HospitalInspections.org

Based on record reviews and interviews, the hospital failed meet the requirements for the Condition of Participation for Patient's Rights as evidenced by failure to ensure patients received care in a safe setting. This deficient practice was evidenced by intubating patients to control behaviors for 1 (Patient #2) of 5 (Patient #1, #2, #3, #4, #5) patient records reviewed (See Findings A-0144).

Based on record reviews and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by intubating patients to control behaviors for 1 (Patient #2) of 5 (Patient #1, #2, #3, #4, #5) patient records reviewed.
Findings:

(Patient #2's medical record was reviewed on 07/28/2022 at 3:16 p.m. This review was conducted during a prior survey involving Patient #2).

Review of Patient #2's medical record revealed Patient #2 was admitted in the emergency department on 07/03/2022 at 10:22 p.m. with a chief complaint of overdose.

Review of the triage note dated 07/03/2022 at 10:24 p.m. revealed in part, Patient #2 was extremely physically combative kicking, punching, spitting, grabbing, and restraining multiple emergency department staff. Patient #2 will not speak. Patient #2 was given Narcan x 4mg in field by EMS with minimal response. Patient #2 was combative with EMS. Patient #2 ripped out multiple IV lines, kicking, swiping arms, grabbing and restraining EMS, attempting to sit upright with EMS as well.

Review of emergency department oxygen assessment dated 07/03/2022 at 10:30 p.m. by S1Staff revealed pulse oximeter 99% on 2 liters nasal cannula. Review of vital signs dated 07/03/2022 at 10:50 p.m. revealed blood pressure 160/99, heart rate 106, SpO2 (oxygen saturation) 99%, and respiratory rate 17. Review of vital signs dated 07/03/2022 at 10:55 p.m. revealed blood pressure 155/102, heart rate 111, SpO2 100%, and respiratory rate 20.
Review of nursing note dated 07/03/2022 at 10:45 p.m. by S1Staff revealed patient is agitated and aggressive with staff, unable to redirect patient, patient unable to follow commands, MD (doctor of medicine) and other nurses at bedside in attempt to help redirect patient, attempts are unsuccessful, patient is AAOx0 (awake, alert, oriented times 0). Will continue to monitor.

Review of the medication administration record revealed on 07/03/2022 at 10:51 p.m. Etomidate 20mg and on 07/03/2022 at 10:52 p.m. Succinylcholine Chloride 100mg were administered to Patient #2. (The medication Etomidate is a sedative and the medication Succinylcholine Chloride is a paralytic. These medications are commonly given to patients prior to intubation).

Review of vital signs dated 07/03/2022 at 11:00 p.m. revealed blood pressure 159/96, heart rate 110, SpO2 100%, and respiratory rate 27. Review of vital signs dated 07/03/2022 at 11:03 p.m. revealed blood pressure 131/89, heart rate 105, SpO2 100%, and respiratory rate 16.

Review of Patient #2's medical record revealed no documentation of Patient #2 being placed in restraints.

Review of Patient #2's medical record revealed no documentation of date and time Patient #2 was intubated.

Review of Patient #2's medical record revealed no documentation of the physician's indication for intubation.

In an interview on 08/01/2022 at 12:44 p.m. S2Staff stated Patient #2 was unconscious upon arrival and when they moved Patient #2 from EMS stretcher to hospital stretcher, Patient #2 woke up. She stated per S5MD verbal order, staff placed Patient #2 in 4 point restraints, easy release and could fit 2 fingers in between Patient #2 and the restraint. S2Staff stated as they were treating Patient #2 and when Patient #2 would wake up he would fight his restraints. She stated Patient #2 kept sliding down the stretcher. S2Staff stated S5MD wanted staff to reposition Patient #2 from arms down to arms up so Patient #2 could not sit up. She stated at that time when staff was trying to reposition Patient #2, Patient #2 sat up and was fighting his restraints. S2Staff stated that is when S1Staff and S3Staff open handedly slapped Patient #2 across his abdomen. S2Staff stated there was a total of 3 slaps. She stated she does not remember who did what. She stated S5MD was not in room, ancillary staff walked into room and stated S5MD wanted to give Ativan and she stated that is when she walked out of the room to verify the verbal order with S5MD. S2Staff stated she pulled the medication and administered the medication to Patient #2. She stated she left the room because she had another patient to take care of. S2Staff stated Patient #2 was not intubated when she was in Patient #2's room. (This interview was conducted during a prior survey involving Patient #2).

In an interview on 08/01/2022 at 1:08 p.m. S4Staff stated when Patient #2 was moved from EMS stretcher to hospital stretcher that is when Patient #2 came alive and started fighting. She stated Patient #2 was trying to hit, kick, and roll out the bed. S4Staff stated she held Patient #2's leg down so other staff could start an IV. She stated Patient #2 pulled out IV that EMS had placed. S4Staff stated staff got the line and then Patient #2 was placed in restraints but Patient #2 kept sliding down the bed. She stated S5MD ordered to place a foley catheter to get a urine sample. S4Staff stated she walked out shortly after the foley catheter was placed. S4Staff stated she left and went to lab. She stated when she returned from the lab, the restraints were tied, and she stated S5MD was in process of intubating Patient #2. She stated S5MD was verifying placement of ET (endotracheal) tube when she walked back in Patient #2's room. S4Staff stated she heard S5MD state that Patient #2 bit her when she was trying to intubate Patient #2. (This interview was conducted during a prior survey involving Patient #2).

In an interview on 08/05/2022 at 8:09 a.m. - 8:21 a.m. S6Staff stated Patient #2 came in drunk. She stated staff performed a sternal rub to stimulate Patient #2. S6Staff stated Patient #2 was put in 4 point restraints. She stated Patient #2 was on nasal cannula off and on and oxygen saturations were fine. She stated Patient #2 was slapped in the thigh while in 4 point restraints. S6Staff stated Patient #2 was slapped in the thigh and belly by S1Staff because Patient #2 was trying to sit up and move. She stated Patient #2's forehead was being held and S3Staff choked Patient #2 with one hand. S6Staff stated Patient #2 was yelled and cussed at by staff. She stated Patient #2 was intubated to appease the charge nurse. S6Staff stated the charge nurse stated are we going to intubate this because I am not dealing with this. She stated then the doctor said intubate to protect the airway. S6Staff stated Patient #2 was not having trouble breathing. She stated Patient #2 was not in respiratory distress. S6Staff stated Patient #2's breathing was non-labored. She stated they have had patients before this incident that have been intubated to control behaviors. S6Staff stated it has happened with different doctors. She stated it's to appease the charge nurse because he didn't want to deal with out of control patients. S6Staff stated the patient was given a paralytic before being intubated. She stated Patient #2 was perfectly fine. She stated not at any time was Patient #2 lethargic. S6Staff stated Patient #2 was a sleepy, drunk guy that wanted to be left alone.

In an interview on 08/09/2022 at 9:23 a.m. S10Staff stated Patient #2 was belligerent, intoxicated, slurring speech, and would scream out in pain. He stated Patient #2 was restrained. S10Staff stated he was holding Patient #2's head and chest down. He stated he was not sure why Patient #2 was intubated. S10Staff stated the sheet the staff placed around Patient #2's chest was used as a way of leverage. He stated the sheet was not used as a 5th restraint. He stated Patient #2 was swinging his arms very hard. S10Staff stated S5MD did order restraints. He stated he didn't think Patient #2 knew what was going on. S10Staff stated Patient #2 did not follow commands at all. S10Staff stated Patient #2 would open his eyes look around and then Patient #2 would close his eyes again.

In an interview on 08/09/2022 at 9:40 a.m. S11Staff stated he did question some intubation cases because patients appeared stable with normal ABGs (arterial blood gases) with a reasonable amount of oxygen.

In an interview on 08/10/2022 at 10:18 a.m. S7Staff stated there were no ABGs drawn before the patient was intubated.

In an interview on 08/11/2022 at 4:48 p.m. S12EMT stated he remembers the call with Patient #2. He stated the call came in as a possible overdose. S12EMT stated Patient #2 had pin-point pupils and was unresponsive. He stated Patient #2 was given Narcan and then Patient #2 became responsive to painful stimuli. S12EMT stated when his partner started Patient #2's IV, Patient #2 pulled it out. He stated Patient #2 even tried to bite him. S12EMT stated Patient #2 was "acting a fool" at the hospital. He stated Patient #2 "started to go bonkers and was fighting." S12EMT stated Patient #2 was not in any respiratory distress. He stated Patient #2 needed something to calm him down. S12EMT stated Patient #2 did not need to be intubated. S12EMT stated if he was in charge of the patient, he would have given Patient #2 a "B52"(Benadryl, Ativan, Haldol) to calm him down. He stated all Patient #2 needed was something to calm him down. S12EMT stated when staff were preparing to intubate Patient #2, he looked at his partner and responded in disbelief. He stated Patient #2's respirations were fine, a little slow, but no type of respiratory distress. S12EMT stated he would have put Patient #2 on nasal cannula with 2-3 liters of oxygen. He stated Patient #2 tried to rip out his foley catheter. S12EMT stated Patient #2 was strong and popped the soft restraints. S12EMT stated in his opinion, Patient #2 did not need to be intubated.

In an interview on 08/11/2022 at 6:00 p.m. S13EMT stated she remembers Patient #2. She also stated his GCS was an 8 but his VS and respirations were good along with his airway. NAD noted. She remembers the patient becoming combative at the hospital, spitting at staff and them placing a surgical mask on him to aid with the spitting. She remembers the doctor giving the order to restrain the patient and he was placed in 4 point soft restraints. She said he was able to free one hand and he reached down and grabbed his Foley Catheter and pulled on it. She noticed this and stepped away as she did not want to see him pull it out. S13EMT said Patient #2's GCS increased to at least a 10. She described his actions as "excited delirium". He was trying to come out of the bed. She said at no point was the patient in any respiratory distress and as a Paramedic, if she was in charge of the patient, she would not have intubated him. She would have sedated the patient. S13EMT also stated that she is aware of drunk patients being brought to this hospital in the past and has repeatedly heard hospital staff talk about how they intubate them. S13EMT said when she heard staff say to get the medications used for intubation, she looked at her partner and said, "What the hell?" Lastly, she said the intubation cases she has heard about were different doctors.