HospitalInspections.org

Based on record review, ED log review, pregnancy guidelines review, American Medical Association Guidelines review, policy review, and staff interview, it was determined the CAH failed to ensure restraints were imposed to ensure the immediate physical safety of the patient or others and were discontinued at the earliest possible time, restraints were in accordance with the order of a physician, and restraint renewal justification by the ordering provider was documented in the medical record for 1 of 1 patients (Patient #4) who were restrained, and whose records were reviewed. Additionally, it was determined the CAH failed to meet the emergency needs of its patients, and ensured licensed clinical staff were functioning within their scope of practice for 5 of 32 patients (Patients #2, #7, #21, #16, and #26) whose records were reviewed. This resulted in unnecessary use of restraint, restraints being applied without physician order, had the potential for a lack of information on which to base additional intervention and treatment decisions. Additionally, clinical staff performing duties outside of their scope, and a lack of patients being treated for presenting symptoms had the ability to affect all patients who presented to the ED for treatment. Findings include:

The cumulative effect of these systemic practices prevented the hospital from providing quality emergency care based upon patients' needs.

1. Least restrictive intervention and alternatives were not utilized and deemed to be ineffective prior to the continued use of restraints.

American Medical Association website accessed 5/25/23 at 9:00 AM included:

"Physicians who order chemical or physical restraints should...

Regularly review the need for restraint and document the review and resulting decision in the patient's medical record.

In certain limited situations, when a patient poses a significant danger to self or others, it may be appropriate to restrain the patient involuntarily. In such situations, the least restrictive restraint reasonable should be implemented and the restraint should be removed promptly when no longer needed." This standard of practice was not followed.

A CAH policy titled "Restraints / Seclusion Standards" dated 8/11/2020, stated, "The Purpose of this policy is to provide direction for the appropriate use of restraints to help protect the patient's health, safety and preserves his or her dignity, rights and wellbeing." The policy also included: "The Use of restraint is based on the assessed needs of the patient. Restraints should only be used when less restrictive interventions or alternatives have been determined to be ineffective to protect the patient. A staff member. Or others from harm." The policy included 8 examples of less restrictive alternatives including:

"1. Re-orientation
2. De-escalation
3. Limit setting
4. Increased observation and monitoring
5. Change in patient's physical environment
6. Review and modification to medication regimens
7. Diversion activities such as TV, music, games, etc.
8. Involve clinical staff and family to be part of exercise, walking and range of motion with patient."

Additionally, the policy included " Restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Restraint may only be employed while the unsafe situation (clinical justification) continues. This policy was not followed. Examples include:

Patient #4 was a 16 year old male who presented to the emergency department on 4/26/23 with his friend with the chief complaint of possible overdose. Patient #4 was evaluated and recommended for inpatient psychiatric treatment. Patient #4 was subsequently signed out AMA from the ED by his parents on 5/01/23 while waiting for inpatient bed placement.

On 4/27/23 at 6:23 PM the note from the paramedic included. "Physician explained to pt that if he remained cooperative and calm restraints could be removed. Pt agreed. Restraints were removed and pt immediately slid his body to end of the bed and got up, stating (using explicit terms) that he was going to leave. Pt was still unsteady on feet and unable to walk or stand without assistant. Pt was instructed to return to bed. Pt became agitated and threatened to cause harm to personnel. [ED Physician and I had to use reasonable force to get pt back into bed. Personnel had to assisted[sic] and law enforcement was called back to hospital." There was no order in the medical record for a new order for the reapplication of restraint after removal.

6:34 PM a note included: "HALDOL [sedative medication used as chemical restraint] IM 5mg given. Given in the left deltoid [upper arm].

6:44 PM a note documented by an RN included: "HALDOL IM 5mg given. Given in the right ventral gluteus.

4/27/23 at 6:58 PM Patient #4's medical record included a note by the paramedic, it included: "PT continued to escalate agitation and became combative. Pt was restrained all extremities with soft restraints, right arm above head and left arm at waste [sic] level. Pt continued to pull and thrash against restraints and bang head against arm rails and hard parts of bed. Pt pulled so hard against restraints that right arm restraint snapped. Pt was at obvious risk of self-harm and harm to others. Haldol was administered to pt IM and pt remained at same level combativeness. Additional sedation was administered with pt responding by relaxing and falling asleep. Pt restraints were adjusted and pt was checked for injuries. None found."

Patient #4's medical record included a restraint form that documented vital signs and and assessment for Patient #4 every 15 min. Beginning on 4/27/23 at 7:08 pm through 4/28/23 at 4:53 AM, a period of 9 hours and 45 minutes, Patient #4 was documented as sleeping and in restraints. Under the section titled "clinical justification" for the continued need for restraint it was marked as "other" with hand written note of "pt sedated / state of mind unknown." Patient #4's medical record did not include attempted least restrictive alternatives were attempted for the 9 hours and 45 minutes Patient #4 was documented as sleeping in restraints.

The paramedic taking care of Patient #4 was interviewed 5/24/23 beginning at 11:00 AM. When asked if restraints removal was attempted between 7:08 PM and 4:53 AM. She confirmed there was no documentation restraint removal was attempted. The Paramedic stated the patient would not have reacted to restraint removal due to his level of sedation from HALDOL medication.

The CNO was interviewed 5/24/23 beginning at 2:00 PM and Patient #4's medical record was reviewed in her presence. When asked about least restrictive interventions being utilized she confirmed the documentation did not follow CAH policy. She stated restraint removal should have been attempted and least restrictive measures should have been attempted when Patient #4 was sleeping.

The CAH failed to use least restrictive alternatives to manage Patient #4's behavior.

2. Patient #4's medical record did not included orders for documented chemical restraints.

A CAH policy titled "Restraints / Seclusion Standards" dated 8/11/2020, stated, "A physician or LIP order should be obtained using the 'physician restraint order form' and should include:

a. Date/time of the order
b. Type of restraint/seclusion to be used
c. Reason for the restraint
d. Release/removal criteria
e. Time limit of restraint."

This policy was not followed examples include:

Patient #4 was a 16 year old male who presented to the emergency department on 4/26/23 with his friend with the chief complaint of possible overdose. Patient #4 was evaluated and recommended for inpatient psychiatric treatment. Patient #4 was subsequently signed out AMA from the ED by his parents on 5/01/23 while waiting for inpatient bed placement.

Patient #4's medical record included a note from the paramedic on 4/27/23 at 6:23 PM it stated: "Physician explained to pt that if he remained cooperative and calm restraints could be removed. Pt agreed. Restraints were removed and pt immediately slid his body to end of the bed an got up, stating (using explicit terms) that he was going to leave. Pt was still unsteady on feet and unable to walk or stand without assistant. Pt was instructed to return to bed. Pt became agitated and threatened to cause harm to personnel. [ED Physician] and I had to use reasonable force to get pt back into bed. Personnel had to assisted [sic] and law enforcement was called back to hospital."

6:34 PM a note included: "HALDOL [sedative medication used as chemical restraint] IM 5mg given. Given in the left deltoid [upper arm].

6:44 PM a note documented by an RN included: "HALDOL IM 5mg given. Given in the right ventral gluteus.

Patient's medical record did not include the 2 chemical restraint orders for the HALDOL IM 5mg.

The CNO was interviewed 5/24/23 beginning at 2:00 PM and Patient #4's medical record was reviewed in her presence. When asked for the orders for the chemical restraint of the HALDOL 5mg on 4/27/23 at 6:34 PM and 6:44 PM she stated there was no documentation of an order from the physician. She confirmed the "physician restraint order form" should be utilized for chemical restraints.

The CAH failed to ensure orders for chemical restraints were documented in the medical record.

3. The CAH failed to ensure documentation of reevaluation and continued need for restraint from the physician of Patient #4 was in the medical record.

Patient #4 was a 16 year old male who presented to the emergency department on 4/26/23 with his friend with the chief complaint of possible overdose. Patient #4 was evaluated and recommended for inpatient Psychiatric treatment. Patient #4 was subsequently signed out AMA from the ED by his parents on 5/01/23 while waiting for inpatient bed placement.

A CAH policy titled "Restraints / Seclusion Standards" dated 8/11/2020, stated: under the section regarding ordering of restraints for violent or self-destructive behavior it included: "At the end of the time frame, if the continued use of restraint to manage violent or self-destructive behavior is deemed necessary based on individualized patient assessment, another order is required ...When the physician or LIP renews an order or writes a new order authorizing the continued use of restraint, there must be documentation in a patients' medical record that describes the findings of the physician's or LIP's reevaluation supporting the continued use of restraint." This policy was not followed. An example includes:

Patient #4's medical record included a "Physician restraint order form." The form included physician restraint order on 4/27/23 at 5:20 PM and 7 separate renewal orders documented every 2 hours beginning on 4/27/23 at 18:23 through 4/28/23 at 6:23 AM.

Patient #4's medical record included a restraint form that documented vital signs and assessment for Patient #4 every 15 min. Beginning on 4/27/23 at 7:08 pm through 4/28/23 at 4:53 AM, a period of 9 hours and 45 minutes, Patient #4 was documented as sleeping and in restraints. Under the section titled "clinical justification" for the need for restraint it was marked as "other" with hand written note of "pt sedated / state of mind unknown.' Patient #4's medical record did not include attempted least restrictive alternatives were attempted for 9 hours and 45 minutes while patient #4 was in the restraints.

There was no documentation in Patient #4's medical record from the physician a reevaluation supporting the continued use of restraints.

The CNO was interviewed 5/24/23 beginning at 2:00 PM and Patient #4's medical record was reviewed in her presence. She confirmed there was no specific physician documentation documenting continued need for restraint. She confirmed CAH policy was not followed regarding restraint renewal orders.

The CAH failed to ensure documentation for Patient #4's continued need for restraint was in Patient #4's medical record.

4. The CAH failed to ensure restraints were not used as PRN.

Patient #4 was a 16 year old male who presented to the emergency department on 4/26/23 with his friend with the chief complaint of possible overdose. Patient #4 was evaluated and recommended for inpatient Psychiatric treatment. Patient #4 was subsequently signed out AMA from the ED by his parents on 5/01/23 while waiting for inpatient bed placement.

A CAH policy titled "Restraints / Seclusion Standards" dated 8/11/2020, stated, "Staff cannot discontinue a restraint intervention and then restart it under the same order. This would constitute a PRN order. A 'trial release' constitutes a PRN use of restraint and therefore is not permitted.

On 4/27/23 at 5:20 PM Patient #4's medical record included a note from a Paramedic working in the ED. The note included, "Code Gray called from inside other patients room. Entered pt's room to find pt. demonstrating aggressive behavior and screaming profanities at EMS personnel, physician and other RN and they were attempting to restrain pt. [ED Physician] verbally ordered soft restraints to be applied."

At 5:47 PM the note from the Paramedic included that arm restraints were moved below Patient #4's waist.

At 6:23 PM the note from the paramedic included, "Physician explained to pt that if he remained cooperative and calm restraints could be removed. Pt agreed. Restraints were removed, and pt. immediately slid his body to end of the bed and got up, stating (using explicit terms) that he was going to leave. Pt was still unsteady on feet and unable to walk or stand without assistant. Pt was instructed to return to bed. Pt became agitated and threatened to cause harm to personnel. [ED Physician and I had to use reasonable force to get pt back into bed. Personnel had to assisted[sic] and law enforcement was called back to hospital." There was no new order in the medical record for the reapplication of restraint after removal.

Patient #4's medical record included a "Physician restraint order form." The form included physician restraint order on 4/27/23 at 5:20 PM, there was a hand-written note that stated, "restraints removed at 1820 [6:20 PM] pt. became quickly aggressive and had to reapply them." There was no signature on this note and it was unclear who wrote the note.

The CNO was interviewed on 5/24/23 beginning at 2:00 PM and Patient #4's medical record was reviewed in her presence. She confirmed that there should have been a new "physician restraint order" form and reapplication of restraints under the same order does not follow policy.

The CAH failed to ensure restraints orders were not PRN.


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5. It was unclear if sufficient treatment and diagnostic testing was provided for presenting symptoms for patients arriving in the ED.

a. According to Nationwide Children's Hospital, accessed 5/30/23, "During pregnancy, you might feel lightheaded or dizzy. There are a couple of reasons why this can happen. Your blood pressure is lower. Plus, your growing uterus can press on and block the large vein carrying blood to your heart. In either case, this reduces the blood supply in your brain. Low blood sugar and low iron can also be factors."

Patient #2 was a 26 year old pregnant female who presented to the ED on 5/16/23 with a chief complaint of dizziness. Her record stated, "26-year-old female presents to the emerged [sic] department by private vehicle with chief complaint of dizziness. Patient reports she was at work ... when she felt lightheaded and had difficulty with mentation. Patient reports these symptoms have resolved. She does report slight headache at this time. Patient is 5 months pregnant." The section titled, "PROGRESS AND PROCEDURES" was left blank. Patient #2 was discharged from the ED without treatment.

According to the ED log, Patient #2 arrived at 13:31, was triaged at 14:07, and was discharged at 14:23. Her total time from triage to departure was 16 minutes.

The ED physician who treated Patient #2 was interviewed by phone on 5/24/23 beginning at 10:05 AM and Patient #2's record was reviewed with him. When asked why there was no assessment of Patient #2's unborn baby, including fetal heart tones, he stated there wouldn't be any need for that since she had no bleeding, pain or cramping. When asked why there was no lab draw or blood glucose assessment, he stated Patient #2 was eating and drinking, and if she was hypoglycemic, she would show symptoms. He stated there would have been nothing useful if labs and or blood glucose were drawn on Patient #2.

b. A CAH policy titled "Triage," approved 7/12/22 stated, "the triage nurse should determine the following information during the triage assessment: ... vital signs which include ... respiration rate, oxygenation." This policy was not followed. An example includes:

Patient #7 was a 21 month old male who presented to the ED on 4/16/23 with chief complaint of cough and fever.

Patient #7's medical record was reviewed. The clinical assessment portion of the record was 2 paragraph addendum documented by the CAH RN and the ED Physician. An addendum by the ED physician which stated, "21-month-old male presents to the emergency department brought in by mother and father with chief complaint of cough and fever. They report the symptoms started recently. Parents report that they were instructed to come to this emergency department for initial work-up after having discussions with their oncology team ... They stated they want to make sure that patient was breathing adequately for transfer to Sacred Heart which is their primary goal ... On exam patient is breathing comfortably in the emergency department lobby. He has no retractions ... Patient appears stable to continue onto their primary location of Sacred Heart. Parents decline additional evaluation at this CAH and will have the full work-up performed at Sacred Heart when they get there." There was an additional addendum by the Paramedic which stated, "Mother stated that pt had been making some grunting noises occationally [sic] when breathing after coughing ... Stated oncologist was concerned about grunting noises. Pt appeared to have ronchi cough, no obvious grunting noises or signs of respiratory distress."

According to the ED log, Patient #7 arrived at 16:05. There was no triage time. The departure time was 16:12. Patient #7's total time spent in the ED from check-in to departure was 7 minutes.

There was no workup of Patient #7. There was no assessment of vital signs, including respiratory rate and oxygen level.

The ED physician who treated Patient #7 was interviewed by phone on 5/24/23 beginning at 10:05 AM and Patient #7's record was reviewed with him. When asked why there was no workup of Patient #7 he stated the family wanted workup at a different hospital. When asked why there were no vital signs he stated, "I don't have the answer." When asked if the respiratory assessment would include vital signs he stated, "yes often times that does."

c. Patient #21 was a 14 year old male who presented to the ED on 12/06/22 with a chief complaint of cough and wheezing.

Patient #21's medical record included a note from the ED physician which stated, "Course of care: ( Patient's [sic] had cough for the last 2 to 3 days. No fever, chills, vomiting, diarrhea. Patient appears well. Lungs are clear to auscultation bilaterally on exam. Patient likely has a benign process. Patient's had multiple sick contacts at school. Mother notes that other children at school had had about [sic] RSV [respiratory syncytial virus]. All questions answered mother prior to discharge. She agrees with discharge plan.). [sic]" There was no treatment or diagnostics for Patient #21 to treat or determine the cause of his cough, and Patient #21 was discharged.

According to the ED log, Patient #21 arrived at 21:12, was triaged at 21:14, and was discharged at 21:32. His total time from triage to departure was 18 minutes.

The ED physician who treated Patient #21 was interviewed by phone on 5/24/23 beginning at 10:05 AM and Patient #21's record was reviewed with him. When asked why he would not test Patient #21 for RSV due to having an RSV exposure, he stated the test result would not change anything for the patient.

d. Patient #16 was a 16 year old female who presented to the ED on 4/14/23 with a chief complaint of chest pain.

Patient #16's medical record included a note from the ED physician which stated, "16-year-old female presents to the emerged [sic] department by private vehicle brought in by father with chief complaint of chest pain. Patient reports she has had ongoing chest pain for the last 2 days ... Physical exam patient appears well. No acute distress resting comfortably in bed sitting upright. She is breathing normally and speaking in full sentences. No retractions. She had generalized tenderness to her chest wall with palpation ... Patient likely has a benign process for her chest discomfort." There was no treatment or diagnostics for Patient #16 to treat or determine the cause of her chest pain, and Patient #16 was discharged.

According to the ED log, Patient #16 arrived at 18:49, was triaged at 18:55, and was discharged at 19:15. Her total time from triage to departure was 20 minutes.

The ED physician who treated Patient #16 was interviewed by phone on 5/24/23 beginning at 10:05 AM and Patient #16's record was reviewed with him. When asked why no diagnostics or treatment were done for Patient #16 he stated testing and diagnostics were not needed. He stated it would be different if it was an older male presenting with chest pain.

It was unclear if the above patients were provided sufficient diagnostics and treatments for their presenting symptoms.

6. LPN's in the ED were not functioning in a dependent role.

Idaho Board of Nursing Rules 24.34.01.002.15, stated the following: "Licensed practical nurses function in dependent roles. The stability of the patient's environment, the patient's clinical state, and the predictability of the outcome determine the degree of direction and supervision that must be provided to the licensed practical nurse." This state statute was not followed, an example includes.

A CAH policy titled "Triage" with and approval date of 7/12/2022, included that the responsibility of ED triage was that of the ED RN, Med/surg RN, LPN, and Paramedic. The policy did not include how the LPN would function in a dependent role during the triage assessment. Additionally, the policy did not include a delegation model for the LPN on what the LPN can do within their scope.

Patient #26 was a 41 year old female who arrived to the ED on 12/22/22 with a chief complaint of suicidal. Her Triage assessment was performed by an LPN. There was no documentation in the record of either the physician or RN on duty reviewing her assessment and agreeing with her findings.

The CNO was interviewed 5/24/23 beginning at 2:00 PM. When asked who can perform triage she stated, "I believe just RN's." When asked if LPN's perform triage she stated she did not know. Patient #26's medical record was reviewed in her presence and she stated that she spoke with the CAH's Accrediting Organization and they said it was up to state of Idaho Statute. The CNO stated she was unable to find state rules defining LPN's role. Idaho State Statute was reviewed with the CNO and she confirmed triage assessment in the ED is outside of the LPN's role.

It was unclear how the LPN was functioning within their scope of practice.