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Based on observations, record reviews, and interviews, the hospital failed to ensure that patients in restraints in the hospital's emergency department received care and services in a responsible manner to ensure the safety of those patients restrained for 1 of 1 patient who died while in an inappropriate hold as well as physical restraints. (Patient 12 )


The findings are:


Cross Reference to A 0049: Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the governance of the hospital failed to ensure the oversight and monitoring of patients in restraints receiving care in the emergency department to ensure clear expectations for the patient's safety were established for 1 of 1 patients in restraints who died while in an inappropriate hold in the emergency department. (Patient 12)

Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the governance of the hospital failed to ensure the oversight and monitoring of patients in restraints receiving care in the emergency department to ensure clear expectations for the patient's safety were established for 1 of 1 patients in an inappropriate hold as well as physical restraints who died in the emergency department. (Patient 12)


The findings are:


On 3/16/2017 at 2:30 p.m., review of the hospital's video of a restraint episode revealed Patient 12 sitting in a chair located in the hallway in the vicinity of the nurse station in Pod C using the telephone. The patient rose from the chair and replaced the telephone. The patient began walking down the hall way. As the patient was walking down the hallway, a security officer was viewed entering the nursing unit and walking in the same direction as Patient 12. Two security officers were observed standing at the end of the same hallway . Obstructing the hallway were three beds lined up beside the nurse station wall on the left and a large dietary food cart was located in the hallway on the right side in front of the patient rooms. Observations showed Patient 12 walked down the hallway passing the dietary cart and stopped in the doorway of the patient room. The dietary cart was located in front of the patient room and blocked Patient 12's body. Only the patient's head was visible above the dietary cart. Observations showed the security officer walked past the dietary cart and walked down the hall past the patient. Then, the security officer turned around and walked back up the hallway in the direction of the patient. The security officer stopped when he reached the patient. A verbal exchange occurred between the security officer and the patient, but the verbal exchange could not be heard since the video had no audio. After the verbal exchange, the patient moves into view in the hallway and hits the security officer in the nose. Then, the security officer grabs the patient and is joined by the two security officers previously viewed in the lower hallway who rush to assist the security officer. The security officer is bleeding from the nose. The three security officers place the patient in a hold and maneuver the patient towards a bed located in the hallway. The patient is resisting as the officers maneuver the patient towards the bed. Upon reaching the bed, the security officers, continuing their hold on the patient, position the patient's upper body face down onto the bed maintaining the hold. The injured security officer removes himself from the patient and another security officer takes his place. A staff member assesses the security officer's injury. For most of the video, the patient cannot be visualized except an occasional glance at the top of the patient's head because the patient's body is surrounded by security guards who appear to be leaning over or on the patient's body. Hospital staff wearing blue scrubs are attempting to apply 4 point restraints and administer an injection. The security officers place the patient face down on the bed. Security staff and hospital staff surround the bed, but the patient is not visible. Then, security officers and hospital staff turn the patient from the stomach to the patient's back. Hospital staff and the security officers continue to surround the stretcher. Then, a staff member is on the bed performing chest compressions on the patient and the bed is transferred to a room. There was no clinical intervention by hospital clinical staff to contain the incident when incident initially erupted in the hallway, and there was no clinical assessments of the patient by either clinical staff or security staff or any clinical interventions by clinical staff during the crisis to assess the patient. Multiple hospital staff were in the hallway watching the event. The clinical staff failed to perform a clinical assessment of the patient during the restraint episode. There was no supervision or leadership coordinating the management of the crisis to ensure the patient's safety. Based on video observations and review of the training policies and materials, titled, "....Aggression Management", the security officers failed to perform a safe take down hold in that the patient's upper body was placed face down on the bed for a period of approximately 10 minutes,
based on the accuracy of the times appearing on the video, and there was no clinical assessment of the restrained patient throughout the incident to ensure the patient's safety. The patient died while restrained in an inappropriate hold , 4 point restraints, and receiving an injection without any evaluations of the patient's condition to ensure the patient's safety when restrained. There was no supervision by hospital staff to manage the crisis throughout the restraint episode. Staff appeared to watch the security officers holding the patient or providing care to the injured officer.

Based on record reviews and interviews, the hospital failed to promote and ensure the safety of 1 of 1 patient who died while in an inappropriate hold as well as physical restraints in the hospital's emergency department with a potential to affect any restrained patient when crisis management, medical management, clinical leadership, and clinical assessments are not implemented during restraint interventions. (Patient 12 )


The findings are:


On 3/16/2017 at 2:30 p.m., review of the hospital's video of a restraint incident revealed Patient 12 sitting in a chair located in the hallway in the vicinity of the nurse station in Pod C using the telephone. The patient rose from the chair and replaced the telephone. The patient began walking down the hall way. As the patient was walking down the hallway, a security officer was viewed entering the nursing unit and walking in the same direction as Patient 12. Two security officers were observed standing at the end of the same hallway . Obstructing the hallway was three beds lined up beside the nurse station wall on the left and a large dietary food cart was located in the hallway on the right side in front of the patient rooms. Observations showed Patient 12 walked down the hallway passing the dietary cart and stopped in front of the doorway by the patient. The dietary cart located in front of the patient room blocked Patient 12's body,and only the patient's head was visible above the dietary cart. Observations showed the security officer walked past the dietary cart and walked down the hall past the patient. Then , the security officer turned around and walked back up the hallway in the direction of the patient. The security officer stopped when he reached the patient. A verbal exchange occurred between the security officer and the patient, but the verbal exchange could not be heard since the video had no audio. After the verbal exchange, the patient moves into view in the hallway and hits the security officer in the nose. Then, the security officer grabs the patient and is joined by the two security officers previously viewed in the lower hallway who rush to assist the security officer. The security officer is bleeding from the nose. The three security officers place the patient in a hold and maneuver the patient towards a bed located in the hallway. The patient is resisting as the officers maneuver the patient towards the bed. Upon reaching the bed, the security officers, continuing their hold on the patient, position the patient's upper body face down onto the bed maintaining the hold. The injured security officer removes himself from the patient and another security officer takes his place. A staff member assesses the officer's injury. For most of the video, the patient cannot be visualized except an occasional glance at the top of the patient's head because the patient's body is surrounded by security guards who appear to be leaning over the patient's body. Hospital staff wearing in blue scrubs apply 4 point restraints and administer an injection. The security officers place the patient face down on the bed. Security staff and hospital staff surround the bed but the patient is not visible. Then, security officers and hospital staff turn the patient from the stomach to the patient's back. Hospital staff and the security officers continue to surround the stretcher. Then, a staff member is on the bed performing chest compressions on the patient and the bed is transferred to a room. There was no intervention by hospital clinical staff when the incident initially occurred in the hallway and there was no assessment of the patient by either clinical staff or security staff or any interventions by clinical staff during the event to assess the patient's safety. Multiple hospital staff were in the hallway watching the event. The clinical staff failed to perform a clinical assessment of the patient during the restraint episode. There was no supervision or leadership coordinating the management of the crisis to ensure the patient's safety. Based on video observations and review of the training policies and materials, titled, "Aggression Management", the security officers failed to perform a safe take down hold in that the patient's upper body was placed face down on the bed for a period of approximately 10 minutes,
based on the accuracy of the times appearing on the video, and there was no clinical assessment of the restrained patient throughout the incident to ensure the patient's safety. The patient died.

Cross Reference to A 0049: The governance of the hospital failed to ensure the oversight and monitoring of patients receiving care in in the hospital's emergency department to ensure that clear expectations for safety were established for 1 of 1 patients who was restrained in an inappropriate hold in the emergency department and the patient died. (Patient 12 )

On 3/13/2017 from 12:15 p.m. to 12:45 p.m., a tour of the hospital's emergency department was conducted with the Emergency Room Director of Nursing. During the tour of the emergency department, the Director of Nursing revealed the emergency department had a Behavioral Health Unit for the holding and the observation of patients presenting to the emergency department with behaviors, suicidal or homicidal ideations. The Director of Nursing for the Emergency Department stated there is overflow of these patients to Pod C and Pod D. There may also be overflow of medical patients located in Pod C. On 3/15/2017 at 10:00 a.m., the Director of Nursing for the Emergency Department revealed there are no policies and procedures or criteria for admission for the Behavioral Health Unit.

Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure its staff followed the hospital's policies and procedures to ensure protection and promote safety for patients in restraints for 1 of 1 patient who died while in an inappropriate hold as well as physical restraints. (Patient 12)


The findings include:


On 3/13/2017 from 12:15 p.m. to 12:45 p.m., a tour of the hospital's emergency department was conducted with the Emergency Room Director of Nursing. During the tour of the emergency department, the Director of Nursing revealed the emergency department has a Behavioral Health Unit for the holding and the observation of patients presenting to the emergency department with behaviors, suicidal, or homicidal ideations. The Director of Nursing for the Emergency Department stated there is overflow of behavioral patients to Pod C and Pod D. There may also be overflow of some medical patients located in Pod C. On 3/15/2017 at 10:00 a.m., the Director of Nursing revealed there are no policies and procedures or criteria for admission for the Behavioral Health Unit.

Cross Reference to A 0144: The governance of the hospital failed to ensure the oversight and monitoring of patients receiving care in in the hospital's emergency department to ensure that clear expectations for safety were established for 1 of 2 patients receiving care in the emergency department

Cross Reference to A 0160: The hospital failed to ensure that assessments are completed prior to administering a drug for the control of the patient's behaviors(restraint) for 1 of 2 patients administered medications in the emergency room.

Based on record reviews and interview, the hospital failed to ensure that patients received the hospital's patient rights information prior to receiving treatment for 20 of 20 patient charts reviewed. (Patient 1 - 20)

The findings are:


On 3/14.2017 to 3/16/2017, review of 20 patient charts revealed there was no system in place for the hospital to verify patients or the patient's representative received a copy of the hospital's patient rights information.
Review of Patient 1's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 2's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 3's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 4's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 5's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 6's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 7's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 8's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 9's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 10's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 11's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 12's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 13's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 14's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 15's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 16's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 17's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 18's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 19's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.
Review of Patient 20's chart revealed there was no documentation that the patient/patient's representative received the hospital's patient rights information.

On 3/15/2017 at 2:15 a.m., the Quality Coordinator provided a copy of the hospital's patient rights documentation, but reported the hospital has no documentation that the patient actually receives the patient's rights information.

Based on record reviews and interview, the hospital failed to ensure patients received and authenticated the hospital's "Consent and Authorization" form for 7 of 20 patient charts reviewed for consent for treatment (Patient 3, Patient 7, Patient 9, Patient 12, Patient 13, Patient 14, and Patient 17), and failed to accurately complete the "Lewis Blackman Patient Safety Information Sheet" for 2 of 20 Patient charts reviewed. (Patient 1 Patient 6)


The findings are:


Based on review of 20 patient charts from March 14, 2017 through March 16, 2017, there was no documentation that 12 of the 20 patient records reviewed had the hospital's consent for treatment form authenticated. Review of the hospital's "Consent and Authorization" form revealed a three part document that included on Page 1, sections identified as "Consent and Authorization For Routine Treatment", "Physicians", "Telemedicine", and "Assignment of Insurance Benefits and Third Party Claims"; Page 2 showed sections for "Financial Agreement", "Medicare Patients", and "Contacting Patients"; and Page 3 revealed "Disclosure of Health Information", Photographing and Videotaping", Personal Valuables/Belongings", and Healthcare Associated Infections". There was either no documentation the patient authenticated a health consent for treatment or the authentication on the form for verbal consent was accurately completed.

Review of Patient 1's chart revealed the patient was treated in the hospital on 02/11/2017 for a Subluxation of the shoulder. Review of the "Lewis Blackman Patient Safety Information Sheet' in the patient's chart revealed in the space designated for the patient's signature was recorded "*verbal" with the date "2/11/17". The section, titled, Person Authorized to Sign for Patient/Relationship" was blank. There were no other signatures on the form.

Review of Patient 3's chart revealed the patient was treated in the hospital on 2/13/2017 poisoning. Review of the patient's chart revealed there was no "Consent and Authorization" forms or "ED Physician Certificate of Inability To Consent to Healthcare Decisions Order For Medical Hold" form on the patient's chart.

Review of Patient 6's chart revealed the patient was treated in the hospital from 2/19/ 2017 to 2/20/2017 in the hospital's emergency department for Unspecified displaced fracture of surgical neck of left Humerus. Review of the patient's chart revealed a form for "ED Physician Certificate of Inability To Consent to Healthcare Decisions Order For Medical Hold" form dated 2/19/17 at 2328 related to the patient's intoxicated state. Review of the patient's chart also revealed the "Consent and Authorization" three page form that showed verbal consent from the patient was received and witnessed by hospital personnel on "2/19/2017 at 2300". Review of the "Lewis Blackman Patient Safety Information Sheet' in the patient's chart revealed in the designated space for the patient's signature was recorded "X Verbal consent" and the date "2/19/17 at 2300". The section of the form, titled, "Person Authorized to Sign for Patient/Relationship", and the section of the form designated for the "date and time" was blank.

Review of Patient 6's chart showed the patient was treated in the hospital's emergency department on 03/01/2017 for a stab puncture wound. Review of the patient's chart revealed there were no "Consent and Authorization" forms on the chart or an "ED Physician Certificate of Inability To Consent to Healthcare Decisions" form on the patient's chart.

Review of Patient 9's chart revealed the patient was treated in the hospital on 03/03/2017 for a psychiatric evaluation and commitment papers. Review of the patient's chart revealed there was neither an "ED Physician Certificate of Inability To Consent to Healthcare Decisions" form or a "Consent and Authorization" form on the patient's chart.

Review of Patient 12's chart revealed the patient was treated at the hospital from 3/05.2017 through 3/06/2017 for a gunshot wound. Review of the patient's chart revealed there was neither an "ED Physician Certificate of Inability To Consent to Healthcare Decisions" form or a "Consent and Authorization" form on the patient's chart.

Review of Patient 13's chart revealed the patient was treated at the hospital from 3/6/2017 to 3/7/2017 for Altered Mental Status. Review of the patient's chart revealed there was neither an "ED Physician Certificate of Inability To Consent to Healthcare Decisions" form or a "Consent and Authorization" form on the patient's chart.

Review of Patient 14's chart revealed the patient received treatment in the hospital's emergency department from 3/7/2017 through 3/8/2017 for homicidal and suicidal ideations. Review of the patient's chart revealed there was neither an "ED Physician Certificate of Inability To Consent to Healthcare Decisions" form or a "Consent and Authorization" form on the patient's chart.

Review of Patient 17's chart revealed the patient received treatment in the hospital from 03/09/2017 to 3/10/2017. Review of the patient's chart revealed there was neither an "ED Physician Certificate of Inability To Consent to Healthcare Decisions" form or a "Consent and Authorization" form on the patient's chart.

On 3/15/2017 at 2:30, the Quality Coordinator verified the findings. The Quality Coordinator explained Supervisor 1 in the Medical Records Department completes all patient charts within 72 hours of the patient's discharge. If the forms are not on the patient's chart that there are none, but the Medical Records Department staff will review the loose sheets in the department, and if the health consent forms are found, the health consent forms will be forwarded to the surveyor. The Medical Record Department submitted no further chart materials for health consent to the surveyor.

Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the governance of the hospital failed to ensure the oversight and monitoring of patients restrained in the hospital's emergency department to ensure clear expectations for safety were established for 1 of 1 patients who died during an inappropriate hold as well as physical restraints in the emergency department. (Patient 12 )


The findings are:


On 3/16/2017 at 2:30 p.m., review of the hospital's video of a restraint incident revealed Patient 12 sitting in a chair located in the hallway in the vicinity of the nurse station in Pod C using the telephone. The patient rose from the chair and replaced the telephone. The patient began walking down the hall way. As the patient was walking down the hallway, a security officer was viewed entering the nursing unit and walking in the same direction as Patient 12. Two security officers were observed standing at the end of the same hallway . Obstructing the hallway was three beds lined up beside the nurse station wall on the left and a large dietary food cart was located in the hallway on the right side in front of the patient rooms. Observations showed Patient 12 walked down the hallway passing the dietary cart and stopped in front of the doorway by the patient. The dietary cart located in front of the patient room blocked Patient 12's body,and only the patient's head was visible above the dietary cart. Observations showed the security officer walked past the dietary cart and walked down the hall past the patient. Then , the security officer turned around and walked back up the hallway in the direction of the patient. The security officer stopped when he reached the patient. A verbal exchange occurred between the security officer and the patient, but the verbal exchange could not be heard since the video had no audio. After the verbal exchange, the patient moves into view in the hallway and hits the security officer in the nose. The video does not show the security officer used either the "punch evasion' technique or the punch block technique shown in the hospital's training guide when the patient hit him. Then, the security officer grabs the patient's arm and is joined by the two security officers previously viewed in the lower hallway who rush to assist the security officer. The security officer is bleeding from the nose. The three security officers place the patient in a hold and maneuver the patient towards a bed located in the hallway. The patient is resisting as the officers maneuver the patient towards the bed. Upon reaching the bed, the security officers, continuing their hold on the patient, position the patient's upper body face down onto the bed maintaining the hold. The injured security officer removes himself from the patient and another security officer takes his place. A staff member assesses the officer's injury. For most of the video, the patient cannot be visualized except an occasional glance at the top of the patient's head because the patient's body is surrounded by security guards who appear to be leaning over the patient's body. Hospital staff wearing in blue scrubs apply 4 point restraints and administer an injection. The security officers place the patient face down on the bed. Security staff and hospital staff surround the bed but the patient is not visible. Then, security officers and hospital staff turn the patient from the stomach to the patient's back. Hospital staff and the security officers continue to surround the stretcher. Then, a staff member is on the bed performing chest compressions on the patient and the bed is transferred to a room. There was no intervention by hospital clinical staff when the incident initially occurred in the hallway and there was no assessment of the patient by either clinical staff or security staff or any interventions by clinical staff during the event to assess the patient's safety. Multiple hospital staff were in the hallway watching the event. The clinical staff failed to perform a clinical assessment of the patient during the restraint episode. There was no supervision or leadership coordinating the management of the crisis to ensure the patient's safety. Based on video observations and review of the training policies and materials, titled, ".....Aggression Management" the security officers failed to perform a safe take down hold in that the patient's upper body was placed face down on the bed for a period of approximately 10 minutes,
based on the accuracy of the times appearing on the video, and there was no clinical assessment of the restrained patient throughout the incident to ensure the patient's safety. The patient died during the restraint episode when an improper restraint hold
was implemented.

On 3/16 2017 at 1:45 p.m., an interview was conducted with NP 3. NP 3 stated the gentleman (Patient 12) was there when she arrived for duty. NP 3 stated he had been there (in hospital) since day before, that his brother had shot him and the patient was on commitment papers. NP practitioner 3 stated that the patient wasn't suicidal or homicidal. NP 3 stated she discussed the patient with the physician and they discussed discharging the patient. NP 3 stated the patient was homeless and wanted to eat breakfast before he left. NP 3 reported that she saw a bunch of people running and three security guys wrestling with the patient trying to contain him. NP 3 stated the security guy asked the patient if the patient wanted to go to the bathroom and told the patient "get back in your room" and the patient punched him. NP 3 said the patient was yelling and trying to get loose but the security guys were moving the patient towards the Hallway Bed 309 and the patient was resisting. NP 3 said she felt things were getting out of hand. NP 3 stated she could not see the patient's face as security had the patient positioned bent over the bed. NP stated the security guard was bleeding. NP 3 stated a nurse gave the patient Geodon and 4 point restraints were placed on the patient. NP 3 stated the patient was placed on the bed on his stomach. NP 3 stated the patient was turned and someone noticed the patient wasn't breathing and a nurse started chest compressions and a code was called.

On 3/13/2017 from 12:15 p.m. to 12:45 p.m., a tour of the hospital's emergency department was conducted with the Emergency Room Director of Nursing. During the tour of the emergency department, the Director of Nursing revealed the emergency department had a Behavioral Health Unit for the holding and the observation of patients presenting to the emergency department with behaviors, suicidal or homicidal ideations. The Director of Nursing for the Emergency Department stated there is overflow of these patients to Pod C and Pod D. There may also be overflow of medical patients located in Pod C. On 3/15/2017 at 10:00 a.m., the Director of Nursing for the Emergency Department revealed there are no policies and procedures or criteria for admission for the Behavioral Health Unit.

On 3/16/2017 at 1:50 p.m., Charge Nurse 1 verified that she was the Registered Nurse in charge of the Emergency Department on 3/6/2017 when the incident occurred in Pod C between the a patient and security. Charge Nurse 1 stated that he/she didn't really see anything. Charge Nurse 1 stated that when she got a call about the incident, she reported to Pod C to perform infection control duties since there had been a blood spill from the security officer. Charge Nurse 1 reported that he/she saw the first stretcher bed in the hallway had a patient laying on the stomach with his head facing to the right. Charge Nurse 1 stated that it was difficult to visualize the patient's face as security was covering the patient. Charge Nurse 1 stated that when the patient was turned on the back, she heard .......NP 3 say, "I believe he is unresponsive. " Charge Nurse 1 stated, "Then chest compressions were started and the code was initiated."

On 3/15/2017 at 2:55 p.m., Nurse Practitioner 2 verified that he/she was on duty in the emergency department in Pod C on 3/5/2017 on the 7 a.m. to 7 p.m. shift. NP 2 reported during the interview that the patient was in Pod C when she reported for duty on 3/5/2017. NP 2 stated that NP 1 reported off on the patient during the shift turnover. ( NP 1 is the practitioner who saw the patient during the patient's first admission prior to the patient leaving AMA.) There was documentation by NP 1 that she consulted on Patient 12 during the patient's second visit on 3/5/2017. NP 2 stated she did not know who made the decision for the patient to stay in the emergency department in Pod C. NP 2 stated that he/she was told the patient was there and needed to be assessed and she assessed the patient.

Based on record review and interview, the hospital failed to ensure that assessments are completed prior to administering a drug for the control of the patient's behaviors(restraint) for 1 of 2 patients administered medications in the emergency room. (Patient 12)


The findings are:


Review of Patient 12's nursing notes dated 3/5/2017 at 7:42 p.m. and recorded by RN 3 revealed " Pt GSW (gun shot wound) wrapped with gauze and cling at this time. Bleeding controlled. RN 3 recorded a note on 3/5/2017 at 7:56 p.m., reads, " Pt yelling out of room at this time, apparently at nothing, when this RN and a security officer went to see what was the matter, the pt said, "Well take me downtown!" and was verbal aggressive towards staff and ....security. Pt threw blankets off of himself and scooted halfway out of bed in an aggressive manner (naked). Pt was persuaded back into bed and voluntarily took a shot of Geodon and stated that he "wanted something to help him sleep." Geodon is not appropriate use for a hypnotic. There was no documentation of an assessment and evaluation of the patient prior to administering the Geodon.

Based on record review and interview, the hospital failed to ensure that a patient in a restraint is assessed for the least restrictive measure before implementation of restraints for 1 of 2 patients in restraints. (Patient 13)


The findings are:


On 3/15/2017 at 4:00 p.m., review of Patient 13's chart revealed the patient presented to the emergency department on 3/6/2017 at 9:50 p.m. for a chief compliant of "Altered Mental Status". Plan : Patient presentation consistent with recreational drug abuse and intoxication. Patient given Ativan to calm her given her agitated state she lives threat to self and others. Was placed in 4 point restraints until Ativan was able to calm her sufficiently then restraints removed. " Review of medical orders dated 3/6/2017 at 10:08 p.m. revealed Ativan 2 milligrams (MGS) intravenous that was administered by nursing on 3/6/2017 at 11:00 p.m.. as well as another medical order dated 3/6/2017 at 10:09 p.m. for 4 point restraints continuous for 4 hours. In the section for types of restraints ordered was recorded as "violent or self destructive adult" 4 point restraint and Medication, and the restraint reason was listed as Danger to self and others. Review of the documentation on the flow sheet dated 3/6/2017 at 2330 revealed the patient had a " Non - Violent Restraints" - wrist restraint to the right wrist and had applied a wrist restraint to the left wrist . The physician order for 4 point restraints was not implemented with no documentation of a change in the physician's order. In the section of the flow sheet, titled, "Less Restrictive Alternative", was recorded " Verbal instructions to patient/family. Medication part of patient care plan."
In the section of the flow sheet labeled "Evaluation for use of least restrictive device?" revealed the nurse recorded "Yes" but did not document the implementation of or the evaluation of the patient for least restrictive measures.

Based on record reviews and interview, the hospital failed to ensure that a patient restrained receives a 1 hour face to face evaluation by a practitioner for 1 of 2 patients in restraints. (Patient 13)


The findings are:


On 3/15/2017 at 4:00 p.m., review of Patient 13's chart revealed the patient presented to the emergency department on 3/6/2017 at 9:50 p.m. for a chief compliant of "Altered Mental Status". Review of the patient's chart showed the husband stated the wife left 6 days ago and returned yelling loudly and incoherently, uncooperative. Review of the history and physical dated 3/7/17 at 12:15 a.m. revealed the patient arrived agitated, hallucinating, stimulated, clinically intoxicated. The patient's history and physical also showed the provider recorded" "Patient given Ativan to calm her given her agitated state, she lives threat to self and others. Was placed in 4 point restraints until Ativan was able to calm her sufficiently then restraints removed. " Review of medical orders dated 3/6/2017 at 10:08 p.m. revealed Ativan 2 milligrams (MGS) intravenous was administered by nursing on 3/6/2017 at 11:00 p.m.. as well as another medical order dated 3/6/2017 at 10:09 p.m. for 4 point restraints continuous for 4 hours. In the section for types of restraints ordered was recorded as "violent or self destructive adult" 4 point restraint and Medication, and the restraint reason was listed as Danger to self and others. Review of the documentation on the flow sheet dated 3/6/2017 at 2330 revealed the patient had a " Non - Violent Restraints" - restraint to the right wrist and a wrist restraint to the left wrist . The physician order for 4 point restraints was not implemented with no documentation of a change in the physician's order. The physician order was for 4 hours, but review of the flow sheet documentation revealed the restraints were not discontinued until 3/7/2017 at 06:56 a.m. which was more than 4 hours. There was no documentation of the 1 hour face to face

Based on record reviews and interviews, the hospital failed to ensure its nurses followed the hospital's policies and procedures to promote safety for restrained patients in high risk problem prone areas in the emergency department for 1 of 1 patient who died while in an inappropriate hold as well as physical restraints in the emergency department. (Patient 12 )


The findings are:


Cross Reference to A 0392: The hospital failed to ensure its nursing staff followed the hospital's policies for evaluating and assessing patients in restraints to ensure the safety of its patients for 1 of 1 patient restrained. (Patient 12)

Cross Reference to A 0395: Nursing Services failed to ensure its nursing staff provided the supervision necessary to protect and assess patients in crisis situations for 1 of 1 patients in restraints. (Patient 12)

Based on record reviews and interviews, the hospital failed to ensure its nursing staff followed the hospital's policies for the assessment of restrained patients to ensure the safety of its restrained patients for 1 of 1 patient who died while restrained (Patient 12).


The findings are:


On 3/6/2017 at 09:30 a.m., Patient 12 was placed in an inappropriate hold by security officers. There was no intervention by hospital clinical staff when the incident initially occurred in the hallway and there was no assessment of the patient by either clinical staff or security staff or any interventions by clinical staff during the event to assess the patient's safety. Multiple hospital staff were in the hallway watching the event. The clinical staff failed to perform a clinical assessment of the patient during the restraint episode. There was no supervision or leadership coordinating the management of the crisis to ensure the patient's safety. Based on video observations and review of the training policies and materials, titled, Aggression Management the security officers failed to perform a safe take down hold in that the patient's upper body was placed face down on the bed for a period of approximately 10 minutes, based on the accuracy of the times appearing on the video, and there was no clinical assessment of the restrained patient throughout the incident to ensure the patient's safety. The patient died.

Review of Patient 12's nursing notes dated 3/5/2017 at 7:56 p.m., reads, " Pt yelling out of room at this time, apparently at nothing, when this RN and a security officer went to see what was the matter, the pt said, "Well take me downtown!" and was verbal aggressive towards staff and ....security. Pt threw blankets off of himself and scooted halfway out of bed in an aggressive manner (naked). Pt was persuaded back into bed and voluntarily took a shot of Geodon, and stated, that he "wanted something to help him sleep." RN 3 documented Geodon 20 mg was administered on 3/5/2017. Geodon is not appropriate to use for a hypnotic.

Based on observations, record reviews, and interviews, Nursing Services failed to ensure its nursing staff provided the supervision and assessment necessary to protect and evaluate restrained patients in crisis situations for 1 of 1 patients in an inappropriate hold who died in the emergency department. (Patient 12 )


The findings included:


Cross Reference to A 0144: The governance of the hospital failed to ensure the oversight and monitoring of patients restrained in the hospital's emergency department to ensure clear expectations for safety were established for 1 of 1 patients who died during an inappropriate hold as well as physical restraints in the emergency department. (Patient 12 )

On 3/6/2017 at 09:30 a.m., review of an incident involving security officers and Patient 12 revealed nursing conducted no clinical assessment for a patient who was restrained in an inappropriate patient hold, and in 4 point restraints, and medicated while restrained. There was no observation of clinical supervision or coordination and management throughout the incident which concluded with cardiopulmonary resuscitation of the patient and the patient's death. On 3/16/2017 at 1:50 p.m., Charge Nurse 1 verified that she was the Registered Nurse in charge of the Emergency Department on 3/6/2017 when the incident occurred in Pod C between the patient and security officers. Charge Nurse 1 stated that he/she didn't really see anything. Charge Nurse 1 stated that when she got a call about the incident, she reported to Pod C to perform infection control duties since there had been a blood spill from the security officer. Charge Nurse 1 reported that he/she saw the first stretcher bed in the hallway had a patient laying on the stomach with his head facing to the right. Charge Nurse 1 stated that it was difficult to visualize the patient's face as security was covering the patient. Charge Nurse 1 stated that when the patient was turned on the back, she heard .......NP 3 say, "I believe he is unresponsive. " Charge Nurse 1 stated, "Then chest compressions were started and the code was initiated."

On 3/16 2017 at 1:45 p.m., an interview was conducted with NP 3. NP 3 stated the gentleman (Patient 12) was there when she arrived for duty. NP 3 stated he had been there (in hospital) since day before, that his brother had shot him and the patient was on commitment papers. NP practitioner 3 stated that the patient wasn't suicidal or homicidal. NP 3 stated she discussed the patient with the physician and they discussed discharging the patient. NP 3 stated the patient was homeless and wanted to eat breakfast before he left. NP 3 reported that she saw a bunch of people running and three security guys wrestling with the patient trying to contain him. NP 3 stated the security guy asked the patient if the patient wanted to go to the bathroom and told the patient "get back in your room" and the patient punched him. NP 3 said the patient was yelling and trying to get loose but the security guys were moving the patient towards the Hallway Bed 309 and the patient was resisting. NP 3 said she felt things were getting out of hand. NP 3 stated she could not see the patient's face as security had the patient positioned bent over the bed. NP stated the security guard was bleeding. NP 3 stated a nurse gave the patient Geodon and 4 point restraints were placed on the patient. NP 3 stated the patient was placed on the bed on his stomach. NP 3 stated the patient was turned and someone noticed the patient wasn't breathing and a nurse started chest compressions and a code was called.

On 3/13/2017 from 12:15 p.m. to 12:45 p.m., a tour of the hospital's emergency department was conducted with the Emergency Room Director of Nursing. During the tour of the emergency department, the Director of Nursing revealed the emergency department had a Behavioral Health Unit for the holding and the observation of patients presenting to the emergency department with behaviors, suicidal or homicidal ideations. The Director of Nursing for the Emergency Department stated there is overflow of these patients to Pod C and Pod D. There may also be overflow of medical patients in Pod C. On 3/15/2017 at 10:00 a.m., the Director of Nursing for the Emergency Department revealed there are no policies and procedures or criteria for admission of patients to its Behavioral Health Unit.