HospitalInspections.org

Based on review of patient records, personnel records, and other pertinent documentation, as well as interviews with staff, it was determined that the hospital was out of compliance with the Condition of Governing Body, as evidenced by failure of the hospital's Governing Body to operate effectively and ensure that the hospital timely corrected deficient practices identified by OHCQ surveyors during the previous Conditions of Participation (CoP) Survey.

A previous CoP survey, conducted on December 18, 2018, determined the hospital's non-compliance with performing and documenting face-to-face evaluations for restraints and seclusion episodes, lack of Cardiopulmonary Resuscitation (CPR) training for security personnel, and failure to provide care in a safe setting by allowing security officers to perform emergency safety interventions on patients without clinical oversight. The plan of correction (PoC) submitted by the hospital on January 28, 2019 outlined corrective actions for the afore-mentioned violations with the targeted completion dates of February 28 - June 1, 2019. The current CoP survey on October 29-30, 2019 determined that the stated interventions had either not been completed or lacked evidence thereof.

The hospital's PoC from January 2019 stated that all CPR training for security personnel would be completed by March 1, 2019. Simultaneous interviews conducted on October 29, 2019 at approximately 10:00 am, with a staff security officer and the Director of Security determined that security staff had not completed the required training for CPR. Review of 5 random security personnel files confirmed the lack of training for all 5 security staff reviewed. During the interview, the Director of Security stated they were currently starting to implement this process; however, no start dates or completion dates were reported (see tag A-0206).

The hospital's PoC from January 2019 stated that changes in the electronic medical record were taking place by February 28, 2019 to ensure the process of documenting face-to-face evaluations by LP's (licensed practitioners) after any restraint and/or seclusion event would be completed timely for all patients. Review of medical records during the onsite survey on October 29-30, 2019 did not reveal evidence of this process. There was at least one patient identified during the survey who was restrained and no face-to-face documentation, including orders for the evaluation, were found (see tag A-0179).

The hospital's PoC from January 2019 stated that the Use of Force policy would be evaluated and updated, as well as mandatory training provided to security and clinical staff by June 1, 2019 to ensure that restraint processes were performed under clinical oversight and that security officers would never have 'free agency' over a patient without clinical oversight. Review of the video footage of a restraint episode during the onsite survey on October 30, 2019 determined that security guards continued to immediately react to patients behaviors without a nurse or physician present (see tag A-0175).

The afore-mentioned findings demonstrated that the hospital's Governing Body failed to provide an effective oversight of the hospital's operations directed at correction of identified problems in the areas of patient care quality and patient safety.

Based on review of patient medical records, policies and procedures, personnel files, interviews with staff, and review of video surveillance footage, it was determined that the hospital was out of compliance with the Condition of Patient Rights, as evidenced by multiple serious deficiencies of the standards under the Condition of Patient Rights that include:

1) failure to allow Patient #5 to exercise their right to refuse treatment (see tag A-0131);
2) failure to provide safe environment of care for Patients # 1, 6, 7, 8, 9, and 12 (see tag A-0144);
3) failure to perform/document a face-to-face evaluation after a restraint episode for Patient #1 (see tag A-0179
3) failure to provide required CPR training to security personnel (see tag A-0206);
4) failure to provide clinical oversight to security personnel participating in a restraint episode involving Patient #13 (see tag A-0175).

Based on review of medical records, hospital policy, and other pertinent documentation, it was determined that the hospital failed to allow Patient #5 to exercise their right to refuse treatment.

Surveyors reviewed the "Informed Consent" policy, dated 8/17/18, which stated under "Refusal: An individual who has the power to give a valid consent for a treatment or procedure may refuse to consent. An effective refusal to consent must be honored". The policy also stated under "H. Certificates for Surrogate Decision Making 1. The attending physician and a second physician shall certify in writing that the patient is incapable of making an informed decision regarding treatment".

Surveyors also reviewed the Patient Bill of Rights (BoR) which was given to patients when they arrived at the hospital. On page 21, BoR stated a patient had the right to: "Make decisions about your care, including the right to refuse care or treatment and to leave the hospital against medical advice of your doctor".

Patient #5 (P5) was a 60+ year old patient who presented to the Emergency Department (ED) after a suspected attempt of self-harm. P5's condition initially declined and the patient was admitted to an intensive care unit. Less than 24 hours later, P5's condition improved and the patient requested to leave the hospital Against Medical Advice (AMA).

Review of P5's medical record revealed a note by the psychiatrist that stated, "Pt is now awake, wanting to leave AMA. MICU (medical intensive care unit) aware [patient] can NOT leave AMA. Will be seen by psych consultant tomorrow. Until then, keep full code, can't leave AMA".

P5's medical record also contained an order, which was placed by the attending physician at approximately the same time as the psychiatrist note, that read "Patient may not leave AMA". The patient was subsequently moved to a locked unit and the order was not discontinued until two days later when the patient was discharged from the hospital.

No documentation was found in P5's record to support that an evaluation and certification was completed by two physicians determining that P5 was incapable of making decisions regarding their care and disposition. In absence of such certifications, the hospital violated P5's right to make decisions regarding their care, including refusal of treatment.

Based on review of medical records, hospital policy, and other pertinent documents, as well as video surveillance footage review, it was determined that the hospital failed to provide a safe environment that protected its vulnerable patients, as evidenced by a lack of assessment, monitoring, and basic precautions to mitigate risk of self-injury and promote care for 2 of 2 Emergency Department patients reviewed that were seeking medical and psychiatric care.

Patient #12 (P12) was a 25+ year old patient who presented to the Emergency Department (ED) with suicidal intentions which were conveyed by the patient to the triage registered nurse (T-RN). Offsite review of video footage by surveyors showed that P12 arrived into a triage room with T-RN at 2:59 am and had vital signs taken and blood drawn. The T-RN exited the triage room at 3:03 am leaving P12 alone and unmonitored for approximately 33 minutes. There were no observed attempts by the T-RN prior to exiting to remove or secure medical equipment and other potentially hazardous items in the triage room, despite known and stated suicidal ideations of P12. At 3:07 am, patient was seen leaving the triage room and going into the waiting area where their personal belongings were and retrieving what appeared to be a book and a writing utensil. P12 then returned to the triage room without staff inquiry or intervention. At 3:35, P12 looked up at a long cord hanging from a monitor that was an arm's distance away, grabbed the cord, wrapped it one rotation around the neck and proceeded to tighten it. At 3:36 am, the T-RN was seen running into the triage room and attempting to yank the cord from P12's neck. After three pulls, the T-RN was able to loosen the cords and remove the cord from the patient's neck. Immediately after, P12 was seen being led out into the hallway and into the main ED by the T-RN, another nurse, and two security officers, without an assessment, vital signs, or any other interventions being completed.

Despite P12 reporting suicidal ideations and the T-RN's awareness of the condition, there was a lack of interventions initiated to mitigate the risk of self-harm. No evidence was found to support that common safety interventions/precautions, such as removal of equipment, securing cords and sharp objects, and 1:1 continuous monitoring (also known as a sitter), were implemented for P12 in the triage. An order for a sitter to be placed at P12's bedside (1:1 continuous monitoring) was not entered until after the self-strangulation incident.

P12's second opportunity of self-harm/ injury was documented in the record less than 9 hours later. The patient was found in the bathroom on the floor after an unwitnessed fall in which P12 struck their head on the wall. The patient was found by a registered nurse (RN #1) around 12 pm. There was no documented evidence in P12's record that a sitter was present at the time of the incident, although the order for the sitter was placed at 3:56 am.

Medical record review determined that between 5:49 am and 3:36 pm Safety visual checks were documented by nursing staff every 15 minutes and contained the following observations: "Self Injurious Thoughts" were documented as "intent and plan" ..., and "Self Injurious Behaviors" were "Yes, Pt observed wrapping blood pressure cord and blanket around neck".

There was a disparity between the documented account of visual monitoring of P12 and the opportunities that P12 had to attempt self- injurious acts, including being unattended in a bathroom.

The hospitals' failure to implement safety precautions and monitoring provided Patient #12 (P12) multiple opportunities to inflict self-harm, with two incidents occurring during the same Emergency Department (ED) visit.

Patient #1 (P1) was a 65+ year old patient who was brought to the ED for evaluation of a behavioral condition. ED provider and nursing documentation stated that the patient was alert and oriented to person, place and time. Approximately four hours later, nursing documentation stated "Pt stating wanting to roll over and die". "Stated [patient] would be better off dead". A 1:1 sitter wasn't initiated for almost an hour after that nursing note was written. Documentation by the sitter was initially completed every 15 minutes for the first 3 hours at which time the documentation stopped and did not start again until 8 hours later.

The provider order for the sitter was not written until 3 hours after the sitter was initiated and the indication for the order stated "confusion". No reference to the patient stating they wanted to die was found in the physician documentation. No follow-up notes were found by nursing staff or physicians regarding these stated thoughts by the patient.

In summary, the hospital failed to establish, initiate, and monitor basic interventions that would promote, protect, and mitigate risks that compromise safety and care of vulnerable patients who presented to the hospital seeking acute medical and psychiatric care.

Based on review of medical records and incident reports, staff interviews, and review of video surveillance footage, it was determined that the hospital failed to provide clinical oversight during a restraint event for Patient #13 (P13).

Tour of the behavioral health unit in the Emergency Department (ED) was conducted on October 29, 2019 at approximately 10:00 am. While on the unit, surveyors interviewed the Director of Security and a staff security officer. Both staff members stated that the nurse's station on this unit must be staffed by a nurse and a security officer at all times.

Surveyors reviewed incident reports involving interventions by security personnel and identified a report describing security interventions performed on P13 in mid-October 2019. The report listed three names of personnel involved who were all security staff. No clinicians were listed on the report. The report stated that the patient was escorted to a room, then became aggressive, was medicated, and officers were cleared. Surveyors requested to review video surveillance footage pertaining to this episode.

P13 was a minor (under 18 years old) patient who was brought to the ED for a behavioral health evaluation. Review of video surveillance footage determined that P13 was engaging in non-violent behaviors at the nurse's station. At 1:51 am, P13 pushed paper through the window at the nurse's station, and the security officer was seen leaving the locked nurse's station and pursuing the patient who had turned to go down the hall. The officer was seen aggressively taking the patient down the hall and into a room. While in the room, the officer engaged in a physical altercation with the patient and was seen holding the patient down flat (back down) on the bed.

The video offered no evidence of clinical oversight provided by the nurse present during this incident. The nurse was seen walking down the hall and picking up the trash that P13 had thrown on the floor while the restraint was occurring. The nurse eventually walked into the patient room, briefly looked at the officer holding the patient down, and then proceeded to leave the room in a non-hurried way without making any attempt at assessing the patient's condition or the situation that led to the physical restraint. A short time later, the nurse was seen walking back into the room and out again, and then more security officers were seen arriving to assist the first officer. The nurse was present during the event intermittently and displayed no attempts to interact with security or the patient, or provide clinical oversight over the restraint episode. In addition, as indicated earlier, no evidence of clinical oversight was documented in the security incident report.

Based on review of medical records, hospital policy, and other pertinent documentation, it was determined that the facility failed to complete and document a face-to-face evaluation for Patient #1 (P1), after the patient was physically held and given medications.

Surveyors reviewed "Restraints and Seclusion Policy" dated 7/16/2019, which stated under Definitions section: "C. Physical restraint: physically holding a patient in order to administer a medication against the patient's wishes." The policy also stated under Violent Restraint and Seclusion section (page 9): "Face to Face evaluation must occur with the LP (licensed practitioner) as soon as possible (no longer than one hour) after the initiation of the intervention. Document the evaluation in the patient's medical record."

Patient #1 (P1) was a 65+ year old patient who was brought to the ED for evaluation of a behavioral condition. ED provider and nursing documentation stated that the patient was alert and oriented to person, place, and time.
While in the ED, nursing documentation stated the patient was "resting at this time. Patient aggressive at times but redirectable". Thirty minutes later, orders were written by the physician for a 'Behavioral Health Hold' and for three different anti-psychotic medications which were administered intramuscularly by nursing staff.

No documentation was found describing what the patient's behaviors were prior to the need for a hold and medications. No order for a face-to-face was found, and no documentation by a physician was found to support that P1 was evaluated at any time after the restraint episode.

Without the face-to-face assessment, it was unclear what behaviors were present prior to the intervention, what other redirection attempts were completed that did not work, or the patient's response to the intervention, including the need to continue the restraint.

Based on review of personnel files and interviews with staff, it was determined that that hospital failed to provide training in the use of Cardiopulmonary resuscitation (CPR) to its security officers as evidenced by lack of CPR education and certification in 5 of 5 security officers' personnel files reviewed.

A sample of five security staff personnel files were reviewed by surveyors, with the years of service at the hospital ranging from 2- 4 years. All five files lacked documentation of CPR certification, which was required in the hospital's job description and by regulatory standards.

It is important to note that the hospital was found to be out of compliance with this requirement back in December 2018 and submitted a plan of correction with a targeted date of February 28, 2019 to have CPR training completed for all security personnel. During an interview with the Director of Security on October 29, 2019 at approximately 10:00 am, it was determined that the hospital was starting to implement this process; however, no start dates or completion dates were reported.

Based on review of patient medical records, hospital policy, and other pertinent documents, as well as video surveillance footage review, it was determined that members of the hospital's nursing staff failed to assess, monitor, and reassess the needs of its vulnerable patient population for 5 of 6 Emergency Department patients reviewed, as evidenced by lack of interventions in place to mitigate risk for Patient #12 which resulted in at least one successful attempt of self-harm and failure to monitor patients #6, 7, 8, and 9, according to the hospital's policy.

Patient #12 (P12) was a 25+ year old patient who presented to the Emergency Department (ED) with suicidal intentions which were conveyed by the patient to the triage registered nurse (T-RN). Offsite review of video surveillance footage by surveyors showed that P12 was taken into a triage room with T-RN at 2:59 am and had vital signs taken and blood drawn. The T-RN exited the triage room at 3:03 am leaving P12 alone and unmonitored for approximately 33 minutes. There were no observed attempts by the T-RN prior to exiting to remove or secure medical equipment and other potentially hazardous items in the triage room, despite known and stated suicidal ideations of P12. At 3:07 am, the patient was seen leaving the triage room and going into the waiting area where their personal belongings were and retrieving what appeared to be a book and a writing utensil. P12 then returned to the triage room without staff inquiry or intervention. At 3:35 am, P12 looked up at a long cord hanging from a monitor that was an arm's distance away, grabbed the cord, wrapped it one rotation around the neck and proceeded to tighten it. At 3:36 am, the T-RN was seen running into the triage room and attempting to yank the cord from P12's neck. After three pulls, the T-RN was able to loosen the cords and remove the cord from the patient's neck. Immediately after, P12 was seen being led out into the hallway and into the main ED by the T-RN, another nurse, and two security officers, without an assessment, vital signs, or any other interventions being completed.

Despite P12 reporting suicidal ideations and the T-RN's awareness of the condition, there was a lack of interventions initiated to mitigate the risk of self-harm. No evidence was found to support that common safety interventions/precautions, such as removal of equipment, securing cords and sharp objects, and 1:1 continuous monitoring (also known as a sitter), were implemented for P12 in the triage. An order for a sitter to be placed at P12's bedside (1:1 continuous monitoring) was not entered until after the self-strangulation incident.

Medical record review showed that the order for a sitter was placed at 3:56 am; however, there was no documented evidence that a continuous 1:1 sitter was assigned to P12 and actually present in the room until 3:36 pm. Continuous 1:1 sitter documentation would generally consist of completed 1:1 observer forms and/or electronic flowsheets documentation observations of patient's condition and behavior. This documentation was not found in P12's medical record until 3:36 pm.

Medical record review also determined that between 5:49 am and 3:36 pm Safety visual checks were documented by nursing staff every 15 minutes and contained the following observations: "Self Injurious Thoughts" were documented as "intent and plan" ..., and "Self Injurious Behaviors" were "Yes, Pt observed wrapping blood pressure cord and blanket around neck". Despite P12's continuous expression of intent to self-harm and a previous witnessed attempt of self-harm in the triage area, the staff failed to continuously monitor P12. This resulted in a possible second opportunity to inflict self-harm when P12 was found in the bathroom on the floor after an unwitnessed fall in which P12 struck their head on the wall. The patient was found by a registered nurse (RN #1) around 12 pm, and there was no documented evidence that a sitter was present, or P12 was being monitored by anyone at the time of the incident.

Nursing staff's failure to implement safety precautions and monitoring provided Patient #12 (P12) multiple opportunities to inflict self-harm, with two incidents occurring during the same Emergency Department (ED) visit.


The following 4 patients were evaluated by the Emergency Department for suicidal thoughts and were awaiting placement to other area hospitals for either voluntary or involuntary inpatient treatment. While in the ED, these behavioral health (BH) patients were not properly monitored.

Surveyors reviewed the hospital policy titled "Care of the admitted patient in the Emergency Department" which stated: "...vital signs every 8 hours unless specified differently by the admitting physician or warranted by the patient's condition... Discuss with physician whether a sitter is needed".

Patient #6 (P6) was a 50+ year old patient who presented to the ED with complaints of suicidal thoughts for the past few days. Nursing notes reviewed showed that the patient was to be transferred to another facility the next day for a voluntary treatment. The last nursing care note was approximately at midnight on the day of presentation to the ED. The only other note found after that time was the discharge note 8 hours later. No documentation was found regarding a discussion for a sitter or whether a sitter was utilized secondary to the patient's suicidal thoughts.

Patient #7 (P7) was an 18+ year old patient who presented to the hospital for suicidal ideations. P7's initial vital signs were taken in triage around 4 pm and then again at 10 pm. The next set of vital signs were not documented until the following morning, around 10 am, resulting in a 12-hour window between the recorded vital signs.

Patient #8 (P8), an 18+ year old patient who presented to the hospital for suicidal ideation. P8 had initial vital signs taken in triage around 8 pm and then again at 11 pm. The next set of vital signs were not documented until the following afternoon around 1pm when P8 was being discharged, resulting in a 14-hour window between the recorded vital signs.

Patient #9 (P9) was a 40+ year old patient who presented to the hospital for suicidal ideation. P9's initial vital signs were taken in triage around 4 pm and then again at 10 pm. The next set of vital signs was not documented in the record until the following morning, around 10 am, resulting in a 12-hour window between the recorded vital signs.

Without timely assessments/re-assessments and effective monitoring of patients, the nursing staff would not be able to properly evaluate ongoing patient needs and appropriately supervise patient care.

Based on a review of medical records, and hospital policies and procedures, it was determined that the hospital failed to maintain an accurate medical record for 4 of 12 patients.

According to the hospital's policy titled "Collection of Paper-Based Documentation for Inclusion in the Electronic Health Record (EHR)", consent forms were to be scanned into the patient's EHR immediately upon receipt by the area that received them.

Patient #1 (P1) was a 65+ year old patient who presented to the Emergency Department (ED) for evaluation and treatment of a behavioral issue. While in ED, P1 was evaluated by a psychiatrist who recommended an involuntary inpatient treatment. At the time of the survey, P1 was awaiting inpatient behavioral health placement to another hospital. Surveyors requested to review the required documentation of an application and certification by two physicians for involuntary admission. The documentation presented by ED staff did not include P1's name or required signatures of two physicians, or a completed application. Without the required information, especially P1's name, it could not be concluded that this incomplete documentation belonged to this patient.

Patient #9 (P9) was a 40+ yr. old patient who presented to the ED after having suicidal ideations with a plan for self-harm. P9 underwent a psychiatric evaluation and the decision for voluntary inpatient psychiatric treatment was made.
Review of P9's medical record showed that the hospital contacted an outside outpatient provider for medication dosage verification during P9's stay, which required verifying the patient's name and date of birth. At that time, the hospital became aware that the date of birth in P9's medical record at the hospital was significantly different than what the outpatient provider had. Hospital staff then asked P9 to verify the date of birth. P9 named the date matching the outpatient provider's records. Nursing staff documented that registration was made aware of the error; however, no evidence was found to show that a correction had been made in the system.

Inaccurate and incomplete medical records, at a minimum, could lead to misdiagnosis, mistreatment, and medication errors putting patients at risk for extreme negative outcomes.