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41287

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on interviews and document reviews, the facility failed to follow processes to ensure patient safety. The facility failed to ensure staff members involved in patient care were aware of the patient's legal medical incapacity hold status to leave the facility in 1 of 1 medical records reviewed of patient's who were placed on Medical Incapacitation Holds (MIH) (Patient #8). The failure resulted in injury of Patient #8 while he was detained by security after attempting to leave the facility.

A-0171 Unless superseded by State law that is more restrictive (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older. Based on interviews and document review, the facility failed to ensure orders were renewed from a physician for physical restraints in 1 of 1 medical records reviewed of patients in the intensive care unit (ICU) with documented use of physical restraints (Patient #4).

A-0175 The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. Based on interviews and document review, the facility failed to ensure patients who were placed in seclusion were monitored to ensure their physical safety in 1 of 1 medical records reviewed for seclusion (Patient #10).

41287

Based on interviews and document reviews, the facility failed to follow processes to ensure patient safety. The facility failed to ensure staff members involved in patient care were aware of the patient's legal medical incapacity hold status to leave the facility in 1 of 1 medical records reviewed of patient's who were placed on Medical Incapacitation Holds (MIH) (Patient #8). The failure resulted in injury of Patient #8 while he was detained by security after attempting to leave the facility.

Findings include:

Facility policy:

According to the policy, Medical Incapacity Hold (MIH), a MIH hold was used to prevent an adult patient from leaving the facility. The following criteria was listed, the patient was making efforts to leave the facility, and by leaving would place himself/herself at grave risk for serious harm, disability, or death, the patient does not have the capacity to understand the risks of leaving and/or declining necessary care, and the patient does not otherwise meet the criteria for an involuntary mental health hold. The placement of a MIH would be determined by the provider, and if the patient met criteria, the provider would place the order for the MIH in the Electronic Medical Record (EMR) ensuring the order includes a start date and time and the criteria present. The nursing staff would focus on elopement precautions and de-escalation and would notify Security when a MIH order was placed. If a patient on MIH hold attempted to leave the facility nursing staff would notify security immediately and security would detain the patient at the nurses request until the physician was present and determines if criteria was present to hold the patient against his/her will. Security would round periodically and consult with nursing staff, check in with the patient if appropriate, and discuss continued need for hold.

According to facility policy, Emergency Department Patient Care Guidelines, some intoxicated individuals may meet the definition of emergency medical condition because the absence of medical treatment may place their health in serious jeopardy, result in serious impairment of bodily functions, or serious dysfunction of a bodily organ. Patients who had been determined to have an emergency medical condition shall not be discharged unless the patient's condition was resolved or the patient was determined to be stable for discharge. Criteria for the discharge of patients who were under the influence of alcohol include the patient was awake and verbally responsive and the patient was able to sit up and ambulate with minimal assistance.

1. The facility failed to ensure patient safety by lack of communication in regards to medical incapacitation holds, for patients who were intoxicated, which resulted in a patient sustaining a fractured and dislocated arm.

a. Review of Patient #8's medical record revealed the patient was brought to the facility on 6/6/19 at 1:43 a.m., after having a seizure while being transported by the police department. The police department attempted to transport the patient to the Alcohol Recovery Center (ARC) for intoxication. According to the medical record, the plan for the patient was to monitor for further seizure activity, and monitor for sobriety.

At 1:48 a.m., the patient had a serum alcohol level of 350 milligrams/deciliter (mg/dL), with a normal sober reference range of 0-10 mg/dL.

At 2:15 a.m., according to the Emergency Department (ED) Clinical Notes the patient was walking around his room and attempting to remove his IV. Patient #8 was escorted back to his bed and security updated regarding the patient's increased "agitation and sporadic behaviors."

At 3:05 a.m., Patient #8 was taken by the radiology department for a cat scan (a type of diagnostic imaging) of his head when security was called for assistance as the patient was getting up during the exam. Security was noted to have responded and was able to redirect the patient back to his bed. Two additional instances, in which the patient required redirection from nursing and security staff in order to remain in his room were identified in the medical record.

At 4:15 a.m. Patient #8 was placed on an Medical Incapacity Hold (MIH) by Physician #5.

b. Review of the Safety Event completed by the facility on 6/23/19 revealed at 4:30 a.m. Patient #8 attempted to walk out without medical staff permission. The event summary stated the patient was "agitated with staff from the beginning of his arrival" and was "verbally abusive and threatening towards staff." The patient was described as attempting to leave the facility when the security officer asked the physician if the patient could leave the hospital or if security should detain him. Per the event summary, the physician informed security the patient was on an MIH and was not safe to leave. The patient was near the ambulance bay exit door when security requested the patient return to his room. The patient initially complied, then turned in an attempt to leave in which security stopped the patient. According to the event summary, the patient began to swing his arms towards one of the security officers and another officer grabbed the patient from behind. The patient was documented as "lost his footing" which resulted in the patient to fall.

The medical record noted the same series of events at 4:28 a.m. as reviewed in the safety event. Following the event, the medical record revealed Patient #8 was having right shoulder pain after the fall and an x-ray of the patient's shoulder revealed a fractured humerus (upper arm bone) and dislocated shoulder which later required surgical intervention.

c. An interview was conducted with Physician #5 on 6/27/19 at 4:40 p.m. Physician #5 stated he was unsure if security was aware of the MIH. He further stated it was not his usual practice to place patients which were intoxicated on holds because most of the patients remain in their bed and asleep until their alcohol level had decreased.

Physician #5 described at the time of the event he was in a different patient's room doing a procedure, when security contacted him about the patient being allowed to leave the facility. He stated he had to step away from the procedure to inform security Patient #8 was not allowed to leave. Physician #5 stated he could have enacted the MIH earlier when the patient was showing behavioral issues, but at the time of the earlier events, the patient was not threatening to leave the facility.

Physician #5 stated despite the absence of a written hold, he did not feel the patient was safe to leave the ED and "everyone knew he couldn't leave because his alcohol level was too high." Furthermore, Physician #5 explained the staff were aware intoxicated patients were not allowed to leave the facility.

d. An interview was conducted with ED Nurse Manager (Manager) #1 on 6/26/19 at 2:55 p.m. Manager #1 stated he was assigned to review the safety event after it had occurred. He explained he was not aware of the time frame in which the MIH was put into effect or if the information had been relayed to Patient #8's nurse or security staff. Manager #1 explained it was the responsibility of the nurse to inform security if a patient was on an MIH, and if Patient #8 was on an MIH, there would have been a failure in communication if security was not notified.

Manager #1 stated had the provider put the patient on a hold then maybe the event could have been prevented and security should have been aware of his status because of Patient #8's behavioral issues since time of arrival.

e. An interview was conducted with Security Officer (Officer) #8 on 6/25/19 at 9:42 a.m. Officer #8 explained the nurses were usually the people to inform the security staff regarding if a patient was placed on a MIH or not. At a second interview on 7/1/19 at 9:08 a.m., Officer #8 explained during pass-on to the next shift, each patient who was identified to be on a hold was discussed between the security officers and a hold sheet was completed and signed by the officers. He explained the status of patient's being on a medical incapacitation hold was usually communicated between nursing and security verbally at first, and later on the paperwork was completed, including obtaining a copy of the patient's hold.

f. Review of the Security Hold Report form for Patient #8 revealed security received verbal report on 6/6/19 at 4:30 a.m. in regards to the MIH ordered for the patient on 6/6/19 at 4:15 a.m. There was no evidence of discussion, prior to 4:30 a.m., by nursing or the physician with security in regards to Patient #8's mental incapacitation hold status.

Based on interviews and document review, the facility failed to ensure orders were renewed from a physician for physical restraints in 1 of 1 medical records reviewed of patients in the intensive care unit (ICU) with documented use of physical restraints (Patient #4).

Findings include:

Facility policy:

According to Restraints and Seclusion: Violent Patient, a physician order was required to initiate the use of a restraint or seclusion in all inpatient care areas. Orders were renewed by nursing assessment and clinical justification up to 24 hours. Orders were time limited for violent patients depending on the age of the patient. A new order was required every four hours for adults ages 18 years and older.

1. The facility failed to ensure restraint orders were renewed throughout the duration of use of violent physical restraints.

a. Review of Patient #4's medical record revealed Patient #4 was placed in violent four point restraints (physical restraint applied to both wrists and ankles and locked to the bed) on 6/19/19 at 8:15 p.m., due to physically threatening and intimidating nursing staff. Patient #4 remained in the violent four point restraints until 6/20/19 at 8:21 a.m., a period of 12 hours and 6 minutes. An initial provider order for the use of the violent restraints was identified in the medical record dated 6/19/19 at 8:15 p.m. There were no other orders identified throughout the remainder of the 12 hour and 6 minute time period which was in contrast to facility policy which required a new order every four hours.

b. An interview was conducted with Registered Nurse (RN) #3 on 6/27/19 at 11:10 a.m. She stated violent restraint orders had to be reordered every four hours by the provider. RN #3 stated the orders need to be renewed every four hours to reassess the patient's condition and to ensure the continued need of the restraint and the safety of the patient. RN #3 verified it was the responsibility of the nurse who was assigned to care for the patient, to manage and obtain the orders every four hours.

c. An interview was conducted with Manager #13 on 6/27/19 at 8:40 a.m. Manager #13, after review of Patient #4's medical record stated there was only one order identified for violent restraints for Patient #4 over the 12 hour 6 minute time frame. She explained it was uncommon for the ICU to have patients in violent restraints and thus the ordered was not renewed per the policy.

41287

Based on interviews and document review, the facility failed to ensure patients who were placed in seclusion were monitored to ensure their physical safety in 1 of 1 medical records reviewed for seclusion (Patient #10).

Findings include:

Facility policy:

The Restraints and Seclusion Violent Patient policy read, assessment/monitoring documentation for the restrained patient includes ongoing monitoring through one to one care or the use of both video and audio equipment that was in close proximity to the patient, as well as face to face checks at least every 15 minutes. Specific to the Behavioral Health Unit there was continuous face to face monitoring for restrained patients and for patients who were simultaneously restrained and secluded. Hourly face-to-face assessment documentation by an RN assessing level of distress and agitation, mental status, cognitive functioning, patient understanding of the need for restraint, physical assessment, and the need for the continuation of the seclusion. A physical safety assessment documented every two hours, including: nutrition/hydration, repositioning and range of motion to restrained limb, skin integrity and circulation, hygiene/elimination, comfort/privacy, and proper application of the restraint.

1. The facility failed to ensure staff monitored Patient #10 while in seclusion to ensure the patient's physical needs were met.

a. A tour of the seclusion rooms on the behavioral health unit was conducted on 6/27/19 at 2:56 p.m. with Manager #11. It was confirmed with Manager #11 while on tour, there were locations, within the two seclusion rooms which were not visible through the door window when the door was closed. It was confirmed, however, the entire room was visible from the security cameras. Manager #11 further stated there were no policies regarding what was allowed in the seclusion room with the patient.

b. An interview was conducted with Manager #11 on 6/27/19 at 2:56 p.m. Manager #11 stated the expectation of staff, for patients in seclusion, was to have visual contact in order to ensure patient safety, from outside the door, of the patient, for the initial one hour period of seclusion. She also stated it was the responsibility of security to monitor the patient remotely via the video monitor as a second set of eyes.

c. Review of Patient #10's medical record revealed on 6/1/19 at 11:22 a.m., the patient arrived to the facility for treatment of depression and suicidal ideation. The patient was transferred from the Emergency Department (ED) to the secured behavioral health unit at 6:25 p.m. At 10:50 p.m., an order was entered for seclusion because the patient was verbally and physically threatening.

The medical record revealed face to face checks documented every 15 minutes starting at 10:56 p.m. From 10:56 p.m. until 11:40 p.m., the 15 minute checks described the patient to be naked, yelling, restless, crying and lying in the corner of the seclusion room.

At 11:40 p.m. there was a note on the 15 minute flowsheet in the medical record which described the observations made by the Mental Health Worker (MHW). The entry outlined the patient was located in the seclusion room in a corner in which only her lower body was visible by the staff who was located outside the seclusion room. The patient was described to have "sat up briefly from the corner of the seclusion room and the MHW noticed the patient had something white tied around her neck and her face appeared purple." Other staff were notified to assist, the seclusion door opened, and the patient was cut free from a pillowcase she had tied around her neck. The medical record revealed an ambulance was called to transport the patient back to the ED for further evaluation following the event.

d. Review of the Safety Event documented on 6/3/19 at 2:04 p.m. revealed the staff located outside the seclusion room were only able to visualize the lower half of the patient. According to the safety event, the settings on the camera were such that if there was no movement detected, the video would continue to display the same image until new movement was detected. Additionally the safety event identified due to the patient having removed her clothing and her skin color was similar to the color of the walls, the video monitoring did not capture or record the patient for security to observe and monitor the patient as required. The safety event review identified the security officer was watching the cameras during the event, but he was also responsible for monitoring many cameras and it was easy to miss a ten second window.

In response to the safety event review, on 6/26/19, the facility changed the sensitivity of the cameras to the maximum level.

e. On 6/28/19, the facility conducted a Root Cause Analysis (RCA) of Patient #10's safety event. From the RCA the facility identified actions to take place to prevent the occurrence of a similar event in the future. Specifically, the facility reported the video sensitivity was changed to continuous recording and the need for additional storage space was to be looked into further by 7/15/19.

The facility recommended pillows, pillowcases and the flat sheet be removed from the seclusion room, but the fitted sheet and the blanket would remain. This change was to be communicated to housekeeping on 7/1/19, Manager #11 sent an email to the staff regarding the change and signs were hung near the seclusion room outlining the items allowed in the room. This change was also added to the ligature risk assessment on 6/28/19.

The facility planned to implement the use of another screen with camera views on it, for the person who remained outside the seclusion room to be able to view all areas of the room to include if the patient were to move to one of the corners not visible from the door. The facility reported this was to be completed by 7/15/19, 44 days after the safety event occurred. Director #2 was able to provide evidence this was in process, but there was no evidence of education to the staff who were responsible to monitor the patients in seclusion regarding the changes or instructions for use.

f. An interview was conducted with Clinical Team Lead (CTL) #7 on 7/1/19 at 10:46 a.m. CTL #7 verified the change in items allowed in the seclusion rooms as a result of the RCA conducted on 6/28/19. CTL #7 stated she was not aware of the change to implementing a separate camera view for the person outside the door and had received no education on the process.