HospitalInspections.org

Based on observation, interview and hospital clinical record review, hospital policy and procedure, and other hospital documentation review it was determined the hospital failed to ensure the patient had the right to receive care in a safe setting (A144), the right to confidentiality of patient records (A146), failed to ensure the use of restraints was in compliance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 481.12 (c) an authorized to order restraint or seclusion by hospital policy in accordance with state law (A168), failed to ensure the condition of the patient who is restrained or secluded must be monitored by a physician other licensed independent practitioner or trained staff that have completed training criteria specified in paragraph (f) of this section at an interval determined by the hospital (A175), failed to ensure the patient was seen face-to-face within one hour after the initiation of the intervention (A179), failed to ensure when restraint or seclusion is used, there must be documentation in the patient's medical record of alternatives or other least interventions were attempted (A186). 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 medical record review, staff interview, facility documentation review and policy and procedures review, the hospital failed to implement a plan to ensure all patients received care in a safe environment following an incident where a Taser weapon was used on Patient #9. A total of of 11 patient medical records were reviewed. The facility census was 163.


Findings include:


Review of the medical record of Patient #9 revealed the patient arrived at the hospital emergency department (ED) via the local emergency medical squad from a local psychiatric outpatient agency on the evening of 06/04/16 under an involuntary admission for psychiatric care. The medical record revealed Patient #9 was admitted with a diagnosis of schizophrenia and was mediated with anti-anxiety and anti-psychotic medications. Patient #9 was monitored closely by the behavioral staff of the emergency department per policy.

The documentation revealed the patient's status remained controlled and uneventful until 06/05/16 when Patient #9 viciously attacked a hospital laboratory staff member as well as a responding security staff member while the lab tech was attending another patient located in the same unit as the patient. A second security guard arrived and neither of the guards could halt the vicious attack on the lab staff person. Documentation revealed Patient #9 failed to respond to security's verbal commands to stop, verbal warnings a Taser would be used, or attempts by two security staff to physically separate Patient #9 from the lab tech. Failed attempts to separate the patient from the hospital laboratory technician resulted in the need to deploy a Taser intervention to ensure safety of hospital staff and to control the patient.

Review of the facility's policy and procedure entitled, Taser, and electronic Control Device with a last revision date of 05/15 revealed the use of the Taser by trained and authorized personnel is permitted. Use of the Taser is authorized when it reasonably appears that an attempt to use other less lethal options would endanger the safety of the subject, officer, or any bystander in the area.

Review of the hospital's incident analysis documentation and resulting action plan was conducted in the presence of Staff A and C on 08/15/16 at 9:15 AM. The hospital determined that Patient #9's behavioral assessment was incomplete and failed to identify increased psychiatric escalation by Patient #9 which resulted in the attack on laboratory Staff E. The analysis documented Staff E continued to work despite the escalation of Patient #9's behaviors. The hospital's conclusion determined that staff failed to respond early enough to escalation of Patient #9's behaviors.

Review of the hospital's Action Plan, part one, directed that all laboratory staff will always check with the behavioral unit office prior to approaching patients and will always be accompanied by behavioral unit staff into the patient care area. The status of this action plan documented that 100 percent of laboratory staff was in-serviced and compliant. Review of Action Plan, part two, of the hospital's action plan documented that the behavioral health director would educate ED behavior health staff by 07/15/16 and that the in-patient behavioral staff education would be completed by 08/15/16.

The completion status of part two of the Action Plan failed to contain any compliance percentages related to completeness status. Additionally, the plan lacked any documentation the entire hospital staff would be educated in regard to recognition of escalation of psychotic behaviors in patients. These findings were confirmed at the time of the first review of the analysis and action plan on 08/15/16 as stated above.

Interview with multiple nursing staff members during hospital tour conducted on 08/15/16 from 08/15/16 at 9:53 AM through completion in emergency department at 3:23 PM revealed when staff were interviewed in relation to receipt of recent in-services and education related to recognition of behavior escalation in the psychiatric patient all staff interviewed verbalized there was no recent education in the preceding two months to current date of 08/15/16.

Interview with Staff D on 08/16/16 at 10:49 AM verbalized he/she assisted with the development of the resulting action plan with regard to the incident which involved Patient #9. Staff D verbalized he/she was tasked with development of education in-services for both the inpatient and ED behavior health staff as well as the laboratory staff. Staff D verbalized the action plan documented the completion of education of the emergency department behavior health staff was to be completed by 07/15/16 and the hospital's behavioral health in patient unit staff documented for completion by 08/15/16.

Staff D failed to provide details related to the education of the entire facility. Staff D continued to explain that education materials for the hospital's behavioral units were still in the developmental stages and would not be added to the hospital's electronic computer education learning system until the end of the current week (08/20/16). Staff D confirmed the hospital was unable to provide the education agenda or sign in sheets which documented the facility's laboratory staff was completed and confirmed behavioral staff was not educated per the action plan.


In an interview with administrative Staff A and Staff C on 08/16/16 at 2:18 PM, Staff A verbalized that during the cause analysis process along with the development of the Action Plans the usual process was to expect completion of the Action Plan between 30 and 60 days. Staff A verbalized the expectation of staff would be if additional time were required to complete the Action Plan, communication of this need would be reflected in documentation in the completion status area of the action plan tool.

Staff A confirmed the completion dates for both of the facility's behavioral patient care areas had elapsed and was unable to provide documentation the facility's behavioral staff were educated. Prior to 08/16/16 there was no updated status in the progress of completion of part two of the facility's Action Plan.

A final request to Staff A for the agenda and sign in sheets for the education of the laboratory staff was requested on 08/16/16 at 2:18 PM. Staff A confirmed the facility was unable to provide any documentation the laboratory staff was educated to the Action Plan, any completion status that both the staff of the facility's ED and in-patient behavioral health units were educated nor was the facility able to provide a plan to educate the entire hospital staff in the early recognition of escalation of psychotic behaviors to ensure care in a safe setting.

Based on observation, medical record review, staff interview and facility policy and procedure the facility failed to secure medical records from unintended access for one of 11 patients ( Patient #11) reviewed for confidentiality of medical records. The facility census was 163.


Findings include:


Review of the agency's policy and procedure entitled Patient Rights and Responsibilities with a most recent revision date of 11/2013 directed that Patient Rights included full consideration of privacy concerning medical care and confidential treatment of all records pertaining to your care and stay at the hospital.

Observational tour of the hospital's one west unit conducted on 08/15/16 at 9:54 AM revealed the wall unit outside the door to Patient #11's room was observed to be open and exposed a flat horizontal surface. Patient #11's medical record was on this surface. There were no staff observed in the immediate vicinity of Patient #11's room. Patient #11's chart was able to be viewed without the knowledge of the unit's staff. The medical record was observed to contain identifying information related to Patient #11 such as name, date of admission, demographic information and billing information , telephone numbers, as well physician documentation.

Interview with Staff F on 08/15/16 at 9:54 AM confirmed Patient #11's chart was left unattended and contained confidential information, that no unit staff were observed in the vicinity, and that outsiders and visitors do visit the unit throughout the course of the day. Staff F confirmed this finding at this time.

Based on policy review, medical record review, and staff interview; the facility failed to ensure all restrained patients had restraint orders documented in the medical record. This affected one of four medical records with restraints used for violent or self destructive behavior (Patient #8). A total of ten medical records were reviewed. The hospital census was 163.


Findings include:


Review of the "Physical Restraint" policy revealed an order must be obtained for each restraint applied. Documentation of a restraint order includes the date and time of the order, duration of the order, rationale for restraint, type of restraint, less restrictive interventions that were ineffective, and the physician's signature with date and time of signature.

Review of the medical record for Patient #8 revealed the patient was brought to the emergency department on 06/01/16 by ambulance with restraints in place due to patient attempt to jump out of the ambulance on the way to the hospital and combative behavior toward the staff. The medical record contained documentation of bilateral wrist and ankle hard restraints placed on the patient from 4:36 PM to 6:33 PM on 06/01/16. The medical record lacked documentation of an order for restraints on 06/01/16.

This was verified by Staff A at 9:21 AM on 08/16/16.

Based on policy review, medical record review, and staff interview; the facility failed to ensure all restrained patients had documentation of patient monitoring every fifteen minutes while restrained. This affected two of four medical records with restraints used for violent or self destructive behavior (Patients #8 and #10). A total of 10 medical records were reviewed for restraints. The facility census was 163.


Findings include:


Review of the "Physical Restraint" policy revealed monitoring of the patient restrained for violent or self destructive behavior be documented every 15 minutes. The documentation was to include checking circulation and proper restraint applied, psychological and physiological status and comfort, nutritional and hydration status, hygiene and elimination needs, readiness for removal of restraints, food and fluid offered, toileting offered, range of motion reposition, and skin integrity checked. In addition, assistance to meet behavioral expectations of discontinuation of restraints and recognizing the need to contact medically trained staff to assess physical status were to be documented as well.

Review of the medical record for Patient #8 revealed the patient was in locked seclusion on 06/04/16 from 9:25 AM to 1:15 PM. The medical record lacked documentation of fifteen minute assessments from 11:10 AM to 1:15 PM on 06/04/16.

Review of the medical record for Patient #10 revealed the patient was in bilateral hard wrist and ankle restraints on 08/16/16 from 3:40 AM to 6:00 AM. The medical record lacked documentation of fifteen minute assessments from 3:40 AM to 4:15 AM.

This was verified by Staff A at 9:21 AM on 08/16/16.

Based on policy review, medical record review, and staff interview; the facility failed to ensure all patients restrained for violent or self destructive behaviors had face to face evaluations by a physician within one hour of restraint initiation documented in the medical record. This affected three of four medical records with restraints used for violent or self destructive behavior (Patients #7, #8, and #10). A total of ten medical records were reviewed for restraint use. The facility census was 163.


Findings include:


Review of the "Physical Restraint" policy revealed any patient restrained or secluded for violent or self destructive behaviors must be seen within one hour of restraint initiation by a physician or licensed independent practitioner. The face to face assessment must include documentation of the immediate situation, medical and behavioral condition, the patient's reaction to the intervention, suggestions on how to help the patient regain control, and the need to continue the restraints.

Review of the medical record for Patient #7 revealed the patient was restrained with bilateral hard wrist and ankle restraints on 07/30/16 from 7:10 PM to 10:50 PM. The face to face was documented at 10:25 PM on 07/30/16.

Review of the medical record for Patient #8 revealed the patient was brought to the emergency department on 06/01/16 by ambulance with restraints in place due to patient attempt to jump out of the ambulance on the way to the hospital and combative behavior toward the staff. The medical record contained documentation of bilateral wrist and ankle hard restraints placed on the patient from 4:36 PM to 6:33 PM on 06/01/16. The patient was seen by a physician in the emergency department at 5:05 PM on 06/01/16, but the physician's documentation did not mention restraints. The medical record lacked documentation of a face to face assessment for restraints.

Review of the medical record for Patient #10 revealed the patient was restrained with bilateral hard wrist and ankle restraints on 08/16/16 from 3:40 AM to 6:00 AM. The order dated 08/16/16 at 3:40 AM for the restraint was signed by the physician, however the details of the face to face assessment were not documented. The section of the "Restraint Order for Violent/Destructive Behavior" form to be completed by the physician was blank except for the signature.

This was verified by Staff A at 9:21 AM on 08/16/16.

Based on policy review, medical record review, and staff interview; the facility failed to ensure all restrained patients had least restrictive measures attempted prior to restraint use documented in the medical record. This affected one of four medical records with restraints used for violent or self destructive behavior (Patient #8). A total of ten medical records were reviewed for restraint use. The facility census was 163.


Findings include:


Review of the "Physical Restraint" policy revealed an order must be obtained for each restraint applied. Documentation of a restraint order includes the date and time of the order, duration of the order, rationale for restraint, type of restraint, less restrictive interventions that were ineffective, and the physician's signature with date and time of signature.

Review of the medical record for Patient #8 revealed the patient was brought to the emergency department on 06/01/16 by ambulance with restraints in place due to patient attempt to jump out of the ambulance on the way to the hospital and combative behavior toward the staff. The medical record contained documentation of bilateral wrist and ankle hard restraints placed on the patient from 4:36 PM to 6:33 PM on 06/01/16. The medical record lacked documentation of any less restrictive measures attempted prior to the use of restraints in the emergency department on 06/01/16.

This was verified by Staff A at 9:21 AM on 08/16/16.