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Based on interview and record review, the hospital failed to provide care in a safe setting when utilizing the hospital's security staff for patients that displayed aggressive behaviors. This failure resulted in a fractured hip for Patient #6 after he was "tackled" to the floor, Patient #5 who was put in four point restraints and medicated, and Patient #2 who was forcibly made to sit on his bed after he was told to do so, but did not. (A144) The failure to provide care in a safe setting resulted in a determination of immediate jeopardy.

See A129, A130, A144, A164, A165, A168, and A187

Based on interview and record review, the hospital violated a patient's right to refuse care and admission to the facility and the right to be free from restraints used as a means of coercion and/or discipline when she refused to take medication and would be released based on her "attitude". This affected one (Patient #5) of 11 sampled patients. The census was 361 patients.

Findings include

Record review for Patient #5 revealed the 22 year old patient presented to the emergency room with a history of endocarditis, stroke, mitral and tricuspid valve replacement, and intravenous (IV) drug abuse. The medical record review revealed she presented to the hospital with a complaint of two weeks of urinary incontinence.

The medical record review revealed nursing assessed the patient as alert and oriented on 03/03/18 at 2:56 P.M. A physician note at 5:16 P.M. that stated the patient was alert and oriented to person, place and time. Another nursing note at 7:40 P.M. stated the patient was alert and oriented. A nursing note at 8:03 P.M. that stated the patient refused to answer any nursing admission assessment questions and did not want to stay in the hospital that night as "she just wants to eat and sleep." The nursing note documented the patient was educated that if she wanted to leave, she must sign out against medical advice. The note continued that a physician then interviewed the patient and told her he could not let her leave the hospital.

Patient #5's record contained an application for emergency admission dated 03/03/18 at 9:00 P.M. that stated the patient was forcibly admitted because "Patient adamantly refuses physical examination, labs or any kind of imaging .....Unable to evaluate capacity as patient repeatedly refuses physical exam, labs, or any kind of intervention ....Pt has been yelling at nursing staff, residents. Has refused to talk with anyone."


There was a physician order dated 03/04/18 at 12:13 A.M. for the patient's wrists and ankles to be restrained to prevent removal of vital equipment or therapies. The medical record review did not reveal what that vital equipment or therapy was.

A nursing note dated 03/04/18 at 12:23 A.M. documented three nurses and security held the patient down and restrained both her arms and legs to her the bed. At 8:10 A.M. the patient demanded to be released from restraints and did not understand why she had been forcibly admitted to the facility. At 9:49 A.M. a nursing note stated if the patient takes a medication (Zyprexa) and cooperates, the restraints would be removed. At 1:56 P.M., a nursing note stated the patient had demonstrated a "cooperative attitude" long enough for restraints to be removed.

During interview on 05/02/18 at 12:30 P.M., Staff A confirmed the above findings.

Review of the hospital patient rights revealed patients have the right to refuse care, treatment, or services after being informed of the consequences of such refusal. Patients have the right be free from restraint or seclusion of any form not necessary for health or safety, which are used as a means of coercion, discipline, convenience, or retaliation by staff.

Based on interview and record review, the facility failed to allow a patient to participate in deciding whether to be admitted to the hospital, in deciding what medication not to take, and in how to use the bathroom. This affected one (Patient #5) of 11 sampled patients. The census was 361 patients.

Findings include:

Record review for Patient #5 revealed the 22 year old patient presented to the emergency room with a history of endocarditis, stroke, mitral and tricuspid valve replacement, and intravenous (IV) drug abuse. The medical record review revealed she presented to the hospital with a complaint of two weeks of urinary incontinence.

The medical record review revealed nursing assessed the patient as alert and oriented on 03/03/18 at 2:56 P.M. A physician note at 5:16 P.M. that stated the patient was alert and oriented to person, place and time. Another nursing note at 7:40 P.M. stated the patient was alert and oriented. A nursing note at 8:03 P.M. that stated the patient refused to answer any nursing admission assessment questions and did not want to stay in the hospital that night as "she just wants to eat and sleep." The nursing note documented the patient was educated that if she wanted to leave, she must sign out against medical advice. The note continued that a physician then interviewed the patient and told her he could not let her leave the hospital.

Patient #5's record contained an application for emergency admission dated 03/03/18 at 9:00 P.M. that stated the patient was forcibly admitted because "Patient adamantly refuses physical examination, labs or any kind of imaging .....Unable to evaluate capacity as patient repeatedly refuses physical exam, labs, or any kind of intervention ....Pt has been yelling at nursing staff, residents. Has refused to talk with anyone."

There was a physician order dated 03/04/18 at 12:13 A.M. for the patient's wrists and ankles to be restrained to prevent removal of vital equipment or therapies. The medical record review did not reveal what that vital equipment or therapy was.

A nursing note dated 03/04/18 at 12:23 A.M. documented three nurses and security held the patient down and restrained both her arms and legs to her the bed. at 8:10 A.M., the patient demanded to be released from restraints and did not understand why she has been forcibly admitted to the facility. At 9:49 A.M. a nursing note stated if the patient takes a medication (Zyprexa) and cooperates, the restraints would be removed. At 9:55 A.M., the patient wanted to sit on the toilet to void. The note stated the nurse refused to allow the patient to use the toilet but to use a bed pan instead. At 1:56 P.M., a nursing note stated the patient had demonstrated a "cooperative attitude" long enough for restraints to be removed.

During interview on 05/02/18 at 12:30 P.M., Staff A confirmed the above findings.

Review of the hospital patient rights revealed patients have the right to refuse care, treatment, or services after being informed of the consequences of such refusal. Patients have the right be free from restraint or seclusion of any form not necessary for health or safety, which are used as a means of coercion, discipline, convenience, or retaliation by staff.

Based on interview and record review, the facility failed to provide a safe setting regarding the use of physical force when utilizing the hospital's security staff for patients that displayed aggressive behaviors. This affected three (Patients #2, #5 and #6) of 11 sampled patients. The census was 361 patients.

Findings include:

1. Medical record review for Patient #6 revealed the 31 year old patient came to the emergency department on 04/13/18 at 1:35 A.M. by ambulance for a chief complaint of multiple seizures. The patient was non-compliant with his/her anti-seizure medication, had a history of traumatic brain injury from a gunshot wound in 2007 and was blind.

A nursing note dated 04/13/18 at 1:47 A.M. documented the patient was alert with non-sensical speaking and combative with ambulance staff. The note also revealed the patient was agitated when the nurse took his/her vital signs, but calmed quickly. Patient #6 was admitted to a medical floor on 04/13/18 at 5:36 A.M. On 04/18/18, a nursing note timed at 7:46 P.M. documented at approximately 7:00 P.M. the patient was observed in the doorway yelling. There was no documentation that nurse attempted to assess the behavior to determine the cause and no documentation that a "code violet" was called.

Review of an incident report dated 04/18/18, presented by Staff F, revealed Staff G, a member of the nursing staff, stated he/she assisted the patient to the bathroom, but the patient walked to the hallway and would not be redirected to go back into the room. According to the report, Staff G stated he/she told fellow staff to call security because "it's about to get ugly". He/she said when security came it "appeared" the patient attempted to hit the officer and that officer plus three others and two male staff members "tackled" the patient to the ground, then placed him/her into bed.

Nursing notes documented on 04/21/18 at 11:02 A.M. the patient complained his/her right leg and hip were tender, and on 04/21/18 at 2:32 PM, an X-ray revealed a fracture to the right femur.

Staff J stated during interview on 04/26/18 at 3:17 P.M. the events on the evening of 04/18/18 could not be ruled out as causing the fracture to Patient #6.

During interview on 04/26/18 at 3:45 P.M., Staff H said he/she was the lone responding security officer to the incident with Patient #6. He/she stated the patient was found in the doorway of his/her room with his/her shirt off and muttering incoherently. He/she stated he/she saw the patient and Staff I, a member of the nursing staff, conversing in the hall. Staff H stated he/she approached the patient and attempted to guide the patient back into his/her room. He/she said when he/she touched the patient, he/she "came at me real fast"-he/she described it as a "trigger". Staff H stated he/she and one other staff member took the patient to the ground until the patient became tired. Then, after the patient became tired, the patient was placed into his/her bed and had both arms and legs restrained.

During interview on 04/27/18 at 5:32 P.M. Staff F confirmed a code violet had not been called during the incident with Patient #6.

The hospital policy titled "Code Violet", revealed code violet is the response by the facility to any behavioral situation that is or could pose a threat to others and assist the acting out person in maintaining control. When the code is called, designated staff from the psychiatric units, the emergency department, other trained personnel, and all available security personnel are to go to the area immediately.

2. Record review for Patient #5 revealed the 22 year old patient presented to the emergency room with a history of endocarditis, stroke, mitral and tricuspid valve replacement, and intravenous (IV) drug abuse. The medical record review revealed she presented to the hospital with a complaint of two weeks of urinary incontinence.

A nursing note dated 03/03/18 at 8:03 P.M. that stated the patient refused to answer any nursing admission assessment questions and did not want to stay in the hospital that night as "she just wants to eat and sleep." The nursing note documented the patient was educated that if she wanted to leave, she must sign out against medical advice. The note continued that a physician then interviewed the patient and told her he could not let her leave the hospital.

Patient #5's record contained an application for emergency admission dated 03/03/18 at 9:00 P.M. that stated the patient was forcibly admitted because "Patient adamantly refuses physical examination, labs or any kind of imaging .....Unable to evaluate capacity as patient repeatedly refuses physical exam, labs, or any kind of intervention ....Pt has been yelling at nursing staff, residents. Has refused to talk with anyone."

A nursing note dated 03/04/18 at 12:23 A.M. stated the patient backed two nurses out of the room. The note continued to say three nurses and security held the patient down and restrained him/her to the bed. The note further stated that two nurses and security held the patient down to give him/her an injection of a sedative to "calm" him/her down. The physician progress note dated 03/04/18 at 12:38 A.M. documented the patient pushed three nurses out of the room and slammed the door on them. There was no documentation a "code violet" was called.

3. Record review revealed Patient #2 was admitted to the facility on 02/19/18 for infection of his/her upper right arm. On 02/21/18 at 1:35 A.M. a registered nurse (RN) documented that Patient #2's intravenous (IV) line appeared to be infiltrated after finishing a dose of IV Vancomycin (medication used to treat bacterial infections). The RN told Patient #2 that he/she would be right back, he/she had to finish something with another critical patient and then he/she would be back to place a new IV. According to documentation, about 30 minutes later, Patient #2 "storms" into hallway demanding a new IV stating that he/she has been waiting for hours and that the RN just let him/her sit there with a bad IV. The RN documented he/she calmly explained to Patient #2 that he/she was with another patient but is here now and willing to put in a new IV to make Patient #2 more comfortable. Patient #2 began to raise his/her voice and become agitated at this time. According to documentation, the RN called security for assistance and safety. Patient #2 "ripped" the covers off of the bed and stood up "lunging" at the RN and security guard. According to documentation the security guard asked Patient #2 to sit back down and when Patient #2 refused, the security guard placed his/her hands on Patient #2's shoulders and forcibly sat Patient #2 down on the bed. Additional security arrived and a code violet was called.

Documentation stated on 02/21/18 at 1:35 A.M. Patient #2 demanded to leave against medical advice (AMA) and the patient "ripped" out his IV catheter. Patient #2 refused to sign the AMA paper and was escorted off the unit with all belongings and security, hands-off, walking along side of him/her.

During interview on 04/27/18 at 3:00 P.M., Staff A verified this finding.

Based on observation and interview, the facility failed to apply the least restrictive restraints to patients. This affected three (Patients #6, #5 and #11) of 11 sampled patients. The census was 361 patients.

Findings include:

1. Review of the record for Patient #6 revealed the 31 year old patient came to the emergency department on 04/13/18 at 1:35 A.M. by ambulance for a chief complaint of multiple seizures. The medical record revealed the patient was non-compliant with his anti-seizure medication, had a history of traumatic brain injury from a gunshot wound in 2007 and was blind.

A nursing note dated 04/13/18 at 1:47 A.M. documented the patient was alert with non-sensical speaking and combative with ambulance staff. The note also revealed the patient was agitated when the nurse took vital signs, but calmed quickly. Patient #6 was admitted to a medical floor on 04/13/18 at 5:36 A.M. A physician progress note dated 04/16/18 at 2:35 A.M. stated he tried to close a door on a staff member and resisted going back in his room. The note documented "[Patient] is yelling random phrases nonstop, sitting on his bed in defensive posture. Not answering questions or paying attention to any staff or myself. On 04/16/18 at 1:45 A.M. a nursing note stated "Patient rocking in chair, talking loudly"; at 2:00 A.M. "in bathroom talking"; and at 2:30 A.M. "patient try to slam the door in my face we went down to the ground". A physician progress note at 2:35 A.M. stated, "Will restrain patient 4 limbs, give Haldol 5 mg and Ativan 2 mg intramuscularly now, and may repeat if needed. Patient is danger to self and others."

The medical record revealed Ativan 2 milligrams (mg) intramuscularly and Haldol 5 mg intramuscularly was given on 04/16/18 at 3:00 A.M. At the same time, both wrists and ankles were restrained because the patient would not follow directions and "would/could" not stay in room. Alternatives attempted included verbal de-escalation "(patient cognitively intact); Verbal redirection (patient cognitively impaired)".

Nursing notes dated 04/18/18 at 7:31 P.M. stated at 7:00 P.M. the patient was in his doorway yelling and that both the nurse and tech attempted to get him to stop yelling and go back into his room. The note stated because the patient took a "violent posture," security was called, came, and asked the patient to go back into his room several times. The note stated upon security touching the patient on the arm, the patient became violent. The patient was then placed in bed with both wrists and legs restrained and given Ativan 2 mg. The note concluded, "[Patient] was physically combative several times with security while attempting to get [patient] into bed."

On 04/16/18 at 3:45 P.M. in an interview, Staff H explained he touched the patient on the shoulder which triggered the patient to become violent and he wrestled him to the ground and held him there until he became tired, and then placed him into bed.

On 04/18/18 at 11:00 P.M., nursing notes documented the patient was observed sleeping. At 11:03 PM the physician ordered the patient to have both wrists and ankles restrained to "prevent removal of vital equipment." The vital equipment was not defined. At 11:15 P.M., the nursing notes again documented the patient was observed sleeping. The patient was placed into the restraints at 11:23 P.M.

On 04/19/18 at 5:23 A.M., the record contained a physician order for the patient to have both wrists and ankles restrained for observed violent behavior to self. The restraint was applied at 6:35 AM. On 04/19/18, the nursing notes documented the patient was observed asleep at 5:00 AM, 5:15 AM, 5:30 AM, 5:45 AM, 6:00 AM, 6:15 AM, and 6:30 A.M. At 10:33 AM the patient had both ankles and wrists restrained because he would or could not follow directions and would or could not stay in his room, but the nursing notes documented the patient was asleep at 9:45 A.M., 10:00 AM.,. and 10:15 A.M. At 5:59 P.M. the patient was placed in restraints for observed violent behavior to others. At 6:02 P.M. the patient was yelling out and was violent with security when they asked him to lay down in bed and stop yelling. At 6:08 PM the physician ordered both the patients ankles and wrists restrained for observed violent behavior to others.

On 04/20/18 at 12:15 A.M. the physician ordered both wrists and ankles restrained to prevent "removal of vital equipment". The notes documented at 12:15 A.M. the patient was in restraints for not following directions and staying in the room.

On 04/27/18 at 1:45 P.M. in an interview, Staff J could not show what behaviors was shown, or clinical reason the patient had, to require both wrists and ankles restrained for any of the instances noted above.

2. Record review for Patient #5 revealed the 22 year old patient presented to the emergency room with a history of endocarditis, stroke, mitral and tricuspid valve replacement, and intravenous (IV) drug abuse. The chief complaint was two weeks of urinary incontinence.

Nursing notes dated 03/03/18 at 2:56 P.M. and 7:40 P.M. as well as a physician note at 5:16 P.M., all documented the patient was alert and oriented to person, place and time.

At 8:03 P.M., the nursing notes stated the patient refused to answer any nursing admission assessment questions and did not want to stay in the hospital that night as "she just wants to eat and sleep." The patient was educated that if she wanted to leave she must sign out against medical advice. A physician then interviewed the patient and told her he could not let her leave the hospital.

An application for emergency admission dated 03/03/18 at 9:00 P.M. that stated the patient was forcibly admitted because "Patient adamantly refuses physical examination, labs or any kind of imaging .....Unable to evaluate capacity as patient repeatedly refuses physical exam, labs, or any kind of intervention ....Pt has been yelling at nursing staff, residents. Has refused to talk with anyone."

A physician order dated 03/04/18 at 12:10 A.M. for the patient to be given Haldol 2 mg. At 12:13 A.M., the physician ordered the patient's wrists and ankles to be restrained to prevent removal of vital equipment or therapies. The medical record review did not reveal what that vital equipment was. A nursing note at 12:23 A.M. stated the patient backed two nurses out of the room. Three nurses and security held the patient down and restrained her to her the bed. The note further stated that two nurses and security held the patient down to give her an injection of a sedative (Haldol) to "calm her down." A physician progress note at 12:38 A.M. that documented the patient had pushed three nurses out of the room and slammed the door on them.

Although the physician order for restraints stated the reason for the patient to have both feet and hands restrained was to prevent removal of vital equipment, the medical record review revealed a nursing progress note dated 03/04/18 at 9:49 A.M. stated if she takes a medication and cooperates, the restraints would be removed. A nursing note at 1:56 P.M. stated the patient had demonstrated a "cooperative attitude" long enough for restraints to be removed.

During interview on 05/02/18 at 10:30 A.M., Staff A confirmed the findings.




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3. Review of Patient #11's medical record revealed an admission date of 04/21/18 due to an altered level of consciousness. A nursing progress note dated 04/26/18 at 3:51 A.M. revealed non-violent soft bilateral wrist restraints were placed on the patient, it also stated that they were the least restrictive restraint needed to protect the patient's safety. Review of the interventions that were attempted were alarms, bed in low/locked position, and call light within reach. No documentation was noted of facility staff providing close monitoring, or staff placing a protective dressing over the IV/tube sites.

Review of the policy/procedure titled "Restrain Use Procedure for Non-Violent/Non-Self-Destructive Behavior and Violent Self-Destructive Behavior (ADM 105)" revealed under General Policies/Procedures for All Restraints and Seclusion: The decision to use restraint/seclusion is based on an assessment of the patient by a physician, LIP or RN. Less restrictive interventions must be determined by staff to be ineffective to protect the patient or others from harm prior to the introduction of more restrictive measures (See Appendix A for examples of less restrictive interventions). Under appendix A it shows examples of less restrictive interventions and these include heightened observation, Close monitoring (staff, family, friends): move patient to a more visible area, bed exit alarm; physical intervention for the patient: scheduled ambulation plan, up in chair for meals, protective dressings over IV/tubes sites; etc.

Based on record review and interview, the facility failed to use the least restrictive type or technique of restraint to protect a patient's intravenous access. This affected one (Patient #11) of 11 sampled patients. The census was 361 patients.

Review of Patient's #11's medical record revealed an admission date of 04/21/18 due to an altered level of consciousness. A nursing progress note dated 04/26/18 at 3:51 A.M. revealed non-violent soft bilateral wrist restraints were placed on the patient as the least restrictive alternative to protect the patient's safety. No documentation was noted that a single soft wrist restraint was tried before the bilateral soft wrist restraints were applied.

During interview on 04/27/18 at 2:32 P.M., Staff A stated the facility restraint policy does not allow orders for a single limb to be restrained.

Review of the policy/procedure titled "Restraint Use Procedure for Non-violent/Non-Self-Destructive Behavior and Violent Self-Destructive Behavior" (ADM 107)" revealed one limb restraint, or two point limb restraints on the same side, (both right arm, right le; both left arm, left leg) are not permitted.

Based on record review and interview, the facility failed to ensure staff applied restraints as ordered by a physician. This affected one (Patient #1) of 11 medical records reviewed. This has the potential to affect all patients with restraints ordered. The facility census was 361 patients.

Review of Patient #1's medical record revealed an admission date of 04/25/18 and an admission reason of reported suicidal attempt. A nursing documentation flow sheet dated 04/25/18 at 9:54 P.M. revealed the patient was placed in hard four point restraints. The restraints were discontinued at 11:02 P.M. No physician order for this type of restraint was noted in the medical record at this time.

During interview on 04/27/18 at 2:32 P.M., this finding was verified by Staff A and Staff .

Review of the policy/procedure titled "Restraint Use Procedure for Non-violent/Non-Self-Destructive Behavior and Violent Self-Destructive Behavior" (ADM 107)" revealed under Procedure for Restraint Application, the RN will select the type of restraint that is appropriate to the patient's condition, or as directed by LIP order if one is present.

Based on record review and interview, the facility failed to ensure staff documented detailed events leading up to the violent restraint. This affected one (Patient #2) of 11 sampled patients. This has the potential to affect all patients receiving services from the facility. The facility census was 361 patients.

Findings include:

Record review for Patient #2 revealed an admission date of 04/25/18 and an admission reason of reported suicidal attempt. A nursing documentation flow sheet dated 04/25/18 at 9:54 P.M. revealed the patient was placed in hard four point restraints. The restraints were discontinued at 11:02 P.M. There was no documentation describing the events leading up to the violent restraint application.

During interview won 04/27/18 at 2:32 P.M., Staff A verified this finding.

Review of the policy/procedure titled "Restraint Use Procedure for Non-violent/Non-Self-Destructive Behavior and Violent Self-Destructive Behavior" (ADM 107)" revealed under Guidelines for Documentation the RN will document events leading up to the initiation of restraint, including patient behavior, less restrictive measures attempted, rationale for restraint application and patient teaching. Family/significant other teaching will be done if given permission to do so by the patient.