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Based on medical record review, restraint and grievance policy review, staff interview and police report review the hospital failed to promote patient rights regarding the use of restraints and failed to ensure the effective operation of the grievance process. The total facility census was 384 patients.

482.13 The Condition of Patient Rights is NOT met as evidenced by the following:

The hospital governing body failed to ensure the effective operation of the grievance process.
Please see A120.

The hospital failed to have hospital policies and procedures which address devices used as restraints. Please see A167.

The hospital failed to ensure less restrictive measures are utilized before implementing restraints. Please see A165.

The hospital failed to ensure that all restraints are applied safely and appropriately. Please see A167.

The hospital failed to ensure restraints are applied only with physician orders. Please see A166.

The hospital failed to ensure when restraints are used, documentation in the medical record describes the patient's behavior. Please see A185.

This deficiency substantiates the allegation contained in Complaint OH00052699.

Based on medical record review, grievance policy review and staff interview, the hospital's governing body did not ensure an inquiry made by a staff member of a receiving hospital was addressed through the established grievance process. This telephone call by the receiving hospital staff was regarding the questionable use of restraints on Patient 3 who was transferred from this hospital to the receiving hospital on 10/19/09 by ambulance for psychiatric treatment. The total facilty census was 384 patients.

Findings include:

Per interview with Staff F, on 03/08/10 in the afternoon, she/he received a telephone call from Staff X on 10/24/09 regarding a telephone call Staff X had received from a nurse practitioner from the receiving hospital where Patient 3 was transferred around 11:22 PM on 10/19/09 for treatment. The receiving hospital representative (Staff Y) told Staff X Patient 3 arrived with makeshift restraints including a large amount of tape, Kerlix gauze and a footie. The patient was also reported to have bruises and red marks. Staff Y wanted Staff F to conduct an investigation.

Per review of the grievance policy(I-36) on 03/10/10, "if a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance." Instead of referring this issue to the risk manager, which is the expectation, according to Staff B, on 03/09/10 at 4:18 PM, Staff F telephoned Staff M and N, the two registered nurses caring for Patient 3 at the time of the need for behavioral intervention at 11:01 PM and recorded their statements on her/his home computer. The file containing the investigation had to be retrieved from Staff F's home on 03/09/10, per Staff F interview.

When interviewed on 03/09/10 at 4:18 PM, Staff F was asked if he/she had interviewed the police officers involved, the behavioral observers, the paramedic, the physician or the ambulance company regarding this incident, she/he stated nothing that was documented. Staff F stated he/she returned the call to the receiving hospital representative but did not know Staff Y's full name or telephone number as it wasn't included on the investigation summary.

Per review of the investigation report on 03/09/10, as written by Staff F, "Upon further investigation of this patient record, it was determined that there was no wrongdoing by any member of the emergency department medical team: and policies and procedures were followed regarding the care and safety of the Behavioral Health patient while in the ED. If there was any action taken it would be to provide ongoing education to the ED staff in Behavioral Health issues such as utilizing organizational resources." These findings were reported to Staff X, according to documentation on the investigation summary. It was confirmed by Staff F that no one else including risk management was made aware of this "inquiry". Staff F also stated on 03/09/10 at 4:18 PM , the inquiry by the receiving hospital was the first he/she had received and did not feel the questions by Staff Y from the receiving hospital constituted a complaint or grievance.

Based on medical record review, staff interviews (Staff E, F, J, K, M and N) and policy review, Patient 3 was restrained in a manner not addressed as the least restrictive type available. A total of 14 patients were reviewed, 7 of whom were restrained during their stay in the emergency department. A total of 395 patients were seen in the 65 bed emergency department on 10/19/09.

Findings include:

Per medical record review on 03/09/10, Patient 3 was admitted to the emergency department (ED) on 10/19/09 at 9:58 AM with complaints of an infected second toe, diarrhea and mental health issues. Due to not having a room available in the ED nursing entries reveal the patient was on a gurney in Hallway B, near the nurses station where behavior observers sit monitoring the audio visual feeds from the four beds in rooms 22, 23, 24 and 25 which are identified as the psychiatric pod. At 5:30 PM, Patient 3 was moved into room 23. Every fifteen minute documentation by the behavior observer revealed a calm and cooperative patient until 11:00 PM when she/he was described as agitated/restless/violent and aggressive This time frame coincides with the arrival of an ambulance company which had been contacted to transport Patient 3 to another hospital for psychiatric treatment. No documentation was found in the medical record that less restrictive measures were attempted.

A physician order for 3-4 leather restraints was ordered by Staff Q, the resident assigned to the patient, at 11:01 PM. Per interview with Staff M, on 03/09/10 between 2:47 PM-3:23 PM by telephone, it was confirmed that Kerlix gauze was wrapped by hospital police department staff (couldn't remember who) to cover the patient's fingers so they couldn't bend . At that time, per police report , Patient 3 was restrained with soft restraints to all limbs to a transport gurney. Per Staff M, the patient was also secured with a seat belt mid abdomen to the gurney. Per interview with Staff M, Patient 3 was attempting to use the fingers of the right hand to release the seat belt. Staff M could not speak to whether Kerlix gauze was used on any of the other three limbs as he/she was at the right of the patient and there were so many other staff members in the room.

Per interview with Staff N, on 03/09/10 between 12:04 PM-12:28 PM, "Sometimes Kerlix is wrapped around the wrists with a ABD pad placed underneath and a quick release fastening tie is used to secure a limb. I observed Kerlix type restraint and a spit sock on (Patient 3) when leaving the ED." Staff N was assigned to the care of Patient 3 on 10/19/09.

Per interview with Staff F, on 03/09/10 at 12:30 PM, "An order would have to be obtained if the Kerlix was required for the length of the patient's stay. It is not necessary to have a physician order for the use of Kerlix on a temporary basis for protection of the staff or patient."

Per interview with Staff E, on 03/08/10 at 10:36 AM the "only restraints permitted for use in the ED are velcro wrists and ankles and leather wrists and ankles."

Per a hospital police report reviewed on 03/08/10, there were 12 hospital police department officers along with at least one local police department officer, two registered nurses (M and N), a paramedic (Staff T) and two behavioral observers (Staff U and V) who "assisted" with this patient. A nurses note written by Staff N was reviewed on 03/09/10. The note written at 11:18 PM stated, " Patient refused to get on EMS gurney. Patient barricaded himself in bathroom. Twelve hospital police officers at bedside. Patient restrained to gurney, spit sock applied. MD at bedside patient medicated."

When Staff J and Staff K were interviewed on 03/08/10 between 3:10 PM-3:35 PM, Staff K confirmed there was no policy or guideline for the use of a spit sock. The spit sock is a mesh cover for the head which has elastic around the neck which is implemented by hospital police, local police or ambulance staff when a patient is spitting, drooling or attempting to bite. The decision to use the spit sock is made by the police officer. Per interview with Staff J on 03/08/10 at 3:10 PM, he is the one who ordered 500 spit socks about one to two years and has distributed these to local police departments and ambulance staff for use outside the hospital.

Currently there are 300-400 spit socks remaining. When Staff F was interviewed on 03/08/10 at 10:45 AM about the use of the spit sock, she/he indicated the spit sock is a biohazard barrier which is not a restraint.

Staff E at 11:45 AM on 03/08/10, indicated there is no requirement for a physician order for the use of a spit sock. No policy or guideline was presented to the surveyors which addresses the use of spit sock. This was confirmed on 03/10/10 at 11:25 AM by Staff W.

Per review of Policy III-16 on 03/08/10, the definition of a restraint includes any manual, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Wrapped Kerlix gauze and a spit sock meet this definition, but are not addressed in the restraint policy. This was confirmed on 03/09/10 by Staff F in the afternoon.

This substantiates the allegation in Compliant OH000552699.

Based on medical record review and staff interview, Patient 3 was restrained with soft limb restraints, Kerlix gauze and a spit sock on 10/19/09 with no evidence of a physician order for any of these interventions. A total of 14 patients were reviewed, 7 of whom were restrained during their stay in the emergency department (ED). On the date of the incident on 10/19/09, 395 patients were seen in the ED.

Findings include:

Per medical record review on 03/09/10, Patient 3 was admitted to the ED on 10/19/09 at 9:58 AM with a chief complaint of an infected second toe, diarrhea and mental health issues. At 11:00 PM, according to Staff N during a telephone conversation on 03/09/10 between 2:47 PM-3:23 PM, after being informed of the plan to transfer the patient to an outside hospital psychiatric facility, Patient 3 barricaded himself/herself in the bathroom in the ED psychiatric pod. Per police report, 13 police officers, Staff M and N, a paramedic, Staff T, and two behavioral observers, Staff U and V, provided assistance when Patient 3 became agitated/restless/violent/aggressive. Per Staff M, he/she assisted two police officers to open the bathroom door and carry the patient to the transport gurney located in the hallway inside the psychiatric pod. Then Staff M assisted with the application of a soft restraint to the right wrist, along with Kerlix gauze used to prevent Patient 3 from bending her/his fingers as he/she was attempting to release the waist seat belt applied by ambulance staff to secure Patient 3 to the transport gurney.

Per medical record review on 03/09/10 no physician order was found for the use of the soft restraints or the Kerlix gauze which had been fashioned in a manner to serve as a mitt, which requires a physician order as it is considered a restraint, according to Staff W on 03/10/10 at 11:25 AM. Findings from the medical record were confirmed by Staff I on 03/09/10 in the afternoon.

Based on medical record review, staff interviews and restraint policy review, Patient 3 was restrained with two types of restraints which are not addressed in the hospital policy and the safety of the restraints can not be ensured. A total of 14 emergency department (ED) records were reviewed of whom 7 were restrained. On 10/19/09, a total of 395 patients were seen in the hospital's ED.

Findings include:

Per restraint policy review on 03/10/10, spit sock and Kerlix gauze limb restraints or finger restraints are not addressed. Per interview with Staff W on 03/10/10 at 11:25 AM, verified that there is no policy regarding the use of a spit sock, Kerlix limb restraints or finger restraint with Kerlix gauze, as described by Staff M on 03/09/10 in a telephone conversation between 2:47 PM-3:23 PM. At that time Staff M told the surveyor, in the presence of Staff F, that Kerlix gauze was applied by one of the police officers from the wrist below the soft limb restraint already applied and wrapped around the fingers to prevent the fingers from bending while Patient 3 attempted to release the waist seat belt which secured the patient to the transport gurney on 10/19/09 at 11:01 PM.

This deficiency substantiates an allegation contained in Complaint OH00052699.

Based on medical record review and staff interview, Patient 3's medical record was silent to why a spit sock was applied over the patient's head prior to transfer to another hospital for psychiatric treatment. A total of 14 medical records were reviewed with Patient 3 being the only patient upon whom a spit sock was used. A total of 395 patients were seen on 10/19/09 in this 65 bed emergency department.

Findings include:

Per medical record review on 03/09/10, Patient 3 had a spit sock applied at 11:18 PM on 10/19/09. A spit sock is a mesh hood-like cover for the head which has elastic around the bottom where the spit sock rests on the neck. Per interview with Staff N on 03/09/10 at 12:04 PM, she/he confirmed she/he saw Patient 3 leave the ED at approximately 11:20 PM on 10/19/09 with a spit sock over the head. This spit sock was applied by a hospital police officer as Patient 3 was allegedly spitting and attempting to bite. Documentation of either of these behaviors was not found in the medical record as confirmed by Staff I on 03/09/10 in the afternoon.

Based on medical record review and staff interview the facility failed to follow their routine care policy for assessing vital signs in the emergency department. This affected 2 of fourteen patients reviewed. (patient 3 and 7 )

Findings include:

The medical record for patient 3 was reviewed on 3/8/10. Review of the patient care timeline revealed the patient was admitted to the emergency department on 10/19/10 at 9:58 AM. and assigned to the psychiatric hall space (B) with safety assessment documentation revealing the nursing call cord was in reach. Interview with Staff I, on 3/9/10 in the afternoon confirmed the psychiatric hall spaces did not have call cord access. The patient's initial vital signs were documented at 10:07 AM as blood pressure 163/114 mmHg, pulse 104, respirations 16, and oxygen saturation 95%. The next entry of vital signs, 10 hours later, was at 8:30 PM and were recorded as blood pressure 143/92 mmHg, pulse 82, respirations 16, and oxygen saturation 98%. Review of the emergency department Routine Care Policy presented by staff I, revealed the vital signs frequency for psychiatric patients was required every 8 hours, or more frequent, based on clinical presentation. Interview with Staff O, on 3/9/10 in the afternoon, revealed the emergency department nurses may have entered the vital signs in another computer window, however, the delay in vital signs was confirmed by Staff O during the interview.


The medical record for patient 7 was reviewed on 3/8/10. The patient was admitted to the emergency department on 9/18/09 at 1:53 AM and triaged to the psychiatric hall space (C). Vital signs were documented at 1:58 AM as blood pressure 128/66 mmHg, pulse 65, respirations 16, and oxygen saturation 97%. The next vital sign was documented at 06:35 AM as blood pressure 101/59 mmHg, pulse 58, respirations 18, and oxygen saturation 100%. The final vital sign was documented at 4:19 PM, or nine hours and forty-four minutes later. Review of the emergency department Routine Care Policy presented by staff I, revealed the vital signs frequency for psychiatric patients was required every 8 hours, or more frequent, based on clinical presentation. Interview with Staff O, on 3/9/10 in the afternoon, revealed the emergency department nurses may have entered the vital signs in another computer window, however, the delay in vital signs was confirmed by Staff O during the interview.