HospitalInspections.org

Based on observation and interview the CAH (Critical Access Hospital) failed to ensure the Emergency Department's (ED's) environment maintained patient safety as evidenced by failing to secure a supply room that contained sharps and other healthcare supplies that could be accessed by any passerby. Findings include:

During a tour of the ED on 5/21/24 at approximately 10:15 AM with the ED Nurse Manager and the Assistant Director of Nursing, a supply room located in the hallway near beds 7, 9, 10, & 11 was noted to be open and unsecured allowing anyone to access. This hallway was a high traffic area for which patients, visitors, and staff moved about in the ED. Some of the items found in the store room were, "Pedialyte (oral electrolyte solution for children), Chlorox Bleach wipes, Hibiclens solution 32 oz (antibacterial cleansing solution), germicidal surface wipes, 20g IV catheters (needles used to put in IV's), 22g IV Catheters, 18g IV catheters, Butterfly 21G (needles used to draw blood), Butterfly 23G, Normal saline flushes (syringes containing sodium chloride commonly used to flush IV's), RX destroyer formula (material used to destroy medications), and "Gallant disposable prep razors". Per interview at that time with the ED Nurse Manager, S/He confirmed that the supply room was open and "never" locked and anyone could access.

Based on interviews, record and policy review the CAH failed to ensure care was provided in accordance with written policies and procedures regarding the use of chemical and physical restraints for 1 applicable patient (Patient #11). Findings include:

Per review of nursing triage notes from 2/01/24 at 09:50, Patient #11 arrived at the ED via ambulance accompanied by police. The patient had come to the ED after calling 911 numerous times. Upon arrival the patient was "praying and yelling" at the EMS squad and not able to communicate effectively with the ED staff.

Per review of nursing progress notes from 2/01/24, at 09:43 AM, "Lorazepam (anti-anxiety medication) IM (intramuscularly) 2 mg (milligrams) given" in right ventral gluteus (bottom) ...at 09:53 AM, "Diphenhydramine (antihistamine) IM 50 mg given" in right ventral gluteus ...at 09:53 AM "Lorazepam IM 2 mg given" right anterior thigh. Review of "Medication Orders" reveals these medications were ordered; however, there was no indication and/or documentation in the record as to why these medications were given.

Per interview on 5/22/24 at 2:03 PM with an ED provider, S/He stated that S/He does not use "chemical restraints" and that if a patient was hallucinating and/or violent they would treat the patient's symptoms with medications to ensure safety.

At 10:00 AM a nursing progress note states, "Patient yelling and fighting with the police and EMS staff as well as hospital staff. Patient attempted to be calmed down with a staff hold. Patient continues to yell, scratch, bite towards the staff as well as attempting to throw (him/her-self) off stretcher. ED physician ordering 4 point locked restraints." Review of the physician's "General Orders" dated 2/01/24 reveal, "Restraints protocol (4 point locked)" were ordered at 10:58. There was no documentation in the record of an order for the physical hold noted above.

A providers note, from 2/01/24 [signed at 17:41] states that Patient #11, "was found extremely anxious and aggressive ...Multiple de-escalation attempts were performed without avail. Intramuscular medications were given to treat agitation with little to no improvement. 4 point restraint was then placed after patient started biting ...self and attempting to bite and scratch ED personnel ...Patient reassessed at the bedside after 4-point restraints were removed." There was no documentation in the record that a face-to-face evaluation of the patient was done by a provider within 1 hour of the application of the restraints.

Per interview on 5/23/24 at 1:38 PM with the ED Nurse Manager, S/He confirmed that a physical hold is a restraint, that a physician's order is required, and that there was no order documented in the record for Patient #11. S/He stated that when Ativan (Lorazepam), Haldol (antipsychotic medication), and Benadryl were used for a patient with behaviors that are violent or self-destructive those medications were considered chemical restraints. At 3:21 PM the Nurse Manager further confirmed that there was no documentation in the record that a face to face was done by a provider within one hour of restraint application for Patient #11 per the hospital policy.

The Restraint and Seclusion Policy-Approved 12/14/2021, states for " Violent or Self Destructive Restraint and/or Seclusion-Patients may be subject to Restraint and/or Seclusion, including medications used as a restraint, in emergency situations where their behavior is violent or self-destructive and jeopardizes the immediate safety of the patient, a staff member, or others, and less restrictive methods of managing the behavior would be ineffective ... MD, DO, PA-C or APRN responsibilities...Issuing an order, or declining to issue an order ...Completing a face to face evaluation ...within one (1) hour of the initiation of Violent or Self-Destructive Restraint and/or Seclusion ...Definitions...Drug used as a Restraint means where a drug is used to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patients' condition ...Restraint means any manual method, physical or mechanical device, material, or equipment that involuntarily immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ...Methods of Restraint and Applications of Restraint...Physical Hold...A Physical Hold involves holding a patient in a manner that restricts the patient's movement against the patient's will. This is considered a restraint."

Based on interviews and policy review the CAH failed to ensure the policies for restraints/seclusion and EMTALA were reviewed and updated biennially. Findings include:

1.) Per review, the CAH's "Restraint/Seclusion Policy" was implemented on "2/1/2002" and was last approved on "12/14/2021". There was no documentation that shows this policy has been reviewed and/or updated since this time.

Per interview on 5/23/24 at 3:10 PM with the Quality/Improvement/Risk Manager, S/He stated that the hospital's Director of Quality left the hospital in December and that "Quality was on hold" since that time. The interim Chief Nursing Officer (CNO) stepped in to manage the quality program; however, it was at a very broad level. S/He confirmed that the CAH was aware that the restraint/seclusion policy should have been reviewed and updated and it was not done.

2.) The EMTALA (Emergency Medical Treatment and Labor Act) requires hospitals with Emergency Departments (ED) to provide a Medical Screening Examine (MSE) to any individual who comes to the ED and requests such an exam, and prohibits hospitals with an ED from refusing to examine and treat an individual with an emergency medical condition. Per review of the CAH policy Patients Seeking Care in the Emergency Department last approved on 1/15/2020, was insufficient, outdated (must be reviewed biannually) and did not reflect the necessary requirements/components necessary for the CAH ED to maintain compliance with EMTALA requirements. ED staff confirmed this was the only policy available.

Based on staff interview and record review, there was a failure of the CAH to ensure the QA/PI (Quality Assurance/Performance Improvement) was ongoing and comprehensive involving all hospital departments. Findings include:

Per interview on 5/23/24 at 2:15 PM staff identified to be part of QA/PI confirmed due to staff changes in December 2023, "Quality was on hold". Staff further stated for the past 5-6 months any CAH QA/PI activities stopped functioning leaving only limited guidance to re-establish the QA/PI program. Staff confirmed the QA/PI program was not ongoing or comprehensive as required. However, it was noted a interim QA/PI consultant had been contracted 1 day per week to assist QA/PI staff in the redevelopment of the program.