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Based on a review of documents, a video recorded occurrence, clinical records, and interview, the hospital failed to protect and promote patients' rights to receive care in a safe setting. This failed practice had the potential to affect all patients admitted to the psychiatric unit. (see A144)


The hospital failed to protect and promote patients' rights by not attempting multiple de-escalation techniques before initiating forensic restraints. (see A154)


The hospital failed to ensure the condition of a patient who was restrained was monitored by a physician, other licensed independent practitioner or trained staff. The hospital failed to protect the rights of a restrained patient. (see A175)

Based on a review of policies and procedures, a video recorded occurrence, clinical records, and interview, the hospital failed to protect and promote patients' rights to receive care in a safe setting. This failed practice had the potential to affect all patients admitted to the psychiatric unit.


Findings:


The surveyors reviewed a document titled "Center of Behavioral Medicine Adult Unit/ 29 EAST/ 1200 Scope of Care 2016." The document described the purpose of the unit, reporting the unit would provide for management of "crisis" situations, to include behavioral disturbances. The document described the goal of the unit, reporting the unit would ensure the environment would promote stabilization of poor impulse control while maintaining the safety of the patient.


The surveyor reviewed a clinical document titled "Initial Assessment Licensed Mental Health Professional Statement" dated 12/16/16 (no time stamp). It reported the patient sought treatment due to a current manic phase, presenting with delusions and agitation. It also reported the patient was admitted involuntarily because he was a danger to himself and others.


The surveyor reviewed a document titled "Patient Rights and the Notification of Physical Restraints" dated 12/16/16. The document described the hospital's process for managing violent behavior and contained sections for the patient/representative to describe situations that might trigger violent behavior in the patient. This form was left blank, including any signatures from staff, or the patient/patient's representative.


The surveyor reviewed a clinical document created at 8:27 AM on 12/18/16 which reported the goal for the patient was to be free from harm/injury. It also documented the patient was still confused and anxious with poor judgement.


A document "Restraint/Seclusion Definitions" reported the hospital was responsible for providing safe and appropriate care for the patient, as well as completing nursing assessments at required intervals to include documentation of care, vital signs, circulation, elimination, etc.


The surveyors reviewed a hospital policy titled "Code 39" which reported a Code 39 was called when there was an immediate need for help to control an aggressive person and that only CAPE trained personnel respond to the code. During a review of a video recording provided by the hospital, the surveyors noted Staff K initiated a take down of Patient #1 12/18/16 at 9:54 p.m.


The guard held the patient prone on the floor and straddled him. A staff member from another unit then laid over the patient's legs. The patient's buttocks were exposed for 4 minutes until a staff member from another unit covered them with a towel. At 9:59 p.m., the guard placed handcuffs on the patient.


During an interview with hospital staff on 12/28/16 at 3:00 p.m., Staff E verified security staff did not attempt to use CAPE and planned to keep the patient in a CLEET restraint until police arrived to arrest the patient. The surveyors requested clarification regarding circumstances in which staff would decide to skip CAPE practices and proceed directly to a CLEET restraint. Staff G reported the decision was made based on "clinical decision making".

Based on a review of policies and procedures, a video recorded occurrence, clinical records, and interview, the hospital failed to protect and promote patients' rights per their policy by not attempting multiple de-escalation techniques before initiating a forensic restraint (meaning not a therapeutic restraint, which is designed to protect a patient from harm).


Findings:


A document titled "Center of Behavioral Medicine Adult Unit/ 29 EAST/ 1200 Scope of Care 2016" was reviewed by the surveyor. The document described the purpose of the unit, reporting the unit would provide for management of "crisis" situations, to include behavioral disturbances. The document described the goal of the unit, reporting the unit would ensure the environment would promote stabilization of poor impulse control while maintaining the safety of the patient.


The surveyor reviewed a policy titled "Therapeutic Hold." The document reported a therapeutic hold was used in place of physical restraints when the patient became physically out of control to allow staff to regain control of emotions and behavior. It further stated that the staff holds the patient for a short period (usually 5 to 10 minutes), until "the impulsive upsurge has passed and the patient has better control."


The surveyor reviewed a document titled, "Restraint/Seclusion Definitions" which defined handcuffs as forensic restraints. It further documented forensic restraints were applied by law enforcement and/or correctional personnel, and as such were considered law enforcement restraints and not governed by hospital restraint guidelines. During an interview with multiple hospital staff members on 12/28/16 at 1500, Staff G reported security personnel are employees of the hospital, not law enforcement personnel.


The document also reported that handcuffs may be applied by Hospital Safety and Security personnel only when necessary to temporarily restrain and/or subdue aggressive, combative individuals whose actions/behaviors are considered to be criminal activity. The document also reported the hospital was responsible for providing safe and appropriate care for the patient, as well as completing nursing assessments at required intervals to include documentation of care, vital signs, circulation, elimination, etc.


A video recording without audio was viewed by the surveyors. The surveyors noted at the beginning of the video, the patient was naked in the day room with three female staff members. The surveyors noted Staff J quickly extend her arms toward the patient. The surveyors noted Staff L walk away from the patient and other staff members and throw her arms in the air.


The surveyors reviewed a hospital policy titled "Code 39" which reported a Code 39 was called when there was an immediate need for help to control an aggressive person and that only CAPE trained personnel respond to the code. During a review of a video recording provided by the hospital, the surveyors noted Staff K initiated a take down of Patient #1 12/18/16 at 9:54 p.m.


The guard held the patient prone on the floor and straddled him. A staff member from another unit then laid over the patient's legs. The patient's buttocks were exposed for 4 minutes until a staff member from another unit covered them with a towel. At 9:59 p.m., the guard placed handcuffs on the patient.


On a multidisciplinary progress note dated 12/19/2016 at 12:03 a.m., RN #1 documented having called a code 39, had security call the police, and notified the doctor who agreed with the RN request to have the patient sent to jail. RN #1 further documented the patient was escorted off of unit around 11:10 p.m. by OKCPD.


During an interview with the Staff G, E, F, and I on 12/28/16 at 3:00 PM the surveyor asked when restraining an out of control patient, was assessment and therapeutic conversation taking place. Staff I reported handcuffs were not considered restraints. Staff #1 reported that in the absence of audio, he/she would hope so. The surveyor asked about the lack of documentation to verify therapeutic conversation and assessment continued. Staff G verified that in the absence of audio in the recording, there should have been documentation to record that therapeutic conversation and assessment continued.


The surveyor asked why so many staff were just standing around watching the incident unfold. Staff G reported that when a code 39 was called, there was an influx of other staff to help with the situation. The surveyor reported the video only showed one person helping (laying on the patient's legs) while the patient was straddled and pinned down by the security guard for more than four consecutive minutes before getting handcuffed. The surveyor further reported the other techs stood watching and the nurses could not be seen assessing the patient for injuries and adequate breathing.


The surveyor also asked what was considered a therapeutic hold. Staff G did not provide a description of a therapeutic hold, but reported that the staff may need to readjust several times to reach a therapeutic hold. The surveyor relayed that the video showed the security guard straddling the patient for over four minutes while another employee laid on the patient's legs with no readjustments. Staff E verified it had been decided when the code 39 was called, his staff was there to take the patient down and hold him until the police arrived to arrest the patient.


The surveyor asked Staff E if that meant it had already been decided when security arrived that the patient was going to be arrested? Staff E verified that was correct. The surveyor relayed the documentation reported the patient came to the hospital seeking treatment for a behavioral crisis and the hospital admitted the patient for management of the crisis. The surveyor relayed the documentation supported the crisis being discussed was managed with forensic restraints, which went against policies for the unit and was not helpful to the patient in a crisis. Staff G reported, "This was not just one event, this began earlier in the day. He was naked and masturbating through the unit. He wouldn't listen. He was out of control." Staff I reported the staff were "traumatized" by the patient.

Based on a review of clinical records, video recording, policies and procedures, and interviews, the hospital failed to ensure the condition of the patient who was restrained was monitored by a physician, other licensed independent practitioner or trained staff. The hospital failed to protect the rights of a restrained patient.


Findings:


A hospital policy titled "Code 39" stated CAPE (Creating a Positive Environment) trained personnel from all behavioral programs, safety and security officers, and appropriate supervisors respond to a Code 39 and that only CAPE trained personnel respond to a Code 39 in the Center of Behavioral Medicine and that a staff member continues to intervene with the patient.


A policy titled "Restraint Utilization" documented the patient's right to privacy, freedom, dignity, comfort and autonomy would be maintained as much as possible and modesty would be preserved. It further documented the hospital was responsible for providing safe and appropriate care for patients, completing nursing assessments at required intervals to include documentation of care, vital signs, circulation and elimination. It further documented that forensic or correction restraints would follow these restraint guidelines.


During a review of a video recording of the patient's restraint that took place on 12/18/16 between 9:54 p.m. and 10:02 p.m., the surveyors noted one staff member approached the patient, Staff M, who attempted to cover the patient's buttocks after 4 minutes of restraint.


The video recording showed that after the take down of the patient by security, no nurse approached the patient for assessment. There was no nursing assessment or reassessment documented in the clinical record. After the patient was restrained by security with forensic restraints, no nurse approached Patient #1 who remained handcuffed in a chair. No nurse was seen providing or attempting to provide restraint monitoring of the restrained patient at any time during the encounter. No nurse was seen completing nursing assessments to include documentation of care, vital signs, circulation or elimination, per the hospital's own policy.


During interviews with Staff G, E, F, and I on 12/28/16 between 1430 and 1545, Staff E reported the security staff was responding to a report of assault against an employee. The surveyor asked what was considered assault? Staff E reported any unwanted act of aggression would be considered assault. The surveyor asked why didn't the nurses begin restraint monitoring and Staff I reported they (the hospital) didn't consider handcuffs to be restraints. Staff G and E reported at that time, they were just waiting for the police to pick up the patient. The surveyor requested clarification if the patient was still receiving care while restrained. Staff G reported the nurses were "traumatized" at that moment and there was no documentation to support nursing care was provided. The surveyor asked at what time the staff decided Patient #1 was no longer a patient and at what time was the patient discharged. Staff F reported she wasn't sure she could answer that question and that the time the patient was handcuffed would not match the time the patient was released to the police.