HospitalInspections.org

Based on observation, interview, and record review, the facility's Governing Body failed to ensure the hospital's operation was conducted in an effective and organized manner by failing to:

1. Ensure staff promoted and protected each patients' rights by failing to ensure staff were trained to intervene appropriately in situations involving violent patients, staff attempted less restrictive restraint or other alternatives before applying restraints and facility policy and procedures did not include the option to write PRN restraint orders. (Refer to A144, 164, and 169).

2. Ensure the emergency needs of patients were met in accordance with acceptable standards of practice, by failing to ensure radiology and laboratory results were communicated to discharged patients, pediatric emergency crash carts contained the required reference tool, staff were using current emergency resource information and staff were instructed in physical maneuvers for treating patients with assaultive behaviors (Refer to A1103, 1104, and 1112).

Based on observation, interview, and record review, the facility failed to ensure patients' rights were protected by failing to:

1. Ensure staff were trained to intervene appropriately in situations involving violent patients (Refer to A144),

2. Ensure staff attempted less restrictive restraint or other alternatives before applying restraints (Refer to A164 and 165)

3. Ensure facility policy and procedure for restraints did not include the option to write PRN restraint orders (Refer to A 169).

The cumulative effects of these systemic problems resulted in the failure of the hospital to ensure all patients' rights were protected, and care was provided in a safe setting.

Based on observation, interview, and record review, the facility failed to ensure staff was trained to intervene appropriately when patients became violent and failed to follow up appropriately when a patient eloped (Patient 206).

This failure resulted in three of three sampled patients who were placed in restraints (Patients 110. 111. and 105), being restrained inappropriately, one patient who eloped and whose welfare was not followed-up creating the potential for harm or death to the patients.

Findings:

1a. The record for Patient 111, was reviewed on February 15, 2012. Patient 111, a 32 year old male, presented to the ED on December 15, 2011, at 1:20 a.m., with complaints of drug abuse and suicide ideations.

The ED nurse's notes indicated the patient was placed in four point restraints (all extremities tied down) on December 15, 2011, at 1:35 a.m., for behavior management.

A video of the restraint application was viewed with the CNO on February 15, 2012, and again on April 4, 2012. accompanied by the ED Director. The video showed the ED CN enter the room to assist other staff members in restraining the patients. The video showed the ED CN got up on the gurney and placed his knee across the patient's chest to hold him down.

During an interview with the ED CN on April 4, 2012, at 11:55 a.m., he stated he remembered the incident. He stated he put his knee across the patients's chest to hold him down. The ED CN stated putting a knee across a patient's chest was not part of the MAB training he received.

b. The record for Patient 110 was reviewed on May 25, 2012. Patient 110, a 66 year old male, presented to the ED on April 24, 2012, at 9:25 p.m., with complaints of chest pain.

The ED nurse's notes indicated at 9:45 p.m., the patient began refusing treatment, and wanted to leave the ED. The notes indicated the patient threatened the ED staff who did not allow him to leave, so security restrained the patient until the police arrived.

A security report dated April 24, 2012, at 9:50 p.m., indicated Patient 110 made an aggressive move toward a nurse, so a security officer grabbed the patient from behind, the two started struggling, and the security officer, "took the patient down to the floor." The report indicated the security officer handcuffed the patients while the waited for the police to arrive.

Police Report 1, dated May 1, 2012, indicated the officer responded to the facility on April 24, 2012, at approximately 9:51 p.m.., and Patient 110 told him he had been thrown onto the ground and handcuffed by hospital security.

Police Report 2, dated May 1, 2012, indicated the officer responded to the facility on April 24, 2012, at approximately 9:50 p.m., and observed Patient 110 laying face down on the ground, handcuffed behind his back, with a security guard on top of him. The report indicated the police officer assisted the security guard to her feet, and checked Patient 110 for injuries.

c. During a tour of the ED on July 17, 2012, at 9:30 a.m., Patient 105 was observed lying on a gurney in Room 23. The patient was observed in four point restraints. He was calm and cooperating with ED staff.

During an interview with Security Officer 2, on July 17, 2012, at 9:35 a.m., the officer stated he was when Patient 105 arrived in the ED. The officer stated the patient was aggressive and yelling at police officers. He stated the patient was not angry with or yelling a ED staff. The officer stated a police officer told him to restrain the patient in four point restraints, so he did. He stated he was supposed to wait for an order from an ED MD, but the police officer said to restrain the patient, so he did.

The record for Patient 105 was reviewed on July 17, 2012. Patient 105 , a 67 year old male, presented to the ED on July 17, 2012, at 8:35 a.m., with complaints of PTSD and abdominal pain.

The record indicated the patient was placed in four point restraints on arrival due to threatening the police and EMS personnel. There was no evidence the patient was threatening the ED staff.

A security report dated July 17, 2012, was reviewed on July 19, 2012. The report indicated the patient was yelling at police officers and poked an ED Tech in the rib using his index finger. According to the report, the police officer then said, "that's it, put him in restraints." The report indicated the patient was then put in four point restraints by facility security.

The Emergency Department Record, Physician Orders section, included an order written at 8:45 a.m., for, "4 point restraints." The order did not indicate the type of restraints to be used, the reason for restraints, the duration of the restraints, or when the restraints could be removed.

The preprinted physician restraint order form was reviewed on July 17, 2012. The form indicated the staff was to use the least restrictive restraint appropriate for the patient. In the section titled "TYPE OF RESTRAINT," leather restraints was not an option.

The facility policy titled, "Use of Leather Restraints in the Emergency Room,: indicated the staff must have a physician's order for the use of restraints.

During a follow-up telephone interview with Security Officer 2 on July 19, 2012, at 11:15 a.m., the officer stated Patient 105 was placed in restraints upon the order of a police officer. He stated the police officer said to the restrain the patient, so he got leather restraints from the security cabinet in the ED and restrained the patient. He stated there was no MD present at the time. The security officer stated he would usually wait for an MD order, but the police officer told him to do it, so he did.

The MAB training sign in sheets were reviewed on July 18, 2012. The records indicated nine of the 16 security officers (56%) and 30 of 78 ED staff members (38%) received the training.

The MAB training agenda was reviewed on April 4, 2012, and again on July 18, 2012. The agenda did not include physical maneuvers for managing violent behavior.

During a telephone interview with the Security Manager on July 18, 2012, at 11:15 a.m., the manager stated the MAB classes did not include physical maneuvers to deal with violent behavior. He stated the people who taught the class were not certified to teach the physical maneuver part. He stated Physical maneuvers had not been taught at the facility since 2010.

The facility policy titled, "Management of Assaultive Behavior," was reviewed on July 18, 2012. The policy indicated all ED and security staff would receive MAB training during orientation and annually thereafter.

2. On June 16, 2012, at 2:28 a.m., Patient 206 went to the ER for treatment of right finger injury. The triage nurse assessed the patient and an X-ray of the right 5th finger was ordered. The triage nurse completed a mental health assessment. The patient scored a "7" on the "Modified Sad Person Scale," indicating the patient might require a psychiatric consultation.

At 6:30 a.m., the nurse documented Patient 206 was agitated and threatening to break glass.

At 8:37 a.m., ER staff found the patient outside sitting on a bench. Patient 206 indicated, "Just wanted something for pain."

At 11:29 a.m., 11:41 a.m., and 11:52 a.m., staff called for Patient 206. Patient 206 appeared to have left the ER, for there was no answer. There was no documentation in the medical record that staff did follow-up on the elopement.

An interview was conducted with the ED Director on July 19, 2012, at 11 a.m.. The ED director stated someone should have telephoned the Patient within 24 hours to see if he was "ok:. The ED director stated staff was to document on the patient's record after they did their follow-up. The ED Director reviewed Patients 206's record and stated it was not done.

The ED director further stated she and her assistant were the individuals who would contact patients who eloped, but both had been out for the month of June. She was not sure if someone else did the follow up in her absence, but believed it had not been completed for the month of June.

The facility's policy and procedure, titled,:Patient Elopement from the Emergency Department, : was reviewed. The policy indicated, "Any patient who has been seen by the Triage Nurse but left prior to an evaluation by the Emergency Department physician...but left before treatment or disposition, is deemed as an elopement....The patient's primary care provider (nurse) will also immediately contact the patient...IF a competent patient wishes to remain in elopement status, this should be documented the medical record. This should be witnessed by two licensed healthcare staff.

Based on observation, interview, and recod review, the facility failed to attempt less restrictive interventions prior to placing one sampled patient in leather restraints. THis failed practice resulted in the potiential for harm to the patient.

Findings:

During a tour of the ED on July 17, 2012, at 9:30 a.m., Patient 105 was observed lying on a gurney in Room 23. The patient was observed in four point restraints. He was calm and cooperating with ED staff.

During an interview with Security Officer 2, on July 17, 2012, at 9:35 a.m., the officer stated he was when Patient 105 arrived in the ED. The officer stated the patient was aggressive and yelling at police officers. He stated the patient was not angry with or yelling a ED staff. The officer stated a police officer told him to restrain the patient in four point restraints, so he did. He stated he was supposed to wait for an order from an ED MD, but the police officer said to restrain the patient, so he did.

The record for Patient 105 was reviewed on July 17, 2012. Patient 105 , a 67 year old male, presented to the ED on July 17, 2012, at 8:35 a.m., with complaints of PTSD and abdominal pain.

The record indicated the patient was placed in four point restraints on arrival due to threatening the police and EMS personnel. There was no evidence the patient was threatening the ED staff.

A security report dated July 17, 2012, was reviewed on July 19, 2012. The report indicated the patient was yelling at police officers and poked an ED Tech in the rib using his index finger. According to the report, the police officer then said, "that's it, put him in restraints." The report indicated the patient was then put in four point restraints by facility security.

The Emergency Department Record, Physician Orders section, included an order written at 8:45 a.m., for, "4 point restraints." The order did not indicate the type of restraints to be used, the reason for restraints, the duration of the restraints, or when the restraints could be removed.

The preprinted physician restraint order form was reviewed on July 17, 2012. The form indicated the staff was to use the least restrictive restraint appropriate for the patient. In the section titled "TYPE OF RESTRAINT," leather restraints was not an option.

The facility policy titled, "Use of Leather Restraints in the Emergency Room,: indicated the staff must have a physician's order for the use of restraints.

During a follow-up telephone interview with Security Officer 2 on July 19, 2012, at 11:15 a.m., the officer stated Patient 105 was placed in restraints upon the order of a police officer. He stated the police officer said to the restrain the patient, so he got leather restraints from the security cabinet in the ED and restrained the patient. He stated there was no MD present at the time. The security officer stated he would usually wait for an MD order, but the police officer told him to do it, so he did.

Based on observation , interview, and record review, the facility failed to attempt less restrictive restraints prior to placing a patient in leather restraints.

Findings:

During a tour of the ED on July 17, 2012, at 9:30 a.m., Patient 105 was observed lying on a gurney in Room 23. The patient was observed in four point restraints. He was calm and cooperating with ED staff.

During an interview with Security Officer 2, on July 17, 2012, at 9:35 a.m., the officer stated he was when Patient 105 arrived in the ED. The officer stated the patient was aggressive and yelling at police officers. He stated the patient was not angry with or yelling a ED staff. The officer stated a police officer told him to restrain the patient in four point restraints, so he did. He stated he was supposed to wait for an order from an ED MD, but the police officer said to restrain the patient, so he did.

The record for Patient 105 was reviewed on July 17, 2012. Patient 105 , a 67 year old male, presented to the ED on July 17, 2012, at 8:35 a.m., with complaints of PTSD and abdominal pain.

The record indicated the patient was placed in four point restraints on arrival due to threatening the police and EMS personnel. There was no evidence the patient was threatening the ED staff.

A security report dated July 17, 2012, was reviewed on July 19, 2012. The report indicated the patient was yelling at police officers and poked an ED Tech in the rib using his index finger. According to the report, the police officer then said, "that's it, put him in restraints." The report indicated the patient was then put in four point restraints by facility security.

The Emergency Department Record, Physician Orders section, included an order written at 8:45 a.m., for, "4 point restraints." The order did not indicate the type of restraints to be used, the reason for restraints, the duration of the restraints, or when the restraints could be removed.

The preprinted physician restraint order form was reviewed on July 17, 2012. The form indicated the staff was to use the least restrictive restraint appropriate for the patient. In the section titled "TYPE OF RESTRAINT," leather restraints was not an option.

The facility policy titled, "Use of Leather Restraints in the Emergency Room,: indicated the staff must have a physician's order for the use of restraints.

During a follow-up telephone interview with Security Officer 2 on July 19, 2012, at 11:15 a.m., the officer stated Patient 105 was placed in restraints upon the order of a police officer. He stated the police officer said to the restrain the patient, so he got leather restraints from the security cabinet in the ED and restrained the patient. He stated there was no MD present at the time. The security officer stated he would usually wait for an MD order, but the police officer told him to do it, so he did.

Based on interview and record review, the facility failed to ensure restraint and seclusion orders were not written as standing orders or on an as needed basis.

Findings:

The facility's policy and procedure titled, "Restraint and Seclusion, " was reviewed on July 19, 2012. The policy indicated, "All patients have the right to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff....Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move arms, legs, body or head freely...4. PRN orders for restraint or seclusion shall not be used except in the following circumstances...the patient requires the use of a geri chair with the tray locked...bedside rails are needed as restraints...Protection from repetitive self mutilating behavior...."

The facility's policy on restraints and seclusion allowed physicians to write PRN restraint and seclusion orders in the hospital.

Based on interview and record review, the facility failed to track medical errors through the PI process. There was no mechanism for tracking ED misreads of x-rays and subsequent follow-up with patients. This resulted in the failure of the ED MD to notify two of two sampled patients (Patient 106 and 107) of radiology misreads, and two of two sampled patients with positive culture results, and the potential for inappropriate diagnosis and treatment of all patients receiving x-rays and cultures in the ED.

Findings:

During an interview with the ED Medical Director on July 17, 2012, at 10:36 a.m., the ED Medical Director on July 17, 2012, at 10:35 a.m., the Director stated ED physicians read x-rays and documented their interpretation of the x-ray results in the computer. He stated the x-rays were re-read by a radiologist the next day and any misreads (when the ED MD interpretation differed from the radiologist reading) were called to the ED physician on duty. The Director stated the ED MD would review the record and if needed, the patient would e asked to return for additional treatment. The Director state the ED MD would dictate or write a note in the patients' record indicating whether treatment was appropriate during the ED visit, or further treatment was needed. The Directors stated a patient call back or misread log was not kept. He stated there was no tracking and trending of misreads by ED physicians, so there was no mechanism to determine if any ED MD's had frequent misreads.

The Director stated the process for laboratory results was similar. When the laboratory called with positive lab results, the results were printed and the patient and their primary physician were notified about the results. According to the Directors, if a test came back positive, the ED MD would dictate a note in the patient's record indicating if additional treatment was needed, and what additional treatment was provided.

during a tour of the radiology department on July 17, 2012, at 11:25 a.m., the Director was asked for information relating to misreads. Two records were selected for review and the following was noted:

1a. Patient 106 presented to the ED on June 25, 2012 at 11:09 p.m., with a chief complaint of left hand pain. The "Emergency Room Report, : indicated the patient's left hand x-ray was read by the EDMD as negative, "No acute fractures, dislocations, or subluxations (misalignment)." According to the note, the patient was discharged home with instructions to follow up with his primary physician for further care.

The DC instructions given to the patient indicated the x-rays would be reviewed by a radiologist and the patient would be notified of any new findings that may affect his care.

On June 26, 2012, at 10:30 a.m., Patient 106's left hand x-ray was read by a radiologist who reported, "A minimally displaced fracture of the fourth metacarpal and the findings were reviewed with (the ED MD) at the time."

There was no evidence in the record the patient was informed of the radiologists findings.

Patient 106 returned to the ED on June 26, 2012, at 1:29 p.m., The Emergency Department record indicated the patient's chief complain was "swelling feeling to left arm.: Patient 106 reported throbbing pain, seven on a ten point scale. The patient seen by the PA at 3:31 p.m. The dictated Emergency Room Report indicated the patient's ace wrap was removed and replaced. The patient's diagnosis was left hand fracture. The patient was told to follow up with the orthopedic department at the County Hospital.

b. Patient 107 presented to the ED accompanied by the police on May 23, 2012, at 12:25 a.m. and singed in for, "Ok to Book...Wound on left hip/injure to finger." X-rays of the right thumb and left hip were orders. The dictated Emergency Room Report indicated x-rays showed no acute changes the patient was diagnosed with left hip sprain and right thumb contusion, and discharged to local law enforcement at 2:230 a.m., On May 23, 2012, at 9:45 a.m., the radiologist reviewed the findings of the x-ray with the ED MD. The radiologist indicated "questionable subtle acetabular fracture. Clinical correlation is advised. If clinically indicated computerized tomography or magnetic resonance imaging might prove useful for further evaluation."

There was no evidence in the record the patient was informed of the radiologist findings.

During an interview with the QA Director and the QA Nurse on July 19, 2012, at 11:35 a.m., the ED QAPI, for medical staff was reviewed. There was no evidence QAPI was being done for radiology misreads by the ED MD's. There was no tracking or trending of misreads being done.

2. On July 19, 2012, at 1:30 p.m., the ICP was interviewed. The ICP stated positive laboratory culture results were faxed to the ED by the lab. The ICP also stated these reports were faxed to the patients' primary physician , if known. The ICP stated the ED MD was responsible for following up with the patient and should be documenting the follow up measures. Two records with positive laboratory reports were requested and the following was noted:

a. Patient 315 presented to the ED on July 3, 2012, at 3:59 a.m., with a chief complaint of "Swollen Lip." According to the "Emergency Room Report" Patient 315 stated he had a pimple that was gradually growing for the last several days. The ED MD indicated fluid was obtained for culture. Patient 315 was discharged home with instructions to follow "Abscess Sheets" and given prescription for Keflex and Bactrim. There was no evidence in the record indicating Patient 315 was notified about the positive culture results from the specimen obtained from the patient's lip. the laboratory results indicated Patient 315's would was positive for MRSA.

b. Patient 316 presented to the ED on July 6, 2012, at 12:20 a.m. with a chief complaint of generalized weakness. Patient 316 had a laboratory report that indicated her urinary culture was positive for bacteria. There was no evidence in the record that patient was contacted and treatment was initiated.

During an interview with the ED Director on July 19, 2012 at 2:45 p.m., the Director stated there should be documentation in the record about follow up information. The Directed stated the ED MD could do an addendum to the dictated note, or the information could be documented in the nurses notes. The Director did not provide evidence of this documentation for these four records.

Based on observation, interview, and record review, the facility failed to meet the emergency needs of patients by failing to:

1. Ensure radiology and laboratory results were communicated to discharged patients (Refer to A1103)

There was no evidence in the record indicating Patient 315 was notified about the positive culture results from the specimen obtained from the patients' lip. The laboratory results indicated Patient 315's wound culture was positive for MRSA (a drug resistant infection).

Patient 316 presented to the ED on July 8, 2012, at 12:20 a.m., with chief complaint of general weakness. Patient 316 had a laboratory report that indicated her urinary culture was positive for bacteria. There was no evidence in the record the patient was contacted and treatment was initiated.

During an interview with the ED director on July 19, 2012, at 2:45 p.m., the Director stated there should be documentation in the record about follow up information. The Director stated the ED MD could do an addendum to the dictated note, or the information could be documented in the nurses' notes. The Director did not provide evidence of this documentation.

2. Ensure pediatric emergency crash carts contained the required reference tool (Refer to A1104).

3. Ensure staff were using current emergency resource information (Refer to A1104)

4. Ensure staff were trained to appropriately intervene with patients exhibiting assaultive behaviors (Refer to A1112).

The cumulative effect of these systemic problems resulted in the failure to ensure the provision of quality care to patients seeking care for an emergency condition.

Based on interview and record review, the facility failed to ensure integration between the ED and radiology and the laboratory by failing to provide evidence patients were contacted when radiology discrepancies and positive cultures were identified. There was no mechanism for tracking ED misreads of x-rays and subsequent follow up with patients. This resulted in the failure of the ED MD to notify two sampled patients of radiology misreads and two patients with positive culture results.

Findings:

During an interview with the ED Medical Director on July 17, 2012 at 10:35 a.m., the Director stated ED physicians read x-rays and documented their interpretation of the x-ray results in the computer. He stated the x-rays were re-read by cardiologist the nest day and any misreads were called to the ED physician on duty. The Director stated the ED MD would review the records and if needed the patients would by asked to return for additional treatment. The Directors stated the ED MD would dictate or write a note in the patients' record indicating whether treatment was appropriate during the ED visit, or further treatment was needed. The Directors stated a patient call back or misread log was not kept.. HE stated there was no tracking and trending of misreads by ED physicians so there was no mechanism to determine if any ED MD's had frequent misreads.

The Directors stated the process for laboratory results was similar. When the laboratory called with positive lab results, the result were printed and their primary physician was notified about the results. According to the Director, if a test came back positive, the ED MD would dictate a note in the patients' record indicating if additional treatment was needed and what additional treatment was provided.

During a tour of the radiology department on July 17, 2012, at 11:25 a.m., the Director was asked for information relating to misreads. Two record were selected for review and the following was noted:

1a. Patient 106 returned to the ED on June 26, 2012, at 1:29 p.m., The Emergency Department record indicated the patient's chief complain was "swelling feeling to left arm.: Patient 106 reported throbbing pain, seven on a ten point scale. The patient seen by the PA at 3:31 p.m. The dictated Emergency Room Report indicated the patient's ace wrap was removed and replaced. The patient's diagnosis was left hand fracture. The patient was told to follow up with the orthopedic department at the County Hospital.

b. Patient 107 presented to the ED accompanied by the police on May 23, 2012, at 12:25 a.m. and singed in for, "Ok to Book...Wound on left hip/injure to finger." X-rays of the right thumb and left hip were orders. The dictated Emergency Room Report indicated x-rays showed no acute changes the patient was diagnosed with left hip sprain and right thumb contusion, and discharged to local law enforcement at 2:230 a.m., On May 23, 2012, at 9:45 a.m., the radiologist reviewed the findings of the x-ray with the ED MD. The radiologist indicated "questionable subtle acetabular fracture. Clinical correlation is advised. If clinically indicated computerized tomography or magnetic resonance imaging might prove useful for further evaluation."

There was no evidence in the record the patient was informed of the radiologist findings.

During an interview with the QA Director and the QA Nurse on July 19, 2012, at 11:35 a.m., the ED QAPI, for medical staff was reviewed. There was no evidence QAPI was being done for radiology misreads by the ED MD's. There was no tracking or trending of misreads being done.

2. On July 19, 2012, at 1:30 p.m., the ICP was interviewed. The ICP stated positive laboratory culture results were faxed to the ED by the lab. The ICP also stated these reports were faxed to the patients' primary physician , if known. The ICP stated the ED MD was responsible for following up with the patient and should be documenting the follow up measures. Two records with positive laboratory reports were requested and the following was noted:

a. Patient 315 presented to the ED on July 3, 2012, at 3:59 a.m., with a chief complaint of "Swollen Lip." According to the "Emergency Room Report" Patient 315 stated he had a pimple that was gradually growing for the last several days. The ED MD indicated fluid was obtained for culture. Patient 315 was discharged home with instructions to follow "Abscess Sheets" and given prescription for Keflex and Bactrim. There was no evidence in the record indicating Patient 315 was notified about the positive culture results from the specimen obtained from the patient's lip. the laboratory results indicated Patient 315's would was positive for MRSA.

b. Patient 316 presented to the ED on July 6, 2012, at 12:20 a.m. with a chief complaint of generalized weakness. Patient 316 had a laboratory report that indicated her urinary culture was positive for bacteria. There was no evidence in the record that patient was contacted and treatment was initiated.

During an interview with the ED Director on July 19, 2012 at 2:45 p.m., the Director stated there should be documentation in the record about follow up information. The Directed stated the ED MD could do an addendum to the dictated note, or the information could be documented in the nurses notes. The Director did not provide evidence of this documentation for these four records.

Based on observation, interview, and record review, the facility failed to ensure:

1. Three of four pediatric emergency crash carts contained supplies according to policy and procedure and crash content list.

2. Staff were using the correct pediatric resuscitation guidelines.

These failures had the potential to result in failed resuscitation of pediatric patients.

Findings:

1. On July 17, 2012, at 10:45 a.m., during a tour of the facility's ED, the pediatric crash cart was observed. The crash cart was a color coded nine drawer cabinet on wheels, based on the Broselow Method for pediatric emergency care. Medications and supplies in each of the color coded drawers corresponded to a color on a Broselow Tape.

During an interview with ED RN 1, on July 17, 2012 at 10:45 a.m., the nurse stated a Broselow Tape was used in the event of a pediatric emergency. The nurse stated the Broselow Tape was kept in the cart. The RN was unable to find the Broselow Tape in either the neonatal or pediatric crash carts.

On July 17, 2012 at 11:25 am, a tour of the radiology department was conducted. The department used the same color coded system the emergency department used. There was no Broselow Tape available in the cart.

The pediatric crash cart on the pediatric unit was observed on July 17, 2012, at 11:35 a.m., with RN 1. There was no Broselow Tape available to estimate patient weight. RN 1 stated "there is not tape needed since we got this book.: The book was a spiral bound, color coded resuscitation guide based on the patients weight. The RN stated patient weight could be obtained from the record. When asked how much her current patient weighed, the nurse reported forty five pounds . The nurse agreed the patient's weight would need to be converted to kilograms to follow the directions in the book.

The facility policy titled "crash cart" with a last revised/reviewed date of October 2012, was reviewed on July 19, 2012. The policy indicated the carts were stocked with supplies and equipment necessary to ensure the effectiveness of cardio-pulmonary resuscitation. The policy indicated the crash cart supplies and equipment were stored according to the list and all carts would be stocked "identical".

The "Pediatric Crash Cart Checklist, " was reviewed on July 19, 2012. The list indicated Drawer #1 contained one Broselow Tape.

2. During a tour of the ED on July 17, 2012, at 10:25 a.m., the pediatric crash cart was observed. The cart, a color coded system, was based on the Broselow Tape,. During a concurrent interview with ED RN 1, the nurse stated they used a Broselow Tape and a book made by a local Medical Center during resuscitation efforts.

During an interview with the ICU Director on July 17, 2012 at 10:55 a.m., the Directors state the "Vital Signs" book had been approved and staff should be following the dosages and directions in that book, not the book written by the local Medical Center.

The two books were reviewed. The "Vital Signs" book contained instructions for the use of D 50 and D 25 The other book contained instructions for D 50 only. The pediatric crash cart contained only D 25. There were no instruction in the second book for the concentration of D 25 currently available in the pediatric crash cart.

During interviews with ED nursing staff, on July 17 and 18, 2012, 6 of 10 staff interviewed believed they should use the second book as a resource during pediatric codes.

On July 18, 2012, at 4:05 p.m., the ED educator was interviewed. The Educator stated he had put together a binder to assist ED personnel with pediatric codes. The Educator stated staff were told to use the bas as an "adjunct" to the "Vitals Signs" book. The Educator stated the binder hadn't been through committee review.

Based on observation, interview, and record review, the facility failed to ensure ED and security staff was trained to intervene appropriately when patients became violent. This failure resulted in three of three sampled patients who were place in restraints., being restrained inappropriately and the potential for harm.

Findings:

1a. The record for Patient 111, was reviewed on February 15, 2012. Patient 111, a 32 year old male, presented to the ED on December 15, 2011, at 1:20 a.m., with complaints of drug abuse and suicide ideations.

The ED nurse's notes indicated the patient was placed in four point restraints (all extremities tied down) on December 15, 2011, at 1:35 a.m., for behavior management.

A video of the restraint application was viewed with the CNO on February 15, 2012, and again on April 4, 2012. accompanied by the ED Director. The video showed the ED CN enter the room to assist other staff members in restraining the patients. The video showed the ED CN got up on the gurney and placed his knee across the patient's chest to hold him down.

During an interview with the ED CN on April 4, 2012, at 11:55 a.m., he stated he remembered the incident. He stated he put his knee across the patients's chest to hold him down. The ED CN stated putting a knee across a patient's chest was not part of the MAB training he received.

b. The record for Patient 110 was reviewed on May 25, 2012. Patient 110, a 66 year old male, presented to the ED on April 24, 2012, at 9:25 p.m., with complaints of chest pain.

The ED nurse's notes indicated at 9:45 p.m., the patient began refusing treatment, and wanted to leave the ED. The notes indicated the patient threatened the ED staff who did not allow him to leave, so security restrained the patient until the police arrived.

A security report dated April 24, 2012, at 9:50 p.m., indicated Patient 110 made an aggressive move toward a nurse, so a security officer grabbed the patient from behind, the two started struggling, and the security officer, "took the patient down to the floor." The report indicated the security officer handcuffed the patients while the waited for the police to arrive.

Police Report 1, dated May 1, 2012, indicated the officer responded to the facility on April 24, 2012, at approximately 9:51 p.m.., and Patient 110 told him he had been thrown onto the ground and handcuffed by hospital security.

Police Report 2, dated May 1, 2012, indicated the officer responded to the facility on April 24, 2012, at approximately 9:50 p.m., and observed Patient 110 laying face down on the ground, handcuffed behind his back, with a security guard on top of him. The report indicated the police officer assisted the security guard to her feet, and checked Patient 110 for injuries.

c. During a tour of the ED on July 17, 2012, at 9:30 a.m., Patient 105 was observed lying on a gurney in Room 23. The patient was observed in four point restraints. He was calm and cooperating with ED staff.

During an interview with Security Officer 2, on July 17, 2012, at 9:35 a.m., the officer stated he was when Patient 105 arrived in the ED. The officer stated the patient was aggressive and yelling at police officers. He stated the patient was not angry with or yelling a ED staff. The officer stated a police officer told him to restrain the patient in four point restraints, so he did. He stated he was supposed to wait for an order from an ED MD, but the police officer said to restrain the patient, so he did.

The record for Patient 105 was reviewed on July 17, 2012. Patient 105 , a 67 year old male, presented to the ED on July 17, 2012, at 8:35 a.m., with complaints of PTSD and abdominal pain.

The record indicated the patient was placed in four point restraints on arrival due to threatening the police and EMS personnel. There was no evidence the patient was threatening the ED staff.

A security report dated July 17, 2012, was reviewed on July 19, 2012. The report indicated the patient was yelling at police officers and poked an ED Tech in the rib using his index finger. According to the report, the police officer then said, "that's it, put him in restraints." The report indicated the patient was then put in four point restraints by facility security.

The Emergency Department Record, Physician Orders section, included an order written at 8:45 a.m., for, "4 point restraints." The order did not indicate the type of restraints to be used, the reason for restraints, the duration of the restraints, or when the restraints could be removed.

The preprinted physician restraint order form was reviewed on July 17, 2012. The form indicated the staff was to use the least restrictive restraint appropriate for the patient. In the section titled "TYPE OF RESTRAINT," leather restraints was not an option.

The facility policy titled, "Use of Leather Restraints in the Emergency Room,: indicated the staff must have a physician's order for the use of restraints.

During a follow-up telephone interview with Security Officer 2 on July 19, 2012, at 11:15 a.m., the officer stated Patient 105 was placed in restraints upon the order of a police officer. He stated the police officer said to the restrain the patient, so he got leather restraints from the security cabinet in the ED and restrained the patient. He stated there was no MD present at the time. The security officer stated he would usually wait for an MD order, but the police officer told him to do it, so he did.

The MAB training sign in sheets were reviewed on July 18, 2012. The records indicated nine of the 16 security officers (56%) and 30 of 78 ED staff members (38%) received the training.

The MAB training agenda was reviewed on April 4, 2012, and again on July 18, 2012. The agenda did not include physical maneuvers for managing violent behavior.

During a telephone interview with the Security Manager on July 18, 2012, at 11:15 a.m., the manager stated the MAB classes did not include physical maneuvers to deal with violent behavior. He stated the people who taught the class were not certified to teach the physical maneuver part. He stated Physical maneuvers had not been taught at the facility since 2010.

The facility policy titled, "Management of Assaultive Behavior," was reviewed on July 18, 2012. The policy indicated all ED and security staff would receive MAB training during orientation and annually thereafter.

Based on observation, interview, and record review, the facility failed to ensure staff was trained to intervene appropriately when patients became violent and failed to follow up appropriately when a patient eloped (Patient 206).

This failure resulted in three of three sampled patients who were placed in restraints (Patients 110. 111. and 105), being restrained inappropriately, one patient who eloped and whose welfare was not followed-up creating the potential for harm or death to the patients.

Findings:

1a. The record for Patient 111, was reviewed on February 15, 2012. Patient 111, a 32 year old male, presented to the ED on December 15, 2011, at 1:20 a.m., with complaints of drug abuse and suicide ideations.

The ED nurse's notes indicated the patient was placed in four point restraints (all extremities tied down) on December 15, 2011, at 1:35 a.m., for behavior management.

A video of the restraint application was viewed with the CNO on February 15, 2012, and again on April 4, 2012. accompanied by the ED Director. The video showed the ED CN enter the room to assist other staff members in restraining the patients. The video showed the ED CN got up on the gurney and placed his knee across the patient's chest to hold him down.

During an interview with the ED CN on April 4, 2012, at 11:55 a.m., he stated he remembered the incident. He stated he put his knee across the patients's chest to hold him down. The ED CN stated putting a knee across a patient's chest was not part of the MAB training he received.

b. The record for Patient 110 was reviewed on May 25, 2012. Patient 110, a 66 year old male, presented to the ED on April 24, 2012, at 9:25 p.m., with complaints of chest pain.

The ED nurse's notes indicated at 9:45 p.m., the patient began refusing treatment, and wanted to leave the ED. The notes indicated the patient threatened the ED staff who did not allow him to leave, so security restrained the patient until the police arrived.

A security report dated April 24, 2012, at 9:50 p.m., indicated Patient 110 made an aggressive move toward a nurse, so a security officer grabbed the patient from behind, the two started struggling, and the security officer, "took the patient down to the floor." The report indicated the security officer handcuffed the patients while the waited for the police to arrive.

Police Report 1, dated May 1, 2012, indicated the officer responded to the facility on April 24, 2012, at approximately 9:51 p.m.., and Patient 110 told him he had been thrown onto the ground and handcuffed by hospital security.

Police Report 2, dated May 1, 2012, indicated the officer responded to the facility on April 24, 2012, at approximately 9:50 p.m., and observed Patient 110 laying face down on the ground, handcuffed behind his back, with a security guard on top of him. The report indicated the police officer assisted the security guard to her feet, and checked Patient 110 for injuries.

c. During a tour of the ED on July 17, 2012, at 9:30 a.m., Patient 105 was observed lying on a gurney in Room 23. The patient was observed in four point restraints. He was calm and cooperating with ED staff.

During an interview with Security Officer 2, on July 17, 2012, at 9:35 a.m., the officer stated he was when Patient 105 arrived in the ED. The officer stated the patient was aggressive and yelling at police officers. He stated the patient was not angry with or yelling a ED staff. The officer stated a police officer told him to restrain the patient in four point restraints, so he did. He stated he was supposed to wait for an order from an ED MD, but the police officer said to restrain the patient, so he did.

The record for Patient 105 was reviewed on July 17, 2012. Patient 105 , a 67 year old male, presented to the ED on July 17, 2012, at 8:35 a.m., with complaints of PTSD and abdominal pain.

The record indicated the patient was placed in four point restraints on arrival due to threatening the police and EMS personnel. There was no evidence the patient was threatening the ED staff.

A security report dated July 17, 2012, was reviewed on July 19, 2012. The report indicated the patient was yelling at police officers and poked an ED Tech in the rib using his index finger. According to the report, the police officer then said, "that's it, put him in restraints." The report indicated the patient was then put in four point restraints by facility security.

The Emergency Department Record, Physician Orders section, included an order written at 8:45 a.m., for, "4 point restraints." The order did not indicate the type of restraints to be used, the reason for restraints, the duration of the restraints, or when the restraints could be removed.

The preprinted physician restraint order form was reviewed on July 17, 2012. The form indicated the staff was to use the least restrictive restraint appropriate for the patient. In the section titled "TYPE OF RESTRAINT," leather restraints was not an option.

The facility policy titled, "Use of Leather Restraints in the Emergency Room,: indicated the staff must have a physician's order for the use of restraints.

During a follow-up telephone interview with Security Officer 2 on July 19, 2012, at 11:15 a.m., the officer stated Patient 105 was placed in restraints upon the order of a police officer. He stated the police officer said to the restrain the patient, so he got leather restraints from the security cabinet in the ED and restrained the patient. He stated there was no MD present at the time. The security officer stated he would usually wait for an MD order, but the police officer told him to do it, so he did.

The MAB training sign in sheets were reviewed on July 18, 2012. The records indicated nine of the 16 security officers (56%) and 30 of 78 ED staff members (38%) received the training.

The MAB training agenda was reviewed on April 4, 2012, and again on July 18, 2012. The agenda did not include physical maneuvers for managing violent behavior.

During a telephone interview with the Security Manager on July 18, 2012, at 11:15 a.m., the manager stated the MAB classes did not include physical maneuvers to deal with violent behavior. He stated the people who taught the class were not certified to teach the physical maneuver part. He stated Physical maneuvers had not been taught at the facility since 2010.

The facility policy titled, "Management of Assaultive Behavior," was reviewed on July 18, 2012. The policy indicated all ED and security staff would receive MAB training during orientation and annually thereafter.

2. On June 16, 2012, at 2:28 a.m., Patient 206 went to the ER for treatment of right finger injury. The triage nurse assessed the patient and an X-ray of the right 5th finger was ordered. The triage nurse completed a mental health assessment. The patient scored a "7" on the "Modified Sad Person Scale," indicating the patient might require a psychiatric consultation.

At 6:30 a.m., the nurse documented Patient 206 was agitated and threatening to break glass.

At 8:37 a.m., ER staff found the patient outside sitting on a bench. Patient 206 indicated, "Just wanted something for pain."

At 11:29 a.m., 11:41 a.m., and 11:52 a.m., staff called for Patient 206. Patient 206 appeared to have left the ER, for there was no answer. There was no documentation in the medical record that staff did follow-up on the elopement.

An interview was conducted with the ED Director on July 19, 2012, at 11 a.m.. The ED director stated someone should have telephoned the Patient within 24 hours to see if he was "ok:. The ED director stated staff was to document on the patient's record after they did their follow-up. The ED Director reviewed Patients 206's record and stated it was not done.

The ED director further stated she and her assistant were the individuals who would contact patients who eloped, but both had been out for the month of June. She was not sure if someone else did the follow up in her absence, but believed it had not been completed for the month of June.

The facility's policy and procedure, titled,:Patient Elopement from the Emergency Department, : wa