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Based on record review and staff interview, the Critical Access Hospital failed to be in compliance with the State of Vermont Statute Title 18, Chapter 42: Bill of Rights for Hospital Patients for one of six medical records reviewed. Per State Statute 1852, Patients' Bill of Rights for Hospital Patients: (1). "The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of his or her personal dignity."
Findings include:

The patient presented to the facility emergency department on December 6, 2013 with a chief complaint of anxiety. {S/he became progressively more anxious and hostile toward hospital staff upon realizing that [s/he] had to register to see the counselor who directed the patient to meet [him/her] in the emergency department. The patient did not want to wear the wristband identification bracelet, and did not want to relinquish [his/her] clothes assuming that the emergency department visit was going to be with the mental health counselor only. The patient became more intense and volatile and had verbalized an intention to drive [his/her] automobile off of a bridge. The patient was not allowed to leave the emergency department pending a mental health evaluation which caused [him/her] to become louder, demanding, and finally threatening toward staff. The patient was ultimately put down to the floor by the physician and a sheriff officer who handcuffed the patient per the request of the physician. The facility has a restraint policy in place that does not include the use of law enforcement handcuffs as a means of clinical intervention. The patient was not afforded an acceptable standard of clinical practice, that being, trained emergency room staff utilizing de- escalation principals and then if warranted the clinical staff applying restraining devices. Per interview of the physician who physically intervened and requested the handcuffs, [s/he] stated that it was emergent and that the hospital restraints were across the room in another examination room. The physician stated the [s/he] was familiar with hospital policy regarding the use of restraints, but confirmed [s/he] did not follow that protocol in this instance.

Based on record review, staff interview and general observation the hospital failed to provide health care services in accordance with their own written policies for one of six patients ( # 1) selected for review. Findings include:

Patient # 1 was admitted into the emergency department on a voluntary basis on December 6, 2013. [S/he] presented with increasing anxiety and apparently the admission process itself caused the patient to further decompensate as evidenced through mental health, nursing, and physician notations. Per record review the patient decompensated to the point that the emergency department physician felt compelled to physically take the patient to the floor and request the contract sheriff deputy to handcuff the patient. Per review of the hospital protocol titled Restraints and Management of a Restraint- Free Environment, effective 04/92 and reviewed last on 12/13, the hospital staff did not intervene according to their written protocol, specifically as follows;
Per hospital protocol as listed, in the section identified as Supportive Data, it states that the decision to use a restraint is not driven by diagnosis, but by a comprehensive individual patient assessment which includes a physical assessment to identify medical problems that may be causing behavior changes in the patient. The physician did not seek information regarding the presentation of the patient, whether medical issues were involved or whether any evaluation had occurred, and approached the patient to tell [him/her]to go into [his/her] room. There was no attempt by the physician to inquire of the patient what [his/her] needs were or to assess the patient's needs. The following protocols in the restraint policy are also noted as not being followed;
1. Physical restraint types: Per hospital protocol handcuffs are not listed as clinical restraining devices.
2. C. General Guidelines: (2). The decision to increase environmental restrictiveness must be based on the assessed protective and safety needs of the patient and/or others. In this case per interview the physician had just arrived for {his/her] shift and heard the patient yelling. [S/he] did not have information regarding the condition of the patient, the needs of the patient, or make an attempt to assess the patient for intervention purposes. Per interview the physician stated [s/he] approached the patient and told [him/her] to go back into [his/her] room. The patient became aggressive at that point.
3. C. General Guidelines: (3). Alternatives to restraints will be attempted initially. No alternatives were attempted or even considered.There is no documentation in the clincal record supportive of the nurse or the physician attempting to de-escalate the patient or that they conferred on a plan to intervene with the patient, or that there was any consideration for lesser restrictive interventions. On March 6, 2014 at 0730 AM the physician who intervened with the patient and requested that the contract officer handcuff the patient confirmed that [s/he] did not attempt to assess the patient and did not include the physical intervention or the use of the handcuffs in [his/her] discharge summary or any other component of the medical record. The physician at this time also confirmed that [s/he] is aware that the hospital has a restraint policy that does not include the use of handcuffs.

Based on record review and on staff interview the Critical Access Hospital staff failed to accurately document a clinical intervention in one of six medical records reviewed. Findings include:

Patient # 1 was admitted to the hospital emergency department on 12/06/2013. Per record review there was no documentation by the primary nurse involved in the care of the patient, or the the physician treating the patient that a physical intervention and subsequent use of restraining devices had occurred. Per interview on March 5, 2014 at 2:30 PM, the primary nurse providing care to the patient confirmed that [s/he] did not enter documentation into the patient record regarding an actual event that [s/he] witnessed regarding the physical take down of a patient and subsequent handcuffing of that patient. When asked why [s/he] failed to to so [s/he] stated that the shift in question included a multitude of anxiety provoking events involving several patients and that [s/he] did not get to it.
Per interview on March 6, 2014 at 0730 AM the physician of record confirmed that [s/he] did not document the physical take down and subsequent handcuffing of a patient. The physician stated that the incident happened quickly and the handcuffs were on for only five minutes.