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Based on observation, record review and interview, the hospital failed to ensure compliance with the rights of a patient (Patient #3) who presented to the pediatric emergency department and was placed on a (PEC) physicians emergency certificate. The hospital failed to ensure personal privacy was maintained as evidenced by placing Patient #3 in room "a" measuring 8 foot 10 inches by 12 foot 2.5 inches with two other patients and a parent.
Findings:

Review of the map of the pediatric emergency room and a map of room "a" revealed room's dimensions were 8 feet and 10 inches by 12 feet and 2.5 inches, with total square footage of 107.84.

An observation was made of the Pediatric Emergency Room on 11/21/11 at 12:45 p.m. with S4Nurse Manager of the Pediatric Emergency Room. Room "a" was reported by S4 as the safe room for pediatric patients waiting for placement in mental health facilities for treatment. She went on to report 4 patients with one parent each could be in the room at one time with a staff member assigned to observe the room at all times. At the time of the observation 1 patient was in the room with a security guard seated in the door way with his chair facing towards the room. There were 2 additional reclining chairs in the room. S4 reported new reclining chairs were on order, which would give the room 4 reclining chairs for the patients and a regular chair for the parents to sit in if they choose to stay in the room with their child. S4 went on to report the staff would place mats on the floor if the patient needed to sleep in the safe room.

Patient #3
Patient #3 was a 13 year old male patient brought to the pediatric emergency department on 11/14/11 at 12:48 p.m. by his mother. The mother was seeking long term placement for her child due to his violent behaviors. The patient was placed on PEC (Physician Emergency Certificate) and transferred to an acute care psychiatric facility on 11/15/11 at 11:51 a.m.

A phone interview was conducted with the mother of Patient #3 on 11/22/11 at 8:30 a.m. Patient #3's mother stated the room they placed her son in while he was in the emergency room had no privacy and took away her son's dignity. She stated her son had to sleep on a mat on the floor.

An interview was conducted with S11RN on 11/23/11 at 7:30 a.m. S11 reported she was the night nurse assigned to Patient #3 on 11/14/11. When questioned about who determines if a patient is a Level 1 (1:1 observation) versus a Level 2 observation, she stated basically the nurses do in conjunction with the physicians. S11 reported if they are a harm to their self or others at the time of the assessment they are assessed as a Level 1 and placed on 1:1 (1 staff member to 1 patient in a private room). If they have a history of aggressive/violent behavior and not acting out at the time of admit they are a Level 2. S11 reported she did receive a complaint from Patient #3's parent on 11/14/11. S11 reported the patient's mom had stated her son was being held in a padded cell, which was too small for all those patients with a "horse chair" to sit in. S11 stated she referred the mom to the nurse manager. When questioned what a "horse chair" was, S11 reported she wasn't sure. The chairs in the room at the time were reclining chairs. At that time there were 2 other patients in the room with a parent.

Review of the ED (Emergency Room Department) Nurses Notes dated 11/14/11 at 20:15 (8:15 p.m.) revealed in part, "...Mother upset length of stay with inability to be placed, states they feel that we are treating them like a prisoner, in a padded cell with horse chairs in the room, mother raising her voice outside the room in nursing station. Explained to the mother that we were sorry for the inconvenience. She states she wishes him to be placed in facility in Texas. I spoke with S12, she states they have been denied placement at two facilities in the state due to child not meeting criteria and can't be taken across state lines due to the PEC process. Mother still unable to be calmed, nurse manager called to speak with family."

An interview was conducted with S4Nurse Manager on 11/22/11 at 10:25 a.m. S4 reported she spoke to the mother of Patient #3 and the mother was concerned about the number of patients in the safe room and concerned that her son's behavior would escalate. S4 reported the mother was also concerned about there not being a mattress for the child to sleep on so they brought a mattress in the room and placed it on the floor so the child could go to sleep.

The Guidelines For Design and Construction of Health Care Facilities 2010 edition as outlined by "The Facility Guidelines Institute" were reviewed for Emergency Department observation unit requirements. The guidelines (2.2-3.1.4.3 Observation unit) indicate if required by the functional program, an observation unit for patients requiring observation up to 23 hours shall be provided in accordance with the following requirements:(1) The size of the unit shall depend on the patient acuity mix and projected use of the unit. (2) Space requirements (a) A patient cubicle with a minimum clear floor area of 100 square feet (9.29 square meters) shall be provided. (b)If a patient room is used, it shall have a minimum clear floor area of 120 square feet (11.15 square meters).(c) Each patient bed area shall have space at bedside for visitors. (3) Patient privacy. Each bed area shall have provision for visual privacy from casual observation by other patients and visitors.

Review of the Hospital's policy on Physicians Emergency Certificate (PEC)/Observation and Monitoring of Behavioral Patients in the ECU (Emergency Care Unit), Serial Code: MH-02, revealed Level I is 1:1 Observation. Level 1 is when the patient is observed on a 1:1 staff/patient ratio when the clinical assessment indicated a high level for immediate or impulsive behavior that may be harmful to self or to others exits. Level 2 is constant observation (Line of sight). Constant observation is less restrictive than 1:1 observation and requires the patient to be in full visual contact by a trained staff member at all times. Up to 4 patients may be clustered in a defined area supervised by 1 staff member, as per patient and unit needs.

Based on record review and interview, the hospital failed to ensure that medications were administered in accordance with the orders of the practitioner responsible for the patient's care for 1 out of 11 sample patients (#3) reviewed for medication administration. Findings:

Patient #3 was a 13 year old male patient brought to the pediatric emergency department on 11/14/11 by his mother. Documentation revealed the mother was seeking long term placement for her child due to his violent behaviors. The patient was placed on PEC (Physician Emergency Certificate) and transferred to an acute care psychiatric facility on 11/15/11 at 11:51 a.m.

Review of the Medication Orders for Patient #3 revealed an order dated 11/15/11 at 05:01 (5:01 a.m.) for Propranolol 40 mg (milligrams) po (by mouth) once and a medication order for Adderall XR ordered on 11/15/11 at 04:58 (4:58 a.m.) for 30 mg po once.

Review of the electronic medical record for Patient #3 with S4Nurse Manager of Pediatric Emergency Room revealed no documentation that Adderall 30 mg po and Propranolol 40 mg po was ever administered to Patient #3 while in the pediatric emergency room.

An interview was conducted with S10RN on 11/22/11 at 2:45 p.m. S10 reported she was the nurse who took care of Patient #3 on 11/14/11 and 11/15/11 on the 7 a.m. to 7 p.m. shift. S10 reported she never gave Patient #3 any medication and if she remembered correctly the mother said she had given the patient his medication already. When questioned if she told the mother it was alright to give the patient his home medications or if she handed the mother her son's medication to give, she stated no.

An interview was conducted with S11RN on 11/23/11 at 7:30 a.m. S11 stated she worked the 7 p.m. to 7 a.m. shift on 11/14/11 and took care of Patient #3. When questioned if see gave Patient #3 his medication (the Adderall and the Propranolol) that was ordered by the physician, she stated she did not administer any medication to Patient #3. When questioned if parents could give home medication to their children in the emergency room or if the nurses could ask the parents to administer medication to their children, she stated no.

An interview was conducted with S4Nurse Manager on 11/22/11 at 2:40 p.m. S4 reported there was no documentation to indicate that Patient #3 had received his medication as ordered by the physician while in the emergency room on 11/14/11 and/or 11/15/11.

Review of the hospital's policy on Medication Administration, Policy Reference # NMA-024 revealed in part, "All medication will be given in a safe and accurate manner and documented by appropriately trained and authorized personnel in accordance with the state and federal regulations."