HospitalInspections.org

Based on document review and interview, the facility failed to ensure a patient received care in a safe setting for 1 of 10 patients (patient #1) see tag 144, failed to ensure patients were free from the use of restraints/handcuffs for 1 of 10 patients (patient #1), failed to ensure a physician order was obtained for the use of handcuffs as a restraint for 1 of 10 patients (patient #1), and failed to ensure the patient right to safe implementation of restraint by trained staff for 1 of 10 patients (patient #1).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to ensure a patient received care in a safe setting as evidenced by the removal of the patient's prosthetic leg by nursing staff for 1 of 10 medical records reviewed (Patient #1).

Findings include;

1. Review of facility policy titled "PATIENT RIGHTS AND RESPONSIBILITIES" reviewed/revised 8/1/2018 indicated the following: "...3.0 PATIENT RIGHTS...3.1...You have the right to be treated with consideration, respect, and full recognition of your personal dignity...3:13...will provide you an environment that preserves your dignity..."

2. A review of facility staff statements related to the incident on 5/15/22 involving Patient #1 provided by A5 (Director of Risk Management) on 6/16/22 at approximately 11:15 a.m. indicated the following:

(a) N6's (Registered Nurse/Emergency Department) statement dated 5/19/22 at 10:02 a.m. "....[Patient #1] is a fall risk since [he/she] has a prosthesis on [his/her] left leg...Pt [Patient] was placed on the floor on a mattress with fall pads around [him/her] for safety. Pt then crawled to the door and began kicking it with both legs, security was called at this time. Pt's prosthesis was removed at this time and security stayed at bedside...Pt heard saying "I need to stand up, I need to stand up" multiple times, I heard security tell [him/her] [he/she] could not.

(b) N5's (Registered Nurse/Emergency Department) statement dated 5/21/22 at 5:58 a.m. "...[He/She] then starts kicking the glass door with [his/her] prosthetic leg and kicking at staff as they try to enter the room. Security was then called to assist due to pts aggressive behavior. They remained at bedside and was encouraging [him/her] to stop [his/her] behavior so the staff can take care of [him//her]. [He/She] wasn't listening and continued kicking the glass door. This writer...removed [his/her] prosthetic leg to prevent [him/her] from kicking through the glass and kicking staff members..."

3. A review of email communication dated 5/18/22 at 2:52 p.m. from C13 (Owner of Contracted Security Company #2) he/she provided a report related to an incident with Patient #1 on 5/15/22 by N4 (Contracted Off Duty Officer/Security Staff) which indicated the following: "...5/15/22 Around [3:00 a.m.] I responded to ER... on a subject the medical staff was needing help with. When I got to the room, there were a lot of nursing and staff around the outside of the room and I could hear banging coming from inside. When I looked, I could see...[Patient #1] with a prosthetic leg kicking the glass door repeatedly. I gloved up and at this time security Officers...had arrived. We made entry in to the room and scooted...[Patient #1] away from the door and back on a mattress. One of the Nurses took...[Patient #1's] prosthetic leg off and put it on the counter..."

4. During an interview with A5 on 6/17/22 at 4:58 p.m., he/she verified that per the facility's investigation, Patient 1's prosthetic leg was removed by a nurse in the emergency department.

Based on document review and interview, the facility failed to ensure a patient was free from the use of restraints/handcuffs as a means of coercion, discipline and/or convenience by staff for 1 of 10 medical records reviewed (Patient #1).

Findings include;

1. Review of facility policy titled "Restraint and Seclusion Policy" reviewed/revised 11/2021 indicated the following: "...V. It is the policy of this facility to: A. Protect the patient and preserve patient's rights, dignity, and well-being during restraint use by: 1) Respecting the patient as an individual...5) Implementing the policy that convenience is not an acceptable reason to restrain a patient...B. Prevent, reduce, and eliminate use of restraints by basing use on patient's assessed needs...2) The rationale that the patient should be restrained because he/she "might" fall does not constitute an adequate basis of using a restraint...III. INSTANCES WHERE RESTRAINT AND SECLUSION STANDARDS DO NOT APPLY...G. Forensic or correctional restrictions for security purposes. The use of handcuffs or other restrictive devices applied by law enforcement officials is for custody, detention, and public safety reasons and is not involved in the provision of healthcare..."

2. A review of an incident report for Patient #1 by N3 (Security Officer) dated 5/15/22 at 6:24 a.m. indicated the following: "...Myself and [N4, Contracted Off Duty Police Officer/Security Staff] assisted the ER [Emergency Room] tech [technician] in taking [Patient #1] up to the [inpatient/observation] room...[Patient #1] was put in the bed in the room, [he/she] refused to allow the PCA [Patient Care Assistant] to take vitals, was still yelling, and continually tried climbing out of bed. [N4] responded the nursing staff order restraints or an enclosure bed for [Patient #1's] safety. While waiting on the enclosure bed and due to [Patient #1] continually trying to get out of bed, [N4] made the decision to restrain [Patient #1] to the bed with [his/her] handcuffs...When the enclosure bed arrived, the handcuffs were taken off and [Patient #1] was moved beds..."

3. A review of email communication dated 5/18/22 at 2:52 p.m. from C13 (Owner of Contracted Security Company #2), he/she provided a report related to an incident with Patient #1 on 5/15/22 by N4 which indicated the following: "...5/15/22 Around [3:00 a.m.] I responded to ER... on subject the medical staff was needing help with...After a few hrs [hours], we got word that [Patient #1] was being transported up to the 5th floor. [N3] and I went with them upstairs and [Patient #1] continued yelling while going up and once we got there. [Patient #1] was not cooperative with these nurses also, so they were unable to get vitals. [He/She] continued trying to get out of bed even though we told [him/her] numerous times [he/she] had to stay in bed. I told [Patient #1] if [he/she] did not quit trying to get up and off the bed, that I would handcuff [him/her] to the bed. [Patient #1] did not listen, so I placed a handcuff on [his/her] wrists and locked them to the bed. [Patient #1] was not happy, but I advised [him/her] that I would take them off if he would stop trying to get out of bed and leave the nurses [to] work. I then went out and talked to the nurses at the [nurse's] station. They stated that they were bringing a special bed up that we could put [him/her] in and [he/she] could not get out...The handcuffs were probably on [him/her] for about 5-10 minutes before the bed arrived. I then took them off..."

4. During an interview with A1 (Market Chief Quality Officer) and A5 (Director of Risk Management) on 6/17/22 10:40 a.m., they verified that Patient #1 was not arrested and was not brought in by police for his/her emergency department visit/admission to the facility on 5/15/22.

5. During a telephone interview with A14 (Project Chief Operating Officer/Chief Nursing Officer) on 6/17/22 at approximately 11:04 a.m., he/she verified that off duty police officers were on premises of the facility for security and were paid by the facility.

6. During an interview with A5 on 6/17/22 at 4:58 p.m., he/she verified that per the facility's investigation, Patient #1 was placed in handcuffs by an off duty police officer working for the facility.

Based on document review and interview, the facility failed to ensure a physician order for the use of handcuffs as a restraint for 1 of 10 medical records reviewed. (Patient #1).

Findings include;

1. Review of facility policy titled "Restraint and Seclusion Policy" reviewed/revised 11/2021 indicated the following: "...E. Orders for Restraint...2) In an emergency application situation, an RN [Registered Nurse]...may initiate the application of restraint prior to obtaining an order from an LIP [Licensed Independent Practitioner]. In this event the order must be obtained either during the emergency application of the restraint or immediately (as soon as possible) after the restraint has been applied..."

2. A review of an incident report for Patient #1 by N3 (Security Officer) dated 5/15/22 at 6:24 a.m. indicated the following: "...Myself and [N4, Contracted Off Duty Police Officer/Security Staff] assisted the ER [Emergency Room] tech [technician] in taking [Patient #1] up to the [inpatient/observation] room...[Patient #1] was put in the bed in the room, [he/she] refused to allow the PCA [Patient Care Assistant] to take vitals, was still yelling, and continually tried climbing out of bed. [N4] responded the nursing staff order restraints or an enclosure bed for [Patient #1's] safety. While waiting on the enclosure bed and due to [Patient #1] continually trying to get out of bed, [N4] made the decision to restrain [Patient #1] to the bed with [his/her] handcuffs. [Patient #1] then continued to yell but seemed slightly calmed down. When the enclosure bed arrived, the handcuffs were taken off and [Patient #1] was moved beds..."

3. A review of email communication dated 5/18/22 at 2:52 p.m. from C13 (Owner of Contracted Security Company #2), he/she provided a report related to an incident with Patient #1 on 5/15/22 by N4 which indicated the following: "...5/15/22 Around [3:00 a.m.] I responded to ER... on subject the medical staff was needing help with...After a few hrs. [hours], we got word that [Patient #1] was being transported up to the 5th floor. [N3] and I went with them upstairs and [Patient #1] continued yelling while going up and once we got there. [Patient #1] was not cooperative with these nurses also, so they were unable to get vitals. [He/She] continued trying to get out of bed even though we told [him/her] numerous times [he/she] had to stay in bed. I told [Patient #1] if [he/she] did not quit trying to get up and off the bed, that I would handcuff [him/her] to the bed. [Patient #1] did not listen, so I placed a handcuff on [his/her] wrists and locked them to the bed. [Patient #1] was not happy, but I advised [him/her] that I would take them off if he would stop trying to get out of bed and leave the nurses [to] work. I then went out and talked to the nurses at the [nurse's] station. They stated that they were bringing a special bed up that we could put [him/her] in and [he/she] could not get out...The handcuffs were probably on [him/her] for about 5-10 minutes before the bed arrived. I then took them off..."

4. A review of Patient #1's medical record lacked documentation of a physician order for the use of handcuffs as a restraint on Patient #1.

5. During an interview with A2 (Network Health Information Management Manager) on 6/17/22 4:46 p.m., he/she verified the medical record information for Patient #1 and the lack of a physician order for handcuffs to be placed on Patient #1.

Based on document review and interview, the facility failed to ensure the patient right to safe implementation of restraint by trained staff for 1 of 4 personnel files reviewed (N4).

Findings include;

1. Review of facility policy titled "EC.01.01.01.5 - Security Management Plan" reviewed/revised 1/5/2022 indicated the following: "...Orientation, Training, and Education...All staff shall attend new employee orientation within 30 days of hire. New employee orientation addresses key issues and objectives of all areas of the Environment of Care, including the role each area and staff play in the overall patient safety program...Competency of education is assessed and documented. Personnel who serve or respond in a security capacity are trained on de-escalation techniques such as CPI (Crisis Prevention Institute) SAMA (Satori Alternatives to Managing Aggression), or equivalent training..."

2. During review of personnel files on 6/16/22 beginning at 4:07 p.m. with A9 (Human Resource Generalist) and A10 (Human Resource Director), A10 verified that there was no personnel file for N4 (Contracted Off-Duty Police Officer/Security Staff).

3. During an interview with A10 on 6/17/22 at 2:48 p.m., he/she verified that there was no personnel file for N4 including no CPI education/training, no restraint/seclusion education/training, no abuse education/training and that the reason for no personnel file for N4 was because N4 was a police officer working under Police Department #1's policies.

Based on document review and interview, the facility failed to ensure a Registered Nurse had a physician order to remove a prosthetic leg from a patient for 1 of 10 medical records reviewed (Patient #1).

Findings include;

1. A review of facility staff statements related to the incident on 5/15/22 involving Patient #1 provided by A5 (Director of Risk Management) on 6/16/22 at approximately 11:15 a.m. indicated the following:

(a) N6's (Registered Nurse/Emergency Department) statement dated 5/19/22 at 10:02 a.m. "....[Patient #1] is a fall risk since [he/she] has a prosthesis on [his/her] left leg...Pt [Patient] was placed on the floor on a mattress with fall pads around [him/her] for safety. Pt then crawled to the door and began kicking it with both legs, security was called at this time. Pt's prosthesis was removed at this time and security stayed at bedside...Pt heard saying "I need to stand up, I need to stand up" multiple times, I heard security tell [him/her] [he/she] could not. When [he/she] did stand up, from what I saw while charting at the nurses' station outside of [patient #1's] room..., [he/she] was taken under the armpits and lowered back to the mattress..."

(b) N5's (Registered Nurse/Emergency Department) statement dated 5/21/22 at 5:58 a.m. "...[He/She] then starts kicking the glass door with [his/her] prosthetic leg and kicking at staff as they try to enter the room. Security was then called to assist due to pts aggressive behavior. They remained at bedside and was encouraging [him/her] to stop [his/her] behavior so the staff can take care of [him//her]. [He/She] wasn't listening and continued kicking the glass door. This writer...removed [his/her] prosthetic leg to prevent [him/her] from kicking through the glass and kicking staff members..."

2. A review of email communication dated 5/18/22 at 2:52 p.m. from C13 (Owner of Contracted Security Company #2), he/she provided a report related to an incident with Patient #1 on 5/15/22 by N4 (Contracted Off Duty Officer/Security Staff) which indicated the following: "...5/15/22 Around [3:00 a.m.] I responded to ER... on a subject the medical staff was needing help with. When I got to the room, there were a lot of nursing and staff around the outside of the room and I could hear banging coming from inside. When I looked, I could see...[Patient #1] with a prosthetic leg kicking the glass door repeatedly. I gloved up and at this time security Officers...had arrived. We made entry in to the room and scooted...[Patient #1] away from the door and back on a mattress. One of the Nurses took...[Patient #1's] prosthetic leg off and put it on the counter..."

3. During an interview with A2 (Network Health Information Management Manager) on 6/17/22 at 10:45 a.m., he/she verified Patient #1's medical record lacked a physician order to remove Patient #1's prosthetic leg.

4. During an interview with A5 on 6/17/22 at 4:58 p.m., he/she verified that per the facility's investigation, Patient 1's prosthetic leg was removed by a nurse in the emergency department.

Based on document review and interview, the facility failed to ensure medical records were complete and accurate for 1 of 10 medical records reviewed (Patient #1).

Findings include;

1. A review of facility staff statements related to the incident on 5/15/22 involving Patient #1 provided by A5 (Director of Risk Management) on 6/16/22 at approximately 11:15 a.m. indicated the following:

(a) N6's (Registered Nurse/Emergency Department) statement dated 5/19/22 at 10:02 a.m. "....[Patient #1] is a fall risk since [he/she] has a prosthesis on [his/her] left leg...Pt [Patient] was placed on the floor on a mattress with fall pads around [him/her] for safety. Pt then crawled to the door and began kicking it with both legs, security was called at this time. Pt's prosthesis was removed at this time and security stayed at bedside...Pt heard saying "I need to stand up, I need to stand up" multiple times, I heard security tell [him/her] [he/she] could not. When [he/she] did stand up, from what I saw while charting at the nurses' station outside of [patient #1's] room..., [he/she] was taken under the armpits and lowered back to the mattress..."

(b) N5's (Registered Nurse/Emergency Department) statement dated 5/21/22 at 5:58 a.m. "...[He/She] then starts kicking the glass door with [his/her] prosthetic leg and kicking at staff as they try to enter the room. Security was then called to assist due to pts aggressive behavior. They remained at bedside and was encouraging [him/her] to stop [his/her] behavior so the staff can take care of [him//her]. [He/She] wasn't listening and continued kicking the glass door. This writer...removed [his/her] prosthetic leg to prevent [him/her] from kicking through the glass and kicking staff members..."

2. A review of an incident report for Patient #1 by N3 (Security Officer) dated 5/15/22 at 6:24 a.m. indicated the following: "...Myself and [N4, Contracted Off Duty Police Officer/Security Staff] assisted the ER [Emergency Room] tech [technician] in taking [Patient #1] up to the [inpatient/observation] room...[Patient #1] was put in the bed in the room, [he/she] refused to allow the PCA [Patient Care Assistant] to take vitals, was still yelling, and continually tried climbing out of bed. [N4] responded the nursing staff order restraints or an enclosure bed for [Patient #1's] safety. While waiting on the enclosure bed and due to [Patient #1] continually trying to get out of bed, [N4] made the decision to restrain [Patient #1] to the bed with [his/her] handcuffs...When the enclosure bed arrived, the handcuffs were taken off and [Patient #1] was moved beds..."

3. A review of email communication dated 5/18/22 at 2:52 p.m. from C13 (Owner of Contracted Security Company #2), he/she provided a report related to an incident with Patient #1 on 5/15/22 by N4 which indicated the following: "...5/15/22 Around [3:00 a.m.] I responded to ER... on subject the medical staff was needing help with...After a few hrs [hours], we got word that [Patient #1] was being transported up to the 5th floor. [N3] and I went with them upstairs and [Patient #1] continued yelling while going up and once we got there. [Patient #1] was not cooperative with these nurses also, so they were unable to get vitals. [He/She] continued trying to get out of bed even though we told [him/her] numerous times [he/she] had to stay in bed. I told [Patient #1] if [he/she] did not quit trying to get up and off the bed, that I would handcuff [him/her] to the bed. [Patient #1] did not listen, so I placed a handcuff on [his/her] wrists and locked them to the bed. [Patient #1] was not happy, but I advised [him/her] that I would take them off if he would stop trying to get out of bed and leave the nurses [to] work. I then went out and talked to the nurses at the [nurse's] station. They stated that they were bringing a special bed up that we could put [him/her] in and [he/she] could not get out...The handcuffs were probably on [him/her] for about 5-10 minutes before the bed arrived. I then took them off..."

4. Review of Patient #1's medical record lacked documentation of Patient #1's prosthetic leg being removed by nursing staff and/or handcuffs being placed on Patient #1 and secured to Patient #1's bed on 5/15/22 by N4.

5. During an interview with A2 (Network Health Information Management Manager) on 6/17/22 at 10:45 a.m., he/she verified the medical record lacked documentation of the removal of Patient #1's prosthetic leg by nursing staff and the use of handcuffs on Patient #1 by N4.