HospitalInspections.org

Based on policy review, document review and interview, the facility does not ensure security officers, who assist with restraints and perform manual holds, are trained in the safe use and application of restraints.

Findings include:

Review of policy "Restraint and Seclusion - Patient Care Services," last revised 11/2017 indicates staff members who have direct patient care contact will have education and training regarding the use of restraints at orientation and in ongoing education.

Review of policy "Security Incident Response Formally Code Silver," last revised 01/2018 indicates if a staff member encounters or witnesses actual or potential violent behaviors by patients in the acute setting, the staff member should call security or police. Security will respond and take reasonable and immediate action to assist in eliminating any immediate threat. If a situation necessitates the use of physical techniques to restrain, detain or seclude agitated, violent or potentially violent individuals, security should employ the least restrictive measures possible for the shortest period of time.

Review of the handwritten Security Officer log dated 02/23/19 at 02:15 PM revealed the officer returned to the ED lobby and located Patient #1 banging on the ED doors, screaming, sticking her fingers down her throat to vomit and banging her head off the walls and pillars. " I physically restrained the patient " and waited for the police to arrive so that Patient #1 would not further injure herself.

Review of the Security Incident Report dated 05/22/19 by Staff (V), Security Officer, revealed at 10:00 AM Patient #1 came to the Emergency Department (ED) with her mother to be seen. Patient #1 was making herself throw up and was screaming at her mother. The security officer approached her and asked her to lower her voice. She screamed obscenities and stormed out of the ED. Patient #1 continued to scream and stated she did not want to live anymore. Patient #1 slammed her head into the pillars and railing. Security prevented her from doing so. At 10:09 AM, police arrived and took over the situation.

Interview on 06/13/19 at 02:30 PM with Staff (L) and (M), Security officers, revealed that they assist clinical staff by holding patients, but that clinical staff apply the restraints (mechanical). They both stated that they have training in "holds " but have not received the hospital restraint training.

Based on policy review, medical record review, document review and interview, the facility does not consistently conduct ongoing/continuing assessments or review of high risk events in the Emergency Department (ED).

Findings include:

Review of policy " Quality and Patient Safety Plan, " effective 01/21/19 indicates the quality program is a mechanism to identify opportunities to improve care and safety as well as identify problems. Improvement activities are based on areas that are high risk, high volume, or problem prone. Data collected to measure performance include (but not limited to) restraint use, care/services provided to high risk populations and significant events. Data is analyzed and communicated through established channels to appropriate leaders of findings, conclusions, recommendations, actions taken, and the results of those actions.

Review on 06/14/19 of the medical record, security documentation, paramedic care records, and police reports for Patient #1 for ED visits on 02/23/19 and 05/22/19 revealed the following:

- On 02/23/19 at 02:04 PM, Patient #1 presented to the ED via ambulance for nausea/vomiting, abdominal pain and self induced vomiting. The patient was triaged and sent to the ED waiting room with security. Patient #1 continued to induce vomiting and began to bang her head on the wall indicating she wanted to kill herself. Police were called and she was restrained by security. Police arrived, the patient was handcuffed and transported by Emergency Medical Services (EMS) to a hospital with a Comprehensive Psychiatric Emergency Program (CPEP) for evaluation.

- On 05/22/19 at approximately 10:00 AM, Patient #1 and her mother entered the ED lobby. Patient #1 was screaming, banging her head and saying she does not want to live anymore. Security intervened and Patient #1 exited the ED lobby with her mother following her. Outside of the ED, Patient #1 continued unsafe behaviors of banging her head, stating she did not want to live, and attempting to walk into hospital traffic. The police arrived, the patient was handcuffed and transported to a hospital with a Comprehensive Psychiatric Emergency Program (CPEP) for evaluation without first receiving a medical screening examination.

Interview on 06/14/19 at 01:30 PM with Staff (A), Quality & Patient Safety Director, revealed the facility did not conduct a review related to these two events.

Based on medical record review, document review and interview, the facility did not ensure the care provided to Patient #1 in the Emergency Department (ED) was in accordance with facility policy related to patient assessment, physician notification and implementation of de-escalation techniques.

Findings include:

Review of policy " Emergency Department Standards of Care, " last revised 10/2018 indicates that the triage nurse responsibilities include assessing patients, assigning the appropriate triage level and documenting the triage assessment including vital signs, medication history, allergies and risk of harm to self or others. Any abnormalities identified during the assessment/reassessment should be communicated to the ED provider.

Review of policy " Restraint and Seclusion- Patient Care Services, " last revised 11/2017 indicates restraints can by initiated by an RN following a thorough assessment to ensure the immediate physical safety of the patient and staff members. Prior to placing a patient in restraints, alternatives such as communication and de-escalation techniques should be considered and attempted. Behavioral management restraints are utilized to protect the patient from harming himself and others from violent and/or self-destructive behavior.

Review of the medical record for Patient #1 dated 02/23/19 revealed triage was completed at 02:05 PM. The triage assessment is incomplete and does not include vital signs, home medications, allergies and risk assessment of harm to self or others. There is also no documentation to indicate that Patient #1 was refusing assessment during the initial triage or that the ED physician was notified that Patient #1 was attempting self harm by inducing vomiting. At 02:37 PM, Patient #1 was sent to the ED waiting room, accompanied by security officers despite the presence of self-harming behavior, which included sticking her fingers down her throat to induce vomiting, banging her head on the wall and stating she wanted to kill herself. Police were called and Patient #1 was restrained (by security). At 02:50 PM, Patient #1 left the ED with paramedics for evaluation at a hospital with a Comprehensive Psychiatric Emergency Program (CPEP).

Review of the Emergency Medical Services patient care record dated 02/23/19 revealed upon arrival at the facility, the police, hospital security and ambulance crew were attempting to physically restrain Patient #1. Facility staff did not make any attempt to assist in the care of Patient #1.

Interview on 06/13/19 at 10:40 AM with Staff (H), ED Medical Director & Physician revealed he was notified by staff that Patient #1 was in the ED waiting room, causing a disturbance and stating she wanted to hurt herself. When he arrived at the ED waiting room, Patient #1 was handcuffed and in police custody.

Interview on 06/14/19 at 11:25 AM with Staff (R), ED RN, revealed Patient #1 was brought in by EMS and triaged. Patient #1 had nausea/vomiting and was making herself vomit. Patient #1 seemed ok, but she was upset. The main bay (ED) was full so Patient #1 was put in the waiting room (ED).