HospitalInspections.org

Based on a review of facility policies , facility documents, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to protect and promote each patient's rights by failing to ensure that each patient received care in a safe setting (A-0144), by failing to ensure that the patient's safety was secure (A-0154), by failing to implement restraints or seclusion when less restrictive interventions were determined to be ineffective to protect the patient, a staff member or other from harm (A-0164), by failing to ensure that the type of restraint used was the least restrictive (A-0165), by failing to ensure that restraints or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law (A-0167), for one of one patient (MR1), and by failing to ensure that use of a restraint or seclusion was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 481.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law (A-0168) for five of five patients (MR1, MR3, MR4, MR6 and MR7).

Findings include:

Review of facility policy, "Patient Bill Of Rights" dated September 2010, revealed "27. The patient has the right to be free from restraints, both physical and chemical, or seclusion that is not medically necessary or used as a means of coercion, discipline, convenience, or retaliation by the staff. Restraints and seclusion shall only be used when other less restrictive measures have been found to be ineffective in protecting the patient or others from harm.

Review of facility policy "Dr. Strong" dated July 2010, revealed "To provide immediate assistance to personnel confronted with a combative or agitated inpatient whose behavior is escalating. III. Definition: Dr. Strong-is defined as an acute behavioral emergency that occurs within the hospital setting. The location is announced overhead by the hospital switchboard operator. Appointed hospital personnel (mandatory responders) are to report immediately to the designated location. ... V. Policy Statement: When a situation occurs whereas a patient becomes combative or causes a disturbance that may require staff to utilize physical means to provide for the safety of the staff, patients, and others, a "Dr. Strong" will be announced. Every effort will be made to protect the disruptive patient's rights, dignity, and well being in the least restrictive manner possible to control and de-escalate the situation. ... VI: Process ... J. In the event the combative patient's behavior cannot be safely contained and controlled, the negotiator and the director make a decision whether to call for support from local law enforcement (9-911). When local law enforcement is required to assist, the director will review with the responding officer the patient's behaviors and health conditions that necessitated the need for law enforcement support and the goal for the intervention."

Review of policy "Workplace Violence Policy" dated September 2010, revealed "Monongahela Valley Hospital has zero tolerance for physical or verbal acts or threats of violence. Monongahela Valley Hospital is committed to providing a safe and secure place for all of its employees, patients, visitors, vendors, volunteers, and medical staff. ... 2. Averting a Workplace Violence Incident. a. If a patient, employee, vendor, volunteer, physician or visitor has exhibited potentially threatening behavior, contact the Security Department at Extension 1092. b. Signs of the potentially violent person. (1) A person becomes unusually angry because of perceived slow service. (2) Person who has made verbal threats of physical harm against an individual or the organization or acts of intimidation. (3) A person with any history of violent behavior."

Review of facility policy "Guidelines For Restraint" dated May 2010, revealed "A. Restraint Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely: Manual method is holding the patient. Mechanical restraints are things such as lap belt, lap buddy, mitts, or soft or locked restraints and seclusion. Chemical restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. ... E. Least Restrictive Measures - Measures which permit the maximum amount of freedom consistent with patient safety and protection from injury. Restraints are to be used when Lesser Restrictive Interventions have been determined to be ineffective to protect the patient or others from harm. ... Violent reasons for the use of restraint or seclusion are primarily to protect the individual against injury to self and/or others because of an emotional or behavioral disorder. If the patient becomes combative and restraints are applied, this is a Violent reason and the Violent Standards must be utilized. ... 5. For Violent Management: The primary reason for use is Emergency or crisis management of situations where a patient's behavior becomes aggressive or violent, presenting an immediate serious danger to his/her safety or that of others."

Review of "Agreement This Agreement made this first day of November, 2010, by and between Monongahela Valley Hospital, Inc., and the The Township of Carroll, ... providing prompt police response to Hospital when same becomes necessary, ... 2. The assigned officer while working at the Hospital may carry out Township work, but notwithstanding, will also be available to Hospital as may be necessary for police response. ..."

1) Review of MR1 revealed the patient had a dyscontrol behavorial event on November 9, 2010. Review of facility "Security Incident Report" revealed that the patient (MR1) was subject to a Taser discharge by the police. (A-0144 and A-0154)

Further review of MR1 revealed no documented evidence that the staff used the least restrictive intervention to protect the patient, staff or others (A-0164 and A-0165), and that the staff ensured that restraints were implemented in accordance with safe and appropriate restraint techniques (A-0154 and A-0167).

2) Review of MR1, MR3, MR4, MR6 and MR7 revealed that restraint or seclusion were not initiated in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under ?482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law (A-0168).

Cross reference with:
482.13(c)(2) Patient Rights: Care In Safe Setting
482.13 (e) Use Of Restraint Or Seclusion
482.13 (e)(2) Patient Rights: Restraint Or Seclusion
482.13 (e)(3) Patient Rights: Restraint Or Seclusion
482.13 (e)(4)(ii) Patient Rights: Restraint Or Seclusion
482.13 (e) (5) Patient Rights: Restraint Or Seclusion

Based on a review of facility policies, review of facility documents, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that patients received care in a safe setting for one of one patient (MR1).

Findings include:

Review of facility policy, "Patient Bill Of Rights" dated September 2010, revealed "27. The patient has the right to be free from restraints, both physical and chemical, or seclusion that is not medically necessary or used as a means of coercion, discipline, convenience, or retaliation by the staff. Restraints and seclusion shall only be used when other less restrictive measures have been found to be ineffective in protecting the patient or others from harm.

Review of facility policy "Dr. Strong" dated July 2010, revealed "To provide immediate assistance to personnel confronted with a combative or agitated inpatient whose behavior is escalating. III. Definition: Dr. Strong-is defined as an acute behavioral emergency that occurs within the hospital setting. The location is announced overhead by the hospital switchboard operator. Appointed hospital personnel (mandatory responders) are to report immediately to the designated location. ... V. Policy Statement: When a situation occurs whereas a patient becomes combative or causes a disturbance that may require staff to utilize physical means to provide for the safety of the staff, patients, and others, a "Dr. Strong" will be announced. Every effort will be made to protect the disruptive patient's rights, dignity, and well being in the least restrictive manner possible to control and de-escalate the situation. ... VI: Process ... J. In the event the combative patient's behavior cannot be safely contained and controlled, the negotiator and the director make a decision whether to call for support from local law enforcement (9-911). When local law enforcement is required to assist, the director will review with the responding officer the patient's behaviors and health conditions that necessitated the need for law enforcement support and the goal for the intervention."

Review of policy "Workplace Violence Policy" dated September 2010, revealed "Monongahela Valley Hospital has zero tolerance for physical or verbal acts or threats of violence. Monongahela Valley Hospital is committed to providing a safe and secure place for all of its employees, patients, visitors, vendors, volunteers, and medical staff. ... 2. Averting a Workplace Violence Incident. a. If a patient, employee, vendor, volunteer, physician or visitor has exhibited potentially threatening behavior, contact the Security Department at Extension 1092. b. Signs of the potentially violent person. (1) A person becomes unusually angry because of perceived slow service. (2) Person who has made verbal threats of physical harm against an individual or the organization or acts of intimidation. (3) A person with any history of violent behavior."

Review of facility policy "Guidelines For Restraint" dated May 2010, revealed "A. Restraint Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely: Manual method is holding the patient. Mechanical restraints are things such as lap belt, lap buddy, mitts, or soft or locked restraints and seclusion. Chemical restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. ... E. Least Restrictive Measures - Measures which permit the maximum amount of freedom consistent with patient safety and protection from injury. Restraints are to be used when Lesser Restrictive Interventions have been determined to be ineffective to protect the patient or others from harm. ... Violent reasons for the use of restraint or seclusion are primarily to protect the individual against injury to self and/or others because of an emotional or behavioral disorder. If the patient becomes combative and restraints are applied, this is a Violent reason and the Violent Standards must be utilized. ... 5. For Violent Management: The primary reason for use is Emergency or crisis management of situations where a patient's behavior becomes aggressive or violent, presenting an immediate serious danger to his/her safety or that of others."

Review of "Agreement This Agreement made this first day of November, 2010, by and between Monongahela Valley Hospital, Inc., and the The Township of Carroll, ... providing prompt police response to Hospital when same becomes necessary, ... 2. The assigned officer while working at the Hospital may carry out Township work, but notwithstanding, will also be available to Hospital as may be necessary for police response. ..."

Review of policy "Nursing Department Emergency Department Violent Behavior in Treatment Area of Emergency Department" revealed "In the instance where a person begins to act out in a verbal or physical manner while in the Treatment Area of the Emergency Department the following actions will be taken to ensure the safety of all patients, visitors and employees. 1. Security will be notified by phone or by alarm button. ...5. If behavior warrants, the police will be notified by the Nurse Manager or other designated employee. ..."

1) Review of MR1 revealed that the patient had a behavorial dyscontrol event on November 9, 2010, and the police were called. Review of "Security Incident Report" revealed that the patient (MR1) was subject to a Taser discharge by police while a patient in the Emergency Department. Continued review of MR1 revealed that the patient was transferred to another facility behavorial health unit.

Interview with EMP3 on November 12, 2010, at 1:15 PM confirmed that MR1 was subject to a Taser discharge by the police. During continued interview, EMP3 was asked if the "Dr. Strong" policy was used for the patient (MR1). EMP3 stated that the facility policy "Dr. Strong" does not apply when a patient is in the Emergency Department.

Cross reference with:
482.13 Patient Rights

Based on a review of facility policy, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure the immediate safety of patients for one of one patient (MR1).

Findings include:

Review of facility policy "Guidelines For Restraint" dated May 2010, revealed "A. Restraint Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely: Manual method is holding the patient. Mechanical restraints are things such as lap belt, lap buddy, mitts, or soft or locked restraints and seclusion. Chemical restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. ... E. Least Restrictive Measures - Measures which permit the maximum amount of freedom consistent with patient safety and protection from injury. Restraints are to be used when Lesser Restrictive Interventions have been determined to be ineffective to protect the patient or others from harm. ... Violent reasons for the use of restraint or seclusion are primarily to protect the individual against injury to self and/or others because of an emotional or behavioral disorder. If the patient becomes combative and restraints are applied, this is a Violent reason and the Violent Standards must be utilized. ... 5. For Violent Management: The primary reason for use is Emergency or crisis management of situations where a patient's behavior becomes aggressive or violent, presenting an immediate serious danger to his/her safety or that of others."

Review of facility policy "Dr. Strong" dated July 2010, revealed "To provide immediate assistance to personnel confronted with a combative or agitated inpatient whose behavior is escalating. III. Definition: Dr. Strong-is defined as an acute behavioral emergency that occurs within the hospital setting. The location is announced overhead by the hospital switchboard operator. Appointed hospital personnel (mandatory responders) are to report immediately to the designated location. ... V. Policy Statement: When a situation occurs whereas a patient becomes combative or causes a disturbance that may require staff to utilize physical means to provide for the safety of the staff, patients, and others, a "Dr. Strong" will be announced. Every effort will be made to protect the disruptive patient's rights, dignity, and well being in the least restrictive manner possible to control and de-escalate the situation. ... VI: Process ... J. In the event the combative patient's behavior cannot be safely contained and controlled, the negotiator and the director make a decision whether to call for support from local law enforcement (9-911). When local law enforcement is required to assist, the director will review with the responding officer the patient's behaviors and health conditions that necessitated the need for law enforcement support and the goal for the intervention."

Review of policy "Workplace Violence Policy" dated September 2010, revealed "Monongahela Valley Hospital has zero tolerance for physical or verbal acts or threats of violence. Monongahela Valley Hospital is committed to providing a safe and secure place for all of its employees, patients, visitors, vendors, volunteers, and medical staff. ... 2. Averting a Workplace Violence Incident. a. If a patient, employee, vendor, volunteer, physician or visitor has exhibited potentially threatening behavior, contact the Security Department at Extension 1092. b. Signs of the potentially violent person. (1) A person becomes unusually angry because of perceived slow service. (2) Person who has made verbal threats of physical harm against an individual or the organization or acts of intimidation. (3) A person with any history of violent behavior." .

Review of "Agreement This Agreement made this first day of November, 2010, by and between Monongahela Valley Hospital, Inc., and the The Township of Carroll, ... providing prompt police response to Hospital when same becomes necessary, ... 2. The assigned officer while working at the Hospital may carry out Township work, but notwithstanding, will also be available to Hospital as may be necessary for police response. ..."

1) Review of a facility "Security Incident Report ... Date of Incident 11-09-10 Time ... 1235 ... Department ... Emergency Room ... Incident Type: ... Patient Security ... Outside Assistance ... Police Department Carroll Twp ... RN ... called for police assistance and Offi (sic) ... responded. The patient was physically restrained by security and staff as medication was administered. The patient continued to be aggressive and combative ... attempted to kick making contact with RN ... Ofc (officer) gave the patient verbal warning and "tased" the patient. The patient was then placed into (4) point restraints. No staff injured as a result of the incident. ... patient was transferred via ... ambulance to [hospital]."

2) Review of the facility's investigation revealed " on 3-11 shift on 11-09-10, [patient] was brought to our ED. ... Dr. ... determined that [the patient] should be treated at [hospital] psyche. ... This caused the pt(patient) to become increasingly agitated and , ...
... officer ... arrived to assist with the pt. ... was dry tased by officer ... after numerous warnings. ... was given ... geodon (antipsychotic medication) injection and restrained with four point leathers for both [patient] safety and that of the staff. Subsequently transferred to [hospital] psyche."

3) A review of MR1 revealed the patient was "talking with delusions ... Homicidal ideations Y (yes) ... Patient Behavior Aggressive, Suspicious, Anxious ... Mood Description Irritable ... Thought Process Loose Associations, Flight of Ideas, Disorganized Delusion Description Paranoid Ideation, Ideas of Reference, Delusions of Persecution ... " Further review revealed that the patient was medicated with Geodon and placed in four point restraints. There was no documented evidence that the patient was Tased.

During an interview with EMP4 on November 12, 2010, at 11:45 AM , EMP4 confirmed the above and stated "No, it's [documentation that the patient was tased] not in there [medical record].

4) A request was made on November 12, 2010, for a policy for use of Tasers in the Emergency Department (ED). None was provided.

Interview with EMP2 on November 12, 2010, at approximately 9:06 AM revealed " Yes we Tased. The Carroll Township police Tases. Our security does not carry any weapons."

Interview with EMP3 on November 12, 2010, at 1:15 PM revealed " ... We do not have a policy for the use of Tasers in the ED."

Cross Reference with:
482.13 Patient Rights

Based on review of policies and procedures, facility documentation, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to implement restraints or seclusion when less restrictive interventions were determined to be ineffective to protect the patient, a staff member, or others from harm in one of one medical record reviewed (MR1).

Findings include:

Review of facility policy, "Patient Bill Of Rights" dated September 2010, revealed "27. The patient has the right to be free from restraints, both physical and chemical, or seclusion that is not medically necessary or used as a means of coercion, discipline, convenience, or retaliation by the staff. Restraints and seclusion shall only be used when other less restrictive measures have been found to be ineffective in protecting the patient or others from harm.

Review of facility policy "Dr. Strong" dated July 2010, revealed "To provide immediate assistance to personnel confronted with a combative or agitated inpatient whose behavior is escalating. III. Definition: Dr. Strong-is defined as an acute behavioral emergency that occurs within the hospital setting. The location is announced overhead by the hospital switchboard operator. Appointed hospital personnel (mandatory responders) are to report immediately to the designated location. ... V. Policy Statement: When a situation occurs whereas a patient becomes combative or causes a disturbance that may require staff to utilize physical means to provide for the safety of the staff, patients, and others, a "Dr. Strong" will be announced. Every effort will be made to protect the disruptive patient's rights, dignity, and well being in the least restrictive manner possible to control and de-escalate the situation. ... VI: Process ... J. In the event the combative patient's behavior cannot be safely contained and controlled, the negotiator and the director make a decision whether to call for support from local law enforcement (9-911). When local law enforcement is required to assist, the director will review with the responding officer the patient's behaviors and health conditions that necessitated the need for law enforcement support and the goal for the intervention."

Review of policy "Workplace Violence Policy" dated September 2010, revealed "Monongahela Valley Hospital has zero tolerance for physical or verbal acts or threats of violence. Monongahela Valley Hospital is committed to providing a sage and secure place for all of its employees, patients, visitors, vendors, volunteers, and medical staff. ... 2. Averting a Workplace Violence Incident. a. If a patient, employee, vendor, volunteer, physician or visitor has exhibited potentially threatening behavior, contact the Security Department at Extension 1092. b. Signs of the potentially violent person. (1) A person becomes unusually angry because of perceived slow service. (2) Person who has made verbal threats of physical harm against an individual or the organization or acts of intimidation. (3) A person with any history of violent behavior."

Review of facility policy "Guidelines For Restraint" dated May 2010, revealed "A. Restraint Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely: Manual method is holding the patient. Mechanical restraints are things such as lap belt, lap buddy, mitts, or soft or locked restraints and seclusion. Chemical restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. ... E. Least Restrictive Measures - Measures which permit the maximum amount of freedom consistent with patient safety and protection from injury. Restraints are to be used when Lesser Restrictive Interventions have been determined to be ineffective to protect the patient or others from harm. ... Violent reasons for the use of restraint or seclusion are primarily to protect the individual against injury to self and/or others because of an emotional or behavioral disorder. If the patient becomes combative and restraints are applied, this is a Violent reason and the Violent Standards must be utilized. ... 5. For Violent Management: The primary reason for use is Emergency or crisis management of situations where a patient's behavior becomes aggressive or violent, presenting an immediate serious danger to his/her safety or that of others."

Review of "Agreement This Agreement made this first day of November, 2010, by and between Monongahela Valley Hospital, Inc., and the The Township of Carroll, ... providing prompt police response to Hospital when same becomes necessary, ... 2. The assigned officer while working at the Hospital may carry out Township work, but notwithstanding, will also be available to Hospital as may be necessary for police response. ..."

1) Review of facility "Security Incident Report" revealed that a patient (MR1) had a behavorial dyscontrol event on November 9, 2010, and was subject to a Taser discharge by the police.

2) Review of MR1 revealed that the patient was brought to the facility at 12:39 PM on November 9 2010. Further documentation at 4:39 PM revealed that the patient was sleeping and awaiting transport to another facility. At 4:59 the patient was refusing to sign the consent for transfer. At 5:35 PM the patient was refusing to be transferred. At 5:45 PM the patient was verbally abusive and agitated and was refusing to get undressed. The patient then attempted to leave the room and then went back into the room. At 6:05 PM the police were called for assistance. Further documentation in MR1 revealed that the patient attempted to kick security and that the patient was placed on the cart and was medicated with Geodon (antipsychotic medication) and placed in four point restraints. At 7:27 PM the restraints were removed and the patient was cooperative. The patient was transferred via ambulance to another facility mental health unit. Continued review revealed no documented evidence that the patient was Tased by police after Geodon was administered, followed by the application of four point restraints.

3) Interview with EMP2 on November 12, 2010, at approximately 9:06 AM revealed " Yes we Tased, the Carroll Township police Tases. Our security does not carry any weapons."

Cross Reference with:
482.13 Patient Rights

Based on review of facility policy and procedures, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that the type or technique of restraint or seclusion used was the least restrictive intervention that was effective to protect the patient or others from harm for patients that had been subject to a Taser discharge in one of one medical record reviewed (MR1).

Findings include:

Review of facility policy "Patient Bill Of Rights" dated September 2010, revealed "27. The patient has the right to be free from restraints, both physical and chemical, or seclusion that is not medically necessary or used as a means of coercion, discipline, convenience, or retaliation by the staff. Restraints and seclusion shall only be used when other less restrictive measures have been found to be ineffective in protecting the patient or others from harm.

Review of facility policy "Dr. Strong" dated July 2010, revealed "To provide immediate assistance to personnel confronted with a combative or agitated inpatient whose behavior is escalating. III. Definition: Dr. Strong-is defined as an acute behavioral emergency that occurs within the hospital setting. The location is announced overhead by the hospital switchboard operator. Appointed hospital personnel (mandatory responders) are to report immediately to the designated location. ... V. Policy Statement: When a situation occurs whereas a patient becomes combative or causes a disturbance that may require staff to utilize physical means to provide for the safety of the staff, patients, and others, a "Dr. Strong" will be announced. Every effort will be made to protect the disruptive patient's rights, dignity, and well being in the least restrictive manner possible to control and de-escalate the situation. ... VI: Process ... J. In the event the combative patient's behavior cannot be safely contained and controlled, the negotiator and the director make a decision whether to call for support from local law enforcement (9-911). When local law enforcement is required to assist, the director will review with the responding officer the patient's behaviors and health conditions that necessitated the need for law enforcement support and the goal for the intervention."

Review of policy "Workplace Violence Policy" dated September 2010, revealed "Monongahela Valley Hospital has zero tolerance for physical or verbal acts or threats of violence. Monongahela Valley Hospital is committed to providing a sage and secure place for all of its employees, patients, visitors, vendors, volunteers, and medical staff. ... 2. Averting a Workplace Violence Incident. a. If a patient, employee, vendor, volunteer, physician or visitor has exhibited potentially threatening behavior, contact the Security Department at Extension 1092. b. Signs of the potentially violent person. (1) A person becomes unusually angry because of perceived slow service. (2) Person who has made verbal threats of physical harm against an individual or the organization or acts of intimidation. (3) A person with any history of violent behavior."

Review of facility policy "Guidelines For Restraint" dated May 2010, revealed "A. Restraint Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely: Manual method is holding the patient. Mechanical restraints are things such as lap belt, lap buddy, mitts, or soft or locked restraints and seclusion. Chemical restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. ... E. Least Restrictive Measures - Measures which permit the maximum amount of freedom consistent with patient safety and protection from injury. Restraints are to be used when Lesser Restrictive Interventions have been determined to be ineffective to protect the patient or others from harm. ... Violent reasons for the use of restraint or seclusion are primarily to protect the individual against injury to self and/or others because of an emotional or behavioral disorder. If the patient becomes combative and restraints are applied, this is a Violent reason and the Violent Standards must be utilized. ... 5. For Violent Management: The primary reason for use is Emergency or crisis management of situations where a patient's behavior becomes aggressive or violent, presenting an immediate serious danger to his/her safety or that of others."

Review of "Agreement This Agreement made this first day of November, 2010, by and between Monongahela Valley Hospital, Inc., and the The Township of Carroll, ... providing prompt police response to Hospital when same becomes necessary, ... 2. The assigned officer while working at the Hospital may carry out Township work, but notwithstanding, will also be available to Hospital as may be necessary for police response. ..."

1) Review of MR1 on November 12, 2010, revealed "Summary Report ... 11/09/10 1805 ... Twp(township) police called for assistance."

2) Review of "Security Incident Report" revealed "The patient(MR1) was physically restrained by Security and staff as medication was administrated. The patient continued to be aggressive and combative after the medication was administered attempted to kick making contact with RN ... Officer ... gave the patient a verbal warning and the[sic] "Tasered" the patient. The patient was then placed into (4) point restraints."

3) Interview with EMP3 on November 12, 2010, a 1:15PM confirmed that MR1 was subject to a Taser discharge by the police. During continued interview, EMP3 was asked if the "Dr. Strong" policy was used for the patient (MR1). EMP3 stated that the facility policy "Dr. Strong" does not apply when a patient is in the Emergency Department.

Cross Reference with:
482.13 Patient Rights

Based on review of Pennsylvania Department of Health's provider message board information, review of facility policies and procedures, review of medical records (MR), and interviews with facility staff (EMP), it was determined that the facility failed to implement safe and appropriate restraint and seclusion techniques as determined by hospital policy and in accordance with the Pennsylvania Department of Health's message board statement for patients that had been subject to a Taser discharge or Taser drive stun in one of one medical record reviewed (MR1).

Findings include:

Review of Pennsylvania Department of Health - Division of Acute and Ambulatory Care - "Message Board" notice to providers dated July 28, 2005, revealed, "The attached article reports on consequences of use of Taser in a California hospital. Pennsylvania hospitals are expected to employ the LEAST RESTRICTIVE means to control patient behaviors and to assure the health and safety of anyone on hospital property. This requires effective staff training and ongoing monitoring and assessment of all use of restraints and seclusion. The use of Taser, stun gun or like weapons against patients is not permitted."

Review of facility policy, "Patient Bill Of Rights" dated September 2010, revealed "27. The patient has the right to be free from restraints, both physical and chemical, or seclusion that is not medically necessary or used as a means of coercion, discipline, convenience, or retaliation by the staff. Restraints and seclusion shall only be used when other less restrictive measures have been found to be ineffective in protecting the patient or others from harm.

Review of facility policy "Dr. Strong" dated July 2010, revealed "To provide immediate assistance to personnel confronted with a combative or agitated inpatient whose behavior is escalating. III. Definition: Dr. Strong-is defined as an acute behavioral emergency that occurs within the hospital setting. The location is announced overhead by the hospital switchboard operator. Appointed hospital personnel (mandatory responders) are to report immediately to the designated location. ... V. Policy Statement: When a situation occurs whereas a patient becomes combative or causes a disturbance that may require staff to utilize physical means to provide for the safety of the staff, patients, and others, a "Dr. Strong" will be announced. Every effort will be made to protect the disruptive patient's rights, dignity, and well being in the least restrictive manner possible to control and de-escalate the situation. ... VI: Process ... J. In the event the combative patient's behavior cannot be safely contained and controlled, the negotiator and the director make a decision whether to call for support from local law enforcement (9-911). When local law enforcement is required to assist, the director will review with the responding officer the patient's behaviors and health conditions that necessitated the need for law enforcement support and the goal for the intervention."

Review of policy "Workplace Violence Policy" dated September 2010, revealed "Monongahela Valley Hospital has zero tolerance for physical or verbal acts or threats of violence. Monongahela Valley Hospital is committed to providing a sage and secure place for all of its employees, patients, visitors, vendors, volunteers, and medical staff. ... 2. Averting a Workplace Violence Incident. a. If a patient, employee, vendor, volunteer, physician or visitor has exhibited potentially threatening behavior, contact the Security Department at Extension 1092. b. Signs of the potentially violent person. (1) A person becomes unusually angry because of perceived slow service. (2) Person who has made verbal threats of physical harm against an individual or the organization or acts of intimidation. (3) A person with any history of violent behavior."

Review of facility policy "Guidelines For Restraint" dated May 2010, revealed "A. Restraint Physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely: Manual method is holding the patient. Mechanical restraints are things such as lap belt, lap buddy, mitts, or soft or locked restraints and seclusion. Chemical restraint is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. ... E. Least Restrictive Measures - Measures which permit the maximum amount of freedom consistent with patient safety and protection from injury. Restraints are to be used when Lesser Restrictive Interventions have been determined to be ineffective to protect the patient or others from harm. ... Violent reasons for the use of restraint or seclusion are primarily to protect the individual against injury to self and/or others because of an emotional or behavioral disorder. If the patient becomes combative and restraints are applied, this is a Violent reason and the Violent Standards must be utilized. ... 5. For Violent Management: The primary reason for use is Emergency or crisis management of situations where a patient's behavior becomes aggressive or violent, presenting an immediate serious danger to his/her safety or that of others."

Review of "Agreement This Agreement made this first day of November, 2010, by and between Monongahela Valley Hospital, Inc., and the The Township of Carroll, ... providing prompt police response to Hospital when same becomes necessary, ... 2. The assigned officer while working at the Hospital may carry out Township work, but notwithstanding, will also be available to Hospital as may be necessary for police response. ..."

Review of policy "nursing Department Emergency Department Violent Behavior in Treatment Area of Emergency Department" revealed "In the instance where a person begins to act out in a verbal or physical manner while in the Treatment Area of the Emergency Department the following actions will be taken to ensure the safety of all patients, visitors and employees. 1. Security will be notified by phone or by alarm button. ...5. If behavior warrants, the police will be notified by the Nurse Manager or other designated employee. ..."

1) Review of MR1 on November 12, 2010, revealed "Summary Report ... 11/09/10 1805 ... Twp(township) police called for assistance."

Further review of "Security Incident Report" revealed "The patient (MR1) was physically restrained by Security and staff as medication was administrated. The patient continued to be aggressive and combative after the medication was administered attempted to kick making contact with RN ... Officer ... gave the patient a verbal warning and the[sic] "Tasered" the patient. The patient was then placed into (4) point restraints."

2) A request was made on November 12, 2010, for a policy on use of Tasers in the Emergency Department. None was provided.

Interview with EMP3 on November 12, 2010, at approximately 1:00 PM confirmed the above findings and revealed "We do not have a policy on Tasers. Our staff does not Taser, the police officer did."

Cross Reference with:
482.13 Patient Rights

Based on review of facility policy, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure the use of a restraint or seclusion was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 481.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law for five of five medical records reviewed (MR1, MR3, MR4, MR6 and MR7)

Findings include:

Review of "Medical Staff Rules And Regulations" dated February 17, 2010, revealed "Prescription Of Treatment 1. All orders for treatment shall be in writing"

Review of policy "Guidelines For Restraint" dated May 2010, revealed "Individual Orders (initial and renewal) are needed when physical restraints are initiated based upon patient assessment and reason"

1) Review of MR1 revealed "Restraint Orders For Behavioral Management Physician's Order Sheet ... Ativan 1 mg ...IM(intramuscular) ... Geodon 20 mg(milligrams) IM"

Review of "Summary Report ... 11/9/10 1834 ... Restraint Type Chemical, Locked Left Wrist, Locked Right Wrist, Locked Left Ankle, Locked Right Ankle"

Further review of MR1 revealed no physician order for locked left wrist, locked right wrist, locked left ankle, or locked right ankle.

Interview with EMP1 on November 12, 2010, at approximately 11:00 AM confirmed the above findings and revealed "I don't see it [physician order] written. ..."

2) Review of MR3 revealed "Restraint Orders For Behavioral Management Physician's Order Sheet ... 8/19/10 Time of Application of Restraint: 0553 then 0635 ... Locked Restraint - Wrist-R/L(right/left) Ankle - R/L"

Further review of MR3 revealed no documentation that the restraints were applied as per physician order.

Interview with EMP1 on November 12, 2010 at approximately 12:30 PM confirmed the above findings and revealed "I don't know why that [order] is like that. The documentation says 06:35"

3) Review of MR4 revealed "Admission Note: Patient here on a 201 ... Patient still groggy at this time and not clear on exactly what [they] did, but was placed in four point restraints in the E.D. (Emergency Department)"

Further review of MR4 revealed no physician order for restraints.

Interview with EMP4 on November 12, 2010, at approximately 12:50 PM confirmed the above findings and revealed "They [nursing] must of made a mistake, there is no order for restraints."

4) Review of MR6 revealed " ... Emergency Department Notes ... Restraint [sic]obtained ..." Further review revealed "Restraint Flowsheet/Violent Behavior Requiring Restraint Aggressive and Combative with Security and Staff... Restraint Type Locked Right Wrist ... "

Further review of MR6 revealed no physician order for restraints.

Interview with EMP1 on November 12, 2010, at approximately 1:30 PM confirmed the above findings and revealed " No there is no order for the restraints."

5) Review of MR7 revealed " ... Emergency Department Notes ... Pt placed in 4 point locked restraints ... "

Further review of MR7 revealed a physician order dated 7/10/10 ... "Restraints -Violent"

Interview with EMP1 on November 12, 2010 at approximately 1:00 pm confirmed the above order and revealed " This order is not complete. We missed it when we went computerized with the physicians."

Cross Reference with:
482.13 Patient Rights