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289 COUNTY ROAD

WINDSOR, VT 05089

PATIENT CARE POLICIES

Tag No.: C1006

Based on staff interview and record review the Critical Access Hospital (CAH) failed to ensure that care was provided in accordance with written policies and procedures regarding the use of restraints for 2 of 2 applicable patients (Patient #1 and Patient #7). Findings include:

1.) Per review of a nursing triage note from 2/27/20 at 5:30 PM, Patient #1 was brought into the emergency department (ED) by police. The patient refused to answer questions and was "replying only with threats and profane language". The patient was "agitated, hostile, uncooperative".

Per review of a provider's note from 2/27/20, Patient #1 had a history of post-traumatic stress syndrome, attention deficit disorder, sleep apnea and anxiety. S/He had recently been charged with domestic violence and assault; and over the last couple of days had made several homicidal threats to staff at a local hospital and in the community. Due to significant concerns from Patient #1's crisis provider and police, a mental health warrant was drawn up and the patient was transported to the hospital for a psychiatric evaluation. The patient arrived with police in handcuffs. The patient denied any medical complaints or pain. The patient "is rambling and racing through different thoughts and very quickly becomes aggressive and violent". The patient wanted to be "let go and let out" of the emergency department. "The patient continued to amp up and become even more aggressive and violent in the emergency department significantly disrupting operation of the emergency department as well as endangering other patients here in the department. At that point time a decision was made to sedate and restrain the patient for" his/her "own protection as well as the protection of other staff and patients in the emergency department." At 6:40 PM, the provider ordered "Zyprexa (antipsychotic medication) 10 mg (milligrams) IM" (intramuscularly) and "Ativan (antianxiety/sedative medication) 2 mg IM"; and at 6:41 PM, the provider ordered "Restraints Violent 18 Years and Older-physical abuse to others, bilateral lower extremities, bilateral upper extremities, order valid for 4 hours".

Per review of the "Nursing Annotations" from 2/27/20 at 7:00 PM, "Pt in 4 point restraints, agitated and yelling verbal obscenities at staff, threatening staff members". At 7:30 PM, "pt continues to be agitated, sitter at bedside, restraints remain in place". At 9:00 PM, "Sitter at bedside, pt sedated and breathing easily, see vitals. Pt continues to intermittently pull against restraints. Restraint continuation needed for staff safety and patient safety. At 9:30 PM, "Sitter remains at bedside, no other changes". At 11:30 PM, "status unchanged, sitter at bedside". On 2/28/20 at 12:00 AM, "Pt restrained, sitter at bedside". At 12:42 AM, "pt continues to pull against restraints but will not answer questions without yelling". At 2:00 AM, "Sitter at bedside, pt status unchanged". At 3:00 AM, "Pt intermittently pulling at restraints, no other change in assessment. sitter at bedside". At 4:29 AM, "Pt HR dropped to 40 on heart monitor, new EKG performed, PA notified". At 4:39 AM, "Pt R arm taken out of restraints". At 6:55 AM, "Pt became belligerent /agitated. Placed back in all 4points". At 8:00 AM, "removed right restraint; cooperative; provided with water. 1:1 at bedside". At 8:30 AM, "resting on" his/her "side. 1:1 at bedside". At 10:00 AM, "removed left leg restraint; 1:1 at bedside". At 7:04 PM, "Report received from AM RN, pt in bed lying down with 1 restraint in place, intermittently yelling obscenities". At 8:44 PM, "Pt out of ED in police custody".

Per review of the nursing neurological assessment of the patient on 2/27/20 at 6:45 PM, the patient's level of consciousness was "Drowsy". At 7:00 PM, "Drowsy". At 7:15 PM, "Stuporous". At 7:30 PM, "Stuporous". At 7:45 PM, "Stuporous". At 8:00 PM, "Stuporous". At 8:30 PM, "Stuporous". At 9:15 PM, "Sedated". At 9:30 PM, "Sedated". At 10:00 PM, "Sedated". At 11:30 PM, "Sedated". On 2/28/20 at 12:00 AM, "Sedated". At 12:30 AM, "Stuporous". At 2:00 AM, "Stuporous". At 3:00 AM, "Sedated". At 4:00 AM, "Sedated, Stuporous". At 4:15 AM, "Sedated". At 5:00 AM, "Sedated, sleeping". At 5:15 AM, "Sedated, sleeping". At 5:30 AM, "Sedated, Sleeping". At 5:45 AM, "Sedated, Sleeping". At 6:00 AM, "Sedated, Sleeping". At 6:15 AM, "Sedated, Sleeping". At 6:30 AM, "Sedated, Sleeping". At 6:45 AM, "Hyperalert". At 7:00 AM, "Alert, Drowsy, Sleeping". At 7:00 PM, "Alert".

Per review of the "One on One observation status form" (completed by a staff member assigned to provide constant observations) on 2/27/20 at 7:15 PM, "Pt resting/calm". At 7:30 PM, "Pt thrashing in the restraints and yelling". At 8:00 PM, "Thrashing around and yelling with eyes closed". At 8:15 PM, "Pt thrashing/nurse gave meds". At 8:30 PM "Pt sleeping/hooked up to EKG IV". At 9:15 PM, "Pt sleeping, calm". At 9:30 PM, "Pt sleeping". At 10:15 PM, "Pt is sleeping and calm". At 11:30 PM, "Pt is sleeping and calm". On 2/28/20 at 12:00 AM, "sleeping-calm". At 12:30 AM, "sleeping, calm". At 2:00 AM, "sleeping, calm". At 3:00 AM, "sleeping-calm". At 4:00 AM, "sleeping". At 4:15 AM, "sleeping-staff changed hands nurse in room-EKG". At 4:30 AM, "sleeping". At 4:35 AM, "staff released one arm". At 5:00 AM, "sleeping-calm". At 5:15 AM, "sleeping-calm". At 5:30 AM, "sleeping-calm". At 5:45 AM, "sleeping-calm". At 6:00 AM, "sleeping-calm". At 6:15 AM, "sleeping-calm". At 6:30, "sleeping-calm". At 6:45, "sputtering-staff restrained" his/her "free arm". At 7:00 AM, "sleeping/talking in sleep". At 7:45 AM, "one restraint removed". At 8:00 AM, "resting on" his/her "side". At 8:30 AM, "Sleeping on" his/her "side". At 10:00 AM, "Sleeping". At 7:00 PM, "Sleeping". At 7:15 PM, "Sheriffs Arrived".

Patient #1 was admitted to the ED on 2/27/20 at approximately 5:10 PM and discharged/transferred from the ED on 2/28/20 at approximately 8:47 PM. The providers' and nursing documentation from 2/27/20 and 2/28/20, indicates that Patient #1 was placed in 4-point restraints, was decreased to 3-point restraints, was put back into 4-point restraints; and then was down to a 1-point restraint which s/he had remained in for the rest of his/her ED stay. There was no clear indication of what interventions were tried by staff prior to the restraints being placed. Per review of the "Nursing Annotations", "Neurological Assessment", and the "One to One observation status forms", there was evidence that there were periods of time where Patient #1 was observed to be "Sedated, Sleeping, Calm" and there was no consistent evidence that there was any attempt by staff to remove the restraints from Patient #1 at the earliest possible time.

Per review of the "Restraint and Seclusion Policy"- approved 9/27/2018 it read, "Physical restraints or seclusion are used only when warranted by a patient's violent/self-destructive behavior that threatens the immediate physical safety of the patient, staff or others. Restraint or seclusion may only be used when less restrictive interventions have been determined ineffective to protect the patient, staff or others from harm. A comprehensive assessment of the patient's behavior and needs is performed prior to or immediately following the use of physical restraints or seclusion. Safety enhancements/interventions are made prior to the use of physical restraints or seclusion in an attempt to maintain the least restrictive environment ... .....The use of restraint or seclusion is undertaken as a last resort in the management of the patient's violent/self-destructive behavior ... .....Reassessment addresses the: Use of the least restrictive methods of restraint/seclusion, and Changes in the patient's behavior or clinical condition warranting removal of restraints or removal from seclusion ...Reassessment includes review of: Level of consciousness/behavior of the patient, Need for continued restraint/seclusion".

Per interview on 9/22/20 at 1:53 PM with the Chief Nursing Officer (CNO), s/he stated that the house supervisor, ED nurse, and provider determine the need for a restraint. Restraints were typically removed once patients gained composure. Patients were assessed frequently, and the goal was to remove restraints from patients as soon as possible. S/He stated that s/he reviewed Patient #1's case and confirmed that there was, "no nursing documentation for restraint application and/or trying to take off/removal at earliest possible time". On 9/23/20 at 9:44 AM during a second interview, the CNO re-confirmed that there was "Gaps in documentation, not following policy".


2.) Per review of provider note from 3/11/20 at 2:20 PM, Patient #7 had a history of depression, self-cutting, suicidal ideation, and diabetes. S/He presented to the ED via ambulance after an intentional overdose. Patient #7 had gotten into an argument with his/her caregiver and took 3 to 4 days' worth of his/her medications. Per the provider's exam Patient #7 was alert and cooperative with an appropriate mood and affect. The provider ordered lab-work, cardiac monitoring, and intravenous fluids; and had discussed the case with poison control. On 3/12/20, Patient #7 was medically cleared and was waiting to be evaluated by the crisis screeners.

Per review of a nursing progress note from 3/13/20 at 6:18 PM, Patient #7 came out of the ED treatment room holding his/her cell phone and was yelling. The Registered Nurse (RN) tried to de-escalate the patient; however, s/he walked out of the ED and into the ED waiting room. The provider went to the waiting room and attempted to verbally de-escalate the patient. The patient walked back into the ED where s/he remained agitated and stated to the provider, "I'm going to kill you" and as the provider continued to speak to Patient #7 s/he pushed the provider connecting with the provider's chest. Patient #7 agreed to take medication by mouth to help calm him/her; however, s/he continued to be agitated, and threatening to staff. S/He banged his/her head against the wall and attempted to take out screws and take items off the walls to hurt him/herself and staff. Despite the staff's attempt to verbally de-escalate and use other methods of distraction Patient #7 continued to make threats. The staff manually held the patient's limbs and administered intramuscular medications. Patient #7's limbs were held for approximately ten minutes. Per review of the provider's orders for Patient #7 there was no evidence that an order was written for the physical hold to Patient #7.

Per review of the "Restraint and Seclusion Policy"- approved 9/27/2018 it read, "Physical Restraint: Any manual method, physical or mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely ... ...Restraints or seclusion must be ordered by a physician/APRN(advanced practiced registered nurse)/PA (physician's assistant) who has a working knowledge of MAHHC policy on the use of restraint or seclusion prior to, or during/immediately following restraint application. PRN (as needed) orders and standing orders are not acceptable".

Per interview on 9/22/20 at approximately 3:00 PM with the Director of Quality/Risk, s/he stated that a physical hold was a type of restraint and that an order needed to be written by a provider. During an interview on 9/23/20 at 9:51 AM with the CNO, s/he confirmed that an order was not written for a physical hold for Patient #7 on 3/13/20.

INFECTION PREVENT & CONTROL POLICIES

Tag No.: C1206

Based on observation and staff interview the CAH failed to ensure that the methods for preventing and controlling the transmission of infections were followed for cleaning and disinfecting patient care equipment. Findings include:

On 9/22/20 at approximately 3:00 PM, the Director of Quality/Risk Management brought the surveyors, a locked wrist restraint and a locked ankle restraint to show the surveyors the type of restraints the facility was currently using. When the staff member demonstrated how both the wrist and ankle restraints were applied, there were large areas on the inside of each restraint that were soiled with blood. The Director of Quality/Risk Management confirmed at that time that the restraints were soiled with blood and that they were not clean. Per interview on 9/23/20 at approximately 9:45 AM with the CNO, s/he stated, "I don't know what fell through the cracks, usually when patient discharges, would put equipment in dirty room, would be cleaned and returned to clean room. True for all equipment. Obviously was not adhered to either".

Per review of the policy "General Cleaning/Low-Level Disinfection"-approved 6/9/20, it read, "All non-critical patient care equipment must be routinely cleaned/disinfected by responsible staff using only MAHHC approved products, according to the manufacturer's instructions. Equipment must be cleaned/disinfected between patients. Visual indicator of clean items is required e.g. plastic bags over items or paper tape over toilet seats, etc. All equipment without visual indicators of having been cleaned/disinfected are considered dirty and must be cleaned before patient use. Equipment such as: but not limited to vital sign machines that are frequently used from patient to patient are exempt from the visual indicator rule. It is the responsibility of the staff members using the equipment to ensure that items are cleaned/disinfected prior to use on each patient."