HospitalInspections.org

Based on document reviews and staff interviews, the medical director failed to ensure that the method of recording and tracking police involvement on the unit captured every incident of police involvement on the unit in statistical and analytical data. A critical incident on 1/25/13, in which a patient (D) assaulted the medical director, and which involved police presence on the unit, was not recorded in a manner that documented the presence of the police on the unit. This deficiency impedes the facility's ability to accurately track longitudinal data and to analyze data about police presence on the unit. Furthermore, the deficiency impedes the facility's ability to evaluate the corrective actions that have been introduced to assure staff members manage patient care as effectively as possible without police intrusion in clinical settings.

Specific findings are:

Interviews:

In an interview with the hospital administrator on 1/28/13 at 8:30 a.m., the surveyor was told that the medical director was on medical leave after being assaulted by Patient D on 1/25/13. The administrator stated that the patient was currently in jail after police came onto the unit and arrested him.

In an interview with the Health Information Management Specialist on 1/28/13 at 11:30 a.m., the surveyor requested documentation of police involvement on the unit since the recertification survey in October 2012. At the time of the recertification survey in October, the facility was using the local police to help seclude and restrain patients whom the staff believed they could not manage. The surveyor was provided with a document that reported zero incidents of law enforcement being called to the unit from 12/01/12 through 1/28/13. (12/01/12 was the alleged compliance date on the facility's submitted Plan of Correction responding to the deficient practice of using police to assist with seclusion and restraint.) When questioned how it could be that there were zero incidents documented, when the police had indeed come to the unit on 1/25/13 and arrested Patient D, the Health Information Management Specialist replied, "It will not show up (in the document or the statistics) because we did not call the police. The police came when the ambulance responded to our 911 call for medical assistance for the doctor."

In an interview with the hospital administrator on 1/28/13 at 1:00 p.m., he concurred with the Health Information Management Specialist's report that the hospital's form for reporting police involvement on the unit specifically asked a "Yes-No" question, i.e., did the hospital call the police? He stated that since the hospital staff did not specifically call the police themselves that this incident would not be "captured in the data." He acknowledged that the deficient documentation practice would result in there being no statistical data that recorded the incident of police involvement on the unit on 1/25/13, or that such data would exist for any similar circumstance were it to occur. Consequently, longitudinal data could be skewed.

Document Reviews:

The "SOS (State Operated Services) Incident Report Form" dated 1/25/2013 relating to Patient D's assault and arrest, answered "No" to the question, "Was Police assistance requested?"

On a form entitled "Notification Type: 08-Police/Sheriff," the "# Reports" column was blank. The form was a print-out of Police/Sheriff involvement on the unit from 12/1/12 until the date of the follow-up survey 1/28/13.