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Based on record review of 1 of 10 sampled patients (Patient #1) observations, interviews and review of Hospital policies titled Code Blue, Safety in the Emergency Department (ED), Use of Force by Safety & Security Officers, Patients' Rights & Responsibilities and review of Hospital documents, the Governing Body (GB) failed to be responsible for the conduct of the ED.

Findings include:

1.) The GB failed to ensure that the ED had complete and efficient polices and procedures that were implemented.

See A-0092

2.) The GB failed to ensure that a restraint was safely and appropriately applied to 1 of 10 sampled patients (Patient #1). The failure to apply a restraint safely and appropriately resulted in the fracturing of Patient #1's right arm.

See A-0167
3.) The Governing Board failed to ensure that the area of the ED where psychiatric patients were cared for, was safe and that the environment helped to calm psychiatric patients, decrease environmental stimulation, noise and ED activities.
a. The Surveyor observed during tours of the ED psychiatric area, on 3/18/14 at 9:30 A.M. and 2:30 P.M. and 3/31/14 at 12:00 P.M., a busy ED and Code Blues (call for security officer assistance). The Surveyor observed a cluttered hallway, a pharmacy technician stocking and taking medications out of an automated medication-dispensing machine (Pyxis machine) and a safety observer monitoring patients. The automated medication-dispensing machine was in a small space readily accessible to the hallway, visitors, patients, patient flow and unit activities. In patient rooms, in the psychiatric area of the ED, were movable ceiling tiles, hinged doorknobs and non-safety bars in patient bathrooms. At the end of the psychiatric area hallway was an unlocked door to enter the Magnetic Resonance Imaging (MRI) area. The MRI area led directly to a busy street. The decontamination shower (designed to shower patients after a chemical accident) had 2 hanging chains from the center of the ceiling with circular rings that activated the decontamination shower. The decontamination shower room had 2 doors, one was from the psychiatric area and the other was an un-locked door that led to the area where ambulances arrived with patients.

The Surveyor interviewed the Emergency Department Nurse Director on 3/19/14 at 1:50 P.M. The ED Nurse Director said the ceiling tiles were moveable and that a patient could hide something in the ceiling or hurt themselves because there were exposed pipes. The ED Nurse Director said the doorknobs were regular doorknobs, stretchers had intravenous poles and there was a refrigerator in one of the patient rooms. The ED Nurse Director said that the doorknobs, stretchers and refrigerator were all psychiatric patient safety risks. The ED Nurse Director said that the door in the MRI area, at the end of the hallway, led out of the Hospital to a busy street and that this was a patient elopement risk. The ED Nurse Director said the Pharmacy delivered and retrieved medications and nursing staff prepared patient medications from the Pyxis machine in the hallway. The ED Nurse Director said there were no surveillance cameras in the psychiatric area of the ED. The ED Nurse Director said the ED psychiatric area needed improvements for care of psychiatric patients.

The Surveyor interviewed the Nurse Practitioner (NP) on 3/19/14 at 10:30 A.M. and she said that the Hospital still had ED improvements to make, for example, moving the Pyxis machine.

The Surveyor interviewed the Risk Manager (RM) on 3/18/14 at 9:15 A.M. and on 3/31/14 at 9:30 A.M. The RM said the local Police brought psychiatric patients to the ED as a courtesy and entered with the patient through the main ED doors. The RM said this practice created an audience for the psychiatric patient. The RM said the Hospital was looking at having the Police enter through the ambulance doors for patient privacy, but the Hospital had not made this change.

The Surveyor interviewed the Chief Operations Officer (COO, a high-ranking Hospital executive for Hospital B and the Hospital) at 1:30 P.M., on 3/31/14. The COO said that Hospital B had the ideal psychiatric unit and that the Hospital had some challenges and needs some improvements. The COO said that the Hospital did not have specific plans to address the challenges and improvement needs of the Hospital's ED psychiatric area and that the Hospital had not presented the Board of Trustees a plan to relocate the MRI area. The COO said that the Hospital was reviewing where to move the MRI area, but the Hospital had made no decisions.

Review of the ED Meeting Minutes, dated 3/2014, 12/2013, 9/2013 and 6/2013 did not indicate discussion about improving the environment in the psychiatric area of the ED.

b. The Hospital failed to provide a safe place for showers, for psychiatric patients who have been in the ED for extended periods of time.

The Hospital policy titled, Patients' Rights and Responsibilities, dated 9/29/2011, indicated that patients have the right to be comfortable.

The Surveyor observed in the psychiatric area of the ED on 3/31/14 at 11:30 A.M., the decontamination shower (designed to shower patients after a chemical accident) and observed no other shower area was provided.

The Surveyor interviewed RN #1 on 3/31/14 at 11:30 A.M. RN #1 said that staff used the decontamination shower, to shower psychiatric patients that were in the ED for extended days waiting placement at another hospital.

The Surveyor interviewed the ED Nurse Director on 3/31/14 at 1:50 P.M. and said that the Hospital was no longer using the decontamination shower to shower patients as of 3/31/14. The ED Director said that the Hospital did not have another place for psychiatric patients to shower.


4.) The Governing Body failed to ensure that the Hospital developed and implemented an immediate corrective action plan regarding the incident of Patient #1's broken right arm, by the time of the survey.

The Surveyor interviewed the Risk Manager on 3/19/14 at 7:45 A.M. and she said that a corrective action plan was not immediately implemented because nothing was identified that immediately needed to change.

The failure to provide and or have a plan to create an ED environment and atmosphere in the psychiatric area that de-escalates patients' violent behavior was possibly a contributing factor to Patient #1's violent behavior. ED staff determined that Patient #1's violent behavior required physically restraining him/her and it was during this restraining procedure that Patient #1's right arm was fractured.

The failure to implement a corrective action plan leaves other violent patients, in the ED psychiatric area, susceptible to behavior escalation and potential injury.

Based on record review of 1 of 10 sampled patients (Patient #1), observations, interviews, review of Hospital policies titled Use of Force by Safety and Security Officers, Code Blue, Safety in the Emergency Department (ED) and review of Hospital documents, the Governing Body failed to ensure that ED had policies and procedures governing medical care provided in the ED that were current, implemented and revised as needed.

Findings include:

1.) The Hospital policy titled, Use of Force by Safety and Security Officers, dated 7/20/12, indicated that when a security supervisor became aware of the use of reportable force, the security supervisor would assess the incident, review the circumstances, and make a preliminary review as to the justification of the use of force. The policy did not indicate when a review was to be completed.

The Surveyor interviewed the Security Team Leader (TL) on 3/18/14 at 9:40 A.M. The Security TL said that the management of the incident was justified and he did not do the review according to the Hospital policy titled Use of Force by Safety and Security Officers, because the Hospital was still investigating an incident of Patient #1 suffering a fractured arm while being placed in restraints by security staff.

The Surveyor interviewed the Risk Manager on 3/19/14 at 9:40 A.M. The Risk Manager said that she would have expected the review of the incident from the Security Supervisor TL by now (3/19/14) because it had been over a month since the incident (the date of the incident was 2/6/14).

The failure to make a preliminary review as to the justification of the use of force in the incident of Patient #1's fractured arm was in violation of Hospital policy, and, therefore did not identify any potential immediate corrective actions that could prevent similar situations in the future.

2.) The Governing Body failed to ensure that the Medical Staff had an efficient Code Blue and Safety policies in the ED.

The Hospital policy titled, Safety in the ED, dated 5/2010, indicated that in the event of a disturbance from a patient and/or visitor the ED staff will activate a Code Blue. The policy did not indicate what a disturbance was or provide a definition of a disturbance.

The Hospital policy titled, Code Blue, dated 7/2012, indicated guidelines for Security Officers when responding to a Code Blue. The Code Blue policy did not indicate a definition of a Code Blue or guidelines, criteria or reasons appropriate for Hospital staff to call a Code Blue.

The Surveyor heard, over the Hospital's overhead paging system and during review of documents in an Administrative office, on 3/18/14 and 3/19/14, several Code Blues announcements called to the ED.

The Surveyor interviewed RN #1 on 3/31/14 at 11:30 A.M., RN #2 on 3/19/14 at 2:20 P.M., RN #3 on 3/19/14 at 2:30 P.M., the ED Team Leader on 3/19/14 at 1:45 P.M. and the ED Nurse Director on 3/19/14 at 1:50 P.M. The ED Nurse Director said that the Code Blue policy did not have reasons identified for when it was appropriate for ED staff to call a Code Blue to the ED and the policy should identify those reasons. RN's #1, #2, #3 and the ED Team Leader said the ED called many of Code Blues. RN's #1, #2, #3 and the ED Team Leader said Code Blues were called by different nurses for different reasons.

The Surveyor interviewed Security Officer #1 on 3/19/14 at 1:30 P.M. and he said that there were about 5 to 10 Code Blues called to the ED each day and that ED called some Code Blues for a Security Officer to assist with moving an elderly patient back to bed. The Security Officer said that there was some inappropriate use of Code Blues called for the ED.

The Surveyor interviewed RN #1 on 3/31/14 at 11:30 A.M. RN #1 said that sometimes a Code Blue makes a violent patient more violent and that too many people respond to a Code Blue.

The overuse and failure of the Hospital to identify appropriate use of a Code Blue added to the commotion of the psychiatric area of the ED.

Based on record review of 1 of 10 sampled patients (Patient #1), observation, interviews, Hospital policy titled Patients' Rights and Responsibilities and review of Hospital documents, the Hospital to failed to ensure that Patient #1 received care in a safe setting. The failure to provide care in a safe setting resulted in Patient #1's right arm being fractured.

Findings include:

1.) The Hospital failed to ensure that Patient #1 was cared for in a safe setting by not de-escalating his/her violent behavior prior to transferring him/her from the floor to the bed. The failure to de-escalate Patient #1's violent behavior prior to transferring him/her from the floor to a bed resulted in application of restraints and the fracturing of Patient #1's right arm.

The Hospital policy titled, Patients' Rights and Responsibilities dated 9/29/2011, indicated that patients have the right to receive care and treatment in a safe and secure environment. The policy indicated that staff would attempt alternatives to restraining a patient, including diversion activities.


The Orthopedic Consultation Report, dated 2/6/14, indicated that x-rays showed that Patient #1's right arm was fractured.

Based on record review of 1 of 10 sampled patients (Patient #1), interviews, Hospital policy titled, Patients' Rights and Responsibilities and review of Hospital documents, the Hospital to failed to ensure that Emergency Department (ED) staff restrained Patient #1 safely and appropriately. The failure to restrain Patient #1 safely and appropriately resulted in Patient #1's right arm being fractured.

Findings include:

1.) The Hospital failed to ensure that ED staff safely and appropriately restrained Patient #1.

The Hospital policy titled, Patients' Rights and Responsibilities dated 9/29/2011, indicated that patients have the right to receive safe treatment.

The Hospital policy titled, Restraints, dated 3/14, indicated that the Hospital's standard of practice in the use of restraints was to ensure patient safety and well-being.

The Surveyor interviewed the Risk Manager on 3/19/14 at 1:30 P.M. and she said that the Hospital did not have a policy for transferring a violent patient from the floor to a bed. The Risk Manager said that the Hospital Internal Investigation identified that the Emergency Department needed additional diversion activities for psychiatric patients, but the diversion activities (for example, puzzles) were not purchased.

Nursing Notes dated 2/6/14 at 2:39 P.M. through 3: 00 P.M., indicated that Patient #1 was using foul language in a conversation on his/her cell phone and the nurse was unable to de-escalate Patient #1. The Nursing Notes indicated Patient #1 lunged at a Nurse Practitioner (NP) after the NP asked and attempted to remove the cell phone from Patient #1. The Nursing Note, dated 2/6/14 at 2:49 P.M. indicated that as Patient #1 was being restrained by security staff, Patient #1 complained that his/her arm was "broken."

The Orthopedic Consultation Report dated 2/6/14 indicated that Patient #1's right arm was fractured.

The Surveyor interviewed RN #1 on 3/31/14 at 11:30 A.M. RN #1 said Patient #1 was sitting on the floor, flailing his/her arms but was not hitting or banging his/her head on the floor or wall. RN #1 said that Security Officers moved Patient #1 from the floor to the bed. And, while they were attempting to re-position Patient #1 from the bottom of the bed to the center of the bed and apply restraints to Patient #1's arms, Patient #1 twisted his/her right arm, RN #1 heard a crack and an X-ray confirmed that Patient #1's right arm was fractured.

The Surveyor interviewed the NP on 3/19/14 at 10:30 A.M. The NP said that she attempted to de-escalate Patient #1 by talking to him/her and asked Patient #1 for the phone.

The Surveyor interviewed Security Officer #2 on 3/31/14 at 9:45 A.M. Security Officer #2 said that it remained undetermined if Patient #1's right arm was fractured while moving him/her from the floor to the bed or during the restraining procedure.