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Tag No.: A0115
Based on document review, video surveillance review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights.
Findings include:
1. The hospital failed to ensure that appropriate use of physical hold /crisis prevention intervention was performed in accordance with safe and proper application of restraints. See deficiency at A-0167.
An investigation was conducted on 9/08/2023 for Complaint #IL00163609/2321142 linked with IL00163948/2321182. The Immediate Jeopardy (IJ) began on 8/18/2023 due to the hospital's failure to ensure that the use of physical hold was implemented in accordance with the crisis preventive intervention technique while placing the patient (Pt. #11) in restraints. This failure has the likelihood to cause serious injury, serious harm, serious impairment, or death to any patient admitted to the hospital's ED (emergency department) requiring restraints.
The IJ was identified on 9/08/2023, at 42 CFR 482.13, Patient Rights. The IJ was announced on 9/08/2023 at 3:45 PM, during a meeting with the President; Chief Medical Officer; Chief Nursing Officer; Chief Operating Officer; Vice President of Quality and Safety; Regional Director of Regulatory; Director of Quality and Patient Safety; Director of Regulatory and Risk; Director of Human Resources; Risk Manager; Senior Quality Data Analyst; Assistant Vice President for Security; Director of Security; Vice President of Operations, Behavioral Service Line; Director of Nursing; Director of Behavioral Health; Senior Attorney; National Regulatory; and Nurse Manager, Behavioral Health. The IJ was not removed by the survey exit date of 9/08/2023.
Tag No.: A0167
Based on document review, video surveillance review, and interview, it was determined that for 1 of 1 patient (Pt. #11) in a physical hold in the ED (emergency department), the hospital failed to ensure that appropriate use of a physical hold /crisis prevention intervention was performed in accordance with safe and proper application of restraints. This could potentially affect any patient admitted to the Hospital's ED requiring restriants.
Findings include:
1. On 9/7/2023, the clinical record for Pt #11 was reviewed. On 8/18/2023 at 2:08 AM, Pt. #11 arrived in the ED and was placed in Room 16 by E #23 (ED Charge Registered Nurse/RN). Pt. #11 was brought to the ED by Chicago Police Department due to paranoid (suspicious) and psychotic (disconnection from reality) behavior. The clinical record included:
- On 8/18/2023 at 2:46 AM, E #24's (ED agency registered nurse) indicated that Pt. #11 was pacing back and forth and attempting to come out of Room 16. At 3:14 AM, Pt. #11 was yelling and demanding to speak with Patient Advocacy, including the supervisor of the hospital. Pt. #11 was given PRN (as needed medication) for aggression and threatening behaviors. Security officers were called to assist in administering the intramuscular medications Haldol (antipsychotic) and Ativan (antianxiety) and placing Pt. #11 in restraints due to escalating violent behaviors. The 4-point locked restraints was initiated at 3:10 AM. At 3:55 AM, Pt. #11's restraints were discontinued. An ED disposition was made to admit Pt. #11 to the hospital's 16th floor behavioral health unit.
- On 8/18/2023 at 8:35 AM, E #27's (16th Floor registered nurse) notes indicated, "(Pt. #11) stated (Pt. #11) was physically assaulted in the ER (emergency room), stating, 'They held me down and made me take medication'..."
2. On 9/7/2023, the hospital's Crisis Prevention Institute (CPI) Workbook (2020) was reviewed and included, " ... CPI Guiding Philosophy ... Safety: Protecting rights and minimizing harm ... Authorization and Approval Considerations for Use of Safety Interventions ... Safety intervention procedures taught in this program are based on typical behaviors ... In addition, participants in this training must remember that use of any safety intervention needs to be guided by ... Professional standards for best practice ... Module 6: Introduction to Restrictive Interventions ... Points to Remember ... A restrictive intervention can be generally described as any physical ... intervention used to restrict a person's liberty of movement. Restrictive intervention should be reasonable, proportionate, and least restrictive to maximize safety and minimize harm ... Appendix ... Best Practice Indicators ... All restrictive interventions should be authorized and approved by the organization ... Only staff who have received training should use restrictive intervention skills ..."
3. On 9/07/2023, the video surveillance footages inside Room 16 in the ED on 8/18/2023 from 3:02 AM through 3:55 AM were reviewed. E #19 (Director of the Emergency Department) provided identification, including behavior of Pt. #11 and activities of the ED staff:
- At 3:05 AM, E #25 (Security Officer) was holding Pt. #11's right hand while E #26 (Security Supervisor) was holding Pt. #11's left hand. E #24, an ED crisis worker, and an unidentified staff nurse were also inside the room. Pt. #11 was then placed on the bed in a supine position. E #24 grabbed/pulled Pt. #11's hair from the back to control Pt. #11's head from moving.
- At 3:06 AM, the ED Charge registered nurse (RN/E #23) and another RN came into the room. E #23's left hand held down Pt. #11's forehead to prevent Pt. #11 from biting staff. At 3:07 AM, E #24 again pulled Pt. #11's hair from the back.
- From 3:08 AM to 3:09 AM, E #23's right knee was on Pt. #11's right upper arm/shoulder. During this time, there were ten hospital staff in the room. At approximately 3:10 AM, Pt. #11 was placed in 4-point restraints.
- E #19 stated that it is wrong to grab or pull Pt. #11's hair. To hold down a patient, E #19 stated that CPI (crisis Preventive Institute) does not teach using knee to immobilize a patient. E #19 stated that it was appropriate to hold down a patient's forehead. E #19 stated that improper hold can harm the patient.
4. On 9/07/2023, at approximately 12:21 PM, an interview was conducted with Risk Manager (E #32), Chief Nursing Officer (E #31) and Regional Risk Director (E #33) regarding the investigation process regarding Pt. #11. E #31 indicated that deficiencies in practice were identified regarding CPI techniques used while applying restraints to Pt. #11. E #31 stated that the staff involved in the incident regarding Pt. #11 were the focus of debriefings held and no other ED employees at that time.
5. On 9/7/2023 at approximately 1:04 AM, a telephone interview was conducted with E #23(ED Charge RN). E #23 stated, "I was the charge nurse that evening. (Pt. #11) was very violent and was flailing around while on the bed. They (ED staff) had some issues with applying the restraints properly. It seems that the application of restraints was not executed very well ... (Pt. #11) was grabbing my wrist and hand. I placed my shin on (Pt. #11's) arm to subdue the patient from moving around." E #23 stated that using knee to immobilize a patient is an inappropriate CPI technique because of too much force, which can hurt a patient. Following Pt. #11's incident, E #23 was required to take a CPI refresher course on how to handle patient's aggressive behaviors. E #23 had been working in the ED caring for patients on 8/22/2023, 8/23/2023, and scheduled to work on 9/8/2023, Night Shift. As of 9/7/2023, E #23 has not completed a CPI refresher course.
6. On 9/7/2023 at approximately 2:34 PM, a telephone interview was conducted with E #29 (Crisis Worker/CPI Educator). E #29 stated that it is not permissible to hold or grab a patient's hair to immobilize a patient. When immobilizing a patient's head, E #29 staff should place both hands on both ears. When asked about techniques to hold down a patient, E #29 stated, "There is no specific way to handle a hand or shoulders. You are supposed to use the upper body." When asked about standard of practice in CPI/safety interventions, E #30 stated that techniques taught to hospital staff are based on his life experience.
7. On 9/08/2023 at approximately 9:00 AM, a telephone interview was conducted with E #26 (Security Supervisor). E #26 stated that Pt. #11 shouted that someone was pulling Pt. #11's hair. E #24 saw E #24 pulling Pt. #11's hair. E #26 also stated that Pt. #11 was shouting that someone was suffocating Pt. #11. E #26 stated that the appropriate way for a staff to hold down a patient's arms and legs is by using the staff's arms.
8. On 9/08/2023 at approximately 9:45 AM, an interview was conducted with E #30 (Clinical Care Coordinator). E #30 was present and participated in the application of restraints on 8/18/2023. E #30 stated that the last time training provided about CPI was in October 2022.