HospitalInspections.org

The Condition of Participation of Patient Rights has not been met.

Based on clinical record review, interviews and observations for 1 (P#1) of 10 patients reviewed who were cared for in a net bed enclosure, the hospital failed to ensure care was provided in a safe setting when the patient was able to wrap a hospital gown around his/her neck despite being on continuous electronic surveillance.


Based on clinical record review and interview for 1 (P#4) of 10 patients reviewed for appropriate restraint use the hospital failed to ensure timely evaluation/reevaluation to ensure that the patient was cared for in the least restrictive environment.


Based on clinical record review and interview for 9 (P#1, #2, #3, #4, #5, #6 #7 #9 and P#10) of 10 patients reviewed for patient rights the hospital failed to document that the patients and/or representatives were informed that electronic surveillance of their bedrooms/cubicles was in use.



Please see A143, A144 and A201

Based on clinical record review and interview for 9 (P#1, #2, #3, #4, #5, #6 #7 #9 and P#10) of 10 patients reviewed for patient rights the hospital failed to document that the patients and/or representatives were informed that electronic surveillance of their bedrooms/cubicles was in use. The findings include:

Review of the medical record for P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#9 and P#10 lacked documentation that the patients and/or representatives had been informed of the electronic surveillance monitoring of their bedrooms/cubicles while in the West Wing (behavioral health area) of the ED.

During an interview with the Executive Nursing Director on 7/13/17 at 2:20 PM he/she indicated although the medical record does not identify that the patient has been informed of the electronic surveillance it is the expectation that during orientation to the Emergency Department (ED) West Wing nursing staff will inform the patient that all patients are visualized via electronic surveillance while on the unit. A tour of the unit did not identify signage or information indicating electronic surveillance was in use.

Hospital Patient Bill of Rights indicated the patient has the right to personal privacy and the right to refuse consent for recordings, photographs, films or other images to be produced or used for internal or external purposes other than identification, diagnosis or treatment.

Based on clinical record review, interviews and observations for 1 (P#1) of 10 patients reviewed who were cared for in a net bed enclosure, the hospital failed to ensure care was provided in a safe setting when the patient was able to wrap a hospital gown around his/her neck despite being on continuous electronic surveillance. The findings include:

P#1 was evaluated in the Emergency Department (ED) on 5/5/17. He/she arrived at 2:58 AM and was evaluated immediately in triage at 3:02 AM with a chief complaint of suicidal ideation with no plan, feeling anxious and noncompliance with medication. P#1 had a history of depression with psychotic features (violence, destruction of property).

While in triage P#1 began banging his/her head and was immediately brought to the behavioral health unit of the ED at 3:08 AM and placed on 1:1 observation in Room 4. Nursing documentation indicated P#1 was anxious and attempting to wander around the unit. The nurse's note further indicated P#1 requested to be put in 4 point restraints because the last time he/she was in the ED, he/she started throwing things (computers), needed to be restrained and subsequently had been arrested. Registered Nurse (RN) #1 informed P#1 he/she could not be placed in 4 point restraints. Documentation based on the Columbia Suicide Risk Assessment's conducted at 3:33 AM and 3:37 AM indicated P#1's overall suicidality score was 0, indicating no identified risk for suicide.

At 3:46 AM P#1 was evaluated by Medical Doctor (MD) #1. MD #1's assessment indicated initially P#1 was very clear that he/she was not suicidal and not thinking of injuring him/herself. However, P#1 did specifically state that he/she felt capable of injuring others including staff or damaging facility property. According to the note MD #1 thought it was best to restrain P#1 in a net enclosure bed to keep P#1 and staff safe.

At 4:12 AM an order was entered for a net bed enclosure. The physicians order indicated the clinical justification for use of the net bed enclosure was P#1's escalating agitation, restlessness, wandering from his/her room to the nurse's station, impulsive behaviors exhibited without response to redirection, and poor safety awareness. Rationale for use indicated the risk of not using restraints outweighed the risk of using restraints.

At 4:15 AM and 4:30 AM 15 minute checks were completed according to unit standards at which time documentation indicated P#1 was quiet and resting in the net bed enclosure. According to facility documentation from 4:14 AM to 4:35 AM, while in the net bed enclosure, P#1 was monitored via electronic surveillance by RN #1 in accordance with unit protocol related to safety and enviormental rounds.

According to nursing documentation at 4:35 AM, ED Technician #1 was responding to assist with another patient and as he/she passed P#1's room ED Technician #1 observed P#1 with his/her hospital gown tied around his/her neck. ED Technician #1 immediately activated the unit alarm and RN#1 immediately responded. P#1 had spontaneous respirations at the time and RN #1 removed the hospital gown from around P#1's neck. P#1 continued with spontaneous respirations, was alert and able to appropriately respond verbally to questions. At 4:44 AM P#1 was moved from the Behavioral Health ED to the ED trauma room. Assessment identified a concern for neck swelling. A neck X-ray and neck CT scan were ordered and P#1 was intubated as a precaution for airway protection. CT scan results identified no neck trauma and swelling was possibly due to enlarged thyroid and nodules. At 5:54 AM P#1 was transferred to the Intensive Care Unit (ICU) for observation and was extubated on 5/5/17 at 12:00 PM. On 5/7/17 P#1 was transferred to the Behavioral Health Unit and subsequently discharged on 5/12/17.

Observations made on 5/17/17 and 7/13/17 on the West Wing of the ED identified a staff member seated at the nursing station near an electronic surveillance monitor with visibility of 12 patient cubicles. The visual field was in view from cameras directly above the patient beds. Cubicle 4 (where P #1 was located during the 5/5/17 admission) contained a standard patient bed and was located in the far left corner of the unit. Interview on 7/13/17 with the Executive Director and Nurse Manager of the ED identified there was no hospital policy related to the electronic surveillance monitoring in the West Wing of the ED. However, the electronic surveillance monitoring was part of the enviormental rounds and safety of the unit and did not replace observation such as 1:1 or 15 minute checks.

During an interview with RN #1 on 5/16/17 at 2:10 PM, RN#1 indicated based on assessment P#1 had not expressed SI to him/her during two seperate suicide risk assessments. P#1 indicated that he/she was concerned that he/she would harm others. RN#1 indicated P#1 requested the net bed enclosure and willingly entered the net bed enclosure. At that time P#1 was calm and less anxious. RN#1 indicated he/she was monitoring P#1 via electronic surveillance at the nurse's station. P#1 did not appear restless, his/her movements appeared as if he/she was repositioning him/herself and RN #1 did not see any other movements that would be out of the ordinary. P#1 was wearing two hospital gowns while in the bed enclosure due to lack of available hospital pants in order to provide P#1 with dignity when ambulating out of his/her room. One gown was open in the back and one opened in the front.

During a subsequent interview with RN#1 on 8/2/17 at 8:00 AM RN#1 indicated prior to P#1 going into the net bed enclosure P#1 was initially wandering around his/her room and standing against the wall so he/she could not be visualized on the surveillance monitor. P#1 was redirected away from the wall several times. P#1 came to the nurses station and request to be restrained numerous times. At one point P#1 came running to the nurse's station, exhibiting increased agitation. That was when RN#1 called MD#1 to evaluate P#1. RN#1indicated when P#1 was in the net bed enclosure he/she could clearly see P#1 on the surveillance monitor. P#1 had the white blanket pulled over his/her shoulders and arms. RN#1 indicated he/she could not clearly visualize P#1's neck region completely because the blanket and hospital gown were both white and blended together therefore RN#1 could only completely visualize P#1's face. RN#1 indicated while observing P#1 on the surveillance monitor from 4:30AM to 4:35 AM P#1 was moving around in bed adjusting him/herself and did not exhibit any behaviors that made him/her suspicious of P#1's movements.


During a review of the incident with the Safety Program Manager it was identified that although on the realtime feed of the electronic surveillance RN#1 indicated he/she had clear visualization of P#1 while in the net bed enclosure, due to the location of room #4 in the West Wing and the dark netting on the net bed enclosure, there existed the potential for inadequate visualization of the patient.

During an interview with The Medical Director of the ED on 5/16/17 at 11:45 AM he/she indicated the case was reviewed by him/herself in addition to a morbidity and mortality review conducted by MD#1's peers. All reviews conducted concluded that the standard of care was met and they would not have treated the patient differently. The goal was to meet P#1's needs (requesting restraint) and keep P#1 and staff safe while maintaining a least restrictive environment. The decision to intubate P#1, to protect his/her airway, was made prior to the CT scan and subsequent identification of thyroid nodules as a possible cause of the noted neck enlargement.

During an Interview with MD#1 on 6/6/17 at 8:00 AM, MD#1 indicated he/she was called to the ED West Wing because P#1 was insisting on being placed in 4 point restraints even though he/she was informed by nursing that they could not do that. Upon first contact with P#1, P#1 was sullen, not making eye contact and indicated he/she felt out of control and needed to be restrained so he/she would not damage property or injure staff as had occurred at a previous ED visit. MD#1 indicated P#1 did not exhibit suicidal ideation. MD#1 and P#1 discussed options to help him/her feel in control and P#1 said he/she no longer wanted to be in restraints but felt he/she would be secure in a net bed enclosure. MD#1 indicated at that moment every 15 minute checks would have been sufficient however he/she was not sure long term this would have been effective. Upon surveyor inquiry MD#1 indicated in this case the net bed enclosure was used at the request of P#1 as a protective measure based on P#1's previous history and to keep P#1 from harming himself or others. MD#1 indicated when P#1 was found with a piece of clothing tied around his/her neck, P#1's neck appeared swollen and based on assessment MD#1 felt the concern was acute and intubated P#1 to protect his/her airway in the event the swelling progressed causing an emergent situation.

Facility policy "Decision tree/Net Bed Enclosure" indicated behaviors to warrant the use of a net bed enclosure include harm to self, agitation and disruptive behavior and threatening disruption to the environment. Following this incident, the hospital moved the net enclosure bed to a room/cubicle closer to the nursing desk for better visualization.

The ED West Wing standard of care identified patients were to be checked every 15 minutes at a minimum and facility Observation Guidelines identify patients who exhibit suicidal/homicidal behaviors will be observed every 15 minutes at a minimum and every 2 hours for patients with significant problematic behaviors. Manufacturer's user manual for the net bed included recommendations that the patient be checked every 15 minutes to ensure the patient is free from injury, calm and comfortable. Patients that may require additional observation include violent, aggressive or combative patients and suicidal/homicidal patients.

Based on clinical record review and interview for 1 (P#4) of 10 patients reviewed for appropriate restraint use the hospital failed to ensure timely evaluation/reevaluation to ensure that the patient was cared for in the least restrictive environment. The findings include:

Patient (P) #4 was evaluated in the hospital with a chief complaint of dementia with increased confusion. According to medical record documentation on 5/31/17 at 4:30 AM a physician's order was written for a non-violent bed enclosure for behaviors of climbing out of bed without responding to redirection/reorientation, agitation, confusion and poor safety awareness. Criteria to discontinue the restraint was that P#4 would no longer exhibit the identified behaviors. Medical record documentation indicated on 5/31/17 from 5:56 AM until 5/31/17 at 8:19 PM P#4 was quiet resting and/or asleep. On 5/31/17 at 8:19 PM the enclosure bed was unzipped and opened for a trial without restraint and P#4 immediately attempted to get out of the bed was not responding to redirection. On 5/31/17 at 8:50 PM the net bed enclosure was reordered. Continued documentation identified that despite P#4 being calm, cooperative and/or asleep on 5/31/17 from 9:50 PM to 6/1/17 at 2:30 PM (greater than 16 hours), the enclosure bed was not discontinued until 6/1/17 at 2:30 PM. P#4 was discharged from the ED on 6/1/17 at 2:39 PM.

Review of the net bed enclosure orders and documentation on 7/13/17 at 2:20 PM with the Executive Nursing Director and Nurse Manager of the ED identified the decision to trial a patient out of the enclosure bed is based on an assessment by the Registered Nurse (RN) and should be completed when the identified behaviors have subsided.

Hospital Restraint Policy indicated the physician/Advanced Practice Practitioner (APP)/RN are to discontinue restraints or seclusion at the earliest possible time regardless of the scheduled expiration of the order after completion of assessment of patient behavior and release criteria being met.