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Based on record review and interview, the facility failed to ensure that a patient was given informed consent prior to treatment (A131) and was not restrained by the administration of paralytic and anesthetizing drugs and mechanical ventilation to facilitate treatment (A154). This affected one (Patient #8) of 11 sampled patients and had the potential to affect all patients who presented to the emergency department. The emergency department treats an average of 2,270 patients per month.

Based on record review and interview, the facility failed to ensure that a patient was given informed consent prior to treatment. This affected one (Patient #8) of 11 sampled patients and had the potential to affect all patients who presented to the emergency department. The emergency department treats an average of 2,270 patients per month.
Findings include:

Record review revealed Patient #8 presented to the emergency department triage area on 10/06/18 at 2:50 P.M. The patient was brought to the emergency room by a parent due to confusion and manic behavior.

The emergency department summary, dated 10/06/18, stated Patient #8 was argumentative with paranoid ideation.

Nursing notes revealed Patient #8 was given Etomidate, an anesthetic and Rocuronium, a paralytic, intubated and placed on a ventilator on 10/06/18 at 3:47 P.M., less than an hour after the patient presented to the emergency room.

During interview on 10/10/18 at 11:55 A.M., Nurse Z, who triaged and attended to the patient in the emergency department, stated Patient #8 was manic and bouncing between subjects. When Physician Z came to the room to talk with the patient, the physician explained the patient was very sick and needed medical care. The patient became angry. Physician Z told Patient #8 he/she was unfit to make medical decisions and therefore would be intubated for medical treatment. Upon hearing this, Patient #8's anger escalated and required a group of staff to hold him/her to the bed for the procedure.

The medical record contained no documentation informed consent was obtained from either the patient or his/her parent, who accompanied the patient to the emergency room, prior to treating the patient.

Based on record review and interview, the facility failed to ensure a patient was not restrained by paralytic and anesthetizing drugs and mechanical ventilation as a means to facilitate treatment by staff when the patient became uncooperative and refused medical treatment. This affected one (Patient #8) of 11 sampled patients.

Findings include:

Record review revealed Patient #8 presented to the emergency department triage area on 10/06/18 at 2:50 P.M. The patient was brought to the emergency room by a parent due to confusion and manic behavior.

Nursing notes revealed Patient #8 was given Etomidate, an anesthetic and Rocuronium, a paralytic, intubated and placed on a ventilator on 10/06/18 at 3:47 P.M., less than an hour after the patient presented to the emergency room. At 3:50 P.M., Patient #8 was put in four point wrist and ankle restraints.

Patient #8 was placed under sedation with Propofol, Fentanyl and Ketamine on 10/06/18 at 10:00 P.M. On 10/07/18 at 7:05 A.M., the Ketamine was discontinued. A pulmonologist note dated 10/08/18 at 6:43 A.M. documented the patient was intubated "due to agitation" in the emergency department and that the patient had no acute underlying pulmonary infectious process on chest imaging studies. On 10/09/18 at 4:00 A.M., the Propofol and Fentanyl were discontinued. The four point restraints were in place until 10/09/18 at 6:00 A.M., for not following instructions and pulling at tubes. Patient #8 was extubated and removed from the ventilator on 10/09/18 at 6:50 A.M. A pulmonologist note dated 10/09/18 at 6:52 A.M. stated the patient was intubated "due to agitation" in the emergency department and that the patient had no underlying pulmonary infection identified.

During interview on 10/10/18 at 11:55 A.M., Nurse Z, who triaged and attended to the patient in the emergency department, stated Patient #8 was manic and bouncing between subjects. When Physician Z came to the room to talk with the patient, the physician explained the patient was very sick and needed medical care. The patient became angry. Physician Z told Patient #8 he/she was unfit to make medical decisions and therefore would be intubated for medical treatment. Upon hearing this, Patient #8 became angrier and required a group of staff to hold her to the bed for the procedure.

During interview on 10/10/18 at 3:00 P.M., Physician Z affirmed the patient was neither suicidal or homicidal. He said the patient would not take direction, was cursing, and abusive to staff. Patient #8 tried to get out of bed and didn't demonstrate an ability to listen and cooperate. Physician Z stated Patient #8 was intubated and placed on a ventilator to facilitate running tests, namely a lumbar puncture and computerized tomography (CT) scan. Physician Z stated he did not intubate Patient #8 for declining respiratory status.

During interview on 10/10/18 at 3:00 P.M. Physician Y stated the patient was combative and he/she was told to facilitate a "work up", as the patient was intubated.

There was no documentation in the medical record other interventions, pharmacological or non-pharmacological, were attempted prior to restraining the patient via mechanical ventilation.