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Based on record review, physician and staff interview, one of one applicable Patient (#1's) legal guardian was not informed of a violent physical altercation which caused injury to staff in the Emergency Department (ED) while Patient #1 was waiting for inpatient psychiatric bed placement, the treatment plan and bed search in February 2011.

The findings are as follow:

Patient #1 was transferred from a group home following a violent altercation to the ED.

Patient #1 was medically screened and placed on a Section 12 by the ED Attending Physician.

Review of the psychiatric evaluation dated 02/10/11 at 9 PM indicated Patient #1 had a legal guardian.

Despite the legal guardians presence in the ED approximately one hour after Patient #1's arrival to the ED,there was no documentation by the psychiatric clinicians that the treatment plan was discussed with the legal guardian.

Crisis Worker #1 was interviewed in person on 03/23/11 at 3 PM. Crisis Worker #1 said the evaluation was done at approximately 9 PM. Crisis Worker #1 was aware Patient #1 had a legal guardian. Crisis Worker #1 said Patient #1 said the legal guardian was somewhere on the premises. Crisis Worker #1 had the cell phone number for the legal guardian but did not place a call to inform the legal guardian that a bed search for an inpatient psychiatric admission had been initiated.

Documentation, video surveillance and staff interview with Registered Nurses ( RN) #1, #2, #3 , #4 and #5 indicated Patient #1 had attempted to elope from the ED and a physical altercation ensued with a shattered window near the exit door and a physical put down of Patient #1 to the floor. RN's #1, #2, #4 and #5 denied informing the legal guardian of the physical altercation and mechanical restraint with Patient #1. RN #3 was not assigned to Patient #1 and left the ED prior to the legal guardian's return to the ED.

RN #6 was interviewed in person on 03/22/11 at 1:46 PM RN #6 was called into the ED following the incident with Patient #1 to replace one employee who left the hospital. RN #6 said the legal guardian called to inquire about Patient #1. RN #6 was not able to inform the legal guardian about the circumstances leading to the incident which required physical restraint of Patient #1.

The ED nursing staff said informing the legal guardian of the incident would have been the responsibility of the psychiatric service.

The ED Nurse Manager was interviewed in person on 03/23/11 at 2:30 PM. The ED Nurse Manager did not speak with Patient #1's legal guardian.

ED Attending Physician #1 was interviewed in person on 03/22/11 at 2:45 PM. ED Attending Physician #1 did not inform the legal guardian of the incident with Patient #1.

Crisis Worker #2 was interviewed on 03/23/11 at 3:30 PM. Crisis Worker #2 denied speaking with the legal guardian regarding the incident on 02/11/11.

There were no clearly defined responsibilities for informing the legal guardian of a significant incident whereby Patient #1 became extremely violent resulting in injuries to staff and properly damage.

There was no documentation by the psychiatric service that the legal guardian was informed of the treatment plan which included a psychiatric admission until Patient #1 was transferred from the ED to the inpatient psychiatric unit.

Based on record review and staff interview, the Hospital failed to ensure that 4 out of 10 employees who had physical contact with one of one applicable Patient (#1) in the Emergency Department (ED) during a violent episode and required physical restraint had sufficient training and demonstrated competency as required.

The findings are as follow:

Review of 4 out of 10 employee training files for restraint training lacked annual review of knowledge completion as per Hospital Policy.

Review of the education file for ED Technician #1 indicated the last CPI training expired in 2007. ED Technician #1 assisted in the application of the physical restraint of Patient #1 on 02/11/11 at 9:25 AM.

An employee who responded with the Team Control in the physical restraint of Patient #1 had CPI training documentation which expired in 2009.

Review of RN #1's educational file evidenced CPI training which expired in 2009.

Review of RN # 5's education file lacked retraining in CPI or application of restraints. RN #5 was assigned whilePatient #1 was in four-point leather restraints. RN #5 released the leather restraints approximately two hours after application..

The Hospital failed to ensure that all employees with physical contact with patients requiring restraint had annual competencies and could demonstrate knowledge of restraint training as required.