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Based on staff interview, Emergency Department (ED) record review, policy and procedure (P&P) and central ED log review, the hospital failed to maintain a central log on each individual who comes to the emergency department seeking assistance and document whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged, for 1 of 20 patients reviewed (Patient 3).

Findings:

Review of Emergency Department's policy titled "Register-Emergency Department " (last revised 9/12) indicated the purpose was "To ensure an accurate recording of all Emergency Department (ED) visits in a permanent register." The policy directed that "1. All patients who are registered to be seen in the ED shall be recorded in a permanent register. The T-system (electronic record system) generates a department log. 2. Such register shall contain: date, time of registration, patient name, address, age and sex, method of arrival, diagnosis, time of discharge, transfer or admission and treating physician." The policy did not make a reference to any other ED logs in the hospital.

On 4/10/13 starting at 9 am, the Patient Care Executive stated that ED patient logs were maintained electronically. In addition to the ED log, there was Obstetrical (OB) Central Log patient log maintained by the Family Birth Center in the Labor and Delivery (L&D) unit for all patients presenting to the L&D. The OB log was not maintained electronically.

Review of the "Obstetric (OB) Central Log" showed that Patient 3 presented to the Family Birth Center, Labor and Delivery (L&D) unit, on 3/30/13 at 1:15 p.m. for decreased fetal movement. The log was blank in multiple areas for Patient 3's visit, including assessment/procedure section, length of stay, disposition and time and date of disposition. The OB central log did not indicate if patients presented to the L&D unit for routine (scheduled) care or for emergency (walk-in, unscheduled) care. Review of Patient 3's L&D record for 3/30/13 at 1:15 p.m. visit showed that Patient 3 presented unscheduled with complaint of decreased fetal movements and that the L&D nurse performed a Fetal Non-Stress test (NST) and the patient was discharged home.

In an interview on 4/11/13 at 11 a.m. the L&D Manager and the ED Manager stated that patients who were pregnant 20 weeks or over were directed and provided a medical screening exam by an L&D RN per the "Medical Screening Exam (MSE)" policy when presenting unscheduled for pregnancy related emergency care. Those patients were logged in the Obstetric Central Log along with any other pregnant patients presenting to L&D unit for scheduled testing, such as routine NST and other appointments. The L&D Manager confirmed the OB log was incomplete for Patient 3. The L&D Manager confirmed that the OB log did not distinguish between emergency and non-emergency patients, and without looking at each patient's record, there was no way of telling which patients were emergency patients. The ED Manager stated that the OB log was not reviewed by the ED Department for emergency care.

Based on staff interview, Emergency Department (ED) record review, policy and procedure (P&P) and other document review, the hospital failed to provide an appropriate medical screening examination conducted by an individual (s) who was determined qualified by hospital bylaws, or rules and regulations, to determine whether or not an emergency medical condition (EMC) existed, for 7 of 20 ED patients reviewed (Patients 1, 9, 11, 13, 18, 19 and 20), as evidenced by:

1. The emergency room physician, MD 1, failed to perform appropriate assessments and provide care based on that assessment for Patient 1.

2. Patient 9 did not receive MSE by qualified medical practitioner (QMP) upon presenting to the hospital for psychiatric emergency medical condition (EMC). The Labor and Delivery (L&D) registered nurse (RN) performing a MSE for patients presenting to L&D unit failed to evaluate Patient 9' presenting complaint of psychiatric problem.

3. The hospital failed to implement the hospital's policies for Triaging patients for patients 11, 13, 18, 19 and 20.

Findings:

1. The emergency room physician, MD 1, failed to perform appropriate assessments and provide care based on that assessment for Patient 1.

Review of Emergency Room (ER) medical record on 4/10/13 showed that on 8/17/12 Patient 1 was brought to the ER on 8/17/12 at 8:55 a.m. by ambulance. The ambulance record showed that the ambulance was called for complaint of "convulsions/seizures". The ambulance documentation showed the following: upon arrival at site Patient 1, a 45 years old female, was found alert and oriented times two, being taken out of shower by her husband and paramedics secondary to seizure-like activity. Per husband's report, Patient 1 was experiencing vertigo, felt hot and decided to take a shower to cool-off. The husband reported hearing "thud" and found his wife in the shower in "the decorticate posture" and unresponsive. (Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight). The husband reported no seizures history for Patient 1 and no recent trauma. The ambulance documentation showed that by the time of arrival to the ER Patient 1 was alert and oriented times four and was complaining of pain in the right side of her back resulting from the fall in the shower. Ambulance staff documented, that Patient 1 had a bruising of mid-right side of her back. The section "impression" noted "Change in Responsiveness" and "Seizure, Diabetic symptoms." The ambulance notes documented that report was called to the hospital ER via Radio at 8:43 a.m.

The ER triage notes on 8/17/12 showed the following documentation in Patient 1 ER record:

Triage time 8:59 a.m. by Registered Nurse (RN) 1
Chief complaint: back pain
Vital signs: Blood Pressure (B/P) 106/65; Heart rate (HR) 73; Respiratory Rate (RR) 16 and Temperature (T) 96 auxiliary (armpit)
Pain level now: 8/10
Medications: Dramamine (motion sickness medicine) Oral

History by RN 1 at 9:21 a.m.:
"This started today. Relates the location as in the right flank area. History of recent trauma (felt dizzy in shower and fell). (Does not remember fall or events)."
Past medical history: vertigo
Arrived by EMS (Emergency Medical Services)
Historian: EMS

"Interventions" note by RN 1 at 9:21 a.m.: 08:59 (a.m.) "to treatment room"
Note by RN 1 at 9:22 a.m.: ecchymosis (bruising) to right thoracic back
Physical Assessment by RN 1 at 9:23 a.m.: "0900. Alert. Oriented x4. (speech slightly slurred). Respirations not labored. Normal heart rate and rhythm. Cardiac rhythm: normal sinus rhythm. Emesis noted. Has vomited several times. Abdomen soft. Bowel sound within normal limits. Soft tissue tenderness. Capillary refill less than 2 seconds and is greater than 2 seconds. Sensation intact in extremities. ROM (range of motion) within normal limits."

Nursing Progress note by RN 1 at 9:23 a.m. indicated that at 8:58 a.m. Patient 1 was gowned, placed on a monitor and ready for evaluation "chart flagged."
At 9:45 a.m. RN 1 documented that the husband was at the patient's bedside.

At 10:09 a.m. another RN (RN 2) documented the following medications were administered to Patient 1:
Ativan (antianxiety medication) 1 mg (milligrams) PO (by mouth)
Meclizine (medication for dizziness) 2 mg PO
Zofran (medication for nausea) 4 mg diluted with NS (Normal Saline) slow IVP (injected into blood vessel via intravenous catheter)
RN 2 noted that medications were for anxiety and nausea.

Review of Physician orders showed the above medications along with orders for blood work and EKG were documented by the ER physician (MD 1) at 10:05 a.m.

RN 2 documented the following vital signs at 10:13 a.m.: BP 122/80; HR 80; RR 16; Oxygen Saturation on room air 96 percent.

Next entries were related to the patient discharge at 11:27-11:30 a.m. documented under the name of RN 1, with a note by RN 3 below those entries, that RN 3 in fact documented the discharge entries. The discharge entries included information that IV was discontinued, fall risk assessments was completed and no fall risk identified, discharge instructions provided and reviewed with the patient and the patient verbalized understanding. The patient was noted discharged home accompanied by spouse. Vital signs at 11:30 a.m. were documented: BP 135/86; HR 66; RR 22; Oxygen Saturation on room air 96 percent. The nurse documented that Patient 1's condition at departure was unchanged.

Review of the ER nursing notes showed no pain treatment and no pain reassessment after initial pain was documented 8/10 in triage. No evaluation of effectiveness of medications administered for vertigo, anxiety and nausea to Patient 1 by RN 2 was documented.

In an interview on 4/12/13 at 12:25 p.m. RN 3 stated that typically she was scheduled and arrived in the ED to start her shift at 10:30 -11 a.m. with providing breaks to other nursing staff. After reviewing Patient 1's ED record, RN 3 confirmed that she discharged Patient 1 as noted above, that if the physician discharged the patient she would so note. RN 3 confirmed that she did not perform assessment of the patient's condition, including pain level, prior to discharge.

In an on-site interview on 4/12/13 at 11:50 a.m. RN 2 confirmed that he answered the radio call from the ambulance alerting the ER that the ambulance was bringing Patient 1 to the ER in 10 minutes as indicated in a document titled "Regional Base Hospital Form" signed by RN 2. RN 2 confirmed he documented on the Form that Patient 1's chief complaint was seizure activity, fall, and postictal (altered state of consciousness that a person enters after experiencing a seizure). RN 2 stated that he did not recall Patient 1, but per record review he administered medications to Patient 1 as documented above. RN 2 admitted that he did not evaluate the effectiveness of the medications and the response of Patient 1 to the medications administered. RN 2 stated that he was not assigned to Patient 1, that he was only helping RN 1 with the patient care. RN 2 confirmed that there was no nursing assessment related to the medications administered. RN 2 also acknowledged that the ER record showed no documentation that Patient 1's pain was re-assessed during the ER stay, after the initial pain scale showed 8/10 pain (severe pain). RN 2 stated that normally a primary ED nurse would perform ongoing assessments, but probably no primary ED RN was assigned to the patient because one staff called off sick and the ED was short of staff that morning.

In an interview on 4/12/13 at 11:50 a.m. the ED Manager confirmed that no primary nurse was assigned to Patient 1 for the ED visit on 8/17/12 due to staff calling off sick, per staffing sheets review.

In an on-site interview on 4/10/13 at 3:25 p.m. RN 1 stated that she remembered Patient 1. RN 1 was the triage nurse as well as the charge nurse. RN 1 believed that RN 2 was assigned to the patient as the primary ED nurse. RN 1 recalled that Patient 1 was the first of three ambulances arriving within 10 minutes. RN 1 recalled that ambulance medic reported that the initial call for Patient 1 was for seizures. Upon arrival the ambulance medic reported fall, loss of consciousness and possible syncopal episode, and back pain. RN 1 stated it was a verbal report and that the medic's documentation usually came later, after it was downloaded to the computer system, so the ER staff probably did not have access to the written report initially. RN 1 quickly triaged Patient 1 and went to greet the other two ambulances. RN 1 stated that she documented the initial assessment, pain 8/10, and bruising to the patient back. RN 1 recalled that Patient 1 arrived on gurney positioned on her stomach for comfort, because of her back pain. The patient's speech was slightly slurred. RN 1 admitted she knew the ambulance call was for seizures but did not document the reported information about the pre-hospital care for Patient 1, only that the patient arrived via EMS. RN 1 stated that the expectation was for the primary ER nurse to perform a complete assessment and document. RN 1 recalled that Patient 1 was taken directly to a treatment room and the physician (MD 1) came to the treatment room while the ambulance medics were giving verbal report on Patient 1.

In reviewing the ER record RN 1 confirmed that there was no documentation of other RNs checking on Patient 1 (evaluating and assessing the patient). RN 2 only documented medications administered and no assessments. RN 1 confirmed that the record did not show reassessments of the patient's pain after her initial assessment. RN 1 stated that she made a few entries as documented because she noticed there were no other entries as she checked on the patient. RN 1 stated that she was not the nurse that discharged the patient home. Apparently she did not sign-out of the computer system and RN 3, who actually discharged Patient 1, documented discharge notes under RN 1's name, and afterwards noted that those entries were her (Patient 1's discharge notes at 11:27-11:30 a.m.). RN 1 stated that she did not see if Patient 1's condition changed upon discharge.

Review of the Emergency Department (ED) Policy and Procedure (P&P) titled "Assessment of adult and pediatric patients" (rev 7/12) indicated the purpose was to provide guidelines for ED nurses to initiate timely, accurate and ongoing assessment of physical and psychological problems of adult and pediatric patients within ED. "Assessment provides a data base for analysis of the nature and severity of illness or injury and the need for intervention." The policy in part indicated that "Patient assessments will be conducted using Universal Standards of Care formulated by this department in addition to standards of care specific to the patient's complaint" and "Nursing care is based upon the assessment and evaluation of the patient." The Procedure section indicated, to "1. Obtain data by history taking, physical examination, review of records, and family interview, if appropriate. 2. Record significant data in the patient's medical record: a. Initial assessment and reassessments; b. Nursing evaluations; c. Nursing interventions performed; d. Patient's response to, and the outcome of the care provided; e. Ability of the patient and /or significant other to manage continuing care needs."

Review of the ED policy titled "Triage" (rev 7/12) in part indicated that "severe acute pain" was one of the conditions declared to be emergency conditions "by statue and regulation." The policy was not specific as to pain assessments and treatment.

Review of the ER "Physician Clinical Report" electronically signed by the ER physician MD 1 on 8/20/12 at 6:05 p.m., showed the following:

Patient 1 arrived by private vehicle, historian -patient

History of present illness section indicated "Dizziness" and "Vertigo" started several months and still present described as mild and nausea; no vomiting or hearing loss. In section "recent medical care" the physician noted: "The patient was seen recently in the office."
Review of systems showed the patient had weakness and experienced syncope, otherwise no positive findings.

The physician documented that "The nursing notes have been reviewed." The physician did not document that the patient arrived by an ambulance after possible seizure with fall in a shower, as per ambulance crew documentation and nursing notes.

In section "Physical Exam" MD 1 documented that Patient 1 appeared alert and "in moderate distress." The physician documented the physical exam findings were normal for all systems, including "Normal Inspection" for "Back."

Review of diagnostic tests showed that blood tests and EKG were performed. No other diagnostic tests were documented ordered or performed (such as x-ray). The physician did not document that the patient had bruising and did not address pain as documented on presentation by nurses.

MD 1 documented in the "Clinical Impression" section: "Dizziness. Vertigo" and in under "Instructions" noted: "take meclizine three times per day. Rest, avoid stairs and heights as your balance wont be too good. dont drive until you are well."

There was no documented assessment of Patient 1 by the physician prior to discharge.

Review of the hospital Medical Staff Rules and Regulations (revised February 28, 2011) in part indicated the following in section I. Emergency Services: "The active medical staff shall have overall responsibility for emergency medical care." Section I item 2 indicated: "An appropriate medical record shall be kept for every patient receiving emergency services. This record shall be incorporated in the patient's medical record chart. The record shall include: a. Adequate patient identification; b. Information concerning the time of patient's arrival and means of arrival; c. Pertinent history of the injury or illness including details relative to first aid or emergency care given the patient prior to his arrival at the hospital; d. Description of significant clinical, laboratory, and roentgenologic findings; e. Diagnosis; f. Treatment given; g. Condition of patient on discharge and transfer; h. Final disposition, including instructions given to the patient and/or family, relative to the necessary follow-up care."

In an on-site interview with MD 1 on 4/10/13 starting at 11:15 a.m., MD 1 stated that he also served as the Emergency Department (ED) Medical Director. MD 1 stated that he did not recall Patient 1 but was familiar with the case, because care for Patient 1 was reviewed by the quality and peer review as a result of family complaint. MD 1 stated that when he saw the patient he did not have an access to the ambulance report. MD 1 stated that at time of seeing the patient he was not aware of the pre-hospital seizure episode. He reviewed nursing notes and primarily obtained history from the patient. The physician stated that he depended largely on the information obtained from the nurse (RN 1) and he was not made aware of the pre-hospital history as documented by the ambulance crew. The patient told him that she fell because she was dizzy. The patient had a history of vertigo so the physician treated the patient for vertigo and nausea. Apparently the patient did not complain of pain during his evaluation. The physician admitted that he did not see the bruising on the patient's back because he did not perform thorough physical examination of the back, even though the presenting chief complaint documented was back pain. The physician claimed that upon discharge Patient 1 was better; however the assessment upon discharge was not documented.

In a telephone interview on 2/6/13 at 3 p.m. Patient 1's husband stated that on 8/17/12 in the morning Patient 1 experienced seizure in the shower (fell and lost consciousness). He called an ambulance and followed the ambulance to Hospital 1's ER. The husband stated that in the short time it took him to park his car and enter the ER, he found Patient 1 in a treatment room apparently already seen by the ED physician. While he was in the room, the ED physician came back into the room and talked with the husband (Patient 1 was slow to respond and confused). The husband stated that he told the physician that his wife had a seizure, fell and lost consciousness, however the physician told him, he was wrong, that his wife got dizzy and fell. The husband did not believe that the physician evaluated Patient 1 in the ED. He was only away from his wife a short time parking the car. Patient 1 had significant bruising to her back (described as purple-black) and bit her tongue, none of which were addressed. The husband stated that after receiving the discharge papers, he took Patient 1 into the car, at which time he now knows the patient had another seizure (locked up muscles, not making sense). The husband called Patient 1's primary care physician who instructed him to take the patient to a hospital's ED, preferably other than Hospital 1, since she already went there. The husband drove Patient 1 directly to the ED of Hospital 2, where after a long wait initially, Patient 1 received care and treatment and was diagnosed with seizures and six fractured vertebrae. The husband stated that during the car trip to Hospital 2 Patient 1 possibly had another seizure. Per husband, Patient 1 had no recollection of detailed events until the day after admission to Hospital 2.

Review of Hospital 2's ER record showed that on 8/17/12 and was triaged at 1:47 p.m. The ED initial note by Hospital 2 ED physician on 8/17/12 at 5:45 p.m. showed Patient 1's chief complaint as "Seizure Resolved". The ED physician documented that history was obtained from the patient and the spouse, reporting, that at 7 a.m. Patient 1 woke up with vertigo and nausea, walked to the bathroom and fell in the shower. The husband heard a loud noise, ran to the bathroom and found Patient 1 lying in the tub with her neck on the side of the tub, unresponsive, jerking of arms and legs and part of her tongue sticking out of her mouth. It was noted that Patient 1 presented to Hospital 1, was told she had vertigo and was discharged with meclizine. The review of systems noted findings positive for neck pain, nausea, back pain, loss of consciousness and headache, and confusion. The Patient had radiological (CT scan) testing performed showing spine fractures (C7, T11, T 12 and L1-no spinal cord injuries documented). Neurology and trauma surgery consultation were obtained and Patient 1 was admitted to Hospital 2 for treatment.

In an interview on 4/12/13 starting at 10 a.m. the Quality Director stated, that the hospital received a complaint from the family and investigated care provided for Patient 1. Peer review was performed as a part of the quality of care review and opportunities for improvements were identified. The Quality Director stated that during their investigation the hospital learned that after discharge from the ER Patient 1 went to Hospital 2's ER on 8/17/12, where the patient was diagnosed with new onset seizures, spinal fractures, and was admitted there for treatment.

2. Patient 9 did not receive MSE by qualified medical practitioner (QMP) upon presenting to the hospital for psychiatric emergency medical condition (EMC). The Labor and Delivery (L&D) registered nurse (RN) performing a MSE for patients presenting to L&D unit failed to evaluate Patient 9' presenting complaint of psychiatric problem.

Review of the Hospital Medical Staff Rules and Regulations (revised February 28, 2011), indicated in Section "I" titled "Emergency Services" that the medical staff shall develop, for approval by the governing body, a Policy and Procedure (P&P) Manual outlining the coverage in the emergency area. "The active medical staff shall have overall responsibility for emergency medical care."

The Medical Staff Rules and Regulations further indicated, that an appropriate medical record shall be kept for every patient receiving emergency service. The record shall include information concerning the means of patient's arrival, pertinent history of the injury or illness including details relative to first aid or emergency care given (to) the patient prior to his arrival at the hospital, diagnosis, treatment given, condition of patient and final disposition.

The review of the Hospital Medical Staff Bylaws (dated November 2011) and the Medical Staff Rules and Regulations (revised February 28, 2011) showed no definition or indication as to who was qualified (which category of medical providers) in the hospital to perform a Medical Screening Exam (MSE) for unscheduled patients presenting to the hospital with potential Emergency Medical Condition (EMC) as defined by the Emergency Medical Treatment and Active Labor Act (EMTALA).

? First hospital visit for Patient 9:

Review of the "Obstetric (OB) Central Log" showed that Patient 9 presented to the Family Birth Center, Labor and Delivery (L&D) unit on 9/20/12 at 3:20 p.m. for "Psych eval /r/o labor" (psychological/psychiatric evaluation/rule out labor) as documented in the section titled "Nature of Complaint/Reason for Procedure." The patient's disposition was documented that Patient 9 was sent to the Emergency Room (ER) on 9/20/12 at 5:15 p.m. The "transport" section documented that the patient "eloped."

According to the OB log Patient 9 remained in the L&D unit for nearly 2 hours before being sent to the ER for evaluation of the presenting psychiatric complaint.

Review of the P&P titled "Psychiatric Behavioral Assessment Documentation" (revised 9/09) indicated, "All patients that present to the ED with a primary diagnosis of behavioral, emotional, suicidal, or homicidal ideations will have a Behavioral Assessment Tool completed" and "when a patient admitted for other diagnosis is identified as a risk to self or others, a Behavioral Assessment Tool will be completed." The policy also indicated that "Law enforcement will be notified to provide security for staff, physicians, and patients. The physician will write an order for Mental Health Consultation. A Medical Screening Exam shall be performed in the ED.

The "ED Psychiatric Protocol -Assessment Tool" attached to the policy indicated that patients presenting with complaints including those of wanting to die/kill self, violent behavior toward self or others, psychotic, or bizarre behaviors, met triage level 1 or 2 (three triage levels per the tool). The tool listed interventions, which should be implemented for each level. For levels 1 and 2 interventions included patient placement in the room, clothing and belongings removed, and physician notification of patient arrival. For patients with triage level 1 (per the tool all suicidal patients, agitated patient, potential danger to self or others or paranoid patients) patients should have 15 minutes checks initiated and continued until discharge, the physician should be notified of patient immediately and call for Mental Health consult should be done.

Review of the OB triage record for Patient 9 corresponding with the entry in the "Obstetric Central Log" showing that Patient 9 presented to the L&D Department on 9/20/12 at 3:20 p.m. for psychiatric complaint showed, that a L&D registered nurse (RN) who performed the Medical Screening Exam (MSE) did not document the presenting psychiatric complaint. The L&D RN documented in the "OB triage" electronic notes at 3:22 p.m., that Patient 9 arrived by wheelchair at 3 p.m. brought in by the local police department (PD 1) and by a community mental health counselor (no name) and that Patient 9 was 38.5 weeks pregnant. The record showed that Patient 9 remained in the L&D for nearly 2 hours while being evaluated for her pregnancy status to rule out labor, which was not the presenting complaint. The record showed the patient was not in labor. At 4:35 p.m. the L&D nurse documented that Patient 9 "talks to self, act hostile at times." At 4:50 p.m. the nurse documented that Patient 9 was very anxious and wanted to go to a different hospital. At 5 p.m. a nursing note indicated that "(name of PD 1) notified to escort pt (patient) to ER for further evaluation."

At 5:15 p.m. the OB triage nursing notes documented "Pt suddenly decides 'Im leaving', pushes her way out of the labor room. She was not yet restrained, due to her violent attitude. She went to ER (Emergency Room) followed by the Hosp. (Hospital 1) Security guard who was pushing her belongings in a wheelchair. She had obtained her keys, and left in her car. (Name of PD 1) never showed up. Pt left, 'eloped' AMA (against medical advice)."

Review of the Family Birth Center Policies and Procedure (P&P) Manual showed a policy titled "Medical Screening Exam (MSE)" (dated 7/09) indicating, "The purpose of this policy is to describe and comply with the requirements of the Emergency Medical Treatment and Labor Act ('EMTALA'). Under this law all individuals who come to the Medical Center with an emergency medical condition must receive an appropriate medical screening examination, within the capability of the Medical Center, to determine whether an emergency medical condition exists. If an emergency medical condition exists, the patient must receive treatment within the Medical Center's capabilities until the patient is stable for transfer or discharge, regardless of the patient's insurance status or ability to pay. The emergency needs of the patient will be met according to acceptable standards of medical practice."

The MSE P&P required that the L&D RN performing MSEs notified LIP (a Licensed Independent Practitioner) immediately upon recognition of emergent condition and upon completion of the initial assessment (within 90 minutes) and the LIP must see any patient for which the RN requests a LIP consultation.

Patient 9's OB triage record showed no documentation that a LIP came to evaluate the patient during the 2 hours the patient spent in the L&D unit, prior to eloping. Review of orders showed a telephone order on 9/20/12 at 3:30 p.m. from a Certified Nurse Midwife for evaluation for labor and a second telephone order from the OB physician (MD 4) on 9/20/12 at 4:15 p.m. to send patient for further evaluation to ER.

In Patient 9's OB triage record on 9/20/12, there was no documentation of evaluation of Patient 9's mental condition per policies. There were no notes related to the events leading to the patient's arrival to the hospital, the reason why the patient was escorted by a mental health staff and a police officer, or any notes explaining why the patient needed psychiatric evaluation. The record contained no documentation that a qualified medical practitioner (QMP) was immediately notified and evaluated Patient 9's presenting psychological/psychiatric complaint, to determine if an emergency medical condition existed. The record showed no documentation that the physician was notified immediately and a call for Mental Health consult was done.

In a collaborative interview with the L&D Manager, ED Manager, QA Director and OB physician, MD 4) on 4/11/13 starting at 1 p.m. the interviewed staff stated the following information:
Patient 9 was brought in to the L&D unit by the local police (PD 1) and by a mental community health worker (MH 1, not known to the hospital staff) who requested that Patient 9's pregnancy be induced due to the patient having psychiatric issues posing danger to self and others (her unborn child). The OB physician, MD 4, stated that he provided prenatal care for the patient on outpatient basis. The patient lived with her grandmother. Patient 9 had a history of bipolar disorder and her condition was stable until recently when her psychological condition deteriorated and she was placed on psychotropic medications. MD 4 stated that Patient 9 ceased taking her medications and became psychotic, reportedly attacked her grandmother and was thrown out to streets by her grandmother. The MD stated that as a result, Patient 9 became homeless. The staff was not clear how the mental health worker, who brought Patient 9 into the L&D with the PD, was involved, or what were her qualifications. The staff speculated that Patient 9 presented to a mental clinic for an appointment and was found having psychotic behaviors. The mental worker was not known to the staff and not available for interview to collaborate any of the information. The interviewed staff stated that they had no written record of what happened before Patient 9 was brought to the L&D, other than Patient 9 had psychiatric problems and a request was made to have her pregnancy induced for the safety of the unborn child from the mother.

There was no documentation in the ED records reviewed for Patient 9 during survey as to what the mental health worker or the PD staff reported to the L&D nurse upon arrival.

The L&D Manager confirmed in the interview on 4/11/13 at 1 p.m. that although Patient 9 presented to the L&D escorted by the mental health and PD with a primary psychiatric complaint, the OB triage nurse did not assess the patient's mental status, instead proceeded with checking the patient's pregnancy status (uterus and fetal monitoring) to evaluate if the patient was in labor, which was not the presenting complaint. The Manager confirmed that a physician was not notified immediately of the patient's presenting psychiatric (non-OB) complaint and a physician did not evaluate the patient's mental status. The Mental Health consult was not initiated. The L&D Manager stated that notifying ED about any patients presenting to the OB was not the practice. Per L&D MSE policy, OB physicians were notified for all patients, within 90 minutes of their arrival, or sooner if in labor or with pregnancy related complications.

The L&D Manager stated during the above interview, that sometime during the patient's evaluation of pregnancy status (uterus and fetal monitoring) the local police (PD 1) left the hospital. The L&D Manager confirmed there was no documentation as to when and why the police left. It was unclear if the mental health person stayed with the patient. The L&D staff later called PD 1 to return to the ED because of Patient 9's mental status and the patient needed to be transported to ED for psychiatric evaluation; however PD 1 did not show up. The L&D staff proceeded to take Patient 9 to the ED for psychiatric evaluation via a wheelchair, after the OB check was completed. As Patient 9 was escorted to the ED in a wheelchair by in-house security, Patient 9 pushed away, retrieved her belongings and car keys from the wheelchair and left the facility. The staff stated that in-house security had hands-off policy and was not authorized to detain patients.

The Department obtained a report on 4/15/13 from the PD 1 to evaluate/collaborate the events prior to Patient 9's presentation to the hospital. The provided PD 1 case report of the events for 9/20/12 documented the following:

9/20/12 at 1:30 p.m.-PD received information from the County Behavioral Health that Patient 9 was being sought for a 5150 (involuntary) W&I (Welfare and Institution) detention. Patient 9 was noted with a full term pregnancy and there was a concern that the baby' life was at risk from being harmed by Patient 9. It was noted that a mental health staff felt it was necessary to have medical staff induce labor, so the baby would be free from potential harm from Patient 9.

9/20/12 at 2:10 p.m. - Patient 9 presented to the lobby at PD 1 and was detained until a representative from mental health arrived (MH 1) with a plan to transport Patient 9 to Hospital 1. It was noted that while MH 1 was escorting Patient 9, the patient fled from MH 1 and drove away recklessly, with MH 1 following and calling 911.

9/20/12 at 2:32 p.m.- an officer was dispatched to the outpatient services entrance at the Hospital (1) to assist MH 1 with an unknown problem. Upon arrival the officer was met by MH 1 and a hospital's security officer and was informed by MH 1 that Patient 9 was uncooperative again and possibly threat to others. MH 1 communicated with the hospital staff in effort to expedite Patient 9's admittance (per the report).

It was noted that eventually, a doctor from OB Department came out to the lobby and spoke with Patient 9, and decided to take the patient directly to the Family Birth Center. The police staff escorted Patient 9 to room 234. The officer noted that "it was apparent that the Family Birth Center staff (MD 4' name) was unaware of (Patient 9's name) condition and "escorted arrival" and that MH 1 "briefed the staff of the circumstances. The staff was divided when it came to security and safety. Some appreciated our presen

Based on staff interviews, Emergency Department (ED) record review and policies and procedures (P&P) review, the hospital failed to provide stabilizing treatment within the capabilities of the staff and the facility for a psychiatric patient awaiting transfer, for 1 of 20 patients reviewed (Patient 9). Patient 9 was not provided clinical care by the hospital while restrained in the ED by Police Department (PD) staff awaiting Mental Health (MH) evaluation and subsequent transfer.

Findings:

The ED log review showed that on 9/21/12 at 2:53 a.m. Patient 9 presented to the ED with chief complaint of psychiatric issues and was diagnosed with "Acute bipolar disorder (manic state); psychosis; Near term pregnancy." The disposition section documented that Patient 9 was transferred on 9/22/12 at 12:50 p.m. The review of ED nursing notes showed that Patient 9 remained in the ED for 33 hours form 9/21/12 at 2:53 a.m. until 9/22/12 at 15: 50 p.m., when the patient was transferred to another hospital (Hospital 3).

Review of ED nursing notes indicated that while in the ED awaiting transfer, Patient 9 was physically restrained (hand-cuffed) by a county sheriff officer (SO). The hospital provided documentation that on 9/21/12 at 3:50 a.m. Patient 9 was placed by the county sheriff on an involuntary hold under the Welfare and Institution (W&I) Code 5150 for the purpose of examination by mental health professionals at the hospital (Hospital 1) because there was a probable cause that the patient was "a danger to himself/herself." There was no record that Patient 9 was arrested or was in the police custody (an inmate). The record showed that on 9/22/12 at 12:50 p.m. the patient was transferred via ambulance to Hospital 3.

Review of the P&P titled "Psychiatric Behavioral Assessment Documentation" (revised 9/09) indicated, "All patients that present to the ED with a primary diagnosis of behavioral, emotional, suicidal, or homicidal ideations will have a Behavioral Assessment Tool completed." The policy also indicated that "Law enforcement will be notified to provide security for staff, physicians, and patients. The physician will write an order for Mental Health Consultation.

The "ED Psychiatric Protocol -Assessment Tool" attached to the policy indicated that patients presenting with complaints including those of wanting to die/kill self, violent behavior toward self or others, psychotic, bizarre behaviors met triage level 1 or 2 and interventions should be implemented such as placement in the room, clothing and belongings removed, and the physician notified of patient arrival. For patients triage level 1 per the tool (all suicidal patients, agitated patient, potential danger to self or others or paranoid patients) patients should have 15 minutes checks initiated and continued until discharge, the physician should be notified of patient immediately and call for Mental Health consult done.

There was no documentation that Patient 9 was placed on suicide precautions until 9/22/12 at 6:40 a.m. (27 hours after admission), when a nursing note documented that suicide precautions were initiated for Patient 9 with the following interventions: one on one supervision, hospital security officer at bedside, every 15 minutes checks performed, clothing/valuables removed and placed at the nurse's station, patient in view of the nurse's station. Review of orders showed no order written for Mental Health Consultation as per the policy above.

There was no documentation in Patient 9's record for the 15 minutes checks performed as noted above.

Review of County Sheriffs' report dated 9/21/12 (provided to the Department by the hospital) showed that at approximately 2:17 a.m. an officer was dispatched to a disturbance apparently caused by Patient 9. Patient 9 was placed on 5150 hold due to her mental status and was brought to Hospital 2 for mental health evaluation and care. The officer documented that "while waiting for mental health to arrive, (name of Patient 9) told me numerous times that she wanted to kill herself... As of 0600 (6 a.m.) hours, when I was relieved of my duties, we were still awaiting the arrival of Mental Health to take custody of (name of Patient 9).

The ED nursing notes documentation contained the following entries showing that Patient 9 was physically restrained by the police officer throughout the stay in the ED while awaiting mental health evaluation and transfer:

9/21/12 at 2:55 a.m. - patient is restless and handcuffed to side rail with officer in room
9/21/12 at 7:28 a.m. - patient remains cuffed to bed with SO (sheriff officer) at bedside
9/21/12 at 8:30 a.m. - SO remains at bedside. Pt remains cuffed
9/22/12 at 7:30 a.m. - patient returned to room, cuffed to gurney, officer at bedside
9/22/12 at 10:10 a.m. - patient back to room with security at bedside and cuff in place

The nursing notes documentation showed that during Patient 9's 33 hour ED stay while awaiting transfer, only twice was the patient released from cuffs and provided with any range of motion:

9/22/12 at 7:19 a.m. - security walking with patient in the ED per patient request. Patient states she is stiff from being on gurney
9/22/12 at 9:52 a.m. - Security supervising patient walking again in the ED

Review of the hospital policy titled "Restraints Management- Medical Restraints and Behavioral Restraints" (reviewed 3/12) indicated the following: Patients have the right to be free from restraints of any form that are not medically necessary. There needs to be a clear rationale for the use of restraints and all other solutions to the problem must be considered. Alternatives to restraint use include companionship (staff or family stay with patient). The policy indicated that "forensic (pertaining to courts of law) handcuffs" were authorized to be used by law enforcement and the law enforcement officer was responsible for the use, application and monitoring of theses restrictive devices, however, "Clinical care of an individual under forensic or correctional restrictions was to be provided by the hospital's clinical staff."

The above policy fell short in describing what and how the clinical care was to be provided by hospital staff for patients restrained by police without the patient being under arrest, while the patient was determined to have a medical emergency condition of psychiatric nature and was awaiting mental health evaluation and care.

In an interview on 4/11/13 at 1 p.m. the Quality Director stated that although the hospital indicated in their P&Ps that the law enforcement officers were to be used for security and safety of their patients, there was no formal written agreement that would indicate that the police or sheriff's department agreed to provide those services and under what circumstances those services were to be provided, or if/how the patient care would be coordinated with clinical staff to ensure proper patient care.

Review of the nursing notes showed that from the presentation to the ED on 9/21/12 at 2:53 a.m. to transfer on 9/22/12 at 12:50 p.m. the patient was not offered adequate nutrition. The following meals and fluids were documented as offered to the patient on 9/21/12:

9/21/12 at 7:36 a.m. - po (by mouth fluids given)
9/21/12 at 7:50 a.m. - sandwich given

There was no documentation that Patient 9 was provided lunch or dinner, or snacks and fluids at any other time on 9/21/12. The next meal provided to Patient 9 was documented on 9/22/12 at 8 a.m. (breakfast tray provided, noted at 8:15 a.m. that patient ate 100%), and then on 9/22/12 two more entries regarding meals/nutrition were documented in the nursing notes: at 9:44 a.m. - turkey sandwich and milk provided and at 11:58 a.m. - lunch tray given.

There was no documentation that Patient 9 was provided with any hygiene or toileting opportunities while restraint.

In a collaborative interview with the L&D Manager, ED Manager, QA Director and OB physician, MD 4 on 4/11/13 starting at 1 p.m., the staff confirmed that although on 9/21/12 at 2:53 a.m. Patient 9 was brought in to the hospital by the police on 5150 hold, the patient was not criminally charged (not arrested and was not an inmate). The administration staff stated that the local police was routinely called in and assisted the hospital with patient safety and monitoring as a courtesy service; however, there was no written agreement between the hospital and the police or sheriff's department(s) for the their officers to monitor patients receiving care in the ED. The hospital had an agreement for county inmate patients only. The hospital had a Memorandum of Understanding (MOU) with the county and the county was to provide a guard and supervise an inmate under a penal code. This MOU did not apply to other ED patients.

In the above interview, the ED Manager stated that patients needing behavioral restraint needed an initial assessment, a physician order for restraints, and ongoing evaluation and monitoring while the patient was restrained. The ED Manager acknowledged that no order for restraints was written for Patient 9, no Behavioral Assessment Tool was completed, no suicide precautions and ongoing monitoring with 15 minute checks was timely initiated and 15 minute checks were not documented in Patient 9's ED record. The ED Manager acknowledged that there was no documentation that Patient 9's care was provided that addressed the patient's physical needs (nutritional needs, providing range of motion for restrained limbs and extremity assessment related to cuffs/restraints) and mental status (monitoring of the patient's ongoing behaviors) as required per hospital policies.

Based on staff interview, Emergency Department (ED) record review, policy and procedure (P&P) and other document review, the hospital failed to provide an appropriate medical screening examination conducted by an individual (s) who was determined qualified by hospital bylaws, or rules and regulations, to determine whether or not an emergency medical condition (EMC) existed, for 7 of 20 ED patients reviewed (Patients 1, 9, 11, 13, 18, 19 and 20), as evidenced by:

1. The emergency room physician, MD 1, failed to perform appropriate assessments and provide care based on that assessment for Patient 1.

2. Patient 9 did not receive MSE by qualified medical practitioner (QMP) upon presenting to the hospital for psychiatric emergency medical condition (EMC). The Labor and Delivery (L&D) registered nurse (RN) performing a MSE for patients presenting to L&D unit failed to evaluate Patient 9' presenting complaint of psychiatric problem.

3. The hospital failed to implement the hospital's policies for Triaging patients for patients 11, 13, 18, 19 and 20.

Findings:

1. The emergency room physician, MD 1, failed to perform appropriate assessments and provide care based on that assessment for Patient 1.

Review of Emergency Room (ER) medical record on 4/10/13 showed that on 8/17/12 Patient 1 was brought to the ER on 8/17/12 at 8:55 a.m. by ambulance. The ambulance record showed that the ambulance was called for complaint of "convulsions/seizures". The ambulance documentation showed the following: upon arrival at site Patient 1, a 45 years old female, was found alert and oriented times two, being taken out of shower by her husband and paramedics secondary to seizure-like activity. Per husband's report, Patient 1 was experiencing vertigo, felt hot and decided to take a shower to cool-off. The husband reported hearing "thud" and found his wife in the shower in "the decorticate posture" and unresponsive. (Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight). The husband reported no seizures history for Patient 1 and no recent trauma. The ambulance documentation showed that by the time of arrival to the ER Patient 1 was alert and oriented times four and was complaining of pain in the right side of her back resulting from the fall in the shower. Ambulance staff documented, that Patient 1 had a bruising of mid-right side of her back. The section "impression" noted "Change in Responsiveness" and "Seizure, Diabetic symptoms." The ambulance notes documented that report was called to the hospital ER via Radio at 8:43 a.m.

The ER triage notes on 8/17/12 showed the following documentation in Patient 1 ER record:

Triage time 8:59 a.m. by Registered Nurse (RN) 1
Chief complaint: back pain
Vital signs: Blood Pressure (B/P) 106/65; Heart rate (HR) 73; Respiratory Rate (RR) 16 and Temperature (T) 96 auxiliary (armpit)
Pain level now: 8/10
Medications: Dramamine (motion sickness medicine) Oral

History by RN 1 at 9:21 a.m.:
"This started today. Relates the location as in the right flank area. History of recent trauma (felt dizzy in shower and fell). (Does not remember fall or events)."
Past medical history: vertigo
Arrived by EMS (Emergency Medical Services)
Historian: EMS

"Interventions" note by RN 1 at 9:21 a.m.: 08:59 (a.m.) "to treatment room"
Note by RN 1 at 9:22 a.m.: ecchymosis (bruising) to right thoracic back
Physical Assessment by RN 1 at 9:23 a.m.: "0900. Alert. Oriented x4. (speech slightly slurred). Respirations not labored. Normal heart rate and rhythm. Cardiac rhythm: normal sinus rhythm. Emesis noted. Has vomited several times. Abdomen soft. Bowel sound within normal limits. Soft tissue tenderness. Capillary refill less than 2 seconds and is greater than 2 seconds. Sensation intact in extremities. ROM (range of motion) within normal limits."

Nursing Progress note by RN 1 at 9:23 a.m. indicated that at 8:58 a.m. Patient 1 was gowned, placed on a monitor and ready for evaluation "chart flagged."
At 9:45 a.m. RN 1 documented that the husband was at the patient's bedside.

At 10:09 a.m. another RN (RN 2) documented the following medications were administered to Patient 1:
Ativan (antianxiety medication) 1 mg (milligrams) PO (by mouth)
Meclizine (medication for dizziness) 2 mg PO
Zofran (medication for nausea) 4 mg diluted with NS (Normal Saline) slow IVP (injected into blood vessel via intravenous catheter)
RN 2 noted that medications were for anxiety and nausea.

Review of Physician orders showed the above medications along with orders for blood work and EKG were documented by the ER physician (MD 1) at 10:05 a.m.

RN 2 documented the following vital signs at 10:13 a.m.: BP 122/80; HR 80; RR 16; Oxygen Saturation on room air 96 percent.

Next entries were related to the patient discharge at 11:27-11:30 a.m. documented under the name of RN 1, with a note by RN 3 below those entries, that RN 3 in fact documented the discharge entries. The discharge entries included information that IV was discontinued, fall risk assessments was completed and no fall risk identified, discharge instructions provided and reviewed with the patient and the patient verbalized understanding. The patient was noted discharged home accompanied by spouse. Vital signs at 11:30 a.m. were documented: BP 135/86; HR 66; RR 22; Oxygen Saturation on room air 96 percent. The nurse documented that Patient 1's condition at departure was unchanged.

Review of the ER nursing notes showed no pain treatment and no pain reassessment after initial pain was documented 8/10 in triage. No evaluation of effectiveness of medications administered for vertigo, anxiety and nausea to Patient 1 by RN 2 was documented.

In an interview on 4/12/13 at 12:25 p.m. RN 3 stated that typically she was scheduled and arrived in the ED to start her shift at 10:30 -11 a.m. with providing breaks to other nursing staff. After reviewing Patient 1's ED record, RN 3 confirmed that she discharged Patient 1 as noted above, that if the physician discharged the patient she would so note. RN 3 confirmed that she did not perform assessment of the patient's condition, including pain level, prior to discharge.

In an on-site interview on 4/12/13 at 11:50 a.m. RN 2 confirmed that he answered the radio call from the ambulance alerting the ER that the ambulance was bringing Patient 1 to the ER in 10 minutes as indicated in a document titled "Regional Base Hospital Form" signed by RN 2. RN 2 confirmed he documented on the Form that Patient 1's chief complaint was seizure activity, fall, and postictal (altered state of consciousness that a person enters after experiencing a seizure). RN 2 stated that he did not recall Patient 1, but per record review he administered medications to Patient 1 as documented above. RN 2 admitted that he did not evaluate the effectiveness of the medications and the response of Patient 1 to the medications administered. RN 2 stated that he was not assigned to Patient 1, that he was only helping RN 1 with the patient care. RN 2 confirmed that there was no nursing assessment related to the medications administered. RN 2 also acknowledged that the ER record showed no documentation that Patient 1's pain was re-assessed during the ER stay, after the initial pain scale showed 8/10 pain (severe pain). RN 2 stated that normally a primary ED nurse would perform ongoing assessments, but probably no primary ED RN was assigned to the patient because one staff called off sick and the ED was short of staff that morning.

In an interview on 4/12/13 at 11:50 a.m. the ED Manager confirmed that no primary nurse was assigned to Patient 1 for the ED visit on 8/17/12 due to staff calling off sick, per staffing sheets review.

In an on-site interview on 4/10/13 at 3:25 p.m. RN 1 stated that she remembered Patient 1. RN 1 was the triage nurse as well as the charge nurse. RN 1 believed that RN 2 was assigned to the patient as the primary ED nurse. RN 1 recalled that Patient 1 was the first of three ambulances arriving within 10 minutes. RN 1 recalled that ambulance medic reported that the initial call for Patient 1 was for seizures. Upon ar

Based on staff interviews, Emergency Department (ED) record review and policies and procedures (P&P) review, the hospital failed to provide stabilizing treatment within the capabilities of the staff and the facility for a psychiatric patient awaiting transfer, for 1 of 20 patients reviewed (Patient 9). Patient 9 was not provided clinical care by the hospital while restrained in the ED by Police Department (PD) staff awaiting Mental Health (MH) evaluation and subsequent transfer.

Findings:

The ED log review showed that on 9/21/12 at 2:53 a.m. Patient 9 presented to the ED with chief complaint of psychiatric issues and was diagnosed with "Acute bipolar disorder (manic state); psychosis; Near term pregnancy." The disposition section documented that Patient 9 was transferred on 9/22/12 at 12:50 p.m. The review of ED nursing notes showed that Patient 9 remained in the ED for 33 hours form 9/21/12 at 2:53 a.m. until 9/22/12 at 15: 50 p.m., when the patient was transferred to another hospital (Hospital 3).

Review of ED nursing notes indicated that while in the ED awaiting transfer, Patient 9 was physically restrained (hand-cuffed) by a county sheriff officer (SO). The hospital provided documentation that on 9/21/12 at 3:50 a.m. Patient 9 was placed by the county sheriff on an involuntary hold under the Welfare and Institution (W&I) Code 5150 for the purpose of examination by mental health professionals at the hospital (Hospital 1) because there was a probable cause that the patient was "a danger to himself/herself." There was no record that Patient 9 was arrested or was in the police custody (an inmate). The record showed that on 9/22/12 at 12:50 p.m. the patient was transferred via ambulance to Hospital 3.

Review of the P&P titled "Psychiatric Behavioral Assessment Documentation" (revised 9/09) indicated, "All patients that present to the ED with a primary diagnosis of behavioral, emotional, suicidal, or homicidal ideations will have a Behavioral Assessment Tool completed." The policy also indicated that "Law enforcement will be notified to provide security for staff, physicians, and patients. The physician will write an order for Mental Health Consultation.

The "ED Psychiatric Protocol -Assessment Tool" attached to the policy indicated that patients presenting with complaints including those of wanting to die/kill self, violent behavior toward self or others, psychotic, bizarre behaviors met triage level 1 or 2 and interventions should be implemented such as placement in the room, clothing and belongings removed, and the physician notified of patient arrival. For patients triage level 1 per the tool (all suicidal patients, agitated patient, potential danger to self or others or paranoid patients) patients should have 15 minutes checks initiated and continued until discharge, the physician should be notified of patient immediately and call for Mental Health consult done.

There was no documentation that Patient 9 was placed on suicide precautions until 9/22/12 at 6:40 a.m. (27 hours after admission), when a nursing note documented that suicide precautions were initiated for Patient 9 with the following interventions: one on one supervision, hospital security officer at bedside, every 15 minutes checks performed, clothing/valuables removed and placed at the nurse's station, patient in view of the nurse's station. Review of orders showed no order written for Mental Health Consultation as per the policy above.

There was no documentation in Patient 9's record for the 15 minutes checks performed as noted above.

Review of County Sheriffs' report dated 9/21/12 (provided to the Department by the hospital) showed that at approximately 2:17 a.m. an officer was dispatched to a disturbance apparently caused by Patient 9. Patient 9 was placed on 5150 hold due to her mental status and was brought to Hospital 2 for mental health evaluation and care. The officer documented that "while waiting for mental health to arrive, (name of Patient 9) told me numerous times that she wanted to kill herself... As of 0600 (6 a.m.) hours, when I was relieved of my duties, we were still awaiting the arrival of Mental Health to take custody of (name of Patient 9).

The ED nursing notes documentation contained the following entries showing that Patient 9 was physically restrained by the police officer throughout the stay in the ED while awaiting mental health evaluation and transfer:

9/21/12 at 2:55 a.m. - patient is restless and handcuffed to side rail with officer in room
9/21/12 at 7:28 a.m. - patient remains cuffed to bed with SO (sheriff officer) at bedside
9/21/12 at 8:30 a.m. - SO remains at bedside. Pt remains cuffed
9/22/12 at 7:30 a.m. - patient returned to room, cuffed to gurney, officer at bedside
9/22/12 at 10:10 a.m. - patient back to room with security at bedside and cuff in place

The nursing notes documentation showed that during Patient 9's 33 hour ED stay while awaiting transfer, only twice was the patient released from cuffs and provided with any range of motion:

9/22/12 at 7:19 a.m. - security walking with patient in the ED per patient request. Patient states she is stiff from being on gurney
9/22/12 at 9:52 a.m. - Security supervising patient walking again in the ED

Review of the hospital policy titled "Restraints Management- Medical Restraints and Behavioral Restraints" (reviewed 3/12) indicated the following: Patients have the right to be free from restraints of any form that are not medically necessary. There needs to be a clear rationale for the use of restraints and all other solutions to the problem must be considered. Alternatives to restraint use include companionship (staff or family stay with patient). The policy indicated that "forensic (pertaining to courts of law) handcuffs" were authorized to be used by law enforcement and the law enforcement officer was responsible for the use, application and monitoring of theses restrictive devices, however, "Clinical care of an individual under forensic or correctional restrictions was to be provided by the hospital's clinical staff."

The above policy fell short in describing what and how the clinical care was to be provided by hospital staff for patients restrained by police without the patient being under arrest, while the patient was determined to have a medical emergency condition of psychiatric nature and was awaiting mental health evaluation and care.

In an interview on 4/11/13 at 1 p.m. the Quality Director stated that although the hospital indicated in their P&Ps that the law enforcement officers were to be used for security and safety of their patients, there was no formal written agreement that would indicate that the police or sheriff's department agreed to provide those services and under what circumstances those services were to be provided, or if/how the patient care would be coordinated with clinical staff to ensure proper patient care.

Review of the nursing notes showed that from the presentation to the ED on 9/21/12 at 2:53 a.m. to transfer on 9/22/12 at 12:50 p.m. the patient was not offered adequate nutrition. The following meals and fluids were documented as offered to the patient on 9/21/12:

9/21/12 at 7:36 a.m. - po (by mouth fluids given)
9/21/12 at 7:50 a.m. - sandwich given

There was no documentation that Patient 9 was provided lunch or dinner, or snacks and fluids at any other time on 9/21/12. The next meal provided to Patient 9 was documented on 9/22/12 at 8 a.m. (breakfast tray provided, noted at 8:15 a.m. that patient ate 100%), and then on 9/22/12 two more entries regarding meals/nutrition were documented in the nursing notes: at 9:44 a.m. - turkey sandwich and milk provided and at 11:58 a.m. - lunch tray given.

There was no documentation that Patient 9 was provided with any hygiene or toileting opportunities while restraint.

In a collaborative interview with the L&D Manager, ED Manager, QA Director and OB physician, MD 4 on 4/11/13 starting at 1 p.m., the staff confirmed that although on 9/21/12 at 2:53 a.m. Patient 9 was brought in to the hospital by the police on 5150 hold, the patient was not c