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Based on staff interview, review of patients' medical records, hospital policies and procedures, grievance documents, medical records requests, and restraint logs, it was determined the hospital failed to ensure patients' rights were protected. This resulted in the inability of the hospital to ensure patients rights were respected and not violated. The findings include:

1. Refer to A123 as it relates to the failure of the hospital to ensure it provided a written notice of findings to patients who filed grievances.

2. Refer to A129 as it relates to the failure of the hospital to define how patients on suicide watch could access a telephone.

3. Refer to A131 as it relates to the failure of the hospital to ensure the rights of patients who were placed on involuntary holds, were protected.

4. Refer to A148 as it relates to the failure of the hospital to promote patient rights by releasing clinical record information.

5. Refer to A154 as it relates to the failure of the hospital to ensure patients, who were admitted to the hospital for medical clearance, pending a psychiatric admission, were free from the threat of restraints imposed as a means of coercion.

6. Refer to A166 as it relates to the failure of the hospital to ensure hospital staff incorporated restraint usage into patients plans of care.

7. Refer to A169 as it relates to the failure of the hospital to ensure restraint orders were not written as PRN orders.

8. Refer to A178 as it relates to the failure of the hospital to ensure patients who were restrained for the management of violent behavior, received a face-to-face evaluation by an appropriately qualified person within 1-hour after the initiation of the intervention.

9. Refer to A186 as it relates to the failure of the hospital to ensure less restrictive interventions were attempted before the use of chemical and/or physical restraints.

10. Refer to A187 as it relates to the failure of the hospital to ensure that patients for whom chemical and/or physical restraints were used, had documentation in the medical records of the conditions and/or symptoms that warranted the use of the restraints.

11. Refer to A188 as it relates to the failure of the hospital to ensure that patients for whom chemical restraints were used, had documentation in their medical records of the response to the intervention.

The cumulative effect of these negative facility practices seriously impeded to ability of the facility to promote and protect the rights of patients.

Based on staff interview and review of hospital policies and grievance files, it was determined the hospital failed to provide written notice to 4 of 5 patients (#27, #30, #31, and #33) whose grievances were initiated between February and April, 2010 and whose grievance files were reviewed. This resulted in delayed responses to patients' greivances. The findings include:

1. A hospital policy, Patient Concern, Complaint, and Grievance Process, dated 6/04/09, had a section titled Investigating and Responding. It stated an acknowledgement letter would be mailed to the patient/representative within 7 days of receipt of a formal complaint/grievance. The timeframe for review and investigation depended on the severity of the complaint/grievance. After the review was complete, the hospital would provide the patient with a written notice of its decision. Whenever possible, concerns and grievances would be resolved within 30 days of receipt. More complex grievances might require more than 30 days to reach resolution. The policy did not address the procedure to be taken if and when the hospital was not able to investigate or resolve the complaints within the timeframes specified within the policy, such as whether they would contact the complainants to let them know of a delay.

The above policy was not followed. Examples include:

a. Patient #33 was a 31-year-old female admitted 3/23/10 and discharged 3/28/10. A Performance Improvement Event (PIE), dated 3/25/10, completed by an RN, described an event that resulted in patient injury. The report stated that after Patient #33 returned to her hospital room from the Endoscopy Department (where she had a bronchoscopy performed), she pointed out a dark bruise to her left shoulder and stated a nurse in the Endoscopy Department told her to breathe deeply and then pinched her really hard causing the bruising. She was angry and upset.

A bronchoscopy is a visual inspection of the tracheobronchial tree through the trachea.

An email communication, dated 4/07/10, documented Patient Relations received the grievance. A Performance Improvement Concern Report, dated 4/07/10, documented Patient Relations then sent a letter to Patient #33 to acknowledge the grievance. This represented a period of 13 days after an RN initiated a written grievance on behalf of Patient #33. Patient #33 did not receive an acknowledgement letter within 7 days of initiating the grievance as required by hospital policy. The Performance Improvement Concern Report also indicated the grievance had been "sent for review" to a staff member who was assigned to be the lead reviewer.

As of 6/08/10, the grievance file did not contain evidence the hospital had investigated or resolved the grievance, or sent a follow-up letter to Patient #33. This represented a period of 73 days, from the time the complaint had been initiated.

During an interview on 6/08/10 at 8:00 AM, the Manager of Patient Relations explained because of a "paper system" there was a delay between the time the complaint was received in one department and the time it arrived with Patient Relations where complaint investigations were initiated. She also stated the complaint had been forwarded to the Endoscopy Department for investigation and review and they had not heard back from the department.

Patient #33 did not receive written notice of the hospital's decision regarding her grievance with 30 days of initiation as stated in hospital policy.

b. Patient #31 was a 27-year-old female who came to the ED on 2/15/10. A hospital email communication, dated 2/16/10, indicated the patient's husband complained the ED had given his wife some pills that led to hemorrhaging and subsequent surgery.

A Performance Improvement Concern Report, dated 2/23/10, indicated Patient Relations received the complaint and sent an acknowledgment to the complainant on 3/04/10 (23 days after the initial complaint was filed). Patient #31 did not receive an acknowledgement letter within 7 days of initiating the greivance as required by hospital policy. Patient Relations Notes, on the same form, indicated the complaint was "sent for review" on 4/12/10 to a staff member who was assigned to be a lead reviewer. This was 62 days after the complaint was initiated. The form further indicated Patient Relations requested an update on 5/25/10 from the lead reviewer to determine the status of the investigation.

No additional information was present in the grievance file to indicate the complaint had been investigated or a letter of response had been sent as of 6/08/10, a total of 116 days after the initial complaint was received.

During an interview on 6/07/10 at 3:20 PM, the Director of Nursing Administration reviewed the grievance file information and confirmed the delay in sending an acknowledgement letter and confirmed a written response had not yet been completed and sent.

During an interview on 6/08/10 at 8:00 AM, the Manager of Patient Relations stated the complaint was first received in Patient Financial Services before being forwarded to Patient Relations. She did not realize until that morning (6/08/10) the hospital had reached a financial resolution with the complainants. She acknowledged a letter had not yet been written and sent to Patient #31.

Patient #31 did not receive written notice of the hospital's decision regarding her grievance with 30 days of initiation, as stated in hospital policy.

c. Patient #27 was a 73-year-old male who was seen in the ED on 4/15/10. An email communication received in Patient Relations, dated 4/28/10, indicated Patient #27 had reported falling while getting into a cab after leaving the ED on 4/15/10. Patient #27 reported having had trouble walking and he was upset with ED staff for not taking him out in a wheelchair. His leg was scratched in the fall and subsequently became infected.

A Performance Improvement Concern Report, dated 4/28/10, documented Patient Relations received Patient #27's grievance, mailed an acknowledgement letter to Patient #27, and initiated a request for a physician and additional staff to review the grievance.

An additional Patient Relations note, dated 5/25/10, stated a request had been made for an update on the investigation. An email response to Patient Relations from the lead reviewer, dated 5/25/10, stated "sorry, I haven't." A second follow-up email, dated 6/08/10, indicated Patient Relations made another attempt to contact the lead reviewer to see if the investigation was complete.

As of 6/08/10, the grievance file did not contain evidence the hospital had completed an investigation and sent a written reply to Patient #27. This represented a period of no less than 38 days from the date the complaint was initiated.

During an interview on 6/08/10 at 8:00 AM, the Manager of Patient Relations confirmed the investigation had not been completed and a letter of resolution had, therefore, not been sent. She explained, Patient Relations had not heard back from the ED Director who was investigating the complaint.

Patient #27 did not receive written notice of the hospital's decision regarding her grievance with 30 days of initiation, as stated in hospital policy.

d. Patient #30 was a 68-year-old male admitted 4/19/10 and discharged 4/26/10. A Performance Improvement Event, dated 4/28/10, completed by an RN, documented the family had reported multiple concerns regarding medical and nursing care issues.

A Performance Improvement Concern Report, dated 4/28/10, indicated Patient Relations sent the complainant a card to acknowledge the complaint and then forwarded the complaint for review to a staff member who was assigned to be a lead reviewer.

An email from hospital staff, dated 5/10/10, documented the investigation was complete. The grievance file was reviewed. There was no evidence, as of 6/08/10, the complainant had been sent a written response regarding the resolution of the grievance. This was 41 days after the initial complaint was received.

During an interview on 6/08/10 at 8:00 AM, the Manager of Patient Relations confirmed the investigation was complete and the letter was due to be sent but had not yet been sent.

Patient #30 did not receive written notice of the hospital's decision regarding her grievance with 30 days of initiation, as stated in hospital policy.

2. A hospital document written by the Manager of Patient Relations, titled Patient and Family Relations Quarterly Departmental Review (1st quarter [September 30, 2009 through December 31] and 2nd quarter FY 2010 [January 1 through March 31]), dated 4/20/10, described challenges facing the Department of Patient Relations, including: 1) an increase in complaints, 2) staff turnover of Patient & Family Relations staff, 3) loss of one position, 4) more complex complaints received requiring more time, and 5) the need for additional support.

During an interview on 6/07/10 at 3:30 PM, the Director of Nursing Administration explained that responses to grievances may have been delayed in the above referenced examples because of staffing issues. She said they had one open position and an employee had been out sick. Also, there had been job transitions among staff.

During an interview on 6/08/10 at 8:00 AM, the Manager of Patient Relations stated it was their goal to resolve 90% of complaints and provide a written response within 30 days. In previous quarters they had met or exceeded this goal. She acknowledged that during the current quarter, beginning April 1, they had gotten behind, probably because they had been down one staff since 4/07/10 and another staff had been ill. She also stated it had been difficult at times to get responses from departments who were assigned to investigate complaints. She stated the departments were very busy and had a hard time getting to investigations. It was her desire to change the model and have staff from the Patient Relations Department lead the investigations. She stated complaints had increased, the hospital was growing, and they lacked staff for follow-through with complaints.

The hospital failed to investigate, resolve, and respond to complainants in writing within the 30 day timeframe as stated in hospital policy.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure access to a telephone for 2 of 9 patients (#16 and #17) whose psychiatric records were reviewed. This limited the ability of patients to communicate and resulted in a violation of patient rights. The findings include:

1. Patient #16 was a 20-year-old female, admitted to the hospital on 4/23/10, after a self-reported medication overdose. Patient #16's record documented she was on suicide watch and was assigned a 1:1 sitter. Patient #16's record contained a nursing note, dated 4/26/10 at 12:16 PM, which stated Patient #16 had a cell phone which the staff attempted to remove from her possession. The note documented that Patient #16 refused to give the cell phone to the staff and was instructed that if she did not cooperate and give up the cell phone, she would be placed in restraints.

The hospital's policy tiltled Care of Patients with Threatened or Actual Suicide Attempt, dated 4/12/09, stated staff would remove any items from the room that could potentially be used for self-harm. The policy referred to the hospital's Safety Checklist. The hospital's Safety Checklist, that was not dated, instructed staff to remove telephone cords from the room and store them in a locked cupboard. Neither the policy, nor the checklist, provided direction to staff as to how to accommodate the patient's desire or need for a telephone.

2. Patient #17 was a 63-year-old female, admitted to the hospital on 1/07/10, after a self-reported overdose. Patient #17's record documented she was on a suicide watch and had a 1:1 sitter. A nursing shift note, dated 1/11/10 from 3:00 PM to 8:00 PM, stated Patient #17 was talking on the phone.

The Clinical Supervisor of the Medical floor, was interviewed on 6/08/10 starting at 12:05 PM. He stated Patient #17 did have a cell phone during most of her hospital stay. He stated that this was an oversight and when it was identified that Patient #17 had a cell phone, the phone was removed from her possession. He stated that patients who were on suicide watch were not allowed a telephone.

The hospital's Social Service Supervisor was interviewed on 6/08/10 starting at 10:35 AM. He stated that patients on suicide watch did not have a telephone in their room. He was unsure as to how staff was to allow patients to use the phone.

Patient #17's physician was interviewed on 6/08/10 starting at 1:00 PM. She stated that Patient #17 did have a cell phone during most of her hospital stay. She also indicated this was an oversight and when it was identified that Patient #17 had a cell phone, the phone was removed from her possession. She was unsure as to how staff were to allow patients to use the phone or if they were even allowed to use one.

Patient #17's telephone use was restricted due to her status of being on suicide watch.

3. Staff were interviewed regarding their understanding of patients'use of telephones while on suicide watch.

Staff N, an RN, was interviewed on 6/08/10 starting at 2:23 PM. She stated that patients on suicide watch did not have a telephone in their room and were not allowed to use a telephone.

Staff P, a RN, was interviewed on 6/08/10 starting at 2:43 PM. She stated that patients on suicide watch did not have a telephone in their room and she did not know how patients were to use the phone.

A RN was interviewed on 6/08/10 starting at 2:25 PM. She stated it was up to the nurse as to whether patients on suicide watch could use a telephone.

A CNA was interviewed on 6/08/10 starting at 2:07 PM. She stated it was up to the nurse as to whether patients on suicide watch could use a telephone.

Hospital staff were not sufficiently trained on how to promote and protect the rights of each patient.

The hospital failed to promote patient rights in its policies and practices related to telephone use.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure the rights of 2 of 2 patients (#2 and #14) reviewed, who were placed on involuntary holds, were encouraged and protected by allowing them to participate in decisions regarding their care. This resulted in 2 patients being placed on involuntary holds for the convenience of staff for discharge planning purposes. The findings include:

Idaho statute 66-326 states a "person may be detained at a hospital at which the person presented or was brought to receive medical or mental health care, if the peace officer or a physician medical staff member of such hospital has reason to believe that the person is gravely disabled due to mental illness or the person's continued liberty poses an imminent danger to that person or others, as evidenced by a threat of substantial physical harm..." Two patients (#2 and #14) were placed on involuntary holds without an evaluation by a physician that their continued liberty posed an imminent danger to themselves or others. Examples include:

1. Patient #2's medical record documented an 81-year-old female who was admitted to the hospital on 3/04/10 and was discharged on 3/05/10. She presented to the emergency department on 3/04/10 at 9:45 PM. A History and Physicial dictated at 12:43 AM on 3/05/10, stated Patient #2 had fallen and suffered a contusion of her forehead and laceration of her nose which required suturing. The report stated Patient #2 thought she had slipped and fallen. The report stated this was her third admission to the emergency department in 2 days. The report stated she had been seen first for a urinary tract infection and confusion. The report stated she had returned later and been treated for confusion related to dehydration. She was rehydrated and sent home again before returning a third time. The report stated "I get the impression that she is markedly depressed as well as somewhat paranoid and concerned about being here in the hospital." The report stated Patient #2 had a history of "...depression with possibly some psychotic features..." The report stated her affect was flat but she was oriented to person, place, and time. The report also stated Patient #2 did not appear to be in any distress but was tearful. The report stated the plan was to admit Patient #2 for hydration and "...possible consideration of a psychiatric evaluation and maybe transferred to [a geriatric psychiatric hospital] for medication evaluation and adjustment."

The next physician note was dated 3/05/10 at 3:00 PM. The entire note stated "Pt alert in no distress. Refused transfer to [the geriatric psychiatric hospital]. When trying to discuss says 'I'm doing horrible. I will make other arrangements rather than go to [the geriatric psychiatric hospital].' Orders including hold for psychiatric debility were signed. Transfer to [the geriatric psychiatric hospital] ." No evaluation of Patient #2's psychiatric condition was documented in the medical record. No description of Patient #2's behavior that indicated she was a danger to herself or others was documented.

The RN documented on the Cumulative Flowsheet Report section of the electronic medical record, at 10:44 AM on 3/05/10. Under the heading Psycho-Social Assessment, the software prompted "Agitated," to which the nurse answered "Yes." No other indication of Patient #2's agitation or description of her behavior was documented. This was the last note in the medical record by a nurse who provided care to Patient #2. A note documenting the time of discharge and condition of the patient at discharge was not present in the medical record. A tracking document from the ambulance dispatch, labeled Transfer information, stated Patient #2 was transported by ambulance at 4:34 PM on 3/05/10 to a geriatric psychiatric hospital.

A Case Management Encounter Note, dated 3/05/10 at 11:55 AM, stated Staff C, the RN Case Manager, met with Patient #2 and her daughter. The note said they discussed the option and possibility of discharging her to the geriatric psychiatric hospital. The note stated Patient #2 currently lived in an ALF and wanted to return there. The note stated, "Pt, at this point, is unsure if she will go to [the geriatric psychiatric hospital] voluntarily. May need to initiate a hold." No behavior was documented indicating Patient #2 was a danger to herself or others or gravely disabled.

A Social Service Assessment was documented at 12:18 PM on 3/05/10 by Staff B, a Social Worker. The assessment quoted directly stated:

"SW Recurrent Illness Patient
SW Multiple Health Issues Patient
Depressed Mood Patient
Hallucinations/Delusions Patient
Mental Health Issues Patient
Cope with Hospitalization Yes
Comfortable asking questions Yes
Income to meet basic needs Yes
Understand Prognosis Yes
Adequate Family Support Yes
Adequate Social Support Yes"

This was the assessment as it was provided to surveyors.

The Social Service Assessment inluded a Social Service Focus Note by the same Social Worker at the same time. The Focus Note stated the Social Worker met with Patient #2 and her daughter. The Focus Note stated Patient #2 had been diagnosed with "Delusional Disorder a few years ago and had spent 3 weeks in a psychiatric hospital in [another state]." The Focus Note stated Patient #2's symptoms had been controlled with medication but, after a change of medication in February 2010, she "has not presented as she had previously, according to [the daughter]...[The daughter] and her brother have an appt [appointment] with an attorney next Tuesday to file for legal guardianship of their mother. He will arrive tomorrow. The pt presented as very flat and withdrawn. She did not want to talk to SW....SW called [the geriatric psychiatric hospital] regarding not knowing who, if anyone, may have medical POA for the pt. They can help work this out once the pt is there and the daughter can sign pt in. If the pt attempts to leave, however, then the POA would need to be notified. SW discussed with the case mgr about the pt meeting criteria for a hold for being gravely disabled if the attending MD wanted to pursue that route."

The last note on the medical record was dated 3/05/10 at 4:33 PM. The note was by the social worker. It stated the patient had been accepted for care by the physician at the geriatric psychiatric hospital. It stated "Transport notified" and said paper work was being prepared for the receiving hospital. A note documenting the discharge of Patient #2, including the time of discharge, the mode of transport, and the condition of the patient at discharge, was not present in the record.

A specific assessment of Patient #2's mental state or behavior was not documented during her stay. The specific behavior(s) that warranted placing Patient #2 on an involuntary hold were not documented.

The Application of Commitment of the Mentally Ill, dated 3/05/10 at 1:31 PM, signed by the physician and filed with the court, stated Patient #2 had been on a steady mental decline, according to her daughter. The application stated Patient #2 had a previous psychiatric diagnosis and had been having paranoid thoughts. The application stated Patient #2 was not able to complete her activities of self-care, had a flat affect, and did not want to talk much today. The application did not state a specific behavioral reason for the involuntary hold.

Patient #2's Interdisciplinary Care Management Plan, dated 3/04/10 and 3/05/10, did not contain a plan related to her behavior or psychological issues. The Patient Focus List, part of the plan, stated "Pt will be able to verbalize needs for self-care." No plan for this was documented.

Staff B, Patient #2's Social Worker, was interviewed on 6/08/10 at 10:30 AM. Staff B was asked what specific behavior Patient #2 exhibited to warrant placing her on an involuntary hold. Staff B could not state one. She stated she did not assess Patient #2's mental status or psychological status. When asked why the patient was placed on an involuntary hold, she replied Patient #2 could not take care of her activities of daily living and had a mental health diagnosis.

Staff D, the physician who signed the involuntary hold, was interviewed on 6/09/10 at 3:05 PM. She stated Patient #2 was admitted by the on-call physician. She said she was told by the hospital that Patient #2 needed to leave, to be transferred, so she left her private practice and came to the hospital. Staff D stated Patient #2 was alert and probably oriented to person, place, and time. She said much of her assessment of Patient #2 was based on her previous history. She stated Patient #2 was psychotic but she did not have a specific example of the patient's psychotic behavior. She said Patient #2 was angry and could not be reasoned with. She said Patient #2 did not want to be in the hospital and did not want to be transferred to another hospital. She said she did not know if other possible placements for Patient #2 had been discussed.

Staff A, the nurse who cared for Patient #2 on 3/05/10, was interviewed on 6/10/10 at 9:20 AM. She stated the last nursing care note was documented at 10:44 AM on 3/05/10. She stated she did not remember Patient #2 and did not know what she meant when she documented the patient was "Agitated." She stated this term was chosen from a menu of choices in the electronic medical record. She stated a discharge note was not documented.

Patient #2 was placed on an involuntary hold without an evaluation of her mental status and for the convenience of hospital staff in order to facilitate discharge planning.

2. Patient #14's medical record documented a 69-year-old male who was admitted to the hospital on 2/12/10 and was discharged on 2/15/10. Diagnoses included dementia, homosexual delusion, and diabetes. An involuntary hold was documented on 2/15/10.

The discharge summary, dated 3/23/10, stated Patient #14, "Did continue to have delusional thoughts regarding homosexuality...The [discharge] plan had been that the patient move from his home setting to an assisted living facility. We were having difficulty finding that due to these delusions, and instead he was transferred to behavioral health." The discharge summary did not state that Patient #14 was placed on an involuntary hold or the reasoning behind that decision.

The Emergency Department record, dated 2/12/10, stated Patient #14 had dementia and his symptoms had been worsening over the past several months. The record stated the patient had answered the door naked and had spoken on the telephone to a family member of homosexual delusions. A psychiatric examination, dated 2/12/10 at 10:52 PM, stated Patient #14 had a calm affect but described receiving "messages that come from his head" regarding homosexual activities. The note stated Patient #14 denied wanting to harm himself or others.

A physician Progress Note, dated 2/13/10 at 12:45 PM, stated "Plan 1. Not safe for discharge to live alone. Must find appropriate ALF. Discussed [with] patient & son at bedside-both agreeable." A physician Progress Note, dated 2/14/10 at 11:45 AM, stated Patient #14 had no complaints. The note stated Patient #14 was sexually inappropriate with a male RN the evening before but there was no "focus note to support." Patient #14 was described as "Alert and oriented to hospital...Plan: ...Await ALF placement." A physician Progress Note, dated 2/15/10 at 9:45 AM, stated Patient #14 was sitting in the hallway with a sitter. The note stated he was aware he was in St. Lukes Regional Medical Center and the physician was covering for Patient #14's regular physician. The note stated "He continues agreeable to ALF placement."

A Progress Note by the Case Manager, dated 2/15/10 at 3:50 PM, stated she met with Patient #14's son and daughter and the Admissions Director for the ALF. The note stated the ALF Director had contacted a geriatric psychiatric hospital and thought Patient #14 would be appropriate for admission there before coming to the ALF. The note stated the Social Worker sent the referral to the geriatric psychiatric hospital and the family was available for transport. A corresponding order by the physician, dated 2/15/10 at 4:40 PM, stated if the geriatric psychiatric hospital accepted Patient #1, to discharge him to his family for transfer there. A physician Progress Note, dated 2/15/10 (no time documented), stated "Discussed [transfer with] patient & he is willing for transfer to [geriatric psychiatric hospital]." A telephone order, dated 2/15/10 at 5:50 PM, stated "place pt on mental health hold." No progress note by the physician accompanied the order.

A Psychological and Social Assessment by the RN, dated 2/15/10 at 9:06 AM, stated "Disoriented-Yes." No clarification was documented and no specific behaviors were documented. A Psychological and Social Assessment by the RN, dated 2/15/10 at 3:35 PM, stated "Disoriented-Yes." Again, no clarification was documented and no specific behaviors were documented. No nursing note on 2/15/10 documented Patient #14 had any behavioral problems or was a danger to himself or others or described that he was gravely disabled.

A progress note by the Case Manager, dated 2/15/10 at 4:43 PM, stated she met with Patient #14 and his son and daughter. The note stated the ALF representative wanted the patient to go to the geriatric psychiatric hospital prior to admission to the ALF. The note stated a referral was sent to the receiving hospital. A Social Service Focus Note by Staff F, the Social Worker, dated 2/15/10 at 4:45 PM, stated she called the geriatric psychiatric hospital and beds were available. The Social Service Focus Note by Staff F, dated 2/15/10 at 6:19 PM, stated because Patient #14's Durable Power of Attorney for Health Care was executed 2 days prior to his hospitalization, the geriatric psychiatric hospital wanted Patient #14 placed on a "Physician Mental Hold." The note stated Staff F informed Staff E, Patient #14's physician, and completed an application for commitment. The note did not include an assessment of Patient #14's psychological status or documentation of specific behaviors to indicate he was a danger of self or others or gravely disabled. The final note in Patient #14's medical record was a "CM Focus Note," dated 2/15/10 at 6:19 PM. It stated Patient #14 was placed on an involuntary hold and the family would transport him to the receiving hospital. An involuntary hold is a legal process where a patient is taken into custody by the hospital. The note did not explain why Patient #14 was being released to his family. A focus note stating the time and circumstances of Patient #14's discharge was not documented.

Patient #14's Interdisciplinary Care Management Plan, dated 2/13/10-2/15/10, did not mention psychological status or direction to staff regarding inappropriate behaviors. A Discharge Planning column, dated 2/15/10, stated, "Pt placed on Physician hold @ request of Dr. [name], admitting MD at [geriatric psychiatric hospital]. Son, daughter will transport."

Staff E, Patient #14's physician, was interviewed on 6/07/10 at 4:25 PM. He stated he did not evaluate Patient #14 prior to placing him on an involuntary hold. He stated Patient #14 was placed on a hold because the social worker said the physician at the receiving hospital would not admit the patient unless he was placed on a hold. He stated he did not speak with the receiving physician.

Staff F, the Social Worker for Patient #14, was interviewed on 6/08/10 at 2:05 PM. She reviewed the medical record and confirmed she did not evaluate Patient #14's psychological status. She stated Patient #14 was placed on an involuntary hold for discharge planning purposes. She stated the hospital sometimes allowed patients on involuntary holds to be transported by family members.

Staff G, the RN assigned to Patient #14 on 2/15/10, was interviewed on 6/08/10 at 2:40 PM. She stated Patient #14 seemed "normal and coherent" although he was sexually inappropriate with young males. She stated Patient #14 had wandered into a 21 year old male's room and said something inappropriate. She stated he was easily redirected by staff. She stated female staff were assigned to him and he was compliant and cooperative with them. She stated he just needed supervision. She stated his plan of care did not include any behavioral interventions. She said staff just reoriented him if needed it and he "was fine" in the room.

Patient #14 was placed on an involuntary hold without an evaluation of his mental status and for the convenience of hospital staff in order to facilitate discharge planning.

Based on review of hospital policies and documentation of requests for release of medical records and interviews with staff and patients, it was determined the hospital failed to promote patient rights by releasing clinical record information for 2 of 2 patients (#18 and #19) whose adoptive parent requested records. This frustrated the legitimate efforts of a parent to gain access to her adopted childrens' medical records. The findings include:

The hospital documented receiving medical record requests on 3/27/09 and 2/18/10 from an adoptive parent for Patient #18 and Patient #19. A computer-generated medical record form showed an "A" next to Patient #18's name and Patient #19's names, indicating the record request was still active or the request had not been finalized. A letter, dated 2/01/10, from a parent of Patients' #18 and #19, was attached to one of the requests. In the letter, the parent stated she had made 5 prior requests for release of information in the previous 4 years, none of which had been fulfilled. She further stated in the letter she had received "an irate phone call" from someone in the medical records department informing her that she did not have to send 5 requests because it would not make them send the records any faster and she should stop sending requests for records.

A phone interview was conducted on 6/07/10 at 2:10 PM with the parent who had requested medical records on her two adoptive children (Patient #18 and Patient #19). She stated she had made multiple requests to have medical records released and had completed the hospital's required paperwork and provided proof of her legal relationship to her children. She stated she had not received the records or any written response from the hospital to her requests. She stated she had two phone conversations with representatives from the Medical Records Department. During one phone conversation, she stated she was told to stop sending requests for medical records, and during a second phone call she was told the childrens' records were closed due to adoption and would not be released. She explained her children were disabled and under medical care and she and the physicians did not want to repeat unnecessary genetic tests that may have previously been conducted. She also stated that she had looked into Idaho statutes about release of records and understood she had a right to access her childrens' medical information.

On 6/08/10 at 12:40 PM, an interview was conducted with the Boise HIM Manager and the Director of Nursing Administration. The Boise HIM Manager acknowledged two unfulfilled requests (dated 3/27/09 and 2/18/10) for medical records from an adoptive parent for two daughters. She stated she realized in looking at the documentation that the hospital had not followed-up with the parent and should have at the time. She also stated the first request had been shredded but should not have been shredded. Although the hospital would not have released the medical record information to the requestor based on the hospital's policy (referenced below), their department should have sent a response to the parent.

The hospital's policy, Confidentiality and Security of Patient Information in Health Information Management (HIM), dated 1/25/10, stated that in order to protect all parties' identities, records on adopted infants would be released only by court order once the child had been discharged from the hospital and identifying information (of birth parents) would be deleted unless the court specified otherwise.

The Boise HIM Manager was interviewed on 6/07/10 at 2:35 PM. Her remarks were consistent with the above-referenced policy. She explained the hospital released information on adoptive children to the adoptive agency or an adoptive parent only by court order. When released, the information regarding the birth parents was "blacked out" to protect the privacy of the birth parents. When asked how the policy or practice was established, she explained it was based on information from the Idaho Hospital Association. The Health Information Manager provided the reference from the Idaho Hospital Association upon surveyor request.

The Guidebook Issues in Health Care Management, published in 2008 by the Idaho Hospital Association had a section titled Release of Information Regarding Adoptions. It recommended that each institution's policy stipulate that the adopting parents had the right to inspect the adoptee's medical records, consistent with state statues on minority. However, such inspection should not include the sealed birth certificate, or identifying information on the child's birth parents. Thus, it was necessary for the institution to take measures to mask the identity of the birth parents.

During an interview on 6/08/10 at 12:40 PM, surveyors asked the Boise HIM Manager how the hospital's policy regarding not releasing medical records to adoptive parents was derived from the reference provided (Guidebook Issues in Health Care Management). The Boise HIM Manager stated she realized there was "a gap" and it would be necessary to revisit the policy and perhaps seek legal council on the appropriateness of withholding medical records from adoptive parents.

The hospital failed to protect and promote adoptive parents' rights to access medical information on their adoptive children.

Based on staff interview and review of medical records, it was determined the hospital failed to ensure 2 of 2 patients (#16 and #38) reviewed, for whom chemical and/or physical restraints were used, were free from the threat of restraints imposed as a means of coercion. This resulted in patients' rights being violated. The findings include:

1. Patient #16 was a 20-year-old female, admitted to the hospital on 4/23/10, after a self-reported overdose. Patient #16's record documented that she was on a suicide watch and had a 1:1 sitter. Patient #16's record contained a nursing note, dated 4/26/10 at 12:16 PM, which stated Patient #16 had a cell phone which the staff attempted to remove from her possession. The note documented that Patient #16 refused to give the cell phone to the staff so staff instructed the patient that if she did not cooperate and give up the cell phone, she would be placed in restraints.

The documentation was confirmed during an interview by the hospital's Director of Accreditation and Nursing Operations on 6/09/10 at 2:00 PM.

Patient #16 was threatened with the use of restraints.



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2. Patient #38 was a 13-year-old female admitted to the hospital on 4/30/10 after a self-reported polydrug ingestion. Patient #38's record contained a nursing note, dated 5/01/10 at 12:40 AM, which stated Patient #38 wanted her IV out and her oxygen saturation monitor off. The note further documented that Patient #38 stated, "It's my time to die. God told me it's my time. I had one thing to do, and I've done it." The note explained the physician came into the room and spoke with Patient #38. The note stated the physician said to Patient #38 that "she had no choice but to get treated" and told her that they would restrain her if need be.

The documentation was confirmed during an interview by the hospital's Director of Accreditation and Nursing Operations on 6/09/10 at 1:40 PM.

The hospital failed to ensure Patient #38 was free from the threat of restraints as a means of coercion.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure hospital staff incorporated restraint usage into the plans of care for 2 of 2 patients (#16 and #38) reviewed, who were chemically and/or physically restrained. This had the potential to interfere with coordination of patient care and could not direct staff in lesser interventions before restraining patients. The findings include:

The Hospital's policy titled Restraint, last revised on 12/14/09, stated, "The use of restraints will be in accordance with written modification to the patient's plan of care..." This policy was not followed. Examples include:

1. Patient #38 was a 13-year-old female admitted to the hospital on 4/30/10 after a self-reported polydrug ingestion. The ED History and Physical dictated by the physician on 4/30/10 at 10:58 PM, stated that Patient #38 reported she had taken a half bottle of Extra Strength Tylenol, 2 full boxes of caffeine pills, and 2 full boxes of Benadryl. The History and Physical stated that Patient #38 remained quite alert without obvious symptoms in the ED. The ED History and Physical stated Patient #38's blood Tylenol levels were less than 10. This was a normal result. The ED History and Physical documented the plan of treatment was to repeat Patient #38's Tylenol levels, and "...monitored continuously with cardiorespiratory monitoring because of her substantial caffeine ingestion by self report and also for hallucinations or alterations in mental status as a result of her Benadryl ingestion."

Patient #38 was discharged on 5/01/10 at 2:35 PM. The physician's progress note dated 5/01/10 at 1:07 PM, stated Patient #38 had no tachycardia (increased heart rate), hypertension (high blood pressure), change in mental status, or increased Tylenol blood levels "to suggest claimed ingestion actually occurred."

The hospital's restraint log for the calender year of 2010 identified Patient #38 as being restrained.

Patient #38's record contained a nursing note, dated 5/01/10 at 12:40 AM, that stated Patient #38 wanted her IV line out and her oxygen saturation monitor off. The note further documented that Patient #38 stated, "It's my time to die. God told me it's my time. I had one thing to do, and I've done it." The note explained that the physician had come into the room and spoke with Patient #38. The note stated the physician said to Patient #38 that "she had no choice but to get treated" and told her that they would restrain her if need be.

Patient #38's record contained a Progress Notes and Doctor's Orders RESTRAINTS form, dated 5/01/10 at 1:00 AM. The progress notes side of the Restraint form titled CLINICAL JUSTIFICATION FOR RESTRAINTS stated Patient #38 was pulling at her IV line again and was expressing suicidal desire and will "sedate/restrain PRN." The sections of "Demonstrates attempts to remove airway or other life saving devices" and "Violent/self-destructive behavior" were checked. On the Doctor's Orders side of the Restraint form, under the "Nonviolent Behavior" section, the box beside "Initiate/Renew Restraint Use" was checked. On the Restraint form, a sentence directly above the physician's dated signature, stated "I have examined the patient and certify the above restraint order is indicated." The Restraint form was signed by the physician on 5/01/10 at 1:00 AM. On the same date, 5 minutes after signing the Doctor's Orders side of Restraint form, at 1:05 AM, the physician ordered Versed (a medication used to induce sleepiness and amnesia during surgery) 4-6 mg IV every 1 hour as needed for excessive agitation. This order was written and signed by the physician in the Doctor's Orders column of a Doctor's Orders and Progress Notes form.

The 2010 Nursing Drug Handbook states Versed is a preoperative sedative and a medication for conscious sedation. The medication was listed as to induce sleepiness and amnesia. Versed was listed as to be given before and/or during surgeries to induce general anesthesia. The listed dosing recommendations for children ages 12 to 16 was to initially give no more than 2.5 mg IV. The 2010 Nursing Drug Handbook states that Versed dosing may be increased to a total dose of up to 10 mg to reach the desired level of sedation.

Patient #38's MAR documented she had received 4 mg of Versed on 5/01/10 at 1:22 AM, 3:00 AM, and 6:28 AM, for a total of 12 mg over a period of 5 hours and 6 minutes. The medical record did not document the reason the medication was given at 3:00 AM and 6:28 AM.

Patient #38's POC was not modified to reflect the chemical restraint orders or the behaviors and interventions to the behaviors to include medication administration.

The hospital's Director of Accreditation and Nursing Operations was interviewed on 6/09/10 starting at 1:40 PM. She had reviewed Patient #38's record. She stated Patient #38's POC was not updated because the hospital staff did not chemically restrain the patient and, therefore, the POC did not have to be updated.

Hospital staff failed to incorporate restraint usage into Patient #38's plan of care.



28957

2. Patient #16 was a 20-year-old female admitted to the hospital on 4/23/10, after a self-reported drug ingestion. Patient #16's record documented she was on a suicide watch and had a 1:1 sitter.

A physicians written order dated 4/23/10 at 10:10 PM, ordered the nursing staff to administer hard restraints on all four extremities. Hard restraints refer to leather material with belts to secure the patient's extremities to the bed.

The physician documented on the Emergency Department section of the medical record, at 10:39 PM on 4/23/10. Under the heading History of Present Illness, was entered, "...very belligerent and fighting treatment and she was placed in soft restraints after which she became somnolent."

Soft restraints were devices made of soft material that are designed to safely fit around the wrists, ankles, or chest of a patient to prevent patients from harming themselves.

Patient #16's record contained a nursing note, dated 4/25/10 at 6:22 PM, which stated Patient #16 was agitated and yelling. The note indicated she removed her telemetry unit and threw it. Documented within the hospital's Interdisciplinary Care Management Plan, dated 4/25 and 4/26 was, "Soft restraints prn, 1 wrist and 1 ankle..."

There was no documentation in Patient #16's Interdisciplinary Care Management Plan, to include alternative or less restrictive measures to be attempted before applying soft or hard restraints prn.

The hospital's Director of Accreditation and Nursing Operations was interviewed on 6/09/10 starting at 1:40 PM and she reviewed Patient #16's record. She confirmed Patient #16's Interdisciplinary Care Management Plan did not include alternative or less restrictive measures to be attempted before resorting to restraints.

Hospital staff failed to incorporated less restrictive measures into Patient #16's plans of care.

Based on staff interview, review of medical records, hospital policies and restraint log, it was determined the hospital failed to ensure restraint orders were not written as PRN orders for 2 of 2 patients (#16 and #38) for whom chemical and/or physical restraints were used. This had the potential to result in patients being restrained unnecessarily and compromise patient safety. The findings include:

1. Patient #38 was a 13-year-old female admitted to the hospital on 4/30/10 after a self-reported polydrug ingestion. Patient #38 ' s record documented she was on a suicide watch and had a 1:1 sitter. The ED History and Physical dictated by the physician on 4/30/10 at 10:58 PM, stated that Patient #38 reported she had taken a half bottle of Extra Strength Tylenol, 2 full boxes of caffeine pills, and 2 full boxes of Benadryl. The ED History and Physical stated that Patient #38 remained quite alert without obvious symptoms in the ED. The ED History and Physical documented that Patient #38's blood Tylenol levels were less than 10. This was a normal result. The ED History and Physical stated the plan of treatment was to repeat Patient #38's Tylenol levels, and "...monitored continuously with cardiorespiratory monitoring because of her substantial caffeine ingestion by self report and also for hallucinations or alterations in mental status as a result of her Benadryl ingestion."

Patient #38 was discharged on 5/01/10 at 2:35 PM. The physician's progress note dated 5/01/10 at 1:07 PM, stated Patient #38 had no tachycardia (increased heart rate), hypertension (high blood pressure), change in mental status, or increased Tylenol blood levels "to suggest claimed ingestion actually occurred."

The hospital's restraint log for the calender year of 2010 identified Patient #38 as being restrained.

Patient #38's record contained a nursing note, dated 5/01/10 at 12:40 AM, which stated Patient #38 wanted her IV out and her saturation monitor off. The note further documented that Patient #38 stated, "It's my time to die. God told me it's my time. I had one thing to do, and I've done it." The note explained the physician came into the room and spoke with Patient #38. The note stated the physician said to Patient #38 that "she had no choice but to get treated" and told her that they would restrain her if need be.

Patient #38's record contained a Progress Notes and Doctor's Orders, Restraint form dated 5/01/10 at 1:00 AM. The progress note side of the Restraint form title Clinical Justification for Restraints stated Patient #38 was pulling at her IV again and was expressing suicidal desire and will "sedate/restrain PRN." The section of "Demonstrates attempts to remove airway or other life saving devices" and "Violent/self-destructive behavior" were checked. The Doctor's Orders side of the Restraint form was checked to Initiate/Renew restraint use. This form was signed by the physician on 5/01/10 at 1:00 AM. At 1:05 AM, the physician ordered Versed (a medication used to induce sleepiness and amnesia during surgery) 4-6 mg IV every 1 hour as needed for excessive agitation.

The Vice President of Medical Affairs was interviewed on 6/09/10 starting at 1:15 PM. He reviewed Patient #38's record. He stated that it was unclear to him as to whether the Versed was ordered as a chemical restraint or used to treat the patient's anxiety. He stated the physician's dosing order was excessive in that it was ordered every hour, as needed.

The hospital's policy titled Restraints, revised 12/09, did not identify PRN orders for restraints as unacceptable. The hospital's Director of Accreditation and Nursing Services was interviewed on 6/09/10 starting at 2:00 PM. She stated restraints were not to be ordered as PRN.

The hospital failed to ensure restraint orders were not written as PRN orders.



28957

2. Patient #16 was a 20-year-old female who was admitted on 4/23/10, after a self-reported overdose.

Two pre-printed restraints forms, signed, dated and timed, were found within Patient #16's record.

The first Progress Note/Doctors Orders, Restraints form, dated 4/25/10 at 4:10 PM, documented Patient #16 was unable to consistently follow/understand directions and was violent and/or had self-destructive behavior.

In addition, there was handwritten documentation that the patient is agitated, considering leaving AMA, and is not medically cleared to leave safely.

On the Doctor's Orders side of the form, documented the patient had Nonviolent Behavior. Both the soft restraints and the one wrist and one ankle boxes were checked. There was no documentation in Patient #16's record that showed restraints were used that day.

The second form, dated 4/26/10 at 12:00PM, documented Patient #16 was unable to consistently follow/understand directions and was violent and/or had self-destructive behavior.

The Doctor's Orders side of the form documented Patient #16' s restraint order was renewed and the order expired in 4 hours. There was no handwritten documentation on the Progress Note side.

The soft restraints, hard restraints, both wrists and both ankles boxes were all checked off. There was no nursing documentation that showed restraints were used that day.

In an interview conducted on 6/09/10 starting at 1:40 PM, the hospital's Director of Accreditation and Nursing Services confirmed that restraints were not used 4/25/10 and 4/26/10 and restraints were not to be ordered as prn.

The hospital failed to ensure restraint orders were not written as prn orders.

Based on staff interview and review of medical records and hospital policy, the hospital failed to ensure 1 of 1 patient (#38) reviewed who was chemically restrained for violent/self destructive behavior, received a face-to-face evaluation by an appropriately qualified person within 1-hour after the initiation of the intervention. This resulted in the inability of the hospital to adequately assess patients for the causes of behaviors and treatment alternatives. The findings include:

The hospital's Restraint Policy, last revised on 12/14/09, stated a LIP would do an in-person examination of patients within 1 hour after the initiation of the restraint. This policy was not followed.

Patient #38 was a 13-year-old female admitted to the hospital on 4/30/10 after a self-reported polydrug ingestion. Patient #38's record documented she was on a suicide watch and had a 1:1 sitter. The ED History and Physical dictated by a physician on 4/30/10 at 10:58 PM, stated Patient #38 reported she had taken a half bottle of Extra Strength Tylenol, 2 full boxes of caffeine pills, and 2 full boxes of Benadryl. The ED History and Physical stated that Patient #38 remained quite alert without obvious symptoms in the ED. The ED History and Physical documented that Patient #38's blood Tylenol levels were less than 10. This was a normal result. The ED History and Physical stated the plan of treatment was to repeat Patient #38's Tylenol levels, and "...monitored continuously with cardiorespiratory monitoring because of her substantial caffeine ingestion by self report and also for hallucinations or alterations in mental status as a result of her Benadryl ingestion."

Patient #38 was discharged on 5/01/10 at 2:35 PM. The physician's progress note dated 5/01/10 at 1:07 PM, stated Patient #38 had no tachycardia (increased heart rate), hypertension (high blood pressure), change in mental status, or increased Tylenol blood levels "to suggest claimed ingestion actually occurred."

The hospital's restraint log for the calander year of 2010 identified Patient #38 as being restrained.

Patient #38's record contained a nursing note, dated 5/01/10 at 12:40 AM, which stated Patient #38 wanted her IV line out and her oxygen saturation monitor off. The note further documented that Patient #38 stated, "It's my time to die. God told me it's my time. I had one thing to do, and I've done it." The note explained that the physician had come into the room and spoke with Patient #38. The note stated the physician said to Patient #38 that "she had no choice but to get treated" and told her that they would restrain her if need be.

Patient #38's record contained a Progress Notes and Doctor's Orders Restraint form, dated 5/01/10 at 1:00 AM. The progress note side of the Restraint form title Clinical Justification for Restraints, stated Patient #38 was pulling at her IV line again and was expressing suicidal desire and will "sedate/restrain PRN." The section of "Demonstrates attempts to remove airway or other life saving devices" and "Violent/self-destructive behavior" were checked. The Doctor's Orders side of the Restraint form was checked to Initiate/Renew restraint use. This form was signed by the physician on 5/01/10 at 1:00 AM. At 1:05 AM, the physician ordered Versed (a medication used to induce sleepiness and amnesia during surgery) 4-6 mg IV every 1 hour as needed for excessive agitation.

The 2010 Nursing Drug Handbook states Versed was a preoperative sedative and a medication for conscious sedation. The medication was listed as to induce sleepiness and amnesia. Versed was listed as to be given before and/or during surgeries to induce general anesthesia. The listed dosing recommendations for children ages 12 to 16 was to initially give no more than 2.5 mg IV. The 2010 Nursing Drug Handbook stated that Versed dosing could be increased to a total dose of up to 10 mg to reach the desired level of sedation.

Patient #38's MAR documented she had received additional doses of Versed on 5/01/10 at 3:00 AM and at 6:28 AM. There was no documentation in Patient #38's medical record of a face-to-face evaluation by an LIP of Patient #38 within one hour of the administration of these chemical restraints.

The hospital's Director of Accreditation and Nursing Operations was interviewed on 6/09/10 starting at 1:40 PM. She had reviewed Patient #38's record. She indicated a face-to-face reassessment of Patient #38 was not completed within an hour of the adminstration of the medication.

The hospital failed to Patient #38, who was chemically restrained, received a face-to-face evaluation by an appropriately qualified person within 1-hour after the initiation of the intervention.

Based on review of clinical records and interviews with staff, it was determined the hospital failed to ensure less restrictive interventions were attempted before the use of restraints for 2 of 2 patients (#16 and #38) reviewed who were chemically and/or physically restrained. The lack of alternatives and/or less restrictive interventions attempted before applying physical restraints resulted in the inability of the hospital to avoid the use of restraints when possible. The findings include:

1. Patient #38 was a 13-year-old female admitted to the hospital on 4/30/10, after a self-reported polydrug ingestion. Patient #38's record documented she was on a suicide watch. The ED History and Physical dictated by the ED physician on 4/30/10 at 10:58 PM, stated that Patient #38 reported she had taken a half bottle of Extra Strength Tylenol, 2 full boxes of caffeine pills, and 2 full boxes of Benadryl. The ED History and Physical stated that Patient #38 remained quite alert without obvious symptoms in the ED. The ED History and Physical documented Patient #38's blood Tylenol levels were less than 10. This was a normal result. The ED History and Physical stated the plan of treatment was to repeat Patient #38's Tylenol levels, and "...monitored continuously with cardiorespiratory monitoring because of her substantial caffeine ingestion by self report and also for hallucinations or alterations in mental status as a result of her Benadryl ingestion."

Patient #38 was discharged on 5/01/10 at 2:35 PM. The physician's progress note dated 5/01/10 at 1:07 PM, stated Patient #38 had no tachycardia (increased heart rate), hypertension (high blood pressure), change in mental status, or increased Tylenol blood levels "to suggest claimed ingestion actually occurred."

The hospital's restraint log for the calendar year of 2010 identified Patient #38 as being restrained.

Patient #38's record contained a nursing note, dated 5/01/10 at 12:40 AM, which stated Patient #38 wanted her IV line out and her oxygen saturation monitor off. The note further documented that Patient #38 stated, "It's my time to die. God told me it's my time. I had one thing to do, and I've done it." The note explained that the physician came into the room and spoke with Patient #38. The note stated the physician said to Patient #38 that "she had no choice but to get treated" and told her that they would restrain her if need be.

Patient #38's record contained a Progress Notes and Doctor's Orders, Restraint form dated 5/01/10 at 1:00 AM. The progress note side of the Restraint form title Clinical Justification for Restraints stated, Patient #38 was pulling at her IV line again and was expressing suicidal desire and will "sedate/restrain PRN." The section of "Demonstrates attempts to remove airway or other life saving devices" and "Violent/self-destructive behavior" were checked. The Doctor's Orders side of the Restraint form was checked to Initiate/Renew restraint use. This form was signed by the physician on 5/01/10 at 1:00 AM. At 1:05 AM, the physician ordered Versed (a medication used to induce sleepiness and amnesia during surgery) 4-6 mg IV every 1 hour as needed for excessive agitation.

Patient #38's MAR documented she had received Versed on 5/01/10 at 3:00 AM and at 6:28 AM. The medical record did not indicate alternatives or other less restrictive interventions attempted before the administration of the versed. The record did not contain documentation that less restrictive interventions had been considered and ruled out, and the reasons why.

The hospital's Director of Accreditation and Nursing Operations was interviewed on 6/09/10 starting at 1:40 PM. She had reviewed Patient #38's record. She stated Patient #38's record did not indicate why the Versed was given. She stated the Versed was ordered for anxiety and nursing staff would not document alternatives or other less restrictive interventions because the medication was not a restraint.



28957

2. Patient #16 was a 20-year-old female admitted to the hospital on 4/23/10 after a self-reported drug ingestion.

Patient #16 ' s record documented she was on suicide watch and had a 1:1 sitter. Patient #16's record contained a nursing note, dated 4/23/10 at 10:39 PM, that stated Patient #16 was, "...very belligerent and fighting treatment and she was placed in soft restraints after which she became somnolent."

Soft restraints are devices made of soft material that are designed to safely fit around the wrists, ankles, or chest of a patient to prevent patients from harming themselves or others. There was no documentation that alternative measures were offered or less restrictive interventions were attempted before placing Patient #16 in soft restraints.

A nursing restraint flowsheet dated 4/23/10 at 10:10 PM, documented soft restraints were applied to both wrists and the ankles of Patient #16. Patient #16 was released from the restraints on 4/23/10 at 10:47 PM. There was no documentation that alternative measures were offered or less restrictive interventions were attempted before placing Patient #16 in soft restraints.

The hospital's Director of Accreditation and Nursing Operations was interviewed on 6/09/10 starting at 1:40 PM. She reviewed Patient #16's record. She stated Patient #16's record did not document less restrictive measures were tried before using physical restraints.

The hospital failed to ensure less restrictive interventions were attempted prior to the use of restraints.

Based on review of clinical records and interviews with staff, it was determined the hospital failed to ensure that 1 of 1 patients, (#38), for whom chemical restraints were used, had documentation in the medical records of the conditions and/or symptoms that warranted the use of the restraints. The lack of documentation prevented the hospital from ensuring patients were physically/chemically restrained only when necessary to ensure their safety or that of others. The findings include:

1. Patient #38 was a 13-year-old female admitted to the hospital on 4/30/10 after a self-reported polydrug ingestion. The ED History and Physical dictated by the physician on 4/30/10 at 10:58 PM, stated that Patient #38 reported she had taken a half bottle of Extra Strength Tylenol, 2 full boxes of caffeine pills, and 2 full boxes of Benadryl. The ED History and Physical stated that Patient #38 remained quite alert without obvious symptoms in the ED. The ED History and Physical stated that Patient #38's blood Tylenol levels were less than 10. This was a normal result. The ED History and Physical stated the planned treatment was to repeat Patient #38's Tylenol levels, and "...monitored continuously with cardiorespiratory monitoring because of her substantial caffeine ingestion by self report and also for hallucinations or alterations in mental status as a result of her Benadryl ingestion."

Patient #38 was discharged on 5/01/10 at 2:35 PM. The physician's progress note dated 5/01/10 at 1:07 PM, stated Patient #38 had no tachycardia (increased heart rate), hypertension (high blood pressure), change in mental status, or increased Tylenol blood levels "to suggest claimed ingestion actually occurred."

The hospital's restraint log for the year of 2010 identified Patient #38 as being restrained.

Patient #38's record contained a nursing note, dated 5/01/10 at 12:40 AM, which stated Patient #38 wanted her IV line out and her oxygen saturation monitor off. The note further documented that Patient #38 stated, "It's my time to die. God told me it's my time. I had one thing to do, and I've done it." The note explained that the physician came into the room and spoke with Patient #38. The note stated the physician said to Patient #38 that "she had no choice but to get treated" and told her that they would restrain her if need be.

Patient #38's record contained a Progress Notes and Doctor's Orders Restraint form, dated 5/01/10 at 1:00 AM. The progress note side of the Restraint form title Clinical Justification for Restraints stated Patient #38 was pulling at her IV line again and was expressing suicidal desire and will "sedate/restrain PRN." The section of "Demonstrates attempts to remove airway or other life saving devices" and "Violent/self-destructive behavior" were checked. The Doctor's Orders side of the Restraint form was checked to Initiate/Renew restraint use. This form was signed by the physician on 5/01/10 at 1:00 AM. At 1:05 AM, the physician ordered Versed (a medication used to induce sleepiness and amnesia during surgery) 4-6 mg IV every 1 hour as needed for excessive agitation.

Patient #38's MAR documented she received Versed on 5/01/10 at 3:00 AM and at 6:28 AM. The medical record did not indicate the conditions and/or symptoms that warranted the use of the chemical restraint. However, in a written statement, dated 6/11/10 by the nurse who administered the Versed, the nurse documented that the Versed was given to Patient #38 because, Patient #38 woke up several times during the night and requested "...more of 'that' medication."

The hospital's Director of Accreditation and Nursing Operations was interviewed on 6/09/10 starting at 1:40 PM. She reviewed Patient #38's record. She stated Patient #38's record did not include why the Versed was given and the conditions and/or symptoms that warranted the use of the chemical restraint. She stated the Versed was ordered for anxiety and so nursing staff did not document the conditions and/or symptoms that warranted the use of the medication.

The hospital failed to ensure that staff documented in Patient #38's medical record the conditions and/or symptoms that warranted the use of the restraints.

Based on review of clinical records and interviews with staff, it was determined the hospital failed to ensure that 1 of 1 patient, (#38), for whom chemical restraints was used, had documentation in her medical record of the response to the intervention. The lack of documentation prevented hospital staff in assessing the effects of the interventions. The findings include:

1. Patient #38 was a 13-year-old female admitted to the hospital on 4/30/10 after a self-reported polydrug ingestion. The ED History and Physical dictated on 4/30/10 at 10:58 PM, stated that Patient #38 reported she had taken a half bottle of Extra Strength Tylenol, 2 full boxes of caffeine pills, and 2 full boxes of benadryl. The ED History and Physical stated that Patient #38 remained quite alert without obvious symptoms in the ED. The ED History and Physical stated that Patient #38's blood Tylenol levels were less then 10. This was a normal result. The ED History and Physical documented the plan of treatment was to repeat Patient #38's Tylenol levels, and "...monitored continuously with cardiorespiratory monitoring because of her substantial caffeine ingestion by self report and also for hallucinations or alterations in mental status as a result of her Benadryl ingestion."

Patient #38 was discharged on 5/01/10 at 2:35 PM. The physician's progress note dated 5/01/10 at 1:07 PM, stated Patient #38 had no tachycardia (increased heart rate), hypertension (high blood pressure), change in mental status, or increased Tylenol blood levels "to suggest claimed ingestion actually occurred."

The hospital's restraint log for the year of 2010 identified Patient #38 as being restrained.

Patient #38's record contained a nursing note, dated 5/01/10 at 12:40 AM, that stated Patient #38 wanted her IV out and her saturation monitor off. The note further documented that Patient #38 stated, "It's my time to die. God told me it's my time. I had one thing to do, and I've done it." The note explained that the physician had come into the room and spoke with Patient #38. The note stated the physician said to Patient #38 that "she had no choice but to get treated" and told her that they would restrain her if need be.

Patient #38's record contained a Progress Notes and Doctor's Orders, Restraint form dated 5/01/10 at 1:00 AM. The progress note side of the Restraint formt title Clinical Justification for Restraints stated Patient #38 was pulling at her IV again and was expressing suicidal desire and will "sedate/restrain PRN." The section of "Demonstrates attempts to remove airway or other life saving devices" and "Violent/self-destructive behavior" were checked. The Doctor's Orders side of the Restraint form was checked to Initiate/Renew restraint use. This form was signed by the physician on 5/01/10 at 1:00 AM. At 1:05 AM, the physician ordered Versed (A medication used to induce sleepiness and amnesia during surgery) 4-6 mg IV every 1 hour as needed for excessive agitation.

The 2010 Nursing Drug Handbook stated that Versed was a preoperative sedative and a medication for conscious sedation. The medication was listed as to induce sleepiness and amnesia. Versed was listed as to be given before and/or during surgeries to induce general anesthesia. The listed dosing recommendations for children ages 12 to 16 was to initially give no more than 2.5 mg IV. The 2010 Nursing Drug Handbook stated that Versed dosing could be increased up to a total dose of up to 10 mg to reach the desired level of sedation.

Patient #38's MAR documented she had received Versed on 5/01/10 at 3:00 AM and at 6:28 AM. However, a written statement, dated 6/11/10, by the nurse who administered the Versed, documented that the Versed was given to Patient #38 because, Patient #38 woke up several times during the nighr and requested "...more of 'that' medication." The medical record did not indicate the response to the intervention.

The hospital's Director of Accreditation and Nursing Operations was interviewed on 6/09/10 starting at 1:40 PM. She reviewed Patient #38's record. She stated that all PRN medications should have documentation of effectiveness whether it was a chemical restraint or not. She did not find documentation of the effectiveness of the 5/01/10 at 3:00 AM and 6:28 AM Versed.

The hospital failed to ensure staff documented in Patient #38's medical record her response to the chemicial restraint intervention.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure nursing plans of care were developed for 2 of 2 patients (#2 and #14) whose medical records were were reviewed for such plans. This resulted in a lack of direction to nursing staff caring for patients. The findings include:

1. Patient #2's medical record documented an 81 year old female who was admitted to the hospital on 3/04/10 and was discharged on 3/05/10. She presented to the emergency department on 3/04/10 at 9:45 PM. A History and Physicial, dictated at 12:43 AM on 3/05/10, stated Patient #2 had fallen and suffered a contusion of her forehead and laceration of her nose which required suturing. The report stated Patient #2 thought she had slipped and fallen. The report stated this was her third admission to the emergency department in 2 days. The report stated she had been seen first for a urinary tract infection and confusion. The report stated she had returned later and been treated for confusion related to dehydration. She was rehydrated and sent home again before returning a third time. The report stated "I get the impression that she is markedly depressed as well as somewhat paranoid and concerned about being here in the hospital." The report stated Patient #2 had a history of "...depression with possibly some psychotic features..." The report stated her affect was flat but she was oriented to person, place, and time. The report also stated Patient #2 did not appear to be in any distress but was tearful. The report stated the plan was to admit Patient #2 for hydration and "...possible consideration of a psychiatric evaluation and maybe transferred to [a geriatric psychiatric hospital] for medication evaluation and adjustment."

An Application of Commitment of the Mentally Ill, dated 3/05/10 at 1:31 PM, signed by the physician and filed with the court, stated Patient #2 was gravely disabled and needed to be placed on an involuntary hold.

Patient #2's Interdisciplinary Care Management Plan, dated 3/04/10 and 3/05/10, did not contain a plan related to her behavior or psychological issues. The plan stated only that Patient #2 was a high fall risk and needed a bed alarm. No other plan directing care for Patient #2 was documented.

Staff A, the nurse who cared for Patient #2 on 3/05/10, was interviewed on 6/10/10 at 9:20 AM. She reviewed the medical record and confirmed the lack of a plan of care for Patient #2.

A nursing plan of care was not developed for Patient #2.

2. Patient #14's medical record documented a 69 year old male who was admitted to the hospital on 2/12/10 and was discharged on 2/15/10. Diagnoses included dementia, homosexual delusion, and diabetes. An involuntary hold was documented on 2/15/10.

An Application of Commitment of the Mentally Ill, dated 2/15/10 at 5:30 PM, signed by the physician and filed with the court, stated Patient #14 needed to be placed on an involuntary hold. Nursing notes on 2/14/10, stated Patient #14 was sexually inappropriate with a male nurse and, on another occasion, had intrusively wandered into another patient's room.

Patient #14's Interdisciplinary Care Management Plan, dated 2/13/10-2/15/10, did not mention his psychological status or direction to staff regarding inappropriate behaviors. The plan stated the patient was to have his blood glucose checked 4 times a day and he was allowed to be out of bed with assistance. Otherwise, no nursing plan of care was documented.

Staff G, the RN assigned to Patient #14 on 2/15/10, was interviewed on 6/08/10 at 2:40 PM. She reviewed the medical record and confirmed the lack of a plan of care for Patient #14.

A nursing plan of care was not developed for Patient #14.

3. Also refer to A166 as it relates to the failure of the hospital to ensure the use of restraints were incorporated into patients' plans of care.