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Based on interview and record review, the facility failed to ensure consistent assessments were completed for a patient physically restrained (Patient 7). The failure of consistent reassessments had the potential for a delay in the identification of the earliest time the restraints could safely be removed, and for the avoidance of injury, and/or death of a patient.

Findings:

During an interview with the Chief Nursing Officer (CNO), on March 24, 2015, at 1:30 p.m., the CNO stated once a sitter was provided for a patient to ensure the patient's safety, restraints if temporarily used, would be removed.

The record for Patient 7 was reviewed. Patient 7 presented to the Emergency Department (ED) by ambulance, on March 14, 2015, at 7:10 p.m., with the chief complaint of "Overdose-Accidental ..."

The nursing triage entry for 7:26 p.m., indicated "...(patient stated to family) she wants to kill herself by taking 5 Valium ( a medication used as a muscle relaxor or for sedation).

The triage entry further indicated Patient 7 was drowsy and easy to arouse.

The physician document titled "Non-behavioral Restraint Order" dated March 14, 2015, at 7:30 p.m., indicated an order for left and right soft wrist restraints to be applied to Patient 7 to prevent falling, climbing out of bed, and unsafe ambulating.

The nurses notes entry for 10:07 p.m., indicated a sitter at bedside was provided for Patient 7.

The nurses notes section titled "Restraints,", indicated the following;

"Time- March 14, 2015, at 7:30 p.m. Physician order is written. Type of restraints used soft. Body parts restrained: left wrist, right wrist. Reason for restraints: altered level of consciousness, fall prevention, protect patient."

"Time- March 14, 2015, at 9:30 p.m. Type of restraints used soft. Body parts restrained: left wrist, right wrist. Reason for restraints: altered level of consciousness, fall prevention, protect patient."

"Time- March 14, 2015, at 11:30 p.m. Type of restraints used soft. Body parts restrained: left wrist, right wrist. Reason for restraints: altered level of consciousness, fall prevention, protect patient."

"Time- March 15, 2015, at 1:30 a.m. Type of restraints used soft. Body parts restrained: left wrist, right wrist. Reason for restraints: altered level of consciousness, fall prevention, protect patient."

"Time- March 15, 2015, at 3:10 a.m. Restraint removed due to improved behavior. one sitter at bedside."

There was no documentation to indicate the discontinuation of restraints was attempted when a sitter was provided for Patient 7 on March 14, 2015, at 10:07 p.m.

There was no documentation to indicate the failure of the least restrictive methods tried, and timely, ongoing assessments to determine the need for the continued use of restraints.

An interview and concurrent record review was conducted with the Emergency Department Manager (EDM), on March 24, 2015, at 3 p.m. The EDM was unable to find documentation to indicate the need for the continued use of restraints for Patient 7. The EDM stated the facility policy was to monitor a restrained patient at least every 15 minutes and to document an assessment to include the patient's condition, and the response to other methods tried to ensure the earliest safe removal of the restraints.

The EDM stated this was not done for Patient 7.

The facility policy and procedure titled "Restraint Use (Non- Behavioral restraints) dated March 12, 2014, indicated "It is the policy of...(name of facility) to utilize restraints only when necessary for medical and post surgical care to limit mobility or temporarily immobilize a patient to prevent situations such as the removal of an iv...Patients who are in restraints for Medical or surgical care reasons will be monitored as follows: Monitoring and documentation shall commence immediately after the restraint is applied. Every 15 minute visual checks for respirations, body alignment.. Every two hours the following will be assessed or performed...release from restraints for 10 minutes, and validating the reasons for continuing restraint use..."

The policy further indicated "Elements to be documented in the record: Behaviors necessitating the use of restraint, the use of less restrictive or alternative methods that failed."

Based on interview and record review, the facility failed to identify opportunities for improvement when patient call back information revealed patients complained of a long wait time to see a physician in the Emergency Department (ED).

Findings:

During an interview with the Chief Executive Officer (CEO), on March 25, 2015, at 8:25 a.m., the CEO stated through the patient call back process, which was initiated approximately one year ago, it was identified patients were dissatisfied with the length of time before being seen by the physician. The CEO stated the facility had recently begun gathering data to include the length of time it took before a provider evaluated a patient in the ED.

The CEO was informed that a review of 27 patient records revealed, three patients left the ED after the triage and room assignment process, and prior to an evaluation by the physician.

A review of the three records was conducted with the CEO.

a. The record for Patient 2 was reviewed. Patient 2 presented to the ED by ambulance, on March 15, 2015, at 8:44 p.m., with the chief complaint of seizures (uncontrolled electrical activity in the brain which may produce symptoms to included shaking).

The nursing triage assessment entry for 8:46 p.m., indicated Patient 2 was witnessed by ambulance personnel having a full body seizure prior to being brought to the ED.

The document titled "Conditions of Admission" dated March 15, 2015, indicated Patient 2 had "eloped" (left). There was no time that indicated the time Patient 2 eloped.

There was no documentation that indicated a physician had evaluated or attempted to evaluate Patient 2 prior to the patient leaving.

b. The record for Patient 5 was reviewed. Patient 5 presented to the ED on March 17, 2015, at 5:07 p.m., with the chief complaint of insect bite or sting.

The nursing triage assessment entry for 5:30 p.m., indicated "Pt. (patient) states she was bitten by an unknown insect and woke up with swelling to her face."

The nursing note titled "Disposition" at 8:24 p.m., indicated "Patient left the department...not found in room at (on) March 17, 2015, 8:24 p.m..."This was 2 hours and 56 minutes after the patient was triaged.

There was no documentation that indicated a physician had evaluated or attempted to evaluate Patient 5 prior to the patient leaving.

c. The record for Patient 11 was reviewed. Patient 11 presented to the ED on March 16, 2015, at 10:58 a.m., with the chief complaint of fall/injury pain.

The nursing triage assessment entry for 11:13 a.m., indicated "Was walking when suddenly both legs gave out."

The nursing note entry titled "Room assignment" indicated "Patient moved to a room at (on) March 16, 2015, 12:52."

Radiology reports dated March 16, 2015, indicated Patient 5 completed three X-ray procedures at 3:49 p.m.

The nursing note titled "Brief reassessment" indicated "Patient left the department or not found in room at (on) March 16, 2015, at 4:30 p.m."

This was three hours and 38 minutes after Patient 11 was moved to a room in the ED.

There was no documentation that indicated a physician had evaluated or attempted to evaluate Patient 5 prior to the patient leaving.

The ED chart review sheet used to evaluate Patient 11's ED admission was reviewed. The section titled "Comments/Concerns", dated March 16, 2015, indicated "Pt. left- unable to wait for MD."

The section of the review sheet that indicated the time the physician evaluated the patient was blank.

An interview was conducted with the Patient Liaison (PL), on March 24, 2015, at 4:10 p.m. The PL stated it was her responsibility to contact all patients that presented to the ED, and inquire how the patient's ED experience was. The PL stated a common complaint of patients was the length of time after triage that it took before a patient was seen by a physician.

The PL stated she had attempted to contact Patient 2 but the patient did not return the call. The PL stated she had contacted Patient 5' family member and was informed the patient left the ED because she had felt the wait to see the physician was too long. The PL stated she had contacted Patient 11 prior to the patient leaving the ED on March 16, 2015, and the patient stated he had waited to see the physician six hours.