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Based on staff interview and record reviews, the hospital failed to assure sufficient staff coverage was available at all times in the Emergency Department (ED) to meet the needs of patients demonstrating psychotic or other behavioral health symptoms. (Patients #5 and #6 ). Findings include:

1. Patient #6 eloped from the ED on 7/19/15 at 0915 hours and there was insufficient staff on duty at the time to respond in a manner that left adequate coverage in the ED and other qualified staff to respond to the emergent situation. Per staff interview and schedule review for 7/19/15, 2 RNs (Registered Nurses) and 1 physician were on duty in the ED when a patient diagnosed with Schizophrenia and Post Traumatic Stress Disorder, experiencing a mental health crisis and awaiting involuntary psychiatric hospital admission, eloped from the ED.
At the time the patient exited the ED and the hospital, one RN was available to respond to the patient and attempt to get them safely back into the ED. The patient stated that the RN yelled loudly and pointed at them to return to the hospital and after they had turned and headed back, the RN grabbed them roughly and pushed them back into the hospital. The patient claimed that the RN then pushed them to the floor and fell on them, causing pain. During interviews on the afternoon of 8/25/15, the CNO and the ED Nurse Manager confirmed that the RN may have felt stressed that no one was available to help him/her with the situation; a Code Grey (emergency call for help) had been called but response time had been slow, per the ED Nurse Manager. The RN had been trained on how to care for patients with aggressive behaviors and mental health diagnoses; however, hospital policies/procedures were not implemented in this case. The CNO verified that they recognized the need for increased availability of staff to help in emergency situations, and to act as 'sitters' for violent or disruptive patients, and had begun the hiring process in June, 2015. As of the date of the incident and the date of survey (8/25/15), the orientation process had not yet started and was planned for September, 2015.

2. After being found wandering in the woods for 24 hours, Patient #5 was brought to the ED on 7/13/15 at 0907 in an agitated and delusional state. Per ED Nursing Documentation Record, Patient #5 was described to have "flight of ideas" but remained cooperative and was assigned a 1:1 LNA (Licensed Nursing Assistant) for close monitoring. During the rest of the day and evening Patient #5 could be redirected but remained delusional. While remaining in the ED for further medical clearance and to be screened for a possible psychiatric hospitalization, Patient #5 became increasingly more agitated. At 0430 on 7/14/15 Patient #5 began yelling and threatening staff, eloped from the ED, left the CAH grounds and was later found and removed from inside a private residence located in the neighborhood near the CAH campus by police. At the time of the elopement, the ED was staffed with the RN night nursing supervisor, a second nurse and ED physician. The Randolph police department returned Patient #5 to the ED at 0510 and continued to remain with the patient. Three police officers remained with Patient #5 while s/he is screened by staff from the Clara Martin Center for an Emergency Evaluation (EE) for involuntary psychiatric hospitalization. At 09:30 the police leave the ED returning to the staff ratio of 2 nurses and a physician. At 09:35 Patient #5's behavior begins to escalate, pushing staff in ED, and then exiting the ED into the Radiology Department. Although a Code Gray was called (emergency assistance from hospital staff during a behavioral emergency) during the second elopement, the ED Nurse Manager stated on 8/25/15 at 1:00 PM, response was slow at the time of the Code Gray, and that, due to insufficient numbers of available staff, an appropriate and safe restraint hold was not attempted while Patient #5 was present in the Radiology Department. Eventually the patient left the Radiology Department and exited the hospital. Police were again called for reinforcement and Patient #5 was returned to the ED a second time. Patient #5 had unsuccessfully attempted a third elopement shortly after being returned to the ED, restraints and emergency medications were administered. The police were again stationed at the patient's bedside for a period of time until medication became effective. During the emergent incidents on 7/14/15, (which placed staff, patients and the general public at risk), the available staff on duty proved to be insufficient to meet the essential needs for all patients.

Based on record review and staff interview, the CAH failed to assure that care and services were provided in accordance with currently established written policies and procedures regarding care provision for patients at risk of violence towards self or others, and/or for the use of restraints for 3 of 8 patients in the total sample. The hospital also failed to develop written policies/procedures regarding the assurance of Patient Rights, and for Medical and Nursing staff, for the use of chemical restraints. (Patients #5, #6 and #8). Findings include:

1. After being found wandering in the woods for 24 hours, Patient #5 was brought to the ED on 7/13/15 at 0907 in an agitated and delusional state. Over the course of 24 hours the patient's behaviors continued to escalate with delusional and agitated rantings, elopements and physical threats of violence toward ED staff. On 7/14/15 at 0950 after attempting to elope for the third time and with increased combativeness, the patient was administered emergency medications to include Haldol 5 mg. (antipsychotic) and Ativan 2 mg (an anti-anxiety agent) IM (intramuscularly) and 4 point restraints were applied. Per review of the Restraint Observation Flow Chart, Patient #5 remained restrained until 11:15 when s/he was observed sleeping and the restraints were removed. Per review of policy Restraints and Seclusion for Behavioral Health Patients effective 05/06/2014 stated "7. If restraints or seclusion are discontinued prior to the expiration of the original order, a new order must be provided by the physician and the initial requirements for the emergency procedure restarted if the patient meets the clinical criteria for involuntary procedure". However, staff failed to obtain a new order for the restraints when they were reapplied at 1600 through 1700 HR on 7/14/15. The ED Nurse Manager confirmed on the morning of 8/26/15 staff's failure to obtain an order for the reapplication of restraints, as per CAH policy.

2. On 7/19/15 at 0220 HR (hours) Patient #7 arrived in the ED via ambulance heavily intoxicated. As a result of the acute alcohol intoxication, Patient #7 required intubation with an endotrachael tube to assist with maintaining an airway. After receiving treatment in the ED, Patient # 7 was admitted to the Special Care Unit (SCU) at 0615 HR. Soft restraints had been applied for medical immobilization to prevent Patient #7 from attempting to remove the endotrachael tube, intravenous catheter and nasal gastric (NG) tube. The History & Physical note written by the admitting hospitalist stated the patient was eventually extubated and his/her NG tube removed and "at this time in 4 point restraints secondary to his/her altered mental status.....the patient is awake, alert but does not understand how s/he got here and has become quite belligerent...". Patient #7 was assessed for alcohol withdrawal and was administered medication for agitation. Per review of nursing progress notes for 7/19/15 from 1046 HR through 1550 HR Patient #7 was observed by staff to be sleeping, however restraints were not removed. During this time period there was no indication the patient was demonstrating a risk to himself/herself or others and least restrictive measures had not been initiated to include the progressive removal of the 4 point restraints as per CAH policy. Per interview on 8/26/15 at 11:40 AM, the Nurse Manager for Medical/Surgical and Transitional Units confirmed the nurse should have removed Patient #7's restraints after the patient's behaviors became calm and was sleeping for a significant period of time.

3. Per review of the medical record record on 8/24/15, Patient #6 was administered involuntary emergency medication when the patient exhibited assaultive and threatening behaviors while in the ED on 7/19/15. The patient was being held involuntarily in the ED due to self-harming behavior, while waiting for placement at a psychiatric facility. Per the provider notes from 3:30 AM on 7/19/15, 'the patient was intent on harming self and had stopped taking medication days ago. The patient became agitated (shouting and throwing items, striking out) and delusional and a risk to him/her self and others'. The provider note of 9:40 AM stated that the patient "was extremely agitated and attempting to physically assault staff, Haldol and Benadryl ordered". The Haldol 10 mg. and Benadryl 50 mg. were administered by Intramuscular Injection (I.M.) at 10:10 AM by the RN, per physician orders.
The hospital's policy "Restraints and Seclusion for Behavioral Health Patients", under Procedure: #4 stated "The physician's order will include the following:
- Date and time of the order
- Type of restraint or seclusion
- Duration of order
- Level of nursing observation
- Clinical criteria for discontinuation of procedure
The policy further stated under "III Staff Competency and Training: D. Physicians and other licensed independent practitioners authorized for ordering restraints for behavioral ......reasons.....and/or involuntary medications will have a working knowledge of the policies regarding these treatment interventions."
Based on a review of the documentation including the orders for the chemical restraints, there was no reason given in the orders for the involuntary medications, as required. Additionally, the RN who administered the medication failed to document the patient's response to and the effect of the medication in the medical record. During interview on 8/25/15 at 3:15 PM, the Medical Director of the Hospital Division (who oversees the ED) confirmed that the hospital's Policies/Procedures regarding restraints did not include written directives regarding the procedures for ordering and administration of chemical restraints (emergency involuntary medication). Refer also to C 273.

4. Per record review and confirmed by CNO interview, the hospital failed to develop a policy/procedure to direct the training and dissemination of information on patient rights to all hospital staff and patients receiving inpatient care and services, as contained in the policy titled "Inpatient Rights and Responsibilities"

Based on staff interview and record review, the CAH failed to operationalize policies and procedures for ordering and administration of chemical restraints for 1 applicable patient of the total sample of 8, as part of it's policy titled "Restraints and Seclusion for Behavioral Health Patients". The CAH also failed to adhere to Emergency Department Medical Staff Rules regarding written clinical guidelines, policies and procedures for the ED. (Patient #6). Findings include:

Per review of the medical record record on 8/24/15, Patient #6 was administered involuntary emergency medication when the patient exhibited assaultive and threatening behaviors while in the ED on 7/19/15.
Although the hospital refers to chemical restraints in it's policy/procedure regarding restraints, they failed to develop protocols for the ordering and administration of emergency involuntary medications for physicians and nursing staff.
Per the provider notes from 3:30 AM on 7/19/15, 'the patient was intent on harming self and had stopped taking medication days ago. The patient became agitated (shouting and throwing items, striking out) and delusional and a risk to him/her self and others'. The provider note of 9:40 AM stated that the patient "was extremely agitated and attempting to physically assault staff, Haldol and Benadryl ordered". The Haldol 10 mg. and Benadryl 50 mg. were administered by Intramuscular Injection (I.M.) at 10:10 AM by the RN, per physician orders.
The hospital's policy "Restraints and Seclusion for Behavioral Health Patients", under Procedure: #4 stated "The physician's order will include the following:
- Date and time of the order
- Type of restraint or seclusion
- Duration of order
- Level of nursing observation
- Clinical criteria for discontinuation of procedure
The policy further stated under III Staff Competency and Training: D. Physicians and other licensed independent practitioners authorized for ordering restraints for behavioral ......reasons.....and/or involuntary medications will have a working knowledge of the policies regarding these treatment interventions.
Based on a review of the documentation including the orders, there was no reason given in the orders for the involuntary medications, as required. There were no specific written policies and procedures and clinical guidelines to manage these treatment services, as stated in the Emergency Department Medical Staff Rules, at #3, Rules/Responsibilities for the Emergency Department Committee, per review on 8/25/15. Rule #3 stated "Provide written clinical guidelines, policies and procedures for the Emergency Department."
The lack of clinical guidelines and P/P were confirmed during interview with the Medical Director of the Hospital Division on 8/25/15 at 3:15 PM. Refer also to C 271.

Based on staff interview and record review, the CAH failed to assure that RNs in all areas of the hospital were appropriately trained to provide care in accordance with the patients' needs related to care provided in the Emergency Department for 1 applicable patient in the sample. (Patient #6). Findings include:

1. Per review of Patient #6's medical record, as well as hospital investigative information, the patient did not receive nursing care in the Emergency Department (ED) in consideration of his/her medical and psychological needs. Based on a review of a patient complaint regarding care provided by one RN in the ED on 7/19/15, the RN failed to consider the patient's mental health needs when attempting to return the patient to the ED after the patient had eloped. The patient was experiencing a psychiatric crisis, including self-harming behaviors, and was brought to the ED by law enforcement. The patient was aggressive and was acting out physically and verbally. The patient was being held emergently in the ED while waiting for a psychiatric facility bed. The RN failed to follow the hospital's policy/procedure titled "Management of Patients at Risk to Themselves or Others" which stated "DO NOT ATTEMPT TO personally RESTRAIN A PERSON", referring to a person who commits an act of aggression or assault. The RN physically restrained Patient #6 alone, in violation of this policy, resulting in rough handling and mental trauma, as described by the patient during interview with the surveyor.
The policy directed staff dealing with a person at risk to: "#4. Assume a non-confrontational manner... #5, Maintain a safe amount of physical space until assistance has arrived." The policy also directed staff to use a calm , quiet voice and to give concrete explanations of everything being done. This did not happen in this case, as confirmed with the CNO and the ED Nurse Manager during interview on 8/25/15 at 1:30 PM. The RN's actions (captured via closed circuit camera at the entrance to the hospital), confirmed the patient restraint process and lack of appropriate nursing care, thus failing to meet the patient's needs.

2. Per record review and confirmed by ED Nurse Manager interview on 8/24/15 at 3:15 PM, another RN was called to the ED from the Medical Surgical Unit to administer emergency involuntary medication (Haldol and Benadryl) to Patient #6. The RN documented administration of the medication at 10:10 AM on 7/19/15. There was no further documentation in the ED notes regarding the effect of the medication and assessment of the patient at the time of administration and following administration. The next note in the ED documentation was not until 10:45 AM and referred to other issues. The ED Nurse Manager and the Medical Director of Hospital Services also confirmed that there were no written policies/procedures to direct Nurses and providers regarding the use of chemical restraints. Refer also to C 271.

3. Per record review and staff interviews, the care plan for Patient #6 failed to address the patient's needs regarding psychiatric disturbances and history of Post Traumatic Stress Disorder (PTSD).

Based on interview and record review, the CAH failed to assure that a complete and effective investigation of alleged patient abuse was conducted for 1 applicable patient, (Patient #6); the hospital also failed to assure consistent ongoing monitoring for the use of restraints for 1 of 8 patients in the total sample. (Patient #1) Findings include:

1. Per record review and confirmed during interviews with hospital staff, the Quality Assurance (QA) staff investigation of Patient #6's allegation of abuse failed to include interview of all known witnesses to the patient's statement of alleged abuse and possible mistreatment. During interviews on 8/25/15 and 8/26/15, the ED Nurse Manager and the CNO confirmed that there were 2 staff present in Patient #6's room in the ED when the patient alleged that a RN who provided care on the morning of 7/19/15 had abused him/her during the process of physically restraining him/her. Another staff person who had witnessed part of the restraint process was also not interviewed related to the allegations. The CNO confirmed that there was no QA member assigned to oversee the process and assure that all investigations into allegations of patient abuse were conducted in a thorough manner and were completed.

2. The Nurse Manager for Medical/Surgical and Transitional Units confirmed on 8/26/14 at 11:40 AM that although s/he has a process for reviewing all restraint use on the patient care units, a review had not been conducted for the use of restraints and the failure to discontinue the restraints when appropriately indicated for Patient #7. Per record review, Patient #7 was treated in the ED for acute alcohol intoxication on 7/19/15 at 02:20. The patient required intubation with an endotrachael tube to assist with maintaining an airway and was admitted to the Special Care Unit (SCU) at 0615. Soft restraints had been applied for medical immobilization to prevent Patient #7 from attempting to remove the endotrachael tube, intravenous catheter and nasal gastric tube (NG). The History & Physical note written by the admitting hospitalist stated that patient was eventually extubated and his/her NG tube removed and at the time in 4 point restraints secondary to his/her altered mental status....."the patient is awake, alert but does not understand how s/he got here and has become quite belligerent...". Per review of nursing progress notes for 7/19/15 from 10:46 through 15:50 Patient #7 was observed by staff to be sleeping, however restraints were not removed. During this period there was no indication the patient was demonstrating a risk to himself/herself or others and least restrictive measures had not been initiated to include the progressive removal of the 4 point restraints, as per CAH policy. The Nurse Manager had also confirmed if s/he had audited the restraint use for Patient #7 it would have been noted a discontinuation of restraints should have resulted. At the time of Patient #7's hospitalization, the Nurse Manager stated s/he was on vacation and this specific case was not brought to the Manager's attention using the present screening process to identify opportunities for improvement.