HospitalInspections.org

Based on interview and record review the facility failed to protect the rights of one (#1) of 4 patients reviewed for safety/behaviors resulting in the potential for the risk for loss of their rights for patient #1.
Findings include:

(See A-144) The facility failed to investigate injuries for patient (#1) during a restraint occurrence.
(See A-194) The facility failed to ensure Security staff N, O and R maintained current Crisis Prevention Intervention (CPI) and restraint application competencies.

Based on interview and record review, the facility failed to provide care in a safe setting for one (#1) of 4 patient's reviewed for safety out of a total sample of 10 patients, by failing to document and investigate injuries that occurred during restraint application resulting in the potential for reoccurrence and less than optimal outcomes for patient #1.

Findings include:
Medical record review on 1/6/2021 at 1300 revealed that the patient of concern (#1) was a 46 -year-old male who presented to the emergency department on 11/1/2020 at 0758 for a "psych" eval. The patient was accompanied by the local authorities and had been petitioned.
Review of nursing notes dated 11/1/2020 at 0815 revealed the patient was cooperative but refused to have his blood drawn.

At 1013 on 11/1/2020, nursing documented security was at the patient's bedside along with another staff nurse and the patient had been held down after being medicated after yelling continuously at staff and stating, "my rights my body, I don't have to do anything, this is not medically necessary."

At 1031 on 11/1/2020, nursing documented the patient continued to go in and out of his room while yelling at staff inspite of being redirected by nursing and security staff to remain in his room. The nurse documented the patient hit security in his face. The patient was placed in restraints and per security sustained a small laceration to his lip. Nursing noted blood was on the floor and the physician was contacted to assess the patient.

On 11/1/2020 at 1037, nursing documented the patient had removed the upper right arm restraint, and security was contacted and went to bedside to "resecure" the restraint.

A phone interview was conducted with ED Staff Nurse L on 1/6/2021 at 1235. She explained she recalled the patient. When queried regarding (#1's) restraints application and lip laceration as documented on 11/1/2020 at 1031 per her nursing notes she responded, "I didn't witness anything." She said I left his (#1) room briefly to have the physician sign off his EKG. When I came back, I saw his lip, there was blood on his sheets. I cleaned his lip and changed his sheets. I informed the doctor as to what I had seen the doctor came in to assess him. When asked to explain who restrained the patient Staff L said she did not know. She stated, "Security can apply restraints with the nurse. However, Staff L said she did not know who might have been with security when the restraints were applied.

An interview and review of the facility's incident/accident (I/A's) reports were conducted with the Staff G (Director of Quality, Patient Safety and Infection Control) on 1/6/2021 at 1315 and revealed there were no (I/A's) logged for the patient of concern (#1). When queried regarding the lack of an (I/A) for a patient who suffered a lip laceration while being restrained Staff G replied, "It may have been appropriate to submit (I/A)." However, no further explanation was provided at that time.

An interview and review of the patient's nursing notes were conducted with ED Staff Nurse M on 1/6/2021 at 1540. At that time, Staff M confirmed that she was the nurse to whom Staff L was referring to 11/1/2020 at 1013. Staff M was asked if she was present during the episode on 11/1/2020 that indicated the patient of concern (#1) was restrained and suffered a laceration to his lip. Staff M said she was in the room earlier and took the patient's blood pressure. She said she did not recall the patient being restrained. She said she did not apply restraints on the patient (#1). Staff M said she heard commotion and responded to support staff safety. When further queried Staff M said "Security applies the restraints at least 9 out of 10 times." Staff M said after the restraints are applied, we (nursing) assess to see if it's done right. She said we make sure the patient has good circulation and a pulse.

An interview and review of a "Security Report" was conducted with Security Staff O on 1/6/2021 at 1300. At that time, Staff O confirmed he was the author of the report dated on 11/1/2020. Staff O said he was present on the unit and had finished assisting nursing staff with medicating the patient (#1). Staff O said the patient of concern (#1) was "yelling and interfering with the processing of another patient across the room from him." Staff O said he repeatedly told the patient (#1) to stay in bed however, he explained the patient continued to yell and curse at the officers standing outside of his doorway. Staff O said the patient then took some paper towels and cups and threw them at the officers in the hallway. Staff O said while accompanied by security Staff R and S and himself they entered the patient's room and the patient (#1) became combative and punched him (Staff O) in the face. Staff O said at that time he and the 2 other officers used CPI (Crisis Prevention Institute) to place the patient in his bed and administered locking restraints to the patient (#1) to all the patient's extremities. Staff O said the physician provided the order. Staff O said they (security) can apply restraints on patients with a physician's order. Staff O was asked if a nurse was present or assisted with the application of restraints. Staff O said he did not recall. Staff O said, "the patient hit his lip on the right side of the bed rail causing a cut to his upper lip." Staff O noted in his report, "patient has redness and slight swelling to his left cheek injuries, no complaints of pain, patient reported he was ok.

An interview was conducted with the Chief Nursing Officer Staff B on 1/6/2021 at 1350. Staff B explained she had been made aware of the surveyor's concerns regarding "security staff use of restraints and the lack of an (I/A) for the patient (#1) lip laceration that occurred while being restrained. Staff B said those were opportunities for improvement and will be thoroughly reviewed.

A review of the facility's "Restraints" policy dated last revised on 2/25/2020 documented:
IV. Assessment, Monitoring and Patient Care:
Violent/Self-Destructive Behavior
"A patient may be placed in restraints by the RN in an emergency ...RN contacts physician ..."

A review of the facility's "RL Solutions Quality/Safety Report Instructions" policy dated last reviewed on 1/9/2018 documented:
I. Definitions:
A. Safety Event (Occurrence) Definition: Any process/incident inconsistent with the routing operation of the hospital or the routing care of patients in any setting. This includes errors that result in actual or potential injury to a patient or visitor, including near misses or unsafe conditions.
B. Safety Category Owner: " ...events will be categorized in the following incident types: q. Restraints-Injury, emotional stress, or death related to use of restraints.
II. Procedure-
A. Responsibility-
1. The person who first discovers an occurrence should:
a. Notify the appropriate department manager or supervisor.
b. Initiate a Quality/Safety Report through the RL Solutions system. Include a complete, factual description of the event, excluding conjecture, opinions or blame." However, this was not done.

Based on interview and record review, the facility failed to ensure three (Security staff N, O, and R) of three employees whose personnel files were reviewed maintained certification and compentency in the facility's protocol for Crisis Prevention Intervention (CPI) and restraint application, resulting in the less than optimal outcomes for all patients currently in the facility (398). Findings include:

A review of personnel files for Security Staff N, O and R was conducted with Human Resource Consultant Staff P on 1/7/2021 at 1410 and revealed the following:
Staff N: CPI training and use of restraints competency expired on 5/16/2018.
Staff O: CPI training and use of restraints competency expired on 5/31/2020.
Staff R: CPI training and use of restraints competency expired on 6/2020. When queried, at that time regarding the expired CPI training and restraint compentencies, Staff P referred the surveyor to the Senior Director of Security Services (Staff Q).

A phone interview was conducted with Staff Q on 1/6/2021 at 1645 who was queried regarding the lack current CPI training and use of restraints competencies for Security Staff N, O and R.
At that time Staff Q replied, due to "COVID" training had been suspended. He said "they plan to resume scheduling and training for CPI and restraint competencies in the first (1st) quarter of 2021."

Review of the facility's "Restraints" policy dated last revised on 2/25/2020 documented:
X. Staff education:
A. Staff must be trained and able to demonstrate competency in the application of restraints, monitoring, assessment, and providing care for a recipient in restraint--(i) before performing any of the actions specified in these standards; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy...2.b. At orientation before the new staff member is asked to implement provisions of this policy. c. Subsequently shall be repeated annually and as determined by the results of quality monitoring activities. However, this was not done.

A review of facility's Job Description for "Security Officer" last updated on 6/1/2018 documented:
Essential Duties:
" ...10. Assists nursing staff with physical management/restraints of patients as ordered by a physician."
Standard Qualifications:
" ...D. Other Qualifications: Within 90 days of hire successfully complete certification and maintain continued competency in: Defensive Tactics (non-patient use of force ...pressure point control techniques), Proactive Non-violent Verbal De-escalation ...and Patient Physical Management/Restraint." However, this was not done.