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Based on interviews and document review, the facility failed to assess patients prior to being discharged or transferred from the emergency department (ED) to ensure they were safe to leave the ED in 5 of 10 ED medical records reviewed (Patients #1, #2, #3, #7, and #9).

Findings include:

Facility policy:

The policy Emergency Department (ED)/Urgent Care (UC) Vital Signs read, discharge vital signs will be taken on all patients within 30 minutes of discharge from the ED/UC. Abnormal vital signs will be reported to the ED/UC physician prior to discharging the patient. Abnormal vital sign parameters for adults include a temperature greater than 99.1 degrees Fahrenheit (F), an oxygen saturation level less than 90% on room air, a systolic blood pressure greater than 140, a diastolic blood pressure greater than 90 and/or no change greater than 15 points from the prior blood pressure.

1. The facility failed to ensure patients leaving the ED had vitals reassessed within 30 minutes of discharge from the ED.

a. Review of Patient #3's medical record revealed the patient presented to the ED on 2/26/18 with a chief complaint of a headache and neck pain related to a fall two days prior. Patient #3 remained in the ED overnight for testing and monitoring. On 2/27/18 at 9:15 a.m., Patient #3's vital signs were assessed and revealed a temperature of 99.7 degrees F and an oxygen saturation level of 90% on room air. There were no further vital signs documented after 9:15 a.m. According to documentation in the Patient Care Timeline, the patient ambulated to take a shower at 9:45 a.m., and then was discharged at 12:08 p.m. (2 hours and 23 minutes after the final set of vitals were assessed).

Review of Patient #7's medical record revealed the patient presented to the ED on 5/26/18 to undergo a psychiatric evaluation. According to documentation in the Patient Care Timeline, Patient #7 became increasingly agitated and was placed in behavioral restraints from 11:39 p.m. until 1:00 a.m. The last set of vital signs were assessed at 7:37 a.m. At 11:32 a.m., Patient #7 was discharged home. This was approximately 4 hours after the final set of vital signs was assessed.

Review of Patient #1's medical record revealed the patient presented to the ED on 11/27/17 with a chief complaint of abdominal pain. At 12:36 p.m., Patient #1's vital signs were assessed and revealed a temperature of 99 degrees F and a blood pressure of 160/86. The next and final set of vitals were assessed at 3:23 p.m. There was no documentation a second temperature was assessed during Patient #1's visit. Patient #1 was discharged home at 4:22 p.m., one hour after the final set of vital signs were assessed.

Similar findings of patient's vital signs not assessed within 30 minutes of leaving the ED were identified during the medical record reviews of Patient #2 and Patient #9. This was in contrast to the policy which stated discharge vital signs would be taken on all patients within 30 minutes of discharge from the ED.

b. On 7/4/18 at 3:05 p.m., an interview was conducted with Paramedic #2 who stated he provided care to patients in the ED. Paramedic #2 stated patients were expected to have vital signs assessed within 30 minutes prior to discharge. Paramedic #2 explained this was important in order to determine if the patient had any adverse reactions to medications given in the ED and to make sure the vital signs positively reflected the treatments received by patients.

c. On 7/5/18 at 8:17 a.m., an interview with the Clinical Manager of the ED (Registered Nurse, RN #4) was conducted. RN #4 stated the facility's expectation was for vital signs to be checked within 30 minutes prior to discharge from the ED. RN #4 further stated the importance of checking vital signs prior to discharge was to check for any changes in condition and to ensure patients were safe to be discharged.

Based on interviews and document review, the facility failed to discontinue behavioral restraints in accordance with facility policy in 1 of 3 medical records reviewed of patients restrained due to behavioral issues (Patient #3).

Findings include:

Facility policy:

The Restraint or Seclusion: Behavioral policy read, restraints must never be limited to only one limb except when the other limb does not exist or the patient has hemiparesis.

1. Facility staff discontinued behavioral restraints one limb at a time, resulting in only one limb restrained.

a. Review of Patient #3's medical record revealed the patient presented to the ED on 2/26/18 with a chief complaint of a headache and neck pain related to a fall two days prior. According to an emergency department (ED) Course note on 2/26/18 at 6:00 p.m., Physician #1 documented Patient #3's workup was normal, however, when discussing the plan to discharge home, the patient had a panic attack and became extremely anxious and agitated. The All Meds and Administration documented the patient received 1 milligram (mg) of intravenous (IV) lorazepam (used to treat anxiety) at 5:45 p.m. and at 7:14 p.m. On 2/27/18 at 3:50 a.m., Patient #3 received a 5 mg intramuscular injection of Olanzapine (an antipsychotic medication).

According to the Behavioral Restraints Flowsheets, on 2/27/18 at 3:50 a.m., Patient #3 exhibited agitated and aggressive behaviors and Velcro limb restraints were placed on all four limbs. The Patient Watch Continuation Sheet documentation revealed the patient's lower limb restraints were removed at 5:00 a.m. and 5:01 a.m. The right wrist was then released at 5:16 a.m. and the left wrist was removed at 5:19 a.m., resulting in the patient being in only one restraint for 3 minutes.

However, conflicting documentation on the Patient Watch Continuation Sheet showed the restraints were removed one at a time in 15 minute increments, beginning with the right ankle restraint removed at 4:30 a.m., the left ankle restraint removed at 4:45 a.m., the right wrist restraint removed at 5:00 a.m., and the left wrist restraint removed at 5:15 a.m. This resulted in only one limb being restrained for 15 minutes and was in contrast to the facility's policy.

b. On 7/4/18 at 3:05 p.m., an interview was conducted with Paramedic #2 who stated he provided care to patients in the ED. Paramedic #2 explained his responsibilities included applying and discontinuing restraints. When determining if a patient was safe to have restraints removed, Paramedic #2 stated his process included taking one arm out of a restraint and assess the patient for 15 minutes to see if the behavior was maintained. If the patient remained calm, he would take the other arm out of the restraint.

c. On 7/4/18 at 4:59 p.m., an interview was conducted with a registered nurse (RN #3), who stated she provided care to patients in the ED. RN #3 stated when removing behavioral restraints she would typically start with one restraint at a time, wait 15 minutes, then continue until all restraints were off.

d. On 7/5/18 at 8:17 a.m., an interview with the Clinical Manager of the ED (RN #4) was conducted. RN #4 stated the facility's expectation was to never have one arm restrained while the other arm was not. RN #4 explained the risk involved with having only one arm restrained at a time included the potential of patients getting out of the stretcher and harming themselves by pulling the stretcher behind them. RN #4 further stated she was unaware staff were utilizing this process when discontinuing behavioral restraints.