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Based on medical record review, document review, observation, review of video footage and interview, the facility failed to ensure that patients in psychiatry received care in a safe setting. Specifically, the facility failed to ensure that (a) Patients in the Psychiatric Emergency Department received care in a safe therapeutic setting; (b) staff utilize nonphysical intervention skills and hospital resources to manage an agitated patient (Patient #1).

This failure affected the effectiveness and safe delivery of care and placed patients at risk for potential harm.

Findings include:

(a) On 1/26/17 between 11:30 AM and 1:00 PM, during tour of the Psychiatric Emergency Department with Staff E, Associate Director of Psychiatry, overcrowding condition was observed on the unit.

Room #175 which is approximately 176 square feet, had five (5) stretchers placed side by side with approximately eight inches between stretcher. The crowded room does not provide privacy for patients and does not permit free movement around each stretcher for routine care and care during the event of an emergency.

Review of the ED census for the past three months; November 2016, December 2016, and January 2017, confirmed the overcrowding condition in the Psychiatric ED. The data showed that in November 2016, the daily census was over capacity 12 times; In December 2016, 16 times, and January 2017, 28 times.


On 1/31/17 at 2:10 PM at interview with Staff E, staff reported that the capacity of the unit is eight (8) patients and the current census was 13. Staff also stated that the Psychiatric ED was often over the regular capacity of the unit about 80 percent of the time.

During interview with Staff B, Behavioral Health Associate (BHA) on 1/31/17 at 9:30 AM, staff reported overcrowding condition in the Psychiatric ED on 1/8/17 when an incident involving Patient #1 and Staff A occurred. Staff stated that Patient #1 witnessed Patient #3 being restrained and medicated in the hallway and was upset and stated to him that he did not want Staff A restraining and medicating him as he did to Patient #3. This seemed to have been the catalyst which increased the patient's agitation, and ultimately led to a physical altercation between Patient #1 and Staff A.

Review of medical record for Patient #1 noted: patient was initially evaluated in the medical ED on 1/8/17 at 12:07 AM, patient stated feeling "very depressed." The patient was cleared by medical ED and admitted to Psychiatric ED on 1/8/17 at 2:39 AM.

Physician assessment on 1/8/17 at 3:19 AM, noted the patient was irritable with poor impulse control and was argumentative with staff. The physician impression: Schizophrenia unspecified. The patient was placed on close observation.
7:45 AM, patient was admitted under emergency status but remained in the Psychiatric ED awaiting psychiatric inpatient bed.
7:02 PM, nurse noted, patient is upset and agitated, threatening staff at nursing station.
9:00 PM, patient continued to be agitated and refused offer of Haldol 5mg by mouth; close monitoring maintained.
11:10 PM, patient remained agitated and refused offer of Haldol 10mg by mouth. Staff A noted that he approached Patient #1 with medication; the patient became verbally abusive and threatening. Patient jumped up and lunged and swung at him.

The daily census for the Psychiatric ED on 1/8/17, the day of the incident was 18 patients; 10 patients over the unit capacity.

(b) Review of video surveillance tape on 01/28/17 at 1:00 PM with facility staff including Staff E, Associate Director of Psychiatry, revealed Staff A entered the patient's room on 1/8/17 at 11:05 PM holding a white cup. At approximately 11:08 PM, Staff A and Patient #1 were seen at the door of the room facing each other. Staff A then placed his right hand on the patient's left shoulder, immediately there was a scuffle between the two and they were both no longer visible except for the patient's left leg that was partially visible and was entangled in a bedsheet.

During interview with Staff B, Behavioral Health Associate (BHA) on 1/31/17 at 9:30 AM, staff reported that on 1/8/17 around 11:00 PM, he responded to a sudden commotion coming out of Room #4 and was soon joined by other staff members. Staff stated that on arrival to the room, he found Patient #1 on the floor and Staff A on top of the patient; he and Staff C, BHA separated them.

At interview with Staff C, BHA on 1/31/17 at 10:00 PM, he stated that when he arrived in the room, he found Staff A and Patient #1 entangled and he and Staff B proceeded to separate them.

Review of policy and procedure titled "Assessment and Management of Violence Risk and Aggression," last revised on 1/3/17, notes that staff should "provide protective actions consistent with Preventing and Managing Crisis Situation (PMCS) techniques that assist to maintain safety". In addition to several interventions, the policy notes that staff would "assess for escalation and provide therapeutic choices to the patient and call the Behavioral Emergency Support Team (BEST) should the patient demonstrate more evident aggressive or threatening behaviors".

On 1/31/17 at 10:35 AM, at interview with Staff F, Educator and Coordinator for Performance Improvement Projects, he acknowledged that Staff A did not use techniques taught in PMCS training and utilize available resources including the Behavioral Emergency Support Team (BEST) in the management of Patient #1 who had become increasingly agitated.
(See Tag A144).

Based on document review, review of surveillance video, and interview, in 2 (two) of 3 (three) patients restrained, the facility did not implement its policy and procedure to ensure patients' right to personal privacy (Patient # 2 and
#3).

Findings include:

Review of ED Psychiatric surveillance video on 1/27/17 at 1:00 PM, revealed two incidents which occurred on 1/8/17 and 1/16/17, where patients were not afforded privacy.

On 1/8/17 at 10:15 PM, Patient #3 was placed in four-point restraint in the hallway. The patient was surrounded by six (6) staff members, another staff member approached and administered an intramuscular injection, in view of other patients and staff. The patient remained in the hallway until restraint was released on 1/9/17 at 12:15 AM. There was no privacy screen for this patient throughout the restraint period.

On 1/16/17 at 10:36, Patient #2 was placed on four-point restraint in the hallway and then received medications intramuscularly with no privacy screen throughout the period of restraint, lasting approximately 30 minutes.

The facility policy titled "Use of Restraint," last revised January 2017, stated the following: "Ensure patients' right to privacy, confidentiality and respect for human dignity at all times... Place restrained patients in a protective environment from potentially violent or provocative patients or visitors, preferably in an area of decreased stimulation as clinically indicated."

During interview with Staff E, Associate Director of Psychiatry on 1/31/17 at 1:00 PM, she stated that restraint and treatment occurs 25 percent of the time in the hallway when the treatment room is unavailable. She reported that privacy screen is never used in the hallway.

Based on medical record review, document review, observation, review of video footage and interview, the facility failed to ensure that patients in psychiatry received care in a safe setting. Specifically, the facility failed to ensure that (a) Patients in the Psychiatric Emergency Department received care in a safe therapeutic setting; (b) staff utilize nonphysical intervention skills and hospital resources to manage an agitated patient (Patient #1).

This failure affected the effectiveness and safe delivery of care and placed patients at risk for potential harm.

Findings include:

(a) On 1/26/17 between 11:30 AM and 1:00 PM, during tour of the Psychiatric Emergency Department with Staff E, Associate Director of Psychiatry, overcrowding condition was observed on the unit.

Room #175 which is approximately 176 square feet, had five (5) stretchers placed side by side with approximately eight inches between stretcher. The crowded room does not provide privacy for patients and does not permit free movement around each stretcher for routine care and care during the event of an emergency.

Review of the ED census for the past three months; November 2016, December 2016, and January 2017, confirmed the overcrowding condition in the Psychiatric ED. The data showed that in November 2016, the daily census was over capacity 12 times; In December 2016, 16 times, and January 2017, 28 times.


On 1/31/17 at 2:10 PM at interview with Staff E, staff reported that the capacity of the unit is eight (8) patients and the current census was 13. Staff also stated that the Psychiatric ED was often over the regular capacity of the unit about 80 percent of the time.

During interview with Staff B, Behavioral Health Associate (BHA) on 1/31/17 at 9:30 AM, staff reported overcrowding condition in the Psychiatric ED on 1/8/17 when an incident involving Patient #1 and Staff A occurred. Staff stated that Patient #1 witnessed Patient #3 being restrained and medicated in the hallway and was upset and stated to him that he did not want Staff A restraining and medicating him as he did to Patient #3. This seemed to have been the catalyst which increased the patient's agitation, and ultimately led to a physical altercation between Patient #1 and Staff A.

Review of medical record for Patient #1 noted: patient was initially evaluated in the medical ED on 1/8/17 at 12:07 AM, patient stated feeling "very depressed." The patient was cleared by medical ED and admitted to Psychiatric ED on 1/8/17 at 2:39 AM.

Physician assessment on 1/8/17 at 3:19 AM, noted the patient was irritable with poor impulse control and was argumentative with staff. The physician impression: Schizophrenia unspecified. The patient was placed on close observation.
7:45 AM, patient was admitted under emergency status but remained in the Psychiatric ED awaiting psychiatric inpatient bed.
7:02 PM, nurse noted, patient is upset and agitated, threatening staff at nursing station.
9:00 PM, patient continued to be agitated and refused offer of Haldol 5mg by mouth; close monitoring maintained.
11:10 PM, patient remained agitated and refused offer of Haldol 10mg by mouth. Staff A noted that he approached Patient #1 with medication; the patient became verbally abusive and threatening. Patient jumped up and lunged and swung at him.

The daily census for the Psychiatric ED on 1/8/17, the day of the incident was 18 patients; 10 patients over the unit capacity.

(b) Review of video surveillance tape on 01/28/17 at 1:00 PM with facility staff including Staff E, Associate Director of Psychiatry, revealed Staff A entered the patient's room on 1/8/17 at 11:05 PM holding a white cup. At approximately 11:08 PM, Staff A and Patient #1 were seen at the door of the room facing each other. Staff A then placed his right hand on the patient's left shoulder, immediately there was a scuffle between the two and they were both no longer visible except for the patient's left leg that was partially visible and was entangled in a bedsheet.

During interview with Staff B, Behavioral Health Associate (BHA) on 1/31/17 at 9:30 AM, staff reported that on 1/8/17 around 11:00 PM, he responded to a sudden commotion coming out of Room #4 and was soon joined by other staff members. Staff stated that on arrival to the room, he found Patient #1 on the floor and Staff A on top of the patient; he and Staff C, BHA separated them.

At interview with Staff C, BHA on 1/31/17 at 10:00 PM, he stated that when he arrived in the room, he found Staff A and Patient #1 entangled and he and Staff B proceeded to separate them.

Review of policy and procedure titled "Assessment and Management of Violence Risk and Aggression," last revised on 1/3/17, notes that staff should "provide protective actions consistent with Preventing and Managing Crisis Situation (PMCS) techniques that assist to maintain safety". In addition to several interventions, the policy notes that staff would "assess for escalation and provide therapeutic choices to the patient and call the Behavioral Emergency Support Team (BEST) should the patient demonstrate more evident aggressive or threatening behaviors".

On 1/31/17 at 10:35 AM, at interview with Staff F, Educator and Coordinator for Performance Improvement Projects, he acknowledged that Staff A did not use techniques taught in PMCS training and utilize available resources including the Behavioral Emergency Support Team (BEST) in the management of Patient #1 who had become increasingly agitated.

Based on observation, and staff interview, the hospital did not ensure that medical records are properly secured, stored, and protected from fire and water damage.

Findings include:

During the tour of the Medical Record Department located in the facility's basement on 1/26/2017 at approximately 10:30 AM, thousands of paper medical records from 2000 to 2017 were filed in open metal cabinets. The medical records were not protected from fire or water damage. There were 60 folded large corrugated flat boxes containing medical records that were stored underneath a stairway and approximately 60 more boxes were stored on the floor in different locations;One of the location was a staff lounge. These medical records were not protected from fire and water damage.

In addition, medical records were stored less than 6 (six) inches from the ceiling preventing proper functioning of sprinklers in the event of a fire.

During interview with Staff I, Senior Associate Director of Health Information Management, on 1/26/17 at approximately 12:45 PM, staff acknowledged findings.