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Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient's Rights as evidenced by failing to ensure the technique of restraint used was the least restrictive intervention to protect the patient, staff member, or others from harm. This deficient practice is evidenced by controlling a combative patient's behavior by administering Etomidate (sedative) and Rocuronium (muscle relaxant/paralytic) for rapid sequence intubation and intubating without trying all less restricitive measures first for 1 (#2) of 2 (#1, #2) patients reviewed for aggressive behavior in the Emergency Department (see findings A-0165).

Based on record review and interview, the hospital failed to ensure a written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 (#2) of 1 patient reviewed with grievances out of a total sample of 5 (#1-#5).

Findings:

Review of the hospital's policy titled Patient Grievance revealed in part:

IV C. In the event an issue is unable to be promptly resolved, the grievance process will be followed, and an investigation will be initiated and completed in a timely, reasonable and consistent manner. The facility will provide a written response to the complainant regarding all grievances.

VB2. The patient relations Department will send out an initial letter to the patient within 7 days confirming receipt of the grievance and explaining the grievance process.

VC4. The Patient Relations Department will send out an extension letter to the patient for all grievances that are not able to be finalized within 30 days.


Review of the hospital's grievances revealed a grievance dated 01/27/2021 from Patient #2's family member. Further review revealed the Patient and Provider Advocate were contacted requesting Patient #2 be transferred to the hospital's main campus three days prior but had not been transferred yet. Further review revealed no copy of a written notice to the family member included with the documentation.

In an interview on 03/25/21 at 12:00 p.m. with S2Quality, she said the hospital did not send a letter to Patient #2's family with the resolution of the grievance.

Based on record review and interview, the hospital failed to ensure the technique of restraint used was the least restrictive intervention to protect the patient, staff members, or others from harm. This deficient practice is evidenced by controlling a combative patient's behavior by administering Etomidate (sedative) and Rocuronium (muscle relaxant/paralytic) for rapid sequence intubation and intubating without trying less restricitive measures first for 1 (#2) of 2 (#1, #2) patients reviewed for aggressive behavior in the Emergency Department.

Findings:

Review of Patient #2's medical record revealed admission to the hospital's emergency department on 01/18/2021 and triaged at 9:42 p.m. Patient #2's chief complaint was documented as Spasms. The complaint was updated to shortness of breath, tachypnea, weakness, and insomnia.

Further review of Patient #2's medical record on 01/19/2021 revealed the following timeline:

12:06 a.m. Patient became increasingly agitated pulling off cardiac monitor leads and pulse ox. Patient #2 got out of the stretcher and pulled out IV. Patient #2 was pacing around the room. Patient #2 remained anxious, tachypnea, and diaphoretic. Patient #2 is combative, Provider remains at bedside.

12:08 a.m. Peripheral IV placed left hand.

12:10 a.m. Diazepam 10mg given. Patient #2 verbalized emotional state anxiety.

12:12 a.m. After administration of Diazepam, pt. becomes acutely agitated. Pt. yelling at staff, pulls out IV and stands up from stretcher. Attempts to redirect or calm pt unsuccessful, pt. pulling away from staff, refusing to sit back on stretcher despite attempts to assist per multiple staff members. S6NP and security brought immediately to bedside.

12:12 a.m. Physical hold restraint.

12:19 a.m. Patient is yelling and attempting to kick staff despite multiple attempts to redirect. Provider remains at bedside along with staff and security.

12:20 a.m. Versed 6mg given

12:21 a.m. Physical hold restraint discontinued.

12:25 a.m. Transferred to Trauma A. Patient unresponsive SpO2: 93% (unresponsiveness determined in interviews with staff to be incorrect.)

12:27 a.m. Rocuronium 150mg given, Etomidate 25mg given, Diprovan 10mg/ml given

12:30 Intubated

12:32 a.m. Cardiopulmonary arrest. Code started.

1:03 a.m. Code ended due to return of spontaneous circulation.

8:00 a.m. Patient received in ICU. On ventilator.


In an interview on 03/26/2021 with S7RN, he said he was the charge nurse in the hospital's ED on 01/18/2021. He said he was involved in the first half of Patient #2's care. He said Patient #2 had pulled off of the monitor and had anxiety about being in the hospital. He said Patient #2 had also removed the IV and was very anxious. S7RN said 10 mg of Xyprexa had been administered but10 min later Patient #2 was still anxious. The staff tried talking to Patient #2 but the patient started pulling himself off of the monitor again. He said Patient #2 would apologize and started pacing and was diaphoretic and not directable but not violent. He said S6NP was in the room and Valium IV was given. Shortly after it was given, S7RN said Patient #2's demeanor changed and began yelling. He said Patient #2 Pulled out the IV, stood up and was pulling away. They were trying to talk Patient #2 into getting on the stretcher but the patient was combative. S7RN said security came into the room at that point and the staff brought Patient #2 to trauma A because it was a bigger room. He said Patient #2 started swinging and kicking and they were trying to redirect the patient but the patient was being physical and not responsive to verbal redirection. Patient #2 was yelling and Versed was given. He said there was somebody holding each of Patient #2's extremities but it was because the patient was kicking and swinging. He said Patient #2 was not PEC'd. S7RN said the staff were ordered to get intubation supplies. He said the patient was screaming before they gave medications to intubate. He said the paralytic was administered a couple of minutes after a sedative had been given. After the paralytic S6NP intubated Patient #2. He verified the staff had never attempted 4 point restraints on Patient #2.

In an interview on 03/26/21 at 10:54 a.m. with S5MD, he said he was an ED physician and was working on the night of 01/18/21. He said Patient #2 was S6NP's patient. S5MD said he became involved when Patient #2 was violent and posed a danger to staff and self. He said Patient #2 was physically aggressive. He said Patient #2 was given medication multiple times to calm the patient during the escalation. He said Patient #5 was physically restrained by staff. He said after they did a physical hold the last resort was to intubate Patient #2. S5MD said the situation was getting out of hand and so the patient was intubated to control behaviors. He said they have done this with other patients although it is not common. He also said he could not recall the staff attempting to place the patient in 4 point restraints.

In an interview on 03/26/21 at 11:28 a.m. with S6NP, she said she was working on 01/18/2021 in the hospital's ED. She said Patient #2 was her patient. She said the patient was brought in by a family member for a 1 year history of falls, weakness, SOB, insomnia, and anxiety. She said Patient #2 was anxious on presentation and received Ativan at 10:20 p.m. She said that helped with the anxiety. She said at 11:15 p.m. Patient #2 was able to be verbally redirected. She said at 11:40 p.m. the patient pulled off the monitor, was anxious and pacing and was verbally redirected at that time. She said Patient #2 was still anxious so she placed an order for Xyprexa which was given at 11:51 p.m. She said the agitation increased, Patient #2 pulled the IV out and was pacing around the room. Around midnight she said Patient #2 wanted to leave the hospital. She said she felt Patient #2 was a danger to themself or someone else. She verified she did not PEC the patient. Patient #2 became combative with staff and was given IV Valium at 12:10 a.m. with no response. S6NP said Patient #2 began yelling and standing up on the stretcher. She said the staff tried to verbally redirect Patient #2 and the patient refused. She said security then came into the room. She said next the staff moved Patient #2 to a trauma room because it is a larger room. She said they try to keep patients out of restraints and Patient #2 was overpowering staff, roughly a dozen staff members, despite having received medications. She does not remember if Patient #2 was ever placed in restraints. She said the patient received Versed at 12:20 a.m. and remained combative. S6NP said Patient #2 was still fighting and was posing a threat to themself and staff so she intubated the patient. She said it is not common but there was a risk of everybody getting hurt. S6NP verified at that time the paralytic, the sedative and the intubation was used to control Patient #2's behavior. She said when somebody is intubated to control their behaviors they are sent to the ICU and she does not know the time frame for removing them from the ventilator. She said they have intubated other patients in the past that can't be controlled with medications. S6NP verified Patient #2 was yelling and fighting until the patient was given the medications prior to intubation. After reviewing Patient #2's medical record, S6NP verified the documentation stating the patient was unconscious at 12:25 a.m. before being given medications and intubated was incorrect.

In an interview on 03/26/21 at 1:36 p.m. with S4MD, he said he was the Medical Director of the hospital's Emergency Department. When asked if intubation was an acceptable method used in the ED to control patient's behavior he said, "No." S4MD said intubation as a form of restraint is not a common practice. He also verified he was unaware this was being done in the hospital's Emergency Department.

In an interview on 03/26/21 at 2:00 p.m. with S1CNO and S2Quality, a request was made for documentation that intubation was best practice or an accepted practice for controlling behaviors. A request was also made for any policies or protocols for patients who were restrained by intubation and medication. None were provided.

Review of the hospital's policy titled Restraint/Seclusion Use revealed no reference to using rapid sequence intubation medications and intubation as a method of managing a patient's behavior.

Based on interview and record review, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of the medical care provided to the patients. This deficient practice is evidenced by the Medical Director of the Emergency Department being unaware that sedating and intubating patients as a method of behavior control was being performed by 2 (S5MD, S6NP) staff members interviewed.

Findings:

Review of Patient #2's medical record revealed admission to the hospital's emergency department on 01/18/2021 and triaged at 9:42 p.m. Patient #2's chief complaint was documented as Spasms. The complaint was updated to shortness of breath, tachypnea, weakness and insomnia.

Further review of Patient #2's medical record on 01/19/2021 revealed the following timeline:

12:06 a.m. Patient became increasingly agitated pulling off cardiac monitor leads and pulse ox. Patient #2 got out of the stretcher and pulled out IV. Patient #2 was pacing around the room. Patient #2 remained anxious, tachypnea, diaphoretic. Patient #2 is combative, Provider remains at bedside.

12:08 a.m. Peripheral IV placed left hand.

12:10 a.m. Diazepam 10mg given. Patient #2 verbalized emotional state anxiety.

12:12 a.m. After administration of Diazepam, pt. becomes acutely agitated. Pt. yelling at staff, pulls out IV and stands up from stretcher. Attempts to redirect or calm pt unsuccessful, pt. pulling away from staff, refusing to sit back on stretcher despite attempts to assist per multiple staff members. S6NP and security brought immediately to bedside.

12:12 a.m. Physical hold restraint.

12:19 a.m. Patient is yelling and attempting to kick staff despite multiple attempts to redirect. Provider remains at bedside along with staff and security.

12:20 a.m. Versed 6mg given

12:21 a.m. Physical hold restraint discontinued.

12:25 a.m. Transferred to Trauma A. Patient unresponsive SpO2: 93% (unresponsiveness determined in interviews with staff to be incorrect.)

12:27 a.m. Rocuronium 150mg given, Etomidate 25mg given, Diprovan 10mg/ml given

12:30 Intubated

12:32 a.m. Cardiopulmonary arrest. Code started.

1:03 a.m. Code ended due to return of spontaneous circulation.

8:00 a.m. Patient received in ICU. On ventilator.


In an interview on 03/26/21 at 10:54 a.m. with S5MD, he said he was an ED physician and was working on the night of 01/18/21. He said Patient #2 was S6NP's patient. S5MD said he became involved when Patient #2 was violent and posed a danger to staff and self. He said Patient #2 was physically aggressive. He said Patient #2 was given medication multiple times to calm the patient during the escalation. He said Patient #5 was physically restrained by staff. He said after they did a physical hold the last resort was to intubate Patient #2. S5MD said the situation was getting out of hand and so the patient was intubated to control behaviors. He said they have done this with other patients although it is not common. He also said he could not recall the staff attempting to place the patient in 4 point restraints.

In an interview on 03/26/21 at 11:28 a.m. with S6NP, she said she was working on 01/18/2021 in the hospital's ED. She said Patient #2 was her patient. She said the patient was brought in by a family member for a 1 year history of falls, weakness, SOB, insomnia, and anxiety. She said Patient #2 was anxious on presentation and received Ativan at 10:20 p.m. She said that helped with the anxiety. She said at 11:15 p.m. Patient #2 was able to be verbally redirected. She said at 11:40 p.m. the patient pulled off the monitor, was anxious and pacing and was verbally redirected at that time. She said Patient #2 was still anxious so she placed an order for Xyprexa which was given at 11:51 p.m. She said the agitation increased, Patient #2 pulled the IV out and was pacing around the room. Around midnight she said Patient #2 wanted to leave the hospital. She said she felt Patient #2 was a danger to themself or someone else. She verified she did not PEC the patient. Patient #2 became combative with staff and was given IV Valium at 12:10 a.m. with no response. S6NP said Patient #2 began yelling and standing up on the stretcher. She said the staff tried to verbally redirect Patient #2 and the patient refused. She said security then came into the room. She said next the staff moved Patient #2 to a trauma room because it is a larger room. She said they try to keep patients out of restraints and Patient #2 was overpowering staff, roughly a dozen staff members, despite having received medications. She does not remember if Patient #2 was ever placed in restraints. She said the patient received Versed at 12:20 a.m. and remained combative. S6NP said Patient #2 was still fighting and was posing a threat to themself and staff so she intubated the patient. She said it is not common but there was a risk of everybody getting hurt. S6NP verified at that time the paralytic, the sedative and the intubation was used to control Patient #2's behavior. She said when somebody is intubated to control their behaviors they are sent to the ICU and she does not know the time frame for removing them from the ventilator. She said they have intubated other patients in the past that can't be controlled with medications. S6NP verified Patient #2 was yelling and fighting until the patient was given the medications prior to intubation. After reviewing Patient #2's medical record, S6NP verified the documentation stating the patient was unconscious at 12:25 a.m. before being given medications and intubated was incorrect.

In an interview on 03/26/21 at 1:36 p.m. with S4MD, he said he was the Medical Director of the hospital's Emergency Department. When asked if intubation was an acceptable method used in the ED to control patient's behavior he said, "No." S4MD said intubation as a form of restraint is not a common practice. He also verified he was unaware this was being done in the hospital's Emergency Department.

Based on record review and interview, the hospital failed to ensure the patient's medical record was accurately written for 1(#2) of 5 (#1, #2, #3, #4, #5) patients sampled.

Findings:

Review of a timeline presented by the hospital of Patient #2's treatment in the ED on 01/19/2021 revealed documentation by multiple disciplines::

12:25 a.m. Transferred to Trauma A. Patient unresponsive SpO2: 93% (unresponsiveness determined in interviews with staff to be incorrect.)

12:27 a.m. Rocuronium 150mg given, Etomidate 25mg given, Diprovan 10mg/ml given

12:30 Intubated

In an interview on 03/26/21 at 11:28 a.m. with S6NP, she said she was working on 01/18/2021 in the hospital's ED. She said Patient #2 was her patient. S6NP verified Patient #2 was yelling and fighting until being given the medications prior to intubation. After reviewing the Patient's medical record, she verified the documentation stating Patient #2 was unconscious at 12:25 a.m. before being given medications and intubated was incorrect.