P1's discharge diagnosis was a right wrist contusion and skin tear.
In an attempt to interview the employee witness, five nursing assistants (NA)'s were interviewed on 11/5/2015. The NA's were working in the ED during P1's 8/5/2015,ED visit. None of the NA's remembered the incident between RN-B and P1.

Interview with RN-B on 11/4/2015, at 4:06 p.m. revealed she was assigned to remove P1's IV and discharge P1. RN-B walked in the room and stood in front of P1 who was sitting in a wheelchair or chair and without explanation to P1 began removing the IV. P1 responded with a scream when touched by RN-B and raised a fist at RN-B. In response RN-B held down both of P1's wrists, one in each hand. RN-B said FM-E repeated to let go of P1's wrists but each time P1 made a fist and attempted to hit RN-B so she continued to hold down P1's wrists. RN-B was unable to recall the amount of force or amount of time required to hold down P1's wrists but indicated she was only in P1's room for a couple of minutes. RN-B said she may have applied a Band-Aid to something for P1 but could not recall the specific information. RN-B said had she known that P1 had dementia she would have approached P1 slower, provided an explanation of the procedure, and looked P1 in the eyes. RN-B confirmed there was no documentation in P1's ED record of a skin tear or interaction with P1.
Interview with RN-D/charge nurse on 11/3/2015, at 11:38 a.m. revealed on 8/5/2015, around 3:00 p.m. she was informed by a security guard that FM-E wanted to report rough treatment of P1 by a RN in the ED. RN-D spoke with FM-E in the waiting room of the ED and was informed an unidentified RN held down P1's wrists too roughly causing an injury. RN-D said FM-E was able to describe RN-B. RN-D said she did not look at the right wrist injury because it was covered with a dressing. RN-D said she could have contacted a patient advocate/risk management employee to assist FM-D with her concerns of RN-B's treatment of P1. Instead, RN-D provided the FM with a grievance form and provided no further investigation or documentation of RN-B's rough treatment of P1.
Interview with the ED director of nursing (DON) on 11/3/2015, at 1:54 p.m. revealed The ED DON interviewed RN-B on 9/17/2015 about the incident on 8/5/15. Following the interview, RN-B was immediately suspended with pay for an eight hour shift and required to complete training about patient safety and respectful patient treatment. No additional monitoring of RN-B was arranged by the ED. The ED DON indicated instead of holding down P1's wrists, RN-B should have explained the procedure to P1, calmly approached P1, and/or used additional staff to assist in the removal of the IV.

Review of the hospital's policy and procedure titled Vulnerable Adults, Reporting Maltreatment with a review/revision date of 1/2013, defined abuse as staff conduct that could produce physical pain, injury, or emotional distress to a patient. An example of abuse was the use of any aversive or depravation procedure and/or unreasonable confinement.

Review of the hospital's policy and procedure titled Restraint and Seclusion with a review/revised date of 5/2012, indicated the hospital is committed to prevent, reduce, and strives to eliminate the use of restraints and utilize nonphysical interventions. The patients have the right to be free from restraint whenever possible and preservation of the patient's rights, dignity, and well-being during use of a restraint. The policy indicates restraints must be implemented safely and appropriately and never act as a barrier in meeting the patient's needs. Restraints will only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff, or others of harm. The policy defines a restraint as any manual, physical, or mechanical device, material, or equipment that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely. In addition, restraints were only to be used when less restrictive interventions had been determined to be ineffective to protect the patient, staff member, or others from harm.

Based on document review and interviews, the hospital failed to ensure patients were free from unnecessary restraints for 1 of 23 (P1) patients records reviewed. RN-B physically restrained P1's wrists in an unsafe and unnecessary manner preventing movement, causing an injury to P1's right wrist and pain, and without attempting a less restrictive alternative.

Findings include:

Interview with FM-E on 11/3/2015, at 4:37 p.m. revealed P1 lives with her because of her dementia and declining health. P1 has osteoarthritis, osteoarthrosis and hearing loss. She took P1 to the ED on 8/5/15, because she had concerns related to P1's urinary tract infection. P1's ED visit was uneventful until just prior to discharge. An unidentified RN (later identified by the ED as RN-B) entered P1's room, who was sitting in a chair, quickly approached P1, and without explanation began removing P1's IV. P1 was startled and raised an arm toward RN-B. RN-B immediately grabbed P1's wrists (one wrist in each hand) and held each wrist down in P1's lap. P1's hands and arms became limp in her lap. FM-E said RN-B's knuckles on both hands were white from tightly holding P1's wrists. FM-E repeated three times for RN-B to let go and each time RN-B responded by saying P1 would hit her. After about three minutes RN-B let go of P1's wrists. FM-E than explained to P1 the need to remove the IV and P1 allowed RN-B to remove the IV without further incident. After having her wrists held down, P1's right wrist was bleeding and indicated the injury was intentionally caused by RN-B.

Review of P1's medical record revealed on 8/5/2015, at 12:31 p.m. P1, a 91 year old, presented to the ED with family member (FM)-E due to increased confusion, combative behavior, and a urinary tract infection (UTI). P1 had a diagnoses of Alzheimer's dementia. P1's medical screening examination revealed P1 exhibited normal mood and affect and followed commands. At 2:33 p.m. the documentation revealed RN-B discontinued the IV from P1's left lower forearm. There was no documentation in P1's record of the use of a physical restraint or right wrist injury.

Review of P1's urgent care medical record dated 8/6/2015, at 11:10 a.m. revealed FM-E brought P1 in to an urgent care clinic to be seen for a right wrist injury and bruising that occurred while being restrained in the ED on 8/5/2015. The skin tear was located on the dorsum (back) of the right wrist and was described as a small moon shaped tear surrounded by at least three centimeters of bruising. The skin tear was cleansed, four Seri-strips were applied, and the right wrist was wrapped with kling. P1's discharge diagnosis was a right wrist contusion and skin tear.
Interview with RN-B on 11/4/2015, at 4:06 p.m. revealed she was assigned to remove P1's IV and discharge P1. RN-B walked in the room and stood in front of P1 who was sitting in a wheelchair or chair and without explanation began removing the IV. P1 responded with a scream when touched by RN-B and raised a fist at RN-B. In response RN-B held down both of P1's wrists, one in each hand. RN-B said FM-E repeated to let go of P1's wrists. Each time RN-B released P1's wrists, P1 made a fist and attempted to hit RN-B. RN-B was unable to recall the amount of force required to hold down P1's wrists. P1 made no physical contact with RN-B. RN-B said had she known that P1 had dementia she would have approached P1 slower, provided an explanation of the procedure, and looked P1 in the eyes. RN-B confirmed there was no documentation of the use of a physical restraint that caused injury in P1's ED medical record.

Interview with the ED director of nursing (DON) on 11/3/2015, at 10:04 a.m. revealed on 9/17/2015, she met with RN-B to discuss an event report/grievance regarding rough treatment of P1 on 8/5/2015. The ED DON indicated instead of holding down P1's wrists, RN-B should have explained the procedure to P1, calmly approached P1, and/or used additional staff to assist in the removal of the IV.
Review of the hospital's policy and procedure titled Restraint and Seclusion with a review/revised date of 5/2012, indicated the hospital is committed to prevent, reduce, and strives to eliminate the use of restraints and utilize nonphysical interventions. The patients have the right to be free from restraint whenever possible and preservation of the patient's rights, dignity, and well-being during use of a restraint. The policy indicates restraints must be implemented safely and appropriately and never act as a barrier in meeting the patient's needs. Restraints will only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff, or others of harm. The policy defines a restraint as any manual, physical, or mechanical device, material, or equipment that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely. In addition, restraints were only to be used when the less restrictive interventions had been determined to be ineffective to protect the patient, staff member, or others from harm.