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Based on documentation review the Hospital (Hospital #1) failed to ensure that: 1). the Patient's physical restraints were removed in a timely manner, and 2). security officers were not supplied with or used items considered to be weapons.

Findings included:

1). The Emergency Services Order Sheet and the Nursing Record, dated 12/24/09, indicated that at approximately 6:45 A.M. intravenous Ativan 0.5 milligrams (mg) was ordered and administered. At approximately 6:55 A.M.: Haldol 5 mg; Cogentin 1 mg, and Ativan 2 mg.

The Physician Orders Restraint Form, dated 12/24/09, 6:52 A.M., indicated that 4-point soft restraints were ordered and applied for aggressive behavior and for the high risk of injury to self or others.

Review of Hospital #1's Policy/Procedure titled Restraint Use in the Acute Care Setting indicated that the order for restraints related to behavioral health reasons was limited to 3 hours.

The Clinical Notes Report, dated 12/24/09, indicated that by 7:01 A.M. the Patient ws sleeping.

The medical record documentation for 12/24/09, 7:00 A.M. until 7:00 P.M., indicated that the Patient remained sleeping, but arousable until approximately 3:30 P.M. There was no evidence of behavioral problems. The 4-point restraints remained in place until approximately 2:30 P.M. The restraints were removed one by one and were discontinued at approximately 3:30 P.M.

There was no indication in the documentation that the need for the continued use of physical restraints was re-evaluated.

2). Review of medical record documentation, dated 12/25/09, indicated that the Patient eloped from the ED.

The Security Officer who pursued the Patient (Security Officer #4) was interviewed on 1/8/10 at 8:40 A.M. and his documentation, dated 12/25/09, was reviewed. Security Officer #4 said and his documentation indicated that after the Patient climbed a snow pile at the back of the parking lot and jumped over the fence he went to the top of the snow pile and observed the Patient proceeding down the road looking into vehicles parked along the street. Security Officer #4 said and his documentation indicated that after several minutes he walked back toward the ED. Security Officer #4 said and his documentation indicated that when the police arrived he reported the direction the Patient had taken when he left Hospital property. Security Officer #4 said and his documentation indicated that one of the police officers asked him to accompany the police officer in the cruiser to identify the Patient. Security Officer #4 said and his documentation indicated that the police officer drove down the street the Patient had been seen. Security Officer #4 said the Patient was observed communicating with an elderly female. Security Officer #4 said and his documentation indicated that the police officer stopped the cruiser and both the police officer and Security Officer #4 exited the cruiser. Security Officer #4 said and his documentation indicated that the police officer radioed their location and pulled out a taser gun. Security Officer #4 said and his documentation indicated that he pulled out pepper spray. Security Officer #4 said he did not use the pepper spray.

A copy of policies and education related to the use of pepper spray was requested by the Surveyor and provided by the Vice President of Facilities who was responsible for the Security Department.

Review of the education determined that the Security Department also was educated to use handcuffs. The policy for handcuffs was requested.

Review of both policies determined there was no guideline as to whom the handcuffs would be used on and the policies did not indicate that law enforcement would be contacted or involved in any way.

The Vice President of Facilities was interviewed throughout the survey. The Vice President said handcuffs and pepper spray were used only as a last resort and each time they were deployed an incident report was completed.

A list of dates/situations for which handcuffs and pepper spray were used in 2009 was requested.

The list provided by Hospital #1 indicated the following:

10. handcuffs were used twice in 2009. On 3/6/09 handcuffs were applied to an eloping patient after a brief struggle in the Hospital parking lot. On 5/17/09 handcuffs were applied per physician order to contain a patient who repeatedly attempted to elope from the Hospital. The physician was present and assisted with the restraints.

2). pepper spray had not been used in 2009.

Based on interview and documentation review Hospital #1 failed to identify all areas of deficient practice when the Patient's elopement was reviewed.

Findings included:

The Chief Quality Officer and the Manager of Quality were interviewed together on 1/7/10 at 2:20 P.M. The Chief Quality Officer said that on 12/28/09 and on 12/30/09 meeting s were held to conduct a review of the Patient's elopement and develop an action plan. The Chief Quality Officer said the review focused on what happened up to the Patient's departure and identified the following problems: 1). there was no process in place regarding sitter assignment and no way of knowing sitter competency; 2). employees such as Sitter #2 may not qualify to sit with certain types of patients; 3). there was a failure on the part of the nurses to communicate with the sitter; 4). the policies related to sitters and suicide needed to be revised; 5). there was a concern of the need to increase the number of positions allotted for sitter positions; 6). there was no visitor policy for the ED; 7). there was direct access to the ambulance entrance from Treatment Room #17, and 8). there were delays with evaluations and re-evaluations by the Psychiatric Service.

Hospital #1's review did not identify that: 1). the Patient's Initial Screening for Self-Harm Potential, dated 12/24/09, was not completed in a timely manner; 2). 1:1 observation was not initiated in a timely manner, and 3). the Patient remained in physical restraints even though he had received multiple medications and slept once the medications took effect.

Based on interview and documentation review the Hospital (Hospital #1) failed to ensure that re-education provided to sitters regarding their responsibilities was effective.

Findings included:

Review of Hospital #1's Incident Log related to elopements for the period of 7/1/09 to 1/7/10 indicated that on 7/30/09 a suicidal patient who was in the Emergency Department (ED) under a Section 12 eloped. The patient was under a Section 12 (temporary involuntary hospitalization application) and was assigned a sitter. Documentation indicated the sitter was assigned to monitor 2 patients. The sitter went to get a glass of water for the other patient and this patient eloped at that time. The Patient was seen by an ED Physician leaving and Security and the police were notified.

Documentation provided by Hospital #1 indicated that the staff member was counseled. On 8/1/09 the sitters were re-educated.

The Chief Quality Officer was interviewed on 1/7/10 and throughout the survey. The Chief Quality Officer said to the best of her knowledge there was no follow-up quality measures to determine the effectiveness of the re-education.

Based on interviews and documentation review the nursing staff failed to ensure that: 1). the Initial Screening for Self-Harm Potential was completed in a timely manner, and 2). 1:1 observation was initiated in a timely manner.


Findings included:

1). Review of Hospital #1's Policy/Procedure titled Suicide Risk Assessment and Interventions indicated that a patient's risk for suicide was assessed in the ED, when indicated, using the S.A.D.P.E.R.S.O.N.S. Suicide Risk Assessment tool. A score greater than 8 indicated the patient was at risk. If the patient was assessed as at risk then a psychiatric consult was obtained as soon as possible. One to one observation in the patient room was required at all times and was documented on the Self-Harm Potential Monitoring Log. The Initial Screening for Self-Harm Potential was completed in the ED and was used to provide report to the oncoming shift nurse and the sitter.

Observation of the Initial Screening for Self-Harm Potential determined it was a pre-printed form with a series of questions designed to determine if the patient was at risk for self harm and if so, the level of observation required (Level 1 = constant; Level 2 = every 15 minutes, and Level 3 = every 30 minutes. The instructions at the top of the form indicated that the form was to be completed at the first part of the admission assessment.

Review of the Patient's medical record documentation indicated that the Patient arrived in the Emergency Department (ED) at 6:20 A.M. The Initial Screening for Self-Harm Potential was not completed until 7:30 P.M.

2). The Physician Orders Restraint Form, dated 12/24/09, 6:52 A.M., indicated that 4-point soft restraints were ordered and applied to the Patient for aggressive behavior and for the high risk of injury to self or others. The Form indicated that when 4-point soft limb restraints or chemical restraints were used then a 1:1 sitter was required.

Review of the ED Restraint Observation Record indicated that the Patient was on constant monitoring/observation however; the observation check section of the Record was not completed.

Review of Hospital #1's Policy/Procedure titled Suicide Risk Assessment and Interventions indicated that 1:1 observation in the patient room was required at all times.

Review of the medical record documentation indicated that the Self-Harm Potential Monitoring Log had not been initiated.

Nurse #2 was interviewed on 1/7/10 at 1:35 P.M. Nurse #2 said an Initial Screening for Self-Harm Potential was not completed because the Patient was in restraints. Nurse #2 said the Patient did not have a sitter while in restraints.

The medical record documentation for 12/24/09, indicated that at approximately 5:00 P.M. the Patient was escorted to the bathroom then brought to Room H4 (a safe room without only built-in seating along several walls of the room and a television that was elevated and bolted down) with security at the doorway. At 7:10 P.M. the Patient went to the bathroom and was observed pulling at the intravenous line. The Patient was escorted to another safe room that contained a stretcher. Security was present and the supervisor was notified to arrange for a 1:1 sitter.

Nurse #3 was interviewed on 1/8/10 at 7:30 A.M. Nurse #3 said she was scheduled to work in the ED from 7:00 P.M. on 12/24/09 to 7:00 A.M. on 12/25/09. Nurse #3 said when she assumed care of the Patient, the Patient was not restrained and was not under 1:1 observation. Nurse #3 said she decided the Patient was not safe, called security, and initiated a 1:1 sitter.