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Based on observation, interview and record review, the facility failed to document the use of restraints according to its policy for 1 (#20) of 20 sampled patients who presented to the emergency department for emergency medical treatment. This deficiency had the potential to affect the patient's safety while in the emergency department. Findings include:

Review of patient #20's electronic medical record showed, patient #20 presented to the emergency department on 7/15/24 via ambulance after being involved in a motor vehicle crash. Patient #20 was combative on the scene, attempted to assault a sheriff deputy, and attempted to take the deputy's weapon. The record showed transport of the patient was delayed to the facility because law enforcement was required to detain the patient. Law enforcement placed the patient in handcuffs and the patient was transported to the hospital in handcuffs. The medical record showed the patient remained in handcuffs while he was in the CT scanner, and during his treatment in the emergency department. The patient's medical record lacked orders for restraints, lacked documentation of circulation distal to the restraints, and did not contain documentation showing the facility tried to place the patient in the least restrictive restraint for medical treatment.

During an interview on 8/14/24 at 4:25 p.m., staff member P stated patient #20 was in handcuffs the entire time he was in the emergency department. She stated the patient was cooperative with her, but he was aggressive towards the officers who were detaining him. Staff member P stated she was unaware restraint documentation was required for a patient in handcuffs.

During an interview on 8/15/24 at 8:43 a.m., staff member Q stated she did not know if there was a policy for law enforcement detained or arrested patients, and she did not know if she was required to assess a patient for restraints if the patient arrived to the facility in handcuffs. Staff member Q said she had not had a situation where that would have been necessary, but she would look at the policy manual to find out what the policy said if she were to have a situation where a patient was detained by law enforcement. Staff member Q said if a patient needed to be restrained in the emergency department, the provider would need to write orders, they would need to ascertain what the least restrictive restraint was for the individual, and they would be required to document the restraints on the restraint flowsheet in the patient's EMR every 15 minutes.

During an interview on 8/15/24 at 8:50 a.m., staff member A said he did not think there was a policy and/or procedure for a patient who presented to the facility that was detained by law enforcement.

Review of a facility policy titled Restraint Policy, dated 4/25/23, showed:

"POLICY STATEMENT: It is the philosophy of [Facility Name] that patients/residents have the right to be restraint free. In the event that restraint is necessary and after alternatives have been attempted the least restrictive method of restraint that meets the patient/resident assessed need will be used. An exception exists if safety issues demand an emergent intervention. The restraint is to be discontinued at the earliest possible time. The patient/resident ' s rights, dignity and well-being will be protected and preserved by the interdisciplinary team providing care. The use of a restraint for coercion, discipline, convenience or retaliation by staff is not permitted ... Documentation: a provider ordered based on the assessment/examination of the patient/resident. This order needs to be reviewed and reordered every 24 hours. The alternatives attempted OR why alternatives were not appropriate. The alternatives attempted OR why alternatives were not appropriate. Patient/resident behavior, condition, or symptom(s) that warranted the use of the restraint and any staff concerns regarding safety risks (patient/resident injury) ... Observations and/or assessments. A restraint assessment will be completed quarterly or with significant changes in resident conditions ..." [sic] The policy did not contain direction for restraints placed by law enforcement.

Review of a document published by the International Association for Healthcare Security and Safety Foundation, titled Violence in Healthcare and the Use of Handcuffs, dated 10/2/2018, showed, "The custodial officer who is with the patient is responsible for the use of handcuffs while treatment occurs. That does not, however, absolve the medical care facility of a responsibility to protect the patient while treatment is being rendered. For example, if handcuffs are too tight or are impeding medical treatment, the healthcare worker must assess the safety of continued use of restraint ..."

Based on interview and record review, the facility failed to ensure 1 (staff member F) of 15 sampled staff members, was current with their ACLS certification. This deficient practice had the potential to affect all patients who received care in the facility. Findings include:

Review of the facility personnel requirements document titled, "Registered Nurse, Job Description", signed by staff member F on 2/12/2024, showed:

" ... Essential Job Functions ...
Minimum Qualifications:

... Healthcare Provider CPR Certification, ACLS, PALS, TNCC or CALS required ..."

Review of the facility personnel file for staff member F showed, an ACLS certificate with a renew by date of 12/31/23.

During an interview on 8/15/24 at 9:17 a.m., staff member A stated he was unable find a current ACLS certification for staff member F.

During an interview on 8/15/24 at 10:12 a.m., staff member P stated it was the expectation that nursing staff working in the ED would have current BLS, ACLS and PALS certifications.