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Based on staff interviews and record review the Condition of Participation: Compliance With Federal State and Local Laws and Regulations was not met during the provision of care and services in the Emergency Department (ED) when staff failed to maintain patient rights in accordance with State statute, Title 18, Chapter 42; Bill of Rights for Hospital Patients; § 1852. 1) The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of his or her personal dignity.
REFER TO TAG: C - 152

Based on staff interview and record review, during the provision of care and services in the Emergency Department (ED) staff failed to maintain patient rights in accordance with State statute, Title 18, Chapter 42; Bill of Rights for Hospital Patients; § 1852. 1) The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of his or her personal dignity, for 3 of 10 applicable patients. (Patients #1, #2 and #4). Findings include:

Per review, the CAH's Restraint and Seclusion policy, which specifies the use of restraints/seclusion and directs the care of patients for whom restraint/seclusion has been deemed warranted, and which was most recently approved for use on 12/11/14 stated: '....It is our responsibility to facilitate the discontinuation of restraint or seclusion as soon as possible.......and we are committed to preserving the patient's safety and dignity when restraint or seclusion is used and ....'Purpose of this policy: To define "restraint and seclusion"...and to describe how to apply restraints safely while maintaining patient rights, dignity and well-being.....A physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body such that he or she cannot easily remove the restraint and that restricts freedom of movement or normal access to one's own body....Methods of restraints and application of restraints....Handcuffs: 1. Handcuffs are only applied by Police Officers/Correctional Officers for patients in their custody. 2. The use of handcuffs, associated with law enforcement activity is not considered a restraint...Restraint and Seclusion Procedure for Violent and Self-Destructive Patient .....2. The order for physical restraint for acute behavioral management is limited to: a. Four (4) hours for adults.....3. After the original order expires, a member of the medical staff will see and assess the patient before issuing a new order..Assessment for early release of the violent and self-destructive patient...A. With each monitoring, the patient is reassessed to determine that continuation of the restraint is necessary. B. Reduction or removal of restraint will be considered when the patient demonstrates a change in the behavior that was the reason for the initial application of the restraint. C. Assessment should include: .......2. If the behavior has decreased so that the risk to the patient and others is no longer present, the restraint may be removed......'

1. Per record review Patient #4, who presented to the ED (Emergency Department) via ambulance on the evening of 4/8/15 for evaluation and treatment following a self-reported suicide attempt by drug overdose, was not treated with dignity and respect when s/he was hand cuffed and physically restrained by police officers, in an effort to assist staff in administering medication to treat his/her aggressive behaviors. A nursing assessment indicated the patient was angry and uncooperative on arrival to the ED. A nursing note at 9:37 PM stated that the patient had attempted to leave his/her room, was asked to stay in the room and then became verbally abusive, threatening bodily harm and not following directions. Multiple staff members intervened and the patient did return to his/her room. A nursing note at 9:45 PM stated that two local police officers had arrived to "help manage the patient." And a subsequent nursing note, at 10:30 PM indicated that Patient #4 stood up on the stretcher and became increasingly threatening to staff and Officers. Police officers then subdued the patient and the patient was then "handcuffed until [s/he] became cooperative." A corresponding note by the attending PA (Physician Assistant) also noted that police officers had to subdue the patient "in order to keep patient safe and for us to be able to give [him/her] meds." The note further indicated that the patient was sleeping after receiving IM meds and stated; "....Based on [his/her] presentation of symptoms in ED [s/he] is acting like [s/he] took bath salts." (a stimulant drug that can induce psychotic and/or violent behaviors).

During interview, at 11:33 AM on the morning of 4/15/15, RN #3, who was responsible for Patient #4's care at the time of police involvement, confirmed that the police had been contacted and their presence was requested for assistance in managing Patient #4's aggressive and threatening behaviors. RN #3 stated that when the police became involved with the patient, staff stepped back to allow the police to "handle" the situation until the patient is under control and no longer at risk for harm to self or others. RN #3 further confirmed that Patient #4 was not in police custody and that hand cuffs had been applied to the patient until the patient calmed.

Security Guard #2 stated, during interview at 3:14 PM on 4/15/15, that s/he had been on duty the night of 4/8/15 and was responsible for providing constant observation of Patient #4. S/he stated that the ambulance crew had informed him/her that Patient #4 had been very combative and suggested that "you may end up calling the police." The guard stated that the patient had become angry and aggressive after being told by the nurse that s/he had to remain in bed. The patient then got out of bed and approached the guard in an aggressive and threatening manner, and at that point the guard told the nurse to contact the police. S/he stated that Patient #4 became "really agitated" when s/he saw police "because [s/he] doesn't like them". The Security Guard further stated that Patient #4 was on the bed and they were going to give [him/her] meds and the patient then stood up in the bed. The guard stated the police tried to get the patient down so the meds could be given and they all ended up on the floor. S/he confirmed that the police applied hand cuffs to Patient #4 and the patient received the medication. Security Guard #2 further stated the hand cuffs were on the patient for approximately 20 minutes until the patient calmed, at which point the police officers put the patient back into bed and removed the cuffs. The guard confirmed the patient was not in police custody and the police left the ED after the patient was put into bed. Security Guard #2 also stated that his/her duties did not include putting hands on a patient. S/he stated that his/her role includes observing patients, documenting observations and notifying the nurse or PA if the patient has made a request or there is a noted concern. S/he further stated that s/he will verbally attempt to de-escalate a patient whose behavior has become agitated or aggressive but if unable to de-escalate the patient verbally, will ask staff to contact the police for their assistance.
Although the PA responsible for evaluating and treating Patient #4 had determined that use of medication was warranted to treat the agitated, threatening and aggressive behavior exhibited by the patient, and that could have been induced by ingestion of drugs, the use of behavioral restraints applied in a respectful manner to assist staff in maintaining the safety of the patient and others, was not utilized. Instead the patient, who was not in police custody, and despite the lack of evidence of criminal activity warranting their use, was subjected to use of hand cuffs, applied by police officers, who had been called to help manage the patient for the purpose of administration of medications by staff.

2. Per record review Patient #2 who presented to the ED via ambulance and police escort on 3/29/15 at 12:30 AM for evaluation and treatment of ingestion of drugs including bath salts, remained in physical restraints for longer than necessary without evidence of any behavior warranting the need for ongoing use of the restraints. The patient presented to the ED in an agitated, violent and combative state and was placed in 4 point restraints, at 12:40 AM, to assure the safety of the patient and others. S/he was medicated with Benadryl and Ativan IM at 1:43 AM and a nursing note at 2:15 AM on 3/29/15, indicated an unsuccessful attempt had been made to release the patient's restraints, as the patient became immediately agitated attempting to thrash his/her arms and legs. Another nursing note, at 3:38 AM, stated that the patient was sleeping and the right ankle restraint was removed at that time. There was a physician order sheet, at 4:00 AM, that directed staff to continue restraints, and the behavior requiring the restraints was listed as danger to self and others. However there was no evidence that an assessment had been completed, at that time, by the MD or any other provider, in accordance with the policy that identified the behavior warranting continued use of restraints. The Observation Flow Sheet identified that Patient #2 was lying on his/her back, sleeping and/or calm between at 4:00 AM and 5:15 AM and the left ankle restraint was removed at 4:45 AM. Although a note at 5:15 AM, by Security Staff providing 1:1 observations, revealed that the patient was kicking off blankets and making noises at that time, all subsequent documentation, every 15 minutes, indicated that the patient was calm and/or sleeping for a period of almost 4 hours thereafter. Despite the lack of evidence of behaviors warranting continued use of restraints, and although there was a physician order, at 8:00 AM that stated reason for discontinuation of restraints: "Pt cooperative", the patient's wrist restraints were not removed until 9:10 AM. In addition, there was no evidence that interventions, identified through the previously cited facility policy as a means of maintaining the patient's respect and dignity during use of restraints, including, removal of the restraint at least every (2) two hours for at least (10) ten minutes, change position every (2) two hours plus provide skin care, ROM, nutrition or toileting, had been provided in accordance with that policy.

During interview, at 9:23 AM on 4/15/15, RN #2, who had been responsible for the care of Patient #2 on 3/29/15, confirmed the lack of documentation regarding assessments of the patient while restrained and acknowledged that staff "could have tried to release [him/her] earlier" from the restraints.

3. Per record review, Patient #1 presented himself/herself to the ED on 12/7/14 at 20:16 with a complaint of suicidal ideation and insomnia, drinking beer in an effort to obtain sleep. The triage assessment described Patient #1 to have "...altered thought processes, verbalized delusions of persecution...appears anxious, restless, agitated, animated and manic". Patient #1's past history includes alcohol abuse and Bipolar disorder requiring multiple psychiatric hospitalizations and is presently non-compliant with prescribed medications. 1:1 Suicide Precautions were initiated utilizing hospital security guards to provide observations of the patient. At 21:20 the patient was evaluated by the PA-C who ordered Ativan 5 mg (anxiolytic) orally and HCRS (Health Care and Rehab Services) was notified Patient #1 required screening for possible psychiatric hospitalization. The patient was cooperative and by 01:00 on 12/8/14 Patient #1 was asleep until almost 06:00. At 08:24 Patient #1 requested a shower but was told s/he would have to wait because the HCRS screener was expected. By 09:00 Patient #1 was screened and it was determined Patient #1 was an individual in need of treatment and required hospitalization. Nurse #1, assigned to Patient #1, states in Emergency Department Clinical Report Patient #1 was "ramping up". Security along with a LNA (Licensed Nursing Assistant) were now monitoring Patient #1. At 13:56 Patient #1 had lunged aggressively at a nurse who had entered Patient #1's assigned ED room for the purpose of cleaning vomit off the floor. Patient #1 grabbed and twisted the nurses's right hand, but the nurse was able to break away from the hold. The police were called and arrived in the ED at 14:05. Patient #1 became more aggressive and combative toward police and ED staff resulting in the patient being placed on stretcher, and with the assistance of 2 police officers the patient was placed in 4 point restraints and held for the administration of emergency medication to include Haldol 10 mg (antipsychotic) IM (intramuscularly) and Ativan 4 mg IM. The patient was not placed in police custody. Only one security guard was present at the time of the application of restraints.

Per review of the CON (Certificate OF Need) for 12/8/14 mechanical restraint application start time was 14:00 and ended at 17:00 and the every 15 minute check note written by Nurse #1 states at 1700 " At this time, patient agrees to contract for safety. Restraints removed....remains somnolent but arousable". Patient #1 is then administered Olanzapine 10 mg. (antipsychotic ). However, per review of the Constant Observation Flow Sheet utilized by assigned security notes at 17:15 Patient #1 is out of arm restraints but continues to remain in secured leg restraints until 2200. Although Nurse #1 continues to document patient is asleep followed by the night nurse who also states 1:1 being maintained and Patient #1 continues sleeping until 12/9/14 at 0330. Although the facility policy states a reduction or removal of restraints will be considered when the patient demonstrates a change in the behavior that was the reason for the initial application of the restraint and the patient is no longer at risk, staff failed to follow process and policy by not removing all 4 restraints when indicated. In addition, the order for physical restraints for acute behavioral management is limited to 4 hours for adults. However, this original order expired at 18:00 on 12/8/14, a member of the medical staff did not see and assess Patient #1 for the ongoing use of lower extremity restraints which continued for another 4 hours. Per interview on 4/15/15 at 3:14 PM, Security Guard #2 assigned to observe Patient #1 on 12/8/14 from 15:30 to 23:15 confirmed his/her documentation stating "I write what I see" and noting in his/her documentation when Patient #1 was requesting to have restraints removed at 22:00.

Based on staff interview and record review the Condition of Participation for Emergency Services was not met as evidenced by:

The CAH Emergency Services failed to provide care and services in accordance with hospital policies and procedures and compliance with State and Local laws for 3 of 10 applicable patients. (Patients # 1,2,4 ) Findings include:

Per review, the CAH's Restraint and Seclusion policy, which specifies the use of restraints/seclusion and directs the care of patients for whom restraint/seclusion has been deemed warranted, and which was most recently approved for use on 12/11/14 stated: '....
It is our responsibility to facilitate the discontinuation of restraint or seclusion as soon as possible.......and we are committed to preserving the patient's safety and dignity when restraint or seclusion is used. Purpose of this policy: To define "restraint and seclusion"...and to describe how to apply restraints safely while maintaining patient rights, dignity and well-being.....A physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body such that he or she cannot easily remove the restraint and that restricts freedom of movement or normal access to one's own body....Methods of restraints and application of restraints....Handcuffs: 1. Handcuffs are only applied by Police Officers/Correctional Officers for patients in their custody. 2. The use of handcuffs, associated with law enforcement activity is not considered a restraint. Restraint and Seclusion Procedure for Violent and Self-Destructive Patient.....2. The order for physical restraint for acute behavioral management is limited to: a. Four (4) hours for adults.....3. After the original order expires, a member of the medical staff will see and assess the patient before issuing a new order....Assessment for early release of the violent and self-destructive patient...A. With each monitoring, the patient is reassessed to determine that continuation of the restraint is necessary. B. Reduction or removal of restraint will be considered when the patient demonstrates a change in the behavior that was the reason for the initial application of the restraint. C. Assessment should include: .......2. If the behavior has decreased so that the risk to the patient and others is no longer present, the restraint may be removed......Procedure for the Care of the Violent and Self-Destructive Patient: A. Patient Rights: Maintain dignity and respect during restraint and seclusion use through monitoring, reassessment, and attention to the patient's needs.....3. The use of behavioral restraints must be assessed every 15 minutes and documented in the medical record every two hours.....5. Remove the physical restraint at least every (2) two hours for at least (10) ten minutes if possible....6. Change position every (2) two hours plus provide skin care, ROM (range of motion), nutrition or toileting. 7. Remove the restraint as soon as possible....D.....The Registered Nurses and PA-Cs in the Emergency Department are responsible for the following: l. Assessing patient needs to determine the reason for which a restraint is being considered; 2. Deciding which category of restraint is appropriate or necessary (medical immobilization or behavioral management)....'

In addition, during the provision of care and services in the Emergency Department staff failed to maintain patient rights in accordance with State statute, Title 18, Chapter 42; Bill of Rights for Hospital Patients; § 1852. 1) The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of his or her personal dignity.

1. Per record review Patient #4, who presented to the ED (Emergency Department) via ambulance on the evening of 4/8/15 for evaluation and treatment following a self-reported suicide attempt by drug overdose was hand cuffed and physically restrained by police officers, in an effort to assist staff in administering medication to treat his/her aggressive behaviors. A nursing assessment indicated the patient was angry and uncooperative on arrival to the ED. A nursing note at 9:37 PM stated that the patient had attempted to leave his/her room, was asked to stay in the room and then became verbally abusive, threatening bodily harm and not following directions. Multiple staff members intervened and the patient did return to his/her room. A nursing note at 9:45 PM stated that two local police officers had arrived to "help manage the patient." And a subsequent nursing note, at 10:30 PM indicated that Patient #4 stood up on the stretcher and became increasingly threatening to staff and Officers. Police officers then subdued the patient and the patient was then "handcuffed until [s/he] became cooperative." A corresponding note by the attending PA (Physician Assistant) also noted that police officers had to subdue the patient "in order to keep patient safe and for us to be able to give [him/her] meds." The note further indicated that the patient was sleeping after receiving IM meds and stated; "....Based on [his/her] presentation of symptoms in ED [s/he] is acting like [s/he] took bath salts." (a stimulant drug that can induce psychotic and/or violent behaviors).


During interview, at 11:33 AM on the morning of 4/15/15, RN #3, who was responsible for Patient #4's care at the time of police involvement, confirmed that the police had been contacted and their presence was requested for assistance in managing Patient #4's aggressive and threatening behaviors. RN #3 stated that when the police became involved with the patient, staff stepped back to allow the police to "handle" the situation until the patient is under control and no longer at risk for harm to self or others. RN #3 further confirmed that Patient #4 was not in police custody and that hand cuffs had been applied to the patient until the patient calmed.

Security Guard #2 stated, during interview at 3:14 PM on 4/15/15, that s/he had been on duty the night of 4/8/15 and was responsible for providing constant observation of Patient #4. S/he stated that the ambulance crew had informed him/her that Patient #4 had been very combative and suggested that "you may end up calling the police." The guard stated that the patient had become angry and aggressive after being told by the nurse that s/he had to remain in bed. The patient then got out of bed and approached the guard in an aggressive and threatening manner, and at that point the guard told the nurse to contact the police. S/he stated that Patient #4 became "really agitated" when s/he saw police "because [s/he] doesn't like them". The Security Guard further stated that Patient #4 was on the bed and they were going to give [him/her] meds and the patient then stood up in the bed. The guard stated the police tried to get the patient down so the meds could be given and they all ended up on the floor. S/he confirmed that the police applied hand cuffs to Patient #4 and the patient received the medication. Security Guard #2 further stated the hand cuffs were on the patient for approximately 20 minutes until the patient calmed, at which point the police officers put the patient back into bed and removed the cuffs. The guard confirmed the patient was not in police custody and the police left the ED after the patient was put into bed. Security Guard #2 also stated that his/her duties did not include putting hands on a patient. S/he stated that his/her role includes observing patients, documenting observations and notifying the nurse or PA if the patient has made a request or there is a noted concern. S/he further stated that s/he will verbally attempt to de-escalate a patient whose behavior has become agitated or aggressive but if unable to de-escalate the patient verbally, will ask staff to contact the police for their assistance.
Despite the current policy that prohibits the application of hand cuffs by anyone but law enforcement, for only those patients who are in police custody, Patient #4, who was not in police custody at the time, was hand cuffed during an attempt by police to physically control the patient's physically aggressive behavior. In addition, although the policy also states, 'The use of handcuffs, associated with law enforcement activity is not considered a restraint' and 'The Registered Nurses and PA-Cs in the Emergency Department are responsible for.....Deciding which category of restraint is appropriate or necessary (medical immobilization or behavioral management)....', there is sufficient evidence to suggest that the use of physical hands on by police officers, in conjunction with the application of hand cuffs, was the method used to restrain Patient #4 for the purpose of administration of medications by staff to assist in calming the patient.

2. Per review of Patient #2's record, the patient presented to the ED via ambulance and police escort on 3/29/15 at 12:30 AM for evaluation and treatment of ingestion of drugs including bath salts (a stimulant drug that can induce psychosis and/or violent behaviors). The patient presented in an agitated, violent and combative state and was placed in 4 point restraints, at 12:40 AM, to assure the safety of the patient and others. S/he was medicated with Benadryl and Ativan IM at 1:43 AM and a nursing note at 2:15 AM on 3/29/15, indicated an unsuccessful attempt had been made to release the patient's restraints, as the patient became immediately agitated attempting to thrash his/her arms and legs. Another nursing note, at 3:38 AM, stated that the patient was sleeping, and occasionally moving arms and legs and the right ankle restraint was removed. There was a physician order sheet, at 4:00 AM, that directed staff to continue restraints, specifically wrist restraints only, and the behavior requiring the restraints was listed as danger to self and others. However there was no evidence that an assessment had been completed, at that time, by the MD or any other provider, in accordance with the Restraint and Seclusion policy that identified the behavior warranting continued use of restraints. In addition, the Observation Flow Sheet identified that Patient #2 was lying on his/her back, sleeping at 4:00 AM. Another nursing note, at 4:45 AM stated; 'Patient sleeping. [S/he does toss and turn a little while....mostly sleeping.....left ankle out of restraints...' Although a note at 5:15 AM, by Security Staff providing 1:1 observations, revealed that the patient was kicking off blankets and making noises at that time, all subsequent documentation, every 15 minutes, indicated that the patient was calm and/or sleeping. Despite the lack of evidence of behaviors warranting continued use of restraints, and although there was a physician order, at 8:00 AM that stated reason for discontinuation of restraints: "Pt cooperative", the patient's wrist restraints were not removed until 9:10 AM. In addition, there was no evidence that assessments had been conducted, after 2:15 AM, in accordance with the policy, to: '5. Remove the physical restraint at least every (2) two hours for at least (10) ten minutes if possible....6. Change position every (2) two hours plus provide skin care, ROM (range of motion), nutrition or toileting.'

During interview, at 9:23 AM on 4/15/15, RN #2, who had been responsible for the care of Patient #2 on 3/29/15, confirmed the lack of documentation regarding assessments of the patient while restrained and acknowledged that staff "could have tried to release [him/her] earlier" from the restraints.

3. Per record review, Patient #1 presented himself/herself to the ED on 12/7/14 at 20:16 with a complaint of suicidal ideation and insomnia, drinking beer in an effort to obtain sleep. The triage assessment described Patient #1 to have "...altered thought processes, verbalized delusions of persecution...appears anxious, restless, agitated, animated and manic". Patient #1's past history includes alcohol abuse and Bipolar disorder requiring multiple psychiatric hospitalizations and is presently non-compliant with prescribed medications. 1:1 Suicide Precautions were initiated utilizing hospital security guards to provide observations of the patient. At 21:20 the patient was evaluated by the PA-C who ordered Ativan 5 mg (anxiolytic) orally and HCRS (Health Care and Rehab Services) was notified Patient #1 required screening for possible psychiatric hospitalization. The patient was cooperative and by 01:00 on 12/8/14 Patient #1 was asleep until almost 06:00. At 08:24 Patient #1 requested a shower but was told s/he would have to wait because the HCRS screener was expected. By 09:00 Patient #1 was screened and it was determined Patient #1 was an individual in need of treatment and required hospitalization. Nurse #1, assigned to Patient #1, states in Emergency Department Clinical Report Patient #1 was "ramping up". Security along with a LNA (Licensed Nursing Assistant) were now monitoring Patient #1. At 13:56 Patient #1 had lunged aggressively at a nurse who had entered Patient #1's assigned ED room for the purpose of cleaning vomit off the floor. Patient #1 grabbed and twisted the nurses's right hand, but the nurse was able to break away from the hold. The police were called and arrived in the ED at 14:05. Patient #1 became more aggressive and combative toward police and ED staff resulting in the patient being placed on stretcher, and with the assistance of 2 police officers the patient was placed in 4 point restraints and held for the administration of emergency medication to include Haldol 10 mg (antipsychotic) IM (intramuscularly) and Ativan 4 mg IM. The patient was not placed in police custody. Only one security guard was present at the time of the application of restraints.

Per review of the CON (Certificate OF Need) for 12/8/14 mechanical restraint application start time was 14:00 and ended at 17:00 and the ever 15 minute check note written by Nurse #1 states at 1700 " At this time, patient agrees to contract for safety. Restraints removed....remains somnolent but arousable". Patient #1 is then administered Olanzapine 10 mg. (antipsychotic ). However, per review of the Constant Observation Flow Sheet utilized by assigned security notes at 17:15 Patient #1 is out of arm restraints but continues to remain in secured leg restraints until 2200. Although Nurse #1 continues to document patient is asleep followed by the night nurse who also states 1:1 being maintained and Patient #1 continues sleeping until 12/9/14 at 0330. Although the facility policy states a reduction or removal of restraints will be considered when the patient demonstrates a change in the behavior that was the reason for the initial application of the restraint and the patient is no longer at risk, staff failed to follow process and policy by not removing all 4 restraints when indicated. In addition, the order for physical restraints for acute behavioral management is limited to 4 hours for adults. However, this original order expired at 18:00 on 12/8/14, a member of the medical staff did not see and assess Patient #1 for the ongoing use of lower extremity restraints which continued for another 4 hours. Per interview on 4/15/15 at 3:14 PM, Security Guard #2 assigned to observe Patient #1 on 12/8/14 from 15:30 to 23:15 confirmed his/her documentation stating "I write what I see" and noting in his/her documentation when Patient #1 was requesting to have restraints removed at 22:00.

Based on staff interview and record review the Condition of Participation: Staff and Staff Responsibilities was not met as evidenced by the failure to assure sufficient staff was available at all times in the Emergency Department to prevent the use of non-employees to assist in the medical care and treatment of patients.

REFER to TAG: C-271

Based on staff interviews and record review the CAH failed to assure that sufficient staffing was available at all times to prevent the use of non-employees to assist in the medical care and treatment for 2 of 10 patients reviewed. (Patients #1, #4 ). Findings include:

1. Per record review Patient #4 presented to the ED (Emergency Department) via ambulance at 9:14 PM on the evening of 4/8/15 for evaluation and treatment following a self-reported suicide attempt by drug overdose. A nursing assessment indicated that the patient presented as angry and uncooperative, refusing to allow vital signs to be assessed as well as refusing to allow use of a cardiac monitor, and stated that no one was to touch him/her "without permission." A nursing note at 9:37 PM stated that the patient had attempted to exit his/her room and when asked to return to the room, became verbally abusive, threatening bodily harm and not following directions. Multiple staff members intervened and the patient did eventually return to his/her room." However, a subsequent nursing note at 9:45 PM stated that two local police officers had arrived to "help manage the patient." Another nursing note, at 10:30 PM indicated that the patient stood up on the stretcher and became increasingly threatening to staff and Officers and the police officers intervened to subdue the patient to assure his/her safety as well as the safety of staff and others. During the physical restraint applied by police officers, handcuffs were also applied to Patient #4. Despite the established policy which stated: 'Handcuffs are only applied by Police Officers/Correctional Officers for patients in their custody' and '....The use of handcuffs, associated with law enforcement activity is not considered a restraint', an ED Physician Assistant (PA) note, that corresponded to the nursing note, stated: "....police officers had to take patient down in order to keep patient safe and for us to be able to give [him/her] meds."

During interview, at 11:33 AM on the morning of 4/15/15, RN #3, who was responsible for Patient #4's care at the time of police involvement, confirmed that the police had been contacted and their presence was requested for assistance in managing Patient #4's aggressive and threatening behaviors. RN #3 stated that when the police became involved with the patient, staff stepped back to allow the police to "handle" the situation until the patient is under control and no longer at risk for harm to self or others. RN #3 further confirmed that Patient #4 was not in police custody and that hand cuffs had been applied to the patient until the patient calmed.

Security Guard #2 stated, during interview at 3:14 PM on 4/15/15, that s/he had been on duty the night of 4/8/15 and was responsible for providing constant observation of Patient #4. S/he stated that the ambulance crew had informed him/her that Patient #4 had been very combative and suggested that "you may end up calling the police." The guard stated that the patient had become angry and aggressive after being told by the nurse that s/he had to remain in bed. The patient then got out of bed and approached the guard in an aggressive and threatening manner, and at that point the guard told the nurse to contact the police. S/he stated that Patient #4 became "really agitated" when s/he saw police "because [s/he] doesn't like them". The Security Guard further stated that Patient #4 was on the bed and they were going to give [him/her] meds and the patient then stood up in the bed. The guard stated the police tried to get the patient down so the meds could be given and they all ended up on the floor. S/he confirmed that the police applied hand cuffs to Patient #4 and the patient received the medication. Security Guard #2 further stated the hand cuffs were on the patient for approximately 20 minutes until the patient calmed, at which point the police officers put the patient back into bed and removed the cuffs. The guard confirmed the patient was not in police custody and the police left the ED after the patient was put into bed. Security Guard #2 also stated that his/her duties did not include putting hands on a patient. S/he stated that his/her role includes observing patients, documenting observations and notifying the nurse or PA if the patient has made a request or there is a noted concern. S/he further stated that s/he will verbally attempt to de-escalate a patient whose behavior has become agitated or aggressive but if unable to de-escalate the patient verbally, will ask staff to contact the police for their assistance.
Despite the current policy that prohibits the application of hand cuffs by anyone but law enforcement, for only those patients who are in police custody, Patient #4, who was not in police custody at the time, was hand cuffed during an attempt by police, (who were called to help manage the patient), to physically control the patient's physically aggressive behavior. In addition, although the policy also states, ''The Registered Nurses and PA-Cs in the Emergency Department are responsible for.....Deciding which category of restraint is appropriate or necessary (medical immobilization or behavioral management)....' and 'The use of handcuffs, associated with law enforcement activity is not considered a restraint' there is sufficient evidence to suggest that rather than utilizing CAH security staff, who provide no hands on approach to patients, the use of physical hands on by police officers, in conjunction with the application of hand cuffs, was the method used to restrain Patient #4 for the purpose of administration of medications by staff to assist in calming the patient.
2. Per record review, Patient #1 presented himself/herself to the ED on 12/7/14 at 20:16 with a complaint of suicidal ideation and insomnia, drinking beer in an effort to obtain sleep. The triage assessment described Patient #1 to have "...altered thought processes, verbalized delusions of persecution...appears anxious, restless, agitated, anitmated and manic". Patient #1's past history includes alcohol abuse and Bipolar disorder requiring multiple psychiatric hospitalizations and is presently non-compliant with prescribed medications. 1:1 Suicide Precautions were initiated utilizing hospital security guards to provide observations of the patient. At 21:20 the patient was evaluated by the PA-C who ordered Ativan 5 mg (anxiolytic) orally and HCRS (Health Care and Rehab Services) was notified Patient #1 required screening for possible psychiatric hospitalization. The patient was cooperative and by 01:00 on 12/8/14 Patient #1 was asleep until almost 06:00. At 08:24 Patient #1 requested a shower but was told s/he would have to wait because the HCRS screener was expected. By 09:00 Patient #1 was screened and it was determined Patient #1 was an individual in need of treatment and required hospitalization. Nurse #1, assigned to Patient #1, states in Emergency Department Clinical Report Patient #1 was "ramping up". Security along with a LNA (Licensed Nursing Assistant) were now monitoring Patient #1. At 13:56 Patient #1 had lunged aggressively at a nurse who had entered Patient #1's assigned ED room for the purpose of cleaning vomit off the floor. Patient #1 grabbed and twisted the nurses's right hand, but the nurse was able to break away from the hold. The police were called and arrived in the ED at 14:05. Patient #1 became more aggressive and combative toward police and ED staff resulting in the patient being placed on stretcher, and with the assistance of 2 police officers the patient was placed in 4 point restraints and held for the administration of emergency medication to include Haldol 10 mg (antipsychotic) IM (intramuscular) and Ativan 4 mg IM. The patient was not placed in police custody. Only one security guard was present at the time of the application of restraints.

Per interview on 4/15/15 at 11:46 AM, Security Officer #1 stated the job expectation for security officers working in the ED is "...to observe that patient and if there's anything that comes up with the patient we are to notify the nurse....if a patient is getting out of hand or becoming violent we are to contact the police department."

Per interview on 4/14/15 at 2:11 PM in discussing the role of security, the ED Nurse Manager stated "...they're really not hands on...they have had the CPI (Crisis Prevention Institute) education...we are trying to use the MHW (Mental Health Workers) and it has been challenging because it seems whenever we need them the Windham Center (PPS psychiatric unit associated with the CAH) also needs them....security staff contracted can help with restraint application some are more comfortable then others...". Per interview at 4/14/15 at 2:15 PM, the ED Day charge nurse who is also responsible for the Quality review and monitoring restraint use in the ED also confirmed "...we had a lot of violent patients lately so we're not always feeling safe.....Night shift staff only have 2 nurses and an LNA and PA on....past few night shifts that I've worked steady....when I look at the restraints....three of them happened on nights.

Per interview on the afternoon of 4/13/15, the PA-C involved with Patient #1 on 12/8/14 at 14:05 when police arrived to assisit in the behavioral management, stated "I heard a rukus and went over" (to Patient #1's room). S/he confirmed police were attempting to interact with Patient #1, however the patient threw a CD player at police and staff. "It took the police and me and XXXX (another nurse) to take him/her down.....we gave him/her a bunch of meds...we had to give him/her medication in order to restrain him/her..." When asked about calling the police, the PA-C stated "...we can call them whenever we want....they are very good and we try not to call them and use them for our security...we call them when we feel we're in danger". The PA-C further stated " I've had CPI training...restraining patients and wrestling them to the ground really isn't our job and we shouldn't be forced to do that...that's the job of the police and security...."

Based on record review and staff interviews the CAH failed to assure that care and services were provided in accordance with currently established policies and procedures for 3 of 10 patients reviewed. (Patients #1, #2 and #4). Findings include:

Per review, the CAH's Restraint and Seclusion policy, which specifies the use of restraints/seclusion and directs the care of patients for whom restraint/seclusion has been deemed warranted, and which was most recently approved for use on 12/11/14 stated: '....
It is our responsibility to facilitate the discontinuation of restraint or seclusion as soon as possible.......and we are committed to preserving the patient's safety and dignity when restraint or seclusion is used. Purpose of this policy: To define "restraint and seclusion"...and to describe how to apply restraints safely while maintaining patient rights, dignity and well-being.....A physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body such that he or she cannot easily remove the restraint and that restricts freedom of movement or normal access to one's own body....Methods of restraints and application of restraints....Handcuffs: 1. Handcuffs are only applied by Police Officers/Correctional Officers for patients in their custody. 2. The use of handcuffs, associated with law enforcement activity is not considered a restraint. Restraint and Seclusion Procedure for Violent and Self-Destructive Patient.....2. The order for physical restraint for acute behavioral management is limited to: a. Four (4) hours for adults.....3. After the original order expires, a member of the medical staff will see and assess the patient before issuing a new order....Assessment for early release of the violent and self-destructive patient...A. With each monitoring, the patient is reassessed to determine that continuation of the restraint is necessary. B. Reduction or removal of restraint will be considered when the patient demonstrates a change in the behavior that was the reason for the initial application of the restraint. C. Assessment should include: .......2. If the behavior has decreased so that the risk to the patient and others is no longer present, the restraint may be removed......Procedure for the Care of the Violent and Self-Destructive Patient: A. Patient Rights: Maintain dignity and respect during restraint and seclusion use through monitoring, reassessment, and attention to the patient's needs.....3. The use of behavioral restraints must be assessed every 15 minutes and documented in the medical record every two hours.....5. Remove the physical restraint at least every (2) two hours for at least (10) ten minutes if possible....6. Change position every (2) two hours plus provide skin care, ROM (range of motion), nutrition or toileting. 7. Remove the restraint as soon as possible....D.....The Registered Nurses and PA-Cs in the Emergency Department are responsible for the following: l. Assessing patient needs to determine the reason for which a restraint is being considered; 2. Deciding which category of restraint is appropriate or necessary (medical immobilization or behavioral management)....'

1. Per record review Patient #4, who presented to the ED (Emergency Department) via ambulance on the evening of 4/8/15 for evaluation and treatment following a self-reported suicide attempt by drug overdose, was not provided care in accordance with established policies and procedures when s/he was hand cuffed and physically restrained by police officers, in an effort to assist staff in administering medication to treat his/her aggressive behaviors. A nursing assessment indicated the patient was angry and uncooperative on arrival to the ED. A nursing note at 9:37 PM stated that the patient had attempted to leave his/her room, was asked to stay in the room and then became verbally abusive, threatening bodily harm and not following directions. Multiple staff members intervened and the patient did return to his/her room. A nursing note at 9:45 PM stated that two local police officers had arrived to "help manage the patient." And a subsequent nursing note, at 10:30 PM indicated that Patient #4 stood up on the stretcher and became increasingly threatening to staff and Officers. Police officers then subdued the patient and the patient was then "handcuffed until [s/he] became cooperative." A corresponding note by the attending PA (Physician Assistant) also noted that police officers had to subdue the patient "in order to keep patient safe and for us to be able to give [him/her] meds." The note further indicated that the patient was sleeping after receiving IM meds and stated; "....Based on [his/her] presentation of symptoms in ED [s/he] is acting like [s/he] took bath salts." (a stimulant drug that can induce psychotic and/or violent behaviors).

During interview, at 11:33 AM on the morning of 4/15/15, RN #3, who was responsible for Patient #4's care at the time of police involvement, confirmed that the police had been contacted and their presence was requested for assistance in managing Patient #4's aggressive and threatening behaviors. RN #3 stated that when the police became involved with the patient, staff stepped back to allow the police to "handle" the situation until the patient is under control and no longer at risk for harm to self or others. RN #3 further confirmed that Patient #4 was not in police custody and that hand cuffs had been applied to the patient until the patient calmed.

Security Guard #2 stated, during interview at 3:14 PM on 4/15/15, that s/he had been on duty the night of 4/8/15 and was responsible for providing constant observation of Patient #4. S/he stated that the ambulance crew had informed him/her that Patient #4 had been very combative and suggested that "you may end up calling the police." The guard stated that the patient had become angry and aggressive after being told by the nurse that s/he had to remain in bed. The patient then got out of bed and approached the guard in an aggressive and threatening manner, and at that point the guard told the nurse to contact the police. S/he stated that Patient #4 became "really agitated" when s/he saw police "because [s/he] doesn't like them". The Security Guard further stated that Patient #4 was on the bed and they were going to give [him/her] meds and the patient then stood up in the bed. The guard stated the police tried to get the patient down so the meds could be given and they all ended up on the floor. S/he confirmed that the police applied hand cuffs to Patient #4 and the patient received the medication. Security Guard #2 further stated the hand cuffs were on the patient for approximately 20 minutes until the patient calmed, at which point the police officers put the patient back into bed and removed the cuffs. The guard confirmed the patient was not in police custody and the police left the ED after the patient was put into bed. Security Guard #2 also stated that his/her duties did not include putting hands on a patient. S/he stated that his/her role includes observing patients, documenting observations and notifying the nurse or PA if the patient has made a request or there is a noted concern. S/he further stated that s/he will verbally attempt to de-escalate a patient whose behavior has become agitated or aggressive but if unable to de-escalate the patient verbally, will ask staff to contact the police for their assistance.
Despite the current policy that prohibits the application of hand cuffs by anyone but law enforcement, for only those patients who are in police custody, Patient #4, who was not in police custody at the time, was hand cuffed during an attempt by police to physically control the patient's physically aggressive behavior. In addition, although the policy also states, 'The use of handcuffs, associated with law enforcement activity is not considered a restraint' and 'The Registered Nurses and PA-Cs in the Emergency Department are responsible for.....Deciding which category of restraint is appropriate or necessary (medical immobilization or behavioral management)....', there is sufficient evidence to suggest that the use of physical hands on by police officers, in conjunction with the application of hand cuffs, was the method used to restrain Patient #4 for the purpose of administration of medications by staff to assist in calming the patient.

2. Per review of Patient #2's record, the patient presented to the ED via ambulance and police escort on 3/29/15 at 12:30 AM for evaluation and treatment of ingestion of drugs including bath salts (a stimulant drug that can induce psychosis and/or violent behaviors). The patient presented in an agitated, violent and combative state and was placed in 4 point restraints, at 12:40 AM, to assure the safety of the patient and others. S/he was medicated with Benadryl and Ativan IM at 1:43 AM and a nursing note at 2:15 AM on 3/29/15, indicated an unsuccessful attempt had been made to release the patient's restraints, as the patient became immediately agitated attempting to thrash his/her arms and legs. Another nursing note, at 3:38 AM, stated that the patient was sleeping, and occasionally moving arms and legs and the right ankle restraint was removed. There was a physician order sheet, at 4:00 AM, that directed staff to continue restraints, specifically wrist restraints only, and the behavior requiring the restraints was listed as danger to self and others. However there was no evidence that an assessment had been completed, at that time, by the MD or any other provider, in accordance with the Restraint and Seclusion policy that identified the behavior warranting continued use of restraints. In addition, the Observation Flow Sheet identified that Patient #2 was lying on his/her back, sleeping at 4:00 AM. Another nursing note, at 4:45 AM stated; 'Patient sleeping. [S/he does toss and turn a little while....mostly sleeping.....left ankle out of restraints...' Although a note at 5:15 AM, by Security Staff providing 1:1 observations, revealed that the patient was kicking off blankets and making noises at that time, all subsequent documentation, every 15 minutes, indicated that the patient was calm and/or sleeping. Despite the lack of evidence of behaviors warranting continued use of restraints, and although there was a physician order, at 8:00 AM that stated reason for discontinuation of restraints: "Pt cooperative", the patient's wrist restraints were not removed until 9:10 AM. In addition, there was no evidence that assessments had been conducted, after 2:15 AM, in accordance with the policy, to: '5. Remove the physical restraint at least every (2) two hours for at least (10) ten minutes if possible....6. Change position every (2) two hours plus provide skin care, ROM (range of motion), nutrition or toileting.'

During interview, at 9:23 AM on 4/15/15, RN #2, who had been responsible for the care of Patient #2 on 3/29/15, confirmed the lack of documentation regarding assessments of the patient while restrained and acknowledged that staff "could have tried to release [him/her] earlier" from the restraints.

3. Per record review, Patient #1 presented himself/herself to the ED on 12/7/14 at 20:16 with a complaint of suicidal ideation and insomnia, drinking beer in an effort to obtain sleep. The triage assessment described Patient #1 to have "...altered thought processes, verbalized delusions of persecution...appears anxious, restless, agitated, animated and manic". Patient #1's past history includes alcohol abuse and Bipolar disorder requiring multiple psychiatric hospitalizations and is presently non-compliant with prescribed medications. 1:1 Suicide Precautions were initiated utilizing hospital security guards to provide observations of the patient. At 21:20 the patient was evaluated by the PA-C who ordered Ativan 5 mg (anxiolytic) orally and HCRS (Health Care and Rehab Services) was notified Patient #1 required screening for possible psychiatric hospitalization. The patient was cooperative and by 01:00 on 12/8/14 Patient #1 was asleep until almost 06:00. At 08:24 Patient #1 requested a shower but was told s/he would have to wait because the HCRS screener was expected. By 09:00 Patient #1 was screened and it was determined Patient #1 was an individual in need of treatment and required hospitalization. Nurse #1, assigned to Patient #1, states in Emergency Department Clinical Report Patient #1 was "ramping up". Security along with a LNA (Licensed Nursing Assistant) were now monitoring Patient #1. At 13:56 Patient #1 had lunged aggressively at a nurse who had entered Patient #1's assigned ED room for the purpose of cleaning vomit off the floor. Patient #1 grabbed and twisted the nurses's right hand, but the nurse was able to break away from the hold. The police were called and arrived in the ED at 14:05. Patient #1 became more aggressive and combative toward police and ED staff resulting in the patient being placed on stretcher, and with the assistance of 2 police officers the patient was placed in 4 point restraints and held for the administration of emergency medication to include Haldol 10 mg (antipsychotic) IM (intramuscularly) and Ativan 4 mg IM. The patient was not placed in police custody. Only one security guard was present at the time of the application of restraints.

Per review of the CON (Certificate OF Need) for 12/8/14 mechanical restraint application start time was 14:00 and ended at 17:00 and the ever 15 minute check note written by Nurse #1 states at 1700 " At this time, patient agrees to contract for safety. Restraints removed....remains somnolent but arousable". Patient #1 is then administered Olanzapine 10 mg. (antipsychotic ). However, per review of the Constant Observation Flow Sheet utilized by assigned security notes at 17:15 Patient #1 is out of arm restraints but continues to remain in secured leg restraints until 2200. Although Nurse #1 continues to document patient is asleep followed by the night nurse who also states 1:1 being maintained and Patient #1 continues sleeping until 12/9/14 at 0330. Although the facility policy states a reduction or removal of restraints will be considered when the patient demonstrates a change in the behavior that was the reason for the initial application of the restraint and the patient is no longer at risk, staff failed to follow process and policy by not removing all 4 restraints when indicated. In addition, the order for physical restraints for acute behavioral management is limited to 4 hours for adults. However, this original order expired at 18:00 on 12/8/14, a member of the medical staff did not see and assess Patient #1 for the ongoing use of lower extremity restraints which continued for another 4 hours. Per interview on 4/15/15 at 3:14 PM, Security Guard #2 assigned to observe Patient #1 on 12/8/14 from 15:30 to 23:15 confirmed his/her documentation stating "I write what I see" and noting in his/her documentation when Patient #1 was requesting to have restraints removed at 22:00.

Based on record review and staff interview, there was a failure of nursing staff in the Emergency Department to assess and document the response to medications administered. Findings include:

1. Per record review, Patient #5 a 34 year old found wandering in the woods was brought to the ED on 12/21/14 at 23:10 with the chief complaint of Drug Overdose and Intoxication. Patient #5 told police s/he "...injected dope into left arm and that s/he didn't feel right and his/her tongue was all swollen.." Upon arrival in the ED, Triage assessed Patient #5 to be "Alert. Appears anxious and in distress.....agitated...angry and hostile...behaviors appear abnormal.....hyperactive body language... thrashing...." . Patient #5 was known to have a history of Bipolar, substance abuse, depression and suicidal ideation. The patient required restraints and sedation. The patient did state s/he thought they took Heroin. Bloods were drawn and laboratory results noted an elevated Acetaminophen level and elevated CPK ( an enzyme test which demonstrates possible organ, muscle injury). The PA-C diagnosed patient with Tylenol poisoning and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). Patient #5 also presented with an aspiration pneumonia.

As a result of how Patient #5 presented, multiple medications were administered to include Narcan (opioid antagonist) 0.2 mg IV (intravenously) and Haldol 10 mg IM and Versed 5mg IM (benzodiazepine/sedation) and Ativan 2 mg. IV. The nurse failed to acknowledge within the Medication Administration Record or nursing notes, the patient's response to medication administered. There was no indication if Narcan was effective in countering the effects of an opioid overdose (if applicable). Drugs administered for the eventual intubation of Patient #5 were listed with no evidence of response. The lack of documentation in regards to the response and effectiveness of medication administration was acknowledged by the ED Nurse Manager on 4/14/15 at 3:00 PM.

Based on staff interview and record review, both the ED nurse and PA-C failed to correctly document who administered medications and what was the actual doses administered to 1 of 10 patients. ( Patient #1) Findings include:

Per record review, Patient #1 presented himself/herself to the ED on 12/7/14 at 20:16 with a complaint of suicidal ideation and insomnia, drinking beer in an effort to obtain sleep. The triage assessment described Patient #1 to have "...altered thought processes, verbalized delusions of persecution...appears anxious, restless, agitated, animated and manic". Patient #1's past history includes alcohol abuse and Bipolar disorder requiring multiple psychiatric hospitalizations and is presently non-compliant with prescribed medications. 1:1 Suicide Precautions were initiated utilizing hospital security guards to provide observations of the patient. At 21:20 the patient was evaluated by the PA-C who ordered Ativan 5 mg (anxiolytic) orally and HCRS (Health Care and Rehab Services) was notified Patient #1 required screening for possible psychiatric hospitalization. The patient was cooperative and by 01:00 on 12/8/14 Patient #1 was asleep until almost 06:00. At 08:24 Patient #1 requested a shower but was told s/he would have to wait because the HCRS screener was expected. By 09:00 Patient #1 was screened and it was determined Patient #1 was an individual in need of treatment and required hospitalization. Nurse #1, assigned to Patient #1, states in Emergency Department Clinical Report Patient #1 was "ramping up". Security along with a LNA (Licensed Nursing Assistant) were now monitoring Patient #1. At 13:56 Patient #1 had lunged aggressively at a nurse who had entered Patient #1's assigned ED room for the purpose of cleaning vomit off the floor. Patient #1 grabbed and twisted the nurses's right hand, but the nurse was able to break away from the hold. The police were called and arrived in the ED at 14:05. Patient #1 became more aggressive and combative toward police and ED staff resulting in the patient being placed on stretcher, and with the assistance of 2 police officers the patient was placed in 4 point restraints and held for the administration of emergency medication to include Haldol 10 mg (antipsychotic) IM (intramuscularly) and Ativan 4 mg IM.

Per review of documentation involving the administration of Emergency Medications to Patient #1 it became unclear what was ordered, how much was administered and who administered the medications. Nurse #1 documents within the Emergency Department Clinical Report - Nurses at 14:20 on 12/8/14 s/he administered Lorazepam IM 4 mg. At 17:58 Nurse #1 documents s/he administered to Patient #1 Haldol IM 10 mg. Per interview on 4/13/15 at 2:20 PM, Nurse #1 was unable to verify if s/he had administered either dose although s/he records s/he has on the Medication Administration Record (MAR). However, per review of Emergency Department Physician/PA Clinical Report for 12/8/15 the PA-C states " S/he was then restrained by police and medicated by myself with ativan and haldol IM. ativan 4 mg. IM x2, haldol 10 mg IM". The Medication Reconciliation Record for Patient #1 the PA-C writes Haldol 10 mg IM x1 and Ativan 4 mg IM x1 with a time of 14:30. The ED Order Sheet notes: Lorazepam IM 4 mg IM & Haldol 10 mg IM at 14:30 ordered by the PA-C. Per interview on the afternoon of 4/13/15 the PA-C was unable to clarify the drug dose and administration discrepancies, stating " I am not understanding what the significance of that is....." In addition, documentation was located on plain paper (without hospital letterhead or title) used by an LNA during the restraint event involving Patient #1 and the police and ED staff on 12/8/14. On the side of this paper is a note written by Nurse #1 which states: "Addendum @ 17:57 12/8/14 pt only received 4 mg. of ativan IM. 8 mg charted in error". No further explanations were provided regarding the inaccuracies noted.

Based on record review and confirmed through staff interviews, the CAH failed to assure the medical records were complete and accurately documented for 2 of 10 patients. (Patients #1 & #2 ). Findings include:

1. Per record review Patient #2's record, lacked documentation related to the ongoing use of physical restraints for a period of greater than 8 hours. Per review of the CAH's Restraint and Seclusion policy, last approved for use on 12/11/14, under Procedure for the Care of the Violent and Self-Destructive Patient: .....3. The use of behavioral restraints must be assessed every 15 minutes and documented in the medical record every two hours.....5. Remove the physical restraint at least every (2) two hours for at least (10) ten minutes if possible....6. Change position every (2) two hours plus provide skin care, ROM (range of motion), nutrition or toileting. 7. Remove the restraint as soon as possible...' Patient #2 presented to the ED via ambulance and police escort on 3/29/15 at 12:30 AM for evaluation and treatment of ingestion of drugs including bath salts (a stimulant drug that can induce psychosis and/or violent behaviors). The patient presented in an agitated, violent and combative state and was placed in 4 point restraints, at 12:40 AM, to assure the safety of the patient and others. S/he was medicated with Benadryl and Ativan IM at 1:43 AM and a nursing note at 2:15 AM on 3/29/15, indicated an unsuccessful attempt had been made to release the patient's restraints, as the patient became immediately agitated attempting to thrash his/her arms and legs. Another nursing note, at 3:38 AM, stated that the patient was sleeping, and occasionally moving arms and legs and the right ankle restraint was removed. There was a physician order sheet, at 4:00 AM, that directed staff to continue restraints, specifically wrist restraints only, and the behavior requiring the restraints was listed as danger to self and others. However there was no evidence that an assessment had been completed, at that time, by the MD or any other provider, in accordance with the Restraint and Seclusion policy that identified the behavior warranting continued use of restraints. In addition, the Observation Flow Sheet identified that Patient #2 was lying on his/her back, sleeping at 4:00 AM. Another nursing note, at 4:45 AM stated; 'Patient sleeping. [S/he does toss and turn a little while....mostly sleeping.....left ankle out of restraints...' Although a note at 5:15 AM, by Security Staff providing 1:1 observations, revealed that the patient was kicking off blankets and making noises at that time, all subsequent documentation, every 15 minutes, indicated that the patient was calm and/or sleeping. Despite the lack of evidence of behaviors warranting continued use of restraints, and although there was a physician order, at 8:00 AM that stated reason for discontinuation of restraints: "Pt cooperative", the patient's wrist restraints were not removed until 9:10 AM. In addition, there was no documentation after 2:15 AM, that assessments had occurred in accordance with the policy, including to: '5. Remove the physical restraint at least every (2) two hours for at least (10) ten minutes if possible....6. Change position every (2) two hours plus provide skin care, ROM (range of motion), nutrition or toileting.'

During interview, at 9:23 AM on 4/15/15, RN #2, who had been responsible for the care of Patient #2 on 3/29/15, confirmed the lack of documentation regarding assessments of the patient while restrained and acknowledged that staff "could have tried to release [him/her] earlier" from the restraints.

2. Per record review, Patient #1 presented himself/herself to the ED on 12/7/14 at 20:16 with a complaint of suicidal ideation and insomnia, drinking beer in an effort to obtain sleep. The triage assessment described Patient #1 to have "...altered thought processes, verbalized delusions of persecution...appears anxious, restless, agitated, animated and manic". Patient #1's past history includes alcohol abuse and Bipolar disorder requiring multiple psychiatric hospitalizations and is presently non-compliant with prescribed medications. 1:1 Suicide Precautions were initiated utilizing hospital security guards to provide observations of the patient. At 21:20 the patient was evaluated by the PA-C who ordered Ativan 5 mg (anxiolytic) orally and HCRS (Health Care and Rehab Services) was notified Patient #1 required screening for possible psychiatric hospitalization. The patient was cooperative and by 01:00 on 12/8/14 Patient #1 was asleep until almost 06:00. At 08:24 Patient #1 requested a shower but was told s/he would have to wait because the HCRS screener was expected. By 09:00 Patient #1 was screened and it was determined Patient #1 was an individual in need of treatment and required hospitalization. Nurse #1, assigned to Patient #1, states in Emergency Department Clinical Report Patient #1 was "ramping up". Security along with a LNA (Licensed Nursing Assistant) were now monitoring Patient #1. At 13:56 Patient #1 had lunged aggressively at a nurse who had entered Patient #1's assigned ED room for the purpose of cleaning vomit off the floor. Patient #1 grabbed and twisted the nurses's right hand, but the nurse was able to break away from the hold. The police were called and arrived in the ED at 14:05. Patient #1 became more aggressive and combative toward police and ED staff resulting in the patient being placed on stretcher, and with the assistance of 2 police officers the patient was placed in 4 point restraints and held for the administration of emergency medication to include Haldol 10 mg (antipsychotic) IM (intramuscularly) and Ativan 4 mg IM.

Per review of documentation involving the administration of Emergency Medications to Patient #1 it became unclear what was ordered, how much was administered and who administered the medications. Nurse #1 documents within the Emergency Department Clinical Report - Nurses at 14:20 on 12/8/14 s/he administered Lorazepam IM 4 mg. At 17:58 Nurse #1 documents s/he administered to Patient #1 Haldol IM 10 mg. Per interview on 4/13/15 at 2:20 PM, Nurse #1 was unable to verify if she had administered either dose although she records s/he has on the Medication Administration Record (MAR). However, per review of Emergency Department Physician/PA Clinical Report for 12/8/15 the PA-C states " S/he was then restrained by police and medicated by myself with ativan and haldol IM. ativan 4 mg. IM x2, haldol 10 mg IM". The Medication Reconciliation Record for Patient #1 the PA-C writes Haldol 10 mg IM x1 and Ativan 4 mg IM x1 with a time of 14:30. The ED Order Sheet notes: Lorazepam IM 4 mg IM & Haldol 10 mg IM at 14:30 ordered by the PA-C. Per interview on the afternoon of 4/13/15 the PA-C was unable to clarify the drug dose and administration discrepancies, stating " I am not understanding what the significance of that is....." In addition, documentation was located on plain paper (without hospital letterhead or title) used by an LNA during the restraint event involving Patient #1 and the police and ED staff on 12/8/14. On the side of this paper is a note written by Nurse #1 which states: "Addendum @ 17:57 12/8/14 pt only received 4 mg. of ativan IM. 8 mg charted in error". No further explanations were provided regarding the inaccuracies noted.

Based on staff interview and record review, the CAH failed to effectively analyze and evaluate the appropriate use of restraints in the Emergency Department resulting in the failure to identify opportunities for improvement. Findings include:

Per interview on 4/14/15 at 2:11 AM with the ED day charge nurse and the Nurse Manager for the ED the process for restraint use was discussed. The charge nurse, identified as the responsible person to monitor and track the use of restraints in the ED, stated other ED nurses are supposed to notify her/him if a restraint is used on their shift. The ED Nurse Manager also receives information regarding restraint use during the daily 9:00 AM meeting. A restraint review tool is used which notes specific times patient placed in restraints, checking to assure nurses are charting every hour the patient is in restraints that circulation checks are being performed, justification for use and when they are discontinued. If the day charge nurse identifies a problem s/he will speak directly to the nurse involved at the time of restraint use. It was also noted during chart audits debriefing is not always conducted between staff involved in the event resulting in the use of restraints.

Despite the ongoing process of chart auditing, it was brought to both the ED Nurse Manager and the day charge nurse's attention that during the process of interview and record review it was identified ED staff on 3 separate occasions failed to follow CAH policy and procedures regarding the use of restraints. Staff had failed to discontinue the use of restraints at the earliest possible time; staff had allowed police to handcuff a patient for an extended period who was not under protective custody; staff utilized police to restrain patients and to hold a patient down for the administration of emergency medications. It was also noted staff failed to obtain a physician order for the ongoing use of a restraint beyond the first 4 hours. The present chart auditing process had not captured the issues in the provision of patient care services in theED. As a result, the opportunity to correct and improve present ED processes, expand staff education and prevent the use of non-hospital employees to provide hands-on care in the ED has not been addressed.

Per interview on 4/14/15 at 8:45 AM, the Chief of Quality and Systems Improvement stated the ED Nurse Manager reviews restraint use to make sure the policies are followed and if there are any problems then s/he might get involved.