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Based on staff interview, the facility failed to assure that patients' rights for privacy and dignity were maintained with regard to videotaping while undergoing treatment in the Emergency Department (ED). This had the potential to affect all patients who are boarded in the ED hallway during overflow periods as well as patients receiving involuntary procedures/treatments that extend into the hallway. Findings include:
Per interview, on 8/20/14 at 4:50 PM, the Director of Quality (DOQ) confirmed that Patient #1 who had presented to the ED on 8/8/14 with increasing anxiety and agitation was videotaped while being involuntarily escorted by two hospital security officers in the ED. The video tape of the incident was later reviewed by the Risk Management team. During the same interview, a Nursing Excellence staff member reported that the hospital had considered the ED hallway as a "public area" and had not identified that when there is an "overflow" in the ED, patients who were receiving medical treatment were boarded in hallway beds and were being recorded.
Per 8/20/14 review, the facility policy, "Patient Rights," approved on 6/26/14 states that "Video or other electronic monitoring/recording methods may not be used while the patient is being examined without consent." At the time of the survey, the hospital did not provide evidence that patient consents had been obtained prior to the video recording in the ED.

Based on observation, staff interview and record review the facility failed to assure that care was provided in a manner that promoted a physically and emotionally safe environment for one of ten patients in the survey sample (Patient #5); and failed to ensure that appropriate infection control practices were consistently utilized in the cleaning and disinfecting of patient care equipment in a manner to reduce the risk of cross contamination which had the potential to affect all patients who required the use of multi-patient use restraints in the Emergency Department. Findings include:

1. Per record review staff failed to assure ongoing safety of the environment for Patient #5, a 13 year old who presented to the ED (Emergency Department) on the afternoon of 7/9/14 with suicidal ideation. An evaluation was conducted by a Crisis Clinician at 6:00 PM that evening which revealed that the patient, who had a past history of "multiple" suicide attempts, including a drug overdose in March of 2014, was verbalizing suicidal ideation with a plan. A decision was made to hold the patient in the ED until bed availability could be secured at an appropriate inpatient psychiatric facility. The patient was placed on suicide precautions, which included a 1:1 observation status. Per review of nursing and physician progress notes the patient was agreeable to the plan for inpatient admission, and was calm and cooperative throughout the evening and night, and a nurse's note at 8:15 AM on 7/10/14, stated the patient......was oriented and cooperative at that time.

The facility's policy, identified by staff as the current established policy for Suicide Risk Screening and Precautions, dated 4/15/14, stated: "B. PURPOSE:...2. To ensure that the client's immediate safety needs and most appropriate setting for treatment are addressed .....The procedure included: 2. Implementing Precautions: Emergency Department, ".....I ) The patient's room is to be assessed for potentially harmful items. 2) The patient will be placed in a snap hospital gown only..........d. If the physician determines that the patient requires inpatient admission for medical reason, precautions shall be continuously maintained....f. All patients and their possessions will be carefully inspected in the Emergency Department upon being placed in exam room. i. The Emergency Department staff will confirm the belongings search with documentation on Suicide Precautions Environmental Risk Assessment...ii. Patient belongings presenting potential safety risks will be secured outside the patient room....."

Per review of the Suicide Precautions Environmental Risk Assessment for Patient #5 there was no evidence that a belongings search had been conducted when the initial assessment was completed at 4:44 PM on 7/9/14. Two separate assessments, completed at 11:00 PM on 7/9/14 and 6:15 AM on 7/10/14, each indicated only 'No new items'. A nursing note, dated 7/10/14 at 8:50 AM, stated; "pt was found in [his/her] street clothes. [Patient] was advised that, per policy, [patient] had to remain in hospital attire during the course of [his/her] stay here. [Patient] adamantly refused.....advised pt that in the event [s/he] would not cooperate, [s/he] would be assisted out of [his/her] own clothes and back into hospital clothing by staff.....[Patient] changed, keeping a pair of nylon shorts on as allowed ..." A subsequent physician note, dated 7/10/14 at 9:42 AM stated; "....patient became very aggressive and violent at approximately 9:30. According to staff [patient] had changed into [his/her] street clothes....was encouraged to change back into a gown and [patient] was cooperative. [Patient].....mother came in [patient]started becoming agitated [patient] reached into [his/her] pocket and tried to pop some pill. Security stepped over to [patient] to ask what they were and asked [patient] to please give it to them. At this point the patient became extremely agitated and combative trying to bite kick spit screaming and cussing at staff. it required numerous staff to restrain the patient. [Patient] was placed in four-point restraints and 5 mg of Haldol as well as 2 mg of Ativan were given lM."

Although a suicide risk assessment identified Patient #5 at moderate to high risk, there was no evidence the patient and his/her belongings had been inspected/searched on admission and that items presenting potential safety risks had been secured away from the patient. In addition, the patient was allowed access to personal belongings, including contraband located in a pocket of his/her clothing, which created a potentially unsafe environment. The patient refused to release the contraband to security, and attempts to secure the unknown contraband (later identifed as a pill) resulted in escalation of agitated and aggressive behavior by the patient, ultimately ending in the use of 4 point restraints, a spit mask and IM (Intramuscular) medication to control the patient's behavior.

On the afternoon of 8/20/14, the ED Nurse Educator and the Manager of Performance Improvement, who reviewed Patient #5's medical record with the Surveyor at the time of interview, both acknnowledged that, although the facility policy directed that patients on Suicide Precautions be placed in a hospital gown, Patient #5 did have access, at some point to his/her clothes. Each also agreed that the record lacked evidence that the patient's belongings had been checked on admission to the ED.

2. Per interviews on 8/19/14 at 1:40 PM, ED staff were not aware of the approved cleaning/disinfecting method (per manufacturer's instructions) to be utilized for clearing of reusable soft cloth wrist and ankle restraints used by ED staff as necessary for patients presenting an immediate danger to themselves or others. During observations of the Emergency Department on 8/19/14 at 1:40 PM, accompanied by the RN ED Director of clinical Services, an ED Technician (Tech.) was asked to demonstrate and describe the application of 4 point restraints. When the surveyors asked to look at the wrist restraint, it was observed that the inner part of the restraint, which would come into contact with a patient's wrist, was stained with a dark brown color noted along the inner edge. After the demonstration, the ED Tech. was asked to describe how the soft cloth restraints are cleaned. The ED Tech. stated that the restraints may be cleaned by ED staff, either by wiping with the available sanitizing/disinfecting disposable cloths, or they may be sent to the laundry for cleaning. Per review of the hospital policy "Exposure Control Plan-Housekeeping Practices Equipment Cleaning, Non critical patient equipment should be cleaned and disinfected with an agent authorized (or not contraindicated) by the manufacturer's directions. Any equipment purchased should be accompanied by a care manual establishing the recommended method of disinfection. Staff will be educated how to clean non critical patient equipment upon hire and with any new piece of equipment." The policy goes on to describe Non critical items as: 'Come in contact with intact skin but not mucus membranes....includes but not limited to BP cuffs, stethoscopes, skin probes (ultra sounds or scanners) etc'.
At times, patients may have areas of skin that are not intact, as was the case with Patient #5 above, who had multiple skin tears noted on the arms. When the ED Director was asked how staff know what method to use for the multi-use soft restraints, he/she could not provide a definitive answer and there was no copy of the manufacturer's cleaning recommendations immediately available to direct staff in the cleaning of this equipment. Per review of the manufacturer's instructions on the afternoon of 8/20/14, these products should be laundered under CDC guidelines for materials as either contaminated or non contaminated, using the required wash and rinse temperatures as appropriate for the type of soiling present.
On 8/20/14 at 2:17 PM, the Infection Prevention Registered Nurse confirmed during interview that ED staff was cleaning restraints for re-use by wiping them with standard disinfecting wipes. She/he stated that they should have been following manufacturer's instructions for laundering. He/she explained that they had discussed the appropriate cleaning process with the ED Director and nursing staff.

Based on staff interview and record review the facility failed to utilize an established process for reviewing use of restraints and/or seclusion as a means to analyze their cause and to identify opportunity for improvement for 1 of 10 patients in the survey sample (Patient #5). Findings include:

Per record review Patient #5 was a 13 year old who presented to the ED (Emergency Department) on the afternoon of 7/9/14 with suicidal ideation. An evaluation was conducted by a Crisis Clinician at 6:00 PM that evening which identified that the patient had a past history of "multiple" suicide attempts, most recently, a drug overdose in March of 2014. A suicide risk assessment identified Patient #5 at moderate to high risk for suicide and a decision was made to hold him/her in the ED until bed availability could be secured at an appropriate inpatient psychiatric facility. The patient was placed on suicide precautions, which included a 1:1 observation status.

The facility's policy, identified by staff as the current established policy for Suicide Risk Screening and Precautions, dated 4/15/14, directed that the patient should be placed in a snap hospital gown only, all patients and their possessions will be carefully inspected in the ED (Emergency Department) upon being placed in exam room, and patient belongings presenting potential safety risks will be secured outside the patient room. The policy further directed that the "Emergency Department staff will confirm the belongings search with documentation on Suicide Precautions Environmental Risk Assessment..."

Despite the Suicide Risk Screening and Precautions policy there was no evidence that any search/inspection of the patient's belongings had occurred at the time of the patient's admission or that those belongings had been secured in a place not accessible by the patient, creating the potential for an unsafe environment. A nursing note, dated 7/10/14 at 8:50 AM revealed the patient had been found dressed in his/her personal clothing and, although the patient agreed to remove the clothing s/he was allowed to continue wearing a pair of nylon shorts. A physician note, at 9:42 AM, stated that at approximately 9:30 AM Patient #5 had reached into his/her pocket and removed an unknown object, which s/he refused to surrender, and therefore, subsequently required intervention by security to retrieve in an effort to assure the safety of the patient and others. Further documentation indicated that intervention by security led to an escalation in agitated and aggressive behavior by the patient ultimately resulting in the use of 4 point restraints, a spit mask and IM (Intramuscular) medication to calm the patient.

During interview, on the afternoon of 8/20/14, the Manager of Performance Improvement stated that all restraint use is reviewed for quality purposes, and the review included looking at the Emergency Involuntary Procedure documentation to assure all components were accurately documented. S/he further stated that review of the medical record, including nursing and physician progress notes, was not always conducted as part of the quality review of Emergency Involuntary Procedures, and acknowledged that the failure to do a comprehensive review created the possibility for missed opportunity to identify areas for improvement. The PI Manager also confirmed that, although Patient #5 was only 13 and had required use of restraints, s/he was not aware that any in depth review of that patient's case had been done by the quality department.

Based on staff interview and record review, nursing staff failed to provide consistent assessment, reassessment and management of pain for 1 applicable patient in a sample of 10 patient records that were reviewed, in accordance with accepted standards of nursing practice and hospital policy. (Patient #1). Findings include:

Per record review during the survey (the period from 8/13/14 and concluding on 8/20/14), Patient #1 presented to the Emergency Department (ED) on 8/8/14 with symptoms of "anxiety that was becoming unbearable." After being placed in an exam room, s/he became "very agitated ..." Per 8/18/14 at 3:40 PM interview, security staff member #1 (SS #1) reported that Patient #1 tried to leave the exam room and "got aggressive...flailing [his/her] hands around ...hollering..." SS #1 reported that s/he and security staff member #2 each got hold of one of the patient's arms to escort him/her back to the exam room; SS #1 reported that the patient was fighting, wiggling and resisting. Subsequently a code was called and Patient #1 was placed in 4 point restraints (securing both arms and legs to the frame of his/her ED bed) and administered an injection of Haldol (an antipsychotic medication) for his/her personal and staff safety. Per 8/18/14 at 11:37 AM interview with ED tech #1 who assisted with application of the restraints, s/he reported that Patient #1 struggled against the restraints, pulling, twisting and yanking ...trying to sit up and strike out at staff... Per the Emergency/Involuntary Procedures form, Four point restraints were applied on 8/8/14 at 22:15. At 22:30 while in restraints, the patient was "...still yelling, striking out." On 8/8/14 at 23:20 Patient #1 was reported as calm and his/her arm/wrist restraints were removed.
On 8/19/14 at 11:16 AM, Registered Nurse #1 (RN #1), who was assigned as Patient #1's ED nurse for the night of 8/8/14-8/9/14, reported that s/he observed Patient #1 struggling against his restraints and trying to bend himself up. S/he reported that after s/he calmed and the restraints were removed, Patient #1's mother reported that Patient #1 was having shoulder pain. RN #1 reported s/he did not assess his/her pain at the time, but went to check other patients; when s/he returned to check on Patient #1, s/he denied having any pain. The nurse confirmed that s/he did not document completing a pain assessment or reassessment once the shoulder pain had been reported. Per 8/19/14 interview with a crisis clinician who evaluated Patient #1 in the ED on 8/9/14 (between the hours of 3:00 AM and 5:18 AM), s/he reported that at the time of the assessment, Patient #1 was holding his/her arm and that his/her mother reported that his/her right shoulder might have been injured when s/he was restrained and questioned whether s/he needed an x-ray. S/he reported telling a staff member of the mother's concerns. The clinician's "Behavioral Health Emergency Team Report " completed on 8/9/14 at 5:18 AM documented that the "Client complained of [his/her] shoulder bothering [him/her] ..."
On 8/9/14 at 8:04 AM, RN #2 documented that Patient #1 complained of "right anterior shoulder discomfort; Tylenol given as ordered." Per interview on 8/18/14 at 11:59 AM, RN #2 reported that Patient #1 said his/her right shoulder hurt ...an ache. S/he reported this to an ED physician and reported that the patient had requested Tylenol. RN #2 stated that Patient #1 was rubbing his/her shoulder; s/he did not check the patient's shoulder for ROM (range of motion). Per record review, there was no documentation that a pain scale had been completed.
On 8/9/14, RN #3 documented that Patient #1 arrived on the psychiatric unit at 9:15 AM and started to complain immediately of right shoulder pain; Patient #1 reported that s/he had gotten hurt "while struggling" in the ED but could not recall exactly what had occurred. The patient was not able to sign any of the paperwork for admission due the right shoulder pain and being right handed. RN #3 notified Patient #1's provider who then ordered an x-ray of the shoulder at 9:30 AM. At 10:00 AM, RN #3 documented that Patient #1 reported pain level of 8 (8 out of 10 on a pain scale; 10 being the most severe). Per review, an 8/9/14 right shoulder x-ray identified a comminuted greater tuberosity fracture with mild displacement.
Per review of the facility policy, "Pain Management," section C. 1 a. States that Pain will be assessed, reassessed and documented on an as needed basis. Under section E. Procedure, states that Pain must be assessed utilizing one or more of the following tools ... and lists a 0-10 pain scale, Wong Baker Faces Scale, verbal pain scale and other scales. The policy states that pain assessments will be completed for "new event or change in condition ..." Per review of the medical record, there is no evidence that a pain assessment with utilization of a pain scale to determine severity was completed following either the initial report of shoulder pain by the patient's mother or following the report of the crisis clinician until 8/9/14 at 9:15 AM when Patient #1 was transferred for admission to the psychiatric unit and was subsequently found to have a shoulder fracture. The lack of documentation of pain assessments and the need for improvement in documentation and communication between nursing staff and physicians around pain and pain assessments was confirmed by the Director of Quality on 8/20/14 at approximately 4:45 PM.
Reference: Per Vermont title 26: Professions and Occupations, Chapter 28, Nursing, "Registered Nursing " means the practice of nursing which includes: (A) Assessing the health status of individuals and groups; (H) Maintaining safe and effective nursing care rendered directly or indirectly; (I) Evaluating response to interventions; (L) Collaborating with other health professionals in the management of health care.