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Based on observation, interview and review of medical records, it was determined that the hospital failed to assure personal privacy for patients.
The hospital's failure to do so resulted in 6 of 14 patients (identified by room numbers noted in deficiency) in the Emergency Department (ED) on 4/23/2010 having a loss of personal privacy and 1 of 6 surgical patients (Patient #2) having a loss of personal privacy. The hospital's failure to protect patients' personal privacy, and to develop and implement a policy and procedure to guide staff practice relative to patient privacy, placed all patients at the hospital at risk for similar loss of privacy.

Findings include:

Observation

On 4/23/2010, at 1:10 p.m., a tour of the ED was conducted in the presence of the hospital's Chief Nursing Officer. All patient rooms and the area surrounding the nursing station were observed.

Room #1 - The door and window coverings were open, and the patient was observed.
Room #2, A&B - The window covering was partially open, and 1 patient was visible.
Room 3 1/2 - The area did not have a door, only a curtain which was open. The patient was visible, receiving care.
Room 4 - The door and window covering was open. The patient was visible and receiving care.
Room 5 - The door and window covering were open and the patient was observed.
Room 9 - The door and window covering were open and the patient was observed.
Two patients were on gurneys in the hall and were observed to be receiving care. No privacy screens were available and the Charge Nurse stated the ED did not have privacy screens for patients in the halls.

Medical Record Review

Review of the medical record for Patient #2 revealed that a Physician Assistant (PA) student had been present for the patient's surgery. Review of the PA student's file revealed that s/he had been previously sponsored as a student at the hospital by 2 physicians: 1.) a family practice physician who did not perform surgery and 2.) an orthopedic surgeon. Patient #2 had undergone a gynecological surgery, which was not within the scope of either sponsoring physician.

Interview on 4/23/2010 at 2 pm with the Director of Medical Staff and the Medical Staff Coordinator, revealed that the hospital's policy was to require students in the Operating Room (OR) to be sponsored by a physician in the same specialty as the operating surgeon.

Review of the medical record of the patient revealed that there was no documentation that Patient #2 had been made aware that an observer would be in the OR, nor had s/he given consent for such an observer. The Chief Nursing Officer confirmed that no such consent had been documented as obtained from the patient, the surgeon, the anesthesologist or the Director of Surgical Services.

The hospital's Policy & Procedure "Observers in the O.R." [operating room] was reviewed and found to contain the following directions:
"All observers in the operating room must obtain permission from the the patient, the surgeon,the anesthesiologist and the Director of Surgical Services..."

On 4/23/2010, the Director of Surgical Services was interviewed regarding the practice of having observers in the OR. The Director stated that there was not a policy regarding observers in the OR, and it was up to the surgeon to obtain the consent from the patient. When asked how s/he would know that the surgeon had done so, s/he stated "because I trust my surgeons". When asked why it was not required to document that consents had been obtained from the patient and others, the Director stated "I don't see it as necessary".

Further review of the hospital's brochure "Patients' Rights and Responsibilities", which the Director of Quality stated was provided to all patients upon registration, revealed the following:

"We will strive to treat you and your loved ones with respect and courtesy..." and listed as a patient right was the right:
"To privacy during treatment, personal care, activities, and care discussions..."

Based on observation and interview, review of medical records and hospital documents, it was determined that the hospital failed to ensure that all patients received care in a safe setting. The hospital's failure to do so resulted in patients in the hospital's Emergency Department (ED) being placed at risk for unsafe care.

Findings include:

Code Gray - Quality Monitoring

On 4/21/2010, a "Code Gray" was observed in the ED. Interview with the Manager of Security revealed that the "Code Gray" consisted of multiple hospital staff coming to the scene, and was utilized to intimidate patients into complying with staff requests and directions. The scene observed on 4/21/2010 involved 14 people inside and outside of the room of the patient.

When asked how the hospital assured that Code Gray activities had been implemented and utilized correctly, the Manager of Security stated that a debriefing after the Code Gray, was up to the team captain, however, such debriefings did not occur consistently. The Manager of Security also stated that there was no involvement of the Department of Quality to track, trend or monitor the Code Gray activities.

The Director of Quality was also interviewed about how the Code Gray activites were monitored to assure that all participants had the necessary training, and that activities were conducted in a way that promoted patient safety. The Director stated that such monitoring did not occur.

Release of Restraints - Restraints Not Released Periodically

Complainant #1 stated that Patient #1 had been restrained in the ED with her/his arms above her/his head for several hours and was refused a request to re-position her/his arms for comfort.

Review of the medical record for Patient #1 revealed that the patient had been placed in 4-point (all limbs secured) restraints. The nursing notes also document that at 0000 hours the patient "...asked if arms will be restrained in current position much longer. Advised will be repositioned when transferred to ambulance gurney. States 'ok'."

On 4/23/2010, an ED charge nurse and an ED staff nurse were interviewed regarding their understanding and practices regarding the release of restraints. The charge nurse stated that the decision about when to perform ROM was up to the RN, based on the RNs assessment, but there was no set rule. The staff nuse stated that s/he was unsure about any specific guidelines regardin ROM.

Review of the hospital's policy and procedures for restraints did not reveal directions to staff on how often to release restraints, how or when to perform range of motion (ROM) on restrained arms, or what injuries could potentially occur if restraints were not released occasionally.

The Chief Nursing Officer also reviewed the restraint policies and procedures and confirmed that such guidance was not provided in the policies.

Volunteers in the ED

On 2/223/2010, a tour of the ED was conducted. During the tour, a hospital staff person was observed to instruct another person to assist an ED patient to the commode, get the patient dressed for discharge and obtain a set of vital signs. The Chief Nursing Officer (CNO) stated that the second person, who was instructed to provide personal care to the patient, was a volunteeer in the department, and was not part of the nursing staff.

The CNO stated that there was no Policy and Procedure available regarding the scope of services for volunteers. Review of the volunteer's personnel file revealed that the volunteer"s job description did not include toileting, transporting, dressing or vital signs, all of which the volunteer had been directed to do.

The CNO confirmed that the volunteer had been acting outside of her/his scope of practice. The CNO also stated that s/he had been aware that volunteers had provided personal care services to ED patients in the past, but s/he thought that practice had been discontinued.

Based on medical record review, it was determined that the hospital failed to ensure that less restrictive interventions had been considered to be ineffective prior to implementing the use of restraints. The hospital's failure to do so resulted in 4 of 10 Emergency Department (ED) patients (#3, 6, 7, 8) being placed in restraints without documentation that less restrictive interventions may have been effective, and potentiallly placed all patients at similar risk.

Findings include:

Review of the medical records of 10 patients who had been placed in restraints, revealed that less restrictive interventions were not documented as having been considered for Patients #3, 6, 7 and 8.

Patient #3

The patient was intiaially seen by the ED physician at 7:54 AM, and orders for restraints were written at 7:55 AM. The nursing assessment stated that the patient was slightly agitated and verbally abusive, and 4-point restraints (all 4 limbs were secured) were initiated at 7:55 AM. No documentation was found regarding why the patient needed to be restrained, why all 4 limbs had to be restrained, or that less restrictive interventions, (for example, seclusion without restraints), had been considered.

Patient #6

The patient, who had a history of stroke, was admitted to the ED with a chief complaint of weakness and impaired speech. The patient had also reportedly consumed alcohol. The physician's assessment stated that the patient had "abnormal verbal response. Expressive aphasia. Dysphaisa. The patient has had weakness of the right face (moderate), right arm (moderate), right hand (moderate), right lef (moderate) and right foot (moderate). The physician's assessment also stated that the patient may have had a seizure and/or a stroke, as well as alcohol intoxication.

Nurse's notes state that at 3 AM, the patient was restrained with 4 side rails, and a soft jacket. The reason documented was "physical risk for harm". No specific reason for restraints was stated, nor was there documentation that a less restrictive intervention might have been appropriate, especially given the patient's documented physical limitations.

Patient #7

The patient was brought to the ED by ambulance after s/he suffered a possible stroke, and fell and struck her/his head. At 12:50 PM, the patient was noted to be "...restless. Slt combative. Moving around in bed..."
At 13:45 PM, the patient "...continues restless and combative and tring to swing w/rue and trying to get out of bed. 4 point restraint applied."
Documentation did not state why, specifically, 4 point restraints were required for the patient, or if less restrictive alternatives had been considered.

Patient #8

The patient presented to the ED by private vehicle, accompanied by a parent.The ED physician noted that the patient was "minimally cooperative". The patient had been transported to the hospital in 4-point restraints due to combative behavior at home.

The nursing assessment at 1637 documented "pt. cooperative. sitting on gurney. states not trying to hurt self..." Patient was placed in seclusion.

Nursing documentation included the following:

1713, the patient was still in seclusion "crying out".
1725, "pt. tearful. wants [her/his] Dad. Dad left for home.
1735, "pt. knocking loudly on door. when asked what needed, pt. asks for Dad and refuses to let door shut. Pt. repeatedly asked to sit down on bed. Refused. Code 3 [now referred to as "Code Gray", a show of force], called due to progressing aggressive behavior. Pt. placed into 4 point restraings without difficulty...pt. now tearful, yelling out, kicking feet..."

No documentation was found to explain why the patient required 4-point restraints, or what less restrictive alternatives had been considered, and whether or not the use of restraints had possibly escalated the patient's behavior.

Based on interview and review of medical records, it was determined that the hospital failed to ensure that restraints and/or seclusion was used only in accordance with the order of a physician or other licensed, independent practitioner who was responsible for the care of the patient. The hospital's failure to do so resulted in 8 of 8 restrained/secluded patients not having complete physicians' orders for the restraint/seclusion, and potentially placed all patients at risk for the inappropriate use of restraints/seclusion.

Findings include:

Medical Record Review

Patient #1

The patient was brought to the ED by the Police Department at 20:38. A Code 3 [now called a Code Gray, meaning a show of force] was called to restrain the patient. At 2040, the patient was placed in seclusion and hard 4-point restraints.

Physicians orders, timed at 2040, ordered "restraints", but did not specify the type or number of restraints to be utilized, nor was there an order to also seclude the patient. The patient was restrained and secluded until 0030 when s/he was released to the ambulance crew for transport.

Patient #2

The patient was brought to the ED by the Police Department at 13:55. The patient was physically violent and verbally abusive. The patient was placed in hard, 4-point restraints and seclusion at 13:55.

Physician orders, which were untimed, but noted by the RN at 13:40, stated seclusion and restraints, but did not specify the type or number of restraints to be utilized. At 14:33, the patient was discharged to jail.

Patient #3

The patient was brought to the ED by the Police Department at 7:52. The patient was noted to be "agitated and not cooperating" and was placed in hard, 4-point restraints at 08:04.

The physician's orders, timed at 07:55 and 11:55, were for "restraints", but did not note what kind or how many. The order was not noted by the RN. The physician's order timed at 13:05, was for seclusion only and did not include restraints. Nursing notes confirm that at 13:05, the patient was unrestrained and in seclusion only. The patient was discharged from the ED at 15:25.

Patient #4

The patient was brought to the ED by the Police Department at 22:05. At 22:55, nursing notes documented "pt. trying to get up out of bed. Pt. placed in restraints [4 points]..."

Physician's orders timed at 22:55 were for "restraints" and did not note what type of restraints or how many.

At 2335, nursing notes documented "...pt. remains somnolent, opens eyes briefly only to name...pt.in restraints to extremities x4 due to trying to get out of bed/restless..."
At 0122, arm restrains were removed, then leg restraints.
At 01:55, restraints were re-applied.

Physician's orders undated and untimed, but noted by the RN at 01:55, called for "restraints", but did not specify what type or how many.

A last physician's order was undated and untimed and was for seclusion only. The order was noted by the RN, but without a time on the notation.

At 02:05, restraints were removed when the patient was discharged to home with spouse.

Patient #5

The patient arrived at the ED 01:03, with a new onsent of weakness and impaired speech. The patient had also been consuming alcohol prior to admit.

Nursing notes documented that at 03:00 the patient was at "physical risk for harm" and was restrained by placing all 4 siderails up and placing a soft jacket on the patient. Nursing notes further documented that at 10:30 the day following admission to the ED, restraints were discontinued because the patient was "no longer risk for harm".

The medical record did not contain physician's orders for the restraints.

Patient #6

The patient arrived at the ED via ambulance at 12:43, after possibly sustaining a stroke. The patient had been restrained in the ambulance due to combative behavior en route.

Nursing notes document that the patient was placed in 4-point restraints, type not documented, at 13:45. Nursing notes document at 14:35, the patient was removed from restraint and at 17:07, hands were restrained. Type of restraint was not noted.

Physician notes timed at 13:00 were for "ativan 2 mg. IM PRN agitation" and at 13:15 stated "restraint PRN". Type and number of restraints to be used was not stated. No further restraints were ordered, including the hand restrains applied at 17:07.

Patient #7

The patient had been found down and unresponsive, and was brought to the ED at 22:39 by ambulance.

Nursing notes document that 4-point restraints, type not described, were applied at 23:30.

The physician's orders, written at 23:15, were for "restraints" and did not note how many or what type were to be applied.

Restraints were removed at 0015, and the patient was discharged to home shortly after.

Patient #8

The patient was brought to the ED at 16:10 via an ambulance , accompanied by a parent, for "acting out at home".

Nursing notes document that at 16:35, the patient was placed in seclusion. At an unknown time, a "Code 3" [now called a Code Gray, a show of force] was called and the patient was placed into 4-point restraints. The type of restraint was not noted.

At 18:05, the right arm restraint was removed, and at 18:15, the patient discontinued the left arm restraint. At 18:30, the patient still had both legs restrained, and at 18:45 the leg retraints were removed. Nursing notes document that the patient remained in seclusion, asleep, at 23:15. The next nursing note was for 10:20 the following morning, when the patient was placed in restraints for ambulance transport to another hospital.

Physician's orders for restraint were timed at 16:35 and 18:30 the day of admit, did not note the number or type of restraint to be used. The next physican's order was untimed, and was for seclusion only. That order was noted by the RN at 18:45. The next 7 physician orders were for seclusion only. There was no physician order to re-apply the restraints when the patient was transferred.

Based on medical record review, it was determined that the hospital failed to assure that the use of restraints or seclusion were not written on an "as needed" or PRN basis. The hospital's failure to do so resulted in 1 patient (Patient #7) having restraints ordered on a PRN basis, and potentially placed all patients at risk for PRN restraint use.

Findings include:

Review of the medical record for Patient #7 revealed that on 5/27/2009, the physician wrote the following orders:

At 13:45: "...restrain PRN...
At 14:00 "Ativan 2 mg. IM PRN agitation"

The use of PRN orders placed the patient at risk for not having appropriate assessments by Registered Nurses, with the evaluation for the use of potentially less restrictive measures, or the discontinuation of restraints at the earliest possible time. The use of PRN orders also placed the patient at risk for not having appropriate evaluations by physicians.