HospitalInspections.org

Based on record reviews and interviews, the Condition Participation for Governing Body was not met as evidenced by the hospital's failure to meet the Condition of Participation for Emergency Services (§482.55).

Finding:

The governing body is responsible for the conduct of the hospital including the hospital's requirement to comply with the requirements of §482.55 (Emergency Services). Based on record reviews and interviews, the hospital failed to comply with the requirements of §482.55 (Emergency Services) as evidenced in the review of 3 of 11 sampled patient records of nine patients presenting to the emergency department since 6/15/18 (Patient #1, #2, and #3). See A-1100 for details.

The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.

Based on record reviews and interviews, the hospital failed to comply with the requirements of §482.55 (Emergency Services) as evidenced in the review of 3 of 11 sampled patient records of nine patients presenting to the emergency department since 6/15/18 (Patient #1, #2, and #3).

Finding:

Based on records reviewed and interviews, the Condition Participation for Emergency Services (§482.55) was not met as evidenced by the hospital's failure to ensure care was provided in accordance to standards for 3 of 11 sampled patient records of nine patients presenting to the emergency department since 6/15/18 (Patient #1, #2, and #3). See A-1100 for details.

Based on observations and interviews, the hospital failed to ensure that patients would receive care in a safe environment in 1 of 2 areas within the emergency department (area known as the behavioral emergency department).

Findings:

1. On 7/23/18 between 12:10 PM and 12:46 PM, during a tour of the area known as the behavioral emergency department (BED) with the Director of the Emergency Department (ED), two surveyors observed that, in the short hallway by the metal detector screener and over the plastic dresser type drawers, there was a clear heavy plastic (plexi glass) cover that covered the medical gas pipes. This cover could be easily removed and the cover had sharp edges. This cover created a potential safety issue for any patient who had the potential to be in this area without staff present. During interviews conducted with hospital staff on 7/23/18 between 12:10 PM and 12:46 PM and 7/24/18 at 1:06 PM and 1:39 PM, a surveyor verified that there was a potential that a patient could be in this area without staff present. On 7/24/18 at approximately 1:00 PM, the surveyor discussed this safety hazard with the Director of the ED.

2. On 7/23/18 between 12:10 PM and 12:46 PM, two surveyors observed that the door handle, of one of the doors in Room #25 in the BED, was a regular horizontal type handle and there was a regular hospital bed with side rails attached in the room. Both the door handle and the siderails on the bed created a ligature risk. A ligature risk is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. At the time of the observation, the Director of the ED indicated that this room had two cameras which could be monitored if someone was in this room.

On 7/24/18 between 1:06 PM and 1:36 PM, a Registered Nurse was interviewed. The RN indicated that there are cameras throughout the BED and if a patient is determined to be at risk the camera image would be monitored on the security screen monitor. Observations by the surveyor, on 7/23/18, indicated that the security screen monitors are located on the outside desk area.

On 7/25/18 at 8:18 AM, the Director of the ED was asked if any type of ligature risk assessment was done in the BED and he indicated that it had been done when the BED first opened. When asked specifically about the door handle in Room #25, he indicated that it was picked up on a safety assessment. He also indicated that Room #26 also had the same type of door handle on one of the doors. Both of these rooms have two cameras that can be utilized and monitored when patients, who are at risk, are in the rooms.

On 7/25/18 at 8:25 AM, two surveyors and the Director of the ED went into the BED. There was a patient in Room #25 and it was noted that this room was not on the security screen monitor in the BED. The Director attempted to bring the camera image up on the security screen monitor and then had the security officer bring the image up on the screen. The surveyor noted that there was one corner of the room that could not be seen on the camera image. The security officer stated that there are areas in rooms that they cannot see. He also indicated that if a patient was determined to be unsafe they are made aware and the camera image would be monitored.

On 7/25/18 at 9:54 AM, Room #25 was empty. One surveyor went into the room and another surveyor observed the camera image of the room with the security officer. It was noted that one of the corners of the room, beside the horizontal door handle, could not be seen. This area that could not be observed created a potential safety issue. This observation was verified with the Director of the ED at the time of the observation.

33759


Based on observations and interviews, the hospital failed to ensure patient safety as evidenced by windows that could be opened wide enough that a patient had the potential to fall out and/or jump out in 1 of 4 inpatient units (C-3). In addition, based on observation and interviews, the hospital failed to maintain a clean environment in Surgical Services and Endoscopy in such a manner that the well-being of patients was assured.

Finding:

On 7/24/2018 at 10:50 AM, windows were observed that could be opened fully in the public restroom off the Solarium, Room C-331B. Patient Rooms C-336, C-337, C-338, and C-339 were also observed to have similar windows which opened fully. The Director of Facilities confirmed that these windows opened fully at the time of the observations. The windows with even numbers opened onto a roof which had a 2-story drop off on it and rooms with odd numbers opened to a 2-story drop to the ground below. The Nurse Manager of C-3 stated that "There was a high probability of having patients with confusion, dementia, or pediatric patients."

At 11:20 AM, the Director of Facilities stated that "They had secured the windows in C-2 and the Women's Area with blocks to restrict the windows opening to 4 inches. C-3 had temporary fixes to prevent the locks from opening, but apparently, the staff had removed those. They were not aware that C-3 had not been completed."

At 12:25 PM, the Director of Facilities stated that "They had no window monitoring program." He also stated that "The carpenter was securing all the windows on that unit that had been unsecured by installing blocks in the windows of the (17) patient rooms, plus in the bathroom windows (18 rooms in all) that would prevent the windows from opening more than 4 inches."

Upon further investigation, it was determined that there had not been any incidents involving patients falling or attempting to jump out the window.

Based on observation, record review, and interview, the hospital failed to ensure supplies on the cardiac emergency cart were not expired for 1 of 1 carts in the Radiology Department.

Finding:

On 7/23/18 at approximately 12:30 PM, during a tour of the Radiology Department, the following expired medical care devices were observed on the cardiac emergency cart located in the echocardiogram room: one defibrillator electrode pad package with an expiration date of 2/28/18; one defibrillator electrode pad package with an expiration date of 6/18/18, and the cardiac emergency cart did not contain any non-expired defibrillator electrode pads.

A review of the emergency cart log indicated the cart was inspected daily and was found to be ready for use.

This finding was confirmed, by the Radiology Department Director, on 7/23/18 at approximately 12:39 PM.

Based on observations, interviews, and record reviews, the facility failed to ensure that proper temperatures were maintained in 2 of 6 unit refrigerators.

Findings:

The Refrigerator Temperature Log forms "All Refrigerator temperatures should be 37 to 41 F. *Contact Dietary Supervisor if temperature out of normal range. If it has been determined that the refrigerator has been above 41 F for more than four hours the food will be discarded."


1. On 7/24/2018 at 1:45 PM, during a tour of the facility with the Director of Facilities, a check of the refrigerator in Room D-4, revealed a temperature that was 46 degrees Fahrenheit (F).

Documentation on the temperature log, which was located on the D-4 refrigerator, indicated 39 of 40 recordings during the month of July were above 41 degrees F.

At 2:00 PM, the Director of Facilities contacted the kitchen to send someone up to check the safety of the foods. The kitchen staff person measured the temperature of the chicken salad, egg salad, and the milk. The food items were all reported to the surveyor and the Director of Facilities to be 47 degrees Fahrenheit.

2. On 7/25/2018 at 8:30 AM, a check of the refrigerator in Room E-289 in the Intensive Care Unit (ICU) patient food refrigerator, revealed a temperature of 42 degrees F.

Documentation on the temperature log, located on the refrigerator, indicated 24 of 28 recordings above the 41 degrees. Additionally, on 16 other occasions the temperature had not been recorded. The Director of Facilities called the kitchen and the kitchen staff person reported the milk temperature to the surveyor and the Director of Facilities to be 46.5 degrees Fahrenheit.

On 7/26/2018, at 8:00 AM, the Food Service Director provided the June 2018 Refrigerator Temperature Log for the ICU refrigerator. The form indicated that the temperature of the refrigerator was not recorded on 15 of 30 days

At 10:20 AM, the Director of Nutrition Services stated that "He had no idea why staff didn't check out temperatures that were above the temperature range and why it was not reported."

Upon further investigation, it was determined there had not been any reports of any food borne illnesses that may have been the result of food in these refrigerators.

Based on observations and interviews, the hospital failed to have a system in place to ensure that the facility maintained a sanitary environment in 11 of 16 areas (Kitchen, Intensive Care Unit, Emergency Department, Operating Supply Room, .

Findings include:

1. Three ice machines were observed to be lacking air gaps thus creating on opportunity for the back flow of waste water into the ice machine. The observations were as follows:

- On 7/23/2018 at 12:25 PM, no functional air gap was observed on the drain line of the ice machine in the kitchen. This finding was confirmed, with the Director of Food Service, at the time of the observation.

- On 7/24/2018 at 8:25 AM, an improperly designed drainage with no air gap was observed on the ice machine plumbing in Room #E-289 in the Intensive Care Unit (ICU). This finding was confirmed, with the Director of Facilities (DOF), at the time of the observation.

- On 7/25/2018 at 12:45 PM, no air gap was observed on the drain line of the ice machine in Room #F-1107 in the Emergency Department (ED). This finding was confirmed, with the DOF, at the time of the observation.

2. On 7/23/2018 between 3:15 PM to 4:10 PM, non-intact vinyl coverings were observed on two Yellow Fin Stirrups in the Operating Room (OR) Supply Room. This non-intact vinyl created a surface which could not easily be cleaned and sanitized. This finding was confirmed, with the Director of Surgical Services (DSS), at the time of the observations.

3. On 7/23/18 at 11:20 AM., during a tour of the Surgical Services Department, the surveyor and Director of Surgical Services observed one visibly dusty code cart, two visibly dusty optomology microscopes, and a punctured operating room mattress covered with Tegaderm. The punctured mattress created a surface which could not be easily cleaned and sanitized. These findings were confirmed, with the Surgical Services Director, at the time of the observations.

4. On 7/24/2018 between 9:00 AM to 2:45 PM, the following was observed:

- Torn vinyl on an exercise mat in Storage Room #D-403A.

- An approximate 4-inch hole in the wall on the left of heating unit in Patient Room #D-429.

- Scrapes, gouges, and/or worn finish on the wooden arms of chairs in Rooms #C-307, #C-340, #C-352, #C-356, #C-350, and #C-355.

- Worn finish on the wood wall trim in Rooms #C-339, #C-340, #C-341, #C-352, #C-357, #C-354, #C-359, and #C-350.

- Cracked arm pads on four crutches in the Physical Therapy Storage Room #C-363.

The above findings created surfaces which could not easily be cleaned and sanitized and were confirmed, with the DOF, at the time of the observations.

5. On 7/24/18 at 10:40 AM, during a tour of the Endoscopy Department, the surveyor and Director of Endoscopy observed an exam chair in Exam Room #3 that had a dime sized tear in the vinyl of the seat exposing foam, worn material on the leg/foot holsters, and a rusty metal gear that adjusts the seat position, thus creating uncleanable surfaces. These findings were confirmed, with the Director of Endoscopy, at the time of the observations.

6. On 7/25/2018 between 6:15 AM to 7:20 AM, with the DSS, a corkboard in the clean room of Central Sterilization. This finding was confirmed with the DSS at the time of the observation.

7. On 7/25/2018, between 7:30 AM to 2:45 PM, the following was observed:

- A one inch long opening in the wall next to the heater in the bathroom and an unfinished wall near the call light switch, in Behavioral Unit (BU) Room #332.

- A one inch gouge in the wall between the sink and the radiator in the bathroom of BU Room 334 (Seclusion Room).

- Cracked caulking around the toilet in the bathroom of BU Room #353.

- Broken/damaged wallboard on the outside corner of bathroom wall in Room #C-251;

- A taped together linen cart in the hallway of ICU.

- Worn finish on a wooden chair in ICU Room #5.

- A tear in the seat exposing foam on a chair in Room ICU #1.

- Areas of missing veneer on two cabinet doors in the Hyperbaric Room.

- Broken wallboard on the corner of the column in Ultrasound Exam Room #3.

- Non-intact vinyl on the corners of a positioning wedge in the CT Scan Slice Room #2.

- Missing paint on an X-ray grid holder and a broken table top mended with tape in X-ray Room #5.

- Worn/torn seat cushions on four Staxie chairs in the ED entry area.

- A stained ceiling tile and bubbled up wall area to the left and above the sink in The Isolation Anti-room of the ED, Room #F-1052.

- A stained ceiling tile and laminate missing from end of sink cabinet in ED Room #F-1101.

- Torn/broken vinyl on the arm rest and the seat of the draw chair in ED Room #F-1131.

- Non-intact vinyl on the back, seat, and leg/foot pads of the procedure table in the Endoscopy Procedure Room, Room #W-041.

The above findings created surfaces which could not easily be cleaned and sanitized and were confirmed, with the DOF, at the time of the observations.

8. Rusted surfaces, which created a surface which could not be easily cleaned and sanitized, were observed on several items. The observations were as follows:

- On 7/23/2018 between 3:15 PM and 4:10 PM, rusted casters were observed on an Intravenous (IV) pole in OR #6. This finding was confirmed, with the DSS, at the time of the observation.

- On 7/24/2018 between 9:00 AM and 2:45 PM, rusted casters were observed of an IV pole in Room #C-468. This finding was confirmed, with the DOF, at the time of the observation.

- On 7/25/2018 between 6:15 AM and 7:20 AM, rust was observed on the base of an IV pole in OR #2. This finding was confirmed, with the DSS, at the time of the observation.

- On 7/25/2018 between 7:30 AM and 2:45 PM, rusted surfaces were observed as follows: on the base of a trash stand in the ICU Soiled Utility Room, Room #E-237; on the casters of an IV pole in the Interventional Radiology Room; on the casters and the base of an IV pole base in ED Room #F-1053; and on the base and casters of an IV pole in the Critical Care Alcove. These findings were confirmed, with the DOF, at the time of the observations.

9. An accumulation of dust or debris, indicating areas that had not been cleaned and sanitized, was observed as follows:

- On 7/24/2018 between 9:00 AM and 2:45 PM, dust was observed on top of the monitor arm in Room #C-464; on the upper surface of the lamp over the sink; on the top of the door frame in Room #C-461, and on the upper surface of the light over the sink in Room C-459. This finding was confirmed, with the DOF, at the time of the observation

- On 7/25/2018, during a tour of Surgical Services, between 6:15 AM and 7:20 AM, dirt/debris was observed on the floors in all corners of the room and along the pallets holding the soap barrels. This finding was confirmed, with the DSS, at the time of the observation

- On 7/25/2018 between 7:30 AM to 2:45 PM, a dark gray discoloration was observed on the ceiling in the BU Shower Room - Room #348. This finding was confirmed, with the DOF, at the time of the observation.

These findings were confirmed, with the DOF, at the time of the observation.

Based on records reviewed and interviews, the Condition Participation for Emergency Services was not met as evidenced by the failure to ensure care was provided in accordance to current standards for 3 of 11 sampled patient records of nine patients presenting to the emergency department (Patient #1, #2, and #3).

Findings:

It is standard practice for all patients who seek care through the emergency department (ED) of a hospital to receive a thorough evaluation/assessment, stabilizing treatment, and discharge to home or to previous living environment in a stable condition, admission to the hospital for continuing treatment, or transfer to another hospital for further treatment that the hospital is unable to provide. The assessment and the medical decision making related to treatment and discharge should be documented in the record.

Patients may present to the ED with various symptoms including behavioral or psychiatric symptoms. "Routine Psychiatric Assessment", a 2017 article by Michael B. First, MD, available in the Merck Manual Professional Edition, indicated the following:

- "Complaints or concerns may be new or a continuation of a history of mental problems."

- "Routine psychiatric assessment includes a general medical and psychiatric history and a mental status examination."

- "A mental status examination uses observation and questions to evaluate several domains of mental function, including speech, emotional expression, thinking and perception, and cognitive functions."

- "Speech can be assessed by noting spontaneity, syntax, rate, and volume."

- "Emotional expression can be assessed by asking patients to describe their feelings. The patient's tone of voice, posture, hand gestures, and facial expressions are all considered. Mood (emotions patients report) and affect (emotional state interviewer notes) should be assessed. Affect and its range (i.e., full vs constricted) should be noted as well as the appropriateness of affect to thought content (e.g., patient smiling while discussing a tragic event)."

- "Thinking and perception can be assessed by noticing not only what is communicated but also how it is communicated. Abnormal content may take the form of the following: Delusions (false, fixed beliefs); Ideas of reference (notions that everyday occurrences have special meaning or significance personally intended for or directed to the patient); and Obsessions (persistent ideas, feelings, impulses, preoccupations)."

- Cognitive functions include the patient's level of alertness; attentiveness or concentration; orientation to person, place, and time; immediate, short-term, and long-term memory; abstract reasoning; insight; and judgment."


1. Patient #1's record indicated the patient presented to the ED on 6/15/18 at 5:38 AM.

The triage note completed by the RN at 5:52 AM indicated "PT [patient] suicidal after arrest. Present for jail clearance."

The ED Physician note, signed on 6/15/18 at 5:55 AM indicated the following: the patient was arrested and presenting with suicidal ideation he/she expressed to the police officer; he/she stated his/her plan may be to jump off a bridge; he/she had thoughts of killing other people but will not tell the physician who; and he/she had a depressed mood and mood congruent affect. Under the Medical Decision-Making Section, the physician documented, "patient is well appearing with normal vital signs and no signs of or history suggesting overdose, trauma or serious acute medical illness. No further medical workup is indicated for this patient emergently. At this point, patient is medically stable for incarceration. Will place on suicide watch and have evaluated by crisis prior to discharge from jail."

The record indicated that the diagnosis was "suicidal ideation" and "homicidal ideation".

There was no evidence in the records that this patient's presenting symptoms (suicidal and homicidal ideation) were thoroughly assessed before being discharged to jail.

On 7/25/18 at approximately 2:45 PM, this patient's record was discussed with the Medical Director of the Emergency Department and the Chief Medical Officer. They indicated that "this record had room for improvement."

2. The ED log, indicated that ED Patient #2 presented to the ED on 7/10/18 at 7:04 PM and was discharged home on 7/11/18 at 12:40 PM. The log indicated that the presenting complaint was "Mental Health Problem; Crisis w/pd; Homicidal ideations; Restlessness and agitation; Bipolar disorder, unspecified". No entry was made in the diagnosis column of the electronic log that was given to the surveyors.

The ED log, indicated the patient returned to the ED on 7/13/18 at 12:50 PM and was discharged with law enforcement on 7/13/18 at 12:55 PM. The log indicated that the presenting complaint was "jail clearance, homicidal ideations, restlessness and agitation". No entry was made in the diagnosis column of the electronic log that was given to the surveyors.

A review of ED Patient #2's record was completed for the ED visit on 7/13/18. The record indicated that the triage process started on 7/13/18 at 12:15 PM.

An entry by a RN, electronically signed by the RN on 7/13/18 at 12:39 PM, indicated the following: "Pt [patient] refused assessment from RN. Pt uncooperative, hostile, assaultive, spitting, making threats of violence to RN and security staff. LPD [Lewiston Police Department] present with pt. Pt in no apparent distress, resp [respirations] even and non-labored. Color pink, disheveled/soiled condition. Released to LPD to go to jail".

The ED Physician note, signed on 7/13/18 at 12:33 PM, indicated the following:

The patient "arrives to the emergency department by the Lewiston Police Department after report of threatening with a knife". The patient does have a history of bipolar disorder and was seen in this behavior emergency department a few days ago. Patient states that [he/she] out of his/her medication. [He/She] has no medical complaints or concerns at this time. [He/She] is quite upset. [He/She] is in handcuffs. [He/She] is threatening the officer. [He/She] is actively spitting."

In the problem list section of the note: there was an entry of unresolved "Bipolar 1 disorder" which was noted on 7/11/18 by a Nurse Practitioner.

In the past medical history section of the note: The patient "reports that [he/she] has stage 4 lung cancer". Other diagnoses included diabetes and psychiatric disorder.

In the review of systems section of the note: Psychiatric/Behavioral: "The patient is nervous/anxious."

In the physical exam section of the note: General: "awake alert, disabled, poor hygiene, yelling, spitting threatening to police"; Psychiatric: "combative verbally threatening to kill the police officer spitting."

In the medical decision-making section: "This is a 35-year-old [male/female] who is angry and spitting threatening police in handcuffs presents for evaluation. [He/She] reports a history of mood disorder. [He/She] is requesting Ativan. [He/she] denies suicidal ideation but is threatening to kill the police officer. On exam [he/she] is disheveled poor hygiene ... ... .... Medically and psychiatrically clear for jail. [He/She] she reported history of lung cancer. I cannot find any mention of lung cancer in [his/her] chart here. [He/She] was seen here for medical condition recently. There is no mention of lung cancer at that time. The last evaluation for a psychiatric standpoint was 3 days ago. After some stand up but [he/she] would emergency department [he/she] became calm and ultimately discharged with outpatient treatment. [He/She] has common read directable when I interview [him/her] I do not think [he/she] needs medication at this time [he/she] is noticeably upset. [He/She] is very angry at police but I think [he/she] is appropriate to be transported to jail."

The primary diagnosis was homicidal ideations and agitation.

The RN documented on 7/13/18 at 12:54 PM the patient was "stable" and departed "in police custody".

As stated above, this patient was brought to the ED by the police after a report of threatening with a knife; he/she was disheveled with poor hygiene, reported he/she was out of his/her medications, was "nervous/anxious", had a diagnosis of unresolved bipolar disorder, and was upset and threatening to kill the police officer. In addition, the patient reported that he/she had stage 4 lung cancer and the ED physician could not find a record of this. However, there was no evidence in this patient's medical record of the following which would be expected to be documented:

- A review of the patient's current medications and which medication he/she was out of and had not been taking.

- A thorough and complete routine psychiatric assessment.

On 7/25/18 at 2:20 PM, the surveyors discussed this patient's record with the Director of Emergency Service. He stated that he felt that the medical decision making documentation described the patient very well; that the patient was appropriate to go to jail; and that he read the note to indicate that the patient's anger was towards the police for being arrested.

On 7/25/18 at 3:43 PM, the surveyors discussed this patient's record with the Medical Director of the Emergency Department and the Chief Medical Officer. The Medical Director indicated that the medical decision making indicated that the patient was calm and redirectable which would mean the patient was not psychotic or manic. They both expressed that the documentation that the patient was calm and was able to be redirected was the psychiatric evaluation/assessment and that this was an adequate assessment for this patient.

3. Patient #3 presented to the ED on 6/24/18 at 12:02 AM. Documentation in the record (3A) indicated the reason for the visit was "foot pain and mental health problem". During this ED visit, ED Physician #1 documented that the patient had a history of bipolar disorder, schizophrenia, and depression; he/she had not been on his/her medications for two to three weeks; the patient stated he/she did not have provider in the area; he/she had no access to his/her medications, he/she wanted to get back on his/her medications; and he/she wanted to speak to a Psychiatrist. When the ED Physician informed the patient he/she could see a Psychiatric Nurse Practitioner (PNP) in the morning as there was no Psychiatrist available in person at that time, the patient became upset with this plan as he/she only wanted to speak to a Psychiatrist. The patient was upset with the overall visit, wanted to leave, and he/she was subsequently discharged. He/she was encouraged to return to the ED if he/she chose and he/she could be seen by the crisis team and the Nurse Practitioner. The record indicated that patient departed at approximately 12:41 AM.

Patient #3 returned to the ED on 6/24/18 at 1:30 AM. Documentation in the record (3B), by ED Physician #1 at 1:38 AM, indicated the patient presented to the ED with the police stating he/she was actively suicidal with thoughts of slitting his/her wrists and again indicated the patient had been without medications for the past three weeks. The Physician documented "Telemedicine is not available at this hour" and the patient agreed to wait until morning to speak with the Nurse Practitioner (NP).

At 6:08 AM, ED Physician #1 documented the patient had an uneventful night; he/she was waiting to be seen by the NP; and the patient's care would be turned over to the morning ED Physician.

At 9:16 AM, RN #2 documented the patient was alert, apathetic; irritable, his/her affect was flat; his/her judgement was intact, he/she had thoughts of suicide; he/she had a history of violence with prior assaults on a RN and property damage during a prior inpatient stay.

At 11:34 AM, documentation by a PNP indicated an psychiatric evaluation had been completed and the patient needed inpatient admission but the hospital was at capacity; therefore, the patient would be presented to the crisis agency.

One of the roles of the crisis agency is to assist in locating an inpatient bed within the State for the patient.

At 3:20 PM, RN #2 documented the following: "Pt [patient] noting to be increasingly hostile. PT states "I'm bored, can you get me a 1:1?' Pt making frequent requests. Pt demanding milk and demanding to choose [his/her] own meals, staff attempting to redirect pt. Pt states "you have to act out to get things here." Pt continues to make verbal threats, threatening to "stab" and "kill" people. Pedi [Pediatric] patient moved from Pedi area and pt transferred to Pediatric area to be by himself to ensure safety of [his/her] peers."

At 3:31 PM, Ativan (a medication used for anxiety) was ordered as a medication that could be administered once. The Ativan was administered, by RN #3, at 3:39 PM.

At 4:13 PM, documentation by RN #3 indicated the following: "Pt in milieu when another pt became aggravated and started to yell. This triggered pt to get angry and began to yell at pt threatening to hurt him. Pt got up and started walking towards Pt #2 when staff, security, and police interviewed and pt was offered po [by mouth] prn [as needed]. Pt was then escorted to Pedi side of milieu for space from other patients. Pt yelling and being uncooperative. Pt telling staff that we can "fuck off" and that we will "starve [himself/herself] because we haven't done anything for me. Pt pacing and cursing and saying "fuck this place" NP talked to pt and pt was still uncooperative. Will continue to monitor."

At 4:30 PM, documentation by RN #2 indicated the following: "Pt becoming increasingly hostile. Pt continues to make demands and is [his/her] needs are not met then [he/she] will start to yell and make verbal threats. Pt pacing. Pt stated "How much time would I get if I hit one of you?" Pt alert. Speech is clear. [He/She] has good eye contact. No delusions or paranoia noted."

At 4:31 PM, documentation by ED Physician #3 indicated the following: "Patient was signed out to me at start of shift. [He/She] started having escalating behavior toward staff. [He/She] did not appear manic or psychotic. [He/She] started making statements "I am bored I needed a 1 on 1." [He/She] threatened to stab the nurses. [He/She] also was making statements like he was going to "trashed this place." The patient has a history of violent behavior towards hospital property and staff. Currently 2 behavioral nurses are pregnant and fearful for their safety. The police were called and the patient is being discharged in police custody. I recommend 15 minute checks since the patient was making suicidal statements earlier today. [He/She] She is medically cleared for incarceration."

The primary diagnosis documented in the record was "bipolar depression". Other diagnoses documented was "aggressive behavior of adult" and "homicidal ideation".

At 5:02 PM, documentation by RN #1 indicated the following: "Pt was discharged to LPD [Lewiston Police Department] due to continued threats to physically harm staff and destroy property. Per past records pt [patient] has a hx [history] of following through on these threats. RN staff have attempted to assist pt in maintaining control by offering medications, offering a room for decreased stimulation. PT continues to terrorize staff. PT has been discharged to law enforcement. Pt [patient] does not appear delusional or hallucinating. PT is oriented X [times] 3."

Documentation by the PNP, signed at 7:22 PM, indicated that "patient became increasingly demanding and agitated in the milieu, making numerous demands and making threats. [He/She] threatened to assault providers, making clear purposefully menacing statements. [He/She] threatened to assault staff, postured physically and continue to escalate. [He/She] was not reporting any psychosis and did not appear to be responding to any internal stimuli; [He/She] was threatening to punch/kill staff, asking how much jail time he would have to serve. Because of [his/her] purposeful threats and known history of violence, police were called for support and patient was discharged to PD custody to jail. Suicide precautions were recommended by ED MD."

The crisis agency assessment was reviewed. This assessment indicated the patient was a moderate risk of harm to himself/herself based on the report of suicidal ideation and he/she was at risk for continued decompensation. The assessor documented that "based on SI [suicidal ideations], currently being off medications, no psychiatric providers, no natural supports, and homeless CSP and NP recommend inpatient level of care and client is in agreement."

A review of the hospital's "Code Gray" policy, last revised in 1/2017, indicated the following: "it is the policy of Behavioral Services that a patient who threatens to carry out any acts of harm to another patient, self, staff member or visitor on the unit, for whatever reason, is designated as being combative or assaultive at that time. A situation considered to be imminent danger is one in which a patient is verbally or physically threatening physical harm or a patient who has a weapon. Certain precautionary measures may then be implemented within the context of utilizing the least restrictive intervention consistent with safety and therapeutic goals, as presented in the Crisis Prevention Intervention (CPI) Training Program and hospital procedures." The procedure described actions staff members were to implement, what protective equipment may be used in cases of imminent danger, if the identified measures were not effective and people remained in imminent danger that a code gray was to be a called. The procedure also directed staff to "fully document all measures taken to manage the assaultive patient in the medical record"; indicated a "silent code gray" may be utilized when there are adequate staff on the unit to implement the Code, or known available staff/personnel from other areas of the hospital are called to the unit"; and "a paged Code Gray is called when there is not adequate staff on the unit to maintain control of an unsafe situation".

A review of the police report, dated 6/24/18, indicated the following: Police were dispatched to the BED for a disturbance on 6/24/18 at approximately 4:35 PM. RN #2 reported to the officer the patient was out of control and had "trashed" two rooms; he/she was swearing and yelling; he/she was demanding his/her own meals, private room and private bathroom; the patient had told her that if he/she didn't get what he/she wanted that he/she would stab and kill her and had said "I wonder how much time I'd get for killing you". The RN indicated that she had taken this as a threat and was scared for her safety. The RN indicated the patient had several police involvements all day and stated that was an ongoing issue. Police records indicated the patient had six previous law enforcement contacts within the previous 16 hours (not including this one) and the majority of the contacts were for being disorderly and belligerent to hospital staff. The patient had been issued a disorderly conduct warning an hour before this call.

On 7/23/18 between 12:10 PM and 12:46 PM, the Director of the ED indicated to surveyors that psychiatric services are available as follows:

- From 7:00 AM to 12:00 PM - One Nurse Practitioner (NP) on site in the behavioral area of the ED which is known as the BED

- From 12:00 PM to 7:00 PM - Two NPs on site in the BED

- From 3:00 PM to 3:00 AM - One NP via Telemedicine

- From 3:00 AM to 7:00 AM - a crisis agency covers and they are available 24 hours a day 7 days a week (24/7)

- 24/7 a Psychiatrist is on call.

On 7/24/18, staffing for the BED was reviewed with the Director of the ED. The designated core staff for the BED consisted of two RNS on duty 24 hours a day and a Psych Tech for 12 hours a day. On 6/24/18, during this patient's stay in the BED, there were three RNS on duty and a Psych Tech came on duty at 11:00 AM.

On 7/25/18 at 10:10 AM, surveyors discussed this patient with the Director of the ED. He was asked about Telemedicine being "unavailable". He indicated that Telemedicine stops taking new patients after 2:00 AM. When asked what other options can be utilized if Telemedicine is unavailable, he indicated that the patient could wait until the morning when the NP came in, the crisis agency could be called, or the on-call Psychiatrist could be called.

On 7/25/18 at 2:39 PM, surveyors interviewed ED Physician #1 who was on duty at the time Client #3 came to the hospital and who documented that Telemedicine was not available. ED Physician #1 indicated that the first time he saw the patient (i.e.: during the 12:02 AM visit), the patient was new to the State; he/she was not aware a Psychiatrist was not present at the hospital at all times; he/she didn't understand that a NP through Telemedicine was utilized during the overnight hours; he/she wanted to see a Psychiatrist in person; they talked about his/her previous inpatient admission; he/she was given options; and the patient's demeanor and attitude changed when the other options were discussed. He stated the patient "shut down" when the options were discussed; he/she declined to stay, and subsequently was discharged. When the patient returned for the third visit (i.e. 1:30 AM), he (the ED Physician) inquired about the availability of Telemedicine; he was made aware the Telemedicine NP was interviewing another patient as they also provide evaluations on patients in other hospitals; and that the Telemedicine services were only available until 2:00 AM. He acknowledged that he felt the patient needed to have a consultation with psychiatric services; he offered the patient NP services, and that the NP would be coming in at 7:00 AM, and the patient agreed to stay. The ED Physician indicated that plan was for the patient to be seen in the morning and if Telemedicine had been available the patient would have been seen then. When asked what other options were available if Telemedicine was unavailable, he indicated that the crisis agency is available 24 hours a day; he was not sure if he recommended for the crisis agency to be called or not; he asked the patient if he would wait for the NP in the morning and he/she agreed; and if needed the Psychiatrist could be called.

On 7/26/18 at 8:35 AM, surveyor interviewed the PNP who saw the patient on 6/24/18. The following information was obtained during this interview: She gets report from the nursing staff and depending on the acuity of the patients will determine who she sees first; if the patients are of equal acuity she will see the patients based on who came in first; she can't remember the exact time she saw Patient #3 but it was mid-morning; she recalls that this patient was escalating throughout the day - frequently asking for specific food items and 1:1; they had several acutely ill patients that day in the BED; this patient was moved to the Pediatric side of the BED to help deescalate him/her; he/she was making threats to staff - asking how long he/she would get if he/she assaulted someone; he/she physically postured at one point as if to hit; his/her behaviors were escalating and deescalating for a couple of hours; they call the police if they can't keep people safe; she can't remember if they called for support from others to help the situation before calling the police; and the crisis agency was involved in searching for an inpatient bed for the patient.

On 7/26/18 at 9:32 AM, surveyors interviewed RN #2. The following information was obtained during this interview: initially the patient wanted to sleep but as the day progressed he/she saw the PNP and a representative from the crisis agency for evaluations; the PNP and the crisis agency evaluations were done around the same time before lunch; she gave the patient medications; at lunch, the patient was upset with the portion size of the meal and snacks; the BED was very busy and the milieu can change on a dime; there was an exchange of words between this patient and another patient; this patient was offered a private area to deescalate; it was clear the patient was getting more agitated; he/she wanted a private room with a private bathroom - this was not available; the hospital lacked capacity (i.e.: no inpatient beds) and the patient wanted to be upstairs (inpatient unit); he/she became increasingly agitated making more threats to stab people and asking how much time he/she would get if he hit us; he/she was clearly not psychotic, had good eye contact, and had control over his/her behaviors; there were multiple patients who were psychotic at the time in the BED and police had been called for a patient, who was psychotic and throwing furniture; police were present several times in the BED throughout the day; safety for the patients was a concern; this patient said I know what I need to do to get what I want; the patient did not like the milieu in the BED; they moved the patient from the adult side of the BED to the Pediatric side of the BED; it was felt that the patient's threats were volatile and could be harmful; things continued to go south - they wanted to be proactive not reactive and did not want the situation to become violent therefore, the called the police; and the patient was medicated. The RN also stated that since she has worked at the hospital, this day was one of the highest acuity days (i.e.: a day in which patients required a lot of intervention/care) and they had 3 RNs on duty that day. When asked what the time span of the events were, the RN indicated from the time she medicated the patient (per documentation 11:26 AM) to approximately 4:00 PM.

The identified issues related to this patient's care in the BED were as follows:

- This patient was evaluated, by the PNP and the crisis unit, to need inpatient care. However, the patient displayed behaviors and was discharged to jail instead of being provided needed psychiatric inpatient care.

- The ED Physician intended for this patient to be seen for a psychiatric consult by Telemedicine on 6/24/18 during the early hours of the morning (1:38 AM); Telemedicine was not available; and other options, that were available, were not utilized.

- Per interviews, the patient's behavior escalated and deescalated over a two to approximately 4.5 hour, the patient was making threats, the BED was busy with multiple patients who were psychotic, the day was described as the one of the highest acuity days and staffing consisted of three RNs and one Psych Tech who came on duty at 11 AM. When this patient displayed threatening behaviors, there was no evidence that the hospital staff initiated a "code gray" per their policy to handle the situation before the police were called and the patient subsequently arrested.


The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.