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3535 SOUTHERN BOULEVARD

KETTERING, OH 45429

PATIENT RIGHTS

Tag No.: A0115

Based on medical record review, observations made during a tour of the Emergency Department, review of policies, and staff interviews, the facility failed to prevent the elopement of one patient with suicidal and homicidal ideations and failed to ensure basic and maximum suicidal precautions were implemented. (A144) The facility failed to ensure staff obtained a consent to treat patients presenting to the Emergency Department (A131) and failed to ensure staff assessed the need for restraints as required by facility policy. (A205) The cumulative affect of this systemic practice had the potential to affect all patients receiving care in the facility.

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on record review and interview it was determined the emergency department failed to ensure three of 13 medical records reviewed contained a signed informed consent prior to treatment. (Patients #4, #7 and #9) The current hospital census was 383.

Findings include:

1. Patient #4's medical record revealed the patient arrived by squad with altered mental status at 3:12 PM. Physician orders were placed on 12/29/17 at 5:21 PM for a portable chest X-ray STAT, electrocardiogram and saline lock IV. AT 5:29 PM orders were placed for serum toxicity screening and drug abuse urine tests. At 6:05 PM the X-ray of the chest resulted as normal. The ED timeline note revealed at 6:09 PM registration was complete.

Review of the form for consent to treatment included the patient or his agent, recognizing the need for hospital care, consents to hospital services as ordered by the attending physician, including emergency, laboratory procedures, x-ray examination or other hospital services rendered under the general and specific instructions of the physician.

Interview with Staff G on 02/15/18 at 12:15 PM confirmed Patient #4 did not have a signed consent in the ED record.

2. Patient #7 presented to the Emergency Department with complaint of chest pain on 02/12/18 at 10:12 PM. The Emergency Department physician ordered a stat portable chest x-ray, a standard 12 lead EKG, Complete Blood Count, Troponin, and Basic Metabolic Panel. The standard 12 lead EKG was completed as ordered at 10:21 PM and the stat portable chest x-ray was completed at 10:35 PM.

Review of the medical record lacked documentation the patient signed a consent to be treated.

3. Patient #9 presented to the Emergency Department with complaints of chest pain on 02/12/18 at 10:53 PM. At 10:56 PM an Emergency Department physician ordered a standard 12 lead EKG, a stat portable chest x-ray, a peripheral IV, Troponin, Basic Metabolic Panel, Complete Blood Count. All orders were completed, however, the medical record lacked documentation the patient signed a consent to treat.

Staff A was interviewed on 02/15/18 at 11:30 AM and confirmed the medical records of Patient #7 and Patient #9 both lacked documentation of a signed consent to treat.












28999

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on medical record review, observations made during tour of the Emergency Department, facility policy review, and staff interview, the hospital failed to prevent the elopement of Patient #6 and failed to ensure staff followed current facility policies related to suicide precautions for Patient #6 and Patient #12. A total of 13 medical records were reviewed. The current hospital census was 383.

Findings include:

The facility policy titled Suicide Precautions was reviewed on 02/16/18 at 1:30 PM. According to the policy under basic precautions staff are instructed to check the patient's whereabouts and safety every 15 minutes. The policy further instructed staff under maximum suicide precautions to ensure constant one-on-one supervision by a health care worker within arm's reach of the patient at all times, including when the patient is sleeping and using the bathroom. If the patient is actively engaging in harmful behavior, such as head banging, wall punching, or self-biting, direct the patient to stop. If the patient doesn't stop the harmful behavior, consider instituting physical restraints as a last resort to help prevent self-harm.

The facility policy titled Hospital Sitter Policy was reviewed on 02/16/18 at 1:45 PM. According to the policy deployment of a hospital sitter for direct patient observation should be implemented to maintain a safe environment for the patient. Nursing safety assessment will determine the need for constant observation. The patient should be assessed for the need for constant observation based on the following criteria: 1. Suicide precautions 2. Removal of self from restraints with a high risk condition 3. Emergency Application for Admission 24 hour hold 4. Consider use of sitter if falls score is greater than 100, if restraint is not appropriate.

1. Patient #6, a 20 year old with a history significant for ADHD (attention deficit hyperactivity disorder, and previous psychiatric inpatient and outpatient treatment, was transported to the Emergency Department via the local police department on 01/07/18 at 2:14 PM after a physical altercation with family. During the altercation the patient threatened to kill self and family members. The Emergency Physician's History of Present Illness stated the patient wanted to end his life and that of family members. A licensed social worker's note stated the patient made homicidal threats. The patient was described by staff as having racing thoughts, rapid mood swings, and being easily agitated.

The patient was placed in a private Behavioral Health bed within the Emergency Department on an involuntary hold. An involuntary hold form with the Statement of Belief section completed by a police officer was noted in the medical record. Despite the patient's involuntary hold, suicidal and homicidal thoughts, the medical record lacked documentation suicidal precautions were instituted.

At 2:40 PM a staff nurse assessed the patient's acuity as a 2, or emergent, on the five scale Emergency Severity Index (ESI). A nursing note at 4:03 PM stated the patient was resting quietly. At 5:25 PM the patient, still waiting for a room at a psychiatric facility, was noted to be walking around in the room. A nursing note at 6:20 PM stated the patient became increasingly agitated while waiting on a bed in a psychiatric facility.

The medical record lacked documentation suicidal precautions were initiated.

At 6:26 PM the patient was told he/she was being admitted and became increasingly agitated and hit the wall with fist.

A Nursing Note at 6:56 PM revealed that when 2 nurses opened the door to the Behavioral Health area, the patient pushed the staff out of the way and ran out of the Behavioral Health area and out of the facility, eloping. The patient was noted to be wearing only scrub pants and was barefoot at the time of the elopement. Security and local police were notified and attempted unsuccessfully to locate the patient.

A nursing note at 10:44 PM stated the patient's emergency contact was phoned and informed of the patient's elopement.

Review of an adverse event report revealed correspondence dated 01/11/18 expressing concern that Patient #6 was able to elope from a locked unit. The report lacked evidence action was taken based on this correspondence.

Staff A was interviewed on 02/16/18 at 2:30 PM. Staff A confirmed Patient #6 exhibited signs of harmful behavior that warranted maximum suicide precautions, however, the record lacked documentation suicidal precautions were initiated. The record lacked documentation a nursing safety assessment was completed and lacked evidence of one to one supervision.


2. Tour of the ED Behavioral Health area on 02/16/18 at 10:30 AM revealed Patient #12 in a bed with no staff in the 4 bed unit.

Patient #12 immediately got out of bed and asked "Who are you? I'm not a druggy, I came here because I was having a crisis. I wanted to kill myself. You guys aren't helping me. You threw me in a room and left me here. When are you going to help me?"

Review of the ED record revealed Patient #12 presented to the Emergency Department on 02/16/18 at 7:37 AM with complaints of suicidal and homicidal ideations. The record lacked evidence of documented safety checks for a suicidal patient every 15 minutes as required by policy.

Staff A confirmed this finding during interview on 02/16/18 at 2:30 PM. Staff A also confirmed Patient#12's record lacked evidence of a nursing safety assessment to determine the need for constant observation.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0205

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff assessed the clinical justification for restraints for one of 13 medical records reviewed. (Patient #11)

Findings include:

Patient #11 was admitted to the facility for surgery on 01/26/18 at 5:43 AM. The Operative Report revealed surgeons performed a craniotomy. A nursing note on 02/01/18 at 1:00 PM stated the patient was making an effort to exit the bed. It was also stated that the patient was unable to follow commands. The attending physician ordered bilateral soft wrist restraints on 02/02/18 at 03:24 AM. A daily order for the bilateral wrist restraints was noted as required by facility policy. On 02/06/18 from 10:00 AM to 6:00 PM the medical record lacked documentation staff assessed the patient for a clinical justification for the bilateral wrist restraints.

The facility policy titled Restraints and Seclusion was reviewed on 02/20/18. According to the policy ongoing assessment and monitoring of the patient's condition is crucial for the prevention of a patient injury or death. Monitoring ensures the patient's emotional and physical well-being, that the patient's rights and safety are maintained, if the restraint has been appropriately applied or maintained, and if the least restrictive measures are possible. The policy further instructs staff to assess the clinical justification upon initiation and every 2 hours.

Staff D, Director of Nursing for Surgical Intensive Care Unit, was interviewed on 02/20/18 at 9:45 AM. It was confirmed the medical record lacked documentation of clinical justification for the restraints as required.