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Based on staff interviews and record review, the hospital failed to assure that there were sufficient staff on duty at all times to provide the services required in the Emergency Department related to care provision for 1 of 10 applicable patients reviewed. (Patient #1). Finding include:

A complaint investigation subsequent to allegations of a lack of appropriate care provision for a patient treated in the hospital Emergency Department (ED) during May, 2017, found regulatory violations related to the lack of sufficient staffing in the ED for 2 applicable dates of service (DOS) reviewed during the on-site survey.

Patient #1 was seen in the ED on several dates in May, (5/3/17 - 5/7/17), including one overnight admission (5/4/17 - 5/5/17), to treat an electrolyte imbalance. The Patient returned via ambulance with police and EMTs (Emergency Medical Technicians), on 5/8/17 due to exhibiting behaviors presenting a risk of harm to self and was subsequently screened by Mental Health Crisis staff and determined to need involuntary treatment. The patient was held in the ED for 6 days until a psychiatric inpatient bed became available. During the time the patient received care in the ED, there were two dates when non-hospital staff, including police and/or EMTs, participated in hands on patient care.

On 5/8/17, when the patient was resisting allowing a lab technician to draw blood from the arm, 2 policemen and 2 EMTs 'held down the patient's arm to allow the lab tech to draw blood for testing'. The RN was also present in the room at the time of restraint of the patient's arm. On 5/9/17, at 0040, the RN wrote "Pt tried to run out of room...medicated as ordered while being held down by police....returned to bed by police and staff...trying to fight...placed in leather restraints."

The RN Nurse Manager of the ED stated on 6/27/17 after a tour of the ED that the usual staffing pattern for the night shift in the ED included 2 RNs and 1 physician provider between the hours of 12 AM and 7 AM. Per review of the May, 2017 RN schedule, there were 2 RNs and 1 MD on duty during those stated hours. Regarding the use of non-hospital staff for hands on patient care, the Nurse Manager confirmed that it does happen at times, and police are asked to provide assistance to help manage physically assaultive and aggressive patients in the ED. One nurse's progress note described the night of 5/9/17 as 'very busy with several critical patients' and included Patient #1, who attempted elopement and was attempting to strike and hit staff, and throw items in the environment.

The failure to provide sufficient numbers of trained hospital staff to be available at all times of the day and night to provide needed patient care was confirmed during interview with the Vice President of Patient Care Services during the late morning of 6/28/17. The hospital's practice of relying on the use of police (or other non-hospital staff) to augment staffing when needed was not compliant with hospital regulatory requirements.

Based on staff interview and record review, the hospital failed to assure that health care services were furnished in accordance with it's approved written policies, consistent with applicable State law for 1 of 10 patients in the targeted sample. (Patient #1).
Findings include:

Per record review and staff interviews, ED staff failed to consistently adhere to the policy regarding the use of restraints, both physical and chemical, related to every 15 minute assessments during care provision to Patient #1 on 5/4/17 and 5/9/17. Per review, the hospital's "QPS - Restraint Use Policy" last reviewed 8/25/16, stated that for patients who are violent (section B) and attempts to manage are unsuccessful and the patient remains a risk to self or others, obtain a physician order for restraint. The policy stated under 4. "Assess and assist the patient at least every 15 minutes to determine and document:
a) Signs of any injury associated with the application of the restraint;
b) Whether patient meets criteria for release of restraint;
c) Nutrition/hydration;
d) Circulation and range of motion in the extremities and appropriate application;
e) Vital signs;
f) Hygiene and elimination;
g) Physical and psychological status and comfort;
h) That rights, dignity and safety of the patient are managed; and
i) Whether less restrictive methods of restraint are possible."

On 5/4/17, Patient #1 arrived to the ED via ambulance, restrained, accompanied by EMTs and police and brought to a room. Per interview with the RN who was on duty at the time, 'the patient was spitting, combative and talking about the apocalypse'. The physician was also in the room with the RN and EMTs and police. The physician ordered chemical restraints due the patient's continued attempts to assault staff. The medications included: Geodon 20 mg. IM (intramuscular) at 1830, Ativan 2 mg. IM at 1834 and Geodon 20 mg. again at 1843.

At 1850, staff attempted to move the patient from EMS stretcher to a hospital stretcher with 9 people in the room; patient was fighting staff. At 1852, the RN wrote that the patient (Pt) was in 4 point restraints. 'Pt appears to be more calm now'. At 1907 reassessment, the RN wrote 'Pt more calm now, spit shield removed...Pt appears to be sleeping.' At 1917, 'patient's behavior improved, continues to be in restraints.' At 1938, 'patient continued to be in 4 point restraints, behavior is more cooperative.' At 1951, 'Restraints removed ...'.

Per review of the RN documentation of the Pt's response to the medication administered IM, at 1900 the RN wrote 'Pt more calm now.' Based on the hospital policy section (i), the nurse did not document any attempt to decrease the 4 point restraints per the policy, even after noting that the patient appeared to be asleep.

On 5/9/17 at 0040, 'the patient was restrained after trying to run out of the room...police called and patient fighting police and staff...held down by police while medicated...returned to bed by police and staff....placed in leather restraints.' Per record review, the patient was calmer, laughing in room at the time of the 0102 reassessment. The next note, at 0130 stated 'Pt appears to be sleeping'; and at 0150 documentation stated 'resting quietly....leather restraints X 4 to all extremities in place.' At 0215, the RN documented 'Pt. taken out of restraints.' The time elapsed since the Pt was noted to be calm was 1.25 HR yet no attempts had been made to release any of the restraints in place.

For each of these dates, ED staff failed to adhere to the hospital policy for the management of physical and chemical restraints. Staff's failure to follow the policy for restraints was confirmed during interviews with the ED Nurse Manager and the V.P. of Patient Care Services on 6/28/17 at 11 AM.

Based on staff interview and record review, the hospital failed to assure that there were written guidelines, such as general instructions and protocols for the medical management of patient's health problems related to the use of physical and chemical restraints for 1 of 10 patients in the total sample of ED (emergency department) records reviewed. (Patient #1). Findings include:

Per record review and staff interviews, Patient #1, who was exhibiting combative, psychotic symptoms, was brought to the ED by EMTS and police and placed in 4 point restraints as ordered by ED physicians. A review of the physician orders showed a failure to include the reason for the necessity, or indication for use, of restraints (physical as well as chemical) on 2 occasions reviewed. On 5/4/17 and 5/9/17, the patient required physical and chemical restraints to manage violent and threatening behaviors towards staff and others. Per review of the physician orders, there was no reason documented in the orders for the restraints to indicate why the involuntary procedures (restraints) were necessary. When surveyors asked to review the medical guidelines for managing patient restraints, staff explained that they had not developed any written provider guidelines for managing violent patient behaviors with the use of physical and/or chemical restraints.