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Based on policy and procedure review, medical record review and staff interviews the facility staff failed to get an order for a physical hold for 1 of 1 restraints reviewed.

Review on 10/25/2019 of a policy titled "Restraint Management Program" last revised 08/2018 revealed "...Physical Hold: Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint...Licensed Independent Practitioner (LIP)...Provides assessment, evaluation, documentation & ordering of appropriate restraint to include re-evaluation per policy...1. Restraint or seclusion must be ordered by a provider recognized by the state of North Carolina and credentialed by (Facility Name). The type of restraint ordered will depend on patient condition and observed patient behaviors. 2. Qualified licensed staff (RN - Registered Nurse) many initiate restraints for patient safety without prior provider orders, but must have a physician assess the patient within time limits depending on restraint type. Notification of restraint application is reported to the provider and is documented in the medical record/nursing notes..."

Review on 10/22/2019 of Patient #12's medical record revealed Patient #12 arrived to the Emergency Department (ED) via EMS (Emergency Medical Services) on 9/12/2019 at 0006. Review of the triage notes at 0008 revealed " ...EMS sts (states) pt (patient) wasn't acting right but couldn't provide specifics. Spoke with (Staff member at Assisted Living Facility) and she sts the pt walked to the med room holding a blanket and asked 'why did you leave me?'. (Staff member) sts she walked him back to his room and he shoved her. (Staff member) then sts her RA (resident assistant) then took the patient to his room, and he was stating, 'I don't want to die here.', and minutes later he ran out of the room and attempted to run out of the facility. Pt able to tell me his birthday at this time but refuses to speak to me anymore at this time. Pt resp (respirations) even and unlabored..." Review revealed Patient #12 was evaluated by the ED physician and set for discharge on 09/12/2019 at approximately 1600. Review revealed Patient #12's assisted living facility refused to pick Patient #12 up and Patient #12's family refused to pick Patient #12 up. Review revealed case management started looking for a safe discharge place for Patient #12 on 09/13/2019 to 09/17/2019. Review of MD #1's progress note on 09/17/2019 at 0030 revealed " ...PATIENT HAS BECOME AGGRESSIVE INTACT (sic) 1 THE ER (Emergency Room) NURSES FOR NO REASON. PATIENT IS AWAKE ALERT AND ORIENTED. PATIENT WILL BE DISCHARGED IN THE CUSTODY OF POLICE FOR ASSAULT ON HEALTHCARE WORKER ...Discharge Diagnosis (1) Aggressive behavior Status: Acute ...Disposition Type: Discharge (IN CUSTODY OF POLICE DEPARTMENT) Condition: Stable ..." Review of the nursing note on 09/17/2019 at 0115 revealed "...Pt wandered around ER. Nurse to pt stating 'I have some medicine to give you.' Pt came toward nurse and grabbed nurse's chest and would not release nurse's chest and clothing leaving an abrasion and redness to chest. pt placed in prt (physical restraint technique) taught by handle with care. (Police) called; pt contained by (police) and taken to jail..." Review revealed Patient #12 was discharged to jail with police at 0045. Review of physician orders revealed no order for a physical hold restraint for Patient #12.

Review of the police report on 10/24/2019 revealed "...ER nurse...states she went to assist a patient that was roaming around the ER causing issues with staff. The patient (Patient #12), acted as if he was going to fall. Upon (RN #3) attempting to help (Patient #12) he grabbed her neck and chest causing scratch marks on her skin. The clawing assault did not break the victims skin, only redness and swelling...On 09/17/2019 (Police Name) units responded to (Hospital Name) in reference to an assault. After arriving on scene, ER security had the suspect secured on the floor. After further investigation it was determined suspect has grabbed a female nurse and grabbed her neck area..."

Video review on 10/24/2019 at approximately 1600 revealed on 09/17/2019 at 0039 Patient #12 was walking around the ER. Review revealed at 0041 Patient #12 went up to RN #3 and grabbed her scrub top and chest. Review revealed at 0042 other staff came to Patient #12 to get Patient #12 to release RN #3's scrub top. Review reveled Patient #12 was brought to the ground on his bottom and staff held his arms. Review revealed at 0042 two security staff came and turned Patient #12 to the prone position with Patient #12's head turned to the left and secured his arms behind his back on the ground and another nursing staff held Patient #12's legs. Review revealed from 0042-0051 Patient #12 was secured on the ground until at 0051 police came and handcuffed Patient #12 while he was on the ground. At 0054 Patient #12 was put in a wheelchair with police and taken into police custody.

Interview on 10/24/2019 at 1408 with RN #3 revealed she was Patient #12's primary nurse on 09/17/2019. Interview revealed RN #3 went to get Patient #12 a medication and approached Patient #3 in the ED hallway to tell him she was going to give him a medication in his room. Interview revealed Patient #12 came toward RN #3 and she thought Patient #12 was going to fall. Interview revealed Patient #12 reached forward and grabbed the front of RN #3's scrubs and pulled down. Interview revealed staff came and put Patient #12 in a therapeutic hold on the ground to let go of RN #3's scrubs. Interview revealed security came and held Patient #12 down on the ground with his hands behind his back. Interview revealed RN #3 considered Patient #12's hold a restraint and it would need an order. Interview revealed RN #3 did not recall if there was a restraint order for Patient #12.

Interview on 10/24/2019 with MD #1 (Medical Doctor) who was present during Patient #12's physical hold on 09/17/2019 revealed he did not consider Patient #12's hold a restraint and therefore did not write an order for a restraint. Interview revealed when asked about Patient #12 being held for 8 minutes by staff would he consider that a restraint MD #1 replied he would not consider that a restraint and would not write an order for that.

Based on policy and procedure review, medical record review, and staff interview, nursing staff failed to complete a suicide screening per policy for patients in the emergency department for 9 of 20 medical records reviewed (Patient #6, #9, #12 #13, #14, #16, #17, #23, and #25) and failed to reassess a patient in the emergency department waiting area for 1 of 1 patients who needed waiting room reassessment reviewed (Patient #9).

The findings included:

A. Review on 10/24/2019 of a policy titled "Triage/Acuity" last revised 11/2018 revealed "...The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department (ED) into either resuscitation, emergent, urgent, semi-urgent or non-urgent...The initial evaluation shall include:...12. Suicide Screening..."

1. Review on 10/22/2019 of Patient #6 revealed he arrived to the ED on 06/21/2019 at 2157 for a chief complaint of "headache." Review revealed Patient #6 was triaged at 2219. Review failed to reveal documentation of a suicide screening.

Interview on 10/25/2019 at 1331 with the Chief Nursing Officer (CNO) revealed a suicide screening should be done on all ED patients.

2. Review on 10/23/2019 of Patient #9 revealed he arrived to the ED on 08/18/2019 at 1735 for a chief complaint of "pain and growth on testicle." Review revealed Patient #9 was triaged at 1745. Review failed to reveal documentation of a suicide screening.

Interview on 10/25/2019 at 1331 with the Chief Nursing Officer (CNO) revealed a suicide screening should be done on all ED patients.

3. Review on 10/22/2019 of Patient #12 revealed he arrived to the ED on 09/12/2019 at 0549 for a chief complaint of "fall." Review revealed Patient #12 was triaged at 0550. Review failed to reveal documentation of a suicide screening.

Interview on 10/25/2019 at 1331 with the Chief Nursing Officer (CNO) revealed a suicide screening should be done on all ED patients.

4. Review on 10/23/2019 of Patient #13 revealed he arrived to the ED on 10/03/2019 at 0833 for a chief complaint of "flank pain." Review revealed he was triaged at 0834. Review failed to reveal documentation of a suicide screening.

Interview on 10/25/2019 at 1331 with the Chief Nursing Officer (CNO) revealed a suicide screening should be done on all ED patients.

5. Review on 10/23/2019 of Patient #14 revealed he arrived to the ED on 08/17/2019 at 1230 for a chief complaint of "abdominal pain." Review revealed he was triaged at 1235. Review failed to reveal documentation of a suicide screening.

Interview on 10/25/2019 at 1331 with the Chief Nursing Officer (CNO) revealed a suicide screening should be done on all ED patients.

6. Review on 10/23/2019 of Patient # 16 revealed she arrived on 09/12/2019 at 1611 for a chief complaint of "fall with left sided weakness." Review revealed she was triaged at 1616. Review failed to reveal documentation of a suicide screening.

Interview on 10/25/2019 at 1331 with the Chief Nursing Officer (CNO) revealed a suicide screening should be done on all ED patients.

7. Review on 10/23/2019 of Patient #17 revealed she arrived on 08/04/2019 at 1806 for a chief complaint of "pregnancy." Review revealed she was triaged at 1815. Review failed to revealed documentation of a suicide screening.

Interview on 10/25/2019 at 1331 with the Chief Nursing Officer (CNO) revealed a suicide screening should be done on all ED patients.

8. Review on 10/23/2019 of Patient #23 revealed he arrived on 08/07/2019 at 2359 for a chief complaint of "kidney stone." Review revealed he was triaged on 08/08/2019 at 0008. Review failed to reveal documentation of a suicide screening.

Interview on 10/25/2019 at 1331 with the Chief Nursing Officer (CNO) revealed a suicide screening should be done on all ED patients.

came back: 8/9/19 at 1612 back pain nausea triaged 1618 d/c 1921

9. Review on 10/23/2019 of Patient #25 revealed she arrived on 10/22/2019 at 1317 for a chief complaint of "abdominal pain and headache." Review revealed she was triaged at 1335. Review failed to reveal documentation of a suicide screening.

Interview on 10/25/2019 at 1331 with the Chief Nursing Officer (CNO) revealed a suicide screening should be done on all ED patients.


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B. Review of the policy titled "Treatment and Care in the Emergency Department", revised 11/2018, revealed "...Patients need to have vital signs reassessed every 2 hours.... Patients required to wait in lobby need to have completed a secondary reassessment within 2 hours. They need to have a reassessment of the complaints every two hours while waiting in the lobby. The triage nurse and the charge nurse will be responsible staff for these patients. If a paramedic is in the secondary triage area they can complete focused reassessments, including VS (vital signs) and pain levels. ..."

ED record review revealed Patient #9, a 78 year old, arrived to the ED as a "walk-in" on 08/18/2019 at 1735. Review of the Triage Assessment, documented at 1745, revealed "... Description of Symptoms GROWTH ON LEFT TESTICLE NOTICED IT LAST NIGHT CAUSING LARGE AMOUNT OF PAIN. ..." Triage assessment review revealed Patient #9 had a normal airway assessment, was breathing without difficulty, with skin pink, warm, and dry, and was noted to be alert and oriented. Pain intensity was documented as 10 on a scale of 0-10 (where 10 equals the worst pain). Review of vital signs at 1745 revealed Temperature was 98.1, Pulse 128 [noted to be obtained from the monitor], Respirations 20, Blood Pressure 102/66, and Pulse Oximetry 95% on room air. Record review did not reveal any further documentation on Patient #9 except for "Emergency Discharge Date/Time: 08/18/19 22:40" and a "Status" listed as "Discharged". Review failed to reveal any reassessment of Patient #9 after 2 hours. Record review revealed Patient #9 returned to the ED on 08/19/2019 at 0039 and expired at 0303.

Interview with Administrative Staff [AS] #9, on 10/23/2019, revealed Patient #9 ' s record should not have stated discharge, instead it should have been documented as a walk-out A [left without being seen].

Interview with RN #10, on 10/23/2019, revealed she was the triage nurse for Patient #9. Interview revealed Patient #9 was in the waiting room because it was "full in the back", there were no beds available at the time. At about 1845, the RN stated, Patient #9 came up and stated he thought he would just go home and try some ointment. RN #10 stated she encouraged the patient to stay and he agreed. RN #10 went off duty at 1900, she stated, and at that time Patient #10 was still in the waiting room. Interview revealed vital signs in the waiting room should be checked by the triage nurse every two hours. They were not due, at the time the patient came up, because it had not been two hours since he arrived.

Telephone interview, on 10/24/2019 at 1530, with RN #11 revealed the RN was the triage nurse the night of 08/18-19/2019. Interview revealed RN #11 remembered Patient #9 being in the ED. Interview revealed the ED was "slammed" and patients were in hallway beds. Interview revealed the ED census had been lower for awhile and the hospital had placed some staff on call during low census times, including that day, then it got very busy. RN #11 stated she knew Patient #9 was still standing there about an hour into her shift, and stated he was probably there about 3 hours, "I knew he had been there a long time". Interview revealed the RN did not know what time Patient #9 left the ED, that he did not come up to her to tell her he was leaving. RN #11 stated the standard was to reassess patients in the waiting room every hour and because nothing was documented it made her think maybe he was not there an hour. Interview revealed it was hard to keep up with the new triage patients and on that night the triage nurse was also trying to cover the "ancillary room". RN #11 stated the "ancillary room" is a room behind triage where patients could be taken for an immediate EKG or something simple like stitches removal. "It was a perfect storm", RN #11 stated. Further interview revealed unless they were aware of when a patient left, the patient should be called 3 times and those calls should be documented.

Telephone interview with the night shift Charge Nurse from 08/18-19/2019, RN #12, revealed the nurse recalled the situation. Interview revealed it was a high volume day and patients were being cared for in the hallway. Interview revealed patients in the waiting room should be rounded on and receive vital signs every hour.

Interview with the Chief Nursing Officer [CNO], on 10/25/2019 at 1315, revealed that on 08/19/2019 some nursing staff in the ED were upset related to what happened with Patient #9 and staffing and met with the CNO to voice their concerns. Interview revealed a supervisor had looked at the census and decided to flex staffing down without consulting with the ED and then the department became very busy. The CNO acknowledged policy was not followed.

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