HospitalInspections.org

Based on document review, observation, and interview it was determined that, the Hospital failed to ensure the Patient Rights protected and respected for a patient in the Emergency Department. This potentially affects an average of 87 patients daily on census in the Emergency Department. As a result, the Condition of Participation for Patient Rights, 42 CFR 482.13, was not in compliance:

Findings include:

1. The Hospital failed to ensure that the patient was free from restraints of any form. See deficiency cited A-0154.

2. The Hospital failed to ensure that the patient's request for a change of physician, was accomodated. See deficiency cited A-0129.

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) Emegency Department clinical records reviewed of a patient requesting for a change of physician, the Hospital failed to ensure the patient was provided with a new physician.

Findings include:

1. On 10/16/19 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 walked into the Hospital's Emergency Room (ER) on 09/21/19 at 10:34 PM with a chief complaint of abdominal pain. Pt. #1 signed out against medical advice (AMA) from the ER on 09/22/19 at 2:56 AM.

2. The Emergency Room ER Nurse (E #10) documentation dated 09/22/19 at 12:56 AM, included, "Pt. [Pt. #1] asking to see another ED Physician. This RN (E #10) explained to patient that ER MD (MD #1) will be her only provider ..."

3. The Hospital's policy titled, "Patient Rights and Responsibilities" dated 02/17 was reviewed. The policy included, "Procedure: A Patient Rights and Responsibilities document is provided to all admitted patients, as well Emergency Department patients, observation patients and outpatient surgery patients ...The right to request a consultation or second opinion from another physician as well as to change physicians, hospitals or outpatient centers ..."

4. The Hospital's Emergency Department (ED) Physician Roster dated 09/01/19 - 09/30/19 was reviewed. The physician roster indicated, "On 09/21/19 - ER Physician (MD #1) worked in the ED between 4:00 PM - 1:00 AM and ER Physician (MD #4) worked in the ED between 10:00 PM - 6:00 AM ..."

5. On 10/17/19 at approximately 12:45 PM, the Director of Nursing (E #14) was interviewed and stated, "I am not sure why the patient (Pt #1) was not reassigned to the alternate physician, when the patient requested. If there are two ED physicians working on that day, then it is fine to refer the patient to the other ED physician. I am not sure why the nurse did not facilitate it for the patient."

6. On 10/17/19 at approximately 2:10 PM, the Registered Nurse (E #10) was interviewed. E #10 stated, "I tried to help the actual nurse who was taking care of the patient. I told her that she is with ER Physician (MD #1) and she can only be seen by (MD #1). I was not aware that there was another physician working in the ED." Upon asking if she knew ER Physician (MD #4) was working in the ED at the same time and if she inquired with the charge nurse, E #10 responded that, she was not aware about it.

Based on document review, observation, and interview it was determined that for 1 of 3 (Pt. #1) emergency department clinical records reviewed for restraints usage, the Hospital failed to ensure that patient was free from restraints of any form that are not medically necessary.

The findings include:

1. On 10/16/19 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1, walked into the Hospital's Emergency Room (ER) on 09/21/19 at 10:34 PM, with a chief complaint of abdominal pain. Pt. #1 signed out against medical advice (AMA), from the ER on 09/22/19 at 2:56 AM.

- ER note by Registered Nurse (RN) (E #9) dated 09/21/19 at 11:49 PM, included, "Pt. (Pt. #1) is AX0X4 (Alert, oriented to person, place, time and situation). C/O (complaints of) left upper and lower abd. (abdominal) pain ...with nausea and vomiting. Was at another local Hospital and signed out AMA ...Was told to come to this treatment Hospital (Hospital A) by PCP (Primary Care Physician) ...changed to (Hospital) gown ...pt. connected to continuous monitor ...provide warm blanket for comfort ...seen by ER Physician (MD #1)."

- ER Physician (MD #1) note dated 09/21/19 at 11:51 PM, included, "Chief Complaint: Patient presents with abdominal pain ...AXOX4 ambulatory with c/o LUQ (Left Upper Quadrant)/ LLQ (Left Lower Quadrant) pain onset yesterday, hx (history) of diverticulitis (Inflammation of the colon) ...The patient (Pt. #1) is a ...presents with complaints of abdominal pain. Patient states pain started yesterday. Patient describes pain in her left lower quadrant and left upper quadrant. Pain has been constant ...Patient states that they were not controlling her pain adequately ...Patient states that she has had multiple abdominal scans and that she just wants pain medication and IV (Intravenous to the vein) fluids. Patient states that her son dropped her off to the emergency room and plans to pick her up if discharged. She states she was diagnosed with diverticulitis in the past and has had abdominal surgeries ..."

- The medication administration record documentation dated 9/21/19 at 11:53 PM by the RN (E #9) included, "Peripheral IV at Left antecubital (elbow joint), Morphine (strong sedative and analgesic) Injection 4 mg (milligrams) IV (intravenous to the vein) given."

- The Registered Nurse (RN - E #9) documentation dated 09/22/19 at 1:23 AM, included, "Pt. (Pt. #1) attempting to leave. Pt. resisting and screaming to staffs. Pt. creating disturbance in the hallway. Escorted with security staffs to room. Pt. (Pt. #1) unable to redirect. Violent restraints (restraints that fully immobiizes body) ordered per MD (ER Physician -MD #1)."

- The ER Physician's (MD #1) order dated 09/22/19 at 1:30 AM, included, "Type of Restraint: Violent Locked X4 - All wrist and ankles ..."

- The E #9 documentation dated 09/22/19 at 2:10 AM, included, "Pt. (Pt. #1) requested to speak to son on the phone. Wireless phone provided and pt. (Pt. #1) spoke to son and called local PD (Police Department)."

2. The Hospital's policy titled, "Restraints Use Non-violent and Non-Self-Destructive Behavior Violent and Self-Destructive Behavior" dated 01/16 was reviewed. The policy included, "Restraints are used only when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff or others. Patient's rights, dignity and safety are protected and maintained. Restraints are used in the least restrictive, safest, and most effective manner possible ..."

3. The Hospital's policy titled, "Patient Rights and Responsibilities" dated 02/17 was reviewed. The policy included, "Procedure: A Patient Rights and Responsibilities document is provided to all admitted patients, as well Emergency Department patient, observation patients and outpatient surgery patients ...The right to receive care and treatment consistent with sound nursing, medical, and rehabilitation practices in a safe setting free of abuse or harassment of any kind. Patient's requests for preferences will be considered in patient care assignments as feasible. When intimate care is provided, consideration for providing two caregivers should be considered ...The right to be free from seclusion and restraints of any form that are not medically necessary, or are used as a means of coercion, discipline, convenience, or retaliation by staff ...

4. On 10/17/19 at approximately 1:45 PM, the Registered Nurse (E #9) was interviewed. E #9 stated, "I followed the physician's order and the security placed the patient on four (4) point violent restraints. The patient did not develop any injury during the incident. I have been an ED nurse for six (6) months. This patient wanted to sign-out AMA (Against Medical Advice). She was alert and oriented. But, the physician did not want her to drive back home because we had given her Morphine IV (Intravenous into the vein) at 11:53 PM. She was placed on restraints at 1:30 AM and released from restraints at 2:15 AM. This patient had a steady gait. She was discharged AMA, accompanied by the local police officers and her son."

5. On 10/17/19 at approximately 8:30 AM, the Nursing Supervisor (E #2) was interviewed. E #2 stated, "The patient (Pt. #1) wanted to speak with me. She wanted to go home, since the physician refused to give her any more pain medication or anxiety medications, since she was just medicated. The patient was refusing to go to the scanning test. Patient wanted to sign-out AMA (against medical advice). She was willing to sign the papers. I spoke with the charge nurse (E #12) and advised to give her the AMA papers while she waits for her son to drive her back home. I did not think that this patient should have been on four (4) point restraints, since she is trying to go home AMA, she was alert and in her right mind. She did not look drowsy to me. She was up and about."

6. On 10/17/19 at approximately 12:45 PM, the Director of Nursing (E #14) was interviewed and stated, "I did not watch the video surveillance. We will review the chart during the ED quality review and that has not happened yet. I looked briefly into the documentation in the clinical record, I noticed patient was placed on four (4) point violent restraints while the patient is requesting to be discharged AMA. I am not sure why the restraints were used, for this patient. Probably, the Physician's decision to have the patient restrained."

7. On 10/17/19 at approximately 2:20 PM, the Chairman for ED (MD #2) was interviewed. MD #2 stated, "This patient (Pt. #1) clinical record is scheduled for medical peer review. We have not completed our peer review yet. If the patient was alert and oriented and had a steady gait and was able to make decisions willing to sign the AMA papers, then I am not sure why the physician decided to place the patient on four (4) point violent restraints. I was not present, not sure why the physician made that decision."

8. On 10/17/19 at approximately 3:10 PM, the Chief Medical Officer (MD #3) was interviewed. MD #3 stated, "I am not sure why the Physician (MD #1) put the patient (Pt. #1) in restraints. They could have just called for a cab to transport the patient home."