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Based on interview, and record review, it was determined the facility failed to ensure the Condition of Participation for Patient Rights was met by;


1. Failing to ensure for one patient admitted to the Emergency Department, (Patient 1) on a 5150 hold, (when a qualified clinician or officer can involuntarily confine an individual with a mental health disorder who is deemed to be a danger to himself or others) to provide a safe environment as the patient left the x-ray department of the facility unattended and was not located until 24 hours later in the community (A 144);

2. Failing to ensure for one patient, (Patient 22), on a 5150 hold, a safe environment as the patient left the Emergency Department after having been admitted, and was located in a different area of the facility after a search was conducted (A 144) and;

3. Failing to ensure consistent reassessments were implemented for a physically restrained patient, (Patient 7). (A 175).


The cumulative effects of these systemic practices resulted in the failure of the facility to deliver statutorily mandated compliance with the Federal regulations for the Condition of Participation: Patient Rights, to ensure these patient's right to a safe environment by implementing consistent oversight, observation and reassessment.

Based on interview and record review the facility:

1. Failed to ensure for one patient admitted to the Emergency Department, (Patient 1) on a 5150 hold, (when a qualified clinician or officer can involuntarily confine an individual with a mental health disorder who is deemed to be a danger to himself or others) to provide a safe environment as the patient left the x-ray department of the facility unattended and was not located until 24 hours later in the community, and;

2. Failed to ensure for one patient, (Patient 22), on a 5150 hold, a safe environment as the patient left the Emergency Department after having been admitted, and was located in a different area of the facility after a search was conducted.

Together these failures could potentially have led to the injury of both Patients 1 and 22, due to the lack of consistent oversight and observation of those vulnerable patients.

Findings:

A review of the facility policy, "5150 Psychiatric Hold Patients (Approval Date 11/2014)," was conducted, (5150 Hold-when a qualified clinician or officer can involuntarily confine an individual with a mental health disorder who is deemed to be a danger to himself or others). The policy indicated, "An officer will stay with the patient until Emergency room staff is available to provide one to one care/supervision and it is determined that the patient does not pose an immediate threat to him/herself, the staff, or other customers."


1. During an interview with the Emergency Department Manager (EDM), on March 24, 2015, at 11:40 a.m., the EDM stated the facility's practice was to provide one to one care (one staff to one patient) to all patients on a 5150 hold.

A review of Patient 1's record was conducted on March 24, 2015. Patient 1 presented to the Emergency Department (ED), on March 20, 2015, with the chief complaint of 5150.

The nursing triage document dated March 20, 2015, at 3:10 p.m., indicated "Patient was brought in by police as a 5150. Patient states that he has been hearing voices and wants the police department to dig up his yard and look for dead bodies."

The document further indicated Patient 1 had a plan to harm himself or others.

The nursing entry titled "Brief reassessment" dated March 20, 2015, at 4:46 p.m., indicated "Patient went to radiology for a CXR PA/LAT(chest X-ray) with ...(name of X-ray staff). After the chest X-ray...(name of X-ray staff) went to develop the CXR film and the patient eloped..."

The nursing entry dated March 21, 2015, at 6:10 p.m., indicated "Patient brought back by the...police department..." This was 26 hours and 44 minutes after the patient left the facility.

During an interview with the EDM, on March 24, 2015, at 11:40 a.m., the EDM stated Patient 1 was not provided with one to one care while the patient was in the X-ray department.

2. A review of Patient 22's record was conducted on March 24, 2015. Patient 22 was admitted to the Emergency Department (ED) on March 14, 2015, on a 5150 hold. The patient was diagnosed with drug abuse and a severe acute exacerbation of psychosis (mental health disorder).

An interview was conducted with the Registered Nurse (RN) 10, on March 25, 2015, at 10:45 a.m. RN 10 stated he was assigned to take care of Patient 22 in the ED. RN 10 stated the patient was confused at intervals, was occasionally talking to himself and was mildly agitated. RN 10 stated when he went to observe Patient 22 he could not find the patient as the chair where the patient had been seated was empty. RN 10 further stated after a search the patient was found in the medical surgical hallway. RN 10 stated he did not remember if the patient had a sitter (one to one observation) when he was in the ED.

During an interview with the EDM conducted on March 24, 2015, at 11:40 a.m., the EDM stated it was the facility's practice to provide one to one care (one staff to one patient) to all patients on a 5150 hold.

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.

29542

Based on interview and record review, the facility failed to ensure four of seven employees regularly assigned to the Emergency Department (ED) received training and security education regarding the care of patients with aggressive and violent behaviors. This failure had the potential to negatively impact the care and safety of patients and/or victims with violent behavior.

Findings:

An interview was conducted with the Chief Nursing Officer (CNO), on March 24, 2015, at 1:30 p.m. The CNO stated ED hospital staff provided care for patients who were determined by qualified professionals to be a danger to themselves or others.

The CNO stated it was the facility's practice for staff to attend training regarding patients who were a danger to themselves or others, to ensure care was provided in a safe environment.

A concurrent review of the ED regularly scheduled staff training certificates was conducted.

The CNO was unable to find documentation that four of seven regularly scheduled ED employees received education and training in the management of patients with violent and/or aggressive behaviors.

The CNO stated, "I will schedule another class."

29542

Based on interview and record review, the facility failed:

1. To ensure periodic assessments of the length of time before a provider assessed patients in the Emergency department (ED);

2. To ensure Registered Nurses (RN) provided the timely reassessment of the effect of pain medication after the administration of pain medications for Patient 17 and Patient 19; and

These failures had the potential to directly impact the provision of medical care provided for patients in the Emergency Department (ED).

Findings:

1. 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 were 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 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.

2 a. The record for Patient 17 was reviewed. Patient 17 presented to the ED by ambulance, on March 13, 2015, at 11:34 a.m., with the chief complaint of "Pain in multiple sites."

The nursing triage assessment entry for 11:35 a.m., indicated "Pt. (patient) brought in by (ambulance) due to generalized pain. Pt. has cervical cancer...Pain 10 on a 1-10 scale (the number 10 indicated the most severe pain)."

The nursing note entry for 1:49 p.m., titled "Treatment"indicated Patient 17's pain was 8 on the scale of 1-10, and the patient received pain medication.

The record indicated Patient 17 was discharged at 2:30 p.m.

There was no documentation that indicated Patient 17's pain was reassessed after receiving pain medication, or prior to discharge.

b. The record for Patient 19 was reviewed. Patient 19 presented to the ED by ambulance, on March 14, 2015, at 1:12 a.m., with the chief complaint of Motor Vehicle Accident.

The nursing triage assessment entry for 1:38 a.m., indicated "...Co (complained of) left eye pain and swelling...right shoulder pain, right foot and right side of head pain...Pain 7 on a 1-10 scale"

The medication administration document indicated Patient 19 received pain medication at 2:06 p.m., 4:39 p.m., and 8:58 p.m.

There was no documentation that indicated Patient 19's pain was reassessed after receiving pain medication at 2:06 p.m., 4:39 p.m., and 8:58 p.m.

During an interview and concurrent record review with the Emergency Department Manager (EDM), on March 24, 2015, at 11:35 a.m., the EDM was unable to find documentation that Patient 17, and Patient 19's pain was assessed after receiving pain medication. The EDM stated a patient's pain and response to pain medication was to be assessed one hour after receiving medication and prior to discharge.

The facility's policy and procedure titled "Pain Management" review date March , 2014, indicated "To promote the control of pain for every patient...Appropriate pain management includes but not limited to...Ongoing assessment for the presence of pain...Evaluation of a patient's pain response to pain management and intervention...documenting pain assessment, intervention, and evaluation activities in a clear and concise manner..."