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Based on a review of 36 medical records, interviews with staff, and review of policies and personnel records, it was determined that the hospital was out of compliance with the Condition of Patient Rights. For two emergency department (ED) patients, the hospital staff restrained using techniques contraindicated by the patient condition, restrained without orders, failed to obtain face to face assessments by providers, and failed to release patients from restraints at the earliest possible time. In addition the hospital failed to train one security staff person in safe restraint techniques and failed to ensure that all staff who may restrain patients had CPR certification.

See the following Patient Rights Deficiencies.

Based on review of hospital policy, 18 open and 17 closed medical records, it was determined that hospital staff failed to follow the hospital's policy on obtaining patient #22's advance directive.

Per hospital policy titled "Patient Self Determination in Healthcare Decisions" (06/2018), "If the patient has executed an advance directive, a copy will be requested of the patient or patient's representative and scanned into the EMR."

Patient #22 was a 65+ year old who presented to the hospital due to a severe skin rash. Per admission history, patient indicated they had an advance directive. There was no documentation in patient #x's record indicating that an attempt was made to obtain the patient's advance directives. Patient #22 was in the hospital for 4 days.

Based on a review of the emergency department on 4/30/19, it was determined that the hospital did not maintain a safe environment by failing to ensure the safety of both patients and visitors within the emergency department to be free from injury resulting from unsecured needles, sharps, and intravenous IV equipment. In addition, it was determined after review of the hospital policy "Security Use of Firearms & Less Than Lethal Weapons" (SUFLTLW), security staff might use weapons or non-healthcare physical interventions on patients without accessing clinical decision-making or clinical oversight.

1.) During unit review of this 23 bed emergency room, a supply cart containing needles and IV start materials located in the main hallway was noted to be unsecured and the drawers were able to be opened. In addition, there was an unsecured suture cart that contained boxes of individual suture needles. This suture cart also contained suture kits, suture removal scissor, and other related sharps items. The suture chart lacked any mechanism to be locked.

2.) The hospital had a contracted security service of which only supervisors were armed with guns.

The SUFLTLW policy stated, in part, "Security personnel authorized to carry weapons shall not use physical force against persons unless the employee reasonably believes that such force to be necessary to protect the employee or another individual from imminent bodily harm." While the hospital received patients on a daily basis who might strike out due to any number of clinical conditions, it is not within the scope of security to determine who is a patient, and not within the scope of security to depart from accessing clinical oversight for the management of patients with behavioral issues. According to the policy provision, security staff were authorized to depart from clinical oversight.

The policy went on to describe 6 levels of Force Continuum. Within the 6 levels, level 3 stated in part, "Pain compliance holds could apply here but only after ordinary holds fail to control an aggressive suspect." Authorization for the use of pain techniques, and the verbiage of "suspect" indicated police-type concepts of patient management.

Level 4 described in part, " ...When used by surprise, pepper gel is an excellent distraction allowing the officer time to get away, call the police, or subdue the suspect ..." No guidance was found in the policy related to the deployment of pepper gel in sensitive or crowded areas such as the emergency department, and this part of the policy lacks mention of clinical decision-making or oversight.

Level 5 described in part, "At level five, properly used defensive and offensive moves (including take downs, knee, hand, and elbow strikes) are allowed under the right circumstances." This level allowed for non-healthcare physical restraint and control techniques.

Level 6 determined that deadly force with a gun could be utilized based on the Armed guard decision to use such force.

All levels of the SUFLTLW failed to give guidance related to the identification of patients vs. non-patients in order to access clinical decision-making related to medical conditions. Although no patient injuries occurring during interactions with security personnel were identified during the survey, the failure to require clinical decision-making or oversight created a high risk of security personnel using police methods of behavioral management on patients who may have required healthcare interventions for clinical conditions which caused behavioral issues. Therefore, the hospital failed to provide care in a safe setting.

Based on a review of 16 closed and 20 open medical records, it was determined that the hospital staff failed to obtain an order for patient #9 who was placed in 4-point restraints, and failed to obtain an accurate restraint order for another restraint episode for patient #9, who was restrained in 4-points with a non-violent restraint order.

Patient #9 (P9) was a 45+ year old with a history of a seizure disorder who presented to the emergency department (ED) in December 2018. P9 presented with continuous seizures. P9 was placed into 4-point restraint around 8 PM which was documented as a non-violent/non-self-destructive restraint due to "Pulling at lines and tubes." However, the use of 4-point restraints represented a violent restraint intervention and was contraindicated and unsafe in a patient having continuous seizures. Further review of the record determined no restraint order of any kind, though a face to face identified physician documentation of "wrist" restraints.
While there was no definitive documentation of discontinuation, restraint documentation stopped the following morning at 0800. This meant that without an order to do so, P9 was restrained in 4-point restraints for up to 12 hours.

P9 presented again in April 2019 via EMS due to recurring seizures. Per EMS, during patient's postictal state (altered state of consciousness following an epileptic seizure) P9 was agitated and delirious. P9 also had an elevated blood alcohol level. Within an hour of presenting to the ED, patient was placed in 4-point restraints.

Per nursing restraint flow sheet documentation at 19:05, patient was "Agitated," "Combative" and "Violent/Self destructive-imminent risk of harm to self and others." Next to the type of restraint ordered it stated, "Violent/Self destructive." The physician was notified. Per provider order at 19:26, an order for non-violent, 4 point restraint was written which gave a rationale of "Interference with medical treatment."

Review of the record determined that while patient #9 required violent restraints for violent behaviors, a non-violent order, with less intense nursing oversight requirements was written and conducted.

In summary, the hospital failed to write accurate orders for restraints and to utilize restraints appropriate to the condition of the patient.

Based on a review Restraint and Seclusion policy, and of 16 closed and 20 open medical records, it was determined that the hospital staff failed to document restraint monitoring for patient #9 for two non-violent restraint episodes.

Per hospital policy titled, "Restraint and Seclusion" (09/2010), the monitoring components for nonviolent restraints are a "Minimum of every 2 hours" that includes "Visualization Psychological Status" and "Circulation, Range of Motion, Elimination."

Patient #9 (P9) was a 45+ year old with a history of a seizure disorder who presented to emergency department in December 2018 having continuous seizures. P9 was placed into 4-point restraint around 10PM which was documented as a non-violent/non-self-destructive restraint due to "Pulling at lines and tubes.

Documentation indicates that P9 was reassessed one time at 2205, but not again, though it appeared that P9 continued in restraint at least through the night until 0800 of the following morning.

P9 presented again in 4/2019 via EMS due to recurring seizures. Patient #9 subsequently required intubation and was admitted to the ICU. While in the ICU, patient #9 required 2-point soft wrist restraints to keep from pulling at medical equipment. On patient's 10th day of admission a provider ordered a non-violent 2-point wrist restraint at 05:18. A social worker progress note at 1915 that same day stated patient was still in restraints. Another order was placed the following day at 10:34. There was no nursing note or flow sheet documentation indicating patient was being monitored every 2 hours during this time. It was also not clear when the patient was released from this restraint episode due to lack of documentation.

Based on a review of 16 closed and 20 open records, it was determined that two separate face to face assessments for patient #9 failed to identify patient medical conditions that placed patient #9 at greater risk when placed in restraint; and the hospital failed to conduct face to face assessments for patient #17 who had multiple restraint events.

1) Patient #9 (P9) was a 45+ year old with a history of a seizure disorder who presented to emergency department in December 2018 with continuous seizures. P9 was placed into 4-point restraint around 8 PM which was documented as a non-violent/non-self-destructive restraint due to "Pulling at lines and tubes."

A face to face of 2004 determined in part, "6. Assessment of high risk factors: Preexisting medical conditions that place a patient at greater risk when placed in restraints: None." P9 had a seizure disorder and was actively seizing when placed in restraints which placed P9 at high risk for aspiration or choking and is a contraindication to four-point restraints.

P9 presented again in 4/2019 via EMS due to recurring seizures. Within an hour of presenting to the ED patient was again placed in 4-point restraints. A face to face for this restraint episode also failed to identify seizures as a risk factor for restraint.

2) Patient #17 (P17) was a 50+ year old patient who presented to the emergency department in March 2019 via EMS following an overdose. P17 had physical holds to administer medication, two-point hard (violent) restraints, 4-point violent restraints, and 2-point soft wrist restraints over the course of one day. No face to face assessments were noted in the record for any of the violent and physical hold restraint events as required.

In summary, the face to face for P9 for two discreet restraint events failed to identify a high risk condition which placed P9 at greater risk when placed into restraints, and no face to face assessments were noted for multiple restraint episodes involving P17.

Based on a review of the emergency department behavioral health area on 4/29/19 and the competency record for security staff #1 (SG1), it was determined that SG1, who was assigned as a sitter for 4 behavioral health patients, was not trained in healthcare restraint methods.

Review of the emergency department (ED) identified an area containing at least 4 gurneys, each holding a behavioral health patient. SG1 was the only staff monitoring the behavioral health patients in this area. Observation determined SG1 documenting periodically for each patient in the manner of a sitter. SG1's personnel file documented a hire date in February 2019. Review of SG1's employee file identified that SG1 had completed an online program "Basics of Patient Restraint," which discussed fundamentals of restraint, but offered no actual restraint training.

While SG1 had completed the online restraint "Basics of Patient Restraint," SG1 had not received actual healthcare restraint training. However, hospital assignment placed SG1 with patients at high risk to require restraint interventions.

Based on review of two employee files for security personnel, interview with staff, and review of the security contract, it was determined that the hospital does not mandate security staff who have occasion to restrain patients to be certified in cardiopulmonary resuscitation (CPR).

A review of two security employee files found no certifications of CPR. Interview with the Director of security on 4/30/2019 determined that while CPR certification was available to security staff, it was not mandated. Review of the security staff contract with the hospital determined in part, "l. Training ...Security will train officers at a minimum in ...First Aid/CPR ..." Following review of all information, the hospital failed to train security staff who also restrain patients, in CPR.

Based on a review of five nursing personnel files and the personnel files of four operating room technologists (OR techs) along with interviews with the Acting Nurse Manager of surgical services and Human Resources professionals on 4/30/19, it was determined that the hospital failed to perform performance and quality reviews for the nursing staff for all of 2018 and failed to provide evidence of competency evaluations or educational updates for the OR techs since 2010.

The hospital suspended its formal annual competency evaluation process for the entire nursing staff for the year of 2018. A sample of five nursing personnel credentialing, competency, and performance evaluation were picked for review. In all 5 of 5 nursing personnel files reviewed the last employee competency were dated October or November 2017. The human resource manager, in an interview on 4/30/19, was asked about the lacked of competency evaluations for the 2018 calendar year and stated that due to organization changes the decision was made to forgo 2018 formal competency. During this time the unit manager were to conduct ongoing assessment of staff in lieu of the formal annual competency skills process.

The manager of the human resource department was able to provide an email from hospital leadership that discussed the announcement. The hospital previously conducted three-day clinical skills education, assessment, and validation for the entire nursing staff in October and November of each calendar year, the last time being in 2017.

The four OR techs had been hired between 1997 and 2002. Review of their personnel files identified the last competency evaluations as 2010. in addition, the hospital failed to provide evidence of on-going or periodic updates to the techs' training, for instance when professional standards changed in 2013 regarding the process for preventing surgical site infections.

The failure of the hospital to perform on-going competency evaluations with periodic educational updates for staff placed patients at risk.

During the observation of the lunch meal service on 4/29/2019 at 11:30, the surveyor observed the dietary staff plating the patients' lunches. The staff used utensils to serve the main course and vegetables appropriately . However, the employee used his gloved hands to place the fruit on the plate and did not use a serving utensil . Additionally, the large trash can was blocking access to handsink next to the serving line during the lunch service.

The food service manager immediately addressed each issue during the survey.

Based on findings from concurrent Life Safety Code (LSC) and Emergency Preparedness Surveys during the validation survey, it was determined that the hospital was out of compliance with the Condition of Physical Environment. Please see the attached LSC deficiencies.

Based on a tour of the hospital and interviews with staff it was determined that the hospital had failed to maintain the facility at an acceptable level of safety as evidenced by:


1. During a tour of the third floor medical unit at approximately 11:00 am on April 29, 2019 , several unoccupied patient rooms did not have call cords for the nurse call system attached at the bedside receptacle. When questioned the charge nurse accompanying the surveyor on the tour indicated that there were some malfunctioning cords in some occupied rooms and that these cords were removed to replace the broken ones. A check of the occupied rooms revealed that there were equipped with call cords.

2. During a tour of the forensic medical unit on April 29, 2019 at 1:30 PM , a container of Non Acid Disinfectant Cleaner was left unsecured in the dialysis room ( SW280) where it could have been obtained by patients.

3. During a tour of the the building on April 29, 2019, the surveyor noted several slop sinks and drains that have not been maintained clean and in a manner to prevent odors. Theses included:
· Room SW354,
· Room SW 332 - Slop sink was dry but had dry dark residue indicative of a possible back up;
· Room SW312 - Infrequently used slop sink was dirty.
· Room SW250 - The tub was disconnected but covered by a board but the drain was still open and odors were present indicative of possible sewer gas .

4. During the tour on the third floor medical unit on 4/29/2019 at 11:00 am it was observed that the hand rail in hallway near SW374 was loose and the handrail next to SW 349 required repair.

5. The floor under and behind the ice maker on the forensic medical unit was observed to be dirty and wet during the tour on the unit on 4/29/2019 at approximately 2:00

6. During the tour on the morning of 4/29/2019 the surveyor observed damaged walls in SW 430 and SW 358 and stained ceiling tiles and stained ceiling tile in hall near SW 508.

7. During a tour of the medical gas storage room on 4/29/2019 at approximately 2:00 PM it was noted that there were fluorescent light fixtures that were not not shielded or spark proof fixtures.

8. During a tour of the forensic medical unit on 4/29/2019 at approximately 2:00 PM , it was observed that the exterior door on the sally port had a large space at the base of the door, which could allow the entrance of rodents and insects.

Based on a review of 6 outpatient surgical records and hospital policy review, it was determined that the hospital failed to apply discharge criteria consistently when discharging patients from the post-anesthesia care unit (PACU). In addition, some patients were sent home from the PACU without any discharge criteria noted in the discharge order and the medical records of 4 patients with abnormal vital signs lacked evidence of physician notification prior to discharge.

The policy "Discharge Criteria (PACU): outpatient" states that the patient will be transferred to Phase II Recovery after meeting the criteria for Phase I. (Phase 1 recovery refers to the immediate post-operative period when patients are recovering and waking up from anesthesia and is considered to be an intensive care unit level of staffing and care. Phase 2 recovery is a transitional period between intensive observation and either admission to a surgical unit or discharge home.) No criteria or expectations were listed in the policy for discharge home from Phase II.

Examples include:

Patient #27 had an order to notify the physician if their heart rate went below 60 beats per minute. The patient was discharged with a heart rate of 58 with no documentation that the physician was notified of this abnormal result.

Patient #26 did not have an order for parameters regarding vital signs but the patient's blood pressures just prior to discharge were 182/91, 163/92 and 155/95. No documentation was found regarding whether the physician was notified or if these were normal blood pressures for this patient.

Patient #28 that was medicated for pain with two different medications with a documented pain level of 8/10, however no documentation was found to determine if the patient's pain was reassessed prior to discharge. No discharge nursing or physician notes were found to determine what time the patient was discharged and in what condition.

Patient #30 had documented blood pressures of 168/99, 159/99 and 158/99 with no evidence that the physician was notified. Also patient's pain level prior to discharge was not assessed/documented and no nursing discharge note was in the chart.

The charge nurse of Phase II (which is also the pre-operative prep area), during an interview on 4/30/19, stated that the expectation was to take three sets of vital signs on patients in this area prior to their discharge. The nurse was unaware of a written policy specifying discharge criteria, the frequency and timing of vital signs, or what the expectations were for notifying a physician regarding abnormal results.

There was inconsistent application of discharge criteria due to the policy not requiring all orders to contain discharge criteria. The policy also did not specify how often vital signs were to be done or the process for communication of abnormal results.