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Tag No.: A0115
Based on staff interview, review of patients' medical records, hospital policies and procedures, grievance documents, security incident reports, and viewing of security video recording, it was determined the hospital failed to ensure restraints were applied safely and appropriately and grievances filed were responded to in writing. This resulted in the inability of the hospital to ensure patients rights were protected. The findings include:
1. Refer to A123 as it relates to the failure of the hospital to ensure it provided a written notice of findings to persons who filed grievances.
2. Refer to A144 as it relates to the failure of the hospital to ensure patient care was provided in a safe setting.
3. Refer to A154 as it relates to the failure of the hospital to use patient restraint only as a means to protect the immediate physical safety of the patient, staff, and others.
4. Refer to A194 as it relates to the failure of the hospital to ensure safe implementation of restraint.
5. Refer to A200 as it relates to the failure of the hospital to ensure staff were educated, trained, and met yearly competencies related to safe implementation of restraint usage.
The cumulative effect of these negative facility practices seriously impeded to ability of the facility to promote and protect the rights of patients.
Tag No.: A0123
Based on review of grievances and facility policy, and staff interview it was determined the facility failed to provide written responses which included the results of the grievance process for 2 of 5 patients (#2 and #13) and/or family members who filed grievances related to care provided in the Emergency Department and those grievances had been referred to Risk Management. This failure resulted in a lack of clarity and closure regarding the resolution of the grievance and had the potential to interfere with patient/family understanding and satisfaction. Findings include:
A policy, titled "Patient Grievance", approved and signed 4/12/09, stated upon resolution of a grievance, the facility would provide the patient or family with a written response.
Five grievances and the results of their investigations were reviewed. One grievance involved allegations of inappropriate restraint by facility security. The medical record for Patient #2 documented a 27 year old male who presented to the ED on 7/09/10 at 7:46 PM. The patient had presented with a dislocated right shoulder. Following an outburst, Patient #2 was restrained by a total of 3 security guards, and "taken down" multiple times. The patient subsequently filed a grievance.
A letter from the hospital to Patient #2 was dated 7/23/10. In the letter the facility acknowledged the grievance, and enclosed a copy of the "Patient Rights and Responsibility" brochure. The letter stated within approximately thirty calendar days of receiving the grievance, the facility would provide a written response about the findings of the investigation and the action taken to resolve the grievance.
The Director of Risk Management was interviewed on 12/01/10 at 2:30 PM. She stated because the complaint involved legal action, and was not considered to be resolved, no letter of resolution had been sent to Patient #2. She stated when an attorney became involved, the grievance process halted and the case was referred to the legal department.
Another grievance involved the abrupt manner a patient and his mother had been treated by a physician. The medical record for Patient #13 documented a 2 month old male infant had been brought in to the ED on 9/07/10 by his mother. The infant had a severe cough, had turned blue, and had difficulty breathing. The grievance was filed on 9/15/10, and stated Patient #13's mother felt the physician had not listened to her concerns and felt he dismissed her as being overly protective. The grievance stated Patient #13 was diagnosed two days later with Whooping Cough, and the mother wanted to be advised of the investigation outcome.
A letter from the hospital to the mother of Patient #13 was dated 9/16/10. In the letter the facility acknowledged the grievance, and stated within approximately thirty calendar days of receiving the grievance, the facility would provide a written response about the findings of the investigation and the action taken to resolve the grievance.
The Director of Risk Management was interviewed on 12/01/10 at 2:30 PM. She stated the grievance had been documented as being resolved 10/05/10 after the department director had talked with the mother of Patient #13 on the phone. She confirmed a letter of resolution had not been sent to the mother as directed by the hospital policy.
The hospital failed to ensure all grievances were investigated and resolved and patients were notified of their resolution.
Tag No.: A0144
Based on observation of security video recording, medical record review, review of hospital policies and staff interview, it was determined the hospital failed to ensure a safe environment was provided for patients who were restrained by the hospital security officers. This directly impacted 1 patient (#2), whose security video and records were reviewed, and had the potential to impact all patients who were restrained by hospital security officers. This failure had the potential to place all patients at risk of inappropriate physical intervention and possible injuries by security. Findings include:
1. Patient #2 was a 27 year old male who presented to the ED on 7/09/10 at 7:46 PM after dislocating his right shoulder. Observation of security surveillance video on 12/02/10 at 9:45 AM, (no sound was provided), showed a male with his right arm in an immobilizer, who was identified by the risk manager as being Patient #2. He was accompanied by a female. They were standing in an empty room with unoccupied chairs along one side. The male was noted to be pacing, and at one point stepped up to the admissions clerk, as if speaking to her. A tall male individual, who was identified as being part of the security staff, entered the admission clerk's room. The security officer then was noted to step out of the room, and stride towards Patient #2. The security officer made a motion of pointing with his right hand towards the double doors and entrance area of the emergency department. The recording showed the officer raising his hand towards Patient #2 and a movement by Patient #2 as if to deflect the officer's arm with his left arm. The officer then immediately seized the left arm of Patient #2 and brought it to his back. The officer placed his other hand on Patient #2's right shoulder, and holding the left hand against his back, directed Patient #2 out through the double doors. The security video was not able to show Patient #2 and the officer after they exited through the doors. The video recording continued, and a second security officer was seen running towards the doors. After a short period of only noting the movement of shadows in the distance, Patient #2 and three officers came back into view. Patient #2 was walking towards the entrance to the ED, and then suddenly he was knocked to the ground by the three officers. When Patient #2 fell to the ground, he fell without being able to protect himself from the fall. He struggled to get up, and was knocked face down again. A wheelchair was brought towards Patient #2, and he was assisted in to the wheelchair and taken back into the Emergency Department. At that point the security video recording stopped. During the altercation with the security officers, Patient #2's dislocated right shoulder was put back in place.
2. Review of the incident report provided by the security officer that had first contact with patient #2, did not indicate any attempt at de-escalation. The report stated Patient #2 had been heard swearing in a loud voice. The officer stated he told Patient #2 to go outside. The report stated "within a few seconds, I was able to grab his left arm and put it behind his back. I then began forcing him out towards the doors." The incident report completed by the officer stated Patient #2 had abrasions to his knee, both hands, his nose, and forehead as a result of the restraint actions.
Review of training and education for two of the three security officers involved documented CPI recertification on March 16, 2006. The third officer involved did not have evidence of CPI training in his training records.
Review of "KOOTENAI COUNTY MEDICAL CENTER Security Department Standard Operating Procedures And Training Guidelines," under the section "Physical Restraints," dated 9/02/10, described physical restraints as putting hands on a person to control their body movement. In addition, it stated they may use reasonable physical restraint techniques, such as CPI, to protect others and themselves. The booklet also included a section about handcuffs. It stated: "handcuffs may not be used on any patient in Behavior Health or on other patients unless a direct relationship between Police and the incident is present." "Visitors, transients, and high-risk discharges that present a danger to others may be handcuffed for short durations."
3. The director of security operations was interviewed on 12/02/10 at 1:15 PM. When questioned about the training of the security officer staff, he stated all the officers have had POST training, (Police Officer Standards Training.) He stated some of the staff had attended Law Enforcement Training. He confirmed there was no evidence of POST training or law enforcement training in the three education records reviewed. The director of security stated "Non-Violent Crisis Prevention and Intervention Program," also known as "CPI" training was a requirement of the hospital, with a 4 hour yearly recertification. The director of security stated he did not think the CPI program was a good program, and confirmed his staff had not attended in 4 years. He stated the hospital had been looking for a better program to offer its employees.
In addition, during another interview on 12/7/10 at 2:20 PM, the director of security confirmed his staff carried handcuffs as part of the uniform and equipment requirements. He stated it was acceptable for his staff to use handcuffs anywhere in the facility except the behavioral health units. The director of security stated "handcuffs are used if there is no other way to control the patient or visitor for a short period of time when an individual or staff is in danger." The director of security stated the incident with Patient #2 and the officers was handled appropriately, and he fully supported the actions of his staff.
In the process of the interview with the director of security operations, it became apparent the security department maintained a separate incident report and tracking system. The director of security stated the software for the security incident reporting system is separate from the rest of the hospital, and unavailable for risk management or other departments in the facility to access.
The facility failed to ensure security staff was trained and recertified in non-violent intervention methods of dealing with patients and visitors.
4. In an interview on 12/02/10 at 4:20 PM, the Director of Risk Management stated she thought she was able to review all incident reports submitted throughout the facility, and was unaware of the separate incident reporting system completed and maintained by the security staff until the present survey was in progress. The Director of Risk Management stated she had been unable to question the security staff involved in the incident with Patient #2 as the director of security operations had insisted she speak with him and not the staff. The Director of Risk Management stated after reviewing the grievance involving Patient #2 she had initiated a PI related to all aspects of education and training, policy and procedures, the "Code Grey" process, and roles and responsibilities of security staff. She stated she spoke with the Vice President of Human Resources, and asked for his support in working with security. She stated a task force had been formed, and had held two meetings, but no changes had been implemented to protect patients. The Director of Risk Management stated it was the facility policy and expectation that all clinical staff who had direct patient contact take the CPI course and yearly recertification. She stated it was a general assumption that non violent methods of de-escalation would be attempted by the security staff.
The facility failed to provide a safe environment for patients and visitors.
Tag No.: A0154
Based on staff interview, review of clinical records, hospital policies and observation of security video recording, it was determined the hospital failed to ensure restraint measures were only used to ensure the safety of patients and others for 1 of 4 patients (#2), whose records were reviewed for restraint by security. This resulted in a patient being needlessly restrained which resulted in patient injury. The findings include:
1. Patient #2 was a 27 year old male who presented to the ED on 7/09/10 at 7:46 PM after dislocating his right shoulder. Observation of security surveillance video on 12/02/10 at 9:45 AM, (no sound was provided), showed a male with his right arm in an immobilizer, who was identified by the risk manager as being Patient #2. He was accompanied by a female. They were standing in an empty room with unoccupied chairs along one side. The male was noted to be pacing, and at one point stepped up to the admissions clerk, as if speaking to her. Within seconds, a tall male individual, who was identified as being part of the hospital's security officer staff entered the admission clerk's room. The security officer then was noted to step out of the room, and stride towards Patient #2. The security officer made a motion of pointing with his right hand towards the double doors where patients came in to the emergency department. The recording showed the officer raising his hand towards Patient #2 and a movement by Patient #2 as if to deflect the officer's arm with his left arm. The officer then immediately seized the left arm of Patient #2 and brought it to his back. The officer placed his other hand on Patient #2's right shoulder and holding the left hand against his back, directed Patient #2 out through the double doors. No evidence was noted of an attempt to talk with Patient #2 or de-escalate the situation during the three seconds with which Patient #2 was approached and forced out of the room with his arm held behind his back. The security video was not able to show Patient #2 and the officer after they exited through the doors. The video recording continued, and a second security officer was seen running towards the doors. After a short period of only noting the movement of shadows in the distance, Patient #2 and three security officers came back into view. Patient #2 was walking towards the entrance to the ED, and then suddenly he was knocked to the ground by the three officers. He struggled to get up, and was noted to be knocked face down again. A wheelchair was brought towards Patient #2, and he was assisted in to the wheelchair and taken back into the Emergency Department, at that point the security video recording stopped.
Review of the incident report provided by the security officer that had first contact with patient #2, did not indicate any attempt at de-escalation. The report stated Patient #2 had been heard swearing in a loud voice. The officer stated he told Patient #2 to go outside. The report stated "within a few seconds, I was able to grab his left arm and put it behind his back. I then began forcing him out towards the doors."
2. The Hospital Policy titled "Code Gray- Out of Control Individual," reviewed and approved 8/31/06, stated: "Whenever possible, attempts will be made to prevent or defuse potentially assaultive behavior through early intervention. Physical control and restraint will be used only as a last resort after all verbal intervention efforts have been exhausted and only when the individual presents a danger to self or others."
Review of "KOOTENAI COUNTY MEDICAL CENTER Security Department Standard Operating Procedures And Training Guidelines," under the section "Physical Restraints," dated 9/02/10, described physical restraints as putting hands on a person to control their body movement. In addition, it stated they may use reasonable physical restraint techniques, such as CPI, to protect others and themselves.
3. The director of security operations was interviewed on 12/02/10 at 1:15 PM. The director of security stated the incident with Patient #2 and the guards was handled appropriately, and he fully supported the actions of his staff.
4. In an interview on 12/02/10 at 4:20 PM, the Director of Risk Management stated it was her expectation that all security staff would first attempt de-escalation measures before engaging in a physical measure to restrain the individual.
The facility failed to utilize restraints only to protect the physical safety of patients and others.
Tag No.: A0194
Based on review of medical records, security video recording, staff interview, and review of hospital policies and procedures, it was determined the facility failed to ensure security staff were trained in the safe implementation of restraint measures affecting care of 1 of 4 patients (#2), whose records were reviewed and were restrained by hospital security. Findings include:
1. Patient #2 was a 27 year old male who presented to the ED on 7/09/10 at 7:46 PM after dislocating his right shoulder. Observation of security surveillance video on 12/02/10 at 9:45 AM, (no sound was provided), showed a male with his right arm in an immobilizer, who was identified by the risk manager as being Patient #2, accompanied by a female. They were standing in an empty room with unoccupied chairs along one side. The male was noted to be pacing, and at one point stepped up to the admissions clerk, as if speaking to her. Within seconds, a tall individual who was identified as being part of the security officer staff entered the admissions clerk room. The security officer then was noted to step out of the room, and stride towards Patient #2. The security officer made a motion of pointing with his right hand towards the double doors and entrance area where patients came in to the emergency department. The recording showed the officer raising his hand towards Patient #2 and a movement by Patient #2 as if to deflect the officer's arm with his left arm. The officer then immediately seized the left arm of Patient #2 and brought it to his back. The officer placed his other hand on Patient #2's right shoulder and holding the left hand against his back, directed Patient #2 out through the double doors. The security video was not able to show Patient #2 and the officer after they exited through the doors. The video recording continued, and a second security officer was seen running towards the doors. After a short period of only noting the movement of shadows in the distance, Patient #2 and three officers came back into view. Patient #2 was walking towards the entrance to the ED, and then suddenly he was knocked to the ground by the three officers. He struggled to get up, and was noted to be knocked face down again. A wheelchair was brought towards Patient #2, and he was assisted in to the wheelchair and taken back into the Emergency Department, at that point the security video recording stopped.
The medical record of Patient #2 stated he was triaged at 8:34 PM. The triage note stated Patient #2's dislocated right shoulder was relocated during the take down, and he had abrasions on his forehead and arms.
2. In an interview on 12/3/10 at 7:45 AM, the RN that provided care for Patient #2 after triage stated Patient #2 had a bloody nose as well as abrasions to his face and upper body. The RN stated he placed an ace wrap on Patient #2's knee, but did not remember if it was to secure a dressing or to brace the knee. The RN stated security remained with Patient #2 but he was no longer agitated.
3. The Policy titled "Code Gray- Out of Control Individual," reviewed and approved 8/31/06, stated: "Whenever possible, attempts will be made to prevent or defuse potentially assaultive behavior through early intervention. Physical control and restraint will be used only as a last resort after all verbal intervention efforts have been exhausted and only when the individual presents a danger to self or others." Regarding staff training, the policy stated "Staff members who are responsible for implementing physical control and restraint techniques will be trained, not only in the technical skills required, but also in all policies governing the use of restraints in the facility. Refresher training will be provided and required each year. All staff trained in the use of physical control and restraint techniques will first be trained in verbal and non-verbal de-escalation skills and Code Gray Team training. All staff training will be documented and a summary of training submitted by the Educational Services Department to the Director of Patient Relations every six months."
4. The director of security operations was interviewed on 12/02/10 at 1:15 PM. When questioned about the training of the security officer staff, he stated all the officers have had POST training, which means Police Officer Standards Training. He stated some of the staff had attended Law Enforcement Training. The director of security stated "Non-Violent Crisis Prevention and Intervention Program," also known as "CPI" training is a requirement of the hospital, with a 4 hour yearly recertification. The director of security stated he does not think the CPI program is a good one, and confirmed his staff has not attended in 4 years. Review of training and education for two of the three security officers involved documented CPI recertification on March 16, 2006. The third officer involved did not have evidence of CPI training in his training records. He stated the hospital has been looking for a better program to offer its employees. The director of security stated the incident with Patient #2 and the officers was handled appropriately, and he fully supported the actions of his staff.
The facility failed to ensure safe implementation of restraint measures by qualified and trained staff.
Tag No.: A0200
Based on interview with hospital staff and review of policies, it was determined the hospital failed to ensure security officers had education, training, and demonstrated knowledge in the use of nonphysical intervention skills. This resulted in the potential for the unnecessary use of restraints due to unmet training needs. Findings include:
1. Review of "KOOTENAI COUNTY MEDICAL CENTER Security Department Standard Operating Procedures And Training Guidelines," under the section "Physical Restraints," dated 9/02/10, described physical restraints as putting hands on a person to control their body movement. In addition, it stated they may use reasonable physical restraint techniques, such as CPI, to protect others and themselves.
The Policy titled "Code Gray- Out of Control Individual," reviewed and approved 8/31/06, stated: "Whenever possible, attempts will be made to prevent or defuse potentially assaultive behavior through early intervention. Physical control and restraint will be used only as a last resort after all verbal intervention efforts have been exhausted and only when the individual presents a danger to self or others." Regarding staff training, the policy stated "Staff members who are responsible for implementing physical control and restraint techniques will be trained, not only in the technical skills required, but also in all policies governing the use of restraints in the facility. Refresher training will be provided and required each year. All staff trained in the use of physical control and restraint techniques will first be trained in verbal and non-verbal de-escalation skills and Code Gray Team training. All staff training will be documented and a summary of training submitted by the Educational Services Department to the Director of Patient Relations every six months."
2. The director of security operations was interviewed on 12/02/10 at 1:15 PM. When questioned about the training of the security officer staff, he stated all the officers have had POST training, which means Police Officer Standards Training. He stated some of the staff has attended Law Enforcement Training. The director of security stated "Non-Violent Crisis Prevention and Intervention Program," also known as "CPI" training is a requirement of the hospital, with a 4 hour yearly recertification. The director of security stated he does not think the CPI program is a good one, and confirmed his staff has not attended in 4 years. He stated the hospital has been looking for a better program to offer its employees. The director of security stated the incident with Patient #2 and the officers was handled appropriately, and he fully supported the actions of his staff.
The facility failed to maintain training and education for staff on nonphysical intervention measures.
Tag No.: A1104
Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure policies governing the medical care of ED patients provided direction to ED staff regarding the treatment of patients who were placed on the hospital's pain management program. This resulted in a lack of treatment for 3 of 5 patients (#8, #12, and #18) who had been placed on the pain management program and whose medical records were reviewed. The findings include:
1. The policy "Pain Care Management," dated 12/08, defined a pain care committee to "Manage patients with chronic pain or pain related complaints..." Inclusion Criteria for patients to be placed on the Pain Care Management program included "Multiple Emergency Department visits...Documented drug seeking behavior...Providing false information," and other criteria. Patients were placed on the program involuntarily. ED physicians were notified when a patient on the Pain Care Management program presented to the ED. The policy did not provide direction to physician or nursing staff related to the assessment of patients on the Pain Care Management program.
2. Patient #8's name was entered on the computer at 3:15 PM on 12/01/10 by the ED registration clerk. The physician was automatically notified on the screen of the following: "ED CARE GUIDELINES: The Pain Care Management Committee of Kootenai Medical Center, Coeur d'Alene, Idaho, formulated the following guidelines...No controlled substances should be administered [to Patient #8] in the ED or prescribed from the ED unless objective findings dictate their use. Narcotic medication for dealing with pain will be administered by the primary care provider."
The Nursing Case Manager for the ED, 1 of 2 persons who managed the Pain Care Management program, was interviewed on 12/02/10 at 10:15 AM. She stated a committee reviewed the cases of patients who presented to the ED and exhibited drug seeking behaviors. She stated the program attempted to limit those patients' use of the ED for obtaining narcotics. She stated the committee made recommendations as to whether to place patients on the Pain Care Management program or not. She stated, if patients were placed on the program, an ED physician would be notified by the hospital's computer that the patient was on the program. She confirmed the Pain Care Management policy did not provide directions to staff regarding the assessment or treatment of patients.
3. Patient #8's medical record documented a 25 year old male who presented to the ED on 9/04/10 at 9:03 PM. He stated his blood glucose had been elevated to 496 when measured at home at 8:00 PM that evening. He also complained of left ear pain. The Triage Assessment, dated 9/04/10 at 9:06 PM, stated "KMC PAIN CARE MANAGEMENT PT, SEE GUIDELINES..." Nursing notes at 9:10 PM on 9/04/10, stated Patient #8 rated his pain intensity at 7 of a possible 10. The location of this pain was not documented. Nursing notes at 10:16 PM on 9/04/10, stated Patient #8 rated his pain intensity at 9 of 10. The location of his pain was "STOMACH." Nursing notes at 11:13 PM on 9/04/10, stated Patient #8 rated his pain intensity at 3 of 10. The location of this pain was not documented. Nursing notes at 10:25 PM on 9/04/10, stated Patient #8 complained of increased abdominal pain and asked for pain medication. The note stated the nurse would ask the physician. Patient #8 did not receive pain medication.
Physician dictation, untitled, dated 9/05/10, stated Patient #8 had an elevated blood glucose level and complained of ear pain. The dictation stated Patient #8 was on the hospital's pain care management plan. The dictation stated the physician could not find an objective cause for his pain but a description of the pain was not documented. An examination of the patient specific to pain was also not documented.
The physician who treated Patient #8 was interviewed on 12/01/10 beginning at 3:50 PM. He described the pain management program and said all physicians were notified by the computer if a patient was on the program. He reviewed Patient #8's record and confirmed an assessment of the patient's pain was not documented.
4. Patient #12's medical record documented a 43 year old female who presented to the ED on 11/14/10 at 11:03 AM. The triage note stated Patient #12 had been discharged from the hospital 3 days earlier for pneumonia. Her pain at 11:12 AM and 12:27 PM was rated at 7 of 10. A location was not documented. She was medicated with Tylenol at 12:13 PM but the reason was not documented. Nursing notes stated she was discharged at 1:34 PM and her pain at that time was 5 of 10. Again, a location was not documented.
The physician dictation, dated 11/14/10, stated Patient #12 was "...on an alert with the Kootenai Medical Center Emergency Department Pain Management guidelines." The physician dictation did not mention Patient #12's pain or an assessment of her pain.
The Director of the ED was interviewed on 12/02/10 at 3:25 PM. She reviewed Patient #12's record and confirmed an assessment of her pain was not documented.
5. Patient #18's medical record documented a 66 year old male who presented to the ED on 11/09/10 at 9:57 AM. The triage note stated Patient #18 was on KMC Pain Care Management guidelines. The triage note stated Patient #18 complained of nausea, vomiting, and a leg infection. A nursing note on 11/09/10 at 10:02 AM, 12:10 PM, and 1:20 PM, stated Patient #18 had leg pain rated at 10 of 10. Patient #18 was medicated with Flexeril at 11:29 AM. A nursing note at 1:14 PM on 11/09/10 stated Patient #18 requested pain medication and the physician was aware of the request. Patient #18 was discharged at 5:16 PM. Pain was not documented after 1:20 PM. Pain medication was not documented.
The physician dictation, dated 11/09/10, noted Patient #18 complained of leg pain. An assessment of the pain was not documented.
The Director of the ED was interviewed on 12/02/10 at 3:25 PM. She reviewed Patient #18's record and confirmed an assessment of his pain was not documented.
The hospital did not provide direction to ED staff regarding pain assessments for patients who were on the hospital's pain management program.