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A. Based on clinical record review and staff interview, it was determined that for 1 of 1 patient who died after being in restraints (Pt. #1), the Hospital failed to develop and implement a written policy for timely reporting to CMS and the required clinical record documentation.

Findings include:

1. On 3/10/10 at approximately 9:30AM, the clinical record for Pt. #1 was reviewed. Pt. #1, a 59 year old male, was admitted to the Emergency Department (ED) by ambulance on 2/19/10 at 2:04AM for a drug overdose and suicidal ideation. The triage assessment dated 2/19/10 at 2:04AM contained documentation that Pt. #1 arrived awake with rambling speech. The history included ingestion of 10 to 20 Altenol pills (cardiovascular drug) and 10 to 20 Klonopin pills(antihypertensive) at approximately 9:30PM on 2/18/10.

At 4:30AM the physician ordered 5 point restraints (4 point locked velcro restraints with a chest belt) due to combative behavior. The restraint observation flow sheet, dated 2/19/10 at 4:30AM contained documentation that Pt. #1 was placed into 5 point restraints 4:30AM. Vital signs at 4:30AM were: B/P 106/72, pulse 64, resp 18 and pulse ox of 95%. At 5:00AM the nurse documented that the Pt. was asleep on the cart with decreased pulse ox and decreased respirations and moist skin.

The restraints were removed at 5:00AM. Vital signs at 5:00AM were : B/P 102/58, pulse 58, and respirations of 18 and a pulse ox of 84%. The physician documented that at 5:45AM that Pt. #1 became suddenly unresponsive. A code was called at 6:00AM when Pt. #1 became pulseless and after five physicians unsuccessfully attempted to secure the airway (intubate). Pt. #1 was pronounced dead at 7:01AM on 2/19/10. Pt. #1 died approximately 2 hours after removal of the restraints.

2. The facility lacked a written policy for CMS notification of deaths in restraints.

3.The Hospital failed to report the patient death within 24 hours and failed to document in the medical record the date and time the death was reported to CMS.

4. The above findings were confirmed by the Director of Risk Management during an interview on 3/10/10 at approximately 10:00AM

A. Based on review of the Hospital's CQI Plan, clinical record review and staff interview, it was determined that the Hospital failed to ensure, for 1 of 1 clinical record reviewed of a patient (Pt.#1) death in the emergency department (ED), that a physician quality of care review was conducted to identify any quality of care issues.

1. On 3/10/10 at approximately 2:15PM the Hospital's "CQI Plan" for 2009 and 2010 was reviewed. The Plan included," The role of the Hospital and Medical Staff Departments is to be accountable for performance monitoring which demonstrates the ability to provide quality care".

2. On 3/10/10 at approximately 9:30AM, the clinical record for Pt. #1 was reviewed. Pt. #1, a 59 year old male, was admitted to the Emergency Department (ED) by ambulance on 2/19/10 at 2:04AM for a drug overdose and suicidal ideation. The triage assessment dated 2/19/10 at 2:04AM contained documentation that Pt. #1 arrived awake with rambling speech. The history included ingestion of 10 to 20 Altenol pills (cardiovascular drug) and 10 to 20 Klonopin pills(antihypertensive)) at approximately 9:30PM on 2/18/10.

At 4:30AM the physician ordered 5 point restraints (4 point locked velcro restraints with a chest belt) due to combative behavior. The restraint observation flow sheet, dated 2/19/10 at 4:30AM contained documentation that Pt. #1 was placed into 5 point restraints 4:30AM. Vital signs at 4:30AM were: B/P 106/72, pulse 64, resp 18 and pulse ox of 95%. At 5:00AM the nurse documented that the Pt. was asleep on the cart with decreased pulse ox and decreased respirations and moist skin.

The restraints were removed at 5:00AM. Vital signs at 5:00AM were : B/P 102/58, pulse 58, and respirations of 18 and a pulse ox of 84%. The physician documented that at 5:45AM that Pt. #1 became suddenly unresponsive. A code was called at 6:00AM when Pt. #1 became pulseless and after five physicians unsuccessfully attempted to secure the airway (intubate). Pt. #1 was pronounced dead at 7:01AM on 2/19/10. Pt. #1 died approximately 2 hours after removal of the restraints.

3. Upon request, the Hospital was unable to provide:

- documentation of a medical record review to identify any quality of care issues for Pt. #1.

- Emergency Department restraint monitoring data for 2009 and 2010.

4. The above findings were confirmed by the Medical Director of the ED, the Director of Risk Management, and the Director of Quality Measurement during an interview on 3/10/10 at approximately 10:30AM.