HospitalInspections.org

26313

Based on observation, record review, and interview, the hospital failed to ensure contracted security guards had the necessary training in the care of a patient who had been PEC'd (Physician Emergency Certificate) and/or CEC'd (Coroner Emergency Certificate) as evidenced by lack of documentation from the contracted security guard company of crisis prevention intervention training for 2 of 5 patients currently admitted to the hospital in a total sample of 14 (#2, #3). Findings:

On 2/29/12 at 9:15 a.m., an observation revealed S6 RN sitting outside the door of patient #3 in visual view and S32 Security Guard sitting in visual view of patient #2.

On 2/29/12 at 11:10 a.m. in an interview with S8 Director of Plant Operations, he stated he supervises the contracted security guards while on-duty. He stated he does not review the security guards' credentials and/or competencies. He added the hospital Human Resource Department conducts the hospital orientation of all staff, both employed and contracted.

Record review of New Associate Orientation form revealed that crisis prevention intervention (CPI) was not included in the orientation packet for either staff or contracted help.

Record review of the contract between the hospital and the Security guard revealed the following "All officers employed by (USC) must meet all the qualifications set forth by the Louisiana State Board of Private Security Examiners, must pass pre-employment urinalysis and a criminal background check.

On 2/29/12 at 11:30 a.m. in an interview with S9 Human Resource Director, she stated she did not know which of the security guards had training in crisis prevention intervention prior to being called to sit with patients who had been PEC'd. She stated if the physician PEC'd or CEC'd patients, then the nursing staff call the security company directly and ask for a guard.

On 2/29/12 at 1:30 p.m. in an interview with S4 Emergency Department (ED) Director, she stated the security company sends whichever guards are available. She further stated she did not know if the security guards were trained to handle patients who were violent or those individuals with mental disturbances.

On 2/29/12 at 2:40 p.m. in an interview with S12 Registered Nurse (RN), she stated the security guards who are called to sit with a patient in ED do not touch the patient. If a patient becomes too violent, they have to call the city police to help to restrain a violent patient.

(Cross Reference A0144)

26313

Based on interview and policy review, the hospital failed to (1) have a mechanism in place to evaluate the contracted security guard services were supervised and competent to carrying out the duties as outlined in the contract and (2) failed to include the evaluation of the contracted security guard services into the QAPI (Quality Assurance Performance Improvement ) plan. Findings:

1) On 2/29/12 at 11:10 a.m. in an interview with S8 Director of Plant Operations, he stated he supervises the contracted security guards while on-duty. He stated he does not review the security guards' credentials and/or competencies. He added the hospital Human Resource Department conducts the hospital orientation of all staff, both employed and contracted.

Record review of the contract between the hospital and the Security guard revealed the following "All officers employed by (USC) must meet all the qualifications set forth by the Louisiana State Board of Private Security Examiners, must pass pre-employment urinalysis and a criminal background check.

On 2/29/12 at 11:30 a.m. in an interview with S9 Human Resource Director, she stated she did not know which of the security guards had training in crisis prevention intervention prior to being called to sit with patients who had been PEC'd. She stated if the physician PEC'd or CEC'd patients, then the nursing staff call the security company directly and ask for a guard. She confirmed she was not sure the contracted security guards had received the necessary crisis prevention intervention in order to monitor a patient who had been PEC'd into the hospital for suicidal behaviors.

On 3/1/12 at 12:45 p.m. in an interview with S13 VP of Finance, he confirmed he evaluates the hospital's contracts. However, he stated the Human Resource Director ensures the contracted security guards are competent to carry out their role in the hospital. S13 also stated he was not sure if their role consisted of monitoring a patient who had been PEC'd into the hospital for suicidal behaviors.


2) On 3/1/12 at 12:20 p.m. in an interview with S3 QI Director, he stated to his knowledge, the contracted security guard service was not incorporated into his QAIP plan.

Based on observation, record review, personnel files, policy review, and interview the hospital failed to meet the requirements for the Condition of Participation for Patient Rights
by failing to ensure patient's rights were protected and promoted as evidenced by:

1) Failure to ensure patients received care in a safe setting for 5 of 5 sampled patients (#1, 2, 3, 4,5) and 2 of 9 Random sampled patients (R5, R9) by:

a. Failing to ensure 4 of 5 sampled patients (#2, 3, 4, 5) and 2 of 9 random sampled patients (R5, R9)received a medical screening examination by the ED physician who determined these patients were in need of emergency inpatient psychiatric treatment and ordered a Physician's Emergency Certificate for them to be admitted to psychiatric treatment programs. These patients were then held in inpatient rooms, although not admitted to this hospital as inpatients due to this hospital having no psychiatric unit. Patients were held in the
rooms for up to 13 days and received no inpatient psychiatric treatment until the time they were discharged to home thus not promoting the patients right to receive the appropriate treatment. (Cross reference to A0144)

b. Failing to ensure that patients who were committed by PEC and/or CEC were provided care by trained staff. 1 of 1 sampled patient in ED (#1), 4 of 5 sampled patients (2, 3, 4, 5) and 2 of 9 random sampled patients ( R5, R9) received medical screening examination by the ED physician who determined these patients were in need of emergency inpatient psychiatric treatment and ordered a PEC for them to be admitted to psychiatric treatment programs. Patients (#2, 3, 4, 5, R5 and R9) were then held in inpatient rooms, although not admitted to this hospital as inpatients due to this hospital having no psychiatric unit. All of the above listed patients were being watched by nurses and/or security guards, who through interview, personnel file review and/or contracted service review, reflected no training in providing care to psychiatric patients. In addition, Patient #5 was tased by police when staff at ED had to call them for assistance due to the patient's behavior. (Cross Reference to A023 and A0144).

c. Failing to ensure that patients who were PEC/CEC'd for suicidal and/or homicidal ideations resided in rooms that were safe. 4 of 5 sampled patients (2, 3, 4, 5) and 2 of 9 random sampled patients (R5, R9) received medical screening examination by the ED physician who determined these patients were in need of emergency inpatient psychiatric treatment and ordered a PEC for them to be admitted to psychiatric treatment programs. These patients were then held in inpatient rooms, although not admitted to this hospital as inpatients due to this hospital having no psychiatric unit. Observations of these rooms revealed they contained electrical beds, call bells, blinds with pull strings, suction apparatus/suction tubing, blood pressure cuffs with extended cord and/or shower curtains, and patients were not observed at all times while in these rooms. 1 of 1 sampled patient (#1) was observed in ED to be in a room that had suction apparatus and tubing, needle sharps container and blood pressure cuff with tubing.

(Cross Reference to A0144).

d. Failing to ensure policies and procedures were developed and implemented to provide guidance to staff on providing care to psychiatric patients, providing safe environment, providing guidance on observation levels and maintaining patient rights. This was determined through interviews, review of personnel files, review of contracted services for security guards, and review of policies and procedures (Cross Reference A023, A0144, A0397, A1104).

Based on observation, record review, and interview the hospital failed to ensure patients received care in a safe setting for 5 of 5 sampled patients (#1, 2, 3, 4,5) and 2 of 9 Random sampled patients (R5, R9). The hospital failed to ensure patients who entered the hospital's emergency department received psychiatric services in a safe environment provided by trained staff as evidenced by:

a. Failing to ensure that 4 of 5 sampled patients (2, 3, 4, 5) and 2 of 9 random sampled patients (R5, R9), who were medically screened by a Physician and was ordered a Physician's Emergency Certificate to be admitted to psychiatric treatment programs, were not held in inpatient rooms, although not admitted to this hospital as inpatients, due to this hospital having no psychiatric unit. These patients were held in rooms for up to 13 days and received no inpatient psychiatric treatment until the time they were discharged to home thus not promoting the patients right to receive the appropriate treatment.

b. Failing to ensure that patients who were committed by PEC and/or CEC were provided care by trained staff. Patients (#1, 2, 3, 4, 5, R5 and R9) received medical screening examination by the ED physician who determined the patients were in need of emergency inpatient psychiatric treatment and ordered a PEC for them to be admitted to psychiatric treatment programs. These patients were being watched by nurses and/or security guards, who had no documented evidence of training in providing care to psychiatric patients. In addition, Patient #5 was tazed by police after being called to hospital to assist staff due to the patient's behavior in ED.

c. Failing to ensure that patients who were PEC/CEC'd for suicidal and/or homicidal ideations resided in rooms that were safe. Patients (#1, 2, 3) were observed to be in regular hospital rooms with equipment to include electrical beds, call bells, blinds with pull strings, suction apparatus/suction tubing, blood pressure cuffs with extended cord, needle sharps containers, and/or shower curtains, and the patients were not observed at all times while in these rooms.

d. Failing to ensure policies and procedures were developed and implemented to provide guidance to staff regarding care to psychiatric patients, providing a safe environment, providing guidance on observation levels and maintaining patient rights.

Findings:

Patient #1

Review of patient #1's medical record revealed the patient presented to the Emergency Department (ED) on 2/27/12 at 1425 (2:25 p.m.). Review of the patient's psychiatric diagnosis reflected "Acute Psychotic Episode". Review of the record reflected the patient was PEC'd on 2/27/12 at 7:00 p.m. Further review of the PEC revealed documentation to reflect the patient was currently violent, very confused and gravely disabled. Review of the "Mental Condition" noted on the PEC reflected "Disoriented, slurred speech, hallucinations".

Observation of the ED department on 2/28/12 at approximately 2:00 p.m. revealed patient #1 was in Room 5 and a security guard was sitting outside of the room. Observation of the room revealed the room contained equipment for an ED patient, a blood pressure cuff with an extended tubing,and the suction apparatus and suction tubing was noted to be hanging above the head of the bed. The needle sharps container was also observed in the patient's room.

Observation of the security guard revealed he was sitting in the hallway beside room 5 and was not in view of the patient.

Further review of patient #1's record revealed a physician's order dated 2/28/12 at 2:30 a.m. which reflected the patient was placed on "one on one supervision".

Interview with S4, RN, ED Director on 3/1/12 at approximately 1:00 p.m. she confirmed that equipment was in the room, and when she realized the patient was PEC'd the equipment was removed. S4, stated she was not sure of the time equipment was removed. S4 confirmed the patient was placed on one on one supervision.

S4 further stated that there was no distance rule established for one on one supervision as long as the patient could be viewed. S4 stated that sometimes the security guard may sit in the room, however, it depended on the patient. She stated that most times, the security guard sit outside of the door and if the patient has to go to the bathroom then no one watches the patient during that time.


Patient #5

Review of patient #5's ED record dated 8/7/2012 at 6:45 p.m. reflected the patient presented to the ED with a complaint of right (R) flank pain. Documentation of the patient's mental status reflected patient #5 had a depressed mood, was hostile and the patient had suicidal ideation. Further review of the ED physicians orders reflected the patient final diagnosis was listed as "UTI [Urinary tract infection], Trichomoniasis - suicide ideation". Documentation on the physician's orders reflected the patient was placed on "PEC" on 8/7/11 at 7:30 (no a.m. or p.m. was noted on the orders).

Further review of the ED progress notes dated 8/8/11 at 9:10 a.m. reflected the patient was upset, "yelling & screaming, through furniture around...."

Review of the hospital's "Confidential Hospital Occurrence Report" dated 8/8/11 at 0925 (9:25 a.m.) completed by S15 RN, reflected "Patient Kicking at staff, threatening staff-very uncooperative". Review of the occurrence report reflected the patient was "tazered". Review of the brief factual description revealed the patient was "cursing [and] kicking at staff. Pt throwing bedside table [and] food/drink all over floor. Refusing care. Very agitated [and] aggressive. Threatening bodily injury to staff". Two police officers names (from facility A) were noted on the report as witnesses. Further review of the report reflected the report was also signed and investigated by S4, ED Director.

Review of the hospital's "Occurrence Investigation Report" dated 8/8/11 at 0925 (9:25 a.m.) completed by S4, ED Director, revealed "Nature of Occurrence: PEC became uncooperative and threatening (after Dr. [S15] would not allow her to go smoke) to do bodily harm to staff - throwing furniture [and] food all over room. Immediate Action Taken: Staff called" [facility A] "for assistance......""Investigative Summary: Staff [and]security attempted to calm patient, MD [Medical Doctor] ordered IM meds which were given after [facility A police] tased patient." "Recommendations: Staff attempted appropriate calming techniques without improvement of situation."

During an interview with S4, ED Director on 3/1/12 at approximately 1:10 p.m., she confirmed the incident occurred in the ED, and the police had to be called. S4 confirmed she completed the investigation report on 8/8/11 and she was not aware of any other incidents concerning patients being tased while in ED. She confirmed no staff in ED had been trained concerning crisis intervention since she became the director in 2010.

Interview on 3/1/12 at 2:25 p.m. with S3, Quality Director, revealed Patient #5 was an ED patient at the time she was "tazed". S3 stated police was called when the patient became combative and aggressive and the police "tazed" the patient. S3 revealed there were no policies and procedures to guide nurses regarding proper procedure for handling psychiatric patients when they are combative and/or aggressive toward staff.

Review of patient #5's record reflected she remained at the hospital and was transferred to the second floor of the hospital at 1815 (6:15 p.m.) on 8/9/11, escorted by an RN and security guard. Further review at that time reflected "Orientation to room. Limitations [and] treatment plan explained to patient. Pt. lying in bed [with] sullen demeanor. Refuses medications. Call light left [with] patient. Watching tv. Security outside door."

Review of the hospital's "Discharge Instruction Summary" reflected patient #5 was discharged from "ER" on 8/13/11 at 7:44 p.m. Further review reflected the patient had a diagnosis of "Suicidal Ideation".

There was no documentation to reflect the patient received any psychiatric consultations or evaluations by psychiatry while hospitalized. Review of the record reflected Patient #5 was at the hospital from 8/7/11 until 8/13/11 for a total of 7 days.

Patient #4

Review of the medical record for patient #4 reflected the patient was PEC'd on 2/1/2012 at 1750 (5:50 p.m.) due to being violent, dangerous to self, dangerous to others and gravely disabled. Documentation on the Coroner's Emergency Certificate, signed 2/5 at 3:30 p.m., reflected patient #4 was examined on 2/4/12 at 8 PM.


Documentation reflected patient #4 presented to the hospital's emergency room by law enforcement on 2/1/12 at 18:30. It was noted in the medical record that the patient was PEC'd by a "mental health doctor" prior to the patient arriving to the hospital.


Further review reflected "CHIEF COMPLAINT: PEC by mental health needs medical clearance, Not sleeping, not eating, catatonic at times, continually laughing, angry, acting out." Review of the Clinical Impression reflected "Schizophrenia with Active hallucinations". It was further noted that the patient's condition was stable and disposition was "transferred". Review of the "Time" section reflected no time of transfer was documented.

Review of the medical record reflected patient #4 remained in ER from 2/1/12 until 2/5/12. Review of Nurses' Notes dated 2/5/12 at 0005 (12:05 a.m.) reflected patient #4 was transferred to room 229 on the second floor of the hospital.

Review of the record reflected patient #4 remained in the hospital until 2/14/12. Documentation reflected the patient was discharged on 2/14/12 at 1435 (2:35 p.m.) and was taken home by "guard". Review of the Emergency Physician Record Psychiatric Follow-up reflected documentation on 2/14/12 at 1400 (2:00 p.m.) that the patient's "PEC expires today PT Back to Base"_______"D/C PT to F/U [with]" facility B (a mental health center).


There was no documentation to reflect the patient received any psychiatric consultations or evaluations by psychiatry while hospitalized. The patient was in ED from 2/1/11 until 2/5/11 and was on the 2nd floor from 2/5/12 until 2/14/12. The patient remained in the hospital for a total of 13 days.

Patient #R9
Record review for Patient R9 revealed a Physician Emergency Certificate signed by a MD on 10/9/11 at 2022.

Record review of Emergency Department Physician Orders dated 10/10/11 for patient R9 revealed the patient had taken approximately 15-20 Depakote tablets. Review of the orders reflected the MD ' s final diagnosis was Suicide attempt and documentation reflected the MD PEC ' d the patient.

Record review of Psychiatric Orders dated 10/10/11 at 1140, revealed under Suicide precautions, MD documented " Patient Guards ". CEC in place.

Record review of Nurse ' s Notes (unsure of date) written by S37, RN at 0830 revealed 2 South was contacted for possible transfer upstairs to the second floor. Documentation at 1140 (11:40 a.m.) reflected the patient was asking if his mother could visit, and it was explained that because he was PEC ' d he could not have any visitors. Then he asked if he could just talk to her on the phone. Further review reflected the RN notified ED MD. Documentation at 1125 (11:25 a.m.) revealed the patient stated he was " on the verge of flipping out " and wanted to just talk to his mother. Documentation at 1130 (11:30 a.m.) reflected the patient was moved to Rm 228.

There was no documentation to reflect the patient was allowed to talk to his mother.

Record review of Inpatient Nurse ' s Notes revealed:
On 10/10/11, S25, LPN documented that at 1140, patient arrived via ambulatory to Rm 228 accompanied by staff and guard. Patient requested to use the phone. Explained he could not. Patient appears agitated.

On 10/11/11, the LPN documented at 0800, ' guard outside door. ' At 1155, patient became agitated and upset about being " locked in room " and not being able to talk to family.

On 10/11/11, (unknown staff RN) documented at 1130, patient was very frustrated with being so confined, denied being suicidal, talked about death of father, and break-up with girlfriend. Denied being depressed, but finally admitted he needed help.

Review of the record reflected the ED MD utilized the Emergency Physician Record Psychiatric Follow-up form to document daily visits on Patient R9 for 10/14/11, 10/15/11, 10/16/11, 10/18/11, 10/19/11, 10/20/11, 10/21/11, and 10/22/11. Further review reflected the ED MD documented " continue to attempt placement. " On 10/23/11 at 1740, MD documented CEC up tonight; cont to attempt placement. "

Review of documentation reflected that on 10/23/11 at 0800 (8:00 a.m.), patient R9 was requesting to know discharge time. RN instructed him to ask MD. Verbalized understanding. At 1000 (10:00 a.m.) of the same day, patient requesting to know when the time of discharge and when would MD be in to see him. Review reflected the Unit Secretary called ED and reported MD stated patient ' s discharge time was 2000 (8:00 p.m.), but he will be readmitted if needed.

Documentation at 1015 (10:15 a.m.) reflected, RN notified patient of what the MD stated. At 1200 (12:00 p.m.), it was noted that patient reported to nurse he was ready to go home and if he was not discharged by 2200 (10:00 p.m.), he would leave the hospital on his own.

Documentation at 1740 (5:40 p.m.), reflected the ED MD visited the patient and ordered patient to be able to be discharged tonight(10/23) at 2000 (8:00 p.m.) . S5, RN documented at 2000 (8:00 p.m.), that patient was escorted by the nurse to the ER for discussion of release.

There was no documentation to reflect the patient received any psychiatric consultations or evaluations by psychiatry while hospitalized. Review of the record reflected the patient was in a room on the second floor at the hospital from 10/10/11 to 10/23/11 for a total of 13 days.


Patient #R5
Review of patient R5's record revealed the patient was a 26 year old male who entered the ED on 1/3/12 at 12:45 p.m. Review of the record reflected the patient's main complaint was "hearing voices and had been under lots of stress. " Documentation reflected the patient stated he had suicidal thoughts, but had no intention or plan to carry out. Review of the patient's past medical history reflected the patient had a history of bipolar disorder.

Review of ED Physicians Orders dated 1/3/12 and timed 1410 revealed patient R5's final diagnosis was " depression, schizophrenia, and suicidal ideations." Documentation in the record reflected the ED physician completed a PEC on the patient on 1/3/12 at 1735 (5:35 p.m). Further review of Coroner ' s Emergency Certificate dated 1/4/12 and signed at 7:57, revealed Examining Coroner had assessed the patient as being violent.


Record review of the Nursing Shift Documentation dated 1/4/12 at 09:45 (9:45 a.m.)revealed a shift handoff verbal report was given to the oncoming ED RN. Under Safety Measures, the following was listed: Side rails up X1; call bell within reach; bed in low position and locked.

Review of Nurses Note Reassessment on 1/4/12 at 0950 (9:50 a.m.) by S38, Licensed Practical Nurse (LPN) reflected patient R5 arrived to the room ambulating with an ED RN and security guard. It was noted that the patient stated he had no suicidal thoughts, was orientated to the room, and instructed to call for all needs.

Review of Progress Notes: Nursing Shift Documentation reflected the following:
On 1/5/12 at 05:23, LPN documented patient R5 was lying quietly in bed watching TV with the Guard sitting in hallway. At 0500, the Guard remains sitting in hallway.

On 1/8/12, S36, RN documented at 1950 (7:50 p.m.), patient R5 was standing at the door talking to day shift nurse, wanting the security guard to take him downstairs to smoke. Patient was informed that he could not leave the floor. At 1935 (? Time), RN documented the security guard informed RN that patient was complaining, acting belligerent and making derogatory remarks about staff. Spoke with patient who said that he was feeling very stressed and the nicotine patch was not helping. Patient R5 was given Haldol. At 2400 (12:00 a.m.), RN documented security guard was outside patient ' s room.

On 1/8/12, the LPN documented at 1255 (12:55 p.m.), patient was wanting to go outside. It was noted that patient R5 stated " I feel like I am about to climb the wall." At 1513, LPN was called to the room and patient stated he was ready to leave because he felt better. Patient R5 stated he had signed himself into the hospital and now he was ready to sign himself out. He also requested to speak to the doctor. At 1515, LPN called ER and requested the doctor to come speak to the patient. The ED RN told LPN that the MD would come later, but he would send up an ER staff member. At 1730, LPN called ER a second time and was told by the MD he would be up shortly. ER MD arrived to see patient R5 at 1745.

On 1/9/12, the RN documented at 1300, patient #R5 called her to the room. He told her " I ' m about to twist off. " RN explained to patient that this would be unacceptable behavior and reminded him that he was on a Pediatric floor. Patient requested medications to " calm " him.

On 1/10/12, S36, RN documented at 1955, patient was standing in doorway wanting to go downstairs to smoke even though he had been told repeatedly that he could not. He became belligerent and agitated, requesting that the doctor be called. At 2100, patient was standing in doorway talking to security guard.


On 1/10/12, S39, RN documented at 1200, patient asked to see the MD. The ward clerk called to ED and notified MD that patient wanted to see him. At 1600, patient was standing by the door talking with guard, stating he wants to see the doctor today and wants to go home. Patient states he has no intention of hurting himself and has an appointment with his psychiatrist for next week. Patient was told the MD would be notified.

On 1/11/12, S36,RN documented at 2000 that patient was standing in the doorway talking to security guard and demanding to see the nurse. Patient had the usual c/o about not being able to go downstairs to smoke and wanted something to calm down.

On 1/12/12, S39, RN documented at 1800, patient was given cell phone to make calls to find a ride for discharge in a.m. (Cell phone was in patient ' s backpack in the med room). After patient finished phone call, the cell phone was replaced in the patient ' s backpack.

On 1/12/12, S36, RN documented at 2000, patient was calling for the nurse because he wanted to go downstairs to smoke. RN informed patient again that he could not leave his room, he then wanted the nurse to call the doctor. Day shift had talked to the doctor and he had been up to see the doctor earlier. Patient continues to complain about not being able to smoke. At 2030, patient refused to take his night meds if he couldn ' t go downstairs to smoke. Patient then accepted the medications. At 2100, patient continued to complain and is becoming more anxious.

On 1/13/12, RN documented at 0615, MD saw patient; discharge orders written. 0710, Patient was transferred to ER per S10, RN for discharge. Patient in stable condition.

Record review of Progress Note dated 1/13/12 at 07:39 (7:39 a.m.) revealed ED Nurse Disposition indicated patient #R5 was discharged from ER at 1/13/12 at 07:28 (7:28 a.m.). Documentation reflected the patient was hospitalized from 1/3/12 to 1/13/12, for a total of 10 days.








26313

Patient #2

Record review revealed patient #2 entered the ED on 2/28/12 at 6:47 p.m. and was triaged by S12 ED Nurse at 19:06 (7:06 p.m.). According to the ED Progress Note, patient #2's chief complaint was being depressed for the past 13 years. Patient reported he could not take it anymore. His depression stemmed from his wife running off with his brother. He has been suicidal and hostile stating "If I don't get help, I will hurt myself or someone".


Record review of Psychiatric Orders 2/28/12 at 7:45 p.m. with a diagnosis of Suicidal Ideations/Attempt. Security Attendant at all times was checked " yes ". Patient is under PEC is checked; PEC is completed on chart is checked; Notify Coroner/CEC need; Corner notified/CEC needed at 1009.

Record review of Emergency Department Physician ' s Orders dated 2/28/12 at 7:45 p.m. revealed ED MD ' s final diagnosis was " Suicidal Ideations " and PEC.

Record review of CEC revealed MD examined patient on 2/19/12 at 5:24 (Unsure if it was a.m. or p.m.) Under Findings of Examination: History of present illness: " Wife and kids left. Tried to run into 18 wheeler ...and cuts wrist ... "

Addendum documented by S12 RN revealed Late entry from triage note: "Patient reports he wanted to pull out in from of an 18 wheeler and approximately 2 cm superficial scratch to Lt wrist, reports he cut himself with a knife."

On 2/29/12 Handoff checklist signed by S15 RN indicated patient was brought to the inpatient floor.

Record review of Telephone/Verbal Order Documentation Sheet dated 2/29/12 at 0450 indicated patient was sent to the Medical/Surgical inpatient unit.

Record review of Medical Restraint: Physician Order for Restraint, under Initial Order: Place in specified restraint up to 24 hours (not to exceed 24 hrs). Under Reevaluation Note Contents: 1. Behavior that indicates continued need for restraint, ED MD documented " Tried to injure himself. "

Record review of Inpatient Nurses ' Notes on 2/29/12, revealed documentation indicating Patient #2 was to remain in room with BR (bathroom) privileges only with supervision. " At 0320, Patient #2 tried to cut his wrist with a plastic fork that he had broken. Extra security and home supervisor were notified stat to the room. Documentation revealed all trashbags, the call lights, and all cords removed from the room after patient #2 attempted to cut his wrist with the plastic fork. Security reinforced and sitting in the room for safety watch and measures.

On 2/29/12 at 0745, S16 RN documented the Security guard was sitting in hallway outside of patient #2's room, monitoring patient. Guard reports the plastic fork was missing from patient ' s breakfast tray after he finished eating; breakfast tray was sitting on table beside guard. Spoon and knife (both plastic) noted on tray. Informed patient that plastic fork is missing from breakfast tray. Patient #2 denied having the plastic fork in his possession. Patient #2 repeatedly denies having fork and reports no fork was delivered with his tray only spoon and knife.

At 0750, S16 RN notified the unit supervisor, S17 RN. S17 RN supervisor instructed staff to search room. Room and bathroom was searched by S16 RN, S7 RN, and S19 RN. No fork was found. Patient angry, cursing, repeatedly denying he had the fork. At 0800, S16 RN asked the kitchen supervisor if a plastic fork was delivered with patient #2's tray; the kitchen supervisor confirmed it was. At 0805, patient #2 was crying and denying he had the plastic fork. Ativan 2 mg IM given to right dorsal gluteal. Patient now being monitored 1:1. At 0815, the kitchen supervisor called back and reported that the plastic fork was removed from the tray.

At 1530, patient #2 requested to go smoke outside; At 1535, S18 ED MD denied smoking privileges. At 1715, S18 ED MD denied telephone privileges for patient #2.

Record review of Progress Notes dated 2/29/12 at 3:00 a.m. revealed S20 ED MD documented "Called by RN that patient tried to cut wrist with plastic fork. Security guard stopped patient. Superficial abrasion only noted on left wrist. Gave patient Geodon/Ativan for agitation. Instructed nurse to call for restraint order if patient attempts again. Security guard to keep patient in line of sight at all times. "

On 2/28/12 at 12:00 p.m. in an interview with S2 VP of Patient Care and S3 QI Director, both stated that the rooms are stripped down so the patients who have been PEC'd cannot harm themselves or others.

On 2/29/12 at 9:15 a.m. in an observation of patient #2's room, the shower contained a vinyl shower curtain and a call light cord next to the toilet.


Patient #3
Patient #3 arrived to the ED on 2/17/12 at 10:51 p.m. by law enforcement. Patient's chief complaint was feeling suicidal following death of his wife last year and recent loss of employment. From Alabama, wandering the states on his way to Texas to look for work. Was seen standing on the bridge and picked up by passerbyers and driven to sheriff ' s substation where he reported suicidal thoughts. Previous suicide attempts twice last year via overdose on prescription medication and beer following wife's death.

Record review of ED Communication Note dated 2/17/12 at 14:00 revealed S21 RN was contacted on the inpatient Medical/Surgical unit that patient #3 had been PEC'd and would be admitted to this unit (which was 2 North on the second floor of the hospital).
Record review of Physician Emergency Certificate dated 2/17/12 at 11:45 a.m. revealed ED MD signed this form (signature was unreadable).

Record review of Coroner ' s Emergency Certificate dated 2/17/12 at 7:45 p.m. revealed under S22 Coroner's exam, "patient was drinking; had an auto accident (ran into the police car); got into fight with deputies outside of police station". Under mental condition, coroner documented that the patient was depressed, aggressive, and intoxicated. Coroner checked off that the patient was suicidal and homicidal.

Record review of a 2nd Coroner ' s Emergency Certificate dated 2/17/12 at 7:52 p.m. revealed under History of present illness, " 52 year old w/m climbed on highway overpass waiting for car to come under pass. Sheriff deputies found him before he jumped. The coaxed him done. " Under Mental Condition, coroner documented that " patient was depressed; still wants to run. " Coroner documented patient was suicidal.

Record review of Psychiatric orders dated 2/17/12 at 11:40 a.m. revealed MD ' s diagnosis was depression with suicidal ideations. Security attendant at all times was checked " yes " . " No restraints " was checked. Under activity, ED MD checked " remain in room " and " bathroom privileges with supervision. "

Record review of Inpatient Nurse ' s Notes dated 2/17/12 at 1410 signed by S21 RN revealed patient arrived to the floor transferred to the Medical/Surgical floor via wheelchair per ER staff. At 1430, RN documented patient resting in bed, call light in reach.. At 1610, RN documented " guard at doorway. " On 2/18/12 at 0800, patient requested the IV to be removed. The S23 LPN called the ED MD for an order to remove IV. IV was taken out. At 1230, patient requested telephone call. Was advised that he could not make a call, patient then stated " well then I ' m gonna leave. " Advised patient that he could not leave until the MD says he can'. Pt then stated that he was " on strike " when asked if he needed any thing. Guard outside door. At 1225, patient requested " shot " states he is upset now that he knows he cannot make a phone call or leave. "

On 2/20/12 at 0838, S16 RN informed patient that no phone calls was part of the PEC order and he will have to further discuss this with the ER MD.

On 2/20/12 at 2000, S24 RN documented patient was very distraught and extremely depressed, stated " nobody around here not taking care of my needs, ie. Meds not given " Patient stated he called this a.m. 2x for pain medication. Nurse acknowledge missing first call; then he refused when she brought him pain medicines. Then nobody came again to give pain medication. At 2400, patient continued to voice displeasure with staff; unable to answer questions.

On 2/12/12 at 0800, S25 LPN stated patient awakened easily but had a flat affect; will not make eye contact, depressed mood. At 0905, ED MD ordered limited phone contact with family if patient wishes. At 2000, S26 RN documented that patient #3 was very depressed, non-compliant with vital signs, medications, stated " I don ' t trust this place. "

Record review of Telephone/Verbal Order Documentation Sheet dated 2/22/12 at 1135 and signed by S26 RN revealed S27 ED MD okayed to put a phone in room to contact family.

On 2/23/12 at 0730, S27 ED MD came in to see patient, reported patient is not to have telephone in room at all times. At 0750, patient requested to see the social worker. Patient refused to allow the nurse to perform an assessment. Security guard at doorway. On 2/23/12 at 1030, S14 LSCW came in to see patient. S14 reported to nurse that patient #3 was unsafe to be discharged due to mental state; reports patient was stating he is depressed and wants to kill himself. S14 LCSW also stated that patient did not want to contact his family.

At 1430, S14 LCSW (License Clinical Social Worker) completed needed paperwork for transfer to facility. At 1845, S21 RN documented that patient #3 became agitated and stated " If you guys would just let me out of here, I can do what I am needing to do (commit suicide). I have my mind made up and am content with my decision. " Informed patient this is the reason we will be transferring him to a facility to receive the appropriate treatment. Pt verbalized understanding.

On 2/23/12 at 2000, S28 RN documented the patient requested the phone, so the S28 RN plugged in the phone and dialed the number for the patient. Pt was unable to reach family member at this time, so while unplugging phone, patient states that "he doesn ' t understand why we just don ' t leave it (the phone) in the room, because there are many other things in the room that he can use to harm himself." S28 RN stated that the patient ' s anxiety was a 6/10.

On 2/24/12 at 0800, patient requested his wallet. S29 RN informed the patient that these were the rules. Patient stated he did not care about the rules. At 0945, patient #3 said that if he wanted to kill himself, he could. He added he was tired of the ED MD and he needed the phone so he could strangle himself.

On 2/27/12 at 1940, S5 RN documented that patient was upset because S30 ED MD had told him he could leave in 2 days; but now it is 4 days.

On 2/28/12 at 1000, patient requested soap and towels for a shower. Patient was instructed to inform the nurse when shower completed. At 1430, patient #3 stated "I am not getting the help I need here." At 1810, patient expressed his anger about the ED MD. He stated the doctor was threatening him today by saying "he (the MD) can make me stay here another month or even incarcerate me. " On 1940, patient became more cooperative and allowed staff to take vital signs. Patient stated he did not appreciate the ' hard-headed ER Doc " that told him he could make him do what he wanted him to or even make him stay here longer. " Pt states he feels so confined, a little fresh air or a cigarette would help to calm. S5 RN contacted S30 ED MD at 2115 about letting patient go outside to smoke; MD agreed. At 2225, patient was escorted per S5 RN and a security guard outside.

On 2/28/12 at 11:15 a.m. an observation of patient #3's room revealed a suction machine with tubing above patient's bed, a vinyl curtain hanging in shower, and a call bed cord next to the toilet in the bathroom. The bed in patient #3's room was a standard electric bed with 1/2 side rails on each side. In back of the electrical bed was a window with a window cord hanging down on top of the bed.

At the same time as the observation, a hospital guard was sitting across from the patient outside the patient's room. S31 Security Guard stated he was "guarding" patient #3 because the patient had been PEC'd. While standing next to the guard, the patient was not in visible sight. S31 Security Guard stated patient "must be in the bathroom."


During an attempt to interview patient #3, he was openly hostile and did not want to answer any questions. When asked how long had he been here, patient #3 stated "Too d..n long!" He then sat down on the chair next to the bed and propped his feet up on the bed.


On 2/28/12 at 12 noon, both S2 Vice-President of Patient Care and S3 QA Director stated PEC patients can be moved to any inpatient setting of the hospital, whichever room was available. Both agreed that rooms are stripped down so the patients cannot harm themselves.


Interview with S2, RN, VP of Patient Care and S3, RN, QI Director, on 2/28/12 at approximately 12:20 p.m. revealed that patients who are PEC'd are held in ED for 24 hours and after 24 hours the patient is moved to the second floor unit until placement can be found. S2 and S

Based on interview and policy review, the hospital failed to (1) track quality indicators as evidenced by lack of tracking of the issues related to psychiatric patients needing psychiatric services (2) take action as the number of patients entering the ED requiring psychiatric care increased.
Findings:

1) On 3/1/12 at 12:20 p.m. in an interview with S3 QI Director, he stated to his knowledge, the contracted security guard service is not incorporated into his QAIP plan. To his knowledge, the ED has not tracked the number of times a security guard was called to monitor a patient who had been PEC'd or CEC'd.

2) The record review of the Emergency Department Council meeting minutes of June 15, 2010 revealed the issues of patients PEC'd were addressed by S3 QI Director under the topic of Patient Advocates. No recommendations or actions were found on these minutes of the meeting.

In an interview on 3/1/12 at approximately 3:30 p.m. with S3, he confirmed the issue of placing the PEC'd patients under "house arrest" was introduced at the Emergency Department Council meeting dated June 15, 2010. No recommendations were noted by the Council.

Record review of the Emergency Department Council meeting minutes of September 14, 2010 revealed S33 RN Director of ED (during 2010) reported the ED was having problems with the psychiatric patients. She stated these patients can sit in the ER from one day to two weeks. She noted that there are security guards that sit with them, but S33 felt there needed someone with more experience with these patients. S33 acknowledged the importance of caring for this population to meet the standards of care and reduce risks for these patients. No recommendations or actions were found on these minutes of the meeting.

Record review of the Emergency Department Council meeting minutes dated October 6, 2011 revealed a discussion was held regarding the hospital wide policy development regarding PEC'd patients and how to provide care for this population.

Record review of the hospital's Governing Body revised February 2010 (pg 6 of 10) under Quality Improvement Committee revealed "the committee shall collect, screen, and evaluate information which might identify opportunities for improving care and identify problems that directly impact patient care, and establish action to achieve those improvements and/or resolve problems.

Record review of the hospital's policy titled "Administration/Quality Improvement" reviewed 2/2010 and revised 6/3/11 (pg 5 of 7) revealed patients' perception of care, treatment and services are areas which provides the hospital about process stability, risks, and sentinel events. Under Patients' perception of care, treatment and services, the patients' specific needs and expectations are measured; how well the hospital meets needs and expectations are measured; how the hospital can improve patient safety are measured; and the effectiveness of pain management, when applicable is measured.

Based on observation, interview, and policy review, the hospital failed to ensure the safety of the psychiatric patients who had been placed on the inpatient medical unit as evidenced by the untrained inpatient nursing staff being assigned to provide care to meet the needs for 2 of 5 sampled patients who were currently hospitalized (#2, 3).

Findings:

Record review of Medical Staff meeting minutes dated February 22, 2011 (pg 3 of 6) under New Business revealed S18 MD suggested having two or three patient rooms designated on the floor for PEC patients that present to ER. S18 reminded the committee that at times a PEC patient can occupy an ER room for 2 or 3 days, and by having rooms available on the floor this would allow for all rooms in the ED to be available at all times. Recommended action was to have S2 VP Patient Care and S3 QA Director contact DHH and see if the hospital can designate two or three patient rooms for PEC patients presenting to ER.

On 2/29/12 at 9:15 an observation of the Medical/Surgical unit revealed a staff nurse and a security guard sitting in the hallway across from 2 patients' rooms.

On 2/29/12 at 11:45 a.m. in an interview with S10 RN- Team Leader on 2 South, she stated PEC'd patients can be housed anywhere in the hospital and at times have been placed in the unit, which houses pediatric patients. She stated the patients always have a guard present outside the door. S10 added that the CNAs or floor nurses relieve the security guards for bathroom breaks, but no more than 5-10 minutes. She stated that meals are provided to the security guards when the patient's tray is brought to the unit. S10 RN Team Leader stated she has not had any training in crisis prevention intervention (CPI) or in the care of a patient who has been PEC'd/CEC'd.

On 2/29/12 at 12:00 noon, in an interview with S6 RN, she stated she normally works in Nursery, but since there were no babies, she was asked to "sit" with patient #3. She stated she did not receive any report, so she was unsure of his diagnosis. She stated that usually if staff or a security guard has to sit with patients, then they probably have been PEC'd or CEC'd. She confirmed she has not had any CPI training or how to care for a psychiatric patient.

On 2/29/12 at 12:05 p.m. in an interview with S7 RN Team Leader of 2 North, she stated she was the supervisor on the unit today. She stated she had 15 actual patients and 2 Psychiatric patients. She stated one patient was PEC'd (patient #2) and one patient was CEC'd (patient #3). S7 stated she and her staff do not feel comfortable caring for these type of patients because they have not been trained. She did say in order to prepare the rooms, and they remove the phones, remove the chairs to prevent the patient from breaking windows. S7 confirmed the rooms contained electric beds and shower curtains in the showers.

On 2/29/12 at 1:30 p.m. in an interview with S4 (current) ED Director, she stated the ED MDs perform a medical screening on all patients and if they determine a patient needs psychiatric care, they will PEC the patient. If the patient has a medical condition, they are sent to the floor. If they are not many patients in the ED, then the patients can remain in the ED. S4 confirmed that the nurses on the floor provide nursing care and the ER MDs provide medical care. She added that the floor nurses can call ER MD for any concerns or new orders. S4 stated that while the PEC'd patient is being cared for on the floor, the ED nurses and unit secretaries are trying to find placement for the patient. S4 confirmed the nursing staff in the ED have not had any CPI training to her knowledge. (She assumed the position of ED Director in February 2011.)

On 2/29/12 at 2:00 p.m. in an interview with S11 ED RN, she stated she triages patients when they enter the ED. She confirmed the ED MD assess the patient and determines if the patient needs psychiatric services. She confirmed she has not had any CPI training while working at the hospital.

On 2/29/12 at 2:40 p.m. in an interview with S12 ED RN, she confirmed that patients with psychiatric needs have stayed in the ED "two weeks at a time." She also confirmed she has not been trained in CPI. She added if the ED MD assesses the patient and determines the patient needs psychiatric care, then she notifies the Supervisor and then calls the security guard company to request a security guard.

Record review of the Position Description/ Performance Evaluation of the Medical/Surgical Unit Registered Nurse (pg 1 of 6) revealed the RN must demonstrate competency by performing all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors. On pg 2 of 6, the RN must demonstrate competency by maintaining a safe, comfortable, and therapeutic environment for patients and families in accordance with hospital standards.

Record review of the Position Description/Performance Evaluation of the Medical/Surgical Unit Licensed Practical Nurse (LPN) (pg 2 of 6) revealed the LPN must demonstrate competency by performing all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

(Cross Reference A144)

Based on record review and interview the hospital failed to ensure policies and procedures governing medical care of patients who were committed by PEC and/or CEC were established, evaluated and/or updated on an ongoing basis. Findings:

The record review of the Emergency Department Council meeting minutes of June 15, 2010 revealed the issues of patients PEC'd were addressed by S3 QA Director under the topic of Patient Advocates. No recommendations or actions were found on these minutes of the meeting.

In an interview on 3/1/12 at approximately 3:30 p.m. with S3, he confirmed the issue of placing the PEC'd patients under "house arrest" was introduced at the Emergency Department Council meeting dated June 15, 2010. No recommendations were noted by the Council.

Record review of the Emergency Department Council meeting minutes of September 14, 2010 revealed S33 RN Director of ED (during 2010) reported the ED was having problems with the psychiatric patients. She stated the patients could sit in the ER from one day to two weeks. She noted that there were security guards that sit with them, but S33 felt there needed someone with more experience with these patients. S33 acknowledged the importance of caring for this population to meet the standards of care and reduce risks for these patients. No recommendations or actions were found on these minutes of the meeting.

Record review of the Emergency Department Council meeting minutes dated October 6, 2011 revealed a discussion was held regarding the hospital wide policy development regarding PEC'd patients and how to provide care for this population.

Review of the policies and procedure manual for the Emergency Department reflected a policy dated 11/2011. The subject of the policy reflected "Psychiatric Patient Treatment". The purpose of the policy reflected "To develop a policy guiding the care of psychiatric patients hospital wide".

Further review of the hospital's policy dated 11/2011 concerning "Psychiatric Patient Treatment" revealed ".....Once the PEC hold is placed on an Emergency Department patient, the Emergency Department psychiatric orders will be initiated per the Emergency Department physician order..... In some circumstances patient safety, comfort or in response to patient flow issues, the Emergency Department may move the physical location of the patient to another area of the hospital. In this event the Emergency Department physician will continue to care for the patient and will reassess them at a minimum of every shift. In the Emergency Department or other physical location in the hospital, a security officer or dedicated staff member will be at the patient's bedside or be able to visualize the patient to provide a safe environment..........Social Services may be consulted for help with patient needs, family concerns and discharges to assist in scheduling the Mental Health visit and providing supporting documentation. If a PEC/CEC patient attempts for elope from the facility, or becomes agitated/aggressive towards staff, the [facility A] Police should be contacted.........for assistance. Under no circumstance should the staff chase the patient. Once the patient has been PEC'd or CEC'd a plan of care must be initiated and the ED Physician must evaluate the patient daily... "

There were no other policies or procedures noted concerning care of the psychiatric patient, training of staff in regards to caring for psychiatric patients, nor were there policies to address levels of observation and/ or supervision for patients who were PEC/CEC.

Interview with S2, RN VP of Patient Care, on 2/29/12 at approximately 11:40 a.m., confirmed the hospital had one policy in place concerning PEC patients and that policy was the policy dated 11/2011. S2 revealed there were no policies to guide staff concerning observation levels of the patient, nor were there any policies to direct staff concerning the type of care to be provided to the patients while the patients remained on the second floor.

Interview with S2, RN, VP of Patient Care and S3, RN, QI Director, on 2/28/12 at approximately 12:20 p.m. revealed that patients who were PEC'd were held in ED for 24 hours and after 24 hours the patient were moved to the second floor unit until placement could be found. S2 and S3 further stated that the patients remain on the second floor for observation and the staff on the second floor Med-Surgical unit provided care to the patients. S2 and S3 revealed that the patients were still considered to be ED patients, and therefore they were not included on the inpatient census report. S2 and S3 further stated that the ED physicians assume the care of the patients until they can be transferred to a psychiatric unit.