HospitalInspections.org

Based on document review, medical record review, staff interview and video review, it was determined the facility failed to protect and promote each patient's rights. The facility failed to ensure emergency room staff were trained in the safe management of disruptive patient behavior and physical restraint, failed to ensure all patients were free of all forms of abuse, and failed to ensure all patients had the right to be free from restraint.

Findings included:

The facility failed to ensure emergency room staff were trained and able to demonstrate competency in physical restraint. See A0196

The facility failed to ensure patients were free of all forms of abuse. See A0145

The facility failed to ensure patients had the right to be free from restraint. See A0154

Video Evidence Obtained

Based on document review, medical record review, staff interview and video review it was determined the facility failed to ensure patients were free from all forms of abuse for one (#3) of seventeen patients sampled.

Findings included:

Review of the facility policy, B.5, "Workplace Violence/Weapons," stated 3.0 Violence or Threats of Violence: any acts or threats of violence by any employee against any other employee, patient, visitor or any other person on hospital or other affiliated premises, or during an employee's working hours, are expressly forbidden. Any employee who engages in any threatening behavior or acts of violence or who uses obscene, abusive or threatening language or gestures will be subject to disciplinary action, up to and including immediate termination.

Review of the security log revealed an event on 1/23/2020 for an aggressive individual which occurred in the Emergency Department (ED). Review of the security report revealed a security event occurred at 1:40 pm. The narrative report stated while patrolling the ED sounds of a disturbance came from the area of the main nurse's desk. Security documented as the area was approached a male and female nurse were seen standing over a patient who was on the floor. The male nurse was asked to step away from the patient so security could handle the situation. Security noted the patient offered no resistance or inappropriate behaviors and he was escorted outside of the building. Security noted the patient had an injury to his forehead. Security documented the ED Nurse Manager advised security to call the police as the ED staff were pursuing charges against the patient for assault.

Review of the security report revealed interview with the male nurse revealed the nurse was in fear of imminent harm, so he was forced to take the patient to the ground. Documentation stated other nursing staff were reluctant to give a statement. Police were called, investigated, and the patient was arrested and transported from the property by the Police.

Review of the video footage as recorded by security cameras located in the ED and saved by the security department, revealed on 1/23/2020 the patient can be seen in a stretcher located in the hallway of the Emergency Department. The video footage revealed at 1:26 pm a male EVS (Environmental Services) staff member moved the patient's stretcher from one side of the hallway to the other side. Another female staff member was seen walking by the patient in the hall stretcher and then used a radio device, in what appeared to be, to alert another staff member that the patient in the hall stretcher got off the stretcher and was walking toward the exit doors.

The video revealed at 1:28 pm a male staff member, near the nurse's desk by the ED exit doors, donned a pair of gloves and appeared to say something to the patient (no sound available during video review). At 1:29 pm two female staff are seen at the area of the subject patient and male nurse as well as another male staff member standing nearby. The staff are seen standing near the patient, talking to him, as the patient removed his jacket and a hospital gown. The staff were, what appeared to be checking the patient's arms for any IV's (Intravenous lines) in place. The patient put his jacket back on and one of the female nurses handed him his bag of belongings. At 1:30 pm the male staff member can be seen holding the patient's left wrist as the patient, in what appeared to be trying to pull away from the male staff members grip. The patient appeared to drop his belongings held in his right hand and lowered his head slightly and appeared to be trying to get the male nurse to release his grip. The male staff member was seen grabbing the patient behind his neck and took him down to the ground. The male staff member was seen holding the patient on the ground with his knee in the patients back and hands on the back of the patient. A male security officer was then seen walking up to the location of the event. The male staff member is then seen releasing the patient and walked away from the immediate area. The two female staff members stayed at the area until the patient was on his feet.

Review of the medical record for patient #3 revealed the patient was brought to the facility Emergency Department (ED) on 1/23/2020 via ambulance. Review of the Emergency Medical Services (EMS) Patient Care Report revealed emergency response were dispatched for a call regarding an intoxicated person at 11:59 am. They arrived to find a person that admitted to drinking heavily and requested transportation to the hospital. Assessment documented by the EMS provider at 12:02 pm noted the neurological status of the person was confused. EMS transported the person and arrived at the hospital's ED at 12:18 pm.

Review of the Emergency Documentation revealed the patient was initially seen by a physician at 12:27 pm. The ED physician's documented history of the present illness stated the patient presented with alcohol intoxication, the onset was chronic, and symptoms were constant. The Review of Systems, as documented by the ED physician, revealed the neurological symptoms were altered level of consciousness, no headache, no dizziness with all other systems negative. The Physical Examination of the patient revealed the patient's neurological status was alert and oriented to person, place, time, and situation. The patient's psychiatric status was assessed as cooperative. Laboratory tests were ordered and collected at 1:20 pm.

Review of the record revealed the Registered Nurse (RN) assessed the patient at 12:46 pm and documented the patient's mental status was alert/full consciousness, the chief complaint was alcohol intoxication, and the patient's vital signs were all within normal range.

Review of the Emergency Documentation revealed the ED physician noted the re-examination, no time documented, that the patient became aggressive and got into an altercation with staff. The patient said he wanted to leave. The patient was able to ambulate without difficulty and was alert and oriented. The patient left the emergency department without paperwork. The ED physician documented the plan as: the patient's condition was stable, disposition was discharged to home, and the patient was counseled regarding the diagnosis of alcohol intoxication, diagnostic results, and the treatment plan. The patient indicated understanding of instructions. The record was electronically signed by the ED physician on 1/23/2020 at 1:57 pm.

Review of the laboratory results revealed a critical laboratory value was called on 1/23/2020 at 2:07 pm. The critical lab was an Ethanol level of 0.427 (documented reference range is 0.005; 0.08 is legally intoxicated).

Interview with the Director of Security on 2/11/2020 at 2:42 pm was conducted via telephone regarding the event on 1/23/2020 in the ED. The Director stated any security event which could potentially be held against a patient or the facility is saved and reported up the chain of command. The Director stated he was informed of the event of 1/23/2020 in the ED and confirmed he informed the Public Safety Director on 1/23/2020. He stated he reviewed the video and wrote his report on 1/24/2020 and provided it to the Public Safety Director. He stated when he watched the video, he saw what looked like inappropriate actions by the nurse. The Director of Security stated the nurse grabbed the patient and took him to the ground "kind of violently." He stated head injuries can be very serious and this was not the way to take a patient down to the ground. He stated, "he (the patient) obviously hit his head because he was bleeding."

Interview with the Public Safety Director was conducted on 2/12/2020 at 9:47 am regarding the event of 1/23/2020 in the ED. He stated he received the report on 1/24/2020 from the Director of Security and following review of the video by the police the assault charges were dropped against the patient and he was only charged with public intoxication. The Public Safety Director stated he escalated the event up the chain of command and informed the Director of Support Services to whom he reports. He also stated he told the Director of Support Services the Chief Executive Officer (CEO) needed to be informed due to the patient injuries sustained during the event and possible actions taken against the male nurse. The Public Safety Director stated he went to the Risk Management department on 1/24/2020 to inform the Director of Risk Management of the event but she was out for the day. He stated it was Friday and she wasn't due back until Monday, 1/27/2020. On 1/27/2020 at 8:00 am he went back to the Risk Management department and informed the Director of Risk Management of the event.

Interview with the Director of Risk Management (RM) was conducted on 2/12/2020 at 10:20 am regarding the event on 1/23/2020. The Director of RM stated she did not recall being informed of the incident by the Public Safety Director and only became aware of it yesterday (2/11/2020).

Review of the medical record for patient #3 revealed the patient had a second visit to the ED on 1/23/2020. Review of the Emergency Medical Services (EMS) Patient Care Report revealed they were dispatched to the local jail at 5:06 pm. EMS documentation revealed they arrived to the jail at 5:12 pm for a patient that assaulted a nurse, as informed of by Police, that had been seen in the ED for alcohol intoxication, but he was not medically cleared from the bump on his head or the pain in his right knee, so Police requested he be taken back to the facility's ED for clearance. EMS documented arrival at the ED was 5:56 pm.

Review of the medical record revealed the patient arrived on 1/23/2020 at 6:00 pm with police for medical clearance. Review of the ED Physician's examination, noted at 6:04 pm, revealed the patient was previously here for alcohol intoxication with a blood alcohol level greater than 400. The patient was noted to have a laceration above his left eyebrow, and he complained of right knee pain. Documentation revealed on examination the right knee had suprapatellar swelling and diffuse tenderness to palpation. Results of testing revealed the patient's alcohol level, noted at 6:39 pm, was 0.268 and an x-ray of the right knee, noted at 8:02 pm, revealed a patellar fracture. The CT scan of the head and cervical spine were negative for abnormal findings. Documentation revealed a 3 cm (centimeter) laceration was repaired, the patient was provided information on the diagnostic results, the treatment plan, and the need for follow-up. The patient was discharged to police custody at 11:04 pm.

Video Evidence Obtained

Based on document review, medical record review, staff interview and video review it was determined the facility failed to ensure patient's rights to be free from physical abuse and free from restraint, of any form, were implemented for one (#3) of seventeen patients sampled.

Findings included:

Review of the facility policy, B.5, "Workplace Violence/Weapons," stated 3.0 Violence or Threats of Violence: any acts or threats of violence by any employee against any other employee, patient, visitor or any other person on hospital or other affiliated premises, or during an employee's working hours, are expressly forbidden. Any employee who engages in any threatening behavior or acts of violence or who uses obscene, abusive or threatening language or gestures will be subject to disciplinary action, up to and including immediate termination.

Review of the security log revealed an event on 1/23/2020 for an aggressive individual which occurred in the Emergency Department (ED). Review of the security report revealed a security event occurred at 1:40 pm. Review of the security narrative report revealed interview with the male nurse revealed the nurse was in fear of imminent harm, so he was forced to take the patient to the ground. Documentation stated other nursing staff were reluctant to give a statement.

The security narrative report stated while attempting to gather more information from the patient, concerning the incident, he escorted the patient from the building and noted the patient had an injury to his forehead. Security was informed by the ED Nurse Manager they wanted Police called and charges pursued against the patient for assault on staff. Documentation revealed Police were called, investigated, and the patient was arrested and transported from the property by the Police.

Review of the video footage as recorded by security cameras located in the ED and saved by the security department, revealed on 1/23/2020 the patient can be seen in a stretcher located in the hallway of the Emergency Department. The video footage revealed at 1:26 pm a male EVS (Environmental Services) staff member moved the patient's stretcher from one side of the hallway to the other side. Another female staff member was seen walking by the patient in the hall stretcher and then used a radio device, in what appeared to be, to alert another staff member that the patient in the hall stretcher got off the stretcher and was walking toward the exit doors.

The video revealed at 1:28 pm a male staff member, near the nurse's desk by the ED exit doors, donned a pair of gloves and appeared to say something to the patient (no sound available during video review). At 1:29 pm two female staff are seen at the area of the subject patient and male nurse as well as another male staff member standing nearby. The staff are seen standing near the patient, talking to him, as the patient removed his jacket and a hospital gown. The staff were, what appeared to be checking the patient's arms for any IV's (Intravenous lines) in place. The patient put his jacket back on and one of the female nurses handed him his bag of belongings. At 1:30 pm the male staff member can be seen holding the patient's left wrist as the patient, in what appeared to be trying to pull away from the male staff members grip. The patient appeared to drop his belongings held in his right hand and lowered his head slightly and appeared to be trying to get the male nurse to release his grip. The male staff member was seen grabbing the patient behind his neck and took him down to the ground. The male staff member was seen restraining the patient on the ground with his knee in the patients back and his hands holding the back of the patient. A male security officer was then seen walking up to the location of the event. The male staff member is then seen releasing the patient and walked away from the immediate area. The two female staff members stayed at the area until the patient was on his feet and the saved video footage ended.

Review of the medical record for patient #3 revealed the patient was brought to the facility Emergency Department (ED) on 1/23/2020 via ambulance at 12:18 pm. Review of the Emergency Documentation revealed the patient was initially seen by a physician at 12:27 pm. The ED physician's documented history of the present illness stated the patient presented with alcohol intoxication, the onset was chronic, and symptoms were constant. The Review of Systems, as documented by the ED physician, revealed the neurological symptoms were altered level of consciousness, no headache, no dizziness with all other systems negative. The Physical Examination of the patient revealed the patient's neurological status was alert and oriented to person, place, time, and situation. The patient's psychiatric status was assessed as cooperative. Laboratory tests were ordered and collected at 1:20 pm.

Review of the record revealed the Registered Nurse (RN) assessed the patient at 12:46 pm and documented the patient's mental status was alert/full consciousness, the chief complaint was alcohol intoxication, and the patient's vital signs were all within normal range.

Review of the Emergency Documentation revealed the ED physician noted the re-examination, no time documented, that the patient became aggressive and got into an altercation with staff. The patient said he wanted to leave. The patient was able to ambulate without difficulty and was alert and oriented. The patient left the emergency department without paperwork. The ED physician documented the plan as: the patient's condition was stable, disposition was discharged to home, and the patient was counseled regarding the diagnosis of alcohol intoxication, diagnostic results, and the treatment plan. The patient indicated understanding of instructions. The record was electronically signed by the ED physician on 1/23/2020 at 1:57 pm. Review of the record revealed no further documentation by the nurse following the event which occurred at approximately 1:30 pm according to review of the video footage.

Review of the laboratory results revealed a critical laboratory value was called on 1/23/2020 at 2:07 pm. The critical lab was an Ethanol level of 0.427 (documented reference range is 0.005; 0.08 is legally intoxicated).

An interview was conducted on 2/11/2020 at 1:55 pm, via telephone, with the Respiratory Therapist (RT) that was present in the ED and witnessed the event of 1/23/2020. The RT stated the patient was wobbling and unsteady on his feet and wanted to leave the facility. He stated the patient kept yelling and cursing and kept repeating over and over, "let me go" and "I want to leave." The RT stated the male nurse stopped the patient and checked his arms for an IV (Intravenous) line. He stated the male nurse held the patient's arm and then "just like in WWE" he took the patient down to the ground. The RT stated the patient hit his head very hard on the floor and stated the male nurse was too aggressive in the way he took the patient down. He stated the security officer then showed up. He stated the patient was bleeding from over his eye and he did not witness the patient receive any medical attention.

Interview with the Director of Security on 2/11/2020 at 2:42 pm was conducted via telephone regarding the event on 1/23/2020 in the ED. The Director stated any security event which could potentially be held against a patient or the facility is saved and reported up the chain of command. The Director stated he was informed of the event of 1/23/2020 in the ED and confirmed he informed the Public Safety Director on 1/23/2020. He stated he reviewed the video and wrote his report on 1/24/2020 and provided it to the Public Safety Director. He stated when he watched the video, he saw what looked like inappropriate actions by the nurse. The Director of Security stated the nurse grabbed the patient and took him to the ground "kind of violently." He stated head injuries can be very serious and this was not the way to take a patient down to the ground. He stated, "he (the patient) obviously hit his head because he was bleeding."

Interview with the Public Safety Director was conducted on 2/12/2020 at 9:47 am regarding the event of 1/23/2020 in the ED. He stated he received the report on 1/24/2020 from the Director of Security and following review of the video by the police the assault charges were dropped against the patient and he was only charged with public intoxication. The Public Safety Director stated he escalated the event up the chain of command and informed the Director of Support Services to whom he reports. He also stated he told the Director of Support Services the Chief Executive Officer (CEO) needed to be informed due to the patient injuries sustained during the event and possible actions taken against the male nurse. The Public Safety Director stated he went to the Risk Management department on 1/24/2020 to inform the Director of Risk Management of the event but she was out for the day. He stated it was Friday and she wasn't due back until Monday, 1/27/2020. On 1/27/2020 at 8:00 am he went back to the Risk Management department and informed the Director of Risk Management of the event.

Interview with the Director of Risk Management (RM) was conducted on 2/12/2020 at 10:20 am regarding the event on 1/23/2020. The Director of RM stated she did not recall being informed of the incident by the Public Safety Director and only became aware of it yesterday (2/11/2020).

Review of the medical record for patient #3 revealed the patient had a second visit to the ED on 1/23/2020. Review of the Emergency Medical Services (EMS) Patient Care Report revealed they were dispatched to the local jail at 5:06 pm. EMS documentation revealed they arrived to the jail at 5:12 pm for a patient that assaulted a nurse, as informed of by Police, that had been seen in the ED for alcohol intoxication, but he was not medically cleared from the bump on his head or the pain in his right knee, so Police requested he be taken back to the facility's ED for clearance. EMS documented arrival at the ED was 5:56 pm.

Review of the medical record revealed the patient arrived on 1/23/2020 at 6:00 pm with police for medical clearance. Review of the ED Physician's examination, noted at 6:04 pm, revealed the patient was previously here for alcohol intoxication with a blood alcohol level greater than 400. The patient was noted to have a laceration above his left eyebrow, and he complained of right knee pain. Documentation revealed on examination the right knee had suprapatellar swelling and diffuse tenderness to palpation. Results of testing revealed the patient's alcohol level, noted at 6:39 pm, was 0.268 and an x-ray of the right knee, noted at 8:02 pm, revealed a patellar fracture. The CT scan of the head and cervical spine were negative for abnormal findings. Documentation revealed a 3 cm (centimeter) laceration was repaired, the patient was provided information on the diagnostic results, the treatment plan, and the need for follow-up. The patient was discharged to police custody at 11:04 pm.

There was no further documentation and staff interview confirmed there was no further investigation of the event which occurred in the ED on 1/23/2020. Interview with the Chief Executive Officer (CEO) was conducted on 2/12/2020 at 10:43 am. The CEO confirmed the ED staff did not receive adequate training for verbal and non-verbal de-escalation techniques in order to provide care and services to the patient population that present to the ED with similar complaints as patient #3.

Video Evidence Obtained

Based on medical record review, staff interview, and video review it was determined the facility failed to ensure staff were trained and able to demonstrate competency in the application of physical restraint and assessment and care of a patient physically restrained for one (#3) of seventeen patients sampled.

Findings included:

Review of the security log revealed an event on 1/23/2020 for an aggressive individual which occurred in the Emergency Department (ED). Review of the security report revealed a security event occurred at 1:40 pm in which an ED nurse physically forced a patient to the ground and restrained the patient until security arrived. Review of the security narrative report revealed interview with the male nurse revealed the nurse was in fear of imminent harm, so he was forced to take the patient to the ground. Documentation stated other nursing staff were reluctant to give a statement.

The security narrative report stated while attempting to gather more information from the patient, concerning the incident, he escorted the patient from the building and noted the patient had an injury to his forehead.

Review of the video footage as recorded by security cameras located in the ED and saved by the security department, revealed on 1/23/2020 the patient can be seen in a stretcher located in the hallway of the Emergency Department. The video footage revealed at 1:26 pm a male EVS (Environmental Services) staff member moved the patient's stretcher from one side of the hallway to the other side. Another female staff member was seen walking by the patient in the hall stretcher and then used a radio device, in what appeared to be, to alert another staff member that the patient in the hall stretcher got off the stretcher and was walking toward the exit doors.

The video revealed at 1:28 pm a male staff member, near the nurse's desk by the ED exit doors, donned a pair of gloves and appeared to say something to the patient (no sound available during video review). At 1:29 pm two female staff are seen at the area of the subject patient and male staff member (identified as a nurse) as well as another male staff member standing nearby. The staff are seen standing near the patient, talking to him, as the patient removed his jacket and a hospital gown. The staff were, what appeared to be checking the patient's arms for any IV's (Intravenous lines) in place. The patient put his jacket back on and one of the female nurses handed him his bag of belongings.

The video revealed at 1:30 pm the male staff member can be seen holding the patient's left wrist as the patient, in what appeared to be trying to pull away from the male staff members grip, dropped his belongings held in his right hand and lowered his head slightly in what appeared to be an attempt to get the male nurse to release his grip. The male staff member was seen grabbing the patient behind his neck and took him down to the ground. The male staff member was seen restraining the patient on the ground with his knee in the patients back and his hands holding the back of the patient. A male security officer was then seen walking up to the location of the event. The male staff member is then seen releasing the patient and walked away from the immediate area. The two female staff members stayed at the area until the patient was on his feet and the saved video footage ended.

Review of the medical record for patient #3 revealed the patient was brought to the facility Emergency Department (ED) on 1/23/2020 via ambulance at 12:18 pm. Review of the Emergency Documentation revealed the patient was initially seen by a physician at 12:27 pm. The ED physician's documented history of the present illness stated the patient presented with alcohol intoxication, the onset was chronic, and symptoms were constant. The Review of Systems, as documented by the ED physician, revealed the neurological symptoms were altered level of consciousness, no headache, no dizziness with all other systems negative. The Physical Examination of the patient revealed the patient's neurological status was alert and oriented to person, place, time, and situation. The patient's psychiatric status was assessed as cooperative. Laboratory tests were ordered and collected at 1:20 pm.

Review of the record revealed the Registered Nurse (RN) assessed the patient at 12:46 pm and documented the patient's mental status was alert/full consciousness, the chief complaint was alcohol intoxication, and the patient's vital signs were all within normal range.

Review of the Emergency Documentation revealed the ED physician noted the re-examination, no time documented, that the patient became aggressive and got into an altercation with staff. The patient said he wanted to leave. The patient was able to ambulate without difficulty and was alert and oriented. The patient left the emergency department without paperwork. The ED physician documented the plan as: the patient's condition was stable, disposition was discharged to home, and the patient was counseled regarding the diagnosis of alcohol intoxication, diagnostic results, and the treatment plan. The patient indicated understanding of instructions. The record was electronically signed by the ED physician on 1/23/2020 at 1:57 pm. Review of the record revealed no further documentation by the nurse following the event which occurred at approximately 1:30 pm according to review of the video footage.

Review of the laboratory results revealed a critical laboratory value was called on 1/23/2020 at 2:07 pm. The critical lab was an Ethanol level of 0.427 (documented reference range is 0.005; 0.08 is legally intoxicated).

An interview was conducted on 2/11/2020 at 1:55 pm, via telephone, with the Respiratory Therapist (RT) that was present in the ED and witnessed the event of 1/23/2020. The RT stated the patient was wobbling and unsteady on his feet and wanted to leave the facility. He stated the patient kept yelling and cursing and kept repeating over and over, "let me go" and "I want to leave." The RT stated the male nurse stopped the patient and checked his arms for an IV (Intravenous) line. He stated the male nurse held the patient's arm and then "just like in WWE" he took the patient down to the ground. The RT stated the patient hit his head very hard on the floor and stated the male nurse was too aggressive in the way he took the patient down. He stated the security officer then showed up. He stated the patient was bleeding from over his eye and he did not witness the patient receive any medical attention.

An interview was conducted on 2/12/2020 at 9:47 am with the Public Safety Director. The Director was asked if the Emergency Department (ED) staff are provided training in strategies for preventing, de-escalating, and safe physical restraint/take down of dangerous patient behavior. The Public Safety Director stated the security personnel are provided training on both de-escalation and physical take down/holds. He confirmed the clinical staff do not receive training as far as he knew. He stated the clinical staff are provided an online annual education which is more about educating the staff to assess the situation, it is not any hands-on competency based training.

Review of the medical record for patient #3 revealed the patient had a second visit to the ED on 1/23/2020. Review of the Emergency Medical Services (EMS) Patient Care Report revealed they were dispatched to the local jail at 5:06 pm. EMS documentation revealed they arrived to the jail at 5:12 pm for a patient that assaulted a nurse, as informed of by Police, that had been seen in the ED for alcohol intoxication, but he was not medically cleared from the bump on his head or the pain in his right knee, so Police requested he be taken back to the facility's ED for clearance. EMS documented arrival at the ED was 5:56 pm.

Review of the medical record revealed the patient arrived on 1/23/2020 at 6:00 pm with police for medical clearance. Review of the ED Physician's examination, noted at 6:04 pm, revealed the patient was previously here for alcohol intoxication with a blood alcohol level greater than 400. The patient was noted to have a laceration above his left eyebrow, and he complained of right knee pain. Documentation revealed on examination the right knee had suprapatellar swelling and diffuse tenderness to palpation. Results of testing revealed the patient's alcohol level, noted at 6:39 pm, was 0.268 and an x-ray of the right knee, noted at 8:02 pm, revealed a patellar fracture. The CT scan of the head and cervical spine were negative for abnormal findings. Documentation revealed a 3 cm (centimeter) laceration was repaired, the patient was provided information on the diagnostic results, the treatment plan, and the need for follow-up. The patient was discharged to police custody at 11:04 pm.

Interview with the Chief Executive Officer (CEO) was conducted on 2/12/2020 at 10:43 am. The CEO confirmed the ED staff did not receive adequate training for verbal and non-verbal de-escalation techniques in order to provide care and services to the patient population that presented to the ED with similar complaints as patient #3.

Video Evidence Obtained

Based on review of hospital policy and procedures, review of medical records, and staff interview it was determined the facility failed to ensure an adverse patient event was reported, analyzed, and preventive actions implemented for one (#3) of seventeen patients sampled; and failed to ensure the governing body, medical staff, and administrative officials are responsible and accountable for ensuring clear expectations for safety are established.

Findings included:

Review of the facility policy, "Event Reporting," stated all staff report patient safety events via the hospital reporting system. A patient safety event is defined as an event, incident, or condition that resulted or could have resulted in harm to a patient.

The policy further states required action for all staff, for a patient safety event, requires notification to the physician if an event reaches the patient. The staff involved in the patient safety event are to report the event in the hospital reporting system as soon as possible or by the end of the work shift.

Required action steps of the supervisor/department manager include conducting a brief investigation and documenting investigation findings in the reporting system.

Required action steps for Risk and Quality leaders include review of the supervisor/department manager investigation and determine if additional investigation is needed.

Required action steps for the Executive Team includes establishing priorities and allocation of resources, communicating the status of the investigation, addressing issues or concerns from the team and providing reports to appropriate hospital committees and other reporting groups.

Review of the facility security log revealed an event in the facility's ED (Emergency Department) occurred on 1/23/2020 at 1:40 pm. Documentation revealed a patient had an altercation with the ED staff. Review of the security narrative summary of the event revealed the ED Nurse Manager stated the patient assaulted the nursing staff and she requested police be called and charges pressed against the patient. Documentation revealed the patient was arrested and left in police custody.

Review of the medical record for patient #3, the subject patient involved in the ED altercation with staff, was reviewed. The medical record revealed the patient was brought to the facility Emergency Department (ED) on 1/23/2020 via ambulance at 12:18 pm.

Review of the Emergency Documentation revealed the patient was initially seen by a physician at 12:27 pm. The ED physician's documented history of the present illness stated the patient presented with alcohol intoxication, the onset was chronic, and symptoms were constant. The Review of Systems, as documented by the ED physician, revealed the neurological symptoms were altered level of consciousness, no headache, no dizziness with all other systems negative. The Physical Examination of the patient revealed the patient's neurological status was alert and oriented to person, place, time, and situation. The patient's psychiatric status was assessed as cooperative. Laboratory tests were ordered and collected at 1:20 pm.

Review of the record revealed the Registered Nurse (RN) assessed the patient at 12:46 pm and documented the patient's mental status was alert/full consciousness, the chief complaint was alcohol intoxication.

Review of the Emergency Documentation revealed the ED physician noted the patient was re-examined, no time documented, and that the patient became aggressive and got into an altercation with staff. The patient stated he wanted to leave. The patient was able to ambulate without difficulty and was alert and oriented. The patient left the emergency department without paperwork.

Review of the record revealed no evidence of reassessment of the patient following the altercation with the staff. Review of the facility ED log revealed the patient presented to the facility ED a second time the same day of 1/23/2020.

Review of the medical record for the patient's second visit revealed the Emergency Medical Services (EMS) Patient Care Report documented they were dispatched to the local jail at 5:06 pm. EMS documentation revealed they arrived to the jail at 5:12 pm for a patient, that assaulted a nurse as indicated by Police, that had been seen in the ED for alcohol intoxication, but he was not medically cleared from the bump on his head or the pain in his right knee, so Police requested he be taken back to the facility's ED for clearance. EMS documented arrival at the ED was 5:56 pm.

Review of the medical record revealed the patient arrived on 1/23/2020 at 6:00 pm with police for medical clearance. Review of the ED Physician's examination, noted at 6:04 pm, revealed the patient was previously here for alcohol intoxication with a blood alcohol level greater than 400.

On examination the patient was noted to have a laceration above his left eyebrow, and he complained of right knee pain. Documentation revealed the right knee had suprapatellar swelling and diffuse tenderness to palpation.
Results of testing revealed the patient's alcohol level, noted at 6:39 pm, was 0.268 (previous result, from the patient's first ED visit, at 2:07 pm was 0.427) and an x-ray of the right knee, noted at 8:02 pm, revealed a patellar fracture. The CT scan of the head and cervical spine were negative for abnormal findings. Documentation revealed a 3 cm (centimeter) laceration was repaired with sutures, the patient was provided information on the diagnostic results, the treatment plan, and the need for follow-up. The patient was discharged to police custody at 11:04 pm.

Interview with the Risk Manager was conducted on 2/11/2020 at 2:25 pm. She confirmed there was no event report submitted into the facility reporting system. She confirmed she had no knowledge of the patient safety event therefore no investigation had been conducted.

An interview was conducted with the Director of Security on 2/11/2020 at 2:42 pm via telephone. The Director of Security stated he was informed of the event on 1/23/2020, investigated the event on 1/24/2020, and informed the facility's Public Safety Director of the event on 1/24/2020. He stated he pointed out and documented in his investigative report potentially inappropriate actions by the ED staff member. He stated after watching the video it appeared the patient was intoxicated and wanted to leave the facility. He was confronted by ED staff and after some interactions with the staff the male nurse grabbed the patient and put him on the ground "kind of violently" and then put a knee in his back to hold him there. The Director of Security stated head injuries can be very serious, and this was not the way to take the patient down.

An interview was conducted with the Public Safety Director on 2/12/2020 at 9:47 am. The Public Safety Director stated he reviewed the video and security's investigation and reported the event up the chain of command. He stated he reported the event to the Administrative Director of Support Services and told him the Chief Executive Officer needed to be informed due to the patient being injured during the event and possible action against the ED staff member.

The Public Safety Director stated on 1/24/2020 he went to the Risk Management department to speak to the Director of Risk Management, but she was not in. He stated on Monday (1/27/2020) morning he went to the Risk Management department and informed the Director of Risk Management of the event. He stated he informed her the video had been uploaded to the facility's folder for her to review and investigate.

An interview with the Director of Risk Management on 2/12/2020 at 10:20 am stated she did not remember the Public Safety Director informing her of the patient event of 1/23/2020. She stated if she had known about it she would have investigated the event immediately.

An interview was conducted with the Chief Executive Officer (CEO) on 2/12/2020 at 10:43 am. The CEO confirmed she was informed of the event but had not been apprised of anything further regarding the event until yesterday. The CEO was asked if the staff are provided verbal and non-verbal crisis intervention training. The CEO stated the facility needed to provide crisis intervention training especially the ED staff. She stated the staff have to provide care to this patient population on a daily basis and we need to make sure they have the tools and resources to do it.

Based on review of medical records, staff interview, facility policy and procedure review and video review, it was determined the facility failed to ensure emergency services were provided that met the needs of the patients.

Findings included:

The facility failed to ensure emergency services policies were adhered to by emergency department personnel. The facility personnel failed to ensure patient #3's Emergency Medical Condition had been stabilized prior to discharge. The facility failed to ensure patient #3 was reassessed following an event in the emergency department and prior to discharge. The facility failed to ensure patient #1 was reassessed by an RN (Registered Nurse) at regular intervals per facility policy. See A1104

The facility failed to provide adequate nursing personnel qualified in emergency care to meet the needs of the patients. The facility failed to provide Emergency Department (ED) personnel with appropriate specialized training and education for de-escalation and physical crisis intervention techniques related to the patient population that presents to the facility ED for care and services. See A1112

Video Evidence Obtained

Based on review of medical records, staff interview, facility policy and procedure review and video review, it was determined the facility failed to ensure personnel adhered to emergency services policies which governed the medical care provided for two (#1, #3) of seventeen patients sampled.

Findings included:

Review of the facility policy, "Emergency Department Assessment and Reassessment," stated the purpose of the policy was to provide structure and guidelines for rapid, systemic collection of data through patient assessment and reassessment with which to determine priority of care and implement appropriate interventions for ED (Emergency Department) patients in a timely manner. Section V Procedure stated ED patients are monitored and reassessed by a RN (Registered Nurse) at regular intervals as indicated by the patient condition and based on response to care, change in condition, diagnostic test results, and physician orders. Minimally, nursing reassessment will be performed as follows ... critical care patients, every hour; all other patient populations, every 2 hours. Assessment and reassessment should include appropriate body systems as indicated per patient complaints, condition, diagnosis, and acuity; vital signs to include blood pressure, pulse, respirations, and temperature, oxygen saturation, pain score if indicated.

Review of the medical record for patient #1 revealed the patient was seen on 1/22/2020 at 12:26 pm for chest pain and alcohol intoxication. The physician noted the patient's blood alcohol level was 0.175% (reference range 0.05%) and blood troponin levels were negative (troponin levels are used to detect a heart attack). The physician and nursing notes revealed the patient left against medical advice at 3:30 pm. The patient was counseled regarding the risks of leaving against medical advice.

Review of the record for patient #1 revealed the patient presented a second time at the facility ED on 1/22/2020 at 6:09 pm via ambulance for alcohol intoxication. Review of the medical screening examination performed by the Nurse Practitioner (NP) at 6:14 pm revealed the patient presented with alcohol intoxication, amount unknown, with no other associated symptoms. The NP indicated the patient had been seen recently.

Nursing triage assessment revealed the patient's vital signs, including blood pressure, pulse, respirations, oxygen saturation, and pain assessment, were obtained at 6:16 pm by the RN. Review of the laboratory results, resulted at 6:40 pm, revealed the patient's blood alcohol level was 0.311 (reference range 0.05%) and was noted to be a critical level.

Review of the NP documentation revealed the patient was administered one liter of IV (intravenous) fluids. The NP re-examined the patient on 1/23/2020 at 12:43 am and noted the patient's condition was improved, the patient was clinically sober and ambulatory with a steady gait. The patient was counseled and discharged.
Review of the record revealed no evidence the RN reassessed the patient or obtained the patient's vital signs per facility policy of every two hours. Interview with the ED Nurse Manager on 2/11/2020 at 10:30 am confirmed the findings.

Review of the facility policy, "Medical Screening, Stabilization, and Transfer Criteria," stated under IV Policy, C. Individuals Who Have an Emergency Medical Condition, 1. When the physician or Qualified Medical Person determines the individual has an Emergency Medical Condition (EMC), the Hospital: i. within the capability of the staff and facilities available at the Hospital, treats the patient to the point where the EMC has resolved and the individual is stabilized; D. Individuals Who Have an Emergency Medical Condition but Refuse to Consent to Treatment or To Transfer, 1. If the individual refuses examination or treatment, the Hospital shall document in the medical record the refusal. The medical record shall contain a description of the examination, treatment, or both, if applicable, that was proposed but refused by or on behalf of the individual.

Review of the medical record for patient #3 revealed the patient was brought to the facility Emergency Department (ED) on 1/23/2020 via ambulance. Review of the Emergency Medical Services (EMS) Patient Care Report revealed emergency response were dispatched for a call regarding an intoxicated person at 11:59 am. They arrived to find a person that admitted to drinking heavily and requested transportation to the hospital. Assessment documented by the EMS provider at 12:02 pm noted the neurological status of the person was confused. EMS transported the person and arrived at the hospital's ED at 12:18 pm.

Review of the Emergency Documentation revealed the patient was initially seen by a physician at 12:27 pm. The ED physician's documented history of the present illness stated the patient presented with alcohol intoxication, the onset was chronic, and symptoms were constant. The Review of Systems, as documented by the ED physician, revealed the neurological symptoms were altered level of consciousness, no headache, no dizziness with all other systems negative. The Physical Examination of the patient revealed the patient's neurological status was alert and oriented to person, place, time, and situation. The patient's psychiatric status was assessed as cooperative. Laboratory tests were ordered and collected at 1:20 pm.

Review of the record revealed the Registered Nurse (RN) assessed the patient at 12:46 pm and documented the patient's mental status was alert/full consciousness, the chief complaint was alcohol intoxication, and review of the patient's vital signs revealed all were within normal range.

Review of the Emergency Documentation revealed the ED physician noted the re-examination, no time documented, that the patient became aggressive and got into an altercation with staff. The patient stated he wanted to leave. The patient was able to ambulate without difficulty and was alert and oriented. The patient left the emergency department without paperwork.

The ED physician documented the plan as: the patient's condition was stable, disposition was discharged to home, and the patient was counseled regarding the diagnosis of alcohol intoxication, diagnostic results, and the treatment plan. The patient indicated understanding of instructions. The record was electronically signed by the ED physician on 1/23/2020 at 1:57 pm.

Review of the laboratory results revealed a critical laboratory value was called on 1/23/2020 at 2:07 pm. The critical lab was an Ethanol level of 0.427 (documented reference range is 0.005; 0.08 is legally intoxicated).

Review of the security log revealed an event occurred in the facility's ED on 1/23/2020 at 1:40 pm. Documentation revealed patient #3 had an altercation with the ED staff. Review of the security narrative summary of the event revealed the ED Nurse Manager stated the patient assaulted the nursing staff and she requested police be called and charges pressed against the patient. Documentation revealed the patient was arrested and left in police custody.
Review of the record revealed no evidence of reassessment of the patient following the altercation with the staff. Review of the facility ED log revealed the patient presented to the facility ED a second time the same day of 1/23/2020.

Review of the medical record for the patient's second visit revealed the Emergency Medical Services (EMS) Patient Care Report documented they were dispatched to the local jail at 5:06 pm. EMS documentation revealed they arrived to the jail at 5:12 pm for a patient, that assaulted a nurse as indicated by Police, that had been seen in the ED for alcohol intoxication, but he was not medically cleared from the bump on his head or the pain in his right knee, so Police requested he be taken back to the facility's ED for clearance. EMS documented arrival at the ED was 5:56 pm.

Review of the medical record revealed the patient arrived on 1/23/2020 at 6:00 pm with police for medical clearance. Review of the ED Physician's examination, noted at 6:04 pm, revealed the patient was previously here for alcohol intoxication with a blood alcohol level greater than 400.

On examination the patient was noted to have a laceration above his left eyebrow, and he complained of right knee pain. Documentation revealed the right knee had suprapatellar swelling and diffuse tenderness to palpation.
Results of testing revealed the patient's alcohol level, noted at 6:39 pm, was 0.268 (previous result at 2:07 pm was 0.427) and an x-ray of the right knee, noted at 8:02 pm, revealed a patellar fracture. The CT scan of the head and cervical spine were negative for abnormal findings. Documentation revealed a 3 cm (centimeter) laceration was repaired with sutures, the patient was provided information on the diagnostic results, the treatment plan, and the need for follow-up. The patient was discharged to police custody at 11:04 pm.

Review of the video footage, as recorded by security cameras located in the ED and saved by the security department, revealed on 1/23/2020 the patient can be seen in a stretcher located in the hallway of the Emergency Department. The video footage revealed at 1:26 pm a male EVS (Environmental Services) staff member moved the patient's stretcher from one side of the hallway to the other side. Another female staff member was seen walking by the patient and then used a radio device, in what appeared to be, to alert another staff member that the patient in the hall stretcher got off the stretcher and was walking toward the exit doors. The patient appeared unsteady on his feet while ambulating.

The video revealed at 1:28 pm a male staff member (later identified as an RN), near the nurse's desk by the ED exit doors, donned a pair of gloves and appeared to say something to the patient (no sound available during video review). At 1:29 pm two female staff (later identified as two RN's) are seen at the area of the subject patient and the male nurse as well as another male staff member (later identified as a Respiratory Therapist) standing nearby. The staff are seen standing near the patient, talking to him, as the patient removed his jacket and a hospital gown. The staff were, what appeared to be checking the patient's arms for any IV's (Intravenous lines) in place.

The patient put his jacket back on and one of the female nurses handed him his bag of belongings. At 1:30 pm, according to the video timestamp, the male staff member can be seen holding the patient's left wrist as the patient, in what appeared to be the patient trying to pull away from the male staff members grip. Interview with the Respiratory Therapist on 2/11/2020 at 1:55 pm, regarding the event on 1/23/2020 in the ED, confirmed he witnessed the event. He stated the patient was wobbling and unsteady on his feet. He stated the patient was yelling over and over "let me go" and "I want to leave."

Review of the video revealed the patient appeared to drop his belongings held in his right hand and lowered his head slightly. The patient appeared to try to get the male nurse to release his grip. The video revealed the male staff member grabbed the patient behind his neck and took him down to the ground. The male staff member was seen holding the patient on the ground with his knee in the patients back and hands on the back of the patient.
Interview with the Respiratory Therapist on 2/11/2020 at 1:55 pm, regarding the event on 1/23/2020 in the ED, stated the male nurse was holding onto the patient by the arm and then "just like in WWE (World Wrestling Entertainment)" he took the patient down to the ground. The RT stated the patient hit his head very hard on the ground and he was bleeding from over his eye.

On 2/12/2020 at 11:06 am an interview was conducted with the physician that evaluated the patient on his first visit to the facility ED on 1/23/2020. The physician was asked on 1/23/2020 when was the last time she evaluated the patient. She stated because the patient was located on a stretcher in the hall of the ED she was continuously evaluating and talking to the patient each time she passed by him.

The physician was asked how she was informed or if she witnessed the altercation between the patient and staff. She stated she had gone to another area of the ED to see another patient and stated she heard the patient yelling but did not witness anything. She stated the nursing staff informed her that the patient was belligerent and was swinging at the staff. The physician was asked if she assessed the patient before he left the facility. She stated because she was assessing him continually each time, she walked by him and previously saw him ambulate on his own that the patient was safe to discharge.

Video Evidence Obtained

Based on staff interview, document review, and video review, it was determined the facility failed to ensure Emergency Department (ED) personnel were qualified in emergency care and interventions of patients that required personnel with specialized training and education for de-escalation and physical crisis intervention techniques for two (Registered Nurse (RN) A, RN B) of three ED personnel reviewed.

Findings included:

Review of the facility security log revealed an event in the facility's ED occurred on 1/23/2020 at 1:40 pm. Documentation revealed a patient had an altercation with the ED staff. Review of the security narrative summary of the event revealed the ED Nurse Manager stated the patient assaulted the nursing staff and she requested police be called and charges pressed against the patient. Documentation revealed the patient was arrested and left in police custody.

Review of the video footage, as recorded by security cameras located in the ED and saved by the security department, revealed on 1/23/2020 the patient can be seen in a stretcher located in the hallway of the Emergency Department. The video footage revealed at 1:26 pm, as indicated on the video timestamp, a male EVS (Environmental Services) staff member moved the patient's stretcher from one side of the hallway to the other side. Another female staff member was seen walking by the patient and then used a radio device, in what appeared to be, to alert another staff member that the patient in the hall stretcher got off the stretcher and was walking toward the exit doors. The patient appeared unsteady on his feet while ambulating.

The video revealed at 1:28 pm a male staff member (RN A), near the nurse's desk by the ED exit doors, donned a pair of gloves and appeared to say something to the patient (no sound available during video review). At 1:29 pm two female staff (RN B and RN C) are seen at the area of the subject patient and the male nurse as well as another male staff member (later identified as a Respiratory Therapist) standing nearby. The staff are seen standing near the patient, talking to him, as the patient removed his jacket and a hospital gown. The staff were, what appeared to be checking the patient's arms for any IV's (Intravenous lines) in place.

The patient put his jacket back on and one of the female nurses handed him his bag of belongings. At 1:30 pm, according to the video timestamp, RN A can be seen holding the patient's left wrist as the patient, in what appeared to be the patient trying to pull away from RN A's grip. Interview with the Respiratory Therapist on 2/11/2020 at 1:55 pm, regarding the event on 1/23/2020 in the ED, confirmed he witnessed the event. He stated the patient was wobbling and unsteady on his feet. He stated the patient was yelling over and over "let me go" and "I want to leave."

Review of the video revealed the patient appeared to drop his belongings held in his right hand and lowered his head slightly. The patient appeared to try to get RN A to release his grip. The video revealed RN A grabbed the patient behind his neck and took him down to the ground. RN A was seen holding the patient on the ground with his knee in the patients back and his hands on the back of the patient.

Interview with the Respiratory Therapist on 2/11/2020 at 1:55 pm, regarding the event on 1/23/2020 in the ED, stated RN A was holding onto the patient by the arm and then "just like in WWE (World Wrestling Entertainment)" he took the patient down to the ground. The RT stated the patient hit his head very hard on the ground and he was bleeding from over his eye.

An interview was conducted with RN B on 2/11/2020 at 3:27 pm via telephone. RN B confirmed she was working on 1/23/2020 and witnessed the event. She stated she heard the patient yelling and she went to see if she could assist the other staff. She confirmed the patient was intoxicated, was acting belligerent and was yelling at an EVS (Environmental Services) staff member. She stated RN C told the patient she needed to check his arms for an IV (Intravenous) line before he left and confirmed the patient cooperated at that time by removing his jacket. RN B stated the patient started to walk away but then turned and was "kind of swinging his arms around." She stated that's when RN A took the patient down to the ground. She stated it appeared he was maybe going to try to hit someone. She confirmed she didn't feel threatened at the time but stated she was standing about two arm's length away. RN B was asked how long she had worked in the ED and what education and training had she received regarding de-escalation or physical intervention with intoxicated patients. She stated she had worked in the ED for approximately 5 months and remembered learning de-escalation techniques in nursing school as she graduated in March 2019. She stated they learned some de-escalation techniques in orientation. She stated she had talked to security and they told her the facility used to provide training in crisis intervention but that it wasn't provided any longer.

An interview was conducted with RN A on 2/12/2020 at 12:35 pm via telephone. RN A was asked if he received any de-escalation or physical intervention training since he has been employed at the facility. He stated he did not remember any formal training but stated maybe at orientation some hands-on training was provided. He confirmed he has worked in the facility ED for approximately 5 years.

RN A described the event that occurred in the ED on 1/23/2020. He stated the patient was intoxicated and he kept the patient in the hall stretcher so more staff could have eyes on the patient. He stated the patient became upset with EVS when they moved his bed and he began yelling and cursing at them. RN A stated he got up and put gloves on and tried to de-escalate the patient. He stated the patient was yelling, cursing, and pacing back and forth in front of the EMS doors saying he wanted to leave. RN A stated he also lunged at one of the EVS workers and was saying "why did you hit me" and "keep your hands off me."

RN A stated the patient was ambulating okay and he wasn't stumbling so we were going to let him leave but wanted to make sure he didn't leave with an IV still in his arm. He confirmed the patient took his jacket off while he was checked for an IV. He stated we were helping him get his jacket back on and then he started swinging his arms. RN A stated he made enough movements that "I felt threatened" and then he made a move toward RN C which led me to take him to the ground. He stated I wanted to kind of swing him around toward the EMS doors but due to his instability and our momentum he went down to the ground. He stated it was a judgement call and the patient was getting more and more threatening so "I thought it was the best thing to do." He stated right after the patient went down to the ground security showed up and took over the situation.

An interview was conducted with the Chief Executive Officer (CEO) on 2/12/2020 at 10:43 am. The CEO confirmed the facility no longer provided de-escalation or physical crisis intervention training. She confirmed the staff needed to have the tools, resources, and education in order to provide care and services to their patient population.

Video Evidence Obtained