HospitalInspections.org

Based on review of the hospital's Governing Body Bylaws, review of hospital reports, review of clinical records and staff interviews, it was determined the Governing Body:

1. failed to ensure hospital staff provided the level of care required by an inpatient of the Behavioral Health Unit (Patient #7). The staff called the local police department who arrested the patient on the unit for "disorderly conduct." The court ordered the patient be returned to the hospital for mandatory treatment, and the hospital refused to admit the patient. The patient was eventually transferred to another inpatient facility in another city for the same level of care as provided in their own BHU.

2. failed to ensure all patients who presented with a need for acute psychiatric inpatient admission were evaluated based on their presenting status. Patients #7, #16, and #19 were not admitted to the Behavioral Health Unit because they had prior admissions, and the patients were on a "Do Not Admit" list. This deficient practice resulted in the patients being held in the ED without needed psychiatric care and services.

3. failed to ensure non-hospital personnel (law enforcement) were not utilized in assisting with the care and treatment of behavioral health patients. (Patients #4, #6, # 7, #11, and #18) This deficient practice poses the risk of harm to patients by law enforcement who use unauthorized techniques.

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 that protects patient rights.

Based on review of the hospital's Governing Body Bylaws, review of hospital reports, review of clinical records and staff interviews, it was determined the Chief Executive Officer (CEO) failed to ensure the following:

1. hospital staff provided the level of care required by an inpatient of the Behavioral Health Unit (Patient #7). The staff called the local police department who arrested the patient on the unit for "disorderly conduct." The court ordered the patient be returned to the hospital for mandatory treatment, and the hospital refused to admit the patient. The patient was eventually transferred to another inpatient facility in another city for the same level of care as provided in their own BHU.

2. all patients who presented with a need for acute psychiatric inpatient admission were evaluated based on their presenting status. Patients #7, #16, and #19 were not admitted to the Behavioral Health Unit because they had prior admissions, and the patients were on a "Do Not Admit" list. This deficient practice resulted in the patients being held in the ED without needed psychiatric care and services.

3. failed to ensure non-hospital personnel (law enforcement) were not utilized in assisting with the care and treatment of behavioral health patients. (Patients #4, #6, # 7, #11 and # 18) This deficient practice poses the risk of harm to patients by law enforcement who use unauthorized techniques.

Findings Include:

The hospital has a 19-bed Behavioral Health Unit who voluntarily accepts petitioned, court-ordered patients.

The Bylaws of Board of Trustees of Canyon Vista Medical Center includes: "Role of the Board...The purposes, goals and objectives of the Board shall be, in cooperation with the Corporation and the Medical Center Medical Staff...to implement policies and to provide direction that supports the following...support, manage and furnish facilities, personnel, and services; provide diagnosis, medical, surgical, and hospital care, outpatient care, and other hospital and medically related services to sick, injured, or disabled persons...Provide appropriate facilities and services to best serve the needs of patients...Improve the standards of health care in the community...Maintain a commitment to continued comprehensive quality assurance and quality improvement in all aspects of health care provided by the Medical Center in cooperation with the Medical Staff, administration and Medical Center personnel...Power and Authority of the Board of Trustees....the Board shall have full power and authority to assume the responsibilities...including the following...Require a process designed to assure that all individuals who provide patient care services...are competent to provide such services, and receive reports of quality assurance information regarding competency of care providers not subject to the privilege delineation process...Establish, maintain, and support, through the CEO and the Medical Staff and its designated committees, a comprehensive, hospital-wide program for quality assessment and improvement, receive reports of quality improvement information on a regular basis from the Medical Staff, and assure that all aspects of the program are performed appropriately...Establish policies to assure that all patients with the same health care problem are receiving the same level of care in the Medical Center...."

1., 2., 3., Patient # 7

Patient #7 was an involuntary admission to the hospital's Behavioral Unit on 03/29/2017. Documentation in a Security Information Report dated 04/05/2017 at 8:04 a.m. revealed Security Officers (SO's) were called by the BHU staff requesting assistance with medicating Patient #7. The patient's behaviors escalated and three SO's and clinical staff physically restrained the patient to the floor at which time he was medicated. The patient said he would cooperate, and he was released and assisted up from the floor. The patient, however, went to the counter in the day room that had pitchers of water. The patient started to yell and throw the pitchers of water. The SO's and clinical staff again physically restrained the patient to the floor. The Director of the BHU directed a staff member to call the police. The patient was held down on the floor until the police arrived, handcuffed. The documentation included: "(Patient #7) was arrested and removed from the hospital at approximately 0840 hours." The only nurse documentation of the incident was at 8:30 a.m.: "Pt became agitated and aggressive. Security was called. Pt is currently discharged from the unit."

The physician's Discharge Summary dated 04/06/2017 included: "At time of discharge showed that he was densely psychotic, agitated with pressured speech, grandiose, paranoid delusions and dangerous to self and others behavior. He was discharged directly to jail. He was not discharged on any medications as he was discharged to jail...CONDITION UPON DISCHARGE: Quite guarded. It is my understanding that he was then released from jail and taken back to the Emergency Room. His petition is still being continued and apparently he is being transferred to (name of another hospital)."

Patient #7 admitted to receive care and services for his psychiatric diagnoses was handcuffed and arrested on the unit for behaviors directly related to his psychosis and taken to jail.

Patient #7 was brought back to the ED by the police department on 04/05/2017 at 2:25 p.m. The ED physician's documentation included: "Patient was released from behavioral health earlier today and sent to jail when...judge ordered him to inpatient treatment. Patient has had several episodes of acting out while he was admitted to the floor. Today they had him arrested for disorderly conduct...."

The Behavioral Health Unit was contacted by the ED staff when the patient arrived. The ED nurse documented that the Director of the unit reported: "...they have decided that it would be in the patents best interest to be placed at another facility due to the behavior and lack of progress pt made during his last admit to them."

An outside crisis management organization was contacted who came to the hospital and assessed the patient at 3:26 p.m. The evaluator documented the patient acknowledged that he got into an altercation with staff on the BHU because of his poor judgement. The evaluator documented the patient was arrested for disorderly conduct and noted that the patient's face was "swollen" from the altercation with the police. The evaluator documented the patient needed inpatient treatment and the hospital's BHU would not accept the patient.

The patient eloped from the ED the following morning, 04/06/2017 at 9:50 a.m. The patient was located by the police department and returned him to the ED at 10:48 a.m. The patient was transferred by law enforcement to an inpatient behavioral health hospital in Tucson on or around 4 p.m.

2. Patient #16

Patient #16 was admitted to the BHU on 05/11/2017. Documentation revealed the patient had a history of chronic schizophrenia and was admitted after overdosing on his antipsychotic medication and discharged on 05/16/2017. The physician's discharge summary dated 05/16/2017 revealed the patient made several threatening comments during his admission including that he was going to get a gun and come back and hurt the staff. The physician documented the patient admitted to making those statements but said he was not going to hurt anybody. The physician's documentation included: "He will be discharged from this facility today. I have informed the patient that the law enforcement authorities are going to be called to investigate his treats to the staff here and that additionally as it had been discussed at his last hospitalization when he made numerous threats, he is going to be placed on the do not admit list of the Psychiatric Unit at this facility."

Patient #19

Patient #19 was taken to the ED on 01/13/2017 at 3:54 p.m. for hallucinations and behaviors dangerous to others. An ED nurse documented at 5:17 p.m. that the BHU was contacted and requested to come to the ED and do a psychological evaluation on the patient. The nurse documented the staff member on the BHU said the patient was "blacklisted" and that they would not evaluate the patient. An outside crisis management provider was contacted. The patient required inpatient hospitalization at a behavioral health hospital and remained in the ED until placement could be located.

On 1/15/2017 the patient's behaviors escalated and Security was contacted. Documentation in the Security Information Report at 5:40 p.m. revealed the patient was trying to leave the ED and told the Security Officer: "...he was sick of this place and being trapped in his room." The patient became more aggressive at which time the SO's placed both of the patient's hands in a "wrist lock" and the patient was taken down to the floor. The SO's report included: "This PT has continually returned to the ED for Behavioral Health issues. The 4th floor no longer accepts him as well as many other places." Patient #19 remained in the ED until 01/19/2017 when he was transferred to a lower level of care in Tucson. The patient did not receive behavioral health specific care and treatment he required during the six days he was there.

Patient #19 was again taken to the ED on 02/25/2017 related to his chronic psychiatric issues. A Behavioral Health Evaluation and Report was performed on the patient by an Evaluator from the hospital's BHU. The Evaluator documented the patient met criteria for admission but was not accepted to the BHU. The reason was: "Pt is on CVMC (Canyon Vista Medical Center) BHU's do not admit list." The patient remained in the ED until 02/28/2017 when an inpatient bed was located in an acute inpatient psychiatric hospital. The patient did not receive acute psychiatric care and services during that time.

Patient #19 was back to the ED on 03/14/2017 for psychiatric related issues. The hospital's BHU did not perform a Behavioral Health Evaluation and an outside provider was contacted to do the mental health evaluation. The patient remained in the ED two days until placement could be found at an acute inpatient psychiatric hospital in Tucson.

Patient #19 was taken back to the ED on 03/24/2017 after overdosing on insulin. Again, there was no documentation that the hospital's BHU performed a Behavioral Health Evaluation and an outside provider was contacted to do a mental health evaluation and locate an acute psychiatric inpatient hospital for an available bed. The patient remained in the ED for three days.

The Director of the Behavioral Health Unit reported that he was not aware of a specific documented list of patients that were on a "Do Not Admit" list. However, the Director acknowledged there were some patients that they had admitted and felt they could no longer help them and should be at another facility with "more resources." The Director also reported there were some patients who he felt "abused the system" by repeatedly using hospitalization to avoid going to jail.

3. Patient #4

Patient #4 was taken to the ED on 08/13/2017, for exhibiting behaviors that were dangerous to himself and/or others. A Security Information Report dated 08/13/2017 revealed Security personnel were called to the ED because the patient was disruptive, "highly belligerent," and threatening staff. The physician ordered an intramuscular (IM) injection be given to the patient to calm him down, however the patient refused. The patient continued to threaten the staff, and Security personnel instructed the staff to contact the local police department. Three police officers arrived. The patient argued with the police officers and refused to cooperate with medication administration. The patient was physically restrained and held by the police officers and security personnel until the medication was administered and physical restraints applied.

The ED nurse documented at 9:49 p.m. that the patient was "belligerent" and refused to go to the Behavioral Health Unit upstairs or take medications. Security was at the patient's bedside and the police department was called and present. The nurse documented the patient was "almost tazed" but laid down on the bed so 4-point restraints could be applied. However, the patient became combative and was "taken down" by the police department officers and intramuscular (IM) medication administered to calm him down and 4-point leather restraints applied. The patient was taken to the Behavioral Health Unit (BHU) with Security personnel, Police Department officers and BHU staff. Patient #4 was discharged on 08/15/2017.

Patient #4 was taken back to the ED on 08/19/2017 at 3:41 p.m. with suicidal ideations and hallucinations. An ED Nurse Practitioner (NP) documented at 6:53 p.m.: "pt has become more agitated, aggressive, police asking for pt to be restrained. They are willing to place restraints." At 9:38 p.m. the NP documented the patient refused to take any medication and the BHU would not accept the patient until he was medicated. The NP documented that once the involuntary evaluation paperwork was received: "...will call police to assist for medication of pt and escort to 4th floor."

ED nursing documentation at 4:15 p.m. and 7 p.m. revealed police department officers were still at the patient's bedside. An ED nursing note at 7:10 p.m. included: "Went to administer medications and apply 4 point restraints and police had talked pt into willingly putting on restraints and was cooperative but verbally stated that he would be calm and did not want any medications....Police remain at bedside and sitter placed at bedside."

Patient #6

Patient #6 was transferred to the ED on 06/01/2017 at 6:15 p.m. from a hospital in a nearby town. The patient was in the process of being petitioned for court ordered evaluation and treatment and was transported by law enforcement from that town. At the time of arrival the patient was striking out at staff and security personnel and threatening harm. A Security Information Report dated 06/01/2017 at 5:30 p.m. revealed the patient was brought in with handcuffs on. At 6:35 p.m. the ED physician ordered the patient to be restrained. The Security Officer (SO) documented the police officer(s) removed their restraints (handcuffs) and the patient was held down by Security and Police so that medication could be administered. The SO documented they (Security and Police) continued to hold the patient down until 6:44 p.m. when the clinical staff applied the leather restraints to the patient's wrists.

Patient # 7 Refer to above under # 1

Patient #11

Documentation in a Security Information Report dated 03/10/2017 at 2:15 a.m. revealed that when SO's responded to a "Code Orange," they found Patient #11 trying to leave the hospital. The SO's tried to block the patient which caused him to become violent and threatening to harm one of the SO's. The SO directed the clinical staff to contact the local Police Department, and the SO's, "continued to stand their ground" until two police officers arrived. Documentation in the report included: "Patient only calmed down after one of the (police department officers) had a taser in hand and redirected the patient into trauma 1."

Patient #18

Patient #18 presented to the ED on 04/30/2017 at 3:43 a.m. with suicidal ideations. Documentation in the ED record revealed the patient became upset because he was trying to call his mother but she was not answering. He began to escalate when the staff could not call his mother continuously until she answered. Security was called. The Security Information Report dated 04/30/2017 at 4:50 a.m. revealed the patient would not listen to the SO's commands to sit down on the bed. The patient hit the clock in the room causing the glass around the clock to break. The report included: "Patient then pushed Officer (name), Officer (name of a different Officer) pushed patient back." The patient "attacked" the officer who pushed him, and then the patient was taken to the ground and a "Dr. Strong" was called along with the local police department. The police officers arrived and assisted with the application of 4-point restraints. The ED nurse documented the patient was "wrestled down to floor" by the security officers during the altercation.

The hospital had no policy that addressed if and when law enforcement be contacted to intervene with hospital patients.

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

A-122: failed to follow their policies and procedures to investigate and respond to 1 of 3 patients who filed a grievance. (Patient #25) This deficient practice poses the risk of patient complaints not investigated and opportunities for improvement not identified.

A-167: failed to ensure for 1 of 1 patient whose restraint was observed on security video (Patient #3) the method and length of time the patient was restrained was the safest and most appropriate. This deficient practice poses the potential harm of positional asphyxia when the patient is placed in a position interfering with the ability to breathe properly.

A-168: failed to ensure physician orders were obtained for physical holds on 10 of 10 patients who were physically held to control them, (Patients #2, #3, #4, #6, #7, #8, #17, #19, #21, and #24). This deficient practice poses the risk of restraint usage without the knowledge of a physician responsible for their care.

A-174: failed to ensure restraints were removed at the earliest possible time for 2 of 7 patients who had mechanical restraints applied. (Patients #4 and #6). This deficient practice poses the risk of physical and emotional harm to patients when they are restrained without justification.

A-179: failed to ensure for 9 of 12 patients who were restrained by physical holds and/or by mechanical restraints that the patients were assessed by a physician to determine the patients's reaction to the restraint, the patient's medical and behavioral condition, and the need to continue or remove the restraint. (Patients #2, #3, #4, #6, #7, #17, #19, #21, and #24) This deficient practice poses the risk of a change in the medical or psychological condition of the patient not being identified.

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 that protects patient rights.

Based on review of hospital policies and procedures, clinical record review, and staff interview, it was determined for 1 of 3 patients who filed a grievance with the hospital, the hospital failed to follow their policies and procedures to investigate and respond to the patient. (Patient #25) This deficient practice poses the risk of patient complaints not investigated and opportunities for improvement not identified.

Findings include:

The hospital's policy and procedure titled, "Patient Rights and Responsibilities" (#ADM172), includes: "...You have the right to...File a grievance. If you want to file a grievance with the hospital, you may do so by writing or by calling the Quality Director...The grievance committee will review each grievance and provide you with a written response within ten days. The written response will contain the name of the person to contact at the hospital, the steps to investigate the grievance, the results of the grievance process, and the date of completion of the grievance process."

Patient #25 submitted a written complaint to the hospital related to care and services he received during Emergency Department visits in October 2016 and January 2017. The hospital sent a letter dated 03/13/2017, to the patient acknowledging receipt of the patient's concerns. The letter stated the concerns would be reviewed and a written response would be sent within 30 days.

The Quality Operations Coordinator reported there was no documentation that the patient's concerns were investigated and a written response provided to the patient.

Based on review of hospital policies and procedures, review of hospital reports, review of security video, and staff interview, it was determined the hospital:

1. failed to ensure for 1 of 1 patient whose restraint was observed on security video (Patient #3), that the methods, techniques and length of time the patient was restrained was the safest and most appropriate. This deficient practice poses the risk of significant harm to a patient when the patient is placed in a position interfering with his ability to breathe.

2. failed to ensure for 3 of 12 patients who were restrained, the most appropriate and safest techniques were used to prevent injury. (Patients #4, #7, and #16). This deficient practice poses the risk of significant harm to a patient when the patient is not restrained appropriately.

Findings include:

The hospital's Policy and Procedure titled "Restraints and Seclusion" includes: "Risks of Restraint Use...The use of restraint has the potential to produce serious consequences such as physical and psychological harm, and even death."

1. Patient #3

Documentation in a Security Information Report dated 08/04/17, revealed security staff were called to the inpatient behavioral health unit at 7:05 p.m. Patient #3 had punched the windows in the nurses station and was pacing up and down the hallways and trying to leave the unit. The RN had medication to administer to the patient to help him calm down, however, the patient would not go to his room so the charge nurse gave the security staff "the okay" to restrain him. The patient was taken to the floor by clinical and security staff. The report included: "Meds were given and we waited there a while longer because (Patient #3) kept tensing up...(name of security officer) and I assessed him to the standing position but we still weren't comfortable with releasing his hands because he tensed up again...(Patient #3) was fine for a few minutes then he slammed his head into the wall and tried to push us back and was trying to fight again. For his and our safety he was assisted back to the floor. That's where we remained for some time until (Patient #3) finally calmed down enough, so that (name of security officer) and I could assist him to a chair. At approx. 1940 the BHU (Behavioral Health Unit) staff returned with some more meds to help (Patient #3)."

A review was made of Security video from the inpatient behavioral health unit on 08/04/2017, when security staff responded to the unit for assistance with Patient #3. The time stamp on the video started at "19:21:07" (7:21 p.m.). The video started with the patient in a hallway surrounded by approximately 8 staff members plus and 3 Security Officers. The patient was taken to the floor and held face down. The patient was held face down on the floor until 7:32 p.m. at which time the Security Officers stood him up and placed him face-forward to a wall with his upper torso directly against the wall and his arms held behind his back by the Security Officers. The patient was observed turning his head from side-to-side and with his chin on the wall hyperextending his neck looking at the ceiling. The patient was not observed to "slam" his head into the wall in the security video provided. The patient was held against the wall so there was not enough room for him to "slam" his head. The patient was held against the wall until 7:36 p.m. at which time they turned him around. Within seconds the security officers forced the patient back to the floor face down. The patient struggled, and the security officer on the patient's right straddled the patients legs to keep him down and then used his left knee on the patient's left thigh to control him. He was held face down on the floor until 7:46 p.m. at which time he was pulled up and placed in a chair. A female guard was behind him and male guards at either side. His right arm was extended at the shoulder, and held by one of the officers. The video ended at 7:52 p.m. and the patient was still sitting in the chair in the middle of the hallway with the security officers in position. The patient was held face down on the floor for 21 minutes; was held face forward against the wall for 4 minutes and then held down on the chair for at least 6 minutes.

A face down restraint can lead to restraint-related positional asphyxia. It is caused when a person is placed in a position in which their ability to fully and properly breathe is impaired and they're not able to take in enough oxygen. Pressure placed on the patient to hold them down including arms and/or legs can interfere with a person's ability to move their chest and abdomen in order to fully inhale and exhale. The lack of oxygen can lead to cardiac disturbances and death. The patient was given Ativan 2 mg and Benadryl 50 mg IM when he was first taken down to the floor. Both of these medications cause respiratory depression and increase the risk of harm to the patient being held down in a prone position.

The Manager of Security acknowledged during an interview on 08/21/2017 that taking patients down to the floor in a prone position was a technique taught in the hospital's program for crisis intervention and that it was the quickest and safest method to use on violent patients. The Manager reported that the crisis intervention program used by the hospital did not focus on de-escalation techniques specific to the behavioral health population.

2. Patient #4

Leather restraints were applied in the ED to both of Patient #4's wrists on 08/19/2017 at 7:10 p.m. even though nursing documentation revealed the patient was cooperative and the patient stated he would be calm. The restraints were removed at 10:45 p.m. There was no documentation that justified the use of restraints during that time. The patient was transferred and admitted to the Behavioral Health Unit at 11:45 p.m. A nurse documented on 08/20/2017 at 5 p.m. that the patient complained of pain and numbness in his pinky, ring and middle fingers of his left hand due to the restraints that were applied in the ED.

Patient #7:

Documentation in Patient #7's clinical record revealed he was "taken down" by Security Officers and/or staff on 04/02/17 at 7:30 a.m.; 04/03/2017 at 9:50 a.m.; and on 04/04/2017 at 5:09 p.m. A nurse documented on 04/04/2017 at 4:15 a.m. that the patient was at the nurses' station demanding to see a physician because of abdominal pain. The nurse documented a chest x-ray of the patient's left ribs was ordered.

A physician's progress note dated 04/04/2017 at 5 p.m. included: "I was called to assess patient on restraint. Complains of chest pain on Lt side ribs ...In extreme agitation. In restraints ...Tenderness of left lower chest wall ...Needs rib-x-ray. Medical management of agitation to discontinue restraints as soon as possible . The physician ordered a "STAT" chest x-ray at 4:54 p.m. There was no documentation that a chest x-ray was obtained and no documentation that clarified why.

Patient #16

A Security Information Report dated 05/13/2017 at 9:20 p.m. revealed Security Officers were called to the unit. Patient #16 was confused and aggressive. The patient was taken to the floor by staff and two officers and 4 point restraints applied. Documentation revealed: " ...in order to transport patient to the seclusion room." The documentation identified the patient continued to try to attack the staff and an injection was administered and they were eventually able to move the patient into the seclusion room where the restraints were hooked to the bed frame.

The patient was evaluated by a physician at 9:50 p.m. whose documentation included: "I was called to assess patient since he is in 4 point restraints ...Rt arm pain & bruise ...Patient declined exam except for Rt arm. Bruise around Rt elbow...still able to move elbow, tenderness at the bruise site. Recommend using pharmacological therapy and discontinue restraints as soon and safe as possible. Recommend Rt elbow x ray to R/O (rule out) fractures ...." The X-ray results were negative for fracture.

The above clinical records were discussed with nurse leadership including the Director of the Behavioral Health Unit, Director of Emergency Services and/or the Quality Department RN's during which they acknowledged the documentation of patient reported or actual injury related to restraints.

Based on review of hospital policies and procedures, review of clinical records, review of security footage, review of hospital reports and logs and staff interviews, it was determined for 11 of 12 behavioral health patient who were restrained by being physically held and/or taken down to the floor to control them in the total sample of 27, the hospital failed to ensure physician orders were obtained for the physical holds. (Patients #2, #3, #4, #6, #7, #8, #17, #18, #19, #21, and #24). This deficient practice poses the risk of restraint usage without the knowledge of a physician responsible for their care.

Findings include:

The hospital's policy and procedure titled "Restraints and Seclusion", #PCS139, includes the following: "...Definitions...8.1 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...8.3 Violent/Self-Destructive Restraint: physical restraint that is used only in an emergency or crisis situation if the patient's behavior becomes aggressive or violent, presenting an immediate, serious risk to his/her safety or that of others, and non-physical interventions are not effective. Examples include, but are not limited to, violent psychiatric patients, suicidal patients, and alcohol/drug related behavioral crises...PROCEDURE...3. Licensed Independent Practitioner (LIP) Order...3.2 Violent/Self-Destructive Restraints: In an emergency situation, the least restrictive, yet effective restraint may be applied by an RN based on appropriate assessment of the patient. The LIP primarily responsible for the patient's on-going care, a LIP designee, or other LIP must then be contacted immediately, and a face-to-face assessment must be completed by a licensed independent practitioner and orders must be written within 1 hour...."

Patient #2

Nursing documentation dated 12/16/2016 at 5:25 a.m. revealed Patient #2 was trying to leave the behavioral health unit where he was an inpatient. The staff were unable to redirect the patient who began to run down the halls and throw objects around the unit. The patient refused medication to calm him down, and security staff was called who responded and "assisted" with the intramuscular (IM) injection." At 7:35 p.m. the patient was yelling, noncompliant, and unable to be redirected. The patient "had to be assisted to room" and an IM injection administered to calm him down. The patient tried to hit and kick the staff at which time he was "...assisted to seclusion room and restrained."

Patient #3

Refer to Tag A-167 for specific details regarding Patient #3 who punched the windows in the nurses station and was pacing up and down the hallway and trying to leave the unit.

A review was made of Security video from the inpatient behavioral health unit on 08/04/2017, when security staff responded to the unit for assistance with Patient #3. The time stamp on the video started at "19:21:07" (7:21 p.m.). The patient was taken to the floor and held down until 7:32 p.m. at which time the Security Officers stood him up and placed him face-forward to a wall with his upper torso directly against the wall. They kept him there until 7:33 p.m. and then took him back to the floor. They held him face down on the floor until 7:46 p.m. and then pulled him up and sat him in a chair where he was held until the video ended at 7:52 p.m.

Patient #4

Patient #4 was taken to the ED on August 13, 2017 for behavioral health related issues. Documentation in the clinical record revealed the patient was "taken down" and held by both security staff and local police officers for the administration of medications and application of 4 point restraints.

Patient #6

Patient #6 was taken to the ED on 06/01/2017 related to danger to self/danger to others behaviors. Documentation in a security report at 5:30 p.m. revealed the patient was held down by security staff and law enforcement staff while medication was administered.

Patient #7

Patient #7 was taken to the ED on 03/28/2017, and admitted to the BHU on 03/29/2017, for psychotic, danger to self/danger to other behaviors. Documentation in the clinical record revealed the patient was "taken down" to the floor, and held on numerous occasions up to and including 04/05/2017 when the staff called the police and had the patient arrested.

Patient #8

Patient # 8 who was under the age of 15 years-old was taken to the ED on 08/06/2017, by law enforcement for aggressive and threatening behavior. Documentation in a Security Information Report on that date revealed the patient was in handcuffs at the time of arrival to the ED. The patient was placed in 4-point restraints immediately. The SO documented in the report that two SO's continued to hold the patient until the medications took effect.

Patient #17

Patient #17 was a pediatric behavioral health patient taken to the ED on 08/17/2017. Nursing and security documentation dated 08/18/2017 revealed the patient had to be physically held by security and clinical staff in order to be given an intramuscular injection of medication to control his behaviors and then to have restraints applied to his extremities.

Patient #18

Patient #18 presented to the ED on 04/30/2017 at 3:43 a.m. with suicidal ideations. Documentation in the ED record revealed the patient became upset because he was trying to call his mother but she was not answering. He began to escalate when the staff could not call his mother continuously until she answered. Security was called. The Security Information Report dated 04/30/2017 at 4:50 a.m. revealed the patient would not listen to the SO's commands to sit down on the bed. The patient hit the clock in the Room causing the glass around the clock to break. The report included: "Patient then pushed Officer (name), Officer (name of a different Officer) pushed patient back." The patient "attacked" the officer who pushed him and then the patient was taken to the ground and a "Dr. Strong" was called along with the local police department. The police officers arrived and assisted with the application of 4-point restraints. The ED nurse documented the patient was "wrestled down to floor" by the security officers during the altercation.

Patient #19

Patient #19 was a behavioral health patient who was taken to the hospital's ED on 01/13/2017, for delusional ideation and threatening harm. Documentation in a Security Information Report dated 01/15/2017 at 5:40 p.m. revealed the patient became aggressive and attempted to leave the ED. The patient did not respond to verbal commands to stop, and Security Officers placed a "wrist lock" on both hands. The Security Officers tried to take the patient back to his room in the ED, however, he tried to pull away so the patient was taken down to the floor.

ED nursing documentation dated 01/15/2017 at 5:40 p.m. included: "Pt walking out of ER cursing and yelling at staff...walked out of ER into lobby. Security called and attempted to talk pt into coming back into ER, pt tackled by security placed on a hospital bed and escorted back into ER by staff...."

Patient #21

Documentation in a SIR dated 03/10/2017 at 10:30 p.m. revealed security was called to the BHU because the patient was refusing medication. Nursing documentation described the patient as "agitated" and "irate" and then became physically aggressive with the security guards at which time, "Pt was taken down by security." The nurse documented the patient was given an injection and: "Pt agreed to stay in his room and calm down."

Patient #24

Nursing and Security documentation revealed the patient was physically restrained by security staff and then held down while clinical staff applied leather restraints to all four extremities while in the ED on 08/26/2017.

The Director of the Behavioral Health Unit and the Director of Emergency Services revealed during interviews conducted on 08/27/2017, that physical holds including take-downs by staff and Security personnel are not considered restraints even though the hospital's policy included "manual" holds as restraints.

Based on review of hospital policies and procedures, review of clinical records, and staff interview, it was determined for 2 of 7 patients who had mechanical restraints applied, the restraints were not removed at the earliest possible time. (Patients #4 and #6). This deficient practice poses the risk of physical and emotional harm to patients when they are restrained without justification.

Findings include:

The hospital's policy and procedure titled "Restraints and Seclusion" (#PCS139) includes: 2.2 Restraints will be applied with safe and appropriate restraining techniques, evaluated frequently for continuation and ended at the earliest possible time.

Patient #4

Patient #4 was taken to the ED on 08/19/2017 with suicidal ideations and hallucinations. An ED nurse documented at 7:10 p.m.: "Went to administer medications and apply 4 point restraints and police had talked pt into willingly putting on restraints and was cooperative but verbally stated that he would be calm and did not want any medications. Provider notified. Pt placed in 2 point hand leather restraints and no medications given at this time. Pt informed if he acts up again he will be getting IM medication and 4 point restraints. Pt verbalized understanding." The restraints were removed at 10:45 p.m. There was no documentation that justified the use of restraints during that time. The patient was transferred and admitted to the BHU at 11:45 p.m. A nurse documented on 08/20/2017 at 5 p.m. that the patient complained of pain and numbness in his pinky, ring and middle fingers of his left hand due to the restraints that were applied in the ED. The nurse documented an assessment of the patient's hand and wrist were normal.

An RN Director acknowledged during an interview on 08/22/2017, that the above documentation indicated the patient was restrained even though he was cooperative and verbalized he would be calm.

Patient #6

Patient #6 was transferred to the ED on 06/01/2017 at 6:15 p.m. from a hospital in a nearby town. The patient was in the process of being petitioned for court ordered evaluation and treatment and was transported by law enforcement from that town. At the time of arrival the patient was striking out at staff and security personnel and threatening harm. There was a Violent/Self-Destructive Restraint Order dated 06/01/2017 at 6:35 p.m. for "keyed leather wrist" restraints. Nursing assessments of the patient after the application of restraints were at 6:45 p.m. and 7 p.m. during which times the patient was documented to be sleeping, however, the nurse documented "yes" in the section "Patient continues to meet Clinical Indications for Restraints." Vital signs were recorded every fifteen minutes with the last entry at 9:30 p.m. The ED physician documented at 12:55 a.m.: "Patient remains in restraints." Nursing clinical notes between 7:50 p.m. to 2:35 a.m. on 06/02/2017 revealed the patient was sleeping, and the entries after that revealed the patient was cooperative when he was awake. There was no documentation of when the restraints were removed.

Patient #6's clinical record was reviewed with the Manager of Emergency Services who acknowledged there was no documentation that justified keeping the patient restrained.

Based on review of hospital policies and procedures, review of clinical records, review of security reports, and staff interviews, it was determined for 10 of 12 patients who were physically restrained (Patients #2, #3, #4, #6, #7, #17, #18, #19, #21, and #24) in the total sample of 27, the hospital failed to ensure the patients received both physical and behavioral assessments within one hour after the initiation of the restraint intervention. This deficient practice poses the risk of a change in the medical or psychological condition of the patient not being identified.

Findings include:

The hospital's policy and procedures titled, "Restraints and Seclusion" include the following definition of a 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."

The hospital's policy and procedure titled "Restraints and Seclusion" (#PCS139) includes: "3.2 Violent/Self-Destructive Restraints...3.2.1. The in-person evaluation by a LIP is to be conducted within one hour of the initiation of restraint for the management of violent/self-destructive behavior and the assessment includes:
3.2.1.1. An evaluation of the patient's immediate situation
3.2.1.2. The patient's reaction to the intervention
3.2.1.3. The patient's medical and behavioral condition
3.2.1.4. The need to continue or terminate the restraint...."

The pre-printed "Violent/Self-Destructive Restraint Order" form used by the hospital includes the following statement above the physician signature line: "My face-to-face assessment indicates the need for restraints."

The following patients were physically restrained without documentation that an in-person assessment was performed by an LIP that included the elements documented above in the hospital's policy and procedure.

Patient #2

Nursing documentation dated 12/16/2016 at 5:25 a.m. revealed Patient #2 was trying to leave the behavioral health unit where he was an inpatient. The staff were unable to redirect the patient who began to run down the halls and throw objects around the unit. The patient refused medication to calm him down, and security staff was called who responded and "assisted" with the intramuscular (IM) injection." At 7:35 p.m. the patient was yelling, noncompliant, and unable to be redirected. The patient "had to be assisted to room" and an IM injection administered to calm him down. The patient tried to hit and kick the staff at which time he was "...assisted to seclusion room and restrained."

Patient #3

Patient #3 was held down on the floor and then stood up and held against a wall for a total period of approximately 25 minutes on 08/04/2017. A Hospitalist consultation was ordered at 10 p.m. because the patient "intentionally" hit his head against the wall. The consultation was performed at 10:01 a.m. on 08/05/2017. The Hospitalist documented the neuro exam showed "no deficits." There was no face-to-face assessment documented that addressed the patient being physically held down.

Patient #7

Patient #7 was an involuntary admission to the hospital's Behavioral Unit on 03/29/2017. Documentation in a Security Information Report dated 04/05/2017 at 8:04 a.m. revealed Security Officers (SO's) were called by the BHU staff requesting assistance with medicating Patient #7. The patient's behaviors escalated and three SO's and clinical staff physically restrained the patient to the floor at which time he was medicated. The patient said he would cooperate, and he was released and assisted up from the floor. The patient, however, went to the counter in the day room that had pitchers of water. The patient started to yell and throw the pitchers of water. The SO's and clinical staff again physically restrained the patient to the floor. The Director of the BHU directed a staff member to call the police. The patient was held down on the floor until the police arrived, handcuffed. The documentation included: "(Patient #7) was arrested and removed from the hospital at approximately 0840 hours." The only nurse documentation of the incident was at 8:30 a.m.: "Pt became agitated and aggressive. Security was called. Pt is currently discharged from the unit."

Patient #21

Nursing and Security documentation revealed the patient was "taken down" to the floor and held by security personnel on 03/10/2017 at approximately 10:30 p.m. so that nursing could administer an injection.

The Director of the Behavioral Health Unit and with the Director of Emergency Services revealed during an interview that because physical/manual holds had not been considered restraints, physicians were not always made aware of the holds and the requirement for a face-to-face evaluation with documentation of the required elements to be addressed.

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

A-273: failed to identify and collect data on the use of physical hold restraints used on behavioral health patients by clinical staff and Security Officers. This deficient practice poses the high potential risk that inappropriate, misuse or excessive use of physical hold/restraints on patients will not be reviewed and addressed.

A-286: failed to ensure restraint related injuries were reported through the hospital's quality system for 3 of 3 patients who were restrained and complained of health related injury (Patients #4, #7, and #16) This deficient practice poses the risk of potentially unsafe restraint use not being identified and corrected.

A-309: Governing Body failed to ensure there was accurate and complete data collection on the use of restraints on behavioral health patients by clinical staff and Security Officers. This deficient practice poses the high potential risk the Governing Body is not overseeing that Performance Improvement activities are addressing patient related issues of concern.

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, reports, logs, committee meeting minutes, review of clinical records and staff interviews, it was determined the hospital failed to identify and collect data on all forms of physical restraints used on behavioral health patients by clinical staff and Security Officers. This deficient practice poses the high potential risk that inappropriate, misuse or excessive use of physical hold/restraints on patients will not be reviewed and addressed.

Findings include:

The hospital's policy and procedure titled, "Quality Assurance Performance" includes: "PURPOSE To provide structure and a systematic approach to improve the safety and quality of the care, treatment, and services we provide throughout the entire organization...The Board of Trustees (a/k/a the Governing Body), Medical Staff and the organizations leadership oversee and integrate Performance Improvement into the organization planning and operations to ensure that the organization provides care, treatment, services and an environment that pose no risk of an 'immediate threat to Health or Safety,' in congruence with our mission, vision, and strategic directives."

The hospital's policy and procedures titled, "Restraints and Seclusion" include the following definition of a 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." The policy and procedure also includes: "Performance improvement activities related to restraints or seclusion will be ongoing. The data collected will be used to identify opportunities to reduce or prevent restraint use through performance improvement activities. This should include, but not be limited to: Collection of data on the incidence and reason(s) for restraint use on all shifts and in all care settings where restraint or seclusion is utilized...Aggregation and analysis of the data to determine if patterns, trends, or clusters of restraint or seclusion use are evident...Identification and evaluation of opportunities to reduce the use of restraint or seclusion and/or redesign care processes...Actions to address opportunities identified...Evaluation of the effectiveness of actions taken...Further action is taken as indicated...Data will be routinely analyzed, action plans developed and reported to the appropriate committees of the hospital, including the Quality Council."

Refer to Tag A-168 for patients who were physically held including patients being "taken down" to the floor by clinical staff and/or Security Officers.

A review of the hospital's Performance Improvement - Restraint Report for the period from February 2017 to August 2017 revealed the only types of restraints reported were mechanical restraints: "soft," and/or "keyed leather."

The Director of the Behavioral Health Unit confirmed during an interview conducted on 08/17/2017, regarding the use of restraints and seclusion on the unit, that physical holds were used on the unit, for example so that medication could be administered. The surveyor asked if physical holds were used to take patients down to the floor and hold them there, and he responded, yes. The Director also acknowledged that the hospital's Security Officer's were often called to assist in dealing with aggressive, violent patients. The Director reported physical holds were not being reported as a restraint even though the hospital's definition of restraint included "any manual method." A separate interview conducted with the Director of Emergency Services revealed physical holds were not being reported as restraints.

Members of the Quality Department acknowledged physical holds were not considered restraints hospital-wide and not being reported as such even though their policy and procedure define them as restraints. None of the patient restraints identified in Tag A-168 were reported as restraints to the Quality Department. They also agreed that elements of their policies and procedures for restraints were not being followed including obtaining physician orders, face-to face evaluations by physicians with documented evaluations of physical condition, psychological condition, etc. and monitoring by nursing staff.

Based on review of hospital policies and procedures, review of clinical records, and staff interview, it was determined for 3 of 12 patients who complained of pain after being restrained, the reported complaints were reported through the hospital's event reporting system. This deficient practice poses the risk of potentially unsafe restraint use not being identified and corrected. (Patient's # 4, # 7, and # 16)

Findings include:

The hospital's policy and procedure titled "Incident Report" (Policy # ADM136) includes: "...Employees, managers, directors and physicians of Sierra Vista Regional Health Center are required to report all incidents or events that have, or have the potential for having, an adverse affect on patient outcomes...DEFINITION...Incident: Any unusual event or circumstance that is not consistent with the normal routine operation of the hospital and its staff. Examples include, but are not limited to: Accidents involving actual or potential injuries to patients...."

Refer to Tag A-167. Patients #4, #7, and #16 had restraint related injuries and/or patient reported complaints of pain.. The Quality Department staff reported not being aware of any restraint related injuries reported.

Based on review of hospital reports, logs, Quality Committee meetings, and interviews, it was determined the Governing Body failed to ensure there was accurate and complete data collection on the use of restraints on behavioral health patients by clinical staff and Security Officers. This deficient practice poses the high potential risk the Governing Body is not overseeing that Performance Improvement activities are addressing patient related issues of concern/ adverse outcomes.

Findings include:

The hospital's "Quality Assurance Performance Improvement Plan" (Policy #ADM155) includes: "The Board of Trustees ultimate responsibility for safety and quality derives from its legal responsibility and operational authority for the organizations performance.

Refer to Tags: A-167; A-168; A174; and A-179.

A review of meeting minutes of the Patient Safety Committee (Quality Council) for the period from 12/01/2016 to 06/22/2017 revealed the use of restraints as reported in the ED and the Behavioral Health Unit. Documentation in the 04/27/2017 meeting minutes revealed there were no restraints used in March 2017 and documentation in the 06/22/2017 meeting minutes revealed there were no restraints used in May 2017. The use of restraints reported every month was reported to be appropriate.

A review of Security Information Reports for the same period revealed several incidents of patients being "held" and/or taken down to the floor by Security Officers.

The hospital's policies and procedures titled "Restraints and Seclusion" includes a definition of "Restraint" as well as requirements for appropriate use, physician orders, face to face evaluation with specific elements to be addressed by the physician, monitoring, release, and documentation.

The hospital's policies and procedures for restraints was reviewed with the staff of the hospital's Quality department and they acknowledged the data collection was incomplete and inaccurate based on their policies.

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

A-395: the hospital failed to ensure for 10 of 10 patients who were physically (manually) restrained that a registered nurse supervised, monitored and assessed the patients for the the use of restraints to prevent potential and actual injury in accordance with the hospital's approved policies and procedures. (Patients #2, #3, #4, #6, #7, #8, #17, #19, #21, and #24). This deficient practice poses the risk of harm to patients when policies and procedures are not followed for use of restraints.

The cummulative effect of this deficient practice resulted in the hospital's inability to ensure the safe provision of quality care in a safe setting by the nursing staff.

Based on review of hospital policies and procedures, review of clinical records, and staff interviews, it was determined for 10 of 10 patients who were physically (manually) restrained, the hospital failed to ensure a registered nurse supervised, monitored and assessed the patients for the the use of restraints to prevent potential and actual injury in accordance with the hospital's approved policies and procedures. (Patients #2, #3, #4, #6, #7, #8, #17, #19, #21, and #24). This deficient practice poses the risk of harm to patients when policies and procedures are not followed for use of restraints.

Findings include:

Refer to Tags: A-165; A-167; A-168; and A-174.

Review of the clinical records of patients who were physically held down revealed nursing staff did not notify and/or obtain a physician order for physical (manual) holds that were being used by both clinical staff and/or Security Officers.

For example, observation of security video revealed Patient #3 taken down to the floor and held face down twice for a total of approximately 20 minutes, held up against a wall in the hallway of the unit face forward with his hands held behind his back, and then placed in a chair surrounded by Security Officers in the middle of the hallway. The nursing documentation of the incident included: "Pt began punching the windows in the nurses station; security was called and patient was held for Geodon injection. Approximately 30 min later, pt is still agitated and agressive (sic) towards staff, pt intentionally hit his head on wall." There was no documentation that the nurse addressed the patient being held face down on the floor for an extended period of time, and put the patient at risk for positional asyphixiation. There was no documentation that the nurse notified the physician of the details of the holds and obtained an order for the holds.

Review of the security video of Patient #3 and review of the Security Information Report revealed that although a Registered Nurse may have directed Security Officer's to take down or hold a patient, the techniques and length of time of the holds were made by the Security Officer's.

The Director of the Behavioral Health Unit and the Director of Emergency Services revealed during an interview conducted on 08/27/17, that they were not familiar with all elements of the hospital's policy, "Restraint and Seclusion", and acknowledged all elements of the policy we not being followed on their respective units.