HospitalInspections.org

Based on review of medical records (MR), policies and procedures, video recording, and interviews with staff, it was determined the facility failed to:

1) Conduct a timely investigation of an occurrence, per policy.

2) Follow their own policy and procedure for restraints.

3) Ensure staff followed the proper guide lines for restraint/ hold according to CPI (Crisis Prevention Intervention) training.

4) Document the restraint on the Restraint Log per policy.

Findings include:

Please refer to tag A-0144 for findings.

Based on review of medical records (MR), policies and procedures, video recording, and interviews with staff, it was determined the facility failed to:

1) Conduct a timely investigation of an occurrence, per policy.

2) Follow their own policy and procedure for restraints.

3) Ensure staff followed the proper guide lines for restraint/ hold according to CPI (Crisis Prevention Intervention) training.

4) Document the restraint on the Restraint Log.

This affected 1 of 3 medical records reviewed and did affect Patient Identifier (PI) # 1, and had the potential to affect all persons admitted to the facility.

Findings include:

Policy: Occurrence Reporting
Date Revised: 4-2014

Policy: BHC (Behavioral Healthcare Center- former name of facility) will assure timely documentation and reporting of occurrences and near misses to appropriate supervisors when an occurrence takes place.

Procedure:

Definition: Incidents or Occurrences- A patient safety event that reached the patient, whether or not the patient was harmed...

1. The hospital will maintain a system for reporting and follow-up of incidents. The incident report serves to:
a. Prevent critical incidents from occurring.
b. Detect problems early.
c. Provides a mechanism to prevent future problems.
d. Provide a system to monitor trending of incidents.

2. When an Occurrence occurs, the individual discovering the incident will:
a. Notify the supervising RN (Registered Nurse) immediately.
...c. The physician will be notified of all occurrences. The RN will document who was notified, with date and time completed.

3. The procedure to complete the Nurse Event Note is as follows:
a. Upon discovery of a patient occurrence, the charge nurse must complete the Nurse's Event Note (Form 4162). The original is to be filed in the patient's chart with the Nurses' Notes.
b. All areas of the note must be completed... The investigation area... must also be completed. Nursing Administration or Risk Manager should complete the Interdisciplinary Team Occurrences Investigation Worksheet and attach report to the Occurrence Investigation...
d. The Occurrence Investigation... should be submitted to the DON (Director of Nursing)... for review and further investigation...
e. An appropriate intervention must be implemented by the charge nurse immediately to prevent recurrence.
f. Observe the patient for the next 72 hours, EVEN IF NO INJURY FOUND. Document observations each shift emphasizing pertinent problems that might occur from the occurrence.
...i. All occurrences MUST be discussed in the morning QA (Quality Assurance) meetings. Interventions must be reviewed for appropriateness at this time.

...5. The investigation will be conducted in a systematic approach:
a. What are details of the events?...
b. Why did the occurrence occur/ happen?
c. What systems were in place? Were the systems effective? Was the system carried out as intended? Was staff properly trained, qualified?...
e. Policy and procedures in place and necessary information is available?
...g. Care standards were acceptable?
h. Leadership involved in the event?
i... If any of the above factors are found to be a cause, what were the corrective actions taken?
j. All occurrences will be tracked and monitored for trends.

6. The occurrence reporting system will be part of the hospital's Quality Assurance Plan...

Policy: Seclusion and Restraint Process
Date Revised: 2-2013

Policy: BHC (Behavioral Healthcare Center) staff embraces the organization philosophy of Limiting Seclusions/ Restraints... Seclusion/ Restraint is used for emergency management intervention when a patient demonstrates a threat of harm to self or others, and when least restrictive/ non-physical interventions have proven unsuccessful...

Definitions:

...Restraint- any manual method, 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, that the patient cannot easily remove, and restricts normal access to ones body.

Physical Holding/ Therapeutic Holds- The use of staff's body contact with the patient in order to restrict freedom of movement of normal access to one's body...

Procedure:

Criteria for Use- Clinical justification is required from a physician and/or Registered nurse....

Interventions- Staff will use various interventions prior to the initiation of restraint/ seclusion as a last resort. (e.g., reading, talking, reduce stimulation, limit settings, writing, walking, music).

Physician Orders- The following are necessary elements for seclusion/ restraint orders:
- Each and every seclusion/ restraint episode requires a physician's order...
- In an emergency situation, the trained registered nurse may authorize the use of seclusion/ restraint. A physician's order (written/ verbal) for seclusion/ restraint must be obtained immediately following, or no later than one hour following the initiation of seclusion/ restraint...
- Orders include:
Type of Seclusion/ Restraint
Rationale for Use
Release Criteria
Less restrictive interventions attempted prior to restraint...
Explanation/ education provided for initiation of use of seclusion or restraint and behavior necessary for discontinuation.
Frequency of monitoring
Verbal order obtained
LIP signature
- The physician or trained RN must see and evaluate the patient face-to-face, as well as sign the order for seclusion/ restraint within 1 hour.
- The RN must assess the patient and complete the Initial Face-to-Face for Behavioral or Seclusion Assessment by RN form within one hour of the intervention initiated...
- The assessment or rationale must be completed within 1 hour by either a LIP or RN, regardless of the length of time the patient is in seclusion or behavioral restraint and place in patients medical record.
-... The primary physician should be notified within minutes but no longer than 1 hour by telephone conference.

Patient/ Family Education and Notification- ...The family/ significant other is notified of the seclusion/ restraint incident as soon as possible but not later than 10 hours after initiation of the intervention. The RN will document all attempts to notify the legal representation in medical records...

1. The surveyor requested the Occurrence/ Incidence reports for June 2019. Employee Identifier (EI) # 5, Risk Manager provided the Occurrence Binder along with some "...reports I have received but have not finished writing them up." EI # 5 stated she/he had returned to work on 6/17/19, from an extended leave.

Included in the additional reports was a statement by EI # 1, Administrator, dated 6/23/19, describing an occurrence dated 6/11/19, which was 12 days earlier, and involved Patient Identifier (PI) # 1. The report included the following documentation by EI # 1, "During my absence, an incident occurred on June 11, 2019, involving EI # 6, MHT (Mental Health Technician) and an agitated patient. Based off witness statements and interviews, it has been determined that EI # 6, nor the MHT's present during the incident (EI # 7, EI # 8, and EI # 9) utilized proper Crisis Prevention Intervention (CPI) techniques in de-escalating the situation. As a result, all MHT's present during the incident... will be re-enrolled in CPI and re-educated on Restraint/ Seclusion, Patient's Rights, Abuse and Proper Body Mechanics. EI # 6 will attend the June 24 th CPI Training and will be suspended from patient care until the close of the investigation... " EI # 1 confirmed she/he had been out of the office for 10 days and had returned on 6/18/19.

Attached to the above report, were Occurrence Investigation Statements, dated 6/11/19, completed by the 4 MHT's that were present when the incident occurred, and a statement dated 6/13/19, signed by EI # 4, CNA (Certified Nursing Assistant), Psychiatric Administrative Assistant, CPI Instructor. EI # 4 stated she had been notified by EI # 8, MHT, on 6/12/19 of the incident. EI # 4 stated she went to EI # 2, Interim Director of Nursing, on 6/13/19, "... to determine how the situation was going to be handled as the incident potentially included an improper hold. As I began the discussion, EI # 3, Human Resources, walked by the Nurse's station... then asked how the situation needed to be handled... EI # 3 then stated 'Corporate will have to review the video before anything can be done.' I (EI # 4) then inquired as to whether EI # 6 needed to be suspended pending an investigation to which EI # 3 did not have an answer but reinforced that it would be a Corporate decision."

Also attached to the above report was a completely blank Nurse Event Note. There was no name, date, time, or place. The type of occurrence was left blank, as well as the area for 'Patient Status After Occurrence.' There was no description of the occurrence, and the area for Physician Notification was left blank.

During an interview on 6/24/19 at 1:15 PM with EI # 1, the above findings were confirmed. The surveyor asked EI # 1 when did she/he first become aware of the incident. EI # 1 stated, "...yesterday (6/23/19) I discovered the MHT's statements in my inbox." EI # 1 stated she then watched the surveillance video of the incident and came to the conclusion the situation was not handled properly. EI # 1 stated EI # 6 held the patient down in a chair not using proper technique, and the MHT should have walked away and let the patient de-escalate. The surveyor asked EI # 1 if the patient was held down, should the restraint reporting process have been initiated, MD (Medical Doctor) notified and order obtained? EI # 1 stated, "Yes."

On 6/24/19 at 1:30 PM the surveyor reviewed the video of the occurrence with EI # 1. On 6/11/19 at 4:58 PM, EI # 6 and PI # 1 appeared to be in an escalating conversation in the group room. They were standing close to one another and both were waving their hands. PI # 1 appeared to slap the hand of EI # 6. At that time, EI # 6 grabbed PI # 1 by both arms and pushed the 87 year old female backwards for 8 steps, at which time she/he landed in a chair, with enough force to slide the chair backwards, out of line of the other chairs. EI # 6 continued to hold the patient down by her/his arms on the chair, while PI # 1 tried to kick the MHT. This continued until 5:00 PM when EI # 2, entered the room and the MHT released the patient from the hold. At 5:01 PM, EI # 6 walked over and confronted the patient again, without any physical contact. EI # 6 left the room at 5:07 PM. After the hold, PI # 1 was observed rubbing her forearms, and holding them out for the patient sitting next to her/him to observe.

Following review of the video, EI # 1 stated corporate was notified by EI # 3 the day of the incident, but confirmed there had been no communication from corporate since then. EI # 1 stated she/he called her/his direct boss, EI # 11, Supervisor, yesterday (6/23/19) who was unaware of the incident. EI # 1 confirmed EI # 6 has continued working since the incident.

An interview was conducted on 6/24/19 at 3:15 PM with EI # 3. EI # 3 stated on the day of the event (6/11/19), EI # 6, the MHT involved in the incident, came to complain about the other MHT's not helping. EI # 3 directed them to do statements and do occurrence report. EI # 3 also stated she notified EI # 10, Human Resources Manager for corporate, on 6/11/19. EI # 3 stated she/he also asked EI # 2 to view video, to which EI # 2 replied she/he did not know how to rewind and view the surveillance videos.

EI # 3 further stated she informed EI # 1 on 6/18/19, the day EI # 1 returned to work and again on 6/20/19, of the incident and the need to view the video. EI # 3 did not hear from EI # 1 again until 6/23/19, when she/he viewed the video.

EI # 3 confirmed she/he had now viewed the video and stated, "... the action appeared too aggressive."

2. PI # 1 was admitted to the facility on 6/3/19 with diagnoses including Alzheimer's Disease with Late Onset, and Dementia in Other Diseased Classified Elsewhere with Behavioral Disturbances.

Review of the MR revealed no documentation of any occurrence happening on 6/11/19. Review of the Nurses Note dated 6/11/19, revealed no documentation in the Patient Care Notes between 0830 (8:30 AM) to 2005 (8:05 PM). Review of the Medication Administration Record (MAR) PRN (as needed) Medications revealed the patient received Ativan 1 mg (milligram), PO (by mouth), on 6/11/19. There is no time documented on the MAR. On the back page of the MAR, in the Reason/ Results column, 1400 (2:00 PM) is documented for Hour of Administration, and Reason is Severe Agitation. This was 3 hours before the patient was restrained.

Review of the Patient Observation form dated 6/11/19 revealed the patient is checked every 15 minutes. Review of the Behavioral Codes revealed A's (Quiet), M's (Cooperative), and H's (Socializing), for all day. At 1400 (2:00 PM), when the patient received Ativan for severe agitation, the MHT documented the patient behavior code was A (Quiet). At 1700 (5:00 PM), when the patient was being held by the MHT and kicking and struggling with the MHT, as evidenced by the video surveillance, the MHT documented the behavior code was A (Quiet).

During an interview conducted on 6/25/19 at 1:46 PM with EI # 2, the above findings were confirmed. EI # 2 further confirmed there was no MD notification of the restraint, no order was obtained, no Nurse Event Note completed, no occurrence form or restraint forms completed, nor had the restraint been added to the restraint log, all per facility policies.