HospitalInspections.org

Based on document review, video review, medical record review and interview, the facility failed to ensure compliance with the Condition of Participation (CoP) of Patient Rights as evidenced by deficient practices identified in the care and treatment provided to patients in the Emergency Department.

These findings placed all patients at risk for potential harm.


Findings include:

The facility failed to ensure that:
a) A patient's right to privacy and dignity was maintained while receiving care and treatment in the Emergency Department.

See Tag A 0143

b) Written physician orders were obtained for patients who were placed in restraints for the management of violent behavior.

See Tag A 0168.

c) Restraints are discontinued at the earliest possible time.

See Tag A 0174

d) Patients in restraints receive ongoing nursing assessment and monitoring and that monitoring activities are documented as per facility's policy.

See Tag A 0175

e) Patients receive a face-to-face evaluation within one (1) hour of the application of restraints and to document the evaluation as required by the regulation and per facility's policy.

See Tag 0179

Based on document review, video review and interview, in one (1) of 18 medical records reviewed (Patient #1), the facility failed to ensure that the patient's rights to privacy, respect and dignity was maintained while receiving care in the Emergency Department.


Findings include:

Review of the facility's surveillance video recording of the ED triage hallway, dated 6/16/19 beginning at 2:41 AM, revealed: a staff member using his cell phone to conduct video recording of the triage area on two separate occasions (2:44 AM and 2:55 AM). The staff's action of video recording could be seen by patients, significant others and staff present in the hallway. The staff member was also seen standing at the doorway of the triage room with his cell phone aimed at the inside of the room.

The Security Personnel who was present during the review of the video, identified the room as the Ambulance Triage Room and also identified the staff member as Staff B, a Physician's Assistant.

During interview on 8/15/19 at 11:15 AM, Staff B admitted taking a photograph and two videos of a patient (Patient #1), while she was in the ED Ambulance Triage Room, on 6/16/19. Staff B denied sharing the video with the EMS staff.

During interview on 8/15/19 at 10:31 AM, Staff D, Assistant Director of Nursing and Administrator who was on duty 6/16/19, reported receiving a complaint of Staff B using his cell phone to take pictures and videos of a patient in the Ambulance Triage Room. She questioned Staff B and he acknowledged taking the photo and video. Staff D stated that Staff B showed her the video and she did see a woman in the video. She asked him to delete it. Staff D stated this happened so fast.

Review of the facility's policy titled "Mobile Device," last reviewed 11/30/2018 states: "...use of personal mobile devices and Bluetooth enabled devices is prohibited during working hours. Employees may use mobile devices during lunch or break periods in a private space away from all patients, common patient care areas, and common work areas."

Review of the facility's policy titled "Cameras, Photographs Video Taping," effective 8/13/19, revealed the facility does not permit the photography of patients unless directed by the clinical staff.

Review of the facility's policy titled "Internet and Cell Phone Use in the ED," effective 11/30/18 stated: Use of personal mobile devices during work hours in the clinical area for non-related matters is prohibited."

Based on document review, in seven (7) of 18 medical records reviewed, the facility failed to ensure there is a physician's order for each episode of emergent restraint (Patient #s 1, 7, 8, 9, 11, 12, 13).

Findings Include:

Review of the medical record for Patient #1 revealed: A 20 year old patient was brought to the Emergency Department (ED) by EMS and police on 6/16/19 at 2:31 AM for alcohol intoxication and aggressive behavior. The Physician Assistant, Staff B, documentation at 2:59 AM stated: Patient comes in aggressive, yelling, and being uncooperative. Patient was talked to several times, but she will not calm down. Patient will be tied down to the bed and sedated for the safety of the ED providers and herself."
At 3:05 AM, Staff C, ED Attending noted that the patient was restrained and heavily sedated at triage.
There was no documented evidence of a physician order for physical restraints.

These findings were shared with Staff C, Attending ED Physician on 8/16/19 at 9:27 AM.

Review of the medical record for Patient #7: Patient is a twenty-year-old who arrived at the ED via ambulance on 5/16/19 11:20 AM, with a Chief Complaint of Irrational Behavior. On 5/16/19 at 11:56 AM, the nurse documented,"Patient alert, responsive to all stimuli, became agitated, restraints 2 point applied to wrist, was administered Haldol 5mg (drug used for sedation) intramuscular and Ativan 2mg (drug used to treat anxiety) intramuscular, placed on 1 to 1 observation by staff.
At 12:34 PM, nursing noted patient in restraints to wrist bilateral, Zyprexa was administered for agitation and restraints applied to lower extremity.
There was no physician order for the application of two-point restraints and for restraints to the lower extremities (4 point restraints).

Review of the medical record for Patient # 8: Patient is forty-six-year-old, brought to the ED on 5/16/19 at 9:00 AM by the mother, due to patient hearing voices. At 9:00 AM the Nurse Practitioner noted that during her assessment, the patient became agitated with mother, screamed at her, banging the table and used inappropriate language. After her discussion with the physician, decision was made to send patient to CPEP for safety concerns since he was demonstrating psychosis. Hospital police was called to escort patient and assist nurse in bringing patient to CPEP. Patient was refusing to go to CPEP and became combative. It required more than 10 police officers to get him to CPEP.
At 12:15 PM, ED the nurse documented the patient was received in bed with bilateral restraints on.
There no written physician order for the application of restraints.


Patient #9: Patient is a 22 year old who arrived at the ED via Emergency Medical Service (EMS) on 5/18/19 at 3:27 AM; Chief complaint left forearm laceration. The ED Physician Assistant, Staff T, documented "patient agitated, being threat to staff and self. Sedation ordered." At 4:00 AM, Physician Assistant, Staff B, documented, Behavioral restraint was ordered by MD.
There was no evidence of a written physician order for the application of restraints.

Patient # 11: This thirty-seven-year-old arrived at the ED on 6/1/19 at 11:23 AM, with the chief complaint of K2 use, which is a synthetic marijuana. At 12: 45 PM, RN documentation stated patient was removing his clothes and began pacing nude and attempting to touch a female staff. Restraints initiated as patient presented a clear danger to others. At 1:35 PM, nurse noted patient was placed in 2-point restraints.
There was no written physician order for 2-point restraints.

Patient #12: The ED physician on 6/2/19 at 12:51 PM, documented: This sixty-year-old patient was brought to the ED by EMS with the chief complaint of alcohol intoxication. The patient was alert and uncooperative. The physician also documented "Patient is sedated and restrained for her own safety."
There was no written physician order for restraints.

Patient #13: On 6/4/19 at 2:10 AM, the ED triage nurse documented, Chief complaint drug/alcohol assessment. Patient is awake, responsive, verbally abusive, agitated and spitting. Patient was sedated as per MD order written for Ativan and Haldol. At 12:25 PM, nursing noted that patient was verbally and physically abusive. Patient not willing to cooperate with vitals. Restraints to bilateral wrist measured with two fingers. Restraint was still in progress.
There was no written physician order for restraints.


Review of facility policy titled "Restraint and Seclusion Policy." last reviewed 6/14/19, stated: A written physician order is required within 30 minutes of the application of restraints for violent behavior..... He/She must assess the patient face-to-face immediately upon arrival and write the order within 30 minutes of the emergency application of the restraints to evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint." The policy also stated if the physician is available at the time of application of the restraint, the order for restraint is to be written by the physician.

These findings were shared with Staff S, Risk Manager, on 8/19/19 at approximately 11:00 AM.

Based on document review and in four (4) of 18 medical records reviewed, it was determined that the facility failed to ensure that restraints were discontinued at the earliest possible time. (Patients #1,7, 12, 13).

Findings include:

Review of the facility's "Restraint and Seclusion Policy," last reviewed 6/14/19, stated:
"Discontinuation of Restraints or Seclusion:
A. Restraint or seclusion shall be discontinued at the earliest possible time, regardless of the length of time in the physician's order.
C. Behavioral criteria for release shall be indicated for patients in violent behavior restraints or seclusion. The RN will document the time and the discontinuation on the restraint flow sheet and the same must be reflected in the patient's progress note with a description justifying the release of the restraint, and inform the physician.
The policy also stated Restraint and Seclusion Time Limits: Up to 2 hours for patient age 18 years and older."

Review of the medical record for Patient #1 revealed: A 20 year old patient was brought to the Emergency Department (ED) by EMS on 6/16/19 at 2:31 AM for alcohol intoxication and aggressive behavior. The Physician Assistant, Staff B, documentation at 2:59 AM stated: Patient comes in aggressive, yelling, and being uncooperative. Patient was talked to several times, but she will not calm down. Patient will be tied down to the bed and sedated for the safety of the ED providers and herself."
At 3:05 AM, Staff C, ED Attending noted that the patient was restrained and heavily sedated at triage.
At 6:30 PM, Staff C documented patient disposition, patient discharge to home/self care.

There was no documentation of the time restraints were discontinued or whether the restraints were removed during the time patient was heavily sedated.

The "Restraint and Seclusion Policy" documents Monitoring Requirements, which includes, "Restraints are removed if patient is asleep."

Review of the medical record for Patient #7 identified: A twenty-nine-year-old patient arrived at the Emergency Department (ED) via ambulance on 5/16/19 11:20 AM. The Registered Nurse (RN) at 11:23 AM documented "patient was found naked in street, was kicking and fighting. Patient needs constant redirection. 1 to 1 supervision initiated."
At 12:01 PM the RN documented patient is alert, responsive to all stimuli, became agitated, restraints 2- point applied to wrist, placed on 1:1 observation by staff. Medicated as ordered.
At 12:34 PM nursing documented patient severely agitated. Not responding to redirection. Patient in 2-point restraints and restraint applied to lower extremity (4-point restraint).
At 12:51 PM Nurse Practitioner consultation noted patient asleep on cardiac monitor.
There was no documented evidence that restraints were removed when the patient was asleep or documentation of the time when the restraints were discontinued.

Review of the medical record for patient #12 identified: This patient is a sixty-year-old brought to the ED by EMS on 6/2/19 at 12:51 PM, with the chief complaint of alcohol intoxication. The patient was alert and uncooperative. ED physician exam of the patient noted patient is alert but agitated and smelling of alcohol. He also noted under Assessment and Plan "Patient is sedated and restrained for her own safety."
At 2:46 PM nursing note stated patient became more restless, agitated and unsafe to herself. Patient was chemically sedated. Patient is now resting comfortably in bed, continuous cardiac monitoring in effect
On 6/2/19 at 9:23 PM, approximately six (6) hours later, the RN documented patient was re-evaluated by provider given discharge instructions. The patient was discharged home with significant other.
There was no documented evidence of the time restraints were discontinued or whether restraints were released when the patient was assessed to be resting comfortably in bed.

Review of the medical record for Patient #13 identified: The ED physician documented on 6/4/19 at 2:03 AM patient is very uncooperative, spiting, agitated as per triage nurse, will sedate with Haldol and Ativan.
At 2:10 AM triage RN documented patient is awake, verbally abusive, agitated/hostile, spitting at staff, and arrived with bilateral handcuffs. The documentation also stated patient was sedated as per MD order with Ativan and Haldol.
At 7:21 AM the physician documented the patient was brought in by ambulance for evaluation of alcohol (ETOH) intoxication with disruptive/aggressive behavior, and was initially treated with Haldol and Ativan. He is now unable to provide much information.
At 12:25 PM, the RN documented patient verbally and physically abusive. Not willing to cooperate with vitals. Restraints to bilateral wrist measured with 2 fingers..... Restraints still in progress.

During the 10 hour time period (2:10 AM to 12:25 PM), there was no documentation of the time restraints were applied and when they were removed.

Staff J, Assistant Director of Nursing was present during medical record review on 8/15/19 at approximately 1:00 PM and validated surveyor's findings.

Based on document review, in seven (7) of 18 medical records reviewed, it was determined that the facility failed to ensure assessment and monitoring of patients in restraints and document monitoring as per facility's policy. (Patients #1,7,8,9,11,12,13)

Findings include:

Review of the policy titled, "Restraint and Seclusion," revised 6/14/1, states: "A documented assessment/observation of the patient's condition including any significant changes in the health status is done in accord with the table below (Monitoring Requirements).....
The assessments and observations are the responsibility of the RN but the monitoring and observation may be carried out by a licensed practical nurse, and any other ancillary staff who have been appropriately trained under the general supervision of a RN.
The policy also states that for Violent Behavior, monitoring in required every 15 minutes by trained staff and every 30 minutes by RN. Patient must be on constant 1:1 observation.
Documentation of patient in restraint or seclusion is completed by the appropriate clinical staff in accordance with the restraint/seclusion flow sheet...
Discontinuation: When restraints are removed, document time and reason for discontinuation in progress note. (Performed only by a RN)."


Review of the medical record of Patient #1 identified a 20-year-old arrived in the ED accompanied by EMS (Emergency Medical Service) and police on 6/16/19 at 2:31 AM for alcohol intoxication and aggressive behavior.
At 2:59 AM Staff B, Physician Assistant note documented: "Patient comes in aggressive, yelling, and being uncooperative. Patient was talked to several times, but she will not calm down. Patient will be tied down to the bed and sedated for the safety of the ED providers and himself."
The patient was discharged to home/self care at 6:30 PM.
There was no documentation in the medical record of the patients condition, assessment, monitoring during the time she was in restraint.

Review of the medical record for Patient #7 identified: A twenty-nine-year-old who arrived at the Emergency Department (ED) via ambulance on 5/16/19 11:20 AM. Registered Nurse (RN) at 11:23 AM documented "patient was found naked in street, was kicking and fighting. Patient needs constant redirection. 1 to 1 supervision initiated".
At 12:01 PM the RN documented that the patient became agitated, restraints 2- point applied to wrist and patient was placed on 1:1 observation by staff. Documentation also stated the patient was medicated with Haldol and Ativan
At 12:34 PM nursing also documented patient severely agitated. Not responding to redirection. Patient in 2-point restraints and restraint applied to lower extremity (4-point restraint).
At 12:51 PM Nurse Practitioner consultation noted patient asleep on cardiac monitor.
There was no documented assessment or monitoring of the patient's condition in accordance with the restraint flow sheet.

Review of the medical record for Patient #8 identified: A forty-six-year-old brought to the ED on 5/16/19 at 9:00 AM by the mother due to patient hearing voices. At 9:00 AM the Nurse Practitioner noted that during her assessment the patient became agitated with mother and decision was made to send patient to CPEP for safety concerns since he was demonstrating psychosis. The documentation also stated the patient was combative and required 10 hospital security police to get the patient to CPEP.
At 11:21 AM the ED physician documented the patient was agitated and had to be restrained by the officers.
At 12:15 PM the ED RN documented she received patient in bed with bilateral restraints on.
At 1:20 PM and at 1:30 PM, nursing reassessment and close observation was documented. Restraints could not be discontinued at that time.
At 2:15 PM nurse practitioner documented patient with bilateral wrist restraints applied for safety.
At 3:27 PM RN documented patient refused to go to CPEP. MD intervened and despite coercion patient continued to be uncooperative, displaying psychosis and delusion stating he wants to leave. Patient was medicated as ordered and bilateral upper extremity restraints order continued. At 7:15 PM patient was transferred to Psych ED.
Patient was restrained from 11:21 AM to 7:15 PM, approximately 8 hours. There was no documented evidence of ongoing nursing reassessments every 30 minutes.


Review of the medical record review for Patient #9 identified: This is a 22 year-old, who the Physician Assistant (PA)documents on 5/18/19 at 3:27 AM; patient agitated, being a threat to staff and self. Sedation ordered.
At 4:00 AM, RN documented patient presented with EMS for left forearm laceration and knee pain. Patient evaluated by Trauma provider and orders done... Behavioral restraint ordered by MD. Restraint documentation maintained as per protocol.
At 5:30 AM RN documented patient is asleep, and restraint was discontinued.
There was no documented evidence of nursing reassessments every 30 minutes.


Review of the medical record for Patient # 11: Registered Nurse at triage documented on 6/1/19 at 11:23 AM, patient is alert and oriented denies any drug use and no visible injuries. There was no other documented data in this triage assessment.
Physician Assistant (PA) noted at 6:19 PM the patient is a thirty-seven-year-old with chief complaint of K2 (synthetic marijuana) use, who presents for possible drug use.
At 12:45 PM RN documents patient continues to masturbate despite being verbally redirected and placed in an area where he would have privacy. He disrobed and began to pace nude, attempting to touch females, responded poorly to redirection, restraints initiated as patient presented a clear danger to others. Will monitor for criteria to discontinue restraints.
At 1:35 PM RN documented patient is agitated, irrational, and placed in 2-point restraint.
At 5:07 PM RN documented patient is awake and oriented, calm and cooperative. Waiting for MD disposition.
Patient was discharged to home on 6/1/19 at 7:47 PM.
There was no documentation of nursing monitoring to include time restraints were removed.


Patient #12 was brought to the ED by EMS on 6/2/19 at 12:51 PM with the chief complaint of alcohol intoxication. The patient is alert and uncooperative. ED physician documented patient is alert but agitated and smelling of alcohol. "Patient is sedated and restrained for her own safety".
At 2:46 PM nursing documented patient became more restless and was chemically sedated, now resting comfortably in bed, continuous cardiac monitoring in effect. On 6/2/19 at 9:23 PM, RN documented patient discharge instructions.
There was no written flowsheet documenting the monitoring of restraints to include the time restraints were released.

Patient #13: The patient was brought in by ambulance to the ED on 6/4/19 at 2:03 AM,chief complaint Drug/Alcohol Assessment. Patient agitated as per triage nurse, will sedate with Haldol and Ativan. Nursing documented, patient arrived with bilateral handcuffs.
At 12:25 PM RN documents patient verbally and physically abusive. Not willing to cooperate with vitals. Restraints still in progress.
There was no evidence of a Restraint Flow Sheet documenting the monitoring of restraint to include the initiation of restraint, on-going monitoring of the patient on restraint or the time when the restraint was discontinued.

Staff J, Assistant Director of Nursing was present during medical record review on 8/15/19 at approximately 1:00 PM, and validated surveyor's findings.

Based on document review, in five (5) of 18 medical records reviewed, it was determined the facility failed to ensure compliance with the requirement for completing and documenting a one (1) hour face-to-face patient evaluation, when restraints are applied. (Patients #1,7, 11,12,13)

Findings include:

Review of the medical record for Patient #1 revealed: 20 year old patient was brought to the Emergency Department (ED) by EMS and police on 6/16/19 at 2:31 AM for alcohol intoxication and aggressive behavior. The Physician Assistant (PA), Staff B, documentation at 2:59 AM stated: Patient comes in aggressive, yelling, and being uncooperative. Patient was talked to several times, but she will not calm down. Patient will be tied down to the bed and sedated for the safety of the ED providers and herself."
There was no documented evidence of a one (1) hour written face-to-face assessment after the application of restraints.


Review of the medical record for Patient #7 identified : A twenty-nine-year-old who arrived at the Emergency Department (ED) via ambulance on 5/16/19 11:20 AM, when "patient was found naked in street, was kicking and fighting.
At 12:01 PM the RN documented patient became agitated, restraints 2- point applied to wrist placed on 1:1 observation by staff. Medicated as ordered.
At 12:34 PM nursing documented patient severely agitated. Not responding to redirection. Patient in 2-point restraints and restraint applied to lower extremity (4-point restraint).
There was no documented evidence of a one (1) hour written face- to- face assessment after the initiation of 2-point and 4-point restraints.


Patient #11: Patient presented to the ED on 6/1/19 at 11:23 AM for possible drug use. At 12:45 PM RN documented restraints initiated as patient presented a clear danger to others.
There was no documented evidence of a one (1) hour written face-to-face assessment after the application of restraints.


Patient #12: This sixty-year-old patient was brought to the ED by EMS on 6/2/19 at 12:51 PM with the chief complaint of alcohol intoxication. ED physician assessment documented patient is alert but agitated and smelling of alcohol. "Patient is sedated and restrained for her own safety." There was no documented evidence of a one (1) hour written face-to-face assessment after the application of restraints.

Patient #13: Patient brought in by ambulance on 6/4/19 at 2:03 AM for evaluation of alcohol (ETOH) intoxication with disruptive/aggressive behavior. At 2:10 AM, RN documented patient agitated and hostile. Patient was sedated as ordered with Haldol and Ativan. At 12:25 PM, RN documented patient verbally and physically abusive. Not willing to cooperate with vitals... Restraints still in progress.
There was no documented evidence of a one (1) hour written face to face assessment after the application of restraint.


Review of facility policy titled "Restraint and Seclusion Policy." last reviewed 6/14/19, stated: "A written physician order is required within 30 minutes of the application of restraints for violent behavior..... He/She must assess the patient face-to-face immediately upon arrival and write the order within 30 minutes of the emergency application of the restraints to evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint."
The policy also stated, "The date and time the face-to-face assessment is done and order is written" is to be included in the written physician order for restraint.

Staff J, Assistant Director of Nursing, validated surveyor's findings on 8/15/19 at approximately 1:00 PM.