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Based on record review and confirmed through staff interviews the facility failed to provide care and services in accordance with established policies for 1 applicable patient. (Patient #4). Findings include:

Per record review staff failed to provide care in accordance with the facility's policy for restraint use for Patient #4, who was physically restrained during the course of his/her treatment in the ED (Emergency Department). The patient had an extended length of stay in the ED, exceeding 24 hours, while awaiting available bed placement for involuntary admission to an inpatient psychiatric unit.

Per record review the policy, titled Physical and Chemical Restraint Policy, approved 03/2013, and identified by staff as the currently established facility policy, stated, under Purpose: A. "Restraints are used for the management of behavior that jeopardizes the immediate physical safety of the patient, staff or others. " And, under Definitions: Restraints are NOT used for: " .....Solely on the patient ' s history of dangerous behavior, if any. " Under Nursing Guidelines: 6. Discontinuation of Restraints " a. Restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Restraint may only be used while the unsafe situation (clinical justification) continues. Once the unsafe situation ends, the use of restraint must be discontinued. "

Per record review Patient #4 was brought to the ED (Emergency Department), by law enforcement escort, at 7:39 PM on the evening of 3/8/13, for evaluation of " Psych Problem " . The patient arrived in handcuffs following an altercation with law enforcement in which s/he had been violent and aggressive. A nurse ' s note, dated 3/8/13 at 9:47 PM, identified the patient ' s behavior as anxious and " verbally combative with PA (Physician Assistant). " A nurse ' s note, at 8:35 PM, stated that handcuffs had been removed at that time and a Restraint Flow Sheet indicated the initiation of 4 point restraints related to the patient's agitated and combative behavior. Subsequent nurses notes stated the patient continued to be verbally abusive and a note at 11:03 PM on 3/8/13, stated that Patient #4 was unwilling to take medication PO (by mouth), continued to be verbally abusive to staff, threatened to harm the nurse and was given an injection of haldol (antipsychotic) and Benadryl (used to promote sleep). At 11:55 PM a nurse ' s note stated the patient was " resting with eyes closed and sonorous respirations " , and indicated the patient was under 1:1 observation by staff and law enforcement personnel as well as a staff member from the community Crisis center. The Restraint Flow Sheet identified the patient as " Asleep " between 11:15 PM on 3/8/13 and 1:30 AM on 3/9/13, and " Awake and Appropriate " between 1:45 AM and 3:15 AM on 3/9/13. A nurse ' s note, at 2:55 AM on the morning of 3/9/13, stated the patient took PO meds willingly and at 3:15 AM was up to the bathroom, " calm and appropriate " , and returned to bed " wishing to go to sleep. " The note further stated that restraints were reduced to 2 point, " feet only " , at that time. A subsequent nurse's note at 6:27 AM indicated that the patient had been resting with the sheriff (as security), a hospital employee providing 1:1 observation and a Crisis center staff member, all present at the bedside, throughout the shift. The note stated that all restraints were removed at that time. Although nurses notes and the Restraint Flow Sheet indicated the patient was either sleeping or awake and appropriate from 11:30 PM on 3/8/13 until the early morning hours of 3/9/13, restraints remained in place until the wrist restraints were removed at 3:15 AM on 3/9/13. The documentation further indicated that Patient #4 was " Asleep " for the next 3 hours between 3:30 AM and 6:30 AM; however, the remaining ankle restraints were not removed until 6:30 AM.

Despite the lack of evidence that the unsafe situation for which the restraints were initiated had continued after 11:30 PM and although there was no evidence for clinical justification for the continued use of restraints the restraints were not discontinued at the earliest possible time, in accordance with the facility policy. This was confirmed by the ED Nurse Manager during interview at 1:20 PM on the afternoon of 4/23/13.

Based on observation and interview, the CAH (Critical Access Hospital) failed to assure anesthesia carts remained locked when not in use and drugs used by anesthesia staff are disposed of after completion of each patient anesthesia case. Findings include:

Per observation of the anesthesia cart in Operating Room #2 on 4/23/13 at 11:30 AM, drawer #2, which contained multiple anesthetic and cardiac drugs used during administration of anesthesia, was found unlocked. Per interview on 4/23/13 at 11:43 AM, the CRNA (Certified Registered Nurse Anesthetist) who last used the cart on 4/23/13 stated s/he had completed a surgical case at approximately 9:00 AM and acknowledged the failure to lock the cart. The CRNA also confirmed the predrawn syringe of the drug Ephedrine 25 mg found sitting on top of the anesthesia cart should have been disposed of by the CRNA at the completion of the anesthesia case.

Per interview the Chief Operating Officer (COO) and the Chief of Anesthesia on the afternoon of 4/23/13 both confirmed the Pyxis Anesthesia System has an automatic locking system which would have locked drawer #2 within 90 minutes after use, despite the fact that the CRNA had neglected to secure the cart. The exception to this would be that the CRNA had not completely closed drawer #2 after use, preventing the automatic locking of the cart to occur. Although, the Chief of Anesthesia and COO also confirmed an alarm would sound when the Pyxis system could not perform a locking function, staff may not have heard the Pyxis alarm 90 minutes after the completion of the last surgical case, due to no perioperative staff being in the vicinity of Operating Room #2 who could have responded to the alarm. However, they both confirmed the CRNA should assure the anesthesia cart is consistently locked when not in use or if left unlocked the cart was within direct supervision of authorized staff. In addition, the drug left on the anesthesia cart by CRNA should have been disposed of by the CRNA at the completion of the surgical case.