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Based on staff interview, review of medical records, and review of policies the facility failed to implement a plan to ensure all patients received care in a safe setting following an incident in which a patient was tased. This included one of 13 medical records reviewed (Patient 2). The facility had a census of 213 at the time of the survey.

Finding include:

The medical record for Patient 2 was reviewed on 12/13/11. The patient was admitted to the facility on 08/04/11 for an involuntary admission to the behavioral health unit. The patient had diagnoses of inappropriate behavior, paranoid thoughts, non-compliance with medications, and a long history of Bipolar disorder. Patient 2 was tasered by security on 08/05/11. The nurses notes documented on 08/05/11 at 3:00 PM that the patient continued to be agitated, refusing to leave the nurses station, and demanding to leave the unit. Security was called for assistance through notification of a Code Violet. The patient began screaming, became physically aggressive, and began fighting with the security staff. Additional security was notified. The patient was thrashing around the office and was unable to be re-directed. The patient was screaming, yelling, and attempting to escape. The patient's aggressive behavior continued. The patient continued to be combative with security. Additional security arrived. The staff requested the patient calm down, but the patient continued to be non-directable, uncooperative, combative, thrashing about the office, screaming, and crying. The staff requested that security subdue the patient for his/her own safety. Security asked the patient to be still, but the patient continued to struggle and attempt to escape the hold of security. The patient was tasered in the back to subdue him/her.

Please refer to A144 for additional information.

Based on observation, interview, and medical record review the facility failed to provide patient rights in a language each patient can understand and failed to post and/or provide the state agency's complaint hotline number in the emergency department. This affected Patient #10 and #14 and all patients and family who come to the facility's emergency department. The sample size was 13 patients, and the census was 213 patients.

Findings include:

On 11/14/11 at 11:20 A.M. the surveyor, Staff B and Staff W conducted a tour of the emergency department. The surveyor was unable to find where the complaint hotline number for the state agency was either posted or provided to patients. Staff B and Staff W were unable to locate the complaint hotline number to the state agency

The medical record review for Patient #10 was completed on 12/14/11. The review revealed the patient was admitted to the facility on 11/30/11 with a diagnosis of osteoarthritis and complications.

On 12/14/11 at 3:20 P.M. the surveyor attempted to interview Patient #10, but the patient only spoke Spanish. The surveyor was able to interview the patient with Staff J, a Spanish-speaking nurse. Through Staff J, Patient #10 said he/she couldn't remember receiving her/his rights in Spanish, but would like to have them in Spanish. On 12/14/11 at 3:20 P.M. in an interview, Staff J didn't know where to find patient rights in Spanish on the floor.

On 12/14/11 at 3:20 P.M. in an interview, Staff O said he/she didn't have any rights in Spanish in the clinical area and in an interview, Staff B said he/she didn't know why the rights in Spanish were not on the floor.

On 12/14/11 at 3:45 P.M. the surveyor went to a different clinical area to determine whether the staff could locate patient rights in Spanish. Staff P, Q, and R were unable to locate patient rights in Spanish.

The medical record review for Patient #14 was completed on 12/14/11. The medical record review revealed the patient was admitted to the facility on 12/13/11 with a fracture to the right wrist.

On 12/14/11 in the early afternoon in an interview Staff O said after talking with the patient, the patient told her she had not received her patient rights, but would like to have them.

Based on interview and medical record review, the facility failed to ensure each patient's advance directive information was made known to clinical staff. This affected one of 13 sampled patients, Patient #9. The facility's census was 213 patients.

Findings include:

The medical record review for Patient #9 was completed on 12/14/11. The review revealed the 75-year-old patient was admitted to the facility on 12/12/11 with diagnoses of acute symptomatic bradycardia. The review revealed a history and physical dictated on 12/12/11 that stated the patient had diabetes and atrial fibrillation and presented with a symptom of dizziness for the last two days.

The medical record review revealed a sheet entitled "Advance Directive Information." The sheet stated: "I have an Advance Directive and am now providing a copy to the hospital for placement in my chart." The box for yes was marked, and the line for living will and durable power of attorney were both marked. The review did not reveal either in the clinical record.

On 12/14/11 at 3:10 P.M. in an interview, Staff T-the nurse who was attending to the patient that day-was asked what the patient's code status was. He/she said he/she was a full code. He/she was asked whether the patient had any advance directives. He/she looked into the chart, found the sheet entitled "Advance Directive Information" and stated he/she did. When asked where they were or what they said, he/she was unable to locate them in the medical record, and said they should have been behind the sheet entitled "Advance Directive Information." He/she said he/she "knew" the patient, and just knew from working with him/her he/she would want to be a full code-i.e, have everything done for him/her.

Based on staff interview, review of medical records, and review of policies the facility failed to implement a plan to ensure all patients received care in a safe setting following an incident in which a patient was tased. This included one of 13 medical records reviewed (Patient 2). The facility had a census of 213 at the time of the survey.

Findings include:

On 12/13/11 at 10:28 AM, the Risk Manager (Staff A) and the Quality Manager (Staff B) were interviewed. Staff B stated the facility was in the process of conducting de-escalation training so that security officers and nurses had a common language, early recognition of the signs of escalation behavior, and were familiar with the types of restraints. This training started in September and is known as NAPPI (Non-Abusive Psychological and Physical Intervention).

The medical record for Patient 2 was reviewed on 12/13/11. The patient was admitted to the facility on 08/04/11 for an involuntary admission to the behavioral health unit. The patient had diagnoses of inappropriate behavior, paranoid thoughts, non-compliance with medications, and a long history of Bipolar disorder. The nurses notes documented on 08/05/11 at 3:00 PM that the patient continued to be agitated, refusing to leave the nurses station, and demanding to leave the unit. Security was called for assistance, a Code Violet. The patient began screaming, became physically aggressive, and began fighting with the security staff. Additional security was notified. The patient was thrashing around the office and was unable to be re-directed. The patient was screaming, yelling, and attempting to escape. The patient's aggressive behavior continued. The patient continued to be combative with security. Additional security arrived. The staff requested the patient calm down, but the patient continued to be non-directable, uncooperative, combative, thrashing about the office, screaming, and crying. The staff requested that security subdue the patient for his/her own safety. Security asked the patient to be still, but the patient continued to struggle and attempt to escape the hold of security. The patient was tasered in the back to subdue him/her. The physician was present and removed the taser prongs. The areas were cleansed with alcohol and bandaids applied. The patient was given an antipsychotic medication by injection at 2:50 PM. The patient continued to be aggressive and was given an anti-anxiety medication by injection to calm him/her at 3:00 PM. The patient was then restrained per the physician's order.

The facility's investigation of the tasering event on 08/05/11 was reviewed on 12/14/11. The facility determined the staff and security acted in compliance with the facility's policies. Three areas for improvement were identified. First, a Process Improvement Team was established including Behavioral Health Staff and Security to review and update departmental policies and to educate the staff. Second, all security and Behavioral Health Staff were to be trained in the NAPPI (Non-Abusive Psychologic and Physical Intervention) program to provide a common language and equip the staff with tools to recognize and de-escalate patients. Third, a Crisis Intervention Team was to be established to respond to events and assist in de-escalation as well as provide patients with an advocate.

The Show of Support policy, the Crisis Intervention Team policy, and the Code Violet policy were reviewed on 12/14/11. The policies stated that the role of security was that of a caregiver or partner in recovery and work under the direction of a physician or a nurse. The use of handcuffs, or weapons such as pepper spray, mace, night sticks, or electric restraint devices such as stun guns and tasers are prohibited. These policies defined a Show of Support as a call placed by nursing staff to assist with maintaining safety and restore calm. The Crisis Intervention Team was defined as a team of NAPPI (Non-Abusive Physical and Psychological Intervention) trained hospital employees who respond to a call in order to assist the care team in restoring calm and restraint techniques. A Code Violet was defined as a call to alert the Crisis Intervention Team, hospital security, hospital leadership, and the staff of a dangerous patient event, or if the patients behavior escalates to a dangerous or threat of lethal level. The Crisis Intervention Team policy and the Code Violet policy stated that clinical staff would determine the need for a Crisis Intervention. A team leader would be designated to be in charge of the crisis response, and to determine what would be done to restore calm using the least restrictive measures. The hospital administration would respond as the patient advocate. The team leader would determine if/when the situation escalates to the level of a Code Violet. Once the team leader determines that all least restrictive and health care interventions have failed and the escalation exceeds a level of dangerous behavior then the team leader will announce that "this is now a police action." Security would then provide the appropriate level of intervention for the behavior displayed.

On 12/14/11 at 4:30 PM, the Lead Officer for Second Shift (Staff D) and the Director of Supply Chain and Security (Staff U) were interviewed. On the rest of the hospital units, security will ask the clinicians what is happening and what is needed, but can work "independently" in determining when to initiate police measures as the rest of the hospital has not had the training and the Behavioral Health unit has special rules.

On 12/15/11 at 8:50 AM, Staff C was interviewed. Staff C is the primary trainer for NAPPI. Staff C stated the Code Violet policy and the Crisis Intervention Team would go into effect on 01/31/12. The emergency room and intensive care staff will be trained on NAPPI from 01/01/12 through 03/31/12, then the rest of the hospital will be trained. The goal is to have everyone trained by mid to late October, but definitely by the end of 2012.

On 12/15/11 at 1:30 PM, Staff M was interviewed. Staff M stated the security staff always take direction from the clinical staff when responding to a call, and if his/her supervisor is present, follows the security supervisor's instructions as well.

Two registered nurses (Staff H and I) from the emergency room were interviewed on 12/14/11. Both nurses had been to NAPPI training but could not relay that the security needed to be told that this was a police action to differentiate between clinical or law enforcement control. Staff H stated the goal of the NAPPI training was to provide a kinder and gentler and restraint free environment. Staff I stated the goal of the NAPPI training was to be more gentle and increase patient safety. Neither staff mentioned non-violence as the goal.

These findings substantiate complaint number OH00062781.

Based on interview, clinical record review, and policy review, the facility failed to implement the use of restraint in accordance with its own policy, specifically, ensuring each restraint order for Patient #3 was timed and indicated the type of restraint to be used, and ensuring Patient #4 was checked every two hours for proper circulation to restrained limbs. The facility census was 213 patients and the sample size was 13 patients.

Findings:

The medical record review for Patient #3 was completed on 12/14/11. The record revealed the patient was admitted to the facility on 12/06/11 with diagnoses of foreign body in the airway and pneumonia. The record revealed a nursing note dated 12/06/11 at 11:55 P.M. that state the patient was placed in soft wrist restraints. The record did not explain why the patient was restrained, or what least restrictive methods had been applied prior to the application of soft wrist restraints.

The medical record review revealed a physician's order for restraint dated 12/10/11 without a time and without the kind of restraint to be employed listed.

The medical record review revealed a physician's order for left soft wrist restraint because less restrictive interventions had been determined to be ineffective. The order was dated for 12/11/11 without a time.

On 12/14/11 a review of the facility's restraint policy titled, "Physical Restraint Policy, " number 600.108 was completed on 12/14/11. The policy stated documentation of the restraint order included date and time order received and type of restraint.

The medical record review revealed nursing documentation dated 12/08/11 that stated at 4:00 P.M. the patient was released from her/his restraint.

The record review revealed a nursing note dated 12/08/11 at 8:00 P.M. that stated: "Restraints not tied at this time."

The medical record review revealed a nursing note dated 12/09/11 at 1:00 A.M. that stated: "Restraints on." The medical record review did not reveal an order to reapply the restraint.

On 12/14/11 a review of the facility's restraint policy titled, "Physical Restraint Policy, " number 600.108 was completed on 12/14/11. The policy stated: "With every reapplication of restraint, a physician order is required."

The medical record review for Patient #4 was completed on 12/14/11. The clinical record review revealed the 61-year-old patient was admitted to the facility on 12/09/11 with diagnoses of exacerbation of chronic obstructive pulmonary disease.

The medical record review revealed a physician's order dated 12/12/11 at 11:30 A.M. to place the patient in bilateral wrist restraints because less restrictive interventions had been determined to be ineffective. The record review revealed a nursing flow sheet dated from 12/12/11 at 7:00 P.M. to 12/13/11 at 6:00 A.M. The flow sheet stated at 7:00 P.M. the patient was in restraints; the flow sheet does not indicated where, while in restraints, the patient was checked every two hours for, among other things, proper application of the restraint and blood flow to the restrained limbs.

On 12/14/11 a review of the facility's restraint policy titled, "Physical Restraint Policy, " number 600.108 was completed on 12/14/11. The policy stated the medical record is to have documentation for checking the proper application of the restraint every 30 minutes, and the checking of the blood flow to the restrained limbs every two hours.

The policy stated: "With every reapplication of restraint, a physician order is required."

The policy stated documentation of the restraint order included date and time order received and type of restraint.

On the afternoon of 12/13/11 in an interview both Staff V and B confirmed the medical record stated Patient #3 had restraints applied, removed, and reapplied without obtaining a physician's order to reapply the restraint. They confirmed not all physician orders for restraints contained the time and type of restraint. They confirmed Patient #4's medical record did not indicate from 12/12/11 at 7:00 P.M. to 12/13/11 at 6:00 A.M. when the patient was restrained that the restraints were checked for proper application or blood flow to the restrained limbs was checked every two hours.