HospitalInspections.org

Based on review of hospital policies and procedures, review of medical records, review of hospital security video, and staff interviews, it was determined that the hospital:

(A143) failed to ensure the rights to privacy for 2 patients (Patients #10 and #22) were protected when the patients were being restrained. This deficient practice posed the high potential risk of a negative impact to their dignity and self-esteem.

(A144) failed to ensure that patients received care in a safe setting when 1 of 1 patients on the geriatric psychiatric unit with a recent suicide attempt, was in a setting in which a substantial oxygen concentrator cord was within view of patients in the milieu (Patient #17). The potential risk is that psychiatric patients on the unit who endorsed suicide could use the cord as a ligature, posing the high risk of physical injury, up to, and including, adverse outcome, and the risk of emotional harm.

(A145) failed to ensure 2 inpatients on the 2-West Behavioral Health Unit were free from verbal abuse and harassment from a staff member during the day shift on 10/06/2016. (Patients #6 and #7) This deficient practice poses the high potential risk of emotional harm to vulnerable adults with psychiatric histories.

(A154) failed to ensure law enforcement techniques and/or devices were not used to restrain 1 of 10 patients where Security Officers assisted in the restraint application (Patient #13) This deficient practice posed the potential risk of harm to the patient by the inappropriate use of law enforcement techniques and/or devices to restrain and control the patients.

(A167) failed to ensure for 2 of 2 patients whose security video was reviewed, that staff were trained for the methods that were used by Security Officers and other staff, to force the patients to the floor. Both patients were injured during the incidents.

(A168) failed to ensure physician orders were obtained for the use of restraints for 2 patients (Patients #11 and #19). This deficient practice posed the potential risk of patients being restrained without the authorization of a responsible physician.

(A178) failed to ensure for 2 patients (Patients #11 and #19) that there was a face-to-face evaluation of the patient by a physician within one hour of the restraint. This deficient practice posed the high potential risk of patients being restrained without the authorization of a responsible physician.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on review of hospital policy and procedures, review of the facility security video, clinical records, and staff interview, it was determined the hospital failed to ensure 2 of 2 patients' rights to privacy were protected when the patients were being restrained. This deficient practice posed the high potential risk of a negative impact to their dignity and self-esteem. (Patient # 10 & # 22)

Findings include:

The hospital's policy titled "Seclusion and Restraint in Behavioral Health Services (Version 12416.5) included: "...Restraint and seclusion are used to protect the patient's health and safety while preserving the patient's dignity, rights, and well-being...."

Patient # 10

Patient #10 was forced to the floor and held there by numerous security officers and behavioral health staff in the Day Room/Eating Area of an inpatient unit. Reviews of the security video of the event revealed the event lasted approximately 8 minutes. Most of the patients were removed from the public area, however, there was one patient who walked to a table nearby and sat down where he watched the patient struggling and the staff's actions of holding him down. During the event, Patient #10's shorts slipped down to where his buttocks were exposed. There was no attempt by staff to remove the observing patient from the area.

After the patient was released, the five Security Officers who participated in taking the patient down to the floor and holding him there were observed grouped behind the patient in close proximity. They appeared to be smiling, and laughing. There was also one RN and two BHS staff members present.

The physician's documentation during the one hour face-to-face assessment dated 10/14/2016 at 7:08 a.m. included: "...Patient is tearful...." A nursing entry at 12:02 p.m. included: "Pt. was quiet and slightly teary in AM after being physically restrained by security and staff."

A Security Officer who reviewed the video with the surveyors reported the officers were debriefing and often "use humor."


20118

Patient #22

Videotaped documentation of a "physical hold," in which Patient #22 was taken down to the floor by three Behavioral Health Technicians (BHTs) and one Security Officer revealed Patients #27 and #28, respectively, in the dining/television room at the time of the incident, and appeared to be within earshot of the interactions between the staff and Patient #22.

At several intervals during the videotaped incident, Patient #27 was observed to be watching the incident intermittently, both before and after the patient was taken to the floor. There was no videotaped documentation that the hospital's staff attempted to move the patient to another part of the milieu to protect the privacy of Patient #22.

Based on the "Adult Patient Standards of Care" policy, the Registered Nurse (RN) job description, record review, observation, and interview, it was determined that hospital failed to ensure that patients received care in a safe setting when 1 of 1 patients on the geriatric psychiatric unit with a recent suicide attempt, was in a setting in which a substantial oxygen concentrator cord was within view of patients in the milieu (Patient #17). The potential risk is that psychiatric patients on the unit who endorsed suicide could use the cord as a ligature, posing the high risk of physical injury, up to, and including, adverse outcome, and the risk of emotional harm.

Findings include:

1. The "Adult Patient Standards of Care" policy revealed: "A Registered Nurse assesses, plans, directs, implements, and evaluates nursing services provided to a patient...6....Staff members integrate the information each caregiver gathers and collaboratively assign priorities to the patient's care...Safety 1. Safety measures begin on admission and are addressed each shift and as appropriate...2. Staff incorporates the appropriate safety measures into patient plan of care based on patient need...."

The RN job description revealed: "POSITION SUMMARY" ...This position is accountable for the quality of nursing services delivered by self or others who are under their direction. This position utilizes specialized knowledge, judgment, and nursing skills necessary to assess data and plan, provide and evaluate care...7. Contributes to society through activities that lead to excellent patient outcomes...and safe care...Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards...."

Cross reference Tag 0395 regarding Patient #17, a young middle-aged patient with complicated medical comorbidities, admitted to the geriatric psychiatric unit after having attempted suicide at an acute care hospital. Review of the patient's medical record revealed that his/her Nurses Global Assessment of Suicide Risk (NGASR) was incorrectly scored as a lower risk on eight occasions by five (5) different Registered Nurses, who failed to supervise and evaluate the care of the patient. The Care Plan for Patient #17 revealed: "Intervention: Secure Environment: Start (date of admission)1. Safety enhancements provided...3. physically safe environment provided...."

Observation during tour of the geriatric psychiatric unit, conducted on 10-24-16 at 12:45 P.M., revealed no wall oxygen outlets on the unit. An oxygen concentrator on wheels was observed inside the doorway of Patient #16's room. The concentrator and the attached elongated electrical cord were visible from the milieu hallway. Direct observation of the electrical cord revealed a durable cord, which was approximately 10 feet long. Nasal oxygen tubing was draped over the concentrator. Surveyor observed that Patients had access to the tubing and could easily move the concentrator and tubing into a patient room at any given time since patients were not monitored by staff at all times in the milieu

Observation during tour conducted on 10-24-16 at 12:55 P.M., revealed a piece of vital sign equipment on a rolling stand, with a sturdy coiled cord. The piece of equipment was in a central part of the milieu, opposite the nurses' station.

Staff #42, the Charge Nurse, stated during interview conducted on 10-24-16 at 12:45 P.M., that she had a "couple" of patients on the unit with suicidal ideation. Staff #42 acknowledged that the oxygen concentrator electrical cord posed a potential risk to patients on the unit.

Staff #5, the Behavioral Health Senior Nurse Manager, acknowledged during interview conducted on 10-24-16 at 12:50 P.M., that the vital signs equipment on wheels should not have been out in the milieu.

Staff #1, the Regulatory Consultant, acknowledged during interview conducted on 10-24-16, at 12:45 P.M., that the oxygen concentrator cord posed a risk to patients in the milieu. The Consultant acknowledged that the electrical cord was approximately 10 feet long, and acknowledged that it was a durable electrical cord. The Consultant acknowledged that, because the oxygen concentrator was on wheels, it could easily be rolled into another patient's room, and the cord could be used as a ligature. The Consultant stated that in a "tracer" report that she provided to hospital management, she had reported on the issue of the oxygen concentrator cord on the unit. When asked in what timeframe she had provided the information to the organization, she stated that it had been a couple of months prior to the survey.

Based on observation, review of clinical records, hospital policies and procedures, security video, and interviews conducted with staff and patients, it was determined that the hospital failed to ensure 2 inpatients on the 2-West Behavioral Health Unit were free from verbal abuse and harassment from a staff member during the day shift on 10/06/2016. (Patients #6 and #7) This deficient practice posed the high potential risk of emotional harm to vulnerable adults with psychiatric histories.

Findings include:

The hospital's policy and procedure titled "Patient Rights and Responsibilities" included: "...Banner Health (BH) shall ensure that patients are informed of, and given, their rights as more fully described in the Patient Rights and Responsibilities brochure. These rights include, but are not limited to...The right to safety and security and to be protected from abuse or harassment...Staff is educated regarding patient rights and responsibilities at new employee orientation...."

The hospital's policy and procedure titled "Report of Vulnerable or Incapacitated Adult or Patient Abuse" (Version 15254.1) includes: "DEFINITIONS: Vulnerable Adult: Individual who is 18 years of age or older and who is unable to protect himself from abuse, neglect or exploitation by others because of a mental or physical impairment...Emotional Abuse: A pattern of ridiculing or demeaning, making derogatory remarks, verbally harassing or threatening to inflict physical or emotional harm on a vulnerable adult...PROCEDURE:...When suspected or observed, the staff member immediately reports the event to the Unit supervisor and to the patient's physician. The staff member also completes an electronic event report. The RN completes a physical assessment of the patient involved and documents all findings on the patient's medical record...The Hospital provides ongoing staff education during new employee orientation programs, department in-services, ethics training and annual performance reviews. Staff members are trained to identify and report events and incidents that may constitute or contribute to patient abuse, and neglect to their immediate supervisors or via other appropriate mechanisms...."

The hospital's "Code of Conduct" for employees includes: "...Each employee must report any issue or practice that he or she believes in good faith may constitute a violation of a law or Banner's compliance policies. People who are found to have engaged in unlawful conduct or conduct in violation of Banner policies, or who have failed to detect, report and/or correct any offense, are subject to corrective action, up to and including termination of employment...."

Patient # 6

Patient #6 was admitted to the 2-West inpatient Behavioral Health unit with depression, suicidal ideation, and recent suicide attempt.

On 10/06/2016 after lunch, the surveyor entered the 2-West inpatient Behavioral Health Unit to conduct a tour and observations. The surveyor was accompanied by the hospital's corporate Regulatory Consultant and the Behavioral Health Nurse Manager. Patient #6 quickly approached the Nurse Manager and stated he needed to talk to him right away. The patient was visibly upset and stated one of the staff members had just cursed at him and called him names. The patient stated it was "unprofessional" for a staff member. The surveyor asked the patient who that staff person was and he pointed out Staff #10 who was identified by the Nurse Manager as a Behavioral Health Specialist (BHS). The surveyor then asked Patient #6 if there was anyone nearby who witnessed the incident and he responded "yes" and pointed out Staff #7 who was also identified to be a BHS. Staff #7 accompanied the Nurse Manager, Regulatory Consultant and the surveyor to a private area just outside of the unit. Staff #7 was asked to relay what he observed and he reported in detail Staff #10's aggressive behavior, cursing and name calling directed to Patient #6 and Staff #7's efforts to intervene. Staff #7 reported the patient said he didn't feel safe after the incident and he (Staff #7) was seeking out the Nurse Manager when we arrived on the unit.

Staff #7's documentation of the incident revealed Patient #6 asked Staff #7 for a telephone number for personal business he needed to take care of. While waiting for the telephone number, Staff #10 walked in and told the patient, "Get the [vulgar swear word] away from the door." Shortly after that Patient #6 was arguing with another patient. Staff #7 documented: "...(Staff #10) came over and instead of de-escalating the situation or separating the two patients he became upset with (Patient #6) and I'm not sure why. (Staff #10) then became loud and aggressive towards the patient calling him a '-[vulgar F word] PUNK' 'LIL '[F word] [P word]' '[F word] [A word H word]' up in the patient's boundaries. I then went to get (Patient #6) and had him walk away with me out the vicinity of (Staff #10)...and (Staff #10) was still yelling calling him a 'LIL [P word] saying he couldn't stand his 'LIL [A word]'. The patient then walked over to me and told me that he wasn't feeling safe and he didn't know what to do and could I get someone so he can talk to and he was persistent not a nurse...."

Patient # 7

Patient #7 was admitted to the hospital with several psychiatric diagnoses and documentation of "numerous" hospitalizations and a history of suicide attempt and history of violence.

Staff #7's written report of the incident included documentation of another incident involving Staff #10 and Patient #7 which occurred prior to the incident involving Patient #6. This incident was not reported at the time the above incident was reported. Staff #7 documented that Patient #7 was verbally aggressive and abusive to another patient and to Staff #7. The documentation included: "...(Staff #10) became verbally aggressive yelling in the patient face telling him to knock it the '[F word OFF' before he gets taken to the seclusion room. I then stepped in the middle and asked patient to just go too (sic) his room and I'll bring his lunch down to him until he calms down. Patient became verbally abusive but was explaining his reasoning on why he was speaking that way, (Staff #10) then stepped up close to patient and yelled, 'IF YOU KEEP IT UP I'M GOING TO [F word ] BE IN YOUR [S word ] ALL DAY YOU LITTLE PUNK [A word]'. I then asked the patient to just go to his room and relax and take a deep breath and I'll bring his lunch...."

The surveyor asked Staff #7 if he reported Staff #10's verbal abuse to Patient #7, during an interview conducted on 10/14/2016 ? He responded that the Charge Nurse (Staff #11) was within hearing distance and heard what was said. Staff #7 said his direct report would be to the Charge Nurse. Staff #7 reported the Charge Nurse was also present when the second incident occurred involving Patient #6. He said Patient #6 was insistent that Staff #10 be reported to someone other than the nurse because the nurse was present and did not do anything. (This was documented in Staff #7's report.)

Staff #11 recalled during an interview conducted on 10/18/2016, hearing raised voices and went to check, however, there was a high level of patient activity on the unit that day, and had to decide where his presence was most needed and not stay when he thought the situations were under control. He said he did not witness or hear the interactions between Staff #10 and Patients #6 and #7 on 10/06/2016.

A review of the security video did not have audio available and compared with the detailed statement by Staff #7. The details of the statement including the location of the incidents were isolated in the videos and revealed Staff #11 was present during the incidents.

Staff #10 was reported to be an employee of Banner Staffing Services and not directly employed by Banner-University Medical Center South Campus. His date of hire at Banner Staffing Services was 11/12/2015, and his personnel record included a job description for Behavioral Health Technician. The "Essential Functions" documented in the job description included: "Maintains patient safety and protects patient rights...Assesses and interacts therapeutically with patients and families. Provides treatment that promotes patient dignity, independence, individuality, strengths, privacy, and choice. Demonstrates respect for cultural diversity and patient boundaries...Provides quality patient care by maintaining knowledge and skill level related to the symptoms and treatment of behavioral disorders relevant to position responsibilities and in accordance with state agency regulations...Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards." The job description was signed by Staff #10 and dated 10/20/2015. There was no documentation of any counseling, coaching or disciplinary actions in the record.

Confidential interviews were conducted with five BHS Staff members who were primarily assigned to work on 2-West and/or 2-East inpatient Behavioral Health Units. All five staff members shared concerns about Staff #10's behaviors with patients and/or staff. A staff member reported having to intervene on two occasions with Staff #10 when he was confrontational with the patients. It was reported that he was not allowed to work on one of the units when another staff member was there because of conflicts. There was another report that Staff #10 was not supposed to be assigned to the units at all. Other staff members reported he did not take direction well, and did not like being told what to do. The staff stated they reported their concerns to a Charge Nurse and/or the Nurse Managers.

The surveyor was initially told by nurse leadership that they were unaware of any concerns regarding Staff #10 prior to the incident on 10/06/2016. However, the Senior Nurse Manager of the Behavioral Health Unit reported on 10/27/2016 that she was aware of prior concerns with Staff #10 but not about verbal abuse. She said the concerns were addressed with the employee as well as the staffing service. She said that because she was not the employee's direct supervisor, any corrective actions imposed by the staffing agency were not shared with her.

Based on review of hospital policies and procedures, review of clinical records, review of the hospital's Security Department Reports, and staff interview, it was determined the hospital failed to ensure law enforcement techniques and/or devices were not used to restrain one of ten (1 of 10) patients where security officers assisted in the restriant application. The total sample size was 26. This deficient practice posed the high potential risk of harm to the patient by the inappropriate use of law enforcement techniques and/or devices to restrain and control the patients. (Patient # 13)

Findings include:

The hospital's policy and procedure titled "Seclusion and Restraint in Behavioral Health Services" (Version 12416.5) included:

"Purpose/Expected Outcome: A. To provide and maintain a safe environment for behavioral health patients and staff. Restraint and seclusion are used to protect the patient's health and safety while preserving the patient's dignity, rights, and well-being and are used in accordance with applicable Federal and State regulations...Definitions:...C. Law enforcement restraint devices: Include handcuffs, manacles, shackles and other chain type restraints, spit masks, and other devices used in law enforcement not as a health care intervention...Policy:...F. Law enforcement restraint devices are never used as mechanical restraints...."

Another hospital policy and procedure titled "System Security: Use of Force" (Version 12985.2) included: "Non-deadly force may be used, when necessary, to control a situation or individual when...Attempting to control a violent patient, visitor, or any other person for a legitimate security purpose and lesser actions have not been successful...Consider the use of force...if, while awaiting the arrival of the police, the suspect's actions escalate and there becomes an imminent threat to you, patients, visitors and/or staff:...Use physical strength and skill (Defensive Tactics)...."

The policy had an attachment titled "Banner Health Security Department Force Continuum" which listed seven "Levels of Force." The "Method of Force" for Level IV "Physical Control" was the use of "OC, Handcuffs." O.C. Spray was defined in the policy as: "...an inflammatory agent whose active ingredient, capsaicin, is derived from the placenta of the common Cayenne pepper plant." "Defensive Tactics" is a term specific to law enforcement personnel defined as a system of controlled defensive and offensive body movements to respond to a person's aggression or resistance.

Documentation in a "BUMC-South Campus Security Department Report" dated 10/06/2016 revealed Patient #13 was able to break through security doors on one of the inpatient psychiatric units and exit the hospital into the parking lot. The patient was pursued by a Registered Nurse (RN), and a Behavioral Health Specialist (BHS) who were able to catch and control the patient. While escorting the patient back, the patient struck the RN, and then the RN and BHS: "...placed the patient down on the pavement and held him." Five Security Officers arrived and then one of the Security Officer's: "...placed handcuffs on the patient." The patient was taken back to the unit where he was taken into the seclusion room and placed in 4-point restraints.

There was no physician or nursing documentation in the clinical record that the patient was brought back into the unit with handcuffs on.

The Security Officer confirmed during an interview conducted on 10/25/16, that he wrote the report documented above, and reported that he handcuffed the patient before bringing him back into the hospital.

A subsequent interview was conducted with the Chief Operating Officer, the Chief Medical Officer, and the Medical Director of Behavioral Health. They were asked if they were aware of Patient #13 being handcuffed by Security Officers, and they responded that they were not.













20118

Based on review of hospital policies and procedures, review of hospital logs, review of patient clinical records, review of security video, and staff interviews, it was determined for 2 of 2 patients whose security video was reviewed, that the hospital failed to ensure staff were trained for the methods that were used by Security Officers and other staff, to force the patients to the floor. Both patients were injured during the incidents. (Patients # 10 and # 22)

Findings include:

The hospital's policy and procedure titled "Seclusion and Restraint in Behavioral Health Services" (Version 12416.5) included: "II. Definitions:...G. Personal restraint: The manual application of physical force without the use of any device, for the purpose of restricting the free movement of a patient's body and/or restricting normal access to one's body...

III.Policy:...A. Staff shall promote the safety, rights, dignity and well being of the patients through alternative interventions whenever possible. B. Banner Behavioral Health strives to create a safe and least restrictive environment...K. Restraint or seclusion is performed in a safe manner and is proportionate and appropriate to the severity of a patient's behavior and to the patient's chronological and developmental age, size, gender, physical condition, medical condition, psychiatric condition, and personal history (including any history of physical or sexual abuse)...M. Restraint or seclusion is performed by clinical staff who has received training in the proper use of such procedures and in behavioral management techniques.

IV. Procedure/Interventions:...

A. personal restraint may be initiated by the RN or designee upon the order of a physician...
G. At all times, staff will protect the patient from undue physical discomfort, harm or pain...
J. Approved techniques for personal restraint are taught during the nonviolent crisis intervention training.
1. Personal Restraints are to be used only:
a. In an emergency safety situation that is an immediate threat to the life or health of a patient or other individual,
b. When less restrictive methods have been attempted and were unsuccessful,
c. For the shortest possible duration of time needed and with the least amount of force required to bring the patient's behavior under control or to prevent harm to the patient or another individual.
d. The RN assesses patient for release (per predetermined criteria) or transfers patient to mechanical restraints/seclusion per physician order."

Patient # 10

Patient #10's clinical record was randomly selected for review from the hospital's restraint log. According to documentation on the Restraint Log, a "physical hold" restraint occurred on 10/14/2016 at 6:47 a.m. and a chemical restraint administered at 6:51 a.m. The surveyor was told that a "physical hold" was the same as a "Personal restraint" defined in their policies and procedures documented above.

Patient #10 was a voluntary admission. Nursing documentation at the time of admission to the unit included: "Pt was calm and cooperative...." The Nurse Practitioner documented in the Admission History and Physical on 10/11/2016 at 11:41 a.m. that the patient was "calm and cooperative." Nursing documentation at 3:54 p.m. described the patient as: "...socializing and laughing with peers...Compliant with medications...." The nursing documentation at 8:58 p.m. revealed the patient continued to be compliant with taking his medications, was calm, cooperative and social with the other patients and had: "No behavioral problems."

On 10/12/2016 at 10:34 a.m. the RN documented: "Patient is pleasant and cooperative, soft spoken...is medication compliant, remains visible on the unit."

The nursing documentation dated 10/13/2016 at 4:15 p.m. included: "Pt is calm, cooperative and social with peers. Taking scheduled medications. Visible on the unit...No behavioral issue on the unit. Very social with peers." There was no documentation that the patient had any negative interactions with the staff or other patients.

Nursing documentation dated 10/14/2016 at 7:32 a.m. included: Pt was refusing to give toothbrush that pt had made a sharp edge to. pt began to threaten staff and security officers. The toothbrush was pulled out of hand of pt then pt attacked staff punching at staff and cursing yelling and was put in hold and chemical restraints was ordered and given...unit supervisor was here. Hold was at 0647 chemical hold started at 0651 physical hold was over at 0655. pt was calm at this point and sitting in chair."

A "Physician One Hour Face to Face Assessment" dated 10/14/2016 at 7:08 a.m. included: "Patient is sitting in chair rubbing his left knee. He state (sic) that he has had surgeries with hardware and when he was held they pressed on the back of his knee...Patient is tearful. States that he was not making a weapon. He says that he has a habit of chewing on hard plastic...Patient's left medial knee near tibial plateau tender to touch. Varicosity noted in that area. Patient refuses XR (x-ray) at this time. Does accept ice pack...Patient does not believe that he should have needed to hand over the toothbrush as he believed they were wrong...Patient is no longer restrained and he is no longer aggressive." A physician's progress note dated 10/14/2016 at 12:36 p.m. included: "Per staff he needed IM medication early this morning when he refused to surrender a toothbrush and glasses he had made into a sharpened point possibly to use against another patient who had been bother him. He stated he just likes to chew on things when he doesn't have gum and didn't mean to hurt anyone...He stated his left knee has been hurting him more since he was 'taken down' by the 'rent a cops' (hospital security)."

Documentation in the BUMC-South Campus Security Department Report dated 10/14/2016 included: "...security responded...for a presence request by RN...While focusing on BHS (Staff #15), S/O (name) confiscated the toothbrush and began to hand it to BHS (name). Patient (name) turned toward S/O (name) and made his advance...I intercepted patient (name) advance by performing a physical hold. S/O's (names of three other officers) aided in the hold. Patient (name) began to struggle and the hold went to the floor. We secured patient (name) and rolled him onto his right side to ensure he could breathe. RN (name) arrived and administered two intra-muscular (IM) restraints...S/O (name) and I helped patient (name) to his feet and assisted him into a chair as he complained of knee pain...."

The security video footage of the "physical hold" performed on Patient #10 was reviewed by the surveyor with sections viewed frame-by-frame. There was no audio. The footage was from a camera in the Day Room/Eating area of the unit. The following is the sequence of events between 6:40 a.m. and 7:53 a.m.

6:40 a.m. The patient was seated in a chair in front of the wall-mounted television and he appeared to be conversing with a patient next to him to his right. There was no indication of conflict between the patients.

6:44 a.m. to 6:47 a.m. A Behavioral Health Specialist (BHS) (Staff #15) entered the Day Room followed by two Security Officers and approached Patient #10. Staff #15 started talking to the patient and one of the Security Officers walked around the back of the chairs and positioned himself behind the patient. The patient stood up and faced Staff #15. The patient was gesturing with his arms while talking to Staff #15, however, there was no attempt to strike him. It was also noted that the patient held something in his left hand. The Security Officers moved in closer and two additional Security Officers arrived from the back of the room (from the hallway outside of the unit). At this point the patient was surrounded by four Security Officers and two BHS staff in addition to three RN's at the periphery, a total of nine staff in close proximity to the patient.

6:47 a.m. While the patient was focused and engaged in conversation with Staff #15, a Security Officer behind the patient grabbed the object from the patient's left hand and walked away. At that point one of the Security Officer's wrapped his arms around the patient's upper torso from behind and the other officers joined in attempting to forcefully take the patient down to the floor. The patient struggled and the Security Officer that grabbed the item from the patient started pushing the patient's head down, first with one hand putting pressure on the back of the patient's neck and then using both of his hands on the back of the patient's head. As the patient continued to struggle, the officer used his shoulders and chest to force the patient's head down and his left hand under the patient's chin/throat. The patient was eventually forced to the floor with the Security Officer's on top of him. The patient was prone (on his stomach) as evidenced on the video by the patient kicking his legs back. (Documentation in the clinical record revealed the patient was 6' 4" in height and weighed 388 pounds.) The three RN's left the scene within 60 seconds of the patient being forced down to the floor. The patient continued to struggle with the four Security Officers and two BHS holding him down. Although there was obvious activity and movement, the six bodies huddled over the patient obscured exactly what was happening with the patient on the floor.

6:50:34 a.m. to 6:53 a.m. the Nurse Manager and another RN came over and appeared to direct the positioning of the patient. A fifth Security Officer arrived shortly thereafter who initially observed but then came around to the patient's head. One of the officers on the floor at the head of the patient took the patient's left arm at the wrist and pulled it up where the standing fifth officer grabbed it with both hands. The patient's arm was pulled into extension now and pulled behind him which forced the patient to roll to his left onto his back. The patient was administered two intramuscular (IM) injections on his right side by two different RN's.

6:53 a.m. to 6:56 a.m. The SO's and BHS staff released their hold from the patient's legs and then the officers holding the patient's arms released their hold. Two SO's lifted the patient to his feet. The patient's head was down with his chin to his chest and it appeared he was not able to walk and/or bear weight because a chair was moved around to the patient's back and he was lowered into the chair. The patient had his left leg extended and was rubbing his left knee.

6:56 a.m. to 7:03 a.m. The physician performed the face-to-face assessment and examined the patient's left knee. The patient continued to rub his left knee and an ice pack ordered by the physician was applied by an RN.

7:03 a.m. to 7:53 a.m. The patient remained in the chair in the Day Room/Eating Area and at 7:53 a.m. stood up and limped (favoring his left leg) over to a table near the patients waiting in line for breakfast. The patient sat at the table interacting with other patients in line. One of the patients brought Patient #10 his breakfast tray before taking his own tray. The patient drank a container of what appeared to be juice, took one bite of what appeared to be scrambled eggs and then covered the tray. He stood up and walked outside of the camera view shortly after that.

The nursing documentation was not reflective of the actual incident that involved several Security Officers and other staff forcing the patient to the floor. The nursing documentation that the patient "attacked" and "punched" staff was not seen in the video. The Security Officer's report was more accurate that the patient began to "struggle" after the SO intercepted the patient's "advance" and the SO attempted a physical hold.

The security footage was reviewed by the surveyor the first time on 10/18/2016 with a SO, the CNO, the Corporate Regulatory Compliance staff, and the Senior Nurse Manager of Behavioral Health. The surveyor questioned the terminology used in the clinical record of a "physical hold" when in actuality the patient was taken to the floor by several staff. The SO acknowledged it was a "take down" adding that the more appropriate term was "assisted to floor."

The Nurse Manager reported during an interview conducted on 10/19/2016, of being in the nurses station at the time of the incident. When he came out of the nurses station he saw that they were restraining the patient face down which was a concern for "asphyxiation."

The security footage was reviewed a second time on 10/19/2016 with a different SO. The SO stated that when it (referring to the "physical hold") goes to the floor, somebody is probably going to get hurt.

An interview was conducted on 10/20/2016 with the BHS who approached Patient #1 and attempted to have him turn over the toothbrush. The BHS reported other staff told him the patient had whittled a toothbrush into a weapon to harm another patient. He said after the Security Officer grabbed the toothbrush away from the patient, the patient went after the Security Officer and that was when "security took over." He said there was concern during the incident to get the patient onto his back so he could breathe.

The training materials for non-violent physical intervention presented to the surveyors did not include the methods observed in the security video and specifically the use of force by multiple staff including Security Officers and BHS staff to take a patient down to the floor.

The website of the non-violent physical intervention training company included objectives of the techniques taught in their training. Some of those objectives included:

-Must be safe and non-traumatic to all all involved;
-Must not be based on strength;
-Does not place any pressure on the thoracic region;
-Does not require a take-down, supine or prone position;
-Does not cause pain;
-Does not use hyper-extension of a limb;
-Does not use off-balance techniques;
-Does not require more than 2 responders to make contact with the patient.

The methods observed in the videos were not in alignment with the objectives of non-violent physical intervention training.

Documentation in the clinical records for both Patients #10 and #22 referred to "physical holds" including the physician's orders and nursing documentation. The methods of multiple staff taking these patients down to the floor was not defined in the hospital's policies and procedures and there was no documented evidence of staff training in the methods provided during the investigation. Both patients reported injuries during those incidents.

RN's, BHS staff, and Security personnel revealed during interviews conducted, a general concensus that when Security was called and on-site for an actual patient concern or potential concern, the Security personnel made the call for taking a patient down to the floor. This was observed in the security video documented above.



20118

Patient #22

The Security Officer job description revealed: "...ESSENTIAL FUNCTIONS 1. Exhibits excellent interpersonal skills and be customer service oriented in all contacts with patients...."

The (Hospital) Code of Conduct revealed: "...Respecting Patient Rights...Upon admission, (Hospital) must provide patients with a written statement of their rights. This statement must include the rights of patients...and it must conform to all applicable state and federal laws and regulations...."

The "(Hospital) Security Department Report regarding Patient #22 revealed: "...As I approached Room (number) Behavioral Health Techs (BHTs) informed me that patient (Patient #22) flooded his room and is being disruptive in the unit...As I stood by, the patient became more disruptive and threw a banana onto the floor...At this time the patient then took the water that he was holding and threw it towards BHT (BHT #48's) face. Due to the patient's behavior and actions we felt that it was best to place the patient into a physical hold...As soon as the I/Ms (intramuscular injections) were given medical staff and I attempted to assist the patient to his feet in which the patient began to kick his feet in attempts to free himself. Due to this it was decided to carry the patient to seclusion...." The report was authored by Staff #50, a Security Officer.

Staff #47, the Registered Nurse (RN) responsible for directing the patient's care during the incident, documented: "Verbally threatening staff, multiple attempts to redirect failed. PO (by mouth) prns (patient request or need) offered, patient refused. Patient flooded toilet in bathroom, redirected and verbally threatening staff stating, 'I'll f*** you up' while holding a banana to the back of this writer's neck. Prn's offered again, patient hit this writer's hand and lunged throwing water at BHS (sic). Hostile and combative, refused to follow direction. Physical hold applied, IM's given and patient escorted to locked seclusion...."

Subsequent to the patient tossing water on the BHT, the Security Officer present, Staff #50, immediately reached with his right arm and placed it behind the patient's head in a lasso-type motion. Simultaneously, three BHTs assisted the Security Officer in taking the patient to the floor. All four of the patient's limbs, and well as his head were restrained. The Security Officer is observed to restrain the patient's right arm with what appeared to be appreciable force of his body weight. No slippage of the patient's arm is observed prior to the Officer then placing his knee with what appeared to be substantial weight on the patient's arm.

Prior to being taken down to the floor, the patient had not physically demonstrated substantial danger-to-self or danger-to-others.

The videotaped record was reviewed in its entirety, frame-by- frame. The tape did not reveal a banana being held to the RN's neck as documented. There was no videotaped documentation that the patient lunged at staff. The videotaped record revealed that the patient tossed a small amount of water on the chest and abdomen of Staff #48, a BHT, when the staff member was approximately 2 feet from the patient. The videotaped record revealed that the water was tossed by the patient with hand and arm movement; the patient appeared to stand still and was not observed to lunge at staff as documented. The videotaped record revealed that the patient was standing nearly still in one spot with arms at sides for most of the occurrence.

The videotaped document did not reveal that security personnel and staff attempted to stand the patient to walk to the seclusion room. The videotape revealed the security personnel and staff lifting the patient from the floor and carrying him out of range of the camera.

Staff #47, the RN who was responsible for directing the care of Patient #22 at the time the patient was taken down to the floor by BHTs and Security officers, documented at 9:00 A.M. on the date of occurrence "...Patient was not injured during restraint/seclusion...Patient c/o (complained of) left wrist pain, full ROM (range of motion) present."

Staff #54, a psychiatrist, documented at 9:36 A.M. on the date of occurrence: "...He is complaining of left wrist pain and it is painful to touch with restricted movement. Will obtain x-ray...."

Staff #25, the Security Officer responsible for education and training of security officers stated, during interview conducted on 10-19-16 at 1:40 P.M. that an arm placed around a patient's neck in a lasso-loop type fashion is called either a "clothesline" or a "headlock." The Officer stated that type of hold is not something that is taught at the hospital, and is not something that he would want the security officers to do. The Officer stated that, in addition to the (Trade Name self-defense course), the hospital employs the principles of a (Trade Name company) that teaches non-violent crisis intervention.

The RN documentation of the "Significant Event" contained no record that she directed the BHTs or Security Officer to use a "clothesline" hold, then take the patient down to the floor as a safety measure due to the floor being slippery.

Based on review of hospital policies and procedures, review of clinical records, review of hospital restraint logs, and staff interviews, it was determined for 2 of 12 patients whose records were reviewed for restraints in the total sample size of 26, the hospital failed to ensure physician orders were obtained for the use of restraints. (Patients #11 and #19) This deficient practice posed the high potential risk of patients being restrained without the authorization of a responsible physician.

Findings include:

The hospital's policy and procedure titled "Seclusion and Restraint in Behavioral Health Services" (Version 12416.5) included: "Definitions:... D. LIP: A Licensed Independent Practitioner (LIP) is any practitioner permitted by state legislated law and hospital policy as having the authority to independently order restraints for patients...
G. Personal restraint: The manual application of physical force without the use of any device, fort he purpose of restricting the free movement of a patient's body and/or restricting normal access to one's body (includes physical escort and/or transport technique)...
H. Restraint: A general term which includes mechanical restraint, personal restraint, or medication restraint...Procedure/Interventions: A. A personal restraint may be initiated by the RN or designee upon the order of a physician...
B. If, as a result of a patient's aggressive, violent, or self-destructive behavior, harm to a patient or another individual is imminent or the patient or another individual is being physically harmed, a personnel member: 1. May initiate an emergency application of f restraint or seclusion for the patient before obtaining an order for the restraint or seclusion, and 2. Shall obtain an order for the restraint or seclusion of the patient during the emergency application of the restraint or seclusion; C. The physician's order for restraint or seclusion is entered in the EMR (electronic medical record) system or on downtime forms as needed. An order for restraint or seclusion is limited to the duration of the emergency safety situation...."

Patient # 11

A "BUMC-South Campus Security Department Report" dated 10/04/2016 revealed three Security Officers responded to the 2-West Behavioral Health Unit at 2:20 p.m. for, "a possible IM (intramuscular) assist" for Patient #11. The patient was described in the report as being "uncooperative" and refusing court ordered medication. The report included: "Per Registered Nurse (name) the Behavioral Health Specialist 'BHS' sat the patient down in a chair and placed her in a physical hold while RN (name) administered 1 injection (court ordered) into the patient right shoulder. While the 'BHS' were holding the patient she kicked RN (name) in the right shin. BHS (name) controlled the left arm while BHS controlled the right arm. The patient was released from the physical hold but was still uncooperative and verbally abusive to all staff. RN (name) instructed us to put the patient in the seclusion room. BHS (name) controlled the right arm while I controlled the left arm...."

The RN's documentation of the above incident entered into the clinical record at 7:42 p.m. on 10/04/2016 included: "At 1423 (2:23 p.m.) pt was informed of prolixin dec injection, pt started cursing and calling staff names (sic) Security came up and tried to talk to the pt but when she went back she kicked nurse (name) in the rt shin times two. then hand went on and injection was given." The RN did not document that security staff were: "...instructed...to put the patient in the seclusion room...." There was no documentation of how long the patient was in the seclusion room.

There was no physician's order for the physical hold or seclusion on 10/04/2016.

The Senior Nurse Manager for Behavioral Health acknowledged on 10/04/2016 that there was no physician's order.

Patient # 19

Patient #19's clinical record included an RN's "Restraint/Seclusion Debriefing" progress note dated 10/4/2016 at 7:24 p.m. which revealed the patient was restrained and/or secluded at "0852" (8:52 a.m.). The RN documented: "...staff instructed patient to stop threatening peers and to get in line for breakfast, patient responded by throwing punches at staff." The progress note did not specify how the patient was restrained and/or secluded. There was no physician's order for a restraint.

Documentation in the hospital's restraint log revealed the type of restraint used on Patient #19 was a "Physical Restraint/Hold."

The clinical record was reviewed on 10/17/2016 with the Senior Manager of the Behavioral Health Units and she acknowledged there was no documentation of a physician's order for the physical hold used on the patient as documented above.

Based on review of hospital policies and procedures, review of clinical records, review of hospital restraint logs, and staff interviews, it was determined for 2 of 12 patients records reviewed for the use of restraints in the total sample size of 26, (Patients #11 and #19), the hospital failed to ensure there was a face-to-face evaluation of the patient by a physician within one hour of the restraint. This deficient practice posed the potential risk of patients being restrained without the authorization of a responsible physician.

Findings include:

The hospital's policy and procedure titled "Seclusion and Restraint in Behavioral Health Services" (Version 12416.5) included: "...Procedure/Interventions: D. A face-to-face assessment of the patient's physical and psychological well-being is performed within one hour after the initiation of restraint or seclusion by a LIP or trained RN, who is either onsite or on-call at the time that the restraint or seclusion was initiated...."

Patient # 11

Documentation in Patient #11's clinical record as well as a "BUMC-South Campus Security Department Report" dated 10/04/2016 revealed a physical hold restraint was used on the patient at approximately 2:30 p.m. for the administration of an intramuscular injection. According to the security report the patient was released from the hold after the injection but then kicked the RN and the RN instructed security and staff to: "...put the patient in the seclusion room." The patient's right arm was "controlled" by a BHS and the left arm was "controlled" by a Security Officer.

There was no documentation that a face-to-face assessment of the patient's physical and psychological well-being was performed by a LIP within one hour after the restraint

Patient # 19

Nursing Documentation in Patient #19's clinical record revealed the patient was restrained by staff at 8:52 a.m. The progress note did not specify how the patient was restrained and/or secluded, however, documentation in the hospital's restraint log revealed a "Physical Restraint/Hold" was used.

There was no documentation that a face-to-face assessment of the patient's physical and psychological well-being was performed by a LIP within one hour after the restraint

The clinical record was reviewed on 10/17/2016, with the Senior Manager of the Behavioral Health Units and she acknowledged there was no documentation of a face-to-face assessment performed after the restraint.

Based on clinical record review, review of hospital policy and procedures, observation, and staff interviews, it was determined:

1. The hospital failed to follow their own policies and procedures and ensure 2 of 2 incidents of verbal abuse were documented in the patients' clinical records and failed to ensure the patients' physicians were notified of the incidents. (Patients #6 and #7) This deficient practice posed the high potential risk of patient needs not identified in the medical record and physicians not aware of an incident that may indicate a change in the treatment plan.

2. The hospital failed to conduct a comprehensive investigation of the above incidents to determine if other patients in the hospital were at risk for verbal abuse or harassment. The Director of Clinical Performance Assessment and Improvement was not aware of the incidents until brought to her attention by the surveyor during a meeting 21 days after the incident. This deficient practice posed the potential risk of patients in other parts of the hospital not identified to be at risk for potential abuse or harassment.

3. The governing body failed to ensure that clear expectations for safety were established, when the Banner Regulatory Consultant reported via a safety tracer, that the oxygen concentrator cords on the geriatric psychiatric unit were a risk to health and safety; and Registered Nurses, physicians, and other professional personnel working in the milieu failed to demonstrate recognition of their responsibility for the safety of patients on the unit.

4. Facility failed to ensure quality reviews of the use of restraints included those used by Security Officers followed hospital policies and procedures. This deficient practice posed the risk of restraints used by non-clinical staff including Security Officers not defined in hospital policies and procedures and authorized by the governing body.

Findings include:

1. The hospital's policy and procedure titled "Event Reporting" (Version: 9062.6) included: "Definitions:... 2. Event: any unusual, untoward or unintended event or practice that is not consistent with the expected level of patient care or procedures that could result in harm or potential harm to the patient...Procedure/Interventions: 2. Notify the attending physician and supervisor/department director/promptly...6. Document factual account of the Event in the medical record...."

Patients #6 and #7 were verbally abused by a staff member on 10/06/2016. There was no documentation in the patient's clinical record of the incident nor documentation that the patient's physician was notified. (Refer to Tag A-145 for more details.)

2. The surveyor requested a copy of Staff #10's work schedule which covered the period between 07/23/2016 to 10/08/2016. According to that schedule Staff #10 was assigned to the inpatient behavioral health units including the Senior Care Unit and the medical/surgical unit(s).

A meeting was conducted on 10/27/2016, with the members of the hospital's Clinical Performance Assessment & Improvement (CPAI) team. The surveyor questioned the hospital's quality activities to determine whether or not other areas of the hospital were addressed to determine whether or not there were concerns with patient rights in other areas of the hospital. The Director of CPAI, the Co-Chair of the Patient Safety Committee, and the Manager of Legal/Risk reported they were not aware of the verbal abuse incidents that occurred on 10/06/2016, a period of 21 days after the incident.

3 Cross reference Tag 0144 related to the statement by the Banner Regulatory Consultant, that she had identified a safety issue with the long cords on oxygen concentrators on the geriatric psychiatric unit approximately two months prior to the survey. The Regulatory Consultant indicated that a tracer report had been sent through the appropriate channels.

Direct surveyor observation revealed that oxygen concentrators were still in use at the time of the survey, posing a risk to the geriatric population on the unit from a falls and/or a ligature perspective.

The Regulatory Consultant acknowledged, during interview conducted on 10-24-16 at 12:45 P.M., that the healthcare professionals working on the unit every day should have recognized and reported the potential ligature risk on a psychiatric unit.

4. The Director of CPAI stated during the meeting on 10/27/2016 that she was not aware of the security department reports of security involved restraints including the use of handcuffs.

The CPAI team members reported that their current quality activities related to restraints included auditing the records to ensure accurate documentation. There were no activities that included quality reviews of the appropriateness of the use of restraints by clinical staff and by the Security Officers.



20118

Based on review of hospital policies and procedures, review of clinical records, and staff interviews, it was determined the hospital:

(A395) 1. failed to ensure Registered Nurses assigned to the care of 2 of 2 patients who were verbally abused by a staff member documented the incidents, notified the physician(s), and assessed the patients. (Patients #6 and #7) This deficient practice posed the potential risk of failure to identify the impact of the verbal abuse on the patients' mental health.

2. failed to ensure that hospital policies and procedures for a Registered Nurse to be responsible at all times for the patient's condition and staff supervision when 2 of 3 patients (Patients #10 and #22) observed on security video were restrained by Security Officers and behavioral health staff.

3. failed to ensure a Registered Nurse supervised and evaluated the care of patients when Registered Nurses on a psychiatric unit failed to evaluate the risk of an oxygen concentrator cord which could have been used as a ligature. The potential risk is to the health and safety of patients with suicidal ideation who may view the cord as a ligature, and act on the ideation.

4. failed to ensure a Registered Nurse appropriately evaluated the patient's health status when the suicide risk tool (Nurses Global Assessment of Suicide Risk) was scored incorrectly for 1 of 1 patients admitted to the geropsychiatric unit with a recent suicide attempt. The potential risk is that a patient with suicidal ideation or intent, may not be placed on the appropriate level of observation, resulting in the risk of harm, up to and including death (Patient #17).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on review of hospital policies and procedures, review of clinical records, the Registered Nurse (RN) job description, the "Nurses' Global Assessment of Suicide Risk (NGASR) guide, review of security video, and staff interviews, it was determined the hospital:

1. Failed to ensure Registered Nurses assigned to the care of 2 of 2 patients who were verbally abused by a staff member documented the incidents, notified the physician(s), and assessed the patients. (Patients #6 and #7) This deficient practice posed the potential risk of failure to identify the impact of the verbal abuse on the patients' mental health.

2. Failed to ensure that hospital policies and procedures for a Registered Nurse to be responsible at all times for the patient's condition and staff supervision when 2 of 3 patients (Patients #10 and #22) observed on security video were restrained by Security Officers and behavioral health staff.

3. Failed to ensure a Registered Nurse supervised and evaluated the care of patients when Registered Nurses on a psychiatric unit failed to evaluate the risk of an oxygen concentrator cord which could have been used as a ligature. The potential risk is to the health and safety of patients with suicidal ideation who may view the cord as a ligature, and act on the ideation.

4. Failed to ensure a Registered Nurse appropriately evaluated the patient's health status when the suicide risk tool (Nurses Global Assessment of Suicide Risk) was scored incorrectly for 1 of 1 patients admitted to the geropsychiatric unit with a recent suicide attempt. The potential risk is that a patient with suicidal ideation or intent, may not be placed on the appropriate level of observation, resulting in the risk of harm, up to and including adverse outcomes. (Patient #17).

Findings include:

1. The hospital's policy and procedure titled "Adult Patient Standards of Care" (Version 10135.20) includes: "...A Registered Nurse assesses, plans, directs, implements, and evaluates nursing services provided to a patient...."

Patient # 6

Patient #6 was admitted to the hospital's 2-West Behavioral Health Unit with depression, suicidal ideation, and recent suicide attempt. On 10/06/2016 at approximately 2 p.m. the patient was verbally abused by a staff member which was witnessed by another staff member. The staff who witnessed the incident reported the patient stated he didn't feel safe after the incident. There was no documentation of the incident in the clinical record, no documentation that a Registered Nurse (RN) assessed the patient after the incident to determine how the incident impacted him psychologically, and no documentation that a physician was notified of the incident. Nursing documentation at 9:36 p.m. included: "Isolative poor eye contact refused to talk to staff."

Patient # 7

Patient #7 was admitted to the hospital's 2-West Behavioral Health Unit with several psychiatric diagnoses and documentation of "numerous" hospitalizations and a history of suicide attempt and history of violence. On 10/06/2016 around noon the patient was verbally abused by a staff member which was witnessed by another staff member. There was no documentation of the incident in the patient's clinical record, no documentation that the patient's physician was notified, and no documentation that an RN assessed the patient to determine if and how the incident impacted him.

Nursing leadership acknowledged during interviews that there was no documentation of nursing assessments of Patients #6 and #7 after the incidents.

2. The hospital's policy and procedure titled "Seclusion and Restraint in Behavioral Health Services (Version 12416.5) included: "III: Policy:...N. An RN is responsible at all times for the patient's condition and staff supervision..."

Patient # 10

Patient #10's clinical record was randomly selected for review from the hospital's restraint log which showed a "physical hold" restraint was performed during his admission. Refer to Tag A-167 for specific details.

The security video of the restraint was reviewed and revealed a situation being handled by a Behavioral Health Specialist deteriorated and resulted in the patient being forced down to the floor and held by four Security Officers and other behavioral health staff for a period of approximately 8 minutes. The patient whose diagnoses included morbid obesity was initially forced face down which is contraindicated because of the danger of asphyxiation. Documentation in the security department report of the incident revealed the decision to take the patient to the floor was made by Security Officers. A review of the video revealed periods of time when there was no RN present during the 8 minutes the patient was held down. The RN's that were initially present left at 6:47 a.m. At 6:50 a.m. the Nurse Manager and another RN went to direct the SO's and BHS staff to be turn the patient onto his back for concerns of asphyxiation (reported by the Nurse Manager in a later interview).

The nursing documentation was not reflective of the actual incident that involved several Security Officers and other staff forcing the patient to the floor. The nursing documentation dated 10/14/2016 at 7:32 a.m. that the patient "attacked" and "punched" staff was not seen in the video. The Security Officer's report was more accurate that the patient began to "struggle" after the SO intercepted the patient's "advance" and the SO attempted a physical hold.

A Security Officer acknowledged during a review of the above security video on 10/19/2016, that there were times when the nursing staff would leave the scene without giving the officers direction on what to do with the patient.

RN's, BHS staff, and Security personnel revealed during interviews conducted a consensus that when Security was called and on-site for an actual patient concern or potential concern, the Security personnel made the call for taking a patient down to the floor. This was observed in the security videos documented above.




20118

3. Patient #17

Cross reference Tag 0144 regarding long substantial electrical cords on oxygen concentrators, which posed a ligature risk on the geropsychiatric unit on which Patient #17 was hospitalized. Registered Nurses on the unit failed to evaluate the care of patients when they failed to identify and report the ligature risk.

4. Patient #17

The "Adult Patient Standards of Care" policy revealed: "...4. A Registered Nurse assesses, plans, directs, implements, and evaluates nursing services provided to a patient...6...Staff members integrate the information each caregiver gathers and collaboratively assign priorities to the patient's care...."

The RN job description revealed: "POSITION SUMMARY" ...This position is accountable for the quality of nursing services delivered by self or others who are under their direction. This position utilizes specialized knowledge, judgment, and nursing skills necessary to assess data and plan, provide and evaluate care...Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards...."

The "Nurses Global Assessment of Suicide Risk (NGASR) guide revealed in the "NGASR Fact Sheet": "Level of Risk: Low 5 or less, Moderate 6-8, High 9-11, Very high 12 or more." For a score of High (9-11), the Fact Sheet indicated "Consider DPO" (Direct Patient Observation). The Fact Sheet revealed points in the scoring scale varied, with "Prior suicide attempt" requiring a score of 3 points.

Patient #17, a young middle aged-male requiring hemodialysis, was admitted to the psychiatric service of the hospital with a major depressive diagnosis, severe, with mood congruent psychotic features, and a history of complicated medical comorbidities, with renal failure requiring hemodialysis.

The initial psychiatric evaluation, conducted by Staff #44, a physician, revealed: "The patient reports that he had been feeling depressed for the past month largely because he feels like he can't do anything because his health is so poor. He states that he no longer wants to go on and that he has active suicidal ideation. He said he was unsure if he would try to kill himself (if) he left the hospital. The patient reports that for the past month or so he has had depressed mood, loss of interest in everything, difficulty concentrating, poor sleep and increasing suicidal ideation. Over the past two weeks or so he reports that he has heard a voice in his head but he is unable to understand what is being said. He does say that the voice scares him...."

Staff #45, a psychiatrist, documented in the electronic medical record on the patient's day of admission: "...presented to the (hospital) as a transfer from an acute care hospital after a suicide attempt by cutting his wrists...." The entry was signed electronically at 1:51 P.M.

Nursing notes authored by Staff #43, an RN, revealed that the patient had left wrist lacerations with sutures, and right wrist multiple lacerations.

Staff #43 conducted a suicide risk assessment of Patient
#17 on the day of admission at 10:08 P.M. The RN documented that Patient #17 had "no" "Recent Stressful Events," "no" "Evidence of Depressive Symptoms," "no" "Warning of Suicidal Intent," "no" Evidence of Plan to Commit Suicide," "No Prior Suicide Attempt," for a NGASR score of "1."

Staff #46, an RN, documented on Day #1 of Patient #17's hospitalization at 11:21 A.M., that the patient had a NGASR score of "7." The RN failed to score "Prior Suicide Attempt," automatically adding three (3) points to the score, which would have given the patient a score of 10. The RN documented the score of 7 required no variation in the patient's "Change in Monitoring."

On Days #2, #3, and #4, respectively, the patient had a NGASR score of "8." Had the score of "3" been added for a "Prior Suicide Attempt," the patient would have had a score of "11," placing him on the upper end of "High" risk.

Five (5) different Registered Nurses, on eight (8) different suicide assessment occurrences, failed to supervise and evaluate the care of the patient, when they failed to acknowledge that the patient had a recent suicide attempt on the NGASR risk assessment, and scored the patient at a lower risk for suicide than he should have been scored.

Review of the observation rounds for Patient #17, from the day he was admitted, through the morning of Day #4 of his hospitalization, revealed that Patient #17 remained on an every 15 minute level of observation, though he should have scored as a high level of risk.
Staff #5, the Senior Nurse Manager for Behavioral Health stated, during interview conducted on 10-26-16 at 3:25 P.M., that if the NGASR score was 9 or greater, the RN should notify the physician, and consider changing the level of observation. The Nurse Manger acknowledged, that the NGASR scores for Patient
#17 were not congruent with the patient's condition, and acknowledged that without correct NGASR scores, the RNs could not accurately determine the potential suicide risk of the patient.