HospitalInspections.org

Based on record review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure a safe environment was maintained for patients held in the ED (emergency department), who were determined by PEC (physician emergency certificate) and/or CEC (coroner's emergency certificate) to be violent, suicidal, homicidal, dangerous to self and/or others, and/or gravely disabled as evidenced by: a) having unsecured entrances and exits; b) having unsecured equipment that could be used as weapons; c) having the practice of taking patients, who had been PEC'd and/or CEC'd for violence, suicidal, dangerous to self and/or others, and/or gravely disabled, by untrained staff to an unsecured area that was accessible to the public; and d) failing to provide report by the RN of adequate patient information regarding the ED psychiatric patient's status to the agency-contracted CNA (certified nursing assistant) prior to his assignment to observe psychiatric patients held in the ED who had been determined by PEC and/or CEC to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled. The failure of this system resulted in a male patient, diagnosed with Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior (#3), to hit and injure another female patient, diagnosed with Depression, Substance Abuse, and Urinary Tract Infection (#4), in the face and head on 09/13/10 (see findings in Tag A0144);

2) Failing to: a) have a system in place to ensure psychiatric patients being held in the ED awaiting bed placement were free of neglect by having only 1 staff person, who had not been provided with prior training on protective interventions to use when patients became agitated and/or hostile, observing 3 patients who were determined by PEC and/or CEC to be violent, suicidal, homicidal, dangerous to self and/or others, and/or gravely disabled which resulted in a male patient being allowed to hit and injure another patient; and b) failing to thoroughly investigate the event of alleged neglect and implement policies and procedures to prevent a recurrence of the situation (see findings in Tag A0145);

3) Failing to have trained staff who were knowledgeable of recognizing signs of physical and psychological distress of patients who were restrained by having 1 single untrained staff responsible for observing a patient (#3) in 3 point restraints in the ED holding area who was later taken, after having the waist restraints removed but remained in bilateral ankle restraints, outside to smoke in an unsecured area accessible to the public with Patient #3 having freedom of movement of his arms. This was evident for 1 of 1 patient reviewed with restraint use from a total of 8 sampled patients (#3) (see findings in Tag A0202).

An immediate jeopardy situation was identified on 09/29/10 at 11:30am and reported to CNO (chief nursing officer) S2. The immediate jeopardy situation was a result of failing to ensure a safe environment for patients held in the ED by:

1) Having unsecured entrances and exits

2) Having unsecured equipment that could be used as weapons in cubicle 3 and the 2 trauma rooms in the ED holding area where psychiatric patients who had been determined by PEC and/or CEC to be to be violent, suicidal, homicidal, dangerous to self and/or others, and/or gravely disabled were being held awaiting bed placement;

3) Having the practice of taking patients to an unsecured area that was accessible to the public who had been PEC 'd for violence, dangerous to self and/or others, gravely disabled, and/or suicidal by untrained staff ; and

4) Failing to provide report by the RN of adequate patient information regarding the ED psychiatric patient's status to the agency-contracted CNA (certified nursing assistant) prior to his assignment to observe psychiatric patients held in the ED who had been determined by PEC and/or CEC to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled.

A corrective action plan was submitted by the hospital on 9/30/2010 at 1:50pm to address the immediate jeopardy situation revealed:

1) The overflow (holding) area of the ED would have all exits locked including:
a) The door from the holding area in ED located next to Cubicle 3 and exiting to the hallway that was accessible to the public coming from the hospital entrance near the ED and from the radiology area would have a secure lock (keyed) installed by 10/01/10 by Facilities.
b) The old ambulance entrance would be walled-off by 10/01/10 by Facilities;
c) The double doors exiting both sides of the ED (the main ED area with 6 patient exam rooms and the holding area where 3 cubicles and 2 trauma rooms are located) and separated by a 38 foot 1/8 inch hall would have the push button exit changed to a key card exit (as is required to enter). This would need the approval by the Fire Marshall with request made by 10/01/10 by Facility Director S5. These changes would include the push button exits on the two Main ED double doors. Once approved, it would be changed;

2) Equipment and supplies currently in Cubicle 3 in the ED holding area would be moved to a storage closet by 10/01/10 by ED Director S4 and/or overseen by her and the doors to the 2 trauma rooms would remain closed;

3) Psychiatric patient would no longer be taken to the unsecured area that is accessible to the public effective immediately;

4) All ED staff would be required to complete the Net Learning course-SBAR: Hand -off Communication by 10/18/10. This would be monitored by ED Director S4 and Education Director S18;

5) Policy 670-231 Hand Off Communication would be reviewed by ED Staff and documented completed by 10/18/10;

6) Director of ED S4 would communicate changes and review policies on a shift-by shift basis until unit staff meeting held on Friday, October 1, 2010 and completed by 10/18/10. After hours and on weekends Administrative Supervisors would ensure that policy is reviewed with staff until completed on 10/18/10.
NOTE: The overflow area would not be used until the area was free of unsecured equipment, the secure lock was installed, and the wall was built to prevent patients exiting the area. In addition, the area would be staffed with the sufficient number of qualified staff.

As a result of the hospital's implementation of the action plan, the immediate jeopardy situation was removed on 09/30/10 at 1:50pm. The hospital's noncompliance remains at the condition level.

Based on observation and interview, the hospital failed to ensure the privacy of psychiatric patients being held in the ED awaiting bed placement by: 1) having the practice of holding psychiatric patients being observed in the hallway in the ED for 2 of 2 patients observed for privacy from a total of 8 sampled patients (#2, #5) and 2) taking a patient in bilateral ankle restraints outside to smoke in an area accessible to the public for 1 of 1 patient restrained from a total of 8 sampled patients (#3). Findings:

1) Holding psychiatric patients in the ED hallway:
Observation on 09/27/10 at 9:25am, with CNO (chief nursing officer) S2 and Director of ED S4 present, revealed Patient #2, diagnosed with Substance Abuse, Cocaine Abuse, Suicidal Ideation, and Depression, and Patient #5, diagnosed with History of Medical Non-Compliance, Cocaine Abuse, Suicidal Ideation, and Depression, seated on stretchers in the hall with ED Tech S28 observing them. Further observation revealed this hall was accessible to other ED patients and family.

In a face-to-face interview on 09/29/10 at 2:05pm, Director of ED S4 indicated the psychiatric patients being held in the ED awaiting bed placement were placed in ED exam rooms until they were examined by the physician, had urinalysis sample taken, and were gowned. She further indicated the patients were placed in the hall after these procedures were done, and they were observed by a sitter, CNA, or ED tech. She further indicated she had looked at the patients being held in the hallway as a means of providing safety of the patient, but she didn't consider the privacy of the patients.

2) Taking a patient with bilateral ankle restraints outside in a public area:
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior.

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed he was placed in 3 point (waist and bilateral ankles) restraints on 09/13/10 at 10:00am by RN Director of ED S4. Review of the "Emergency Department Nursing Medical Record" revealed documentation by RN S10 on 09/13/10 at 2:00pm of "resting quietly on stretcher; waist restraint removed, patient taken outside to smoke, calm, cooperative".

In a face-to-face interview on 09/28/10 at 2:20pm, RN S10 indicated Patient #3's waist restraint was removed, and his ankle restraints remained in place when CNA S22 from Agency A took Patient #3 outside to smoke.

In a face-to-face interview on 09/28/10 at 3:15pm, CNA S22 from Agency A confirmed he took Patient #3 and another psychiatric patient being held in ED outside to smoke in an area that was accessible to the public on 09/13/10, and Patient #3 had bilateral ankle restraints in place.

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Based on observations, record review, and interviews, the hospital failed to ensure a safe environment was maintained for patients held in the ED (emergency department), who were determined by PEC (physician emergency certificate) and/or CEC (coroner's emergency certificate) to be violent, suicidal, homicidal, dangerous to self and/or others, and/or gravely disabled, by: 1) having unsecured entrances and exits; 2) having unsecured equipment that could be used as weapons; 3) having the practice of taking patients, who had been PEC'd and/or CEC'd for violence, suicidal, dangerous to self and/or others, and/or gravely disabled, by untrained staff to an unsecured area that was accessible to the public; and 4) failing to provide adequate patient information regarding the ED psychiatric patient's status to the agency-contracted CNA (certified nursing assistant) prior to his assignment to observe psychiatric patients held in the ED who had been determined by PEC and/or CEC to be suicidal, violent, dangerous to self and/or others, and/or geavely disabled. This resulted in a male patient, diagnosed with Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior (#3), hitting a female patient, diagnosed with Depression, Substance Abuse, and Urinary Tract Infection (#4), in the face and head on 09/13/10. Findings:

1) Unsecured entrances and exits:
Observation on 09/27/10 at 9:25am, with CNO (chief nursing officer) S2 and Director of ED S4 present, revealed the ED had 2 separate areas with a wooden double door separating each with a hall between the two areas. There was 38 feet 1/8 inch of hallway between the 2 double doors. Entrance into the main ED required an employee badge swipe to enter, and exiting required the push of a green button on the wall near the door (this could be performed by anyone, as an employee badge was not required to exit). The main ED had 6 patient exam rooms. Further observation revealed Patient #2, diagnosed with Substance Abuse, Cocaine Abuse, Suicidal Ideation, and Depression, and Patient #5, diagnosed with History of Medical Non-Compliance, Cocaine Abuse, Suicidal Ideation, and Depression, seated on stretchers in the hall with ED Tech S28 observing them. Further observation revealed nurses and a physician present in the main ED.
Observation of the 2nd area of ED which was across the hall and behind the wooden double doors, identified as the "holding" area by ED staff, revealed 2 trauma rooms and 3 cubicles (cubicle 1 and 2 were used to hold psychiatric patients) with a hanging curtain in the front of the cubicle. Entrance from the hallway at the double doors required an employee badge swipe, and exiting this door required only the push of a green button located on the wall inside the area near the door. There was 41 feet 6 inches from the cubicles to the double doors (measured by Maintenance Supervisor S17 on 09/28/10 at 9:20am with CNO S2 present). There was a 2nd entrance and exit into the ED holding area from the main hall accessible to the public coming from the entrance near the ED and from the radiology area. This entrance had no means of locking the door, and the surveyor was able to enter at the time of this observation and again on 09/27/10 at 10:35am, 09/29/10 at 11:00am, and 09/30/10 at 9:00am. This door was 14 feet 2 inches from cubicle 2 and 23 feet 2 inches from cubical 1 (measured by Maintenance Supervisor S17 on 09/28/10 at 9:20am with CNO S2 present). There was 3rd entrance and exit to the holding area of the ED. This was a double door leading outside the building that was used prior to the day of observation for ambulance delivery of patients to the ED. Prior to this day, the door was equipped with a motion sensor that opened the door when someone approached it. Due to construction begun this day, the sensor had been turned off, and the door was able to be pushed open manually. When the door was opened by the surveyor, the outside area was surrounded by a chain-link fence, approximately 5 to 6 feet in height, where the construction would take place. Further observation revealed Patient #1, diagnosed with Suicidal Ideation and Depression, and Patient #6, diagnosed with Depression, Suicidal Ideation, Suicide Attempt, Alcoholic Intoxication, Alcohol Abuse, and Multiple Lacerations of the right distal forearm/wrist were in cubicles 1 and 2 being observed by CNA (certified nursing assistant) S25, a contract employee from Agency C. Further observation revealed no RN or physician present in the holding area.

2) unsecured equipment:
Observation on 09/29/10 at 11am of the holding area for psychiatric patients in the hospital ED revealed
cubicle 1 contained a plastic chair, meal tray, and empty sharps container mounted on the wall. Cubicle 2 contained a meal tray and empty sharps container mounted on the wall. Cubicle 3, identified by staff as not used for holding patients but accessible to the patients being held in cubicles 1 and 2, contained 3 plastic cords attached to otoscopes, a nurse call system with 1 cord attached to the system, 2 nurse call system cords stored in plastic bags, 2 Ambu bags in plastic bags hanging from a hook by string, 2 large plastic trays for storing finger splints, and a medium-size metal garbage container, all of which could be used to injure oneself or others by psychiatric patients who were diagnosed as suicidal, homicidal, and/or violent.

Observation on 09/30/10 at 9am of the holding area for psychiatric patients in the hospital ED revealed two trauma rooms near the entrance to the holding area. Further observation revealed the doors to each trauma room were unlocked, and the doors were open and accessible to patients in the holding area of the ED. The trauma rooms contained crash carts with defibrillators with cords and wires attached, Ambu bags stored in plastic bags with strings, otoscopes with plastic cords, pediatric scale, suction cords, IV (intravenous) poles, large biohazards containers, computer carts on wheels, sharps containers mounted on the wall, linen cart, and a saline warmer on wheels. Stored in the hall were 2 BP (blood pressure) monitors on wheels.

3) Practice of untrained staff taking psychiatric patients to unsecured area accessible to the public:
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder (acuity 4), Gravely Disabled (acuity 4), Dangerous to self and others (acuity 4), and Aggressive/Violent Behavior (acuity 5).

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed he was placed in 3 point (waist and bilateral ankles) restraints on 09/13/10 at 10:00am by RN Director of ED S4. Review of the "Emergency Department Nursing Medical Record" revealed documentation by RN S10 on 09/13/10 at 2:00pm of "resting quietly on stretcher; waist restraint removed, patient taken outside to smoke, calm, cooperative".

In a face-to-face interview on 09/28/10 at 2:20pm, RN S10 indicated Patient #3's waist restraint was removed, and his ankle restraints remained in place when CNA S22 from Agency A took Patient #3 outside to smoke. When asked by the surveyor why she allowed a contract CNA, who had not been trained in CPI (crisis prevention intervention), to take a psychiatric patient, who remained in ankle restraints after having demonstrated violent behavior, outside in an unsecured area and accessible to the public rather than her taking the patient, S10 indicated "he (S22) was a man stronger than I was, and he (Patient #3) was hobbled".

In a face-to-face interview on 09/28/10 at 3:15pm, CNA S22 from Agency A confirmed he did not have certification in CPI. He also confirmed he took Patient #3 and another psychiatric patient being held in ED outside to smoke on 09/13/10, and Patient #3 had ankle restraints in place. He confirmed that he was alone with the 2 patients outside, and there was not a RN present.

In a face-to-face interview on 09/29/10 at 2:05pm, Director of ED S4 indicated psychiatric patients being held in the ED awaiting bed placement were taken outside to smoke with either a CNA or a nurse. She confirmed that the outside area was not secured and accessible to the public.

Review of CNA S22's personnel file revealed he was a contract employee from Agency A, and his first date of work at St. Charles Parish Hospital was 09/09/10. Further review revealed no documented evidence of a job description for the ED, hospital orientation, and orientation to the ED prior to providing direct patient care. Further review revealed the competency assessment for restraint/seclusion and abnormal vital signs was signed by S22 on 09/12/10 with no documented evidence of an assessment by a qualified observer of his competency. Further review revealed S22's evaluation was completed on 09/26/10.

4) Adequate patient report prior to assignment:
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder (acuity 4), Gravely Disabled (acuity 4), Dangerous to self and others (acuity 4), and Aggressive/Violent Behavior (acuity 5).

Review of Patient #3's "Nursing Medical Record" revealed documentation on 09/13/10 at 9:30am by RN S10. Further review revealed "pt walked into female pt's room (obs #1) (observation) instructed by BHU (behavioral health unit) sitter to return to his room (pt did not return to his room) sitter called me to obs area when I arrived pt was sitting on chair in his room, stood up walked to nurses desk asked to go outside and smoke, told he could not go outside and smoke at this time, he then asked if he could make a phone call instructed he could make one phone call and no longer than 5 min (minutes), handed phone to pt, pt stated that he needed to make a private call told that he could not make a private call pt then hung up the phone and returned to his room, at that time I instructed BHU sitter that I was going to get meds for this pt, as I was walking out of the obs area to the ED area pt walked to obs #1 (female pt's room) and began hitting the female pt about the head ...". Further review revealed Patient #3 was placed in 3 point restraints.

Review of the "24 Hour Visibility Documentation Form" for 09/13/10 revealed CNA S22 observed Patient #3 from 11:00am to 5:00pm.

In a face-to-face interview on 09/28/10 at 3:15pm, CNA S22 from Agency A confirmed he observed 2 psychiatric patients (Patient #3 and Patient #8) being held in the ED on 09/13/10 from 11:00am until 5:00pm. He indicated he was told to "sit with 2 guys and told to observe them". He further indicated Patient #3 was in restraints, but he was not given a report from the RN about the diagnosis of either patient. He indicated he was just told to observe the patients.

Based on record review and interviews, the hospital failed to: 1) have a system in place to ensure psychiatric patients being held in the ED (emergency department) awaiting bed placement were free of neglect by having 1 single untrained staff observing 3 patients who were determined by PEC (physician emergency certificate) and/or CEC (coroner's emergency certificate) to be violent, suicidal, homicidal, dangerous to self and/or others, and/or gravely disabled which resulted in a male patient, diagnosed with Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior (#3), hitting a female patient, diagnosed with Depression, Substance Abuse, and Urinary Tract Infection (#4), in the face and head on 09/13/10; and 2) thoroughly investigate the event that resulted in neglect and implement policies and procedures to prevent a recurrence of the situation. Findings:

1) System to ensure patients were free of neglect:
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior. Further review revealed Patient #3 remained in the ED until 09/13/10 at 6:00pm. Further review revealed Patient #3 was PEC'd on 09/09/10 at 3:00pm and was violent, dangerous to others, and gravely disabled. He was CEC'd on 09/11/10 at 3:40pm and was violent, dangerous to self and others, and gravely disabled.

Review of Patient #4's "Emergency Department Physician Medical Record" revealed she arrived on 09/12/10 at 6:48pm with diagnoses of Depression, Substance Abuse, and Urinary Tract Infection. Further review revealed Patient #4 remained in the ED until 09/13/10 at 8:01pm. Further review revealed Patient #4 was PEC'd on 09/12/10 at 7:30pm and was gravely disabled and unable to seek voluntary admission. He was CEC'd on 09/14/10 at 10:20pm and was gravely disabled and unable to seek voluntary admission.

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed he presented to the ED on 09/09/10 at 2:40pm with complaint of a psychiatric history. Further review revealed "pt (patient) states person look at him wrong way and he hit that person. Pt denies suicidal or homicidal ideations. Pt is very anxious and has hx (history) of paranoid schizophrenia and bipolar".

Review of Patient #3's "Nursing Medical Record" revealed documentation on 09/13/10 at 9:30am by RN (registered nurse) S10. Further review revealed "pt walked into female pt's room (obs #1) (observation) instructed by BHU (behavioral health unit) sitter to return to his room (pt did not return to his room) sitter called me to obs area when I arrived pt was sitting on chair in his room, stood up walked to nurses desk asked to go outside and smoke, told he could not go outside and smoke at this time, he then asked if he could make a phone call instructed he could make one phone call and no longer than 5 min (minutes), handed phone to pt, pt stated that he needed to make a private call told that he could not make a private call pt then hung up the phone and returned to his room, at that time I instructed BHU sitter that I was going to get meds for this pt, as I was walking out of the obs area to the ED area pt walked to obs #1 (female pt's room) and began hitting the female pt about the head ..."code white" called pt returned to obs 2 placed in waist and ankle restraints, medicated with haldol, benadryl, ativan".

Review of the "24 Hour Visibility Documentation Form" for 09/13/10 revealed Unit Secretary S16 was observing Patient #3 from 7:00am until 11:00am.

Review of Unit Secretary S16's personnel file revealed a hire date 08/24/09. Documentation revealed S16 had a job description for and orientation to the Unit Secretary position of the ED. Further review of the job description revealed no documented evidence that direct patient care was included in her job description. Further review of the file revealed no documented evidence of an assessment of competency for S16 prior to performing direct patient care of psychiatric patients who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled. Further review revealed no documented evidence of additional training of CPI (crisis prevention intervention) and training to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions.

In a face-to-face interview on 09/28/10 at 2:20pm, RN S10 indicated part of what she documented on 09/13/10 at 9:30am was her observation and part was reported to her by Unit Secretary S16. S10 confirmed she was called to the ED holding area by Unit Secretary S16 who was alone observing 3 psychiatric patients, and after hospital employees arrived as a result of the Code White being called, she left the holding area, with no RN present, to return to the other ED unit to obtain physician orders, restraints, and medication to administer to Patient #3. S10 further indicated, "in retrospect, I probably should not have left the unit". She further indicated there was 1 RN, a physician, and RN Director of ED S4 on the other ED unit who could have brought what was needed to treat Patient #3 and Patient #4.

In a face-to-face interview on 09/28/10 at 2:40pm, Unit Secretary S16 confirmed her job description did not include performing patient care. She indicated she had worked as a "sitter" observing psychiatric patients who were being held in ED while awaiting bed placement. S16 indicated she had no training for patient care in the ED. She indicated that she was alone observing patients and could call the RN if a situation arose that required more assistance. She confirmed that she did not have current CPI certification or training.

Review of the hospital policy titled "Patient Awaiting Psychiatric Evaluations", revised 08/09 and submitted by CNO (chief nursing officer) S2 as their current policy for treating patients awaiting transfer and psychiatric evaluations, revealed, in part, "...For all patients holding in the Emergency Department awaiting psychiatric evaluation and/or placement, the following actions will be taken and documented: 1. The patient will be under eye contact observation at all times. The patient is placed in the hallway in front of the nurse's station until medically cleared. ... 4. Once the Emergency Department physician has evaluated the patient and has determined the patient is a threat to self and/or others (PEC'd, CEC'd). The patient will require constant observation by an ED Tech, CNA (certified nursing assistant) or qualified sitter. ...". Further review revealed no documented evidence that the policy addressed the use of the 2nd observation ED unit, that a RN would be required to be present, and a definition of a qualified sitter (since there was no job description for this position).

2) Investigation of neglect:
Review of the "Hospital Abuse/Neglect Initial Report" completed by CNO S2 on 09/13/10 at 3:30pm revealed the type of incident being reported was "alleged physical abuse", and the date and time of the incident was 09/13/10 at 9:40am. Review of the incident information revealed "At approx. (approximately) 0940 (9:40am), Patient #3 got off of his stretcher and walked to Patient #4's stretcher. He was instructed to return to his stretcher by sitter Unit Secretary S16. S16 then called for the RN. RN S10 responded. Patient #3 then requested to make an emergency phone call. RN S10 put the phone on the counter for patient to use. Patient stated that it had to be a "private" phone call, but RN S10 instructed the patient that they could not leave him to use the phone in private. Patient hung up the phone and returned to stretcher. RN was returning to main ED to get patient some medication, when patient got up and went to Patient #4's stretcher and began hitting her in the head. Sitter called Code White". Further review revealed the initial actions taken were "separated patients - moved victim (Patient #4) to main ED and assessed by ED MD. Orders received for CT (computerized tomography) Scans (Face, Head and Neck), medication and ice pack to forehead".

In a face-to-face interview on 09/28/10 at 9:20am, CNO S2 indicated she interviewed the staff present at the time of the incident with Patient #3 and Patient #4 on 09/13/10 and determined that the sitter Unit Secretary S16 acted appropriately. She further indicated the only documentation that she had was what she had sent to the DHH (Department of Health and Hospitals) Hospital Program Manager. She further indicated she did not document the interviews that she had with the staff. She further indicated the only change made after her investigation was that she arranged for the contract agency staff and non-CNA hospital personnel to be oriented on the duties of observing psychiatric patients in the ED.

Review of the "St Charles Parish Hospital - Sitter Competency" presented by CNO S2 as their current tool to document competency of sitters in the ED revealed, in part, " ...Competency Statement: Employee will be qualified as a sitter to sit and observe patient(s) in their care. Performance Criteria 1. Verbalizes behaviors that require notification of RN: a. Patient unable to be redirected and not following instructions b. Patient agitated and escalating c. Patient requests for smoke break, bathroom break, medications, etc. (and do on) 2. Verbalizes that patient(s) is not to be unattended at any time. 3. Verbalizes the importance to stay alert at all times with attention directed toward patient. 4. Verbalizes that their role is not to de-escalate patient but to call for immediate assistance. 5. Documents patient behaviors and activities. 6. Verbalizes or Demonstrates proper St. Charles Parish Hospital Falls Prevention Protocol ...".

In a face-to-face interview on 09/30/10 at 9:05am, CNO S2 indicated the employees she interviewed as part of her investigation were Director of ED S4, RN S10, and Unit Secretary S16. She further indicated she did not interview any employees who presented to the ED when Code White was called.

In a face-to-face interview on 09/30/10 at 9:30am, CNO S2 indicated she had initially submitted the incident to DHH as an alleged abuse. She further indicated she was directed by the DHH Hospital Program Manager that it should be alleged neglect. CNO S2 indicated she agreed that the incident was neglect since they did not have a nurse available with untrained staff. S2 further indicated CEO (chief executive officer) S1 did not want the incident to be reported as neglect because of the issue it would present with risk management if they admitted patient neglect. S2 could offer no explanation for policies and procedures not being revised to address the incident that occurred and to prevent a recurrence.

In a face-to-face interview on 09/30/10 at 10:15am, CEO S1, with CNO S2, CFO (chief financial officer) S29, and COO (chief operating officer) S30 present, indicated Patient #3 was not violent, and he discussed his concerns regarding having to hold ED psychiatric patients as long as they do as well as financial concerns. When the surveyor informed CEO S1 that Patient #3 had been PEC'd on 09/09/10 at 3:00pm and CEC'd on 09/11/10 at 3:40pm and determined to be violent, dangerous to self and others, and gravely disabled, CEO S1 indicated he disagreed.

Review of the hospital policy titled "Adult/Elderly Abuse or Neglect", last revised 12/05, revealed, in part, "...Definitions 2. Physical Abuse: ...Failure to make a reasonable effort to prevent an action by another person that results in physical injury and substantial harm to the person. ... Internal Complaints Abuse/Neglect Internal Complaints of Abuse/Neglect by patients/family members/caregivers will be investigated immediately and thoroughly by the Department Director and Risk Manager, and reported immediately to the appropriate Administrative Representative. The Abuse/Neglect procedure is followed for patient management. The patient will be closely monitored, protected, and appropriate nursing and medical intervention will be implemented and evaluated...".

Based on record review and interview, the hospital failed to ensure restraints were discontinued at the earliest possible time for 1 of 1 patients reviewed with the use of restraints from a total of 8 sampled patients (#3). Findings:

Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder (acuity 4), Gravely Disabled (acuity 4), Dangerous to self and others (acuity 4), and Aggressive/Violent Behavior (acuity 5).

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed he was placed in 3 point (waist and bilateral ankles) restraints on 09/13/10 at 10:00am by RN Director of ED S4. Review of the "Seclusion/Restraint Flow Sheet" and the "Emergency Department Nursing Medical Record" revealed no documented evidence of attempts to release Patient #3 from restraints. Further review revealed the following documentation by RN S10:
09/13/10 at 10:30am - resting quietly on stretcher;
09/13/10 at 12:00pm - eating lunch;
09/13/10 at 1:00pm - resting quietly on stretcher;
09/13/10 at 2:00pm - resting quietly on stretcher; waist restraint removed, patient taken outside to smoke, calm, cooperative;
09/13/10 at 3:00pm - resting quietly on stretcher; ankle restraint remain in place, calm, cooperative; 09/13/10 at 6:00pm - restraints removed, pt to psych via w/c (wheelchair).

In a face-to-face interview on 09/28/10 at 2:20pm, RN S10 indicated she did not attempt to remove Patient #3's restraints until he was transferred to the psych unit. When told by the surveyor that documentation in the medical record revealed he was calm and cooperative from 10:30am until his restraints were removed at 6:00pm, RN S10 indicated "he was calm and cooperative before he hit the patient", and she couldn't be sure he wouldn't do it again. S10 further indicated when she removed the waist restraint for him to be able to go outside to smoke, Patient #3 was instructed that he would be placed in waist restraints again if he didn't do what he was told to do. RN S10 indicated Patient #3 complied and remained quiet. When asked by the surveyor if Patient #3's restraints could have been removed if a RN had been available to monitor him, S10 indicated a RN was not available as the RNs were needed on the acute side of ED to care for patients.

Review of the hospital policy titled "Seclusion and Restraint", last revised 12/09 and submitted by CNO S2 as their current policy for use of restraints, revealed, in part, "...It is this facilities goal to continually seek ways to decrease/eliminate restraint/seclusion for all patients, therefore discontinuing restraint/seclusion as soon as possible. ...5. Rationale for intervention and criteria for exit are reviewed with patient after assuring the security of restraints. 6. Staff present will state to the patient what the exit criteria includes and the patient progress towards completion. Assist the patient to meet the criteria for exit. ... Also monitored and documented on the flowsheet every 15 minutes are the following: ... i. The RN will reassess the patient for readiness for discontinuing Behavioral Restraint and Seclusion, restate the exit criteria and assist the patient to meet criteria to exit at least once every hour the patient is in Behavioral restraint and seclusion. 10. The patient is released from seclusion/restraint as soon as Exit Criteria is met. Examples of exit criteria are, but not limited to: -Cooperation with treatment - Agreeing to follow unit rules - Following directions ...".

Based on record review and intervention, the hospital failed to ensure the RN documented the rationale for continued use of restraints for 1 of 1 patient reviewed with the use of restraints from a total of 8 sampled patients (#9). Findings:

Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior.

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed he was placed in 3 point (waist and bilateral ankles) restraints on 09/13/10 at 10:00am by RN Director of ED S4. Review of the "Emergency Department Nursing Medical Record" revealed the following documentation by RN S10:
09/13/10 at 10:30am - resting quietly on stretcher;
09/13/10 at 12:00pm - eating lunch;
09/13/10 at 1:00pm - resting quietly on stretcher;
09/13/10 at 2:00pm - resting quietly on stretcher; waist restraint removed, patient taken outside to smoke, calm, cooperative;
09/13/10 at 3:00pm - resting quietly on stretcher; ankle restraint remain in place, calm, cooperative; 09/13/10 at 6:00pm - restraints removed, pt to psych via w/c (wheelchair). Further review revealed no documented evidence of the rationale for continued use of restraints for Patient #3.

In a face-to-face interview on 09/28/10 at 2:20pm, RN S10 indicated she did not attempt to remove Patient #3's restraints until he was transferred to the psych unit. When told by the surveyor that documentation in the medical record revealed he was calm and cooperative from 10:30am until his restraints were removed at 6:00pm, RN S10 indicated "he was calm and cooperative before he hit the patient", and she couldn't be sure he wouldn't do it again. After review of Patient #3's medical record, S10 confirmed she did not document the rationale for the continued use of restraints for Patient #3.

Review of the hospital policy titled "Seclusion and Restraint", last revised 12/09 and submitted by CNO S2 as their current policy for use of restraints, revealed, in part, "...It is this facilities goal to continually seek ways to decrease/eliminate restraint/seclusion for all patients, therefore discontinuing restraint/seclusion as soon as possible. ...5. Rationale for intervention and criteria for exit are reviewed with patient after assuring the security of restraints. 6. Staff present will state to the patient what the exit criteria includes and the patient progress towards completion. Assist the patient to meet the criteria for exit. ... Also monitored and documented on the flowsheet every 15 minutes are the following: ... i. The RN will reassess the patient for readiness for discontinuing Behavioral Restraint and Seclusion, restate the exit criteria and assist the patient to meet criteria to exit at least once every hour the patient is in Behavioral restraint and seclusion. 10. The patient is released from seclusion/restraint as soon as Exit Criteria is met. Examples of exit criteria are, but not limited to: -Cooperation with treatment - Agreeing to follow unit rules - Following directions ...".

Based on record review and interviews, the hospital failed to have trained staff who were knowledgeable of recognizing signs of physical and psychological distress of patients who were restrained by having 1 single untrained staff responsible for observing a patient (#3) in 3 point restraints and later taking the same patient in bilateral ankle restraints outside to smoke in an unsecured area accessible to the public. This was evident for 1 of 1 patient reviewed with restraint use from a total of 8 sampled patients (#3). Findings:


Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior. Further review revealed Patient #3 remained in the ED until 09/13/10 at 6:00pm. Further review revealed Patient #3 was PEC'd on 09/09/10 at 3:00pm and was violent, dangerous to others, and gravely disabled. He was CEC'd on 09/11/10 at 3:40pm and was violent, dangerous to self and others, and gravely disabled.

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed he was placed in 3 point (waist and bilateral ankles) restraints on 09/13/10 at 10:00am by RN Director of ED S4. Review of the "Emergency Department Nursing Medical Record" revealed documentation by RN S10 on 09/13/10 at 2:00pm of "resting quietly on stretcher; waist restraint removed, patient taken outside to smoke, calm, cooperative".

Review of Patient #3's "Seclusion/Restraint Flow Sheet" for 09/13/10 revealed he was restrained from 10:00am until 5:30pm.

Review of Patient #3's "24 Hour Visibility Documentation Form" for 09/13/10 revealed CNA (certified nursing assistant) S22 from Agency A observed Patient #3 from 11:00am to 5:00pm.

Review of CNA S22's personnel file revealed he was a contract employee from Agency A, and his first date of work at St. Charles Parish Hospital was 09/09/10. Further review revealed no documented evidence of a job description for the ED, hospital orientation, and orientation to the ED prior to providing direct patient care. Further review revealed the competency assessment for restraint/seclusion and abnormal vital signs was signed by S22 on 09/12/10 with no documented evidence of an assessment by a qualified observer of his competency. Further review revealed S22's evaluation was completed on 09/26/10.

In a face-to-face interview on 09/28/10 at 2:20pm, RN S10 indicated Patient #3's waist restraint was removed, and his ankle restraints remained in place when CNA S22 from Agency A took Patient #3 outside to smoke. When asked by the surveyor why she allowed a contract CNA, who had not been trained in CPI (crisis prevention intervention), to take a psychiatric patient, who remained in ankle restraints after having demonstrated violent behavior, outside in an unsecured area and accessible to the public rather than her taking the patient, S10 indicated "he (S22) was a man stronger than I was, and he (Patient #3) was hobbled".

In a face-to-face interview on 09/28/10 at 3:15pm, CNA S22 from Agency A confirmed he did not have certification in CPI. He also confirmed he took Patient #3 and another psychiatric patient being held in ED outside to smoke on 09/13/10, and Patient #3 had ankle restraints in place. He confirmed that he was alone with the 2 patients outside, and there was not a RN present, and he observed the same 2 patients in the ED holding area without a RN present.

Based on record review and interview, the hospital failed to ensure personnel records contained the training and successful demonstration of restraint use by staff assigned to observe psychiatric patients being held in the ED (emergency department) while awaiting bed placement for 3 of 6 non-nursing personnel files reviewed (S15, S16, S22). Findings:

Review of Unit Secretary S15's personnel file revealed a hire date 12/12/08. Documentation revealed S15 had orientation to the Unit Secretary position of the ICU telemetry monitoring. Further review of the file revealed no documented evidence of a job description, orientation to the ED, and assessment of competency in the use of restraints for S15 prior to performing direct patient care of psychiatric patients admitted to the ED who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled.

Review of Unit Secretary S16's personnel file revealed a hire date 08/24/09. Documentation revealed S16 had a job description for and orientation to the Unit Secretary position of the ED. Further review of the job description revealed no documented evidence that direct patient care was included in her job description. Further review of the file revealed no documented evidence of an assessment of competency in the use of restraints for S16 prior to performing direct patient care of psychiatric patients who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled.

Review of CNA S22's personnel file revealed he was a contract employee from Agency A, and his first date of work at St. Charles Parish Hospital was 09/09/10. Further review revealed no documented evidence of a job description for the ED, hospital orientation, and orientation to the ED prior to providing direct patient care. Further review revealed the competency assessment for restraint/seclusion and abnormal vital signs was signed by S22 on 09/12/10 with no documented evidence of an assessment by a qualified observer of his competency.

In a face-to-face interview on 09/29/10 at 9:55am, CNO S2 confirmed the above findings.

Review of the hospital policy titled "Competency Assessment Program-Emergency", presented as the hospital's current policy and submitted by CNO S2, revealed, in part, "Policy: All employees of the Emergency Department will participate in the Competency Assessment Program as defined by the Department of Education... Procedure: 1. Initial Competency a. The following competencies will be validated prior to the completion of orientation: ... 3. Position specific competencies ... c. Tech-Age specific, Restraint...".

Review of the hospital policy titled "Emergency Department Orientation", revised 07/09 and submitted by CNO S2 as their current policy for ED orientation, revealed, in part, "Policy: All employees hired into the Emergency Department will be provided an orientation of sufficient time and content to prepare them for their duties and responsibilities in the department. ... The initial orientation period will begin with a one day general hospital orientation and an additional two day nursing orientation conducted by the Education Department. ... Responsibilities ... acquire beginning knowledge and skills appropriate to emergency care. ... Implementation ... Day I (In Emergency Department) Orientee will orient to the department and learn operational format while buddied with qualified staff. Orientee is not to assume patient care. Day II & (and) III Orientee will perform patient care under supervision of qualified observer...".

Review of the hospital policy titled "Contract/Agency/Forensic Personnel", revised June 2010 and submitted by CNO S2 as the hospital's current policy for orienting contract staff, revealed, in part, "Policy: The purpose of this policy is to ensure that all clinical/non-clinical contract/agency staff is qualified and competent to perform the duties assigned as set forth by the guidelines of St. Charles Parish Hospital and appropriate agencies, if applicable... The Profile Sheet is then reviewed by the Department Manager or House Supervisor and a determination is made whether the staff member is qualified and competent to meet the needs of the hospital. If accepted, the staff member will be given the date and time to report (usually one hour prior to the actual time the shift starts to allow time for further clearance/orientation). 3. Upon arrival of the clinical personnel, the Department Director or House Supervisor should begin completing the Agency/Contract Orientation Checklist... Have job description signed and start competency checklist; Review bullet points from Agency/Contract Orientation Acknowledgement Form and have staff member sign and date form... Provide orientation to the unit/department which includes applicable policies and procedures and include the documentation for submittal to the appropriate area... 4. At completion of the staff member's initial shift, ensure that the competency checklist ... and the evaluation ... have been completed and signed...".

Based on review of the ED (emergency department) Quality Improvement Plan and the Performance Improvement Reports and interview, the hospital failed to recognize psychiatric patients held in the ED, who were determined by PEC (physician emergency certificate) and/or CEC (coroner's emergency certificate) to be violent, suicidal, homicidal, dangerous to self and/or others, and/or gravely disabled, awaiting inpatient bed placement as high-risk to safety in their QAPI (quality assurance performance improvement) Plan. Findings:

Review of the "Unit Based Quality Improvement Plan" for the ED revealed the quality control indicators identified were moderate sedation monitoring, restraints, suicide precaution measures, pneumonia, heart failure, and cardiac chest pain/AMI (acute myocardial infarction).

Review of the "Quality Assessment and Improvement Emergency Department Volume Breakdown" revealed the number of psychiatric patients being observed in the ED was being tracked since the second quarter of 2009. Further review revealed the following number of psychiatric patients observed in the ED by quarter:
2nd quarter 2009 - 110;
3rd quarter 2009 - 106;
4th quarter 2009 - 101;
1st quarter 2010 - 111;
2nd quarter 2010 - 105.
Further review revealed no documented evidence that the increase of psychiatric patients being held in the ED who had been determined by PEC and/or CEC to be violent, suicidal, homicidal, dangerous to self and/or others, and/or gravely disabled had been identified as a safety risk. There was no documented evidence of an analysis of medical records, identified opportunities for improvement, action plans to address the safety risk, and evaluation of the action plan.

In a face-to-face interview on 09/29/10 at 9:55am, Director of Quality S3 indicated the number of psychiatric patients being observed in the ED was being tracked, but there had been no analysis of the data accumulated.

In a face-to-face interview on 09/29/10 at 1:05pm, Director of Quality S3 indicated she had identified a problem with the number of psychiatric patients being held in the ED and the length of time they were held through data collection in the 2nd quarter 2010, but there had been no investigation, record reviews, or action plan for improvement.

Review of the hospital policy titled "Unit Based Quality Improvement Plan", last revised 1997 and submitted by CNO (chief nursing officer) S2 as their current plan for the ED, revealed, in part, "...Objectives ...4. To provide a planned and systematic review of routine care/services as measured by ongoing indicators that measure the outcome of care provided against accepted standards in accordance with departmental and hospitalwide policy and procedures. 5. To identify and review problems from a wide variety of aggregate data ... 6. To take corrective action on problems identified within the individual specific areas. 7. To re-evaluate the corrective actions taken and monitor the response. ... 10. To measure outcomes of all indicators/surveys to ensure appropriate actions are taken, if indicated. ... Monitoring and Evaluation ...7. Unit Based QI Process The ongoing, routine collection of information is carried out within the department in a decentralized, unit-based framework and in collaboration with the Emergency Department health care team. Specific indicators are chosen that reflect the scope of care/service and the major functions and standards of practice/care with respect to the following criteria: high-volume, high-risk, and problem-prone ...".

Review of the "Performance Improvement Plan" submitted by Director of Quality S3 as their current PI plan revealed, in part, "...Department Directors: Every department director is responsible for implementing quality improvement activities in their departments. Each department director is responsible for identifying quality indicators, collecting and analyzing data, developing and implementing corrective action to improve and monitoring to insure that improvement is made and sustained. Each department director is responsible for submitting their quality improvement reports to the Quality Management department quarterly. ... Data are formulated into reports that are ultimately reviewed and acted upon by the Quality Improvement Council, Medical Staff Quality Improvement Committee, Medical Staff Executive Committee, and Governing Body. Data will be collected, aggregated, and analyzed at the frequency appropriate to the activity or process being studied. ... Each clinical hospital department evaluates services performed and identifies processes for improvement, with an emphasis on integrating those processes with the hospital's improvement priorities. Indicators are developed to monitor these processes. Thresholds are developed by department directors to monitor their results and develop action plans. Indicators that fall below the thresholds developed by the department director are analyzed and trended. Action plans are developed, implemented and monitored for results ... The results of monitoring are reported to the appropriate department director, administrative representative, and the Quality Management Department at least quarterly.

Based on record review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure a RN (registered nurse) was assigned to supervise care of patients placed in a separate ED holding area used to hold emergent psychiatric patients awaiting admission (see findings in Tag A0392);

2) Failing to ensure a RN supervised all non-employee CNAs (certified nursing assistants) and employed Unit Secretaries working in the ED holding area located off the main hospital's ED where psychiatric patients are held pending admission to the hospital. In addition, the non-licensed personnel were not provided with orientation to policies and procedures, provided training on crisis intervention, and determined qualified to provide oversight and intervention when psychiatric patients exhibited violence or escalated behaviors. This was evident in 2 of 2 employed unit secretaries' personnel files (S15, S16) and 4 of 4 contract CNA personnel records reviewed (S22, S23, S24, S25) (see findings in Tag A0397 and A0398);

3) Failing to ensure the RN supervised and evaluated the nursing care of psychiatric patients being held in the hospital's ED awaiting admission relative to use of restraints, assessment of behaviors prior to medication administration of psychotropic drugs, and policies and procedures on assessments of vital signs and patients' response to medications. This was evident in 8 of 8 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8) (see findings in Tag A0395); and

4) Failing to have a system in place for the development and implementation of a nursing care plan for psychiatric patients, being held in the ED greater than 24 hours up to 4 days while awaiting bed availability to ensure appropriate nursing interventions were implemented to meet the identified emergenct psychiatric needs of the patients for 8 of 8 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8) (see findings in Tag A0396).

An immediate jeopardy situation was identified on 09/29/10 at 11:30am and reported to CNO (chief nursing officer) S2. The immediate jeopardy situation was a result of the following:

1) The hospital failed to ensure a RN was physically present in the ED, where 3 patients who were violent, dangerous to others and/or self, gravely disabled, and/or suicidal, were being held while awaiting an available inpatient bed, to ensure the immediate availability of a RN for bedside care of the patients. This resulted in a male patient diagnosed with Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior (Patient #3) hitting a female patient in the face and head (Patient #4);

2) The hospital failed to provide adequately trained staff by having 1 single untrained staff with 3 patients who were violent, dangerous to self and/or others, suicidal, and/or gravely disabled; and

3) The hospital failed to ensure staff responsible for monitoring patients with psychiatric diagnoses were trained to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions.

A corrective action plan was submitted by the hospital on 9/30/2010 at 1:50pm to address the immediate jeopardy situation which revealed:

1) A RN will be assigned and physically present in the "overflow" holding area at all times when any patients are being treated and/or held in the area. In addition, when psychiatric patients are being held in the overflow area, another CPI trained personnel will be present (i.e. CNA or Behavioral Health Assistant). This was effective immediately as of 09/29/10 and would be monitored by ED Director S4 and CNO S2. After hours and on weekends the Administrative Supervisor on duty would ensure the area was staffed with at least a RN and other qualified staff as necessary. CNO S2 and ED Director S4 met with Administrative Supervisor S27 on 09/29/10 to discuss the above plan. CNO S2 sent an e-mail to House Supervisors on 09/30/10 informing them. A meeting with the House Supervisors and CNO S2 was scheduled for 10/05/10. A tool for monitoring the psychiatric patients in the holding area of ED was developed. The tool included the following: date; time of arrival; record visit number of patient; location of patient (holding area or main ED); qualified staff assigned - yes or no; psych consult requested - yes or no; psych consult answered - yes or no; comments. ED Director S4 will communicate changes to the ED staff at the start of each shift, effective immediately, until the staff meeting was held on 10/01/10. The plan will be monitored daily for the next 60 days (through 11/30/10); if 100% (per cent) compliance was reached at that time, the audit would be done quarterly.

2) Effective immediately, any staff monitoring psychiatric patients would be trained in Crisis Prevention Intervention (CPI) or a similar course with content related to handling patients with psychiatric disorders. This would be monitored by ED Director S4 and CNO S2. After hours and on weekends, the Administrative Supervisor on duty would ensure the staff who were monitoring patients were adequately trained. CNO S2 and ED Director S4 met with Administrative Supervisor S27 to discuss this plan. CNO S2 sent an e-mail to the House Supervisors on 09/30/10 informing them of this change and will continue to inform the House Supervisors on a shift-by-shift basis. A meeting with the House Supervisors was scheduled with CNO S2 on 10/05/10. A monitoring tool was developed to monitor that there were a sufficient number of qualified staff. This would be monitored daily for the next 60 days (through 11/30/10); if 100% compliance was met at that time, the audit would be done quarterly.

3) Effective immediately, any staff monitoring psychiatric patients would be trained in Crisis Prevention Intervention or a similar course with content related to handling patients with psychiatric disorders. This will be monitored by ED Director S4 and CNO S2. After hours and on weekends, the Administrative Supervisor on duty would ensure that the staff monitoring patients were adequately trained.

As a result of the hospital's implementation of the action plan, the immediate jeopardy situation was removed on 09/30/10 at 1:50pm. The hospital's noncompliance remains at the condition level.

Based on observation, record review, and interviews, the hospital failed to ensure a RN (registered nurse) was physically present in the ED (emergency department), where 3 patients who were confirmed by PEC (physician emergency certificate) and/or CEC (coroner's emergency certificate) to be violent, dangerous to self and/or others, gravely disabled, and/or suicidal, were being held while awaiting an available inpatient bed, to assure the immediate availability of a RN for bedside care of the patients. This resulted in a male patient diagnosed with Paranoia and Schizophrenia (#3) hitting a female patient (#4) in the face and head. Findings:

Observation on 09/27/10 at 9:25am of the ED, with CNO (Chief Nursing Officer) S2 and RN Director of ED S4 present, revealed 2 separate areas of the ED with double wooden doors, accessible by employee badge swipe to enter and a green button on the inside to press to exit, with a 38 foot, 1/8th inch hall separating the 2 double doors. Further observation revealed the ED that was staffed with RNs and the physician had 6 exam rooms. Observation of the ED area across the hall, which was used according to CNO S2 as a holding area for patients who were waiting for transfer to a psychiatric facility when an inpatient bed became available, revealed 2 patients awaiting transfer with CNA (certified nursing assistant) S25, who was a staffing agency employee from Facility C, seated at the nursing station observing the 2 patients. Further observation revealed no RN present in this section of the ED.

In a face-to-face interview on 09/27/10 at 10:35am, CNO S2 confirmed the CNA worked as a sitter and was told to call the RN if a nurse was needed. She confirmed there was no hospital policy or job description for a sitter.

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed he presented to the ED on 09/09/10 at 2:40pm with complaint of a psychiatric history. Further review revealed "pt (patient) states person look at him wrong way and he hit that person. Pt denies suicidal or homicidal ideations. Pt is very anxious and has hx (history) of paranoid schizophrenia and bipolar". Further review revealed he was PEC ' d on 09/09/10 at 3:20pm and was noted to be violent, dangerous to others, gravely disabled, and unable to seek voluntary admission. Further review revealed he was CEC ' d on 09/11/10 at 4:40pm and noted to be violent, dangerous to self and others, gravely disabled, and unable to seek voluntary admission.

Review of Patient #3's "Nursing Medical Record" revealed documentation on 09/13/10 at 9:30am by RN S10. Further review revealed "pt walked into female pt's room (obs #1) (observation) instructed by BHU (behavioral health unit) sitter to return to his room (pt did not return to his room) sitter called me to obs area when I arrived pt was sitting on chair in his room, stood up walked to nurses desk asked to go outside and smoke, told he could not go outside and smoke at this time, he then asked if he could make a phone call instructed he could make one phone call and no longer than 5 min (minutes), handed phone to pt, pt stated that he needed to make a private call told that he could not make a private call pt then hung up the phone and returned to his room, at that time I instructed BHU sitter that I was going to get meds for this pt, as I was walking out of the obs area to the ED area pt walked to obs #1 (female pt's room) and began hitting the female pt about the head ...".

Review of the "24 Hour Visibility Documentation Form" for 09/13/10 revealed Unit Secretary S16 was observing Patient #3 from 7:00am until 11:00am.

In a face-to-face interview on 09/28/10 at 2:20pm, RN S10 indicated part of what she documented on 09/13/10 at 9:30am was her observation and part was reported to her by Unit Secretary S16. S10 confirmed she was called to the ED holding area by Unit Secretary S16, and after hospital employees arrived as a result of the Code White being called, she left the holding area, with no RN present, to return to the other ED unit to obtain physician orders, restraints, and medication to administer to Patient #3. S10 further indicated, "in retrospect, I probably should not have left the unit". She further indicated there was 1 RN, a physician, and RN Director of ED S4 on the other ED unit who could have brought what was needed to treat Patient #3 and Patient #4.

Review of the hospital policy titled "Patient Awaiting Psychiatric Evaluations", revised 08/09 and submitted by CNO S2 as their current policy for treating patients awaiting transfer and psychiatric evaluations, revealed, in part, "...For all patients holding in the Emergency Department awaiting psychiatric evaluation and/or placement, the following actions will be taken and documented: 1. The patient will be under eye contact observation at all times. The patient is placed in the hallway in front of the nurse's station until medically cleared. ... 4. Once the Emergency Department physician has evaluated the patient and has determined the patient is a threat to self and/or others (PEC'd, CEC'd). The patient will require constant observation by an ED Tech, CNA or qualified sitter. ...". Further review revealed no documented evidence that the policy addressed the use of the 2nd observation ED unit, that a RN would be required to be present, and a definition of a qualified sitter (since there was no job description for this position).

25065

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care of each patient by: 1) failing to ensure the RN assessed psychiatric patients being held in the ED (emergency department) for behaviors prior to administering psychotropic medications for 5 of 8 sampled patients (#1, #2, #3, #6, #8); 2) failing to assess the effectiveness of medications within 30 minutes of administration as required by hospital policy for 7 of 8 sampled patients (#1, #2, #3, #4, #5, #7, #8); 3) failing to assess vital signs 30 minutes after medication administration as required by hospital policy for 4 of 8 sampled patients (#1, #2, #3, #4); 4) failing to assess the vital signs of patients admitted to the ED (emergency department) according to the ESI (Emergency Severity Index) level as required by hospital policy for 8 of 8 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8); and 5) failing to assess a patient in restraints to ensure the restraints were released at the earliest possible time for 1 of 1 patient restrained from a total of 8 sampled patients (#3). Findings:

1) Failing to ensure the RN assessed psychiatric patients being held in the ED (emergency department) for behaviors prior to administering psychotropic medications:
Patient #1
Review of Patient #1's "Emergency Department Physician Medical Record" revealed she arrived at the ED on 09/25/10 at 12:56am with diagnoses of Suicidal Ideation and Depression. Further review revealed orders for the following medications:
09/26/10 at 6:51pm from Physician S11 - Benadryl 50 mg IM (intramuscularly);
09/26/10 at 6:52pm by Physician S11 - Ativan 2 mg IM; and
09/26/10 at 6:52pm by Physician S11 - Haldol 5 mg IM.

Review of Patient #1's "Emergency Department Nursing Medical Record" revealed her Triage Acuity Level was Urgent (3). Further review revealed RN S6 administered Benadryl 50 mg, Ativan 2 mg, and Haldol 5 mg IM at 7:15pm on 09/26/10. Further review revealed no documented evidence of an assessment of Patient #1's behavior that required the administration of Benadryl, Ativan, and Haldol.

Patient #2
Review of Patient #2's "Emergency Department Physician Medical Record" revealed he arrived on 09/26/10 at 10:43am with diagnoses of Substance Abuse, Cocaine Abuse, Suicidal Ideation, and Depression. Further review revealed orders from Physician S11 on 09/27/10 at 4:14am for Benadryl 50 mg IM and at 4:15am for Ativan 2 mg and Haldol 5 mg IM.

Review of Patient #2's "Emergency Department Nursing Medical Record" revealed RN S7 administered Benadryl 50 mg IM, Ativan 2 mg IM, and Haldol 5 mg IM on 09/27/10 at 4:45am. Further review revealed no documented evidence of an assessment of Patient #2's behavior that required the administration of Benadryl, Ativan, and Haldol.

Patient #3
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder (acuity 4), Gravely Disabled (acuity 4), Dangerous to self and others (acuity 4), and Aggressive/Violent Behavior (acuity 5). Further review revealed the following medication orders:
09/09/10 at 3:03pm by Physician S19 - Ativan 2 mg IM, Benadryl 50 mg IM, Haldol 5 mg IM;
09/11/10 at 8:45am by Physician S11 - "B52 1 unit dose Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg" IM;
09/12/10 at 8:42am by Physician S11 - Ativan 2 mg IM, Haldol 5 mg IM, Benadryl 50 mg IM;
09/13/10 at 8:43am by Physician S11 - Zyprexa 10 mg IM.

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed RN S8 administered Ativan 2 mg IM and Benadryl 50 mg IM at 3:19pm and Haldol 5 mg IM at 3:20pm on 09/09/10. Further review revealed no documented evidence of an assessment by RN S8 of Patient #3's behavior that required the administration of Benadryl, Ativan, and Haldol. Further review revealed RN S9 documented on 09/11/10 at 8:44am Patient #3 "c/o (complained of) agitation, MD (medical doctor) aware, new medication order written". There was no documented evidence of the behaviors Patient #3 was exhibiting prior to Benadryl, Ativan, and Haldol being administered. RN S8 administered Benadryl, Ativan, and Haldol IM on 09/12/10 at 8:54am to Patient #3. Further review of the medical record revealed no documented evidence of an assessment of behaviors prior to administering the medication to Patient #3.

In a face-to-face interview on 09/28/10 at 1:55pm, RN S8 confirmed she did not document the behavior Patient #3 was exhibiting when she administered his medications.

Patient #6
The ED medical record for Patient #6 was reviewed. Patient #6 was admitted on 09/25/10 at 19:40 (7:40pm) The patient was discharged for the ED on 09/27/10 18:00 (6pm) Triage complaint was Suicidal Ideation. Triage Acuity 2 Emergent. Review of the Nursing Medical Record dated 09/26/10 1903 (7:03pm) revealed, in part, "Patient is calm, the patient is cooperative." Further review of the Nursing Medical Record dated 09/26/10 19:16 (7:16pm) revealed Patient #6 was administered Benadryl 50 milligrams (mg), Haldol 5 milligrams and Ativan 2 milligrams. There was no documented evidence of an assessment of the patient's behavior prior to the administration of the psychotropic medications. Documentation revealed Patient #6's vital signs were assessed on 09/26/10 at 11pm (4 hours after the administration of the medication) There was no documented evidence the patient's vial signs were assessed every 15 minutes while held in the ED as per the ED policy for a patient with an acuity level of 2 emergent.

S4, RN ED Director confirmed these finding on 0929/10 at 2:05pm.

Patient #8
The ED medical record for Patient #8 was reviewed. Patient #8 was admitted on 09/12/10 at 00:29. (12:29am) The patient was discharged from the ED on 09/14/10 at 12:07 (12:07pm) Triage complaint was Psychosis. Triage Acuity 1 Critical. Review of the Nursing Medical Record revealed Patient #8 was administered Benadryl 50 milligrams (mg), Haldol 5 milligrams and Ativan 2 milligrams on 09/12/10 10:24am . There was no documented evidence of an assessment of the patient's behavior prior to the administration of the psychotropic medications.

The medical record for Patient #8 was reviewed by S4, ED Director and she confirmed the above findings on 09/29/10 at 2:05pm.

In a face-to-face interview on 09/29/10 at 2:05pm, RN Director of ED S4 indicated it would be appropriate for the ED nurse to document the behaviors of patients requiring psychotropic medications, but it was not included in any hospital ED policy.

2) Failing to assess the effectiveness of medications within 30 minutes of administration as required by hospital policy:
Patient #1
Review of Patient #1's "Emergency Department Physician Medical Record" revealed she arrived at the ED on 09/25/10 at 12:56am with diagnoses of Suicidal Ideation and Depression. Further review revealed orders for the following medications:
09/25/10 at 10:32pm from Physician S20 - Ambien 10 mg (milligrams) by mouth;
09/26/10 at 6:51pm from Physician S11 - Benadryl 50 mg IM (intramuscularly);
09/26/10 at 6:52pm by Physician S11 - Ativan 2 mg IM; and
09/26/10 at 6:52pm by Physician S11 - Haldol 5 mg IM.

Review of Patient #1's "Emergency Department Nursing Medical Record" revealed her Triage Acuity Level was Urgent (3). Further review revealed RN S6 administered Ambien 10 mg orally on 09/25/10 at 10:32pm. Further review revealed no documented evidence of an assessment of the effectiveness of Ambien within 30 minutes after administration as required by hospital policy. Further review revealed Benadryl 50 mg, Ativan 2 mg, and Haldol 5 mg IM were administered at 7:15pm on 09/26/10 by RN S6. Further review revealed no documented evidence of an assessment of the effectiveness of Benadryl, Ativan, and Haldol within 30 minutes after administration as required by hospital policy.

Patient #2
Review of Patient #2's "Emergency Department Physician Medical Record" revealed he arrived on 09/26/10 at 10:43am with diagnoses of Substance Abuse, Cocaine Abuse, Suicidal Ideation, and Depression. Further review revealed orders from Physician S11 on 09/27/10 at 4:14am for Benadryl 50 mg IM and at 4:15am for Ativan 2 mg and Haldol 5 mg IM.

Review of Patient #2's "Emergency Department Nursing Medical Record" revealed RN S7 administered Benadryl 50 mg IM, Ativan 2 mg IM, and Haldol 5 mg IM on 09/27/10 at 4:45am. Further review revealed no documented evidence of an assessment of the effectiveness of Benadryl, Ativan, and Haldol within 30 minutes after administration as required by hospital policy.

Patient #3
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder (acuity 4), Gravely Disabled (acuity 4), Dangerous to self and others (acuity 4), and Aggressive/Violent Behavior (acuity 5). Further review revealed the following medication orders:
09/09/10 at 3:03pm by Physician S19 - Ativan 2 mg IM, Benadryl 50 mg IM, Haldol 5 mg IM;
09/10/10 at 10:58am by Physician S11 - Benadryl 50 mg IM, Ativan 2 mg IM, Haldol 5 mg IM;
09/11/10 at 8:45am by Physician S11 - "B52 1 unit dose Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg" IM;
09/12/10 at 8:42am by Physician S11 - Ativan 2 mg IM, Haldol 5 mg IM, Benadryl 50 mg IM;
09/13/10 at 8:43am by Physician S11 - Zyprexa 10 mg IM, Ativan 2 mg IM, Haldol 5 mg, Benadryl 50 mg IM.

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed RN S9 administered Ativan, Benadryl, and Haldol on 09/10/10 at 11:19am. Further review revealed no documented evidence RN S9 assessed the effectiveness of the medications administered to Patient #3. Further review revealed Patient #3 received Benadryl, Ativan, and Haldol on 09/11/10 at 8:45am, and there was no documented evidence of the assessment of the effectiveness of the medication within 30 minutes of administration as required by hospital policy. RN S8 administered Benadryl, Ativan, and Haldol IM on 09/12/10 at 8:54am to Patient #3. Further review revealed no documented evidence of an assessment of the effectiveness of the medication administered by RN S8 within 30 minutes of administration.

In a face-to-face interview on 09/28/10 at 1:55PM, RN S8 indicated she was not sure of the hospital policy's time interval for assessment of medication effectiveness. She confirmed she assessed the effectiveness 1 hour after administration rather than 30 minutes as required by policy.

Patient #4
Review of Patient #4's "Emergency Department Physician Medical Record" revealed she arrived on 09/12/10 at 6:48pm with diagnoses of Depression, Substance Abuse, and Urinary Tract Infection. Further review revealed the following medication orders:
09/12/10 at 7:30pm by Physician S19 - Ativan 2 mg IM;
09/12/10 at 8:35pm by Physician S19 - Clonidine 0.1 mg by mouth;
09/13/10 at 8:55am by Physician S11 - Motrin 800 mg by mouth;
09/13/10 at 12:54pm by Physician S11 - Toradol 60 mg IM and Norflex 60 mg IM.

Review of Patient #4's "Emergency Department Nursing Medical Record" revealed RN S12 administered Ativan 2 mg IM at 7:35pm and Clonidine at 9:00pm on 09/12/10. Further review revealed no documented evidence of an assessment for effectiveness within 30 minutes of administration of Ativan and Clonidine. Further review revealed RN S10 administered Motrin on 09/13/10 at 8:55am. There was no documented evidence of an assessment of effectiveness of the medication within 30 minutes of administration. Further review revealed RN S10 administered Toradol and Norflex at 1:00pm on 09/13/10. There was no documented evidence of an assessment of effectiveness of the medications within 30 minutes of administration.

In a face-to-face interview on 09/28/10 at 2:20pm, RN S10 confirmed she did not document an assessment for the effectiveness of the medications she administered to Patient #4.

Patient #5
The ED medical record for Patient #5 was reviewed. The patient was admitted on 09/26/10 at 2:26pm. The patient was discharged from the ED on 09/27/10 at 4:22pm. Triage complaint was Drug Abuse. Triage Acuity 5-minor (non -urgent). Review of the Nursing Medical Record dated 09/26/10 16:37 (4:37pm) revealed Patient #5 was administered Benadryl 50 mg, Haldol 5 milligrams and Ativan 2 milligrams. There was no documented evidence the patient was assessed for the effects of the medication until 09/26/10 19:39 (7:39pm) (3 hours 2 minutes after the administration). These findings were confirmed by S8, RN on 09/28/10 at 1pm.

Patient #7
Review of Patient #7's "Emergency Department Physician Medical Record" revealed she arrived on 08/05/10 at 1:12pm with diagnoses of Acute Exacerbation of Bipolar Disorder With Increased Depression, Depression, Suicidal Ideation, Homicidal Ideation, and Gravely Disabled. Review of the "Emergency Department Nursing Medical Record" revealed Patient #7's blood pressure on 08/05/10 at 1:29pm was 147/102. She received Catapres 0.2 mg orally at 2:08pm by RN S32. Review of the "Nursing Medical Record" revealed her vital signs were not reassessed until 5:00pm, almost 3 hours after Patient #7 was medicated for elevated blood pressure.

Patient #8
Review of Patient #8's "Emergency Department Physician Medical Record" revealed he arrived on 09/12/10 at 12:29am with diagnoses of Psychosis, Cocaine Abuse, and Cannabis Abuse. Further review revealed Patient #8 remained in the ED until 09/14/10 at 12:31pm. Further review revealed he was PEC ' d on 09/12/10 at 1:00am and was suicidal, dangerous to self, gravely disabled, and unwilling and unable to seek voluntary admission. He was CEC'd on 09/14/10 at 10:28pm and was suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission. Review of Patient #8's "Emergency Department Nursing Medical Record" revealed RN S14 administered Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg IM on 09/12/10 at 10:24am. Further review revealed no documented evidence the effectiveness of the medications was assessed 30 minutes after administration.

In a face-to-face interview on 09/29/10 at 2:05pm, RN Director of ED S4 indicated the hospital policy required effectiveness of medications to be assessed 30 minutes after administration.

Review of the hospital policy titled "Medication Administration", presented as the hospital's current policy by CNO S2 for medication administration and last revised 12/09, revealed in part, ",,,5. After Medication Administration: reassessment of patient should be obtained in 30 minutes... document all of the above information in the patient record".

3) Failing to assess vital signs 30 minutes after medication administration as required by hospital policy:
Patient #1
Review of Patient #1's "Emergency Department Physician Medical Record" revealed she arrived at the ED on 09/25/10 at 12:56am with diagnoses of Suicidal Ideation and Depression.

Review of Patient #1's "Emergency Department Nursing Medical Record" revealed Ambien 10 mg orally was administered on 09/25/10 at 10:32pm by RN S6, and Benadryl 50 mg, Ativan 2 mg, and Haldol 5 mg IM were administered at 7:15pm on 09/26/10 by RN S6. Further review revealed no documented evidence vital signs were checked 30 minutes after the administration of each medication as required by hospital policy.

Patient #2
Review of Patient #2's "Emergency Department Physician Medical Record" revealed he arrived on 09/26/10 at 10:43am with diagnoses of Substance Abuse, Cocaine Abuse, Suicidal Ideation, and Depression. Further review revealed orders from Physician S11 on 09/26/10 at 11:02pm for Ambien 10 mg by mouth and on 09/27/10 at 4:14am for Benadryl 50 mg IM and at 4:15am for Ativan 2 mg and Haldol 5 mg IM.

Review of Patient #2's "Emergency Department Nursing Medical Record" revealed RN S7 administered Ambien 10 mg orally on 09/26/10 at 11:30pm and Benadryl 50 mg IM, Ativan 2 mg IM, and Haldol 5 mg IM on 09/27/10 at 4:45am. Further review revealed no documented evidence vital signs were checked 30 minutes after the administration of each medication as required by hospital policy.

Patient #3
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder (acuity 4), Gravely Disabled (acuity 4), Dangerous to self and others (acuity 4), and Aggressive/Violent Behavior (acuity 5).

Review of Patient #3's "Emergency Department Nursing Medical Record " revealed he received Ativan 2 mg, Benadryl 50 mg, and Haldol 5 mg IM on 09/09/10 at 3:19pm, Clonidine 0.2 mg orally on 09/09/10 at 5:24pm, Metoprolol 100 mg orally on 09/09/10 at 8:27pm, Benadryl 50 mg, Ativan 2 mg, and Haldol 5 mg IM on 09/10/10 at 11:19am, Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg IM on 09/11/10 at 8:45am, and Ativan 2 mg, Haldol 5 mg, Benadryl 50 mg, and Zyprexa 10 mg IM on 09/12/10 at 8:54am. Further review revealed no documented evidence the vital signs were assessed within 30 minutes after administration of these medications as required by hospital policy.

Patient #4
Review of Patient #4's "Emergency Department Physician Medical Record" revealed she arrived on 09/12/10 at 6:48pm with diagnoses of Depression, Substance Abuse, and Urinary Tract Infection.

Review of Patient #4's "Emergency Department Nursing Medical Record" revealed she received medications on 09/12/10 at 7:35pm, 09/12/10 at 7:53pm, 09/12/10 at 9:00pm,09/13/10 at 8:55am, 09/13/10 at 9:50am, and 09/13/10 at 1:00pm. There was no documented evidence of vital signs being assessed within 30 minutes of medication administration as required by hospital policy.

In a face-to-face interview on 09/28/10 at 1:55pm, CNO (Chief Nursing Officer) S2 indicated the nurses were not assessing vital signs within 30 minutes after medication administration as required by hospital policy.

Review of the hospital policy titled "Medication Administration", presented as the hospital's current policy by CNO S2 for medication administration and last revised 12/09, revealed in part, "... Every patient in the Emergency Department is to have a set of Vital Signs taken at least 30 minutes after the administration of any medication, along with a documented pain assessment score, if indicated ...".

4) Failing to assess the vital signs of patients admitted to the ED according to the ESI level as required by hospital policy:
Patient #1
Review of Patient #1's "Emergency Department Physician Medical Record" revealed she arrived at the ED on 09/25/10 at 12:56am with diagnoses of Suicidal Ideation and Depression.

Review of Patient #1's "Emergency Department Nursing Medical Record" revealed her Triage Acuity Level was Urgent (3). Further review revealed no documented evidence vital signs were taken every 30 minutes as required by hospital policy for patients with an acuity level of 3 (urgent).

Patient #2
Review of Patient #2's "Emergency Department Physician Medical Record" revealed she arrived at the ED on 09/25/10 at 12:56am with diagnoses of Suicidal Ideation and Depression.

Review of Patient #2's "Emergency Department Nursing Medical Record" revealed his triage acuity level was 3 (Urgent). Further review revealed no documented evidence vital signs were taken every 30 minutes as required by hospital policy for patients with an acuity level of 3 (urgent).

Patient #3
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder (acuity 4), Gravely Disabled (acuity 4), Dangerous to self and others (acuity 4), and Aggressive/Violent Behavior (acuity 5).

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed his triage acuity level was 3 (Urgent). Further review revealed no documented evidence vital signs were taken every 30 minutes as required by hospital policy for patients with an acuity level of 3 (urgent).

Patient #4
Review of Patient #4's "Emergency Department Physician Medical Record" revealed she arrived on 09/12/10 at 6:48pm with diagnoses of Depression, Substance Abuse, and Urinary Tract Infection.

Review of Patient #4's "Emergency Department Nursing Medical Record" revealed her triage acuity level was 3 - Urgent. Further review revealed no documented evidence vital signs were taken every 30 minutes as required by hospital policy for patients with an acuity level of 3 (urgent).

Patient #5
The ED medical record for Patient #5 was reviewed. The patient was admitted on 09/26/10 at 2:26pm. The patient was discharged from the ED on 09/27/10 at 4:22pm. Triage complaint was Drug Abuse. Triage Acuity 5-minor (non -urgent). Review of the Nursing Medical Record revealed Patient #5's vital signs were assessed 09/26/10 19:45 (7:45pm) and 09/26/10 11pm. There was no documented evidence the patient's vital signs were assessed every two (2) hours while held in the ED as per the ED policy with an acuity level of minor.

These findings were confirmed by S8, RN on 09/28/10 at 1pm.

Patient #6
The ED medical record for Patient #6 was reviewed. Patient #6 was admitted on 09/25/10 at 19:40 (7:40pm) The patient was discharged for the ED on 09/27/10 18:00 (6pm) Triage complaint was Suicidal Ideation. Triage Acuity 2 Emergent. Review of the Nursing Medical Record revealed no documented evidence the patient's vital signs were assessed every 15 minutes while held in the ED as per the ED policy for a patient with an acuity level of 2 emergent.

S4, RN ED Director confirmed these finding on 0929/10 at 2:05pm.

Patient #7
The ED medical record for Patient #7 was reviewed. Patient #7 was admitted on 08/05/10 at 13:12. (1:12pm) The patient was discharged for the ED on 08/06/10 at 04:40 (4:40pm) Triage complaint was Suicidal Ideation. Triage Acuity 3 Urgent. There was no documented evidence the patient's vital signs were assessed every 30 minutes while held in the ED as per the ED policy for a patient with an acuity level of 3, Urgent.

Patient #8
The ED medical record for Patient #8 was reviewed. Patient #8 was admitted on 09/12/10 at 00:29. (12:29am) The patient was discharged from the ED on 09/14/10 at 12:07 (12:07pm) Triage complaint was Psychosis. Triage Acuity 1 Critical. Review of the Nursing Medical Record revealed no documented evidence the patient's vital signs were assessed every 15 minutes while held in the ED as per the ED policy for a patient with an acuity level of 1.

The medical record for Patient #8 was reviewed by S4, ED Director and she confirmed the above findings on 09/29/10 at 2:05pm.

S2, Chief Nursing Officer indicated through interview on 09/28/10 at 1:15pm the ED policy for assessing Vital Signs was not working for the ED and was being revised.

In a face-to-face interview on 09/28/10 at 1:55pm, CNO S2 indicated the nurses were not assessing vital signs every 15 minutes as required by hospital policy for patients with an acuity level of Emergent.

Review of the hospital policy titled "Vital Sign Assessment and Reassessment", presented as the hospital's current policy by Chief Nursing Officer S2 and last revised 12/04, revealed in part, "Policy: Every patient presenting to St. Charles Parish Hospital Emergency Department shall have an accurate assessment and reassessment. This assessment shall begin and end with appropriate vital signs. Every patient will have admit vital signs and discharge vital signs. ... Procedure: Requirements for vital signs in the Emergency department are as follows:
1. Every patient presenting to the emergency department will immediately have a complete set of vital signs taken and documented on the E.D. record... 2. Every patient in the Emergency Department is to have vital signs taken per the following guidelines:
Emergent-Q15 min. or more frequently if indicated ... Urgent-Q30min or more frequently if indicated... Non-Urgent-Q2 hours...".

5) Failing to assess a patient in restraints to ensure the restraints were released at the earliest possible time:
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder (acuity 4), Gravely Disabled (acuity 4), Dangerous to self and others (acuity 4), and Aggressive/Violent Behavior (acuity 5).

Review of Patient #3's "Emergency Department Nursing Medical Record" revealed he was placed in 3 point (waist and bilateral ankles) restraints on 09/13/10 at 10:00am by RN Director of ED S4. Review of the "Seclusion/Restraint Flow Sheet" and the "Emergency Department Nursing Medical Record" revealed no documented evidence of attempts to release Patient #3 from restraints. Further review revealed the following documentation by RN S10:
09/13/10 at 10:30am - resting quietly on stretcher;
09/13/10 at 12:00pm - eating lunch;
09/13/10 at 1:00pm - resting quietly on stretcher;
09/13/10 at 2:00pm - resting quietly on stretcher; waist restraint removed, patient taken outside to smoke, calm, cooperative;
09/13/10 at 3:00pm - resting quietly on stretcher; ankle restraint remain in place, calm, cooperative; 09/13/10 at 6:00pm - restraints removed, pt to psych via w/c (wheelchair).

In a face-to-face interview on 09/28/10 at 2:20pm, RN S10 indicated she did not attempt to remove Patient #3's restraints until he was transferred to the psych unit. When told by the surveyor that documentation in the medical record revealed he was calm and cooperative from 10:30am until his restraints were removed at 6:00pm, RN S10 indicated "he was calm and cooperative before he hit the patient", and she couldn't be sure he wouldn't do it again. S10 further indicated when she removed the waist restraint for him to be able to go outside to smoke, Patient #3 was instructed that he would be placed in waist restraints again if he didn't do what he was told to do. RN S10 indicated Patient #3 complied and remained quiet. When asked by the surveyor if Patient #3's restraints could have been removed if a RN had been available to monitor him, S10 indicated a RN was not available as the RNs were needed on the acute side of ED to care for patients.

Review of the hospital policy titled "Seclusion and Restraint", last revised 12/09 and submitted by CNO S2 as their current policy for use of restraints, revealed, in part, "...It is this facilities goal to continually seek ways to decrease/eliminate restraint/seclusion for all patients, therefore discontinuing restraint/seclusion as soon as possible. ...5. Rationale for intervention and criteria for exit are reviewed with patient after assuring the security of restraints. 6. Staff present will state to the patient what the exit criteria includes and the patient progress towards completion. Assist the patient to meet the criteria for exit. ... Also monitored and documented on the flowsheet every 15 minutes are the following: ... i. The RN will reassess the patient for readiness for discontinuing Behavioral Restraint and Seclusion, restate the exit criteria and assist the patient to meet criteria to exit at least once every hour the patient is in Behavioral restraint and seclusion. 10. The patient is released from seclusion/restraint as soon as Exit Criteria is met. Examples of exit criteria are, but not limited to: -Cooperation with treatment - Agreeing to follow unit rules - Following directions ...".

Based on record review and interview, the hospital failed to: 1) have a system in place for the development and implementation of a nursing care plan for psychiatric patients, who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled, being held in the ED (emergency department) greater than 24 hours while awaiting bed availability to ensure appropriate nursing interventions were implemented to meet the identified needs of the patients for 8 of 8 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8) and 2) administer medications as ordered for 1 of 8 sampled patients (#8). Findings:

1) System for developing and implementing a nursing care plan:
Patient #1
Review of Patient #1's "Emergency Department Physician Medical Record" revealed she arrived at the ED on 09/25/10 at 12:56am with diagnoses of Suicidal Ideation and Depression. Further review revealed Patient #1 remained in the ED on 09/26/10 and 09/27/10. Further review revealed she was PEC'd (physician emergency certificate) on 09/25/10 at 3:00am and was currently suicidal, dangerous to self, and gravely disabled. Patient #1 was CEC'd (coroner's emergency certificate) on 09/27/10 at 3:15pm and was currently suicidal, dangerous to self, and gravely disabled.

Patient #2
Review of Patient #2's "Emergency Department Physician Medical Record" revealed he arrived on 09/26/10 at 10:43am with diagnoses of Substance Abuse, Cocaine Abuse, Suicidal Ideation, and Depression. Further review revealed he remained in the ED on 09/27/10 at 3:00pm. Further review revealed Patient #2 was PEC'd on 09/26/10 at 11:45am and was dangerous to self, gravely disabled, and unable to seek voluntary admission.

Patient #3
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior. Further review revealed Patient #3 remained in the ED until 09/13/10 at 6:00pm. Further review revealed Patient #3 was PEC'd on 09/09/10 at 3:00pm and was violent, dangerous to others, and gravely disabled. He was CEC'd on 09/11/10 at 3:40pm and was violent, dangerous to self and others, and gravely disabled.

Patient #4
Review of Patient #4's "Emergency Department Physician Medical Record" revealed she arrived on 09/12/10 at 6:48pm with diagnoses of Depression, Substance Abuse, and Urinary Tract Infection. Further review revealed Patient #4 remained in the ED until 09/13/10 at 8:01pm. Further review revealed Patient #4 was PEC'd on 09/12/10 at 7:30pm and was gravely disabled and unable to seek voluntary admission. She was CEC'd on 09/14/10 at 10:20pm and was gravely disabled and unable to seek voluntary admission.

Patient #5
Review of Patient #5's "Emergency Department Physician Medical Record" revealed he arrived on 09/26/10 at 2:23pm with diagnoses of History of Medical Non-Compliance, Cocaine Abuse, Suicidal Ideation, and Depression. Further review revealed Patient #5 was still in the ED on 09/27/10 at 4:36pm. Further review revealed Patient #5 was PEC'd on 09/26/10 at 3:00pm and was dangerous to self and gravely disabled. He was CEC'd on 09/27/10 at 4:30pm and was suicidal, dangerous to self, and unable to seek voluntary admission.

Patient #6
Review of Patient #6's "Emergency Department Physician Medical Record" revealed she arrived on 09/25/10 at 7:40pm with diagnoses of Depression, Suicidal Ideation, Suicide Attempt, Alcoholic Intoxication, Alcohol Abuse, and Multiple Lacerations of the right distal forearm/wrist. Further review revealed Patient #6 remained in the ED until 09/27/10 at 5:45pm. Further review revealed she was PEC'd on 09/25/10 at 9:00pm and was suicidal, dangerous to self, and unable to seek voluntary admission. Patient #6 was CEC'd on 09/27/10, with no documented evidence of the time, and was suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission.

Patient #7
Review of Patient #7's "Emergency Department Physician Medical Record" revealed she arrived on 08/05/10 at 1:12pm with diagnoses of Acute Exacerbation of Bipolar Disorder With Increased Depression, Depression, Suicidal Ideation, Homicidal Ideation, and Gravely Disabled. Further review revealed Patient #7 remained in the ED until 08/06/10 at 3:10pm. Further review revealed Patient #7 was PEC'd on 08/05/10 at 2:00pm and was dangerous to self and others, suicidal, homicidal, gravely disabled, and unwilling and unable to seek voluntary admission.

Patient #8
Review of Patient #8's "Emergency Department Physician Medical Record" revealed he arrived on 09/12/10 at 12:29am with diagnoses of Psychosis, Cocaine Abuse, and Cannabis Abuse. Further review revealed Patient #8 remained in the ED until 09/14/10 at 12:31pm. Further review revealed he was PEC ' d on 09/12/10 at 1:00am and was suicidal, dangerous to self, gravely disabled, and unwilling and unable to seek voluntary admission. He was CEC'd on 09/14/10 at 10:28pm and was suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission.

Review of Patients #1's, #2's, #3's, #4's, #5's, #6's, #7's, and #8's entire ED record revealed no documented evidence of the implementation of a care plan that included the nursing interventions implemented to address the patients' identified needs for the extended stay in the ED while awaiting bed placement.

In a face-to-face interview on 09/30/10 at 1:20pm, CNO (chief nursing officer) S2 indicated the ED did not have a system in place to develop and implement nursing care plans for psychiatric patients who were held in the ED for greater than 24 hours.

2) Administer medications as ordered:
Review of Patient #8's "Emergency Department Physician Medical Record" revealed he arrived on 09/12/10 at 12:29am with diagnoses of Psychosis, Cocaine Abuse, and Cannabis Abuse. Further review revealed Patient #8 remained in the ED until 09/14/10 at 12:31pm. Further review revealed he was PEC ' d on 09/12/10 at 1:00am and was suicidal, dangerous to self, gravely disabled, and unwilling and unable to seek voluntary admission. He was CEC'd on 09/14/10 at 10:28pm and was suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission. Review of the " Current Medications/Reconciliation Form " , signed by Physician S11 on 09/13/10 with no documented evidence of the time it was signed, revealed the following medications were to be continued during the hospital stay: Catapress 0.3 mg by mouth twice daily, Aspirin 81 mg by mouth every day, Zocor 80 mg by mouth every evening, HCTZ 12.5 mg by mouth every day, Norvasc 5 mg by mouth every day, and Vasotec 40 mg by mouth every day. Review of the entire ED medical record revealed no documented evidence these medications were administered as ordered.

In a face-to-face interview on 09/29/10 at 2:05pm, Director of ED S4 indicated the psychiatric patients who were held in the ED awaiting bed placement were monitored and kept safe, but they did not have a psychiatrist evaluate them in the ED. She could offer no explanation for the medications not being administered as ordered for Patient #8.

Review of the hospital policy titled "Medication Administration", presented as the hospital's current policy by CNO S2 for medication administration and last revised 12/09, revealed in part, "... 1. All medications must be ordered by a physician of St. Charles Parish Hospital Medical Staff. ...5. After Medication Administration: reassessment of patient should be obtained in 30 minutes... document all of the above information in the patient record".

25065

Based on record review (personnel files) and interviews, the hospital failed to: 1) ensure a process was in place to ensure all personnel who provided direct patient care to psychiatric patients being held in the holding area of the ED awaiting bed placement and determined to be violent, dangerous to self and/or others, gravely disabled, and/or suicidal had additional training on caring for psychiatric patients to prevent injury to patients and staff by having staff with no evidence of CPI (Crisis Prevention Institute) training and training to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions for 6 of 13 sampled direct care staff files reviewed (S15, S16, S22, S23, S24, S25) and 2) ensure all direct care staff were oriented and assessed for competency prior to performing their job duties in the ED for 6 of 13 sampled personnel records reviewed for orientation and competency (S15, S16, S22, S23, S24, S25). Findings:

1) CPI training:
Unit Secretary S15
Review of the personnel record for S15 Unit Secretary, with a date of hire of 12/12/08, who had assignments on 09/25/10 and 09/26/10 in the Emergency Department to observe psychiatric patients being held in the holding area of the ED awaiting bed placement who were determined to be suicidal, dangerous to self, and gravely disabled, revealed no documented evidence of CPI training and training to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions .

Unit Secretary S16
Review of the personnel record for S16 Unit Secretary, with a date of hire 08/24/10, who had assignments on 09/11/10, 09/12/10, and 09/13/10 in the Emergency Department to observe psychiatric patients being held in the holding area of the ED awaiting bed placement who were determined to be violent, dangerous to self and others, and gravely disabled, revealed no documented evidence of CPI training and training to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions .

CNA (certified nursing assistant) S22 from Agency A
Review of CNA S22's personnel file revealed he was a contract employee from Agency A, and his first date of work at St. Charles Parish Hospital was 09/09/10. Further review revealed he had assignments on 09/09/10, 09/10/10, 09/11/10, 09/12/10, 09/13/10, and 09/26/10 in the ED to observe psychiatric patients being held in the holding area of the ED awaiting bed placement who were determined to be violent, suicidal, dangerous to self and others, and gravely disabled. Further review revealed no documented evidence of CPI training and training to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions .

CNA S23 from Agency 24 from Agency B
Review of CNA 23's personnel file revealed she was a contract employee from Agency B. Further review revealed S23, who had assignments on 09/26/10 in the Emergency Department to observe psychiatric patients being held in the holding area of the ED awaiting bed placement who were determined to be suicidal, dangerous to self, and gravely disabled, had no documented evidence of CPI training and training to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions .

CNA S24 from Agency B
Review of CNA S24's personnel file revealed she was a contract employee from Agency B. Further review revealed S24, who had assignment on 09/25/10 in the Emergency Department to observe a psychiatric patient being held in the holding area of the ED awaiting bed placement who was determined to be suicidal, dangerous to self, and gravely disabled, had no documented evidence of CPI training and training to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions .

CNA S25 from Agency C
Review of CNA S25's personnel file revealed she was a contract employee from Agency C. Further review revealed S25, who had assignment on 09/27/10 in the Emergency Department to observe a psychiatric patient being held in the holding area of the ED awaiting bed placement who was determined to be suicidal, dangerous to self, and gravely disabled, had no documented evidence of CPI training and training to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions .

In a face-to-face interview on 09/28/10 at 9:20am, CNO (chief nursing officer) S2 indicated the unit secretary assigned to observe the psychiatric patients in the ED holding area were assigned as "sitters". She confirmed they were often the only person observing the patients, and the RN was available if needed and called by the sitter. She further confirmed the unit secretaries did not have CPI training and training to recognize signs and symptoms of escalating psychiatric behaviors and implementing appropriate interventions .

In a face-to-face interview on 09/28/10 at 10:10am, RN (registered nurse) Director of Education S18 indicated unit secretaries do not attend annual skills fair for training for restraint use. She further indicated a "sitter" was not a CNA, and the hospital had no job description for a sitter.

In a face-to-face interview on 09/28/10 at 10:45am, RN Director of Education S18 indicated if a unit secretary was assigned duties of a "sitter", he/she should have a job description for Behavioral Assistant in their employee file. She further indicated the job description for Behavioral Assistant required CPI certification within 6 months of employment. She could offer no explanation, if CPI was required after 6 months of employment, why it was not necessary for employees observing psychiatric patients who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled, to be trained in CPI at the time of assignment to direct patient care.

In a face-to-face interview on 09/29/10 at 9:45am, CNO S2 confirmed the contract agency CNAs assigned to observe the psychiatric patients in the ED holding area were not trained in CPI.

Review of the "Position Description" for "Behavioral Health Assistant", effective 08/09, revealed, in part, "...Assists behavioral health patients with the activities of daily living and performs specialized observation of patients. ... Minimum Qualifications: ... 3. CPI certification, may obtain within 6 months of employment. ...Essential Duties/Responsibilities (Position): ... 2. Treatment/Care ... b. Performs specialized observation of patients, including escorting patients to other areas of the hospital ... 5. Safety/Infection Control ... b. Assists in setting limits on patient's behaviors that are destructive to self or others. ... 7. Documentation a. Records observations of the patient in the medical record ... 8. Leadership a. Identifies potential problem situations and intervenes to offset adverse impact; demonstrates a proactive approach to problem-solving...".

2) Orientation and competency:
Unit Secretary S15
Review of Unit Secretary S15's personnel file revealed a hire date 12/12/08. Documentation revealed S15 had orientation to the Unit Secretary position of the ICU telemetry monitoring. Further review of the file revealed no documented evidence of a job description, orientation to the ED, and assessment of competency for S15 prior to performing direct patient care of the psychiatric patient admitted to the ED who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled.

Unit Secretary S16
Review of Unit Secretary S16's personnel file revealed a hire date 08/24/09. Documentation revealed S16 had a job description for and orientation to the Unit Secretary position of the ED. Further review of the job description revealed no documented evidence that direct patient care was included in her job description. Further review of the file revealed no documented evidence of an assessment of competency for S16 prior to performing direct patient care of psychiatric patients who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled.

CNA S22
Review of CNA S22's personnel file revealed he was a contract employee from Agency A, and his first date of work at St. Charles Parish Hospital was 09/09/10. Further review revealed no documented evidence of a job description for the ED, hospital orientation, and orientation to the ED prior to providing direct patient care. Further review revealed the competency assessment for restraint/seclusion and abnormal vital signs was signed by S22 on 09/12/10 with no documented evidence of an assessment by a qualified observer of his competency. Further review revealed S22's evaluation was completed on 09/26/10.

In a face-to-face interview on 09/28/10 at 3:15pm, CNA S22 indicated he was in the main ED on his first day of work on 09/09/10 with ED staff present. He further indicated he was alone in the ED holding area on 09/10/10 observing psychiatric patients who were awaiting bed availability in a psychiatric inpatient facility.

CNA S23
Review of CNA 23's personnel file revealed she was a contract employee from Agency B. Further review revealed S23 was assigned to the ED on 09/26/10. Further review revealed no documented evidence of orientation to the ED and assessment of competency to observe psychiatric patients who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled prior to providing to direct patient care.

CNA S24
Review of CNA S24's personnel file revealed she was a contract employee from Agency B. Further review revealed S24 was assigned to the ED on 09/25/10 to observe psychiatric patients who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled prior to providing to direct patient care. Further review revealed no documented evidence of orientation to the ED and assessment of S24's competency prior to providing direct patient care.

CNA S25
Review of CNA S25's personnel file revealed she was a contract employee from Agency C. Further review revealed S25 was assigned to the ED on 09/27/10 to observe psychiatric patients who were determined to be suicidal, violent, dangerous to self and/or others, and/or gravely disabled prior to providing to direct patient care. Further review revealed no documented evidence of orientation to the ED and assessment of S25's competency prior to providing direct patient care.

In a face-to-face interview on 09/29/10 at 9:55am, CNO S2 confirmed the above findings.

Review of the hospital policy titled "Competency Assessment Program-Emergency", presented as the hospital's current policy and submitted by CNO S2, revealed, in part, "Policy: All employees of the Emergency Department will participate in the Competency Assessment Program as defined by the Department of Education... Procedure: 1. Initial Competency a. The following competencies will be validated prior to the completion of orientation: 1. Hospital wide core competencies a. Age Assessment Specific b. Hazard Communications c. Guest Relations d. Safety-E: Hand Hygiene 2. Department Specific Competencies a. Nurse and ER tech Annual skills checklist 3. Position specific competencies ... c. Tech-Age specific, Restraint, accu-chek, clean catch urine and mod. (moderate) Sedation...".

Review of the hospital policy titled "Emergency Department Orientation", revised 07/09 and submitted by CNO S2 as their current policy for ED orientation, revealed, in part, "Policy: All employees hired into the Emergency Department will be provided an orientation of sufficient time and content to prepare them for their duties and responsibilities in the department. ... The initial orientation period will begin with a one day general hospital orientation and an additional two day nursing orientation conducted by the Education Department. ... Responsibilities ... acquire beginning knowledge and skills appropriate to emergency care. ... Implementation ... Day I (In Emergency Department) Orientee will orient to the department and learn operational format while buddied with qualified staff. Orientee is not to assume patient care. Day II & (and) III Orientee will perform patient care under supervision of qualified observer...".

Review of the hospital policy titled "Contract/Agency/Forensic Personnel", revised June 2010 and submitted by CNO S2 as the hospital's current policy for orienting contract staff, revealed, in part, "Policy: The purpose of this policy is to ensure that all clinical/non-clinical contract/agency staff is qualified and competent to perform the duties assigned as set forth by the guidelines of St. Charles Parish Hospital and appropriate agencies, if applicable... The Profile Sheet is then reviewed by the Department Manager or House Supervisor and a determination is made whether the staff member is qualified and competent to meet the needs of the hospital. If accepted, the staff member will be given the date and time to report (usually one hour prior to the actual time the shift starts to allow time for further clearance/orientation). 3. Upon arrival of the clinical personnel, the Department Director or House Supervisor should begin completing the Agency/Contract Orientation Checklist... Have job description signed and start competency checklist; Review bullet points from Agency/Contract Orientation Acknowledgement Form and have staff member sign and date form... Provide orientation to the unit/department which includes applicable policies and procedures and include the documentation for submittal to the appropriate area... 4. At completion of the staff member's initial shift, ensure that the competency checklist ... and the evaluation ... have been completed and signed...".

Based on record review (personnel files) and interviews, the hospital failed to ensure non-employee CNAs (certified nursing assistants) working in the hospital ED with psychiatric patients who were were determined to be violent, suicidal, dangerous to self and/or others, and/or gravely disabled were knowledgeable of hospital policies and procedures and their clinical activities were supervised and evaluated by an appropriately qualified hospital-employed RN for 4 of 4 contract personnel records reviewed. (S22, S23, S24, S25). Findings:

CNA S22 from Agency A
Review of CNA S22's personnel file revealed he was a contract employee from Agency A, and his first date of work at St. Charles Parish Hospital was 09/09/10. Further review revealed he was evaluated by a hospital-employed RN on 09/26/10, 17 days after his initial date of work.

In a face-to-face interview on 09/28/10 at 3:15pm, CNA S22 indicated he was in the main ED on his first day of work on 09/09/10 with ED staff present. He further indicated he was alone in the ED holding area, without supervision by a hospital-employed RN, on 09/10/10, 09/11/10, 09/12/10, 09/13/10, and 09/26/10 observing psychiatric patients who were awaiting bed availability in a psychiatric inpatient facility.

CNA S23 from Agency B
Review of CNA 23's personnel file revealed she was a contract employee from Agency B. Review revealed S23 was assigned to the ED on 09/26/10 to observing psychiatric patients who were awaiting bed availability in a psychiatric inpatient facility. Further review revealed the last evaluation of S23 by a hospital-employed RN was 07/18/09, and it was an evaluation of her duties as a CNA in the psychiatric department.

CNA S24 from Agency B
Review of CNA S24's personnel file revealed she was a contract employee from Agency B. Review revealed S24 was assigned to observe psychiatric patients being held in the ED while awaiting bed placement on 09/25/10. Review of S24's personnel file revealed her last evaluation by a hospital-employed RN was 10/15/08. There was no documented evidence of S24 being evaluated by an ED RN.

CNA S25 from Agency C
Review of CNA S25's personnel file revealed she was a contract employee from Agency C. Review revealed S25 was assigned to observe psychiatric patients being held in the ED while awaiting bed placement on 09/27/10. There was no documented evidence of an evaluation of S25's performance in the ED.

These findings were confirmed by CNO S2 on 09/29/10 at 9:45am. S2 confirmed the CNAs contracted from the staffing agencies had worked as "sitters" observing the psychiatric patients being held in the ED holding area, and there was not a hospital-employed RN present at all times for direct supervision. Further S2 indicated the system the hospital had in place was to maintain a log of all agency personnel and track pertinent personnel information regarding training and orientation, and missing paperwork had been an issue.

Review of the hospital policy titled "Contract/Agency/Forensic Personnel", revised June 2010 and submitted by CNO S2 as the hospital's current policy for orienting contract staff, revealed, in part, "Policy: The purpose of this policy is to ensure that all clinical/non-clinical contract/agency staff is qualified and competent to perform the duties assigned as set forth by the guidelines of St. Charles Parish Hospital and appropriate agencies, if applicable... The Profile Sheet is then reviewed by the Department Manager or House Supervisor and a determination is made whether the staff member is qualified and competent to meet the needs of the hospital. If accepted, the staff member will be given the date and time to report (usually one hour prior to the actual time the shift starts to allow time for further clearance/orientation). 3. Upon arrival of the clinical personnel, the Department Director or House Supervisor should begin completing the Agency/Contract Orientation Checklist... Have job description signed and start competency checklist; Review bullet points from Agency/Contract Orientation Acknowledgement Form and have staff member sign and date form... Provide orientation to the unit/department which includes applicable policies and procedures and include the documentation for submittal to the appropriate area... 4. At completion of the staff member's initial shift, ensure that the competency checklist ... and the evaluation ... have been completed and signed...".

Based on record reviews, review of the Centers for Disease Control (CDC) Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, and interviews, the hospital failed to: 1) develop a system to ensure all physicians were free of tuberculosis (TB) upon appointment and annually thereafter for 4 of 4 physicians' files reviewed from a total of 11 physicians appointed to the medical staff (S11, S19, S20 and S21) and 2) ensure all personnel with direct patient contact were determined to be free of TB annually for 3 of 8 ED personnel files reviewed for TB from a total of 39 ED staff (S4, S8, S16). Findings:

1) Physician files:
Review of the credentialing files for Physicians S11, S19, S20, and S21 revealed no documented evidence of TB screening.

S13, HR Director was interviewed on 09/28/10 at 11:10am. S13 indicated the hospital did not require physicians to have TB screenings.

Review of Centers for Disease Control Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 revealed in part, "...HCWs (Health Care Workers) refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCWs who should be included in a TB screening program: ... Dental staff ... Physicians (assistant, attending, fellow, resident, or intern), including anesthesiologists, pathologists, psychiatrists, psychologists...".

2) ED staff:
Review of the personnel record for RN (registered nurse) S4 revealed the last documented TB screening done was 09/21/09.

Review of the personnel record for RN S8 revealed the last documented TB screening done was 09/27/09.

Review of the personnel record for S16 Unit Secretary/Sitter revealed the last documented TB screening done was 06/09/09.

The personnel records for S4, S8, and S16 were reviewed by S13, Director of Human Resources (HR) on 09/28/10 at 11:10am who confirmed the TB screenings were not current. Further she indicated there was no system in place for tracking to ensure TB screening did not expire.

Based on record review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Emergency Services by failing to develop policies and procedures for the medical care provided to patients exhibiting acute psychiatric symptoms requiring a higher level of care based on a PEC (physician emergency certificate) and/or a CEC (coroner's emergency certificate) for violence, suicidal, homicidal, dangerous to self and/or others, and/or gravely disabled and awaiting admission to a psychiatric hospital for 8 of 8 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8). This resulted in a male psychiatric patient, (#3), being placed in the ED holding area off the hospital's main ED unit, hitting and injuring another female patient, (#4), in the face and head on 09/13/10.

An immediate jeopardy situation was identified on 09/29/10 at 11:30am and reported to CNO (chief nursing officer) S2. The immediate jeopardy situation was a result of the hospital failing to provide timely treatment for patients exhibiting acute psychiatric symptoms requiring a higher level of care based on PEC and/or CEC for violence, suicidal, dangerous to self and/or others, and/or gravely disabled.

A corrective action plan was submitted by the hospital on 9/30/2010 at 1:50pm to address the immediate jeopardy situation which revealed:

1) Effective immediately, a Psychiatric Consult will occur for any psychiatric patient who is still holding in the Emergency Department for a psychiatric bed overnight. The consult will be placed that morning in order for the patient to be seen that day. This will be monitored by Director of ED (emergency department) S4 and CNO (chief nursing officer) S2. After hours and on weekends, the Administrative Supervisor on duty will ensure that the consults are ordered and occurring.

2) Director of ED S4 and CNO S2 met on 09/29/10 met with Administrative Supervisor S27 to inform him of this plan.

3) CNO S2 sent an e-mail to the House Supervisors on 09/30/10 informing them of this change in policy and will continue to inform them on a shift-by-shift basis.

4) CNO S2 scheduled a meeting with the House Supervisors for 10/05/10. The tool titled "Psychiatric Patients Holding In The Emergency Dept (department)" will be used to monitor the sufficient number of qualified staff and that a psychiatric consult was placed and answered.

5) Monitoring will be done daily for the next 60 days (through 11/30/10); if compliance is 100% at that time, auditing will be done quarterly.

As a result of the hospital's implementation of the action plan, the immediate jeopardy situation was removed on 09/30/10 at 1:50pm. The hospital's noncompliance remains at the condition level.

Based on record review and interviews, the hospital failed to develop policies and procedures for the medical care provided to patients exhibiting acute psychiatric symptoms requiring a higher level of care based on a PEC (physician emergency certificate) and/or a CEC (coroner's emergency certificate) for violence, suicidal, homicidal, dangerous to self and/or others, and/or gravely disabled for 8 of 8 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8). This resulted in a male patient, diagnosed with Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior (#3), hitting a female patient, diagnosed with Depression, Substance Abuse, and Urinary Tract Infection (#4), in the face and head on 09/13/10. Findings:

Patient #1
Review of Patient #1's "Emergency Department Physician Medical Record" revealed she arrived at the ED on 09/25/10 at 12:56am with diagnoses of Suicidal Ideation and Depression. Further review revealed Patient #1 remained in the ED on 09/26/10 and 09/27/10. Further review revealed she was PEC'd (physician emergency certificate) on 09/25/10 at 3:00am and was currently suicidal, dangerous to self, and gravely disabled. Patient #1 was CEC'd (coroner's emergency certificate) on 09/27/10 at 3:15pm and was currently suicidal, dangerous to self, and gravely disabled. Review of the"Emergency Department Physician Medical Record" revealed an entry on 09/26/10 at 6:45pm by Physician S11 that Patient #1 was "becoming more agitated and uncooperative", and S11 ordered Benadryl 50 mg (milligrams), Ativan 2 mg, and Haldol 5 mg IM (intramuscular) at 6:52pm. Review of the entire ED medical record revealed no documented evidence of a psychiatric consult.

Patient #2
Review of Patient #2's "Emergency Department Physician Medical Record" revealed he arrived on 09/26/10 at 10:43am with diagnoses of Substance Abuse, Cocaine Abuse, Suicidal Ideation, and Depression. Further review revealed he remained in the ED on 09/27/10 at 3:00pm. Further review revealed Patient #2 was PEC'd on 09/26/10 at 11:45am and was dangerous to self, gravely disabled, and unable to seek voluntary admission. Review of the "Emergency Department Physician Medical Record" and the "Emergency Department Nursing Medical Record" revealed Patient #2 was ordered Benadryl 50 mg, Ativan 2 mg, and Haldol 5 mg IM by Physician S11 on 09/27/10 at 2:14am, and it was administered at 4:45am by RN (registered nurse) S7, with no documented evidence of the behavior warranting the psychotropic medications. Review of the entire ED medical record revealed no documented evidence of a psychiatric consult.

Patient #3
Review of Patient #3's "Emergency Department Physician Medical Record" revealed he arrived on 09/09/10 at 2:40pm with diagnoses of Acute Exacerbation of Chronic Schizophrenia/Bipolar Disorder, Gravely Disabled, Dangerous to self and others, and Aggressive/Violent Behavior. Further review revealed Patient #3 remained in the ED until 09/13/10 at 6:00pm. Further review revealed Patient #3 was PEC'd on 09/09/10 at 3:00pm and was violent, dangerous to others, and gravely disabled. He was CEC'd on 09/11/10 at 3:40pm and was violent, dangerous to self and others, and gravely disabled. Review of the "Emergency Department Physician Medical Record" revealed Physician S11 spoke with Psychiatrist S31, the psychiatrist on call, on 09/12/10 at 8:35am who recommended that Patient #3 receive Ativan 2 mg, Haldol 5 mg, and Benadryl 50 mg IM every 4 hours and Zyprexa 10 mg IN every 6 hours to control his agitation. Further review revealed Physician S11 ordered the Ativan, Benadryl, Haldol, and Zyprexa at 8:42am. There was no documented evidence these medications were ordered every 4 hours and every 6 hours as recommended by Psychiatrist S31.

Review of Patient #3's "Nursing Medical Record" revealed documentation on 09/13/10 at 9:30am by RN S10 that Patient #3 walked into Patient #4's room and began hitting Patient #4.

Patient #4
Review of Patient #4's "Emergency Department Physician Medical Record" revealed she arrived on 09/12/10 at 6:48pm with diagnoses of Depression, Substance Abuse, and Urinary Tract Infection. Further review revealed Patient #4 remained in the ED until 09/13/10 at 8:01pm. Further review revealed Patient #4 was PEC'd on 09/12/10 at 7:30pm and was gravely disabled and unable to seek voluntary admission. She was CEC'd on 09/14/10 at 10:20pm and was gravely disabled and unable to seek voluntary admission. Review of the "Emergency Department Physician Medical Record" revealed Patient #4 received Bactrim DS "1 unit dose" on 09/12/10 at 7:53pm, and there was no documented evidence Bactrim was continued for treatment of her UTI. Further review of the ED medical record revealed no documented evidence of a psychiatric consult.

Patient #5
Review of Patient #5's "Emergency Department Physician Medical Record" revealed he arrived on 09/26/10 at 2:23pm with diagnoses of History of Medical Non-Compliance, Cocaine Abuse, Suicidal Ideation, and Depression. Further review revealed Patient #5 was still in the ED on 09/27/10 at 4:36pm. Further review revealed Patient #5 was PEC'd on 09/26/10 at 3:00pm and was dangerous to self and gravely disabled. He was CEC'd on 09/27/10 at 4:30pm and was suicidal, dangerous to self, and unable to seek voluntary admission. Review of the Emergency Department Physician Medical Record" revealed Patient #5 received Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg IM on 09/26/10 at 4:37pm for agitation. Further review revealed he received Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg IM on 09/27/10 at 4:40am with no documented evidence of the behaviors that warranted the psychotropic medication. Further review of the entire ED medical record revealed no documented evidence of a psychiatric consult.

Patient #6
Review of Patient #6's "Emergency Department Physician Medical Record" revealed she arrived on 09/25/10 at 7:40pm with diagnoses of Depression, Suicidal Ideation, Suicide Attempt, Alcoholic Intoxication, Alcohol Abuse, and Multiple Lacerations of the right distal forearm/wrist. Further review revealed Patient #6 remained in the ED until 09/27/10 at 5:45pm. Further review revealed she was PEC'd on 09/25/10 at 9:00pm and was suicidal, dangerous to self, and unable to seek voluntary admission. Patient #6 was CEC'd on 09/27/10, with no documented evidence of the time, and was suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission. Review of the "Emergency Department Physician Medical Record" revealed Patient #6 received Geodon 20 mg IM on 09/25/10 at 9:45pm and Ativan 2 mg IM on 09/26/10 at 7:16pm with documentation by Physician S11 that she was "becoming more agitated and manipulative". Further review of the ED medical record revealed no documented evidence of a psychiatric consult.

Patient #7
Review of Patient #7's "Emergency Department Physician Medical Record" revealed she arrived on 08/05/10 at 1:12pm with diagnoses of Acute Exacerbation of Bipolar Disorder With Increased Depression, Depression, Suicidal Ideation, Homicidal Ideation, and Gravely Disabled. Further review revealed Patient #7 remained in the ED until 08/06/10 at 3:10pm. Further review revealed Patient #7 was PEC'd on 08/05/10 at 2:00pm and was dangerous to self and others, suicidal, homicidal, gravely disabled, and unwilling and unable to seek voluntary admission. Further review of the ED medical record revealed no documented evidence of a psychiatric consult.

Patient #8
Review of Patient #8's "Emergency Department Physician Medical Record" revealed he arrived on 09/12/10 at 12:29am with diagnoses of Psychosis, Cocaine Abuse, and Cannabis Abuse. Further review revealed Patient #8 remained in the ED until 09/14/10 at 12:31pm. Further review revealed he was PEC ' d on 09/12/10 at 1:00am and was suicidal, dangerous to self, gravely disabled, and unwilling and unable to seek voluntary admission. He was CEC'd on 09/14/10 at 10:28pm and was suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission. Review of the "Current Medications/Reconciliation Form", signed by Physician S11 on 09/13/10 with no documented evidence of the time it was signed, revealed the following medications were to be continued during the hospital stay: Catapress 0.3 mg by mouth twice daily, Aspirin 81 mg by mouth every day, Zocor 80 mg by mouth every evening, HCTZ 12.5 mg by mouth every day, Norvasc 5 mg by mouth every day, and Vasotec 40 mg by mouth every day. Review of the entire ED medical record revealed no documented evidence these medications were administered as ordered. Further review of the ED medical record revealed no documented evidence of a psychiatric consult.

Review of Patients #1's, #2's, #3's, #4's, #5's, #6's, #7's, and #8's entire ED record revealed no documented evidence of the implementation of a care plan that included the nursing interventions implemented to address the patients' identified needs for the extended stay in the ED while awaiting bed placement.

In a face-to-face interview on 09/30/10 at 1:20pm, CNO (chief nursing officer) S2 indicated the ED did not have a system in place to develop and implement nursing care plans for psychiatric patients who were held in the ED for greater than 24 hours.

In a face-to-face interview on 09/29/10 at 11:50am, Psychiatrist S26 indicated he was presently covering for the Medical Director of the Behavioral Health Unit at St. Charles Parish Hospital. He further indicated he's been to the ED a few times when the ED physician had consulted him, but it was not the routine practice to be called to the ED for a consult.

In a telephone interview on 09/30/10 at 9:15am, ED Physician S19 indicated he was the ED Medical Director. He further indicated they just held psychiatric patients in the ED while attempting to find inpatient bed placement. He further indicated it was not the policy of the hospital to request a psychiatric consult while the patient was in the ED, and they usually wait for the patient to be evaluated by the psychiatrist at the facility to which the patient was transferred. He could offer no explanation regarding the delay in treating patients who were exhibiting acute psychiatric symptoms that required a higher level of care based on PEC and/or CEC for suicidal, homicidal, violence, dangerous to self and/or others, and/or gravely disabled.

Review of the hospital's "Medical Staff Bylaws", presented by CNO (chief nursing officer) S2 as their current bylaws, revealed, in part, "...Rules of Referral and Consultation: 1. Each Medical Staff member shall: 15. The attending practitioner is primarily responsible for requesting a timely consultation when indicated. ... 17. Psychiatric consults are required for all suicidal attempts or questionable suicide attempts... Emergency Care ... Duties: 1. To review overall patient care given by the Emergency Department. This shall include a review of emergency room records, and the performance of the emergency room staff, especially in regards to code blue and other emergency situations. ... 3. To provide reports of conclusions, recommendations, actions taken and the results of the actions taken to the Executive Committee of the Medical Staff ...".

Review of the hospital policy titled "Patient Awaiting Psychiatric Evaluations", revised 08/09 and submitted by CNO S2 as their current policy for psychiatric patients held in the ED, revealed no documented evidence that a psychiatric consult would be ordered for patients held for an extended period of time in the ED.