HospitalInspections.org

Based on hospital policy and procedure reviews, Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training material review, Quality Care Control Report reviews, Daily Security Report reviews, closed and open medical record reviews, video surveillance footage review, education training transcript reviews, staffing schedule reviews, Centers for Medicare and Medicaid (CMS) Services, Appendix A, Interpretive Guidelines review, observation during tours, observations as referenced in the Life Safety Report of survey completed 02/06/2014, cleaning and humidity log reviews, round report reviews, meeting minutes reviews, work order reviews, and staff and patient interviews, the hospital's leadership failed to provide oversight and have systems in place to ensure the protection of patients' rights; failed to ensure an effective QAPI program to investigate, analyze and implement corrective actions for adverse events; failed to have an organized nursing service to ensure the provision of patient care in a safe environment; failed to develop and maintain the facilities in a manner to ensure the safety of patients; failed to prevent and control the spread of hospital-acquired infections and surgical site infections; and failed to meet the emergency needs of behavioral health patients in accordance with acceptable standards of practice.

The findings include:

1. The hospital failed to protect and promote patients' rights for a safe environment for patients by failing to ensure care was provided in a safe setting by qualified and competent staff as evidenced by failing to implement restraint in accordance with safe and appropriate restraint techniques and physical restraint devices during a restrictive intervention for 1 of 1 patients (#37) restrained for violent and/or self destructive behaviors.


~cross refer to 482.13 Patient Rights Condition: Tag A0115

2. The hospital failed to ensure an effective, on-going, data-driven quality assessment and performance system monitoring actions for the use of restraints and non-crisis intervention for behavioral health patients in the hospital's Emergency Department (ED) and failed to identify a cause and analyze surgical site infection (SSI) trends.

~cross refer to 482.21 QAPI Condition: Tag A0263

3. The hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure registered nursing staff supervised and evaluated patient care.

~cross refer to 482.23 Nursing Condition: Tag A0385

4. The hospital staff failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~cross refer to 482.41 Physical Environment Condition: Tag A0700

5. The hospital staff failed to prevent and control the spread of hospital-acquired infections and surgical site infections.

~cross refer to 482.42 Infection Control Condition: Tag A0747

6. The hospital failed to meet the emergency needs of behavioral health patients in accordance with acceptable standards of practice.

~cross refer to 482.55 Emergency Services Condition: Tag A1100

Based on hospital policy and procedure reviews, Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training material review, Quality Care Control Report review, Daily Security Report reviews, closed medical record review, video surveillance footage review, education training transcript reviews, staffing schedule reviews, staff interviews and the Centers for Medicare and Medicaid (CMS) Services, Appendix A, Interpretive Guidelines, the hospital failed to protect and promote patients' rights for a safe environment for patients by failing to ensure care was provided in a safe setting by qualified and competent staff as evidenced by failing to implement restraint in accordance with safe and appropriate restraint techniques and physical restraint devices during a restrictive intervention for 1 of 1 patients (#37) restrained for violent and/or self destructive behaviors.

The findings include:

1. The hospital's staff failed to ensure care was provided in a safe setting by qualified and competent staff as evidenced by failing to implement restraint in accordance with safe and appropriate restraint techniques and physical restraint devices during a restrictive intervention for 1 of 1 patients (#37) restrained for violent and/or self destructive behaviors.

~cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144

2. The hospital's staff failed to ensure the patient's right to be free from all forms of abuse or harassment by failing to provide goods and services in a manner necessary to avoid physical, harm, mental anguish, or mental illness during a restrictive intervention for 1 of 1 patients (#37) restrained for violent and/or self destructive behaviors.

~cross refer to 482.13(c)(3) Patient Rights Standard: Tag A0145

3. The hospital's staff failed to implement restraint in accordance with safe and appropriate restraint techniques for 1 of 1 patients (#37) restrained with handcuffs for violent and/or self destructive behaviors.

~cross refer to 482.13(e)(4)(ii) Patient Rights Standard: Tag A0167

4. The hospital's staff failed to ensure a physician's restraint order was time limited for no longer than four (4) hours for 1 of 1 adult patients (#37) that was restrained for the management of violent or self-destructive behaviors.

~cross refer to 482.13(e)(8) Patient Rights Standard: Tag A0171

5. The hospital staff failed to monitor and assess a restrained patient per hospital policy for 1 of 1 patients (#37) restrained for the management of violent or self-destructive behaviors.

~cross refer to 482.13(e)(10) Patient Rights Standard: Tag A0175

6. The hospital failed to ensure Emergency Department physicians completed restraint and seclusion training per policy.

~cross refer to 482.13(e)(11) Patient Rights Standard: Tag A0176

7. The hospital failed to ensure the physician or other licensed independent practitioner conducting the face-to-face evaluation within 1 hour after the initiation of restraint evaluated the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint for 1 of 1 patients (#37) restrained for the management of violent or self-destructive behaviors.

~cross refer to 482.13(e)(12) Patient Rights Standard: Tag A0179

8. The hospital failed to ensure Emergency Department and Security staff were trained in the use of non-physical intervention skills for 4 of 8 Emergency Department and Security staff (RN #2, RN #3, RN #4, and SO #1).

~cross refer to 482.13(f)(2)(ii) Patient Rights Standard: Tag A0200

9. The hospital failed to ensure education/training records for Emergency Department and Security staff contained documentation of training and demonstration of competency for restraint and non-physical intervention skills were successfully completed for 4 of 8 Emergency Department and Security staff (RN #2, RN #3, RN #4, and SO #1).

~cross refer to 482.13(f)(4)Patient Rights Standard: Tag A0208

Based on hospital policy and procedure reviews, Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training material review, Quality Care Control Report review, Daily Security Report reviews, closed medical record review, video surveillance footage review, education training transcript reviews, staffing schedule reviews, and staff interviews, the hospital's staff failed to ensure care was provided in a safe setting by qualified and competent staff as evidenced by failing to implement restraint in accordance with safe and appropriate restraint techniques and physical restraint devices during a restrictive intervention for 1 of 1 emergency department (ED) patients (#37) restrained for violent and/or self destructive behaviors.

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "1. POLICY: The governing body, administration, the Medical Staff and the patient care team....are equally committed to the provision of a safe environment. ...Restraints are never to be used as punishment, for convenience of staff or in response to behaviors or circumstances that do not constitute danger of injury to self or others. ...Only approved manufactured physical restraints will be used and manufacturer's directions will be followed. ...III. RESTRAINT DEFINITIONS: Physical 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. ...Physical Holding for Forced Medications - Physically holding a patient during a forced psychotropic medication procedure is considered a restraint.... . If physical holding for forced medication is necessary with a violent patient, a restraint order must be obtained using the VIOLENT/SELF DESTRUCTIVE BEHAVIOR RESTRAINT ORDER FORM. ...IV. PROCESS: ...VIOLENT/SELF DESTRUCTIVE BEHAVIOR RESTRAINT ...Restraint or seclusion can only be used when less restrictive interventions have been tried and caregivers are not able to protect the patient, a staff member, or others from harm. ...The USE OF ANY RESTRAINTS FOR VIOLENT/SELF DESTRUCTIVE BEHAVIOR REQUIRES ONE-TO-ONE STAFF. AND MONITORING EVERY 15 MINUTES ...ASSESSMENT An assessment of the patient will occur at the time of the initiation of restraint and every 15 minutes thereafter and will include: a. Type of restraint b. Skin at restraint site c. Circulation d. Respirations e. Range of motion f. Patient position g. Is bed alarm on h. Fluid/Nourishment offered i. Toilet j. Behavior Observed k. Restraint properly applied l. Additional interventions attempted m. Restraint removed n. Patient education o. Order up to date p. Restraint use indicted/not indicated. DOCUMENTATION ...b. Using the Restraint Management Plan of Care Form, nursing staff members monitor and reassess the needs of the patient every 15 minutes using the Restraint Management Plan of Care.... . ...V. PERSONNEL AUTHORIZED AND QUALIFIED TO APPLY RESTRAINTS * Patient Care Services Personnel who have demonstrated competency by annual completion of....Restraint Management Program. ..."

Review of current hospital policy "Security Measures" Policy S-121-201, revised 02/18/2013, revealed "...TRAINING: All Security personnel shall receive security training adequate to perform their job functions. ...RESPONSIBILITIES: * Security personnel stationed at the hospital shall be responsible for the following: ...* Staff assistance with patient restraint and intervention in disruptions by patients, visitors or staff ...."

Review on 02/07/2014 of Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training materials, copyright 2009 (reprinted 2013), revealed "Unit I: The CPI Crisis Development Model." Review revealed "...Definitions 1. Anxiety: A noticeable increase or change in behavior. A nondirected expenditure of energy; e.g., pacing, finger drumming, wringing of the hands, or staring. ...2. Defensive: The beginning stage of loss of rationality. At this stage, an individual often becomes belligerent and challenges authority. ...3. Acting-Out Person: The total loss of control, which results in a physical acting-out episode. ...4. Tension Reduction: A decrease in physical and emotional energy that occurs after a person has acted out, characterized by the regaining of rationality. ...Review of "Unit II: Nonverbal Behavior" revealed "...The CPI Supportive Stance" and "Reasons for using the CPI Supportive Stance 1. Communicates respect by honoring personal space. 2. Is nonthreatening/nonchallenging. 3. Contributes to staff's personal safety if attacked/offers an escape route." Review of "Unit VIII: Nonviolent Physical Crisis Intervention and Team Intervention" revealed "The Nonviolent Crisis Intervention program is a safe, nonharmful behavior management system designed to help human service professional provide for the best possible care and welfare of disruptive, assaultive, and out-of-control persons--even during their most violent moments. In Nonviolent Crisis Intervention training, the emphasis is always on your primary responsibility: the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint is recommended only when all less restrictive methods of intervening have been exhausted, and when the individual presents a danger to self or others. ...Risks involved with physical intervention can be minimized when staff members regularly practice and rehearse procedures for team interventions. Further review revealed "CPI TEAM CONTROL POSITION" and "The CPI Team Control Position is used to manage individuals who have become dangerous to themselves or others. Two staff members hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist, if needed. During the intervention, staff members who are holding the individual should: *Face the same direction as the acting-out person while adjusting, as necessary, to maintain close body contact with the individual. * Keep their inside legs in front of the individual. ...*Bring the individual's arms across their bodies securing them to their hip areas. ...*Place the hands closest to the individual's shoulders in a C-shape position to direct the shoulders forward. ...Control Dynamics 1. Reduce upper-body strength by controlling the arms as weapons. 2. Reduce lower-body strength by controlling the back incline. 3. Reduce mobility by close body contact." Further review revealed "CPI TRANSPORT POSITION" and "The CPI Transport Position will assist you in safely moving an individual who is beginning to regain control. Prior to moving an individual, assist the person into a more upright position and remove your hand from the individual's shoulder. Reach under the individual's arm to grab your own wrist. This cross-grain grip better secures the individual between staff during transport. Remove your leg from directly in front of the individual prior to transport while maintaining close body contact. ...Further review revealed "CPI INTERIM CONTROL POSITION" and "The CPI Interim Control Position is a temporary control position that allows you to maintain control of both of the individual's arms, if necessary, for a short time. Starting from the CPI Transport Position, maintain control of the individual's arm, but release the cross-grain grip. Use your free arm to reach across and gain control of the opposite arm. ...If the individual attempts to strike, use your free arm to block, and safely move away. ..." Review of "Appendix: A Practical Approach for Managing Violent Behavior" revealed "...Team Intervention All of the intervention concepts are best utilized when a team of professionals intervenes. ...Why Nonviolent Crisis Intervention Training? A fundamental purpose of the Nonviolent Crisis Intervention training program is to help people understand the process of behavior escalation and to recognize that people don't act out in a vacuum. The staff member who intervenes with the potentially violent person must realize that her behavior has a tremendous impact on that individual. In any cases, the subsequent escalation or defusion of the person's behavior may depend entirely on how that staff member reacts. Nonviolent Crisis Intervention training stresses that crisis interventions is an integrated process. ...In an effort to maximize the chance of calming the person, it is best to balance or offset the person's behavior with therapeutic responses by staff. The therapeutic environment should be maintained continually, even during the most violent moments. ...By using safer, nonharmful techniques taught in the Nonviolent Crisis Intervention program, it is more likely that the therapeutic relationship you have worked so hard to develop can be maintained." Review of "Appendix: Understanding the Risks of Restraints" revealed "...Dangers of Restraints ....restraints should only be used when a person's behavior is MORE dangerous than the danger of using restraints. Some restraints are more dangerous than others. For example, facedown (prone) floor restraints and positions in which a person is bent over in such a way that it is difficult to breathe are extremely dangerous. This includes a seated or kneeling position in which the person being restrained is bent over at the waist and any facedown position on a bed or mat. Restraint-related positional asphyxia occurs when the person being restrained is placed in a position in which he cannot breathe properly and is not able to take in enough oxygen. Death can result from this lack of oxygen and consequent disturbance in the rhythm of the heart. Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breathe. This includes sitting or lying across a person' back or stomach. When someone is lying facedown, even pressure to the arms and legs can impact the person's ability to breathe effectively. ...When confronted with an emergency situation, always consider the option of disengaging. If the persons is not a danger to self or others while on the floor, staff may make the decision to move away and give a clear directive. Reducing the Risks of Restraints ...Staff members should be trained in and regularly practice safer ways of restraining. ...A physical restraint is an emergency procedure...As with any emergency response procedure, staff members need to practice these skills on a regular basis. ...Key elements of Nonviolent Physical Crisis Intervention responses include: * No element of pain involved. * The intent is to calm the individual. * The intent is to keep the individual off the floor, thus reducing risks of restraint-related positional asphyxia and other injuries. * Team interventions are used when necessary. * Nonviolent Physical Crisis Intervention is used only as a last resort when someone presents a danger. * Nonviolent Physical Crisis Interventions is used to protect - not to punish. The goal is for staff....is to eliminate the need for restraints at all."

Review on 02/05/2014 of a Quality Care Control Report completed by the ED Director on 08/15/2013 regarding a "Behavioral Variance" occurring on 08/07/2013 at 2310 in ED III, involving Patient #37, revealed "Pt (patient) yelling + (and) swearing at staff....(RN name) called for assistance to help with situation. Pt pacing in room. Staff went into give pt. medication shot. Pt refused shot. Pt backed up into corner. 3 male staff tried to secure pt for shot. Pt hit RN....Pt held + shot given. Pt verbally + physically resistant to staff. Handcuffs from security placed on pt by RN. Pt put in sitting position. Police arrived. Spoke to patient. Pt assisted to stretcher, handcuffed to stretcher. Handcuffs removed, pt placed in 4 point soft restraints. Pt became calm. MD assessed pt. Restraints removed one at a time." Review revealed the staff involved were identified as RN #1, RN #2, RN #3, RN #4, RN #5, RN #6, RN #7, SO #1 and SO #2.

Review on 02/07/2014 of a "Daily Security Report" dated 08/07/2013 from 1600 to 0030 completed by SO #1 revealed "...2330 patient in and out of room many times Nurse ask him to go back in the room and stay. Patient refused and started cussing nurse asked patient to get quiet. And was asked if he wanted a shot to help to rest and he refused said they could not give him the meds in the shot called for help to give injection and patient became combative and RPD (local police department). Was called. patient knocked hole in wall with elbow. ..."

Review on 02/07/2014 of a "Daily Security Report" dated 08/08/2013 from 0000 to 0800 completed by SO #2 revealed "2340 (08/07) Went to ED III Room #2 to assist with a patient that RPD was called on. ...0006 (08/08) Started one on one ED III Room #2 ref (reference) subject was placed in restraint 0115 Assisted in removing Restraint one limb at a time every 15 minute last one removed on Thursday 8 of August 0230 Clear one on one. ..."

Closed emergency department (ED) record review on 02/05/2014 for Patient #37 revealed a 26 year old male who presented to the hospital's ED on 08/03/2013 under involuntary commitment (IVC) petition for psychiatric evaluation. Review revealed the patient was diagnosed with "substance abuse disorder." Review revealed the patient was held in the ED from 08/03/2013 until 08/13/2013 (11 days), awaiting placement at a psychiatric hospital. Review revealed on 08/13/2013 the patient was reassessed by the ED physician as "...no longer meets criteria for inpatient treatment" and was subsequently released from IVC petition and discharged from the ED. Review of nursing documentation by RN #6 on 08/07/2013 at 2329, revealed "Approximately 2310 patient went from washing his hands in room to hall sink to wash hands back to room to wash hands and to sink again to wash hands, at the sink he looked at this RN and looked like he was asking a question, this RN asked what he needed but couldn't here [sic] him, this RN then went to doorway of nurses station and asked, '(Patient #37 name), I couldn't hear you, what did you need?' At that point patient started yelling 'I'm singing a Marilyn Manson song, can't someone just sing a song without you f**king getting in their face.' (RN #2 name), RN spoke to patient and asked him to stop yelling and to stop swearing, patient started yelling more and posturing, this RN called on radio that assistance was needed in ED III--(RN #1 name), RN, (RN #4 name), RN, (SO #1 name)--Security, (RN #3 name), RN came to assist, patient starting yelling more and swearing louder. Patient was told he was going to get a shot of Geodon (antipsychotic) if he did not settle down, he just kept yelling, this RN called communications and used hand radio again to notify charge RN (RN #7 name) that communications was called, patient kept yelling and swearing, the other RNs continued to try to talk patient down but patient kept yelling, this RN got the Geodon and prepared it, medication was given while male nurses secured patient, patient remained secured until officers (Law Enforcement Officers) arrived to help with situation, officers requested patient's IVC papers and discussed this with patient, patient did hit (RN #2 name), RN in the jaw and kicked in the shins--report filed, ....(SO #2) from security came on shift and is now present also--sheets have been removed from bed and officers have patient handcuffed to bed, (RN #7), RN talking to officers about handcuffs and (ED Physician #1 name) has walked in at 2345 to assess patient and speak to officers and staff. 1:1 in place with (SO #2 name)--security, restraint orders in place, verified with (RN #7), RN and (RN name), RN from BH (Behavioral Health)." At 0035, revealed "(RN #2 name), RN is being checked for injuries....there is a bruise on patient's l-arm (left arm)--discussed with (SO #1 name) from security--stated the patient had that bruise prior to incident, VS (vital signs) checked as ordered and patient, patient continues to argue that he does not need restraints, when he asked when restraints would be removed, this RN explained when it was safe for him and staff restraints would be removed--patient slammed the bed rail and complained again about his 'f**king situation'. Explained to him that type of behavior would keep him in the restraints. Patient has been offered and given ice water, he is currently being assisted by security to help with urinal." At 0106, revealed "....patient was moved up in bed with assistance from (SO #2 name) from security....patient appeared to be sleeping, VS taken but when patient started to kick a little and argued about being in restraints, is able to turn from l-to-r (left to right), patient did urinate 425 mL (milliliters) with assistance by (SO #2 name), security, patient has continually been offered ice water and given when requested, patient remains agitated but not as noticeable at this time." At 0119, revealed "patient is sleeping but restless with sleep--pulling at restraints at times--this RN called (RN name), RN BH and (RN #7 name), Charge RN to verify taking restraints off--advised to remove one restraint at a time--opposite of each other--l-wrist (left wrist) is removed at this time--1:1 continues with (SO #2 name), Security--he assisted with removing first restraint." At 0131, revealed "r-ankle (right ankle) restraint removed, (SO #2 name) from security is assisting patient with urinal, explained to patient that two restraints have been removed and will continue to remove one at a time if patient remains cooperative, patient did request to urinate--was ambulated by (SO #2 name) from security to BR (bathroom) and returned to room where two restraints were reapplied, patient fell asleep during reapplication." At 0152, revealed "spoke to (RN #7), Charge RN and (ED Physician #1 name) that patient is restless only when VS are checked but is sleeping otherwise--3rd restraint to r-wrist (right wrist) removed, last restraint will be removed at 0200 if patient continues to sleep and remain cooperative, patient sleepily stated he did not want anything to drink at this time." At 0207, revealed "(ED Physician #1) and (RN #7), RN notified that patient's 4th restrain [sic] has been removed, 1:1 will continue until 0230 by (SO #2 name) from security as is ordered in paperwork, patient verbally stated during 0145 VS that he understood, (RN name), RN BH notified as well and advised to continue 1:1 for 30 minutes--advised this is being done, patient is completely self turning at this time--l-arm (left arm) noted earlier as having a bruise--also noted at this time that it is a healing scar with bruising about it." At 0233, revealed "restraints remain off, 1:1 discontinued...." At 0402, revealed "Sergeant (name) arrived at 0400--advised ED staff that patient has one misdemeanor injury to real property and one felony for assault on ED staff--(RN #2 name), RN, we are to notify communications dept (department) when patient is to be dc'd (discharged) from (hospital) or after transfer and release from additional facility....that patient is to be arrested for these charges." Record review revealed the patient was discharged to jail on 08/13/2013.

Review on 02/05/2014 at 1615 with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Quality and Risk Management, Director of Security, Emergency Department Director, and the hospital's Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) Certified Instructor (CI #1) of video surveillance footage without audio; dated 08/07/2013, time interval 23:10:00 to 23:55:00; from hospital security camera, ED III Room 2 revealed at:
23:10:00 to 23:17:59 - Patient #37 observed in treatment room. Holding book in hands. Placing book on and off counter top. Exits and re-enters room two times. Speaking towards doorway. Drinking from container with straw. Pacing within room. Shadows observed at doorway. No physical aggression observed.
23:18:00 - Patient observed standing in room with left side of body adjacent to cabinet/countertop with left hand on countertop. Patient is facing direction of door. Male staff member (RN #1) enters room and goes over to patient's right side. RN #1 carrying medication syringe (Geodon). RN #1 begins to swab/wipe the patient's right shoulder with antiseptic/alcohol wipe. Two male staff members (RN #2, RN #3) appear in doorway. No physical aggression is observed by patient towards staff.
23:18:14 - Patient walks away from cabinet/countertop and RN #1. Patient walks across room to left rear corner of room and turns his back towards the wall, facing staff members. Patient and staff members engaging in verbal communication. Three male staff members are present inside room (RN #1, RN #2, RN #3). No physical aggression is observed by the patient towards staff.
23:18:29 - A fourth male staff member (SO #1) appears at doorway of room.
23:18:38 - SO #1 reaches into room and turns lights on. Patient stands in left rear corner of room with back towards wall. Patient has his hands behind his back. Patient and staff engaging in verbal communication. No physical aggression is observed by the patient towards staff.
23:19:19 - Patient in left rear corner of room with back towards wall. RN #1, RN #2, and RN #3 start moving closer towards patient from three sides (in a corralling stance). No physical aggression is observed by the patient towards staff.
23:19:24 - A fifth male staff member (RN #4) enters room. Patient remains in left rear corner of room with his back to wall, facing staff members. RN #1, #2, #3, #4 in room. SO #1 at doorway.
23:19:47 - Patient remains in left rear corner of room with back towards wall. Facing staff. No physical aggression is observed by the patient towards staff.
23:19:50 - Patient steps backward further into left rear corner of room (away from staff). Patient's arms are crossed in front of chest. No physical aggression is observed by patient towards staff. RN #2 and RN #3 begin approaching patient.
23:19:51 - Patient with back against wall in left rear corner of room, facing staff. Patient arms crossed in front of chest. No physical aggression observed by patient towards staff. Staff observed in a "corralling stance" and then rapidly advance towards patient. RN #2 reaches towards patient and appears to make physical contact with left chest/axilla area of patient. Patient extends left arm outward towards RN #2 and appears to make contact with RN #2. Patient swings right arm and appears to strike RN #2 in left side of face/jaw area. RN #3 reaching towards patient and appears to make contact with the patient's right shoulder. Patient appears to be pushed up against wall of room. Two additional male staff members (RN #4 and RN #5) enter room to assist.
23:19:52 - Patient appears to strike RN #2 in back of neck two times with his right arm. Patient is held against rear wall by male staff members.
23:19:54 - Patient held against wall by male staff members. SO #1 and RN #1, #2, #3, #4 in room. RN #6 enters room and stands at door.
23:19:59 - Patient is held against wall by male staff members.
23:20:03 - SO #1 is observed grabbing patient's left leg and pulling/holding the leg up off the floor. RN #2, RN #3, and RN #4 observed holding patient up against wall.
23:20:05 - RN #3 is observed with his left arm around patient's neck in a "head lock" type position pulling downward.
23:20:11 - The patient is held against the wall. RN #3 is observed with his left arm around patient's neck in a "head lock" type position. RN #2 is observed holding the patient's extended left arm up against the wall. SO #1 is observed holding the patient's left leg up off the floor. RN #1 is observed approaching the patient with a medication syringe in his left hand.
23:20:12 - A male staff members gloved hand is observed covering the patient's chin/mouth area. The patient's neck is observed being hyper-extended backwards.
23:20:13 - The patient is observed being held against the wall. RN #3 is observed with his left hand around the patient's neck. A gloved hand is covering the patient's chin and his neck is hyper-extended backwards. The patient's left arm is bent behind his back by RN #2. SO #1 is holding the patient's leg off the floor. The patient appears to be in a contorted/flexed position.
23:20:14 - RN #1 is observed with a syringe in his left hand.
23:20:21 - Patient is observed to be pulled down onto floor with staff on top of patient.
23:20:28 - RN #1 is observed administering the IM medication to the patient's left arm.
23:20:45 - Patient with head held to floor by gloved hand of RN #3. Gloved hand pushing head downward to floor. Patient body appears contorted/flexed. Staff over patient.
23:20:55 - Patient observed on floor, on left side. RN #2 observed with his left knee against small of patient's back. Staff holding patient down on floor.
23:21:19 - SO #1 is observed removing handcuffs from belt case.
23:21:33 - Staff holding patient down on floor. Three staff members on top of patient, RN #5 enters room.
23:21:38 - SO #1 is observed handing handcuffs to RN #2.
23:21:42 - Patient remains on floor. RN #7 enters room.
23:21:46 - RN #7 exits room.
23:21:53 - Patient on floor on lateral right side, torso is bent forward at waist (fetal like position). Pants pulled down and entire buttocks exposed.
23:21:57 - RN #2 is observed over the patient with his leg over the patient's leg. Patient is held down to floor by male staff members. Patient appears to be on side.
23:22:04 - Patient on floor. Appears to be on right side/facing downward on floor. RN #2 is observed placing a handcuff on patient's left wrist.
23:22:07 - RN #2 is observed placing a handcuff on patient's right wrist.
23:22:08 - Patient's is observed with hands handcuffed behind back. Lying on right lateral side. Facing downward to floor.
23:22:10 - Patient is observed lying face down (Prone position) on floor with hands handcuffed behind back.
23:22:32 - RN #2, RN #5 and SO #1 exit room. Patient remains lying face down on floor with hands handcuffed behind back. Knees bent. RN #3 and RN #4 remain in room.
23:23:00 Patient remains lying face down on floor with hands, handcuffed behind back.
23:24:00 Patient remains lying face down on floor with hands, handcuffed behind back. Patient is moved to sitting position ("Indian style") with staff assistance.
23:24:20 - RN #3 and RN #4 exit room. SO #1 remains in room. Patient remains sitting on floor with hands handcuffed behind back.
23:24:27 - Law enforcement officers (LEO) enter room.
23:31:20 - LEOs present. Remains on floor, with hands handcuffed behind back.
23:38:35 - Patient assisted up off the floor by LEOs into standing position.
23:38:48 - 5 LEOs present. Patient escorted over to bed by LEOs. SO #1 in room.
23:39:35 - 7 LEOs and 1 SO in room with patient. Patient in standing position with hands handcuffed behind back.
23:40:08 - Sheets removed from stretcher by LEO/Staff.
23:40:37 - Patient assisted onto bed by LEOs with hands handcuffed behind back.
23:41:09 - Patient handcuffs removed from back by LEOs. Patient's left and right hand individually handcuffed to left and right bed siderail by LEOs.
23:42:08 - Patient in room alone. Handcuffed to bed siderails. LEO at door.
23:45:00 - Remains on bed handcuffed to siderails.
23:46:28 - Remains in room on bed handcuffed to siderails.
23:47:03 - ED Physician #1 enters room. Stands beside counter. No physical contact with patient observed.
23:47:47 - ED physician #1 exits room.
23:47:49 - RN #7 enters room, goes over to bed. Patient appears to be crying. Remains handcuffed to bed siderails.
23:47:54 - RN #7 exits room.
23:50:06 - RN #7 enters room.
23:50:08 - SO #2 enters room with soft wrist restraints.
23:51:00 - Soft restraints applied to bilateral feet by RN#7 and SO #2.
23:51:54 - Soft restraints applied to bilateral hands by RN #7 and SO #2.
23:54:26 - Handcuffs removed by SO #2.
23:55:00 - Patient observed on bed in 4 point soft restraints. End video.

Continued record review of a "Medical/Surgical Restraint Order Form" dated 08/07/2013 revealed a verbal order for restraint was obtained by RN #7 at 2350 from ED Physician #1. Review revealed ED Physician #1 signed the verbal order on 08/08/2013 at 0030. Review of the order form revealed "A. Reason-based on Nursing Assessment: (check all that apply)." Review revealed under the heading "Medical Surgical/Restraint....5._[hand written check mark on line]_Other_[Violent Behavior handwritten on line]_." Further review revealed under the heading "Violent/Self-Destructive Behavior Restraint **IF ANY OF THE BELOW APPLY-VIOLENT/SELF-DESTRUCTIVE BEHAVIOR RESTRAINT ORDER FORM MUST BE USED** ...Patient needs protection from injuring himself/herself either intentionally or accidentally secondary to cognitive impairment resulting in the following: a. primary psychiatric diagnosis b. Substance abuse c. Suicidal ideation/behaviors d. In an emergency situation (there must be accompanying documentation) e. If the patient's condition warrants ANY restraints ...Others need to be protected from being injured by the patient, either intentionally or accidentally secondary to cognitive impairment. ...Serious disruption to the therapeutic milieu is occurring because of out of control aggressive behavior." Further review revealed "B.__[RN #7 and RN #6 name handwritten on line]__" above "Collaboration with/and Correct Restraint Application Verified by" dated 08/07/2013 at 2350. Review revealed the hand written signature of RN #6 on the line above "Signature of RN assessing patient/applying restraint:" dated 08/07/2013 at 2350. Further review revealed "C. Type of restraint (check all that apply)" with "Soft Limb Holder" right wrist, left wrist, right ankle and left ankle checked. Further review revealed "D. Physician Order (use appropriative code as indicated above) Medical Surgical Care - *Not to exceed 24 hours- Must have face-to-face assessment documented every 24 hours by a Licensed Independent Practitioner (LIP)." Review revealed "Start Date" of 08/07/2013; "Start/Order Time" of 2345; "Stop Date" of 08/08/2013; and "Stop Time" of 0245.

Review of a physican's progress note by ED Physician #1, dated 08/07/2013 at 2345, revealed "Pt. currently handcuffed, alert, nl (normal) airway. Tearful."

Record review revealed documentation the patient was placed into 4 point soft limb restraints on 08/07/2013 at 2345 and was removed from restraint on 08/08/2013 at 0207. Further review of a "Restraint Management Plan of Care" form revealed documentation of nursing assessments/monitoring initiated at 2345 (08/07) and performed every 15 minutes thereafter by RN #6 at 0000 (08/08), 0015, 0030, 0045, 0100, 0115, 0130, 0145, 0200, 0215, and 0230.

Consequently, video surveillance footage review revealed Patient #37 was placed into an inappropriate physical restraint hold by nursing staff on 08/07/2013 at 23:19:51 (25 minutes and 09 seconds earlier than the time of restraint (2345) documented by RN #6) and was then placed into handcuffs (an inappropriate restraint device) by RN #2 at 23:22:04. The handcuffs were removed at 23:54:26 (32 minutes and 22 seconds later). Video review revealed the patient was restrained with his arms handcuffed behind his back in an inappropriate face down (prone) position on the floor from 23:22:08 until 23:24:00 (1 minute and 52 seconds) and sitting position on the floor from 23:24:00 until 23:38:48 (14 minutes and 35 seconds). Video review revealed the patient was physically restrained on the floor from 23:20:21 until 23:38:35 (18 minutes and 14 seconds) before being assisted off the floor and onto the bed. Furthermore, record review failed to reveal any available documentation by nursing staff that Patient #37 was placed into a physical restraint hold on 08/07/2013 at 23:19:51; was placed into handcuffs at 23:22:04 and was removed from handcuffs at 23:54:26. Record review failed to reveal any available documentation of assessment/monitoring of the patient at the time of the initiation of the physical restraint hold at 23:19:51 and 15 minutes thereafter at 23:34:51 to include: a. Type of restraint b. Skin at restraint site c. Circulation d. Respirations e. Range of m

Based on the Centers for Medicare and Medicaid (CMS) Services, Appendix A, Interpretive Guidelines; hospital policy and procedure reviews, Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training material review, Quality Care Control Report review, Daily Security Report reviews, closed medical record review, video surveillance footage review, education training transcript reviews, staffing schedule reviews, and staff interviews, the hospital's staff failed to ensure the patient's right to be free from all forms of abuse or harassment by failing to provide goods and services in a manner necessary to avoid physical, harm, mental anguish, or mental illness during a restrictive intervention for 1 of 1 patients (#37) restrained for violent and/or self destructive behaviors.

The findings include:

Review on 02/07/2014 of the CMS Appendix A, Revision 89, dated 08/30/2013, Interpretive Guidelines for ?482.13(c)(3) revealed "...Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. ..."

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "1. POLICY: The governing body, administration, the Medical Staff and the patient care team....are equally committed to the provision of a safe environment. ...Restraints are never to be used as punishment, for convenience of staff or in response to behaviors or circumstances that do not constitute danger of injury to self or others. ...Only approved manufactured physical restraints will be used and manufacturer's directions will be followed. ...III. RESTRAINT DEFINITIONS: Physical 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. ...Physical Holding for Forced Medications - Physically holding a patient during a forced psychotropic medication procedure is considered a restraint.... . If physical holding for forced medication is necessary with a violent patient, a restraint order must be obtained using the VIOLENT/SELF DESTRUCTIVE BEHAVIOR RESTRAINT ORDER FORM. ...IV. PROCESS: ...VIOLENT/SELF DESTRUCTIVE BEHAVIOR RESTRAINT ...Restraint or seclusion can only be used when less restrictive interventions have been tried and caregivers are not able to protect the patient, a staff member, or others from harm. ...The USE OF ANY RESTRAINTS FOR VIOLENT/SELF DESTRUCTIVE BEHAVIOR REQUIRES ONE-TO-ONE STAFF. AND MONITORING EVERY 15 MINUTES ...ASSESSMENT An assessment of the patient will occur at the time of the initiation of restraint and every 15 minutes thereafter and will include: a. Type of restraint b. Skin at restraint site c. Circulation d. Respirations e. Range of motion f. Patient position g. Is bed alarm on h. Fluid/Nourishment offered i. Toilet j. Behavior Observed k. Restraint properly applied l. Additional interventions attempted m. Restraint removed n. Patient education o. Order up to date p. Restraint use indicted/not indicated. DOCUMENTATION ...b. Using the Restraint Management Plan of Care Form, nursing staff members monitor and reassess the needs of the patient every 15 minutes using the Restraint Management Plan of Care.... . ...V. PERSONNEL AUTHORIZED AND QUALIFIED TO APPLY RESTRAINTS * Patient Care Services Personnel who have demonstrated competency by annual completion of....Restraint Management Program. ..."

Review of current hospital policy "Security Measures" Policy S-121-201, revised 02/18/2013, revealed "...TRAINING: All Security personnel shall receive security training adequate to perform their job functions. ...RESPONSIBILITIES: * Security personnel stationed at the hospital shall be responsible for the following: ...* Staff assistance with patient restraint and intervention in disruptions by patients, visitors or staff ...."

Review on 02/07/2014 of Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training materials, copyright 2009 (reprinted 2013), revealed "Unit I: The CPI Crisis Development Model." Review revealed "...Definitions 1. Anxiety: A noticeable increase or change in behavior. A nondirected expenditure of energy; e.g., pacing, finger drumming, wringing of the hands, or staring. ...2. Defensive: The beginning stage of loss of rationality. At this stage, an individual often becomes belligerent and challenges authority. ...3. Acting-Out Person: The total loss of control, which results in a physical acting-out episode. ...4. Tension Reduction: A decrease in physical and emotional energy that occurs after a person has acted out, characterized by the regaining of rationality. ...Review of "Unit II: Nonverbal Behavior" revealed "...The CPI Supportive Stance" and "Reasons for using the CPI Supportive Stance 1. Communicates respect by honoring personal space. 2. Is nonthreatening/nonchallenging. 3. Contributes to staff's personal safety if attacked/offers an escape route." Review of "Unit VIII: Nonviolent Physical Crisis Intervention and Team Intervention" revealed "The Nonviolent Crisis Intervention program is a safe, nonharmful behavior management system designed to help human service professional provide for the best possible care and welfare of disruptive, assaultive, and out-of-control persons--even during tier most violent moments. In Nonviolent Crisis Intervention training, the emphasis is always on your primary responsibility: the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint is recommended only when all less restrictive methods of intervening have been exhausted, and when the individual presents a danger to self or others. ...Risks involved with physical intervention can be minimized when staff members regularly practice and rehearse procedures for team interventions. Further review revealed "CPI TEAM CONTROL POSITION" and "The CPI Team Control Position is used to manage individuals who have become dangerous to themselves or others. Two staff members hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist, if needed. During the intervention, staff members who are holding the individual should: *Face the same direction as the acting-out person while adjusting, as necessary, to maintain close body contact with the individual. * Keep their inside legs in front of the individual. ...*Bring the individual's arms across their bodies securing them to their hip areas. ...*Place the hands closest to the individual's shoulders in a C-shape position to direct the shoulders forward. ...Control Dynamics 1. Reduce upper-body strength by controlling the arms as weapons. 2. Reduce lower-body strength by controlling the back incline. 3. Reduce mobility by close body contact." Further review revealed "CPI TRANSPORT POSITION" and "The CPI Transport Position will assist you in safely moving an individual who is beginning to regain control. Prior to moving an individual, assist the person into a more upright position and remove your hand from the individual's shoulder. Reach under the individual's arm to grab your own wrist. This cross-grain grip better secures the individual between staff during transport. Remove your leg from directly in front of the individual prior to transport while maintaining close body contact. ...Further review revealed "CPI INTERIM CONTROL POSITION" and "The CPI Interim Control Position is a temporary control position that allows you to maintain control of both of the individual's arms, if necessary, for a short time. Starting from the CPI Transport Position, maintain control of the individual's arm, but release the cross-grain grip. Use your free arm to reach across and gain control of the opposite arm. ...If the individual attempts to strike, use your free arm to block, and safely move away. ..." Review of "Appendix: A Practical Approach for Managing Violent Behavior" revealed "...Team Intervention All of the intervention concepts are best utilized when a team of professionals intervenes. ...Why Nonviolent Crisis Intervention Training? A fundamental purpose of the Nonviolent Crisis Intervention training program is to help people understand the process of behavior escalation and to recognize that people don't act out in a vacuum. The staff member who intervenes with the potentially violent person must realize that her behavior has a tremendous impact on that individual. In any cases, the subsequent escalation or defusion of the person's behavior may depend entirely on how that staff member reacts. Nonviolent Crisis Intervention training stresses that crisis interventions is an integrated process. ...In an effort to maximize the chance of calming the person, it is best to balance or offset the person's behavior with therapeutic responses by staff. The therapeutic environment should be maintained continually, even during the most violent moments. ...By using safer, nonharmful techniques taught in the Nonviolent Crisis Intervention program, it is more likely that the therapeutic relationship you have worked so hard to develop can be maintained." Review of "Appendix: Understanding the Risks of Restraints" revealed "...Dangers of Restraints ....restraints should only be used when a person's behavior is MORE dangerous than the danger of using restraints. Some restraints are more dangerous than others. For example, facedown (prone) floor restraints and positions in which a person is bent over in such a way that it is difficult to breathe are extremely dangerous. This includes a seated or kneeling position in which the person being restrained is bent over at the waist and any facedown position on a bed or mat. Restraint-related positional asphyxia occurs when the person being restrained is placed in a position in which he cannot breathe properly and is not able to take in enough oxygen. Death can result from this lack of oxygen and consequent disturbance in the rhythm of the heart. Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breathe. This includes sitting or lying across a person' back or stomach. When someone is lying facedown, even pressure to the arms and legs can impact the person's ability to breathe effectively. ...When confronted with an emergency situation, always consider the option of disengaging. If the persons is not a danger to self or others while on the floor, staff may make the decision to move away and give a clear directive. Reducing the Risks of Restraints ...Staff members should be trained in and regularly practice safer ways of restraining. ...A physical restraint is an emergency procedure...As with any emergency response procedure, staff members need to practice these skills on a regular basis. ...Key elements of Nonviolent Physical Crisis Intervention responses include: * No element of pain involved. * The intent is to calm the individual. * The intent is to keep the individual off the floor, thus reducing risks of restraint-related positional asphyxia and other injuries. * Team interventions are used when necessary. * Nonviolent Physical Crisis Intervention is used only as a last resort when someone presents a danger. * Nonviolent Physical Crisis Interventions is used to protect - not to punish. The goal is for staff....is to eliminate the need for restraints at all."

Review on 02/05/2014 of a Quality Care Control Report completed by the ED Director on 08/15/2013 regarding a "Behavioral Variance" occurring on 08/07/2013 at 2310 in ED III, involving Patient #37, revealed "Pt (patient) yelling + (and) swearing at staff....(RN name) called for assistance to help with situation. Pt pacing in room. Staff went into give pt. medication shot. Pt refused shot. Pt backed up into corner. 3 male staff tried to secure pt for shot. Pt hit RN....Pt held + shot given. Pt verbally + physically resistant to staff. Handcuffs from security placed on pt by RN. Pt put in sitting position. Police arrived. Spoke to patient. Pt assisted to stretcher, handcuffed to stretcher. Handcuffs removed, pt placed in 4 point soft restraints. Pt became calm. MD assessed pt. Restraints removed one at a time." Review revealed the staff involved were identified as RN #1, RN #2, RN #3, RN #4, RN #5, RN #6, RN #7, SO #1 and SO #2.

Review on 02/07/2014 of a "Daily Security Report" dated 08/07/2013 from 1600 to 0030 completed by SO #1 revealed "...2330 patient in and out of room many times Nurse ask him to go back in the room and stay. Patient refused and started cussing nurse asked patient to get quiet. And was asked if he wanted a shot to help to rest and he refused said they could not give him the meds in the shot called for help to give injection and patient became combative and RPD (local police department). Was called. patient knocked hole in wall with elbow. ..."

Review on 02/07/2014 of a "Daily Security Report" dated 08/08/2013 from 0000 to 0800 completed by SO #2 revealed "2340 (08/07) Went to ED III Room #2 to assist with a patient that RPD was called on. ...0006 (08/08) Started one on one ED III Room #2 ref (reference) subject was placed in restraint 0115 Assisted in removing Restraint one limb at a time every 15 minute last one removed on Thursday 8 of August 0230 Clear one on one. ..."

Closed emergency department (ED) record review on 02/05/2014 for Patient #37 revealed a 26 year old male who presented to the hospital's ED on 08/03/2013 under involuntary commitment (IVC) petition for psychiatric evaluation. Review revealed the patient was diagnosed with "substance abuse disorder." Review revealed the patient was held in the ED from 08/03/2013 until 08/13/2013 (11 days), awaiting placement at a psychiatric hospital. Review revealed on 08/13/2013 the patient was reassessed by the ED physician as "...no longer meets criteria for inpatient treatment" and was subsequently released from IVC petition and discharged from the ED. Review of nursing documentation by RN #6 on 08/07/2013 at 2329, revealed "Approximately 2310 patient went from washing his hands in room to hall sink to wash hands back to room to wash hands and to sink again to wash hands, at the sink he looked at this RN and looked like he was asking a question, this RN asked what he needed but couldn't here [sic] him, this RN then went to doorway of nurses station and asked, '(Patient #37 name), I couldn't hear you, what did you need?' At that point patient started yelling 'I'm singing a Marilyn Manson song, can't someone just sing a song without you f**king getting in their face.' (RN #2 name), RN spoke to patient and asked him to stop yelling and to stop swearing, patient started yelling more and posturing, this RN called on radio that assistance was needed in ED III--(RN #1 name), RN, (RN #4 name), RN, (SO #1 name)--Security, (RN #3 name), RN came to assist, patient starting yelling more and swearing louder. Patient was told he was going to get a shot of Geodon (antipsychotic) if he did not settle down, he just kept yelling, this RN called communications and used hand radio again to notify charge RN (RN #7 name) that communications was called, patient kept yelling and swearing, the other RNs continued to try to talk patient down but patient kept yelling, this RN got the Geodon and prepared it, medication was given while male nurses secured patient, patient remained secured until officers (Law Enforcement Officers) arrived to help with situation, officers requested patient's IVC papers and discussed this with patient, patient did hit (RN #2 name), RN in the jaw and kicked in the shins--report filed, ....(SO #2) from security came on shift and is now present also--sheets have been removed from bed and officers have patient handcuffed to bed, (RN #7), RN talking to officers about handcuffs and (ED Physician #1 name) has walked in at 2345 to assess patient and speak to officers and staff. 1:1 in place with (SO #2 name)--security, restraint orders in place, verified with (RN #7), RN and (RN name), RN from BH (Behavioral Health)." At 0035, revealed "(RN #2 name), RN is being checked for injuries....there is a bruise on patient's l-arm (left arm)--discussed with (SO #1 name) from security--stated the patient had that bruise prior to incident, VS (vital signs) checked as ordered and patient, patient continues to argue that he does not need restraints, when he asked when restraints would be removed, this RN explained when it was safe for him and staff restraints would be removed--patient slammed the bed rail and complained again about his 'f**king situation'. Explained to him that type of behavior would keep him in the restraints. Patient has been offered and given ice water, he is currently being assisted by security to help with urinal." At 0106, revealed "....patient was moved up in bed with assistance from (SO #2 name) from security....patient appeared to be sleeping, VS taken but when patient started to kick a little and argued about being in restraints, is able to turn from l-to-r (left to right), patient did urinate 425 mL (milliliters) with assistance by (SO #2 name), security, patient has continually been offered ice water and given when requested, patient remains agitated but not as noticeable at this time." At 0119, revealed "patient is sleeping but restless with sleep--pulling at restraints at times--this RN called (RN name), RN BH and (RN #7 name), Charge RN to verify taking restraints off--advised to remove one restraint at a time--opposite of each other--l-wrist (left wrist) is removed at this time--1:1 continues with (SO #2 name), Security--he assisted with removing first restraint." At 0131, revealed "r-ankle (right ankle) restraint removed, (SO #2 name) from security is assisting patient with urinal, explained to patient that two restraints have been removed and will continue to remove one at a time if patient remains cooperative, patient did request to urinate--was ambulated by (SO #2 name) from security to BR (bathroom) and returned to room where two restraints were reapplied, patient fell asleep during reapplication." At 0152, revealed "spoke to (RN #7), Charge RN and (ED Physician #1 name) that patient is restless only when VS are checked but is sleeping otherwise--3rd restraint to r-wrist (right wrist) removed, last restraint will be removed at 0200 if patient continues to sleep and remain cooperative, patient sleepily stated he did not want anything to drink at this time." At 0207, revealed "(ED Physician #1) and (RN #7), RN notified that patient's 4th restrain [sic] has been removed, 1:1 will continue until 0230 by (SO #2 name) from security as is ordered in paperwork, patient verbally stated during 0145 VS that he understood, (RN name), RN BH notified as well and advised to continue 1:1 for 30 minutes--advised this is being done, patient is completely self turning at this time--l-arm (left arm) noted earlier as having a bruise--also noted at this time that it is a healing scar with bruising about it." At 0233, revealed "restraints remain off, 1:1 discontinued...." At 0402, revealed "Sergeant (name) arrived at 0400--advised ED staff that patient has one misdemeanor injury to real property and one felony for assault on ED staff--(RN #2 name), RN, we are to notify communications dept (department) when patient is to be dc'd (discharged) from (hospital) or after transfer and release from additional facility....that patient is to be arrested for these charges." Record review revealed the patient was discharged to jail on 08/13/2013.

Review on 02/05/2014 at 1615 with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Quality and Risk Management, Director of Security, Emergency Department Director, and the hospital's Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) Certified Instructor (CI #1) of video surveillance footage without audio; dated 08/07/2013, time interval 23:10:00 to 23:55:00; from hospital security camera, ED III Room 2 revealed at:
23:10:00 to 23:17:59 - Patient #37 observed in treatment room. Holding book in hands. Placing book on and off counter top. Exits and re-enters room two times. Speaking towards doorway. Drinking from container with straw. Pacing within room. Shadows observed at doorway. No physical aggression observed.
23:18:00 - Patient observed standing in room with left side of body adjacent to cabinet/countertop with left hand on countertop. Patient is facing direction of door. Male staff member (RN #1) enters room and goes over to patient's right side. RN #1 carrying medication syringe (Geodon). RN #1 begins to swab/wipe the patient's right shoulder with antiseptic/alcohol wipe. Two male staff members (RN #2, RN #3) appear in doorway. No physical aggression is observed by patient towards staff.
23:18:14 - Patient walks away from cabinet/countertop and RN #1. Patient walks across room to left rear corner of room and turns his back towards the wall, facing staff members. Patient and staff members engaging in verbal communication. Three male staff members are present inside room (RN #1, RN #2, RN #3). No physical aggression is observed by the patient towards staff.
23:18:29 - A fourth male staff member (SO #1) appears at doorway of room.
23:18:38 - SO #1 reaches into room and turns lights on. Patient stands in left rear corner of room with back towards wall. Patient has his hands behind his back. Patient and staff engaging in verbal communication. No physical aggression is observed by the patient towards staff.
23:19:19 - Patient in left rear corner of room with back towards wall. RN #1, RN #2, and RN #3 start moving closer towards patient from three sides (in a corralling stance). No physical aggression is observed by the patient towards staff.
23:19:24 - A fifth male staff member (RN #4) enters room. Patient remains in left rear corner of room with his back to wall, facing staff members. RN #1, #2, #3, #4 in room. SO #1 at doorway.
23:19:47 - Patient remains in left rear corner of room with back towards wall. Facing staff. No physical aggression is observed by the patient towards staff.
23:19:50 - Patient steps backward further into left rear corner of room (away from staff). Patient's arms are crossed in front of chest. No physical aggression is observed by patient towards staff. RN #2 and RN #3 begin approaching patient.
23:19:51 - Patient with back against wall in left rear corner of room, facing staff. Patient arms crossed in front of chest. No physical aggression observed by patient towards staff. Staff observed in a "corralling stance" and then rapidly advance towards patient. RN #2 reaches towards patient and appears to make physical contact with left chest/axilla area of patient. Patient extends left arm outward towards RN #2 and appears to make contact with RN #2. Patient swings right arm and appears to strike RN #2 in left side of face/jaw area. RN #3 reaching towards patient and appears to make contact with the patient's right shoulder. Patient appears to be pushed up against wall of room. Two additional male staff members (RN #4 and RN #5) enter room to assist.
23:19:52 - Patient appears to strike RN #2 in back of neck two times with his right arm. Patient is held against rear wall by male staff members.
23:19:54 - Patient held against wall by male staff members. SO #1 and RN #1, #2, #3, #4 in room. RN #6 enters room and stands at door.
23:19:59 - Patient is held against wall by male staff members.
23:20:03 - SO #1 is observed grabbing patient's left leg and pulling/holding the leg up off the floor. RN #2, RN #3, and RN #4 observed holding patient up against wall.
23:20:05 - RN #3 is observed with his left arm around patient's neck in a "head lock" type position pulling downward.
23:20:11 - The patient is held against the wall. RN #3 is observed with his left arm around patient's neck in a "head lock" type position. RN #2 is observed holding the patient's extended left arm up against the wall. SO #1 is observed holding the patient's left leg up off the floor. RN #1 is observed approaching the patient with a medication syringe in his left hand.
23:20:12 - A male staff members gloved hand is observed covering the patient's chin/mouth area. The patient's neck is observed being hyper-extended backwards.
23:20:13 - The patient is observed being held against the wall. RN #3 is observed with his left hand around the patient's neck. A gloved hand is covering the patient's chin and his neck is hyper-extended backwards. The patient's left arm is bent behind his back by RN #2. SO #1 is holding the patient's leg off the floor. The patient appears to be in a contorted/flexed position.
23:20:14 - RN #1 is observed with a syringe in his left hand.
23:20:21 - Patient is observed to be pulled down onto floor with staff on top of patient.
23:20:28 - RN #1 is observed administering the IM medication to the patient's left arm.
23:20:45 - Patient with head held to floor by gloved hand of RN #3. Gloved hand pushing head downward to floor. Patient body appears contorted/flexed. Staff over patient.
23:20:55 - Patient observed on floor, on left side. RN #2 observed with his left knee against small of patient's back. Staff holding patient down on floor.
23:21:19 - SO #1 is observed removing handcuffs from belt case.
23:21:33 - Staff holding patient down on floor. Three staff members on top of patient, RN #5 enters room.
23:21:38 - SO #1 is observed handing handcuffs to RN #2.
23:21:42 - Patient remains on floor. RN #7 enters room.
23:21:46 - RN #7 exits room.
23:21:53 - Patient on floor on lateral right side, torso is bent forward at waist (fetal like position). Pants pulled down and entire buttocks exposed.
23:21:57 - RN #2 is observed over the patient with his leg over the patient's leg. Patient is held down to floor by male staff members. Patient appears to be on side.
23:22:04 - Patient on floor. Appears to be on right side/facing downward on floor. RN #2 is observed placing a handcuff on patient's left wrist.
23:22:07 - RN #2 is observed placing a handcuff on patient's right wrist.
23:22:08 - Patient's is observed with hands handcuffed behind back. Lying on right lateral side. Facing downward to floor.
23:22:10 - Patient is observed lying face down (Prone position) on floor with hands handcuffed behind back.
23:22:32 - RN #2, RN #5 and SO #1 exit room. Patient remains lying face down on floor with hands handcuffed behind back. Knees bent. RN #3 and RN #4 remain in room.
23:23:00 Patient remains lying face down on floor with hands, handcuffed behind back.
23:24:00 Patient remains lying face down on floor with hands, handcuffed behind back. Patient is moved to sitting position ("Indian style") with staff assistance.
23:24:20 - RN #3 and RN #4 exit room. SO #1 remains in room. Patient remains sitting on floor with hands handcuffed behind back.
23:24:27 - Law enforcement officers (LEO) enter room.
23:31:20 - LEOs present. Remains on floor, with hands handcuffed behind back.
23:38:35 - Patient assisted up off the floor by LEOs into standing position.
23:38:48 - 5 LEOs present. Patient escorted over to bed by LEOs. SO #1 in room.
23:39:35 - 7 LEOs and 1 SO in room with patient. Patient in standing position with hands handcuffed behind back.
23:40:08 - Sheets removed from stretcher by LEO/Staff.
23:40:37 - Patient assisted onto bed by LEOs with hands handcuffed behind back.
23:41:09 - Patient handcuffs removed from back by LEOs. Patient's left and right hand individually handcuffed to left and right bed siderail by LEOs.
23:42:08 - Patient in room alone. Handcuffed to bed siderails. LEO at door.
23:45:00 - Remains on bed handcuffed to siderails.
23:46:28 - Remains in room on bed handcuffed to siderails.
23:47:03 - ED Physician #1 enters room. Stands beside counter. No physical contact with patient observed.
23:47:47 - ED physician #1 exits room.
23:47:49 - RN #7 enters room, goes over to bed. Patient appears to be crying. Remains handcuffed to bed siderails.
23:47:54 - RN #7 exits room.
23:50:06 - RN #7 enters room.
23:50:08 - SO #2 enters room with soft wrist restraints.
23:51:00 - Soft restraints applied to bilateral feet by RN#7 and SO #2.
23:51:54 - Soft restraints applied to bilateral hands by RN #7 and SO #2.
23:54:26 - Handcuffs removed by SO #2.
23:55:00 - Patient observed on bed in 4 point soft restraints. End video.

Continued record review of a "Medical/Surgical Restraint Order Form" dated 08/07/2013 revealed a verbal order for restraint was obtained by RN #7 at 2350 from ED Physician #1. Review revealed ED Physician #1 signed the verbal order on 08/08/2013 at 0030. Review of the order form revealed "A. Reason-based on Nursing Assessment: (check all that apply)." Review revealed under the heading "Medical Surgical/Restraint....5._[hand written check mark on line]_Other_[Violent Behavior handwritten on line]_." Further review revealed under the heading "Violent/Self-Destructive Behavior Restraint **IF ANY OF THE BELOW APPLY-VIOLENT/SELF-DESTRUCTIVE BEHAVIOR RESTRAINT ORDER FORM MUST BE USED** ...Patient needs protection from injuring himself/herself either intentionally or accidentally secondary to cognitive impairment resulting in the following: a. primary psychiatric diagnosis b. Substance abuse c. Suicidal ideation/behaviors d. In an emergency situation (there must be accompanying documentation) e. If the patient's condition warrants ANY restraints ...Others need to be protected from being injured by the patient, either intentionally or accidentally secondary to cognitive impairment. ...Serious disruption to the therapeutic milieu is occurring because of out of control aggressive behavior." Further review revealed "B.__[RN #7 and RN #6 name handwritten on line]__" above "Collaboration with/and Correct Restraint Application Verified by" dated 08/07/2013 at 2350. Review revealed the hand written signature of RN #6 on the line above "Signature of RN assessing patient/applying restraint:" dated 08/07/2013 at 2350. Further review revealed "C. Type of restraint (check all that apply)" with "Soft Limb Holder" right wrist, left wrist, right ankle and left ankle checked. Further review revealed "D. Physician Order (use appropriative code as indicated above) Medical Surgical Care - *Not to exceed 24 hours- Must have face-to-face assessment documented every 24 hours by a Licensed Independent Practitioner (LIP)." Review revealed "Start Date" of 08/07/2013; "Start/Order Time" of 2345; "Stop Date" of 08/08/2013; and "Stop Time" of 0245.

Review of a physican's progress note by ED Physician #1, dated 08/07/2013 at 2345, revealed "Pt. currently handcuffed, alert, nl (normal) airway. Tearful."

Record review revealed documentation the patient was placed into 4 point soft limb restraints on 08/07/2013 at 2345 and was removed from restraint on 08/08/2013 at 0207. Further review of a "Restraint Management Plan of Care" form revealed documentation of nursing assessments/monitoring initiated at 2345 (08/07) and performed every 15 minutes thereafter by RN #6 at 0000 (08/08), 0015, 0030, 0045, 0100, 0115, 0130, 0145, 0200, 0215, and 0230.

Consequently, video surveillance footage review revealed Patient #37 was placed into an inappropriate physical restraint hold by nursing staff on 08/07/2013 at 23:19:51 (25 minutes and 09 seconds earlier than the time of restraint (2345) documented by RN #6) and was then placed into handcuffs (an inappropriate restraint device) by RN #2 at 23:22:04. The handcuffs were removed at 23:54:26 (32 minutes and 22 seconds later). Video review revealed the patient was restrained with his arms handcuffed behind his back in an inappropriate face down (prone) position on the floor from 23:22:08 until 23:24:00 (1 minute and 52 seconds) and sitting position on the floor from 23:24:00 until 23:38:48 (14 minutes and 35 seconds). Video review revealed the patient was physically restrained on the floor from 23:20:21 until 23:38:35 (18 minutes and 14 seconds) before being assisted off the floor and onto the bed. Furthermore, record review failed to reveal any available documentation by nursing staff that Patient #37 was placed into a physical restraint hold on 08/07/2013 at 23:19:51; was placed into ha

Based on hospital policy and procedure reviews, Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training material review, Quality Care Control Report review, closed medical record review, video surveillance footage review, and staff interviews, the hospital's staff failed to implement restraint or seclusion in accordance with safe and appropriate restraint techniques for 1 of 1 patients (#37) restrained with handcuffs for violent and/or self destructive behaviors.

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "1. POLICY: ...Only approved manufactured physical restraints will be used and manufacturer's directions will be followed. ..."

Review on 02/07/2014 of Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training materials, copyright 2009 (reprinted 2013), revealed "Unit I: The CPI Crisis Development Model." Review revealed "...Definitions 1. Anxiety: A noticeable increase or change in behavior. A nondirected expenditure of energy; e.g., pacing, finger drumming, wringing of the hands, or staring. ...2. Defensive: The beginning stage of loss of rationality. At this stage, an individual often becomes belligerent and challenges authority. ...3. Acting-Out Person: The total loss of control, which results in a physical acting-out episode. ...4. Tension Reduction: A decrease in physical and emotional energy that occurs after a person has acted out, characterized by the regaining of rationality. ...Review of "Unit II: Nonverbal Behavior" revealed "...The CPI Supportive Stance" and "Reasons for using the CPI Supportive Stance 1. Communicates respect by honoring personal space. 2. Is nonthreatening/nonchallenging. 3. Contributes to staff's personal safety if attacked/offers an escape route." Review of "Unit VIII: Nonviolent Physical Crisis Intervention and Team Intervention" revealed "The Nonviolent Crisis Intervention program is a safe, nonharmful behavior management system designed to help human service professional provide for the best possible care and welfare of disruptive, assaultive, and out-of-control persons--even during tier most violent moments. In Nonviolent Crisis Intervention training, the emphasis is always on your primary responsibility: the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint is recommended only when all less restrictive methods of intervening have been exhausted, and when the individual presents a danger to self or others. ...Risks involved with physical intervention can be minimized when staff members regularly practice and rehearse procedures for team interventions. Further review revealed "CPI TEAM CONTROL POSITION" and "The CPI Team Control Position is used to manage individuals who have become dangerous to themselves or others. Two staff members hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist, if needed. During the intervention, staff members who are holding the individual should: *Face the same direction as the acting-out person while adjusting, as necessary, to maintain close body contact with the individual. * Keep their inside legs in front of the individual. ...*Bring the individual's arms across their bodies securing them to their hip areas. ...*Place the hands closest to the individual's shoulders in a C-shape position to direct the shoulders forward. ...Control Dynamics 1. Reduce upper-body strength by controlling the arms as weapons. 2. Reduce lower-body strength by controlling the back incline. 3. Reduce mobility by close body contact." Further review revealed "CPI TRANSPORT POSITION" and "The CPI Transport Position will assist you in safely moving an individual who is beginning to regain control. Prior to moving an individual, assist the person into a more upright position and remove your hand from the individual's shoulder. Reach under the individual's arm to grab your own wrist. This cross-grain grip better secures the individual between staff during transport. Remove your leg from directly in front of the individual prior to transport while maintaining close body contact. ...Further review revealed "CPI INTERIM CONTROL POSITION" and "The CPI Interim Control Position is a temporary control position that allows you to maintain control of both of the individual's arms, if necessary, for a short time. Starting from the CPI Transport Position, maintain control of the individual's arm, but release the cross-grain grip. Use your free arm to reach across and gain control of the opposite arm. ...If the individual attempts to strike, use your free arm to block, and safely move away. ..." Review of "Appendix: A Practical Approach for Managing Violent Behavior" revealed "...Team Intervention All of the intervention concepts are best utilized when a team of professionals intervenes. ...Why Nonviolent Crisis Intervention Training? A fundamental purpose of the Nonviolent Crisis Intervention training program is to help people understand the process of behavior escalation and to recognize that people don't act out in a vacuum. The staff member who intervenes with the potentially violent person must realize that her behavior has a tremendous impact on that individual. In any cases, the subsequent escalation or defusion of the person's behavior may depend entirely on how that staff member reacts. Nonviolent Crisis Intervention training stresses that crisis interventions is an integrated process. ...In an effort to maximize the chance of calming the person, it is best to balance or offset the person's behavior with therapeutic responses by staff. The therapeutic environment should be maintained continually, even during the most violent moments. ...By using safer, nonharmful techniques taught in the Nonviolent Crisis Intervention program, it is more likely that the therapeutic relationship you have worked so hard to develop can be maintained." Review of "Appendix: Understanding the Risks of Restraints" revealed "...Dangers of Restraints ....restraints should only be used when a person's behavior is MORE dangerous than the danger of using restraints. Some restraints are more dangerous than others. For example, facedown (prone) floor restraints and positions in which a person is bent over in such a way that it is difficult to breathe are extremely dangerous. This includes a seated or kneeling position in which the person being restrained is bent over at the waist and any facedown position on a bed or mat. Restraint-related positional asphyxia occurs when the person being restrained is placed in a position in which he cannot breathe properly and is not able to take in enough oxygen. Death can result from this lack of oxygen and consequent disturbance in the rhythm of the heart. Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breathe. This includes sitting or lying across a person' back or stomach. When someone is lying facedown, even pressure to the arms and legs can impact the person's ability to breathe effectively. ...When confronted with an emergency situation, always consider the option of disengaging. If the persons is not a danger to self or others while on the floor, staff may make the decision to move away and give a clear directive. Reducing the Risks of Restraints ...Staff members should be trained in and regularly practice safer ways of restraining. ...A physical restraint is an emergency procedure...As with any emergency response procedure, staff members need to practice these skills on a regular basis. ...Key elements of Nonviolent Physical Crisis Intervention responses include: * No element of pain involved. * The intent is to calm the individual. * The intent is to keep the individual off the floor, thus reducing risks of restraint-related positional asphyxia and other injuries. * Team interventions are used when necessary. * Nonviolent Physical Crisis Intervention is used only as a last resort when someone presents a danger. * Nonviolent Physical Crisis Interventions is used to protect - not to punish. The goal is for staff....is to eliminate the need for restraints at all."

Review on 02/05/2014 of a Quality Care Control Report completed by the ED Director on 08/15/2013 regarding a "Behavioral Variance" occurring on 08/07/2013 at 2310 in ED III, involving Patient #37, revealed "...Handcuffs from security placed on pt by RN. ...Handcuffs removed, pt placed in 4 point soft restraints. ...Restraints removed one at a time." Review revealed the staff involved were identified as RN #1, RN #2, RN #3, RN #4, RN #5, RN #6, RN #7, SO #1 and SO #2.

Closed emergency department (ED) record review on 02/05/2014 for Patient #37 revealed a 26 year old male who presented to the hospital's ED on 08/03/2013 under involuntary commitment (IVC) petition for psychiatric evaluation. Review revealed the patient was diagnosed with "substance abuse disorder." Review revealed the patient was held in the ED from 08/03/2013 until 08/13/2013 (11 days), awaiting placement at a psychiatric hospital. Review revealed on 08/13/2013 the patient was reassessed by the ED physician as "...no longer meets criteria for inpatient treatment" and was subsequently released from IVC petition and discharged from the ED. Review of nursing documentation by RN #6 on 08/07/2013 at 2329, revealed "Approximately 2310....this RN got the Geodon and prepared it, medication was given while male nurses secured patient, patient remained secured until officers (Law Enforcement Officers) arrived to help with situation, ...officers have patient handcuffed to bed, (RN #7), RN talking to officers about handcuffs... ."

Review on 02/05/2014 at 1615 with the Chief Executive Officer, Chief Nursing Officer, Director of Quality and Risk Management, Director of Security, Emergency Department Director, and the hospital's Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) Certified Instructor (CI #1) of video surveillance footage without audio; dated 08/07/2013, time interval 23:10:00 to 23:55:00; from hospital security camera, ED III Room 2 revealed at:
23:10:00 to 23:17:59 - Patient #37 observed in treatment room. Holding book in hands. Placing book on and off counter top. Exits and re-enters room two times. Speaking towards doorway. Drinking from container with straw. Pacing within room. Shadows observed at doorway. No physical aggression observed.
23:18:00 - Patient observed standing in room with left side of body adjacent to cabinet/countertop with left hand on countertop. Patient is facing direction of door. Male staff member (RN #1) enters room and goes over to patient's right side. RN #1 carrying medication syringe (Geodon). RN #1 begins to swab/wipe the patient's right shoulder with antiseptic/alcohol wipe. Two male staff members (RN #2, RN #3) appear in doorway. No physical aggression is observed by patient towards staff.
23:18:14 - Patient walks away from cabinet/countertop and RN #1. Patient walks across room to left rear corner of room and turns his back towards the wall, facing staff members. Patient and staff members engaging in verbal communication. Three male staff members are present inside room (RN #1, RN #2, RN #3). No physical aggression is observed by the patient towards staff.
23:18:29 - A fourth male staff member (SO #1) appears at doorway of room.
23:18:38 - SO #1 reaches into room and turns lights on. Patient stands in left rear corner of room with back towards wall. Patient has his hands behind his back. Patient and staff engaging in verbal communication. No physical aggression is observed by the patient towards staff.
23:19:19 - Patient in left rear corner of room with back towards wall. RN #1, RN #2, and RN #3 start moving closer towards patient from three sides (in a corralling stance). No physical aggression is observed by the patient towards staff.
23:19:24 - A fifth male staff member (RN #4) enters room. Patient remains in left rear corner of room with his back to wall, facing staff members. RN #1, #2, #3, #4 in room. SO #1 at doorway.
23:19:47 - Patient remains in left rear corner of room with back towards wall. Facing staff. No physical aggression is observed by the patient towards staff.
23:19:50 - Patient steps backward further into left rear corner of room (away from staff). Patient's arms are crossed in front of chest. No physical aggression is observed by patient towards staff. RN #2 and RN #3 begin approaching patient.
23:19:51 - Patient with back against wall in left rear corner of room, facing staff. Patient arms crossed in front of chest. No physical aggression observed by patient towards staff. Staff observed in a "corralling stance" and then rapidly advance towards patient. RN #2 reaches towards patient and appears to make physical contact with left chest/axilla area of patient. Patient extends left arm outward towards RN #2 and appears to make contact with RN #2. Patient swings right arm and appears to strike RN #2 in left side of face/jaw area. RN #3 reaching towards patient and appears to make contact with the patient's right shoulder. Patient appears to be pushed up against wall of room. Two additional male staff members (RN #4 and RN #5) enter room to assist.
23:19:52 - Patient appears to strike RN #2 in back of neck two times with his right arm. Patient is held against rear wall by male staff members.
23:19:54 - Patient held against wall by male staff members. SO #1 and RN #1, #2, #3, #4 in room. RN #6 enters room and stands at door.
23:19:59 - Patient is held against wall by male staff members.
23:20:03 - SO #1 is observed grabbing patient's left leg and pulling/holding the leg up off the floor. RN #2, RN #3, and RN #4 observed holding patient up against wall.
23:20:05 - RN #3 is observed with his left arm around patient's neck in a "head lock" type position pulling downward.
23:20:11 - The patient is held against the wall. RN #3 is observed with his left arm around patient's neck in a "head lock" type position. RN #2 is observed holding the patient's extended left arm up against the wall. SO #1 is observed holding the patient's left leg up off the floor. RN #1 is observed approaching the patient with a medication syringe in his left hand.
23:20:12 - A male staff members gloved hand is observed covering the patient's chin/mouth area. The patient's neck is observed being hyper-extended backwards.
23:20:13 - The patient is observed being held against the wall. RN #3 is observed with his left hand around the patient's neck. A gloved hand is covering the patient's chin and his neck is hyper-extended backwards. The patient's left arm is bent behind his back by RN #2. SO #1 is holding the patient's leg off the floor. The patient appears to be in a contorted/flexed position.
23:20:14 - RN #1 is observed with a syringe in his left hand.
23:20:21 - Patient is observed to be pulled down onto floor with staff on top of patient.
23:20:28 - RN #1 is observed administering the IM medication to the patient's left arm.
23:20:45 - Patient with head held to floor by gloved hand of RN #3. Gloved hand pushing head downward to floor. Patient body appears contorted/flexed. Staff over patient.
23:20:55 - Patient observed on floor, on left side. RN #2 observed with his left knee against small of patient's back. Staff holding patient down on floor.
23:21:19 - SO #1 is observed removing handcuffs from belt case.
23:21:33 - Staff holding patient down on floor. Three staff members on top of patient, RN #5 enters room.
23:21:38 - SO #1 is observed handing handcuffs to RN #2.
23:21:42 - Patient remains on floor. RN #7 enters room.
23:21:46 - RN #7 exits room.
23:21:53 - Patient on floor on lateral right side, torso is bent forward at waist (fetal like position). Pants pulled down and entire buttocks exposed.
23:21:57 - RN #2 is observed over the patient with his leg over the patient's leg. Patient is held down to floor by male staff members. Patient appears to be on side.
23:22:04 - Patient on floor. Appears to be on right side/facing downward on floor. RN #2 is observed placing a handcuff on patient's left wrist.
23:22:07 - RN #2 is observed placing a handcuff on patient's right wrist.
23:22:08 - Patient's is observed with hands handcuffed behind back. Lying on right lateral side. Facing downward to floor.
23:22:10 - Patient is observed lying face down (Prone position) on floor with hands handcuffed behind back.
23:22:32 - RN #2, RN #5 and SO #1 exit room. Patient remains lying face down on floor with hands handcuffed behind back. Knees bent. RN #3 and RN #4 remain in room.
23:23:00 Patient remains lying face down on floor with hands, handcuffed behind back.
23:24:00 Patient remains lying face down on floor with hands, handcuffed behind back. Patient is moved to sitting position ("Indian style") with staff assistance.
23:24:20 - RN #3 and RN #4 exit room. SO #1 remains in room. Patient remains sitting on floor with hands handcuffed behind back.
23:24:27 - Law enforcement officers (LEO) enter room.
23:31:20 - LEOs present. Remains on floor, with hands handcuffed behind back.
23:38:35 - Patient assisted up off the floor by LEOs into standing position.
23:38:48 - 5 LEOs present. Patient escorted over to bed by LEOs. SO #1 in room.
23:39:35 - 7 LEOs and 1 SO in room with patient. Patient in standing position with hands handcuffed behind back.
23:40:08 - Sheets removed from stretcher by LEO/Staff.
23:40:37 - Patient assisted onto bed by LEOs with hands handcuffed behind back.
23:41:09 - Patient handcuffs removed from back by LEOs. Patient's left and right hand individually handcuffed to left and right bed siderail by LEOs.
23:42:08 - Patient in room alone. Handcuffed to bed siderails. LEO at door.
23:45:00 - Remains on bed handcuffed to siderails.
23:46:28 - Remains in room on bed handcuffed to siderails.
23:47:03 - ED Physician #1 enters room. Stands beside counter. No physical contact with patient observed.
23:47:47 - ED physician #1 exits room.
23:47:49 - RN #7 enters room, goes over to bed. Patient appears to be crying. Remains handcuffed to bed siderails.
23:47:54 - RN #7 exits room.
23:50:06 - RN #7 enters room.
23:50:08 - SO #2 enters room with soft wrist restraints.
23:51:00 - Soft restraints applied to bilateral feet by RN#7 and SO #2.
23:51:54 - Soft restraints applied to bilateral hands by RN #7 and SO #2.
23:54:26 - Handcuffs removed by SO #2.
23:55:00 - Patient observed on bed in 4 point soft restraints. End video.

Continued record review of a "Medical/Surgical Restraint Order Form" dated 08/07/2013 revealed a verbal order for restraint was obtained by RN #7 at 2350 from ED Physician #1. Review revealed ED Physician #1 signed the verbal order on 08/08/2013 at 0030. Review of the order form revealed "A. Reason-based on Nursing Assessment: (check all that apply)." Review revealed under the heading "Medical Surgical/Restraint....5._[hand written check mark on line]_Other_[Violent Behavior handwritten on line]_." Further review revealed under the heading "Violent/Self-Destructive Behavior Restraint **IF ANY OF THE BELOW APPLY-VIOLENT/SELF-DESTRUCTIVE BEHAVIOR RESTRAINT ORDER FORM MUST BE USED** ...Patient needs protection from injuring himself/herself either intentionally or accidentally secondary to cognitive impairment resulting in the following: a. primary psychiatric diagnosis b. Substance abuse c. Suicidal ideation/behaviors d. In an emergency situation (there must be accompanying documentation) e. If the patient's condition warrants ANY restraints ...Others need to be protected from being injured by the patient, either intentionally or accidentally secondary to cognitive impairment. ...Serious disruption to the therapeutic milieu is occurring because of out of control aggressive behavior." Further review revealed "B.__[RN #7 and RN #6 name handwritten on line]__" above "Collaboration with/and Correct Restraint Application Verified by" dated 08/07/2013 at 2350. Review revealed the hand written signature of RN #6 on the line above "Signature of RN assessing patient/applying restraint:" dated 08/07/2013 at 2350. Further review revealed "C. Type of restraint (check all that apply)" with "Soft Limb Holder" right wrist, left wrist, right ankle and left ankle checked. Further review revealed "D. Physician Order (use appropriative code as indicated above) Medical Surgical Care - *Not to exceed 24 hours- Must have face-to-face assessment documented every 24 hours by a Licensed Independent Practitioner (LIP)." Review revealed "Start Date" of 08/07/2013; "Start/Order Time" of 2345; "Stop Date" of 08/08/2013; and "Stop Time" of 0245.

Review of a physican's progress note by ED Physician #1, dated 08/07/2013 at 2345, revealed "Pt. currently handcuffed, alert, nl (normal) airway. Tearful."

Record review revealed documentation the patient was placed into 4 point soft limb restraints on 08/07/2013 at 2345 and was removed from restraint on 08/08/2013 at 0207. Further review of a "Restraint Management Plan of Care" form revealed documentation of nursing assessments/monitoring initiated at 2345 (08/07) and performed every 15 minutes thereafter by RN #6 at 0000 (08/08), 0015, 0030, 0045, 0100, 0115, 0130, 0145, 0200, 0215, and 0230.

Consequently, video surveillance footage review revealed Patient #37 was placed into an inappropriate physical restraint hold by nursing staff on 08/07/2013 at 23:19:51 (25 minutes and 09 seconds earlier than the time of restraint (2345) documented by RN #6) and was then placed into handcuffs (an inappropriate restraint device) by RN #2 at 23:22:04. The handcuffs were removed at 23:54:26 (32 minutes and 22 seconds later). Video review revealed the patient was restrained with his arms handcuffed behind his back in an inappropriate face down (prone) position on the floor from 23:22:08 until 23:24:00 (1 minute and 52 seconds) and sitting position on the floor from 23:24:00 until 23:38:48 (14 minutes and 35 seconds). Video review revealed the patient was physically restrained on the floor from 23:20:21 until 23:38:35 (18 minutes and 14 seconds) before being assisted off the floor and onto the bed. Furthermore, record review failed to reveal any available documentation by nursing staff that Patient #37 was placed into a physical restraint hold on 08/07/2013 at 23:19:51; was placed into handcuffs at 23:22:04 and was removed from handcuffs at 23:54:26. Record review failed to reveal any available documentation of assessment/monitoring of the patient at the time of the initiation of the physical restraint hold at 23:19:51 and 15 minutes thereafter at 23:34:51 to include: a. Type of restraint b. Skin at restraint site c. Circulation d. Respirations e. Range of motion f. Patient position g. Is bed alarm on h. Fluid/Nourishment offered i. Toilet j. Behavior Observed k. Restraint properly applied l. Additional interventions attempted m. Restraint removed n. Patient education o. Order up to date p. Restraint use indicted/not indicated.

Interview with CI #1 during video surveillance footage review on 02/05/2014 at 1615 confirmed the above video findings. Interview revealed at the beginning of the video (23:10:00) the patient appeared "anxious and bored." Interview revealed as the video progressed, the patient "paced more" and "became increasingly agitated." Interview revealed the patient did not appear to be a danger to himself or others. Interview revealed no physical aggression was exhibited by the patient towards staff, until after the staff backed the patient into the corner of the room and attempted to restrain him (23:19:51). Interview revealed staff should never use walls as a means to help hold a patient for restraint. Interview revealed staff should not lift a patient's leg up off the floor in order to attempt restraint. Interview revealed staff should never place their arms around a patient's neck for restraint. Interview revealed staff should never place their hands over a patient's chin/face/mouth for restraint. Interview revealed the patient's head and neck should never be hyper-extended during restraint. Interview revealed staff should never hold a patient's head down on the floor for restraint. Interview revealed staff should never place a patient face-down on the floor or in a sitting position on the floor while restrained. Interview revealed the patient would be at increased risk of nerve damage, cervical spine damage, and asphyxia. Interview revealed it would not be considered a safe environment for the staff member to administer a IM (intramuscular) injection in this situation. Interview revealed staff should have "let go and backed away" until the situation was more controlled. Interview revealed the hospital's nursing staff are not trained to use handcuffs. Interview revealed staff should never use handcuffs for restraint. Interview confirmed the hospital's nursing and security staff performed inappropriate physical restraint holds and used inappropriate physical restraint devices (handcuffs), and failed to appropriately monitor the patient while restrained. Interview revealed the patient was at an increase risk for potential asphyxia and personal injury. Interview revealed "the team control position should have been used." Interview revealed "No component of CPI was followed" and "without audio, I cannot confirm effective limit setting was followed."

Interview on 02/06/2014 at 1000 with SO #1 revealed he is an employee of the hospital. Interview revealed he has been a SO full-time for 2 years. Interview revealed "I do not have powers to arrest." Interview revealed he assists the nursing staff with restraint/seclusion. Interview revealed he assists by holding the patient's extremity or body. Interview revealed he does not apply the restraint device. Interview revealed he is not allowed to apply restraint devices. Interview revealed he carries pepper spray and a flashlight for equipment. Interview revealed "We do not carry handcuffs anymore. After yesterday." Interview revealed he was notified by his supervisor at the start of his shift last night. Interview revealed "prior to yesterday we did carry handcuffs." Interview revealed "we were allowed to use handcuffs on visitors or staff." Interview revealed "we are not allowed to use handcuffs on patients." Interview revealed "when I was hired, my understanding was if a patient was going to jail we could use handcuffs until law enforcement arrived. Approximately 8 months after being hired there was a change in policy, where only visitors or staff could be handcuffed. No patients at all." Interview revealed he does recall the event involving Patient #37 on 08/07/2013. Interview revealed the patient kept going in and out of the room. Interview revealed "he was restless." Interview revealed "the Nurse (RN #6 name) asked if the patient would like a shot of medication to help him relax." Interview revealed the patient stated "no, they could not give him a shot." Interview revealed "she told him they could because he was an IVC patient." Interview revealed the patient still refused so RN #6 called for the charge nurse, (RN #3 name) in the ED. Interview revealed RN #3 came over to talk with the patient. Interview revealed the patient became more agitated so RN #3 called for more help. Interview revealed "the patient was not physically aggressive towards staff until they got the shot to give to him." Interview revealed "the patient was loud to begin with and became louder when staff came in with the medication to give shot." Interview revealed the patient did not display any physical aggression. Interview revealed "I did not feel in danger or that the staff were in danger." Interview revealed "I didn't think the patient was a harm to himself." Interview revealed "once they brought the syringe into give the shot, the patient stated 'she's not going to give it to me.' So one of the male nurses said 'I will give it to you' and the patient said that's fine." Interview revealed the nursing staff proceeded into the room to give the patient the shot. Interview revealed "the patient backed into the corner." Interview revealed "the staff nurses kept stepping towards the patient and at that point the patient got defensive." Interview revealed "the patient put his fists up and one of the nurses got close and the patient swung at the nurse." Interview revealed "the staff pushed and pinned the patient against the wall and gave him the shot." Interview revealed "the patient was still struggling with staff." Interview revealed "the staff put the patient on the floor." Interview revealed "once the patient was on the floor the nurse asked for my handcuffs." Interview revealed "I gave the nurse my pair of hand cuffs and he placed them on the patient." Interview revealed "law enforcement arrived and the nurses backed out." Interview revealed the patient was helped up to his feet and helped to the bed. Interview revealed once the patient was in the bed, his handcuffs were taken off and soft restraints were applied. Interview revealed "it was the first and only time a nurse has asked for my handcuffs." Interview revealed "at the time, I had no knowledge either way, if a nurse could or could not use handcuffs." Interview revealed "the request caught me off guard." Interview revealed "at the time the handcuffs were placed on the patient, he was not under arrest, but because he hit the nurse he was going to jail." Interview revealed "I do not think I had any restraint training, it was far enough back I do not recall." Interview revealed "I had CPI training at the time of the occurrence." Interview revealed "I discussed the incident with my supervisor (COS name) the next day." Interview revealed SO #1 has not had any follow-up or additional training as a result of the incident involving Patient #37.

Telephone interview on 02/06/2014 at 1115 with RN #2 revealed he is a full-time nurse in the ED. Interview revealed he recalled the incident involving Patient #37 on 08/07/2013. Interview revealed he and RN #6 were working in EDIII. Interview revealed "the patient became extremely verbally aggressive, cussing, calling names to (RN #6 name)." Interview revealed he approached the patient and asked him to "please go to his room." Interview revealed the patient started cussing. Interview revealed RN #6 called a "Code Green" and RN #1, RN #3, RN #4, RN #5, and SO #1 responded. Interview revealed the patient was in ED III room 2. Interview revealed "the patient went into the left hand corner of the room." Interview revealed " (RN #1 name) went into the room with Geodon, IM." Interview revealed "at first the patient was going to take the medication. Then he refused." Interview revealed "I asked the patient to sit in the chair, he refused." Interview revealed "he grabbed hold of (RN #3's) clothes." Interview revealed "I grabbed his left hand and arm and (RN #3) grabbed the other arm." Interview revealed "the patient then punched me in the face, neck, and struck me between 3 and 5 times." Interview revealed "the patient was taken to the ground, meds given, police arrived." Interview revealed the patient was placed onto the bed. Interview revealed "I went to the ER to be seen for my bruises on my neck and face and filed felony charges." Interview revealed the patient was placed into handcuffs. Interview revealed "I did, place the patient into handcuffs." Interview revealed "I got the cuffs from (SO #1 name) the security guard." Interview revealed after the police arrived, the patient was placed on the bed in four point handcuffs. Interview revealed the handcuffs were switched out to soft wrist restraints. Interview revealed initially, he (RN #2) did not see any physical aggression by the patient. Interview revealed it was "completely all verbal until he grabbed the staff's personal body (RN #3)." Interview revealed "Geodon takes about 20-30 minutes to take effect. The patient was handcuffed because it was a corner situation and I was in the best position to apply the handcuffs." Interview revealed "I was looking out for myself, staff, and the patient's safety." Interview revealed the patient was not under arrest. Interview revealed "at the time of the occur

Based on hospital policy review, medical record review, and staff interviews, the hospital's staff failed to ensure a physician's restraint order was time limited for no longer than four (4) hours for 1 of 1 adult patients (#37) that was restrained for the management of violent or self-destructive behaviors.

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "...PHYSICIAN ORDER * WITHIN ONE HOUR of restraint application, a physician's order must be obtained. ...* Each order will be time specific: Adults: order not to exceed a four (4) hour period. ..."

Closed emergency department (ED) record review on 02/05/2014 for Patient #37 revealed a 26 year old male who presented to the hospital's ED on 08/03/2013 under involuntary commitment (IVC) petition for psychiatric evaluation. Review revealed the patient was diagnosed with "substance abuse disorder." Record review revealed nursing documentation the patient was placed into physical restraint on 08/07/2013 at 2345 (23:19:51 per video) and was removed from restraint on 08/08/2013 at 0207.

Review of a "Medical/Surgical Restraint Order Form" dated 08/07/2013 revealed a verbal order for restraint was obtained by RN #7 at 2350 from ED Physician #1. Review revealed ED Physician #1 signed the verbal order on 08/08/2013 at 0030. Review of the order form revealed "A. Reason-based on Nursing Assessment: (check all that apply)." Review revealed under the heading "Medical Surgical/Restraint....5._[hand written check mark on line]_Other_[Violent Behavior handwritten on line]_." Further review revealed under the heading "Violent/Self-Destructive Behavior Restraint **IF ANY OF THE BELOW APPLY-VIOLENT/SELF-DESTRUCTIVE BEHAVIOR RESTRAINT ORDER FORM MUST BE USED**... Further review revealed "D. Physician Order (use appropriative code as indicated above) Medical Surgical Care - *Not to exceed 24 hours... ." Review revealed "Start Date" of 08/07/2013; "Start/Order Time" of 2345; "Stop Date" of 08/08/2013; and "Stop Time" of 0245. Review failed to reveal any available documentation of a time limited order not to exceed four (4) hours.

Interview on 02/07/2014 at 0930 with the ED Director revealed restraint orders for the management of violent or self-destructive behaviors must be time limited according to the patient's age. Interview revealed RN #6 called the Behavioral Health (BH) unit to verify what form she needed and thought she had the correct form. Interview revealed "(RN #6 name) used the wrong form." Interview revealed RN #6 used the medical/surgical restraint order form which is time limited for up to 24 hours. Interview confirmed the restraint order obtained for Patient #37, dated 08/07/2013 at 2350, failed to have a written time limit not to exceed 4 hours.

Based on hospital policy review, medical record review, video surveillance footage review, and staff interviews, the hospital staff failed to monitor and assess a restrained patient per hospital policy for 1 of 1 patients (#37) restrained for the management of violent or self-destructive behaviors.

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "...The USE OF ANY RESTRAINTS FOR VIOLENT/SELF DESTRUCTIVE BEHAVIOR REQUIRES ONE-TO-ONE STAFF. AND MONITORING EVERY 15 MINUTES ...ASSESSMENT An assessment of the patient will occur at the time of the initial of restraint and every 15 minutes thereafter and will include: a. Type of restraint b. Skin at restraint site c. Circulation d. Respirations e. Range of motion f. Patient position g. Is bed alarm on h. Fluid/Nourishment offered i. Toilet j. Behavior Observed k. Restraint properly applied l. Additional interventions attempted m. Restraint removed n. Patient education o. Order up to date p. Restraint use indicted/not indicated. DOCUMENTATION ...b. Using the Restraint Management Plan of Care Form, nursing staff members monitor and reassess the needs of the patient every 15 minutes using the Restraint Management Plan of Care.... ."

Closed emergency department (ED) record review on 02/05/2014 for Patient #37 revealed a 26 year old male who presented to the hospital's ED on 08/03/2013 under involuntary commitment (IVC) petition for psychiatric evaluation. Review revealed the patient was diagnosed with "substance abuse disorder." Record review revealed nursing documentation the patient was placed into physical restraint on 08/07/2013 at 2345 (23:19:51 per video)and was removed from restraint on 08/08/2013 at 0207.

Review on 02/05/2014 at 1615 with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Quality and Risk Management, Director of Security, Emergency Department Director, and the hospital's Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) Certified Instructor (CI #1) of video surveillance footage without audio; dated 08/07/2013, time interval 23:10:00 to 23:55:00; from hospital security camera, ED III Room 2 revealed at:
23:19:51 - Patient with back against wall in left rear corner of room, facing staff. Patient arms crossed in front of chest. No physical aggression observed by patient towards staff. Staff observed in a "corralling stance" and then rapidly advance towards patient. RN #2 reaches towards patient and appears to make physical contact with left chest/axilla area of patient. Patient extends left arm outward towards RN #2 and appears to make contact with RN #2. Patient swings right arm and appears to strike RN #2 in left side of face/jaw area. RN #3 reaching towards patient and appears to make contact with the patient's right shoulder. Patient appears to be pushed up against wall of room. Two additional male staff members (RN #4 and RN #5) enter room to assist.
23:22:04 - Patient on floor. Appears to be on right side/facing downward on floor. RN #2 is observed placing a handcuff on patient's left wrist.
23:22:07 - RN #2 is observed placing a handcuff on patient's right wrist.
23:22:08 - Patient's is observed with hands handcuffed behind back. Lying on right lateral side. Facing downward to floor.
23:22:10 - Patient is observed lying face down (Prone position) on floor with hands handcuffed behind back.
23:41:09 - Patient handcuffs removed from back by LEOs. Patient's left and right hand individually handcuffed to left and right bed siderail by LEOs.
23:45:00 - Remains on bed handcuffed to siderails.
23:50:08 - SO #2 enters room with soft wrist restraints.
23:51:00 - Soft restraints applied to bilateral feet by RN#7 and SO #2.
23:51:54 - Soft restraints applied to bilateral hands by RN #7 and SO #2.
23:54:26 - Handcuffs removed by SO #2.
23:55:00 - Patient observed on bed in 4 point soft restraints. End video.

Continued record review of a "Medical/Surgical Restraint Order Form" dated 08/07/2013 revealed a verbal order for restraint was obtained by RN #7 at 2350 from ED Physician #1. Review revealed ED Physician #1 signed the verbal order on 08/08/2013 at 0030. Review of the order form revealed "A. Reason-based on Nursing Assessment: (check all that apply)." Review revealed under the heading "Medical Surgical/Restraint....5._[hand written check mark on line]_Other_[Violent Behavior handwritten on line]_." Further review revealed under the heading "Violent/Self-Destructive Behavior Restraint **IF ANY OF THE BELOW APPLY-VIOLENT/SELF-DESTRUCTIVE BEHAVIOR RESTRAINT ORDER FORM MUST BE USED** ..." Further review revealed "B.__[RN #7 and RN #6 name handwritten on line]__" above "Collaboration with/and Correct Restraint Application Verified by" dated 08/07/2013 at 2350. Review revealed the hand written signature of RN #6 on the line above "Signature of RN assessing patient/applying restraint:" dated 08/07/2013 at 2350. Further review revealed "C. Type of restraint (check all that apply)" with "Soft Limb Holder" right wrist, left wrist, right ankle and left ankle checked. Review revealed "Start Date" of 08/07/2013; "Start/Order Time" of 2345; "Stop Date" of 08/08/2013; and "Stop Time" of 0245.

Record review revealed documentation the patient was placed into 4 point soft limb restraints on 08/07/2013 at 2345 and was removed from restraint on 08/08/2013 at 0207. Further review of a "Restraint Management Plan of Care" form revealed documentation of nursing assessments/monitoring initiated at 2345 (08/07) and performed every 15 minutes thereafter by RN #6 at 0000 (08/08), 0015, 0030, 0045, 0100, 0115, 0130, 0145, 0200, 0215, and 0230.

Consequently, video surveillance footage review revealed Patient #37 was placed into an inappropriate physical restraint hold by nursing staff on 08/07/2013 at 23:19:51 (25 minutes and 09 seconds earlier than the time of restraint (2345) documented by RN #6) and was then placed into handcuffs (an inappropriate restraint device) by RN #2 at 23:22:04. The handcuffs were removed at 23:54:26 (32 minutes and 22 seconds later). Video review revealed the patient was restrained with his arms handcuffed behind his back in an inappropriate face down (prone) position on the floor from 23:22:08 until 23:24:00 (1 minute and 52 seconds) and sitting position on the floor from 23:24:00 until 23:38:48 (14 minutes and 35 seconds). Video review revealed the patient was physically restrained on the floor from 23:20:21 until 23:38:35 (18 minutes and 14 seconds) before being assisted off the floor and onto the bed. Furthermore, record review failed to reveal any available documentation by nursing staff that Patient #37 was placed into a physical restraint hold on 08/07/2013 at 23:19:51; was placed into handcuffs at 23:22:04 and was removed from handcuffs at 23:54:26. Record review failed to reveal any available documentation of assessment/monitoring of the patient at the time of the initiation of the physical restraint hold at 23:19:51 and 15 minutes thereafter at 23:34:51 to include: a. Type of restraint b. Skin at restraint site c. Circulation d. Respirations e. Range of motion f. Patient position g. Is bed alarm on h. Fluid/Nourishment offered i. Toilet j. Behavior Observed k. Restraint properly applied l. Additional interventions attempted m. Restraint removed n. Patient education o. Order up to date p. Restraint use indicted/not indicated.

Interview with CI #1 during video surveillance footage review on 02/05/2014 at 1615 confirmed the above video findings.

Interview on 02/06/2014 at 1151 with RN #6 revealed she was on duty when Patient #37 was restrained on 08/07/2013. Interview revealed she was working in ED III. Interview revealed the patient was admitted to the ED on 08/03/2013. ...Interview revealed "I do not remember seeing the patient being put into handcuffs, but I remember hearing that he was placed into handcuffs." Interview revealed "I do not know who put the handcuffs on." Interview revealed "I do not remember everything that happened that night." ...Interview revealed "I went in every 15 minutes to monitor" and "security was 1:1 with the patient." Interview revealed "I started monitoring the patient at 2345, when the soft wrist restraints were applied." ...Interview confirmed no available documentation of assessment/monitoring of the patient at the time of the initiation of the physical restraint hold at 23:19:51 and 15 minutes thereafter at 23:34:51.

Interview on 02/07/2014 at 1340 with the ED Director revealed when restraints are used for the management of violent or self-destructive behaviors, the patient is to be assessed and monitored every 15 minutes after initiation of restraint and thereafter until released from restraint. Interview confirmed the nurse failed to follow hospital policy.

Based on policy review and staff interview, the hospital failed to ensure Emergency Department physicians completed restraint and seclusion training per policy.

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "...VI. TRAINING OF STAFF Hospital and medical staff members shall receive training in the following subjects as it relates to duties performed under this policy. Such training shall take place during departmental or medical staff orientation (before the trainee is asked to implement the provision of this policy) and shall be repeated periodically as indicated in the hospital's training plan, which is based on the results of quality monitoring activities. ...A. Physicians (or designees, PA's NP's) who order restraint or seclusion shall be trained in the requirements of this policy and shall demonstrate a working knowledge of this policy through ongoing compliance. ...V. PERSONNEL AUTHORIZED AND QUALIFIED TO APPLY RESTRAINTS * Patient Care Services Personnel who have demonstrated competency by annual completion of....Restraint Management Program. ..."

Interview on 02/07/2014 at 1340 with the ED Director revealed ED physicians and mid-level providers, order restraint and seclusion on patients and perform the one hour face-to-face evaluations. Interview revealed the hospital nor the contracted ED physicians' group required the ED physicians or mid-level providers to have restraint or seclusion training. Interview revealed there is no available documentation of restraint and seclusion training in the physician's credential files or on Health Stream (education computer system) for ED physicians.

Based on hospital policy review, medical record review, video surveillance footage review, and staff interview the hospital failed to ensure the physician or other licensed independent practitioner conducting the face-to-face evaluation within 1 hour after the initiation of restraint evaluated the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint for 1 of 1 patients (#37) restrained for the management of violent or self-destructive behaviors.

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "...* WITHIN ONE HOUR, a physician or other LIP (PA or NP) must perform a face-to-face assessment of the patient, evaluate the need for restraint, and address these four (4) elements * The patient's immediate situation * Patient's response to being restrained * Patient's current medical and behavioral condition * Continue restraint/seclusion Yes__No__ ... ."

Closed emergency department (ED) record review on 02/05/2014 for Patient #37 revealed a 26 year old male who presented to the hospital's ED on 08/03/2013 under involuntary commitment (IVC) petition for psychiatric evaluation. Review revealed the patient was diagnosed with "substance abuse disorder." Review revealed nursing documentation the patient was placed into physical restraint on 08/07/2013 at 2345 (23:19:51 per video) and was removed from restraint on 08/08/2013 at 0207. Review of nursing documentation by RN #6 on 08/07/2013 at 2329, revealed "...(ED Physician #1 name) has walked in at 2345 to assess patient.... ."

Review on 02/05/2014 at 1615 with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Quality and Risk Management, Director of Security, Emergency Department Director, and the hospital's Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) Certified Instructor (CI #1) of video surveillance footage without audio; dated 08/07/2013, time interval 23:10:00 to 23:55:00; from hospital security camera, ED III Room 2 revealed at:
23:47:03 - ED Physician #1 enters room. Stands beside counter. No physical contact with patient observed.
23:47:47 - ED physician #1 exits room (44 seconds later).

Review of a physican's progress note by ED Physician #1, dated 08/07/2013 at 2345, revealed "Pt. currently handcuffed, alert, nl (normal) airway. Tearful." Record review failed to reveal any available documentation by ED Physician #1 of an assessment of the patient's reaction to the intervention; behavioral condition; and need to continue or terminate the restraint.

Interview with CI #1 during video surveillance footage review on 02/05/2014 at 1615 confirmed the above video findings.

Interview on 02/07/2014 at 1340 with the ED Director revealed ED physicians and mid-level providers, order restraint and seclusion on patients and perform the one-hour face-to-face evaluations. ...Interview confirmed no available documentation in the one-hour face-to-face conducted by ED Physician #1 on 08/07/2013 at 2345 of Patient #37's reaction to the intervention; behavioral condition; and need to continue or terminate the restraint. Interview confirmed the physician failed to follow policy.

Based on policy review, education training transcript reviews, and staff interview, the hospital failed to ensure Emergency Department and Security staff were trained in the use of non-physical intervention skills for 4 of 8 Emergency Department and Security staff (RN #2, RN #3, RN #4, and SO #1).

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "...VI. TRAINING OF STAFF Hospital and medical staff members shall receive training in the following subjects as it relates to duties performed under this policy. Such training shall take place during departmental or medical staff orientation (before the trainee is asked to implement the provision of this policy) and shall be repeated periodically as indicated in the hospital's training plan, which is based on the results of quality monitoring activities. ...C. Annually, Hospital staff members who assess, monitor or apply restraint in the Emergency Department or the Behavioral Health Unit are required to complete the Non-Violent Crisis Intervention Program (NCI). These staff members also receive training in the following: 1. The underlying causes of threatening behaviors exhibited by the patients. 2. Medical conditions that may lead to aggressive or threatening behavior 3. Influence of staff behavior on patients 4. Alternative techniques such as de-escalation, mediation, self-protection, and other techniques such as time-out 5. Staff members who are authorized to apply restraint or seclusion also receive training on the safe use of restraint, including physical holding techniques, take-down procedures, and the application and removal of mechanical restraint. 6. Staff members shall demonstrate competence in: a. Recognizing how age, developmental considerations, gender issues, ethnicity, and history of sexual or physical abuse may affect the way in which a patient reacts to physical contact b. Using behavior criteria for discontinuing restraint or seclusion and how to help patients in meeting these criteria ..."

Review of current hospital policy "Security Measures" Policy S-121-201, revised 02/18/2013, revealed "...TRAINING: All Security personnel shall receive security training adequate to perform their job functions. ...RESPONSIBILITIES: * Security personnel stationed at the hospital shall be responsible for the following: ...* Staff assistance with patient restraint and intervention in disruptions by patients, visitors or staff ...."

Review of an "Education Review" and "Official Transcript" document dated 02/06/2013 prepared by the CEO revealed 4 of 8 (50%) hospital staff listed; involved in the application/monitoring of restraint for Patient #37 on 08/07/2013, failed to have Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training. Review revealed no available documentation the following staff were qualified and competent in the use of CPI/NCI techniques:
1. RN #2
2. RN #3
3. RN #4
4. SO #1

Interview on 02/04/2014 at 1655 with the ED Director revealed....ED staff are required to have annual restraint and seclusion training and CPI/NCI training within one year of employment.

Interview on 02/07/2014 at 0850 with CI #1 revealed the CPI/NCI certification is good for two years after initial certification. Interview revealed staff who are required to have CPI/NCI training, have one year to complete the course after hire. Interview revealed she has no available documentation RN #3 and RN #4 have had CPI/NCI training. Interview revealed RN #2 has not had CPI/NCI training since he was hired (04/01/2013). Interview revealed 9 classes have been scheduled, with 4 completed since the 08/07/2013 incident involving Patient #37. Interview revealed RN #2 was signed up for the class in 12/20/2013 and she (CI #1) received an e-mail from the ED Director canceling with no reason giving.

Interview on 02/07/2014 at 1015 with the Chief of Security (COS) revealed ..."CPI is required." Interview revealed if a security officer is not certified with CPI upon hire they must get certified as soon as possible.

Based on policy review, personnel file and education training transcript reviews, and staff interviews, the hospital failed to ensure education/training records for Emergency Department and Security staff contained documentation of training and demonstration of competency for restraint and non-physical intervention skills were successfully completed for 4 of 8 Emergency Department and Security staff (RN #2, RN #3, RN #4, and SO #1).

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "...VI. TRAINING OF STAFF Hospital and medical staff members shall receive training in the following subjects as it relates to duties performed under this policy. Such training shall take place during departmental or medical staff orientation (before the trainee is asked to implement the provision of this policy) and shall be repeated periodically as indicated in the hospital's training plan, which is based on the results of quality monitoring activities. Individuals trained shall exhibit their knowledge of the subject matter through the consistent implementation of the matters taught. The training programs will include return demonstrations and post-training tests a the discretion of the trainer. ...B. Hospital staff members who assess patients need for restraint or who apply restraint shall receive training in the following: (It is acceptable to have separate training for staff who deal with Behavioral Health and Medical restraint.) 1. The impact of restraints on the rights and dignity of the patient. 2. Risks associated with the use of restraint to vulnerable populations, such as pediatric, emergency and cognitively or physically challenged patients. 3. Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. 4. The use of nonphysical intervention skills. 5. Alternatives to restraint-choosing the least restrictive intervention based on an individualized assessment of the patient's medical, or behavioral status or condition. 6. The safe application and use of all types of restraint or seclusion used by the staff member, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). 7. Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. 8. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to respiratory and circulatory status, skin integrity, and vital sings. 9. Staff members who are authorized to monitor patients in restraint also receive training in: a. taking vital signs and interpreting their relevance to the physical safety of the patient in restraint. b. recognizing nutritional and hydration needs c. checking circulation and range of motion in the extremities d. addressing hygiene and elimination e. addressing physical and psychological status and comfort f. helping patients meet behavior criteria for discontinuing restraint or seclusion g. criteria for early release and criteria for removal of restraint h. recognizing readiness for early release and/or discontinuing restraint or seclusion i. recognizing incorrect application of restraints j. recognizing when to contact a medically trained licensed independent practitioner, designee, PA or NP to evaluation and or treat the patient's physical status 10. The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic re-certification. C. Annually, Hospital staff members who assess, monitor or apply restraint in the Emergency Department or the Behavioral Health Unit are required to complete the Non-Violent Crisis Intervention Program (NCI). These staff members also receive training in the following: 1. The underlying causes of threatening behaviors exhibited by the patients. 2. Medical conditions that may lead to aggressive or threatening behavior 3. Influence of staff behavior on patients 4. Alternative techniques such as de-escalation, mediation, self-protection, and other techniques such as time-out 5. Staff members who are authorized to apply restraint or seclusion also receive training on the safe use of restraint, including physical holding techniques, take-down procedures, and the application and removal of mechanical restraint. 6. Staff members shall demonstrate competence in: a. Recognizing how age, developmental considerations, gender issues, ethnicity, and history of sexual or physical abuse may affect the way in which a patient reacts to physical contact b. Using behavior criteria for discontinuing restraint or seclusion and how to help patients in meeting these criteria

Review of an "Education Review" and "Official Transcript" document dated 02/06/2013 prepared by the CEO revealed 4 of 8 (50%) hospital staff listed; involved in the application/monitoring of restraint for Patient #37 on 08/07/2013, failed to have Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training. Review revealed no available documentation the following staff were qualified and competent in the use of CPI/NCI techniques:
1. RN #2
2. RN #3
3. RN #4
4. SO #1

Review on 02/06/2014 of the ED nursing staff schedule for 1/19/2014 to 03/01/2014 revealed RN #2, RN #3, and RN #4 were scheduled to work shifts in the ED, even though they do not have current Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training as required for their job.

Interview on 02/04/2014 at 1655 with the ED Director revealed....ED staff are required to have annual restraint and seclusion training and CPI/NCI training within one year of employment.

Interview on 02/07/2014 at 0850 with CI #1 revealed the CPI/NCI certification is good for two years after initial certification. Interview revealed staff who are required to have CPI/NCI training, have one year to complete the course after hire. Interview revealed she has no available documentation RN #3 and RN #4 have had CPI/NCI training. Interview revealed RN #2 has not had CPI/NCI training since he was hired (04/01/2013). Interview revealed 9 classes have been scheduled, with 4 completed since the 08/07/2013 incident involving Patient #37. Interview revealed RN #2 was signed up for the class in 12/20/2013 and she (CI #1) received an e-mail from the ED Director canceling with no reason giving.

Interview on 02/07/2014 at 1015 with the Chief of Security (COS) revealed ..."CPI is required." Interview revealed if a security officer is not certified with CPI upon hire they must get certified as soon as possible.

Based on review of hospital policy and procedure, incident report, medical records, video and staff interview, the hospital failed to ensure an effective, on-going, data-driven quality assessment and performance system monitoring actions for the use of restraints and non-crisis intervention for behavioral health patients in the hospital's Emergency Department (ED) and failed to identify a cause and analyze surgical site infection (SSI) trends.

The findings include:

The hospital failed to investigate an adverse patient event, analyze the cause and implement corrective actions for 1 of 1 restrained behavioral health patient in the emergency department (Patient #37) and failed to identify a cause and analyze surgical site infection (SSI) trends between June 2013 - November 2013 and implement corrective action for 6 of 7 patients with SSI (Patient #43, #44, #45, #46, #47, #48).

~cross refer to 482.21(a)(c)(2), (e)(3) QAPI Standard: Tag A0286.

Based on review of hospital policy and procedure, incident report, logs, medical records, video and staff interview, (A) the hospital failed to investigate an adverse patient event, analyze the cause and implement corrective actions for 1 of 1 restrained behavioral health patient in the emergency department (Patient #37) and (B) the hospital failed to identify a cause, analyze surgical site infection (SSI) trends between June 2013 - November 2013 and implement corrective action for 6 of 7 patients with SSI (Patient #43, #44, #45, #46, #47, #48).

The findings include:

(A) Review of the hospital's policy, "Continuous Quality Improvement Plan", approved 08/01/2013, revealed, "1. PURPOSE (Name of Hospital) is a community focused health care provider. As such, (Name of Hospital) is dedicated to compassionately improve the health and well-being of our patients. With excellence as its standard, (Name of Hospital) serves as a comprehensive resource for the provision of quality, safe...health care services through its people and technology. (Name of Hospital) acknowledges its responsibility to deliver a level of patient care consistent with recognized professional standards that meets or exceeds the expectations of those it serves. To accomplish this, (Name of Hospital) must continually evaluate and improve the quality of services provided throughout the organization. ...".

Review of the hospital's policy, "Incident Reporting: Care and Reporting of Incidents Involving Patients...", revised 09/13/2012, revealed, "POLICY: All incidents involving patients...are to be reported and investigated. ...II. Completing a Quality Care Control (Variance) Report ... 4. The report is completed within 48 hours of the incident or discovery of the incident...III. Investigation of the Incident 1. The investigation of the incident is the responsibility of the person in charge of the area in which the incident occurs. If needed, the Director of Quality & Risk Management can be contacted for assistance. IV. Investigation of the Quality Care Control (Variance) Report 1. In addition to review by the person preparing the report and the department director/supervisor of the immediate area, the Vice President of Patient Care Services and the Director of QRM (Quality/Risk Management) reviews the variance reports for patient incidents. ...2. In addition, physician & hospital committees receive variance outcomes reports as follows: ...Safety Committee...".

Review of the hospital's policy, "Sentinel Events", revised 11/08/2010, revealed, I. POLICY: A sentinel event is an unexpected occurrence that involves...serious physical or psychological injury or the risk thereof. "Or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. ...The goals of this policy are: to have a positive impact in improving patient care; to focus the attention of the organization on understanding the causes that underlie the event, and on making changes in the organization's systems and processes to reduce the probability of any such future event; to increase the general knowledge about sentinel events, their causes and strategies for prevention; to maintain the confidence of the public... . II. PROCEDURE : ...B. If an event meets two of the following three criteria, it is considered a sentinel event: ...2. significant deviation from the usual process(es) for providing health care services or managing the organization and/or; 3. has the potential to or did undermine the public's confidence in the organization. C. When an event of significant serious adverse outcome or one with the potential for serious adverse outcome occurs, as determined by Administration and/or risk manager, the sentinel event plan will be initiated by the risk manager, administrator on call or designee. A root cause analysis will be conducted. D. A root cause analysis (RCA) team may be appointed by Administration... . The analysis will focus on systems and processes; will progress from special causes in clinical processes to common causes in organization processes, and will be completed within 45 working days. ...".

(1) Closed emergency department (ED) record review on 02/05/2014 for Patient #37 revealed a 26 year old male who presented to the hospital's ED on 08/03/2013 under involuntary commitment (IVC) petition for psychiatric evaluation. Review revealed the patient was diagnosed with "substance abuse disorder." Review revealed the patient was held in the ED from 08/03/2013 until 08/13/2013 (11 days), awaiting placement at a psychiatric hospital. Review revealed on 08/13/2013 the patient was reassessed by the ED physician as "...no longer meets criteria for inpatient treatment" and was subsequently released from IVC petition and discharged from the ED.

Review on 02/05/2014 at 1615 with the Chief Executive Officer, Chief Nursing Officer, Director of Quality and Risk Management, Director of Security, Emergency Department Director, and the hospital's Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) Certified Instructor (CI #1) of video surveillance footage without audio; dated 08/07/2013, time interval 23:10:00 to 23:55:00; from hospital security camera, ED III Room 2 revealed Patient #37 in the treatment room, pacing with no signs of physical aggression. Further review revealed a registered nurse (RN #1) entering the room and swabs the patient's right shoulder with alcohol wipe. Two more male staff members (RN #2 and RN#3) appear in the doorway. No physical aggression is observed by Patient #37 towards staff. Patient #37 walks away from RN #1 and walks to the left corner of the room. A Security Officer (SO#1) appears in doorway of the treatment room. RN #1, #2 and #3 walk towards Patient #37. RN #4 enters the room. All staff members rapidly advance toward patient. Staff members grab patient and hold him against the wall. RN #3 is observed with his left arm around the patient's neck in a "head lock" position. Interview with staff present while watching the video confirmed this was an inappropriate physical restraint hold. The patient's neck is observed being hyper-extended. Interview revealed the patient is at increased risk of nerve damage, cervical spine damage, and asphyxia. Interview confirmed the use of an inappropriate physical restraint hold. Patient is placed on the floor with staff on top of the patient. Patient is face down with RN #3 pushing the patient's head to the floor. RN #2 places handcuffs (given to him by SO #1) on the patient's wrist, with arms behind his back while face down on the floor. Concurrent interview with CI #1 revealed the hospital's nursing staff are not trained to use handcuffs. Interview revealed handcuffs are not to be used for restraint. Interview confirmed RN #2 used an inappropriate physical restraint device on the patient. Concurrent interview with CI #1 revealed the staff performed inappropriate physical restraint holds, restraint monitoring, and used inappropriate physical restraint devices. Interview revealed the patient was at an increase risk for potential asphyxia and personal injury.

Review of a "Quality Care Control Report" , dated 08/15/2014, revealed the report was completed by ED Administrative Staff (8 days after the incident related to Patient #37). Review revealed "Briefly Describe Variance: Pt yelling & swearing at staff (RN #6). Called for assistance to help with situation. Pt pacing in room. Staff went in to give pt medication shot. Pt refused shot. Pt backed up into corner. 3 male staff tried to secure pt for shot. Pt hit (RN #2). Pt held & shot given. Pt verbally & physically resistant to staff. Hand cuffs from security placed on pt by RN. Pt put in sitting position. Police arrived. Spoke to patient. Pt assisted to stretcher, handcuffed to stretcher. Handcuffs removed, pt placed in 4 point soft restraints. Pt became calm, MD assessed pt. Restraints removed one at a time". Further review revealed, "Was Patient/Subject Aware of Variance? Wants to press charges against ED Staff". Further review of the Quality Care Control Report revealed the risk manager signed the report on 08/19/2013 (4 days after completion by ED staff, 12 days after incident).

Interview on 02/07/2014 at 0915 with the manager of the hospital's ED revealed, "the staff told me on the morning of August 8th that there had been a take down and the patient was upset and wanted a copy of the video. I reviewed the video, I'm not sure of that date. I knew improper technique had been used. I had the behavioral health manager review the video and she agreed that improper technique had been used. I then talked to (CNO Name) and completed the incident report on August 15". Interview revealed the hospital's policy for incident reporting was not followed. Interview further revealed, "I am not sure which of the nurses have received initial or additional training".

Interview on 02/07/2014 at 0845 with the Quality/Risk Management Director revealed "compliance with CMS regulations is my responsibility". Further interview revealed, "when an event occurs, the incident report should be completed within 24 hours and sent to the department manager for review. The CNO (Chief Nursing Officer) reviews reports from a clinical perspective and then the report is forwarded to me. I review for issues of concern". Interview further revealed the incident report was filed by the ED Department Manager 8 days after the incident involving Patient #37 in the ED on 08/07/2013. Interview further revealed, "I didn't ask about a video of the incident being available. I didn't know there was a video until I saw it yesterday (02/06/2014). I don't know if I even saw the word handcuff in the report. The statement 'handcuffed by nurse' should have jumped out at me. I remember that (Hospital Administrator Name) was working to remove and educate the staff about handcuffs but didn't connect the incident with that. I asked (CNO Name) if the incident had been handled and she said, 'yes' ". Interview further revealed "a root cause analysis was not started for this incident until yesterday (02/06/2014). I wasn't even aware until yesterday (02/06/2014) that staff had not been trained in NCI (non-crisis intervention)". Interview further revealed, "our root cause analysis process and policy was not followed for this incident".



33171

B.Review of the hospital's, "INFECTION PREVENTION PROGRAM", POLICY: D-51-01, Revised 1/31/13, revealed, "C. Duties 1. Infection Prevention Monitor and evaluate healthcare associated infections in an effort to facilitate and improve patient outcomes and promote efficient utilization of medical resources...Review results of any anti-microbial susceptibility resistance trend studies...D. Authority Statement The Infection Prevention Committee of named hospital is granted authority to initiate those procedures to control measures deemed necessary to protect the hospital population, patients, and staff from danger of infectious disease...4. The initiation of Infection Prevention procedures to prevent the spread of infectious disease(s). III. INFECTION SURVEILLANCE SYSTEM B. Mechanism for Identification, Assessment, and Classification of Healthcare associated Infections...The Infection Prevention Practitioner shall seek to identify other possible cases of healthcare associated infection (HAI) through ongoing surveillance...IV. CRITERIA FOR IDENTIFICATION AND CLASSIFICATION OF INFECTIONS B. Criteria for Identification and Classification of Healthcare associated infections at specific focused sites: 3. SURGICAL SITE INFECTION (SSI) V. DATA COLLECTION, ANALYSIS, AND UTILIZATION A. Infection Prevention Meeting Data The Infection Prevention Practitioner will prepare HAI summary reports for presentation to the Infection Prevention Committee. These reports may include, but not be limited to, the following based on the surveillance plan for each year: ...Performance improvement process measures, current review of evidence based practices...B. An epidemiological investigation... Additionally, certain healthcare associated infections are either so sufficiently important that the occurrence (multiple drug resistant microorganisms, group A streptococcus) of one or two or more HAI almost invariably suggests an infection problem and this may call for an epidemiological assessment.

Review of the hospital's, "INFECTION PREVENTION GUIDELINES" Policy: D-51-02, Review/Revise Date: 02/01/13 revealed, "POLICY: The staff of named hospital, under the direction of the Infection Prevention Committee, will share in the responsibility for controlling the transmission of infectious diseases....PROCESS: ...II. Identification of Patient Infections: A. The Director of Infection Prevention or designee will monitor for communicable diseases, elevated temperatures, surgical site infections, evidence of antibiotic resistant organisms, and evidence of HAI as determined by the Infection Prevention plan and microbiology culture reports..."

1. Closed medical record review of Patient #43 revealed the patient had a "RT (RIGHT) OPEN COLECTOMY" in OR #3 on 06/26/2013.

Review of the infection control log revealed Patient #43 ..."INF (infection) Date 7/15/2013, Pathogen CORNEBACTERIUM."

2. Closed medical record review of Patient #44 revealed the patient had an "AXILLARY NODE DISSECTION" in OR #3 on 7/9/2013.

Review of the infection control log revealed Patient #44 "INF (infection) Date 8/5/2013, Pathogen MRSA (METHICILLIN RESISTANT STAPHLOCOCCUS AUREUS)."

3. Closed medical record review of Patient #45 revealed the patient had a "RIGHT HEMICOLECTOMY" in OR #3 on 8/21/2013.

Review of the infection control log revealed Patient #45 "INF (infection) Date 8/26/2013, Pathogen ENTEROBACTER."

4. Closed medical record review of Patient #46 revealed the patient had a "COLON RESECTION" in OR #3 on 08/11/2013.

Review of the infection control log revealed Patient #46 "INF (infection) Date 8/19/2013, Pathogen ENTEROBACTER, E. COLI (ESCHERICHIA COLI)."

5. Closed medical record review of Patient #47 revealed the patient had a "LUMPECTOMY WITH SENTINAL NODE BIOPSY" in OR #3 on 10/8/2013.

Review of the infection control log revealed Patient #47 "INF (infection) Date 10/30/2013, Pathogen STAPH AUREUS."

6. Closed medical record review of Patient #48 revealed the patient had an "OPEN LAPARATOMY, ILEOCECECTOMY WITH PRIMARY REANASTOMOSIS" in OR #3 on 11/19/2013.

Review of the infection control log revealed Patient #48 "INF (infection) Date 11/19/2013, Pathogen STREP, E. COLI, BACTEROIDES OVATUS."

Review of the "Infection Prevention Committee Meeting Minutes" for 08/20/2013 revealed, "Operating Room Issues/concerns There have been no reported events or recalls affecting the Operating Room for the past quarter."

Interview on 02/07/2014 at 1100 with the infection control practitioner revealed the practitioner did not recognize a trend with surgical site infections in OR #3. Interview revealed, "I screwed up. The columns on my tracking sheet were hidden." Interview confirmed the infections were not identified and were not reported to the Infection Control Committee.

Based on hospital policy and procedure review, open and closed medical records review, observation during tours, staff and patient interviews, Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training material review, Quality Care Control Report review, Daily Security Report reviews, video surveillance footage review, education training transcript reviews, staffing schedule reviews, and staff interviews and observation, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure registered nursing staff supervised and evaluated patient care.

The findings include:

1. The nursing staff failed to supervise and evaluate the nursing care for patients by: A. failing to perform skin assessment and wound care per hospital policy and protocol for 3 of 15 open records reviewed (# 34, #35, and #39); B. failing to implement safety measures for 2 of 4 patients identified at High Risk for falls (#24 and #39); and C. failing to respond to telemetry patient monitoring alarms in the emergency department (ED) in 1 of 1 alarms test.

~cross refer to 482.23(b)(3) Nursing Standard: Tag A0395

2. The hospital failed to ensure nursing staff were trained and competent to ensure the safe and appropriate physical restraint of patients for 1 of 1 patients (#37) that was physically restrained for the management of violent and/or self-destructive behaviors.

~cross refer to 482.23(b)(5) Nursing Standard: Tag A0397

3. The hospital failed to ensure non-employee dialysis nurses followed the hospital's policies and procedures by the non-employed nursing staff failing to obtain and document pre dialysis weights for 2 of 3 sampled hemodialysis patients (Patients #30, 31) and by failing to obtain physician dialysis prescription orders for the desired potassium in acid concentrate in 3 of 3 sampled hemodialysis patients (Patients #29, 30, 31).

~cross refer to 482.23(b)(6) Nursing Standard: Tag A0398

Based on hospital policy review, open and closed medical records review, observation during tours and staff and patient interviews the nursing staff failed to supervise and evaluate the nursing care for patients by: A. failing to perform skin assessment and wound care per hospital policy and protocol for 3 of 15 open records reviewed (# 34, #35, and #39); B. failing to implement safety measures for 2 of 4 patients identified at High Risk for falls (#24 and #39); and C. failing to respond to telemetry patient monitoring alarms in the emergency department (ED) in 1 of 1 alarms test.

The findings include:

A. Review of the hospital's Policy: D-50-B03 "Patient Assessment Standard" last revised date of 11/2012 revealed "...The patient's admission assessment, physical assessment ...must be performed and documented within 8 hours of the patient's admission...Using shift assessment, each patient will be reassessed at least every 12 hours, or more frequently as the patient's condition warrants...."

Review of the hospital's Nursing Procedure: D-50-D46 "Pressure Ulcer Prevention and Treatment" last revised date of 02/2013 revealed "On admission an integumentary inspection will be performed on all patients. The Norton Scale will be used to identify patients at risk, the level of risk, and the type of risk. PROCESS: ...A. Skin risk assessment is performed at the time of admission. Based on completion of the Norton Scale, the patient is assigned a level of risk for the development of pressure ulcers. Prevention measures will be implemented as warranted for the patient ' s condition and level of risk...III. Norton Scale: Low Risk (Norton Scale > (greater than) 18); Medium Risk (Norton Scale 14-18); High Risk (Norton Scale 10-14); Very High Risk (Norton Scale < (less than) 10) ..."

Review of the hospital's guidelines and algorithms for wound care "ConvaTec" (no date) revealed "The National Pressure Ulcer Advisory Panel (NPUAP) staging system classified pressure ulcers by the degree of tissue damage observed...Stage I - IV (IV being the worse)...Stage III - full thickness tissue loss ...the depth of a Stage III pressure ulcer varies by anatomical location ...4. Measure size of wound: wound measurements are made in centimeters by recording the greatest length and width 5. Measure depth of wound: wound depth is measured in centimeters ...13. Document wound assessment: the wound assessment should be accurately documented ...the consistent and accurate documentation of the wound condition is an essential process in the management of the chronic wound as it allows for measurement of progress toward goals, provided communication of the wound status for other disciplines, and meets applicable standard of care ..." Continued review of the manual's "Appropriate Wound Care Plan" revealed Stage III wound care management step 6 "choose appropriate wound care plan: cleanse wound with ConvaTec options: SAF-Clens AF Dermal Wound Cleanser or Shur-Clens Wound Cleanser (cleaning solutions) ..."

1. Open medical record review on 02/05/2014 for patient #34 revealed a 63 year old female admitted on 01/28/2014 with a Primary Diagnosis of Atrial Fibrillation (A-Fib) with RVR (rapid ventricular response) (fast heart rate). Review of the RN's Nursing admission assessment dated 01/28/2013 at 0900 revealed "Skin: Pressure Area or Decubitus Present on Arrival/Admission: Yes or No (no documentation in this assessment). Continued review of the admission skin assessment revealed no documentation of the skin "Turgor, Color, or Problem Stage" (8 days since admission). Continued review revealed no Norton Score or Braden Score documented in the medical record.

Review of the RN's (Registered Nurse) shift assessment dated 01/28/2014 at 2000 revealed "Skin Risk Assessment Scale: Moisture Risk: Skin Risk Total Score (points) (no score documented). No documented Risk Assessment Score. Continued review of the RN shift assessments revealed no documented Risk Assessment Score." (8 days since admission)

Interview on 02/05/2014 with RN #7 revealed "we are suppose to do a Braden Scale score and skin assessment upon admission and every shift...I do not know what the Norton score is we've used the Braden Score system since I've been here and I've been here 9 years...there is no Risk Assessment Score documented for this patient (#34) since admission ...they started it but didn't finish it...the skin assessment is incomplete for this patient." Interview confirmed the nursing staff failed to perform a patient's skin assessment per hospital policy.

Interview on 02/06/2014 with RN #8, nursing administration, revealed "Our policy says we are suppose to use the Norton Scoring system to identify patient's at risk for skin break down however we upgraded our computerized documentation system, Meditech, about a year and half ago and it is now a Braden Scoring system. I haven't updated the policy to reflect our current practice ...we've been using the Braden Score system for about a year and half ...the Braden Score is suppose to be done upon admission and when there is a change in the shift re-assessment ...the skin assessment is done upon admission and the reassessment should be done and documented every shift ...I do not see a documented Braden Score upon admission for this patient (#34) and I do not see that one has been completed ..." Interview confirmed the nursing staff failed to perform a patient's (#34) skin assessment per hospital policy.

2. Open Medical Record review on 02/05/2014 for patient #35 revealed an 87 year old male admitted on 02/01/2014 with a diagnosis of Pneumonia, Urinary Tract Infection, Coronary Artery Disease, history of multiple CVA's (cerebral vascular accidents) [stroke], and Kidney Disease.

Review of the RN Nursing Admission Assessment dated 02/01/2014 at 0400 revealed a Skin Risk Assessment Scale: Skin Risk Total Score (points) of "13" (moderate risk). Continued review of the Skin Risk Assessment Scale revealed "Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers: 15 or 16 = low risk; 13 or 14 = moderate risk; 12 or less = High Risk." Continued review of the Nursing documentation revealed a Stage III ulcer on the patient's left heel.

Review of the Nursing Wound Assessment flow sheet dated 02/01/2014 at 0509 revealed the dressing on the patient's heel was "changed". Continued review revealed no documentation of wound length, width, or depth. Continued review dated 02/05/2014 at 1000 a wound assessment of the left heel revealed "Stage III pressure ulcer, dressing changed, wound length - 4, width - 2 ..." Continued review dated 02/06/2014 at 0656 revealed "Stage III ulcer: dressing changed, wound length - 4; width - 6." Continued review dated 02/06/2014 at 0800 revealed the "dressing was changed; wound length - 6 and the width - 4". Continued review revealed no documentation of the wound depth since admission (4 days).

Review of the Physician Orders revealed no order for wound care.

Interview on 02/05/2014 at 1145 with RN #13 revealed "we are doing this patient's (#35) dressing changes on his heel twice a day ...we follow the physician orders if they have written any and if they haven't then we follow the wound care protocol in our book ...our skin assessment is done every shift ...I don't know what a Braden Score is, I've never done one of those...there is no physician order on this patient's chart so we are following the protocol in our Wound Management Book ...but this book is so complicated I can't tell you which protocol to follow...I know we are suppose to measure them but I don't know how often...his primary nurse is doing the dressing changes but she said she can't do step 6 of the protocol because we do not have the cleansing solution to perform the cleansing of the wound ..." Interview confirmed the nursing staff failed to follow hospital policy and protocol for skin assessment and wound care management for patient #34.

Interview on 02/06/2014 with RN #8, nursing administration, revealed "Our policy says we are suppose to use the Norton Scoring system to identify patient's at risk for skin break down however we upgraded our computerized documentation system, Meditech, about a year and half ago and it is a Braden Scoring system. I haven't updated the policy to reflect our current practice ...we've been using the Braden Score system for about a year and half ...the Braden Score is suppose to be done upon admission and when there is a change in the shift re-assessment...the skin assessment is done upon admission and the reassessment should be done and documented every shift...The Conva Tec Wound Care protocol is what we use for wound care. The nurses are to follow the recommendations in the manual ...I did not know they were out of supplies but yes they should be using the cleanser for a Stage III ulcer ..." Interview confirmed the nursing staff failed to follow hospital policy and protocol for skin assessment and wound care management for patient #35.

3. Open Medical Record review on 02/06/2014 at 0945 for patient #39 revealed an 80 year old female admitted on 02/04/2014 with a diagnosis of Fever of unknown origin, possible Pneumonia, Debility, and probably hypovolemia (decreased blood flow), and acute renal failure.

Review of the RN Nursing Admission Assessment dated 02/04/2014 at 1100 revealed a Skin Risk Assessment Scale: Skin Risk Total Score (points) of "17" (low risk). Continued review revealed the next documented skin assessment on 02/04/2014 at 1249 (44 hours and 45 minutes since last documented assessment).

Interview on 02/05/2014 at 1145 with RN #13 revealed "I do not see a skin assessment documented for this patient (#39) since admission the one done on admission ...we are suppose to do them every shift..." Interview confirmed the nursing staff failed to follow hospital policy and protocol for skin assessment for patient #39.

Interview on 02/06/2014 with RN #8, nursing administration, revealed "Our policy says we are suppose to use the Norton Scoring system to identify patient's at risk for skin break down however we upgraded our computerized documentation system, Meditech, about a year and half ago and it is a Braden Scoring system. I haven't updated the policy to reflect our current practice ...we've been using the Braden Score system for about a year and half ...the skin assessment is done upon admission and the reassessment should be done and documented every shift ...I do not see a reassessment for this patient..." Interview confirmed the nursing staff failed to follow hospital policy and protocol for skin assessment for patient #39.

B) Review of the hospital's Policy: D-50-D43 "Falls Management/Bed Rail Entrapment Program" last revised date of 11/2013 revealed "...all patients will be assessed for risk of falling upon admission, with reassessments routinely performed to determine ongoing need for fall prevention precautions. The high Risk Falls Management/Bed Rail Entrapment Program will be implemented for those patients who are assessed to be at high risk for falling or bed rail entrapment...III. PROCEDURE: A. Universal Falls Management/Bed Raiul Entrapment Program: 1. Inpatient will be assessed, upon admission, by the admitting nurse, for risk of falls and possible bed rail entrapment. A score >8 (greater than 8) would result in the patient being placed on High Risk Falls Management/Bed Rail Entrapment Program. .. Upon admission ...if the patient's score is (greater than or equal to) 8, the VIPP (Very Important Patient Program) will be initiated ...write fall precautions on white board; apply yellow fall precautions wrist band and yellow Falls Slipper Socks on patient; ...fall risk reevaluation will be completed every shift and with a change in patient condition ..."

1. Open medical record review on 02/05/2014 for patient #24 revealed a 88 year old male admitted on 02/04/2014 at 0850with a chief complaint of "shortness of breath" and Primary Diagnosis of Congestive heart failure, COPD (chronic obstructive pulmonary disease), and Dementia.

Review of the RN (Registered Nurse) Nursing Admission Assessment dated 02/04/2014 at 0850 revealed a Fall Risk Assessment documented. Review of the assessment revealed a Fall Risk Score of "20" (High Risk for Falls).

Observation during tour on 02/05/2014 at 1015 revealed the patient was not wearing the "yellow Falls Slipper Socks". (25 hours and 25 minutes since High Risk Score)

Interview on 02/05/2014 at 1015 with the family of patient #24 revealed "they didn't put the yellow band on him yesterday they just put the yellow band on him this morning around 0830 or 0900. We haven't seen the yellow socks ..."

On 02/05/2014 at 1020, during the family interview, RN #11 applied the yellow socks to patient #24. Interview with RN #12 revealed "I put his yellow arm band on yesterday along with his socks but I do not know what happened to his socks..."

Interview on 02/05/2014 at 1030 with RN 12, patient #24 ' s primary nurse, revealed "Mr. (name of patient #24) arm band was applied this morning by (name of RN #11)...he didn't have one on when I took over his care today we just put one on this morning and it should have been put on when he was admitted ..." Interview confirmed the facility nursing staff failed to implement safety measures for a patient High Risk for falls.

2. Open Medical Record review on 02/06/2014 at 0945 for patient #39 revealed an 80 year old female admitted on 02/04/2014 at 1100 with a diagnosis of Fever of unknown origin, possible Pneumonia, Debility, and probably hypovolemia (decreased blood flow), and acute renal failure.

Review of the RN's Fall Risk Assessment Score dated 02/05/2014 at 0000 revealed a score of 13 (High Risk for Falls).

Observation during tour on 02/06/2014 at 0945 revealed the patient was not wearing the "yellow Falls Slipper Socks" and the patient did not have on a "yellow arm band". (33 hours and 45 minutes after High Risk assessment).

Interview on 02/06/2014 at 1015 revealed "the patient (#39) is High Risk for falls and should have both the yellow armband and the yellow socks on ...this patient does not have either ..." Interview confirmed the facility nursing staff failed to implement safety measures for a patient at High Risk for falls.



33171

C. Review of the hospital's "EMERGENCY DEPARTMENT POLICY AND PROCEDURE MANUAL REVIEWED 9/10" revealed no policy on telemetry monitoring.

Observation of the emergency department (ED) on 02/05/2014 at 1620 revealed two monitors in the charge nurse area. Observation revealed staff seated in the area. Observation revealed an audible and visual telemetry alarm from room #8 ( a room in front of the nurse station) alarming. Observation revealed one monitor displayed the room of the alarm and the other monitor flashed the room of the alarm in red. Observation revealed no staff came to room #8 to evaluate the telemetry alarm. Observation revealed the alarm was audible inside and outside of room #8.

Interview with ED director on 02/05/2014 at 1620 revealed,"We sometimes have two or three alarms going off at a time. The staff is desensitized to the alarms." Interview on 02/07/2014 at 1042 revealed, "There is no policy in the ED for telemetry monitoring or a monitor tech."

Based on the hospital policy and procedure reviews, Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training material review, Quality Care Control Report review, Daily Security Report reviews, closed medical record review, video surveillance footage review, education training transcript reviews, staffing schedule reviews, and staff interviews, the hospital failed to ensure nursing staff were trained and competent to ensure the safe and appropriate physical restraint of patients for 1 of 1 patients (#37) that was physically restrained for the management of violent and/or self-destructive behaviors.

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "...The USE OF ANY RESTRAINTS FOR VIOLENT/SELF DESTRUCTIVE BEHAVIOR REQUIRES ONE-TO-ONE STAFF. AND MONITORING EVERY 15 MINUTES ...ASSESSMENT An assessment of the patient will occur at the time of the initial of restraint and every 15 minutes thereafter and will include: a. Type of restraint b. Skin at restraint site c. Circulation d. Respirations e. Range of motion f. Patient position g. Is bed alarm on h. Fluid/Nourishment offered i. Toilet j. Behavior Observed k. Restraint properly applied l. Additional interventions attempted m. Restraint removed n. Patient education o. Order up to date p. Restraint use indicted/not indicated. DOCUMENTATION ...b. Using the Restraint Management Plan of Care Form, nursing staff members monitor and reassess the needs of the patient every 15 minutes using the Restraint Management Plan of Care.... . ...VI. TRAINING OF STAFF Hospital and medical staff members shall receive training in the following subjects as it relates to duties performed under this policy. Such training shall take place during departmental or medical staff orientation (before the trainee is asked to implement the provision of this policy) and shall be repeated periodically as indicated in the hospital's training plan, which is based on the results of quality monitoring activities. Individuals trained shall exhibit their knowledge of the subject matter through the consistent implementation of the matters taught. The training programs will include return demonstrations and post-training tests a the discretion of the trainer. A. Physicians (or designees, PA's NP's) who order restraint or seclusion shall be trained in the requirements of this policy and shall demonstrate a working knowledge of this policy through ongoing compliance. B. Hospital staff members who assess patients need for restraint or who apply restraint shall receive training in the following: (It is acceptable to have separate training for staff who deal with Behavioral Health and Medical restraint.) 1. The impact of restraints on the rights and dignity of the patient. 2. Risks associated with the use of restraint to vulnerable populations, such as pediatric, emergency and cognitively or physically challenged patients. 3. Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. 4. The use of nonphysical intervention skills. 5. Alternatives to restraint-choosing the least restrictive intervention based on an individualized assessment of the patient's medical, or behavioral status or condition. 6. The safe application and use of all types of restraint or seclusion used by the staff member, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). 7. Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. 8. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to respiratory and circulatory status, skin integrity, and vital sings. 9. Staff members who are authorized to monitor patients in restraint also receive training in: a. taking vital signs and interpreting their relevance to the physical safety of the patient in restraint. b. recognizing nutritional and hydration needs c. checking circulation and range of motion in the extremities d. addressing hygiene and elimination e. addressing physical and psychological status and comfort f. helping patients meet behavior criteria for discontinuing restraint or seclusion g. criteria for early release and criteria for removal of restraint h. recognizing readiness for early release and/or discontinuing restraint or seclusion i. recognizing incorrect application of restraints j. recognizing when to contact a medically trained licensed independent practitioner, designee, PA or NP to evaluation and or treat the patient's physical status 10. The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic re-certification. C. Annually, Hospital staff members who assess, monitor or apply restraint in the Emergency Department or the Behavioral Health Unit are required to complete the Non-Violent Crisis Intervention Program (NCI). These staff members also receive training in the following: 1. The underlying causes of threatening behaviors exhibited by the patients. 2. Medical conditions that may lead to aggressive or threatening behavior 3. Influence of staff behavior on patients 4. Alternative techniques such as de-escalation, mediation, self-protection, and other techniques such as time-out 5. Staff members who are authorized to apply restraint or seclusion also receive training on the safe use of restraint, including physical holding techniques, take-down procedures, and the application and removal of mechanical restraint. 6. Staff members shall demonstrate competence in: a. Recognizing how age, developmental considerations, gender issues, ethnicity, and history of sexual or physical abuse may affect the way in which a patient reacts to physical contact b. Using behavior criteria for discontinuing restraint or seclusion and how to help patients in meeting these criteria ...V. PERSONNEL AUTHORIZED AND QUALIFIED TO APPLY RESTRAINTS * Patient Care Services Personnel who have demonstrated competency by annual completion of....Restraint Management Program. ..."

Review of current hospital policy "Security Measures" Policy S-121-201, revised 02/18/2013, revealed "...TRAINING: All Security personnel shall receive security training adequate to perform their job functions. ...RESPONSIBILITIES: * Security personnel stationed at the hospital shall be responsible for the following: ...* Staff assistance with patient restraint and intervention in disruptions by patients, visitors or staff ...."

Review on 02/07/2014 of Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training materials, copyright 2009 (reprinted 2013), revealed "Unit I: The CPI Crisis Development Model." Review revealed "...Definitions 1. Anxiety: A noticeable increase or change in behavior. A nondirected expenditure of energy; e.g., pacing, finger drumming, wringing of the hands, or staring. ...2. Defensive: The beginning stage of loss of rationality. At this stage, an individual often becomes belligerent and challenges authority. ...3. Acting-Out Person: The total loss of control, which results in a physical acting-out episode. ...4. Tension Reduction: A decrease in physical and emotional energy that occurs after a person has acted out, characterized by the regaining of rationality. ...Review of "Unit II: Nonverbal Behavior" revealed "...The CPI Supportive Stance" and "Reasons for using the CPI Supportive Stance 1. Communicates respect by honoring personal space. 2. Is nonthreatening/nonchallenging. 3. Contributes to staff's personal safety if attacked/offers an escape route." Review of "Unit VIII: Nonviolent Physical Crisis Intervention and Team Intervention" revealed "The Nonviolent Crisis Intervention program is a safe, nonharmful behavior management system designed to help human service professional provide for the best possible care and welfare of disruptive, assaultive, and out-of-control persons--even during tier most violent moments. In Nonviolent Crisis Intervention training, the emphasis is always on your primary responsibility: the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint is recommended only when all less restrictive methods of intervening have been exhausted, and when the individual presents a danger to self or others. ...Risks involved with physical intervention can be minimized when staff members regularly practice and rehearse procedures for team interventions. Further review revealed "CPI TEAM CONTROL POSITION" and "The CPI Team Control Position is used to manage individuals who have become dangerous to themselves or others. Two staff members hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist, if needed. During the intervention, staff members who are holding the individual should: *Face the same direction as the acting-out person while adjusting, as necessary, to maintain close body contact with the individual. * Keep their inside legs in front of the individual. ...*Bring the individual's arms across their bodies securing them to their hip areas. ...*Place the hands closest to the individual's shoulders in a C-shape position to direct the shoulders forward. ...Control Dynamics 1. Reduce upper-body strength by controlling the arms as weapons. 2. Reduce lower-body strength by controlling the back incline. 3. Reduce mobility by close body contact." Further review revealed "CPI TRANSPORT POSITION" and "The CPI Transport Position will assist you in safely moving an individual who is beginning to regain control. Prior to moving an individual, assist the person into a more upright position and remove your hand from the individual's shoulder. Reach under the individual's arm to grab your own wrist. This cross-grain grip better secures the individual between staff during transport. Remove your leg from directly in front of the individual prior to transport while maintaining close body contact. ...Further review revealed "CPI INTERIM CONTROL POSITION" and "The CPI Interim Control Position is a temporary control position that allows you to maintain control of both of the individual's arms, if necessary, for a short time. Starting from the CPI Transport Position, maintain control of the individual's arm, but release the cross-grain grip. Use your free arm to reach across and gain control of the opposite arm. ...If the individual attempts to strike, use your free arm to block, and safely move away. ..." Review of "Appendix: A Practical Approach for Managing Violent Behavior" revealed "...Team Intervention All of the intervention concepts are best utilized when a team of professionals intervenes. ...Why Nonviolent Crisis Intervention Training? A fundamental purpose of the Nonviolent Crisis Intervention training program is to help people understand the process of behavior escalation and to recognize that people don't act out in a vacuum. The staff member who intervenes with the potentially violent person must realize that her behavior has a tremendous impact on that individual. In any cases, the subsequent escalation or defusion of the person's behavior may depend entirely on how that staff member reacts. Nonviolent Crisis Intervention training stresses that crisis interventions is an integrated process. ...In an effort to maximize the chance of calming the person, it is best to balance or offset the person's behavior with therapeutic responses by staff. The therapeutic environment should be maintained continually, even during the most violent moments. ...By using safer, nonharmful techniques taught in the Nonviolent Crisis Intervention program, it is more likely that the therapeutic relationship you have worked so hard to develop can be maintained." Review of "Appendix: Understanding the Risks of Restraints" revealed "...Dangers of Restraints ....restraints should only be used when a person's behavior is MORE dangerous than the danger of using restraints. Some restraints are more dangerous than others. For example, facedown (prone) floor restraints and positions in which a person is bent over in such a way that it is difficult to breathe are extremely dangerous. This includes a seated or kneeling position in which the person being restrained is bent over at the waist and any facedown position on a bed or mat. Restraint-related positional asphyxia occurs when the person being restrained is placed in a position in which he cannot breathe properly and is not able to take in enough oxygen. Death can result from this lack of oxygen and consequent disturbance in the rhythm of the heart. Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breathe. This includes sitting or lying across a person' back or stomach. When someone is lying facedown, even pressure to the arms and legs can impact the person's ability to breathe effectively. ...When confronted with an emergency situation, always consider the option of disengaging. If the persons is not a danger to self or others while on the floor, staff may make the decision to move away and give a clear directive. Reducing the Risks of Restraints ...Staff members should be trained in and regularly practice safer ways of restraining. ...A physical restraint is an emergency procedure...As with any emergency response procedure, staff members need to practice these skills on a regular basis. ...Key elements of Nonviolent Physical Crisis Intervention responses include: * No element of pain involved. * The intent is to calm the individual. * The intent is to keep the individual off the floor, thus reducing risks of restraint-related positional asphyxia and other injuries. * Team interventions are used when necessary. * Nonviolent Physical Crisis Intervention is used only as a last resort when someone presents a danger. * Nonviolent Physical Crisis Interventions is used to protect - not to punish. The goal is for staff....is to eliminate the need for restraints at all."

Review on 02/05/2014 of a Quality Care Control Report completed by the ED Director on 08/15/2013 regarding a "Behavioral Variance" occurring on 08/07/2013 at 2310 in ED III, involving Patient #37, revealed "Pt (patient) yelling + (and) swearing at staff....(RN name) called for assistance to help with situation. Pt pacing in room. Staff went into give pt. medication shot. Pt refused shot. Pt backed up into corner. 3 male staff tried to secure pt for shot. Pt hit RN....Pt held + shot given. Pt verbally + physically resistant to staff. Handcuffs from security placed on pt by RN. Pt put in sitting position. Police arrived. Spoke to patient. Pt assisted to stretcher, handcuffed to stretcher. Handcuffs removed, pt placed in 4 point soft restraints. Pt became calm. MD assessed pt. Restraints removed one at a time." Review revealed the staff involved were identified as RN #1, RN #2, RN #3, RN #4, RN #5, RN #6, RN #7, SO #1 and SO #2.

Review on 02/07/2014 of a "Daily Security Report" dated 08/07/2013 from 1600 to 0030 completed by SO #1 revealed "...2330 patient in and out of room many times Nurse ask him to go back in the room and stay. Patient refused and started cussing nurse asked patient to get quiet. And was asked if he wanted a shot to help to rest and he refused said they could not give him the meds in the shot called for help to give injection and patient became combative and RPD (local police department). Was called. patient knocked hole in wall with elbow. ..."

Review on 02/07/2014 of a "Daily Security Report" dated 08/08/2013 from 0000 to 0800 completed by SO #2 revealed "2340 (08/07) Went to ED III Room #2 to assist with a patient that RPD was called on. ...0006 (08/08) Started one on one ED III Room #2 ref (reference) subject was placed in restraint 0115 Assisted in removing Restraint one limb at a time every 15 minute last one removed on Thursday 8 of August 0230 Clear one on one. ..."

Closed emergency department (ED) record review on 02/05/2014 for Patient #37 revealed a 26 year old male who presented to the hospital's ED on 08/03/2013 under involuntary commitment (IVC) petition for psychiatric evaluation. Review revealed the patient was diagnosed with "substance abuse disorder." Review revealed the patient was held in the ED from 08/03/2013 until 08/13/2013 (11 days), awaiting placement at a psychiatric hospital. Review revealed on 08/13/2013 the patient was reassessed by the ED physician as "...no longer meets criteria for inpatient treatment" and was subsequently released from IVC petition and discharged from the ED. Review of nursing documentation by RN #6 on 08/07/2013 at 2329, revealed "Approximately 2310 patient went from washing his hands in room to hall sink to wash hands back to room to wash hands and to sink again to wash hands, at the sink he looked at this RN and looked like he was asking a question, this RN asked what he needed but couldn't here [sic] him, this RN then went to doorway of nurses station and asked, '(Patient #37 name), I couldn't hear you, what did you need?' At that point patient started yelling 'I'm singing a Marilyn Manson song, can't someone just sing a song without you f**king getting in their face.' (RN #2 name), RN spoke to patient and asked him to stop yelling and to stop swearing, patient started yelling more and posturing, this RN called on radio that assistance was needed in ED III--(RN #1 name), RN, (RN #4 name), RN, (SO #1 name)--Security, (RN #3 name), RN came to assist, patient starting yelling more and swearing louder. Patient was told he was going to get a shot of Geodon (antipsychotic) if he did not settle down, he just kept yelling, this RN called communications and used hand radio again to notify charge RN (RN #7 name) that communications was called, patient kept yelling and swearing, the other RNs continued to try to talk patient down but patient kept yelling, this RN got the Geodon and prepared it, medication was given while male nurses secured patient, patient remained secured until officers (Law Enforcement Officers) arrived to help with situation, officers requested patient's IVC papers and discussed this with patient, patient did hit (RN #2 name), RN in the jaw and kicked in the shins--report filed, ....(SO #2) from security came on shift and is now present also--sheets have been removed from bed and officers have patient handcuffed to bed, (RN #7), RN talking to officers about handcuffs and (ED Physician #1 name) has walked in at 2345 to assess patient and speak to officers and staff. 1:1 in place with (SO #2 name)--security, restraint orders in place, verified with (RN #7), RN and (RN name), RN from BH (Behavioral Health)." At 0035, revealed "(RN #2 name), RN is being checked for injuries....there is a bruise on patient's l-arm (left arm)--discussed with (SO #1 name) from security--stated the patient had that bruise prior to incident, VS (vital signs) checked as ordered and patient, patient continues to argue that he does not need restraints, when he asked when restraints would be removed, this RN explained when it was safe for him and staff restraints would be removed--patient slammed the bed rail and complained again about his 'f**king situation'. Explained to him that type of behavior would keep him in the restraints. Patient has been offered and given ice water, he is currently being assisted by security to help with urinal." At 0106, revealed "....patient was moved up in bed with assistance from (SO #2 name) from security....patient appeared to be sleeping, VS taken but when patient started to kick a little and argued about being in restraints, is able to turn from l-to-r (left to right), patient did urinate 425 mL (milliliters) with assistance by (SO #2 name), security, patient has continually been offered ice water and given when requested, patient remains agitated but not as noticeable at this time." At 0119, revealed "patient is sleeping but restless with sleep--pulling at restraints at times--this RN called (RN name), RN BH and (RN #7 name), Charge RN to verify taking restraints off--advised to remove one restraint at a time--opposite of each other--l-wrist (left wrist) is removed at this time--1:1 continues with (SO #2 name), Security--he assisted with removing first restraint." At 0131, revealed "r-ankle (right ankle) restraint removed, (SO #2 name) from security is assisting patient with urinal, explained to patient that two restraints have been removed and will continue to remove one at a time if patient remains cooperative, patient did request to urinate--was ambulated by (SO #2 name) from security to BR (bathroom) and returned to room where two restraints were reapplied, patient fell asleep during reapplication." At 0152, revealed "spoke to (RN #7), Charge RN and (ED Physician #1 name) that patient is restless only when VS are checked but is sleeping otherwise--3rd restraint to r-wrist (right wrist) removed, last restraint will be removed at 0200 if patient continues to sleep and remain cooperative, patient sleepily stated he did not want anything to drink at this time." At 0207, revealed "(ED Physician #1) and (RN #7), RN notified that patient's 4th restrain [sic] has been removed, 1:1 will continue until 0230 by (SO #2 name) from security as is ordered in paperwork, patient verbally stated during 0145 VS that he understood, (RN name), RN BH notified as well and advised to continue 1:1 for 30 minutes--advised this is being done, patient is completely self turning at this time--l-arm (left arm) noted earlier as having a bruise--also noted at this time that it is a healing scar with bruising about it." At 0233, revealed "restraints remain off, 1:1 discontinued...." At 0402, revealed "Sergeant (name) arrived at 0400--advised ED staff that patient has one misdemeanor injury to real property and one felony for assault on ED staff--(RN #2 name), RN, we are to notify communications dept (department) when patient is to be dc'd (discharged) from (hospital) or after transfer and release from additional facility....that patient is to be arrested for these charges." Record review revealed the patient was discharged to jail on 08/13/2013.

Review on 02/05/2014 at 1615 with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Quality and Risk Management, Director of Security, Emergency Department Director, and the hospital's Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) Certified Instructor (CI #1) of video surveillance footage without audio; dated 08/07/2013, time interval 23:10:00 to 23:55:00; from hospital security camera, ED III Room 2 revealed at:
23:10:00 to 23:17:59 - Patient #37 observed in treatment room. Holding book in hands. Placing book on and off counter top. Exits and re-enters room two times. Speaking towards doorway. Drinking from container with straw. Pacing within room. Shadows observed at doorway. No physical aggression observed.
23:18:00 - Patient observed standing in room with left side of body adjacent to cabinet/countertop with left hand on countertop. Patient is facing direction of door. Male staff member (RN #1) enters room and goes over to patient's right side. RN #1 carrying medication syringe (Geodon). RN #1 begins to swab/wipe the patient's right shoulder with antiseptic/alcohol wipe. Two male staff members (RN #2, RN #3) appear in doorway. No physical aggression is observed by patient towards staff.
23:18:14 - Patient walks away from cabinet/countertop and RN #1. Patient walks across room to left rear corner of room and turns his back towards the wall, facing staff members. Patient and staff members engaging in verbal communication. Three male staff members are present inside room (RN #1, RN #2, RN #3). No physical aggression is observed by the patient towards staff.
23:18:29 - A fourth male staff member (SO #1) appears at doorway of room.
23:18:38 - SO #1 reaches into room and turns lights on. Patient stands in left rear corner of room with back towards wall. Patient has his hands behind his back. Patient and staff engaging in verbal communication. No physical aggression is observed by the patient towards staff.
23:19:19 - Patient in left rear corner of room with back towards wall. RN #1, RN #2, and RN #3 start moving closer towards patient from three sides (in a corralling stance). No physical aggression is observed by the patient towards staff.
23:19:24 - A fifth male staff member (RN #4) enters room. Patient remains in left rear corner of room with his back to wall, facing staff members. RN #1, #2, #3, #4 in room. SO #1 at doorway.
23:19:47 - Patient remains in left rear corner of room with back towards wall. Facing staff. No physical aggression is observed by the patient towards staff.
23:19:50 - Patient steps backward further into left rear corner of room (away from staff). Patient's arms are crossed in front of chest. No physical aggression is observed by patient towards staff. RN #2 and RN #3 begin approaching patient.
23:19:51 - Patient with back against wall in left rear corner of room, facing staff. Patient arms crossed in front of chest. No physical aggression observed by patient towards staff. Staff observed in a "corralling stance" and then rapidly advance towards patient. RN #2 reaches towards patient and appears to make physical contact with left chest/axilla area of patient. Patient extends left arm outward towards RN #2 and appears to make contact with RN #2. Patient swings right arm and appears to strike RN #2 in left side of face/jaw area. RN #3 reaching towards patient and appears to make contact with the patient's right shoulder. Patient appears to be pushed up against wall of room. Two additional male staff members (RN #4 and RN #5) enter room to assist.
23:19:52 - Patient appears to strike RN #2 in back of neck two times with his right arm. Patient is held against rear wall by male staff members.
23:19:54 - Patient held against wall by male staff members. SO #1 and RN #1, #2, #3, #4 in room. RN #6 enters room and stands at door.
23:19:59 - Patient is held against wall by male staff members.
23:20:03 - SO #1 is observed grabbing patient's left leg and pulling/holding the leg up off the floor. RN #2, RN #3, and RN #4 observed holding patient up against wall.
23:20:05 - RN #3 is observed with his left arm around patient's neck in a "head lock" type position pulling downward.
23:20:11 - The patient is held against the wall. RN #3 is observed with his left arm around patient's neck in a "head lock" type position. RN #2 is observed holding the patient's extended left arm up against the wall. SO #1 is observed holding the patient's left leg up off the floor. RN #1 is observed approaching the patient with a medication syringe in his left hand.
23:20:12 - A male staff members gloved hand is observed covering the patient's chin/mouth area. The patient's neck is observed being hyper-extended backwards.
23:20:13 - The patient is observed being held against the wall. RN #3 is observed with his left hand around the patient's neck. A gloved hand is covering the patient's chin and his neck is hyper-extended backwards. The patient's left arm is bent behind his back by RN #2. SO #1 is holding the patient's leg off the floor. The patient appears to be in a contorted/flexed position.
23:20:14 - RN #1 is observed with a syringe in his left hand.
23:20:21 - Patient is observed to be pulled down onto floor with staff on top of patient.
23:20:28 - RN #1 is observed administering the IM medication to the patient's left arm.
23:20:45 - Patient with head held to floor by gloved hand of RN #3. Gloved hand pushing head downward to floor. Patient body appears contorted/flexed. Staff over patient.
23:20:55 - Patient observed on floor, on left side. RN #2 observed with his left knee against small of patient's back. Staff holding patient down on floor.
23:21:19 - SO #1 is observed removing handcuffs from belt case.
23:21:33 - Staff holding patient down on floor. Three staff members on top of patient, RN #5 enters room.
23:21:38 - SO #1 is observed handing handcuffs to RN #2.
23:21:42 - Patient remains on floor. RN #7 enters room.
23:21:46 - RN #7 exits room.
23:21:53 - Patient on floor on lateral right side, torso is bent forward at waist (fetal like position). Pants pulled down and entire buttocks exposed.
23:21:57 - RN #2 is observed over the patient with his leg over the patient's leg. Patient is held down to floor by male staff members. Patient appears to be on side.
23:22:04 - Patient on floor. Appears to be on right side/facing downward on floor. RN #2 is observed placing a handcuff on patient's left wrist.
23:22:07 - RN #2 is observed placing a handcuff on patient's right wrist.
23:22:08 - Patient's is observed with hands handcuffed behind back. Lying on right lateral side. Facing downward to floor.
23:22:10 - Patient is observed lying face down (Prone position) on floor with hands handcuffed behind back.
23:22:32 - RN #2, RN #5 and SO #1 exit room. Patient remains lying face down on floor with hands handcuffed behind back. Knees bent. RN #3 and RN #4 remain in room.
23:23:00 Patient remains lying face down on floor with hands, handcuffed behind back.
23:24:00 Patient remains lying face down on floor with hands, handcuffed behind back. Patient is moved to sitting position ("Indian style") with staff assistance.
23:24:20 - RN #3 and RN #4 exit room. SO #1 remains in room. Patient remains sitting on floor with hands handcuffed behind back.
23:24:27 - Law enforcement officers (LEO) enter room.
23:31:20 - LEOs present. Remains on floor, with hands handcuffed behind back.
23:38:35 - Patient assisted up off the floor by LEOs into standing position.
23:38:48 - 5 LEOs present. Patient escorted over to bed by LEOs. SO #1 in room.
23:39:35 - 7 LEOs and 1 SO in room with patient. Patient in standing position with hands handcuffed behind back.
23:40:08 - Sheets removed from stretcher by LEO/Staff.
23:40:37 - Patient assisted onto bed by LEOs with hands handcuffed behind back.
23:41:09 - Patient handcuffs removed from back by LEOs. Patient's left and right hand individually handcuffed to left and right bed siderail by LEOs.
23:42:08 - Patient in room alone. Handcuffed to bed siderails. LEO at door.
23:45:00 - Remains on bed handcuffed to siderails.
23:46:28 - Remains in room on bed handcuffed to siderails.
23:47:03 - ED Physician #1 enters room. Stands beside counter. No physical contact with patient observed.
23:47:47 - ED physician #1 exits room.
23:47:49 - RN #7 enters room, goes over to bed. Patient appears to be crying. Remains handcuffed to bed siderails.
23:47:54 - RN #7 exits room.
23:50:06 - RN #7 enters room.
23:50:08 - SO #2 enters room with soft wrist restraints.
23:51:00 - Soft restraints applied to bilateral feet by RN#7 and SO #2.
23:51:54 - Soft restraints applied to bilateral hands by RN #7 and SO #2.
23:54:26 - Handcuffs removed by SO #2.
23:55:00 - Patient observed on bed in 4 point soft restraints. End video.

Continued record review of a "Medical/Surgical Restraint Order Form" dated 08/07/2013 revealed a verbal order for restraint was obtained by RN #7 at 2350 from ED Physician #1. Review revealed ED Physician #1 signed the verbal order on 08/08/2013 at 0030. Review of the order form revealed "A. Reason-based on Nursing Assessment: (check all that apply)." Review revealed under the heading "Medical Surgical/Restraint....5._[hand written check mark on line]_Other_[Violent Behavior handwritten on line]_." Further review revealed under the heading "Violent/Self-Destructive Behavior Restraint **IF ANY OF THE BELOW APPLY-VIOLENT/SELF-DESTRUCTIVE BEHAVIOR RESTRAINT ORDER FORM MUST BE USED** ...Patient needs protection from injuring himself/herself either intentionally or accidentally secondary to cognitive impairment resulting in the following: a. primary psychiatric diagnosis b. Substance abuse c. Suicidal ideation/behaviors d. In an emergency situation (there must be accompanying documentation) e. If the patient's condition warrants ANY restraints ...Others need to be protected from being i

Based on hospital policy review, medical record review, observation, and staff interview, the hospital failed to ensure non-employee dialysis nurses followed the hospital's policies and procedures by the non-employed nursing staff failing to obtain and document pre dialysis weights for 2 of 3 sampled hemodialysis patients (Patients #30, 31) and by failing to obtain physician dialysis prescription orders for the desired potassium in acid concentrate in 3 of 3 sampled hemodialysis patients (Patients #29, 30, 31).

The findings include:

Review on 02/04/2014 of the hospital's policy ""Acid Concentrate" (revised 04/2013) revealed "Purpose: To provide guidelines for use and disposal of acid concentrates. Policy: 1. A physician's order will specify the desired calcium and potassium concentration of the acid concentrate to be utilized".

Review on 02/04/2014 of the hospital's policy "Pre and Post Treatment Assessment and Data Collection" (revised 04/2013) revealed :Purpose: To obtain information for planning the dialysis treatment, assessing and reviewing the patient's response to treatment. Policy: 1. The patient care teammate will obtain and document basic data on each patient pre dialysis. Report from the primary hospital nurse should include code status, isolation status, fall risk, vital signs, recent medications given to the patient, pertinent assessment findings, and any interventions ordered by the physician that need to occur during treatment. 5. Obtain pre treatment hand off report from the patient's primary nurse to include but not limited to: g. Orders to be carried out on Dialysis. 6. Obtain and document data collection on each patient pre dialysis which may include: Weight and scale type used to obtain weight (if ordered by the nephrologist)".

1. An open medical record review on 02/04/2014 for patient #30 revealed the patient was admitted to the hospital on 01/30/2014 with a diagnosis of "Chest Pain". Review of the facility's dialysis "Orders for Treatment" dated for 01/30//2014 and authenticated by the physician revealed the patient was to have "3 kilograms" of weight to be removed during dialysis treatment. A review of the patient's dialysis treatment record for 01/30/2014 revealed the hospital's dialysis nursing staff failed to obtain a pre dialysis weight before the patient's treatment to determine how much weight would be removed from the patient. The review revealed that the nursing staff was unable to determine if the 3 kilograms were removed from the patient.

An interview on 02/04/2014 at 1350 with the hospital's dialysis nurse #1 revealed that she did not obtain a pre dialysis weight on the patient. She stated that some patients come to the dialysis unit on beds without scales and they do not get weighed. The interview confirmed the finding.

2. An open medical record review on 02/04/2014 for patient #31 revealed the patient was admitted to the hospital on 01/27/2014 with a diagnosis of "Altered Mental Status". Review of the facility's dialysis "Orders for Treatment" dated for 01/27/2014 and authenticated by the physician revealed the patient was to have "3 kilograms" of weight to be removed during dialysis treatment. A review of the patient's dialysis treatment record for 01/27/2014 revealed the hospital's dialysis nursing staff failed to obtain a pre dialysis weight before the patient's treatment to determine how much weight would be removed from the patient. The review revealed that the nursing staff was unable to determine if the 3 kilograms were removed from the patient.

An interview on 02/04/2014 at 1350 with the hospital's dialysis nurse #1 revealed that she did not obtain a pre dialysis weight on the patient. She stated that some patients come to the dialysis unit on beds without scales and they do not get weighed. The interview confirmed the finding.

3. An open medical record review on 02/04/2014 for patient #29 revealed the patient was admitted to the hospital on 02/03/2014 with a diagnosis of "Fluid Overload". Review of the facility's dialysis "Orders for Treatment" dated for 02/03/2014 and authenticated by the physician revealed there was no "dialysis potassium" acid concentrate ordered. The review of the dialysis prescription standardized form had a section titled "7. Dialysis Potassium-use algorithm below or as specified _____milli equivalents per Liter" that was left entirely blank. Documentation did reveal the patient had dialysis potassium acid concentrate of "2" used but no physician order or completed algorithm was found for the dialysis prescription of the "2" dialysis potassium.

Interview on 02/04/2014 at 1530 with the hospital's dialysis nurse revealed that no written physician order was obtained for the patient's dialysis potassium level on the order for treatment sheet. The interview confirmed the finding.

4. An open medical record review on 02/04/2014 for patient #30 revealed the patient was admitted to the hospital on 01/30/2014 with a diagnosis of "Chest Pain". Review of the facility's dialysis "Orders for Treatment" dated 01/30/2014 and authenticated by the physician revealed there was no "dialysis potassium" acid concentrate ordered. The review of the dialysis prescription standardized form had a section titled "7. Dialysis Potassium-use algorithm below or as specified _____milli equivalents per Liter" that was left entirely blank. Documentation did reveal the patient had dialysis potassium acid concentrate of "3" used on 01/30/2014 but no physician order or completed algorithm was found for the dialysis prescription of the "3" dialysis potassium.

Interview on 02/04/2014 at 1530 with the hospital's dialysis nurse revealed that no written physician order was obtained for the patient's dialysis potassium level on the order for treatment sheet. The interview confirmed the finding.

5. An open medical record review on 02/04/2014 for patient #31 revealed the patient was admitted to the hospital on 01/27/2014 with a diagnosis of "Altered Mental Status". Review of the facility's dialysis "Orders for Treatment" dated for 01/27/2014 and authenticated by the physician revealed there was no "dialysis potassium" acid concentrate ordered. The review of the dialysis prescription standardized form had a section titled "7. Dialysis Potassium-use algorithm below or as specified _____milli equivalents per Liter" that was left entirely blank. Documentation for 01/27/2014 did reveal the patient had dialysis potassium acid concentrate of "3" used but no physician order or completed algorithm was found for the dialysis prescription of the "3" dialysis potassium.

Interview on 02/04/2014 at 1530 with the hospital's dialysis nurse revealed that no written physician order was obtained for the patient's dialysis potassium level on the order for treatment sheet. The interview confirmed the finding.

Based on hospital policy and procedure review, open and closed medical record review, and staff interviews the facility staff failed to have accessible in the patient's medical record the blood administration record for 1 of 3 patients who received blood (#28).

The findings include:

Review on 02/05/2014 of the hospital's Nursing Medical Procedure: D-50-C33A"Blood Products" last revised date of 01/2014 revealed "... 5. within 20 minutes of starting the blood, take patient's temperature, pulse, respirations and blood pressure ....7.d. Before a blood or plasma unit can be hung and transfused to a patient, TWO RNS OR ONE RN PLUS ONE IV-LPN MUST VERIFY THE FOLLOWING ...11. Take patient's temperature 20 minutes after transfusion begins ...14. After the transfusion is completed and the appropriate information recorded the Transfusion Form should be returned with the blood bag to the Blood Bank, immediately after transfusion is completed. The Charge Nurse is to verify and initial that information on the Transfusion Form is complete and accurate. DO NOT place form on the chart ...16. Take patient's temperature 20 minutes after transfusion ends. 17. Documentation in the Interdisciplinary Notes should include: 1. The ID (identification) blood unit number 2. Time started and completed 3. Amount - document on line under "blood" intake 4. Condition of patient ..."

Review on 02/06/2014 of the hospital's Nursing Management Policy: D-50-A24 "Documentation in the Medical Record" last revised date 08/2012 revealed "PROCESS: 1. Documentation should be done on each shift to reflect observations and care rendered that shift. 2. Observations should be charted as soon after their occurrence as possible and definitely by the end of the nurses' shift ...5. Documentation to be completed each shift ...b. Nursing interventions and assessments as applicable to the patient ...e. patient's response to care and treatment ..."

Open medical record review on 02/05/2014 revealed Patient # 28, a 78 year old male admitted on 01/27/2014 with a diagnosis of Renal Failure, Gastrointestinal Bleed, and Renal Cancer. Continued review revealed a Physician Order dated 01/27/2014 at 1900 to infuse two units of Leukocyte-reduced Pheresis Platelets (blood). Review of the Nurses Notes dated 01/28/2014 at 0109 revealed "Pt (patient) received one unit of apherised platelets and tolerated well. No reaction noted. Vital signs are stable. Pt is resting at this time with no complaints." Continued review of the nurses notes dated 01/28/2014 0535 revealed "Pt received one unit of platelets this shift and tolerated well ..." Continued review of the record revealed no "Transfusion Record" on the chart. Continued review revealed no documentation of 2 licensed staff verification of the blood product with the correct patient. Continued review of the medical record revealed no start time or stop time for the blood administration. Continued review of the medical record revealed no documentation of the vital signs per hospital policy.

Interview on 02/06/2014 at 1030 revealed "all of our documentation for blood administration is documented on the transfusion record then the record is sent to lab, it is not kept on the chart...we do not document the start time or stop time anywhere else in the chart ...the verification by two nurses and all our vital signs are documented on the form ...it's our original document but we are required to send it back to the lab...it wouldn't be documented anywhere else in the chart...I do not see it on this patient's medical record ..." Interview confirmed the blood administration record was not accessible in the patient's medical record.

Interview on 02/06/2014 with administrative staff revealed "the start and stop time as well as vital signs are documented on the blood transfusion record....the blood transfusion record is completed by the nursing staff then sent to lab with the empty blood bag where the lab are suppose to scan the document into the patient's record ...however I can not find the document in this patient's record. There is a nurses note the patient received the blood but I do not see the start and stop times or vital signs. I do not see the blood transfusion record in the medical record...I can not find where it has been scanned into the medical record ..." Interview confirmed the blood administration record was not accessible in the patient's medical record.

Based on policy and procedure review, medical record review, and staff interview, the physician failed to date the medical record of 1 of 7 surgical patients (Patient #14).

The findings include:

Review of the hospital's "HEALTH INFORMATION MANAGEMENT DEPARTMENT POLICIES" no revision date or policy number revealed, "Recording Entries in the Medical Record All entries in the medical record shall clearly identify the date and time of the entry. The date and time shall identify when the entry is made, regardless of whether it relates to prior events ...irrelevant information and humor should be avoided in recording entries."

Closed medical record review of Patient #14 revealed a patient admitted to the hospital 02/02/2014 for a cesarean section. Record review revealed documentation "DATE OF HISTORY AND PHYSICAL/DICTATION/ADMISSION: Groundhog day/Superbowl Sunday 2014." Review of PROGRESS NOTES revealed, "Date: Groundhog Day/Superbowl Sunday 2014 @ (at) 0531." Record review revealed, "H/P (history and physical) dictated Groundhog Day 2014 @ 0612." Record review revealed, "Groundhog Day/SuperBowl Sunday, 2014 @0727." Record review revealed documentation "Groundhog Day 2014 @" was written at the following times: "0739, 1014, 1203,1304, 1342, and 1549."

Interview with the medical records Director on 02/06/2014 at 1528 revealed, "He (Physician #2) has been counseled on trying to be cute. He likes to write Independence day and such as the date. I told him it is against policy. He was writing in Spanish prior to this." Interview confirmed Physician #2 failed to follow hospital policy.

Based on review of hospital policy and acceptable standards of practice for hospital pharmacies, observation and staff interview, the hospital failed to ensure the safe handling and preparation of cytotoxic medications.

The findings include:

Review of the hospital's policy, "Preparation and Safe Handling of IV (Intravenous) Cytotoxic Agents", revised 03/12/2013, revealed, "All I.V. Cytotoxic admixtures must be prepared by a pharmacist in a Class II, Type A vertical laminar flow hood or barrier isolator hood. Proper aseptic technique should be observed and appropriate protective gear must be used. ...".

Review of the Amercian Society of Health-System Pharmacists (ASHP) guidelines of handling hazardous drugs, 1990, revealed, "...hazardous drugs should be compounded in a controlled area where access is limited to authorized personnel trained in handling requirements. Due to the hazardous nature of these preparations, a contained environment where air pressure is negative to the surrounding areas or that is protected by airlock or anteroom is preferred. Positive-pressure environments for hazardous drug compounding should be avoided or augmented with an appropriately designed antechamber because of the potential spread of airborne contamination from contaminated packaging, poor handling technique, and spills....".

Observation during tour of the pharmacy on 02/06/2014 at 1000 revealed the laminar hood used for mixing chemotherapy/cytotoxic medications was in the same room with the hood used for mixing intravenous medications, with no barrier between the laminar hood and other work space in the pharmacy.

Interview on 02/06/2014 at 1035 with the director of the hospital's pharmacy revealed, "we know this is a problem. We need to put this hood for mixing chemo drugs in a seperate room. We have money in the budget to do this. We were recently cited by the Board of Pharmacy and the Joint Commission for this very thing". Interview confirmed the laminar hood used for mixing cytotoxic medications needs to be in a seperate room.

Based on hospital policy reviews, observations during tour, and staff interviews, the hospital's radiology staff failed to ensure drugs and/or biologicals labeled as single-use only were discarded after use and not available for multiple-use on patients in the radiology department.

The findings include:

Review of current hospital policy "Single use sterile drugs and devices" Policy: D-60-A-117, dated 06/09/2010, revealed "STATEMENT OF PURPOSE/POLICY: Single-use sterile drugs and devices shall be used and disposed of in accordance with this policy. ...LENGTH OF USE SINGLE-USE STERILE DRUGS AND DEVICES Single-use sterile drugs and devices shall not be reused. Unused portions of single-use sterile drugs shall not be saved for later use. ..."

Review of current hospital policy "Infection control: multiple use sterile products" Policy: D-60-A-35, dated 06/01/2010, revealed "...LENGTH OF USE OF MULTIPLE-USE STERILE DRUGS Multi-dose injectable vials: Injectable drug vials containing a preservative that are intended for more than one time usage. 1. Initial and date upon opening. ...3. Discard after 28 days after opening or the manufacturers' date whichever is shorter. ...Single-dose Injectable drugs containing no preservatives are intended for ONE TIME USE These vials must be discarded immediately after the initial use, even if the entire contents is not utilized."

Observation during tour of the Radiology Department on 02/05/2014 at 1000 revealed a medication cabinet located in Computed Tomography (CT) Room #1 that contained two 120 milliliter (mL) bottles of 37% Gastrografin (a water-soluble radiopaque contrast medium for oral or rectal administration). Observation revealed one bottle had been opened and was 2/3 empty. Review of the manufacture's label revealed "Single Dose Bottle - Discard unused portion." Further review of the label revealed no date or staff initials when opened. Interview during tour with CT staff revealed the bottle was opened 2 days ago. Interview revealed staff use 10 to 12 mL at a time for each patient (10 patients per bottle). Interview revealed the bottle should have been dated and initialed when opened. Interview revealed the staff member was unaware the bottle was for single-use only. Interview confirmed the radiology staff failed to follow the manufacture's instructions and hospital policy.

Based on observations as referenced in the Life Safety Report of survey completed 02/06/2014 and observation during tour of the patient care units, the hospital staff failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital staff failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~cross-refer to 482.41(a) Physical Environment Standard Tag A-0701

2. The hospital staff failed to assure the safety of patients by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

~cross-refer to 482.41(a) Physical Environment Standard Tag A-0702

3. The hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

~cross-refer to 482.41(a) Physical Environment Standard Tag A-0709

4. The hospital staff failed to ensure safe medical supplies as evidenced by 2 of 2 Bone Marrow Biopsy Kits and 17 of 17 culture swabs, expired, on the Intensive Care Unit (ICU).

~cross-refer to 482.41(a) Physical Environment Standard Tag A-0724

Based on observations as referenced in the Life Safety Report of Survey completed 02/06/2014, the hospital staff failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

BUILDING 01
1. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following building construction type was non-compliant, specific findings include:

A. Fifth floor - the marketing storage room ceiling is not complete as part of the ceiling is cut out as you enter the room on the left.

B. Ground floor - kitchen - openings not sealed in rated ceiling tile by the stove.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

3. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include:

A. Ground floor, Operating Rooms, the HVAC system did not shut down with fire alarm activation. It was confirmed with engineering staff that the system was not a smoke evacuating system and was designed to shut down on general alarm.

B. Verify HVAC shut down remote switches in the following areas:
a. Ground floor kitchen
b. Ground floor radiology
c. Ground floor lab

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067.

4. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following oxygen storage was non-compliant, specific findings include:

A. Ground floor, ER (emergency room) by exam room 3, full and empty oxygen cylinders were stored together. If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)]

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

5. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following relative humidity was non-compliant, specific findings include:

A. Ground floor, Operating Rooms 1 through 5, thirty five out of three hundred sixty five days of the year, a majority of three or more of the five available operating rooms were less than 20% relative humidity. Also see initial comments for high humidity.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0078.

6. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following NFPA 70 items were non-compliant, specific findings include:

A. Ground floor, kitchen electrical room, Panel GKR3 had open spaces where blanks had been removed.

B. Fifth floor, north bedrooms, electrical outlet within six foot of a water source without GFI protection.

C. Birth Place, the environmental services closet had an exposed light bulb in the light fixture.

D. First floor, ICU (intensive care unit) medication room, confirm electrical redundant grounding on the normal circuits. The emergency circuits in the same room showed a hospital grade outlet, however, the normal circuits did not.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0147.

BUILDING 02
1. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include:

A. There was not an HVAC shut off switch for the hyperbaric chamber room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067.

2. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following oxygen storage was non-compliant, specific findings include:

A. Hyperbaric chamber room, there was not empty and full signs for oxygen storage. If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)]

B. Outside tank farm, there was not a cover over the tank farm cylinders to protect from inclement weather.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

Based on observations as referenced in the Life Safety Report of Survey completed 02/06/2014, the hospital staff failed to assure the safety of patients by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Building 01
1. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following exit discharge illumination was non-compliant, specific findings include:

A. Ground floor, kitchen dry storage exit, the light fixture did not have a light bulb installed.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0045.

2. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following generators and its components were non-compliant, specific findings include:

A. Ground floor, switchboard location, Generator #3 did not have an audible signal when tested.

B. Ground floor, mechanical shop, ATS #1, Generator #3 took more than 10 seconds to transfer power.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0144.

Based on observations as referenced in the Life Safety report of survey completed 02/06/2014, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

The findings include:

BUILDING 01
1. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following corridor doors were non-compliant, specific findings include:

A. Fifth floor - the Behavioral Health room 573, the door is swinging in and is held open by a trashcan. There must be no impediment to closing doors.

B. Ground floor - central sterile has a dutch door that does not meet 19.3.6.3.6.

C. First floor rooms 167 and 172 has a gap grater than 1/8th of an inch and does not resist the passage of smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

2. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following smoke barriers were non-compliant, specific findings include:

A. 1st floor - PCU - near room 172, the life safety plans show a smoke wall however the smoke wall was labeled "not a rated wall", verify smoke wall locations.

B. Ground floor - the smoke wall above cross corridor doors that lead to the laboratory has unsealed penetrations in conduit on the left hand side of the smoke wall.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0025.

3. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following door opening in a smoke barrier was non-compliant, specific findings include:

A. Ground floor - birth place, the cross corridor smoke doors on the East Side had a gap greater than 1/8th of an inch and does not keep the doors smoke tight.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0027.

4. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following hazardous area was non-compliant, specific findings include:

A. Fifth floor - the one hour Behavioral Health Unit (BHU) soiled linen/laundry room does not have a ? hour door installed.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

5. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following fire alarm system and components were non-compliant, specific findings include:

A. Ground floor, the Fire Alarm Control Panel (FACP) at the control room was not properly labeled as to panel and circuit from which it is fed.

B. First floor, near room 172, the smoke damper did not close with activation of fire alarm system from either the pull station nor the duct detector.

C. Third floor, mechanical room, air handling units 862 and 861 are not equipped with access doors for maintenance of duct detectors.

D. First floor, smoke doors leading into the ICU did not close with activation of the fire alarm as the electric eye for the door did not deactivate with activation the fire alarm system.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0052.

6. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following automatic sprinkler system and components were non-compliant, specific findings include:

A. The following areas were not equipped with an automatic sprinkler system:
a. Upper and lower levels of the north & south exit stairwell tower
b. Ground floor, ED office across from secondary security
c. Ground floor, registration station #2
d. Ground floor, trash compactor area cover
e. Ground floor, doctor's entrance cover
f. Second floor, south smoke chamber

B. Fire Pump House, main tank supply, the sprinkler tamper alarm did not function properly.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

7. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following maintenance for automatic sprinkler systems were non-compliant, specific findings include:

A. Ground floor, medical records, verify mixed sprinkler heads are compatible

B. The following areas were not equipped with sprinkler escutcheon plates:
a. Fifth floor, marketing storage room
b. Ground floor, materials management storage room
c. Ground floor, radiology pit area, "IT closet"
d. Forth floor, bathroom in staff break room

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0062.

8. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following means of egress was non-compliant, specific findings include:

First floor, old PCU alcove, patient lift plugged into an electrical outlet charging in the corridor. The battery operated item was not in view of the nurses station.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

9. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following Alcohol Based Hand Rub (ABHR) was non-compliant, specific findings include:

Fifth floor, the doctors office has an ABHR installed over an ignition source.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0211.

BUILDING 03
1. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following corridor doors were non-compliant, specific findings include:

A. The Bone Density room door has a door stop installed and does not allow the door to be closed with one motion of the hand.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

BUILDING 04
1. Based on observation, on February 4-6, 2014, at approximately 2:00 PM onward, the following maintenance for automatic sprinkler systems were non-compliant, specific findings include:

A. Sprinkler riser room, accelerator valves not electrically supervised

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0062.

Based on review of hospital policy, observations during tour and staff interview, the hospital staff failed to ensure safe medical supplies as evidenced by 2 of 2 Bone Marrow Biopsy Kits and 17 of 17 culture swabs, expired, on the Intensive Care Unit (ICU).

The findings include:

Review of the hospital's Materials Management policy # D 80-M-2, last revised date 2013, revealed "DISTRIBUTION TECH PROCEDURE: General Information:...distribution Tech (technician) is to bring the stock level for each time up to its appropriate level, rotate stock and remove out of date inventory when needed..."

Observation during tour on 02/05/2013 at 1035 of the ICU's clean supply room revealed a room with multiple shelves stocked with sterile and clean supplies. Observation revealed two (2) Sterile Bone Marrow Kits on the supply shelve with an expiration date of 12/31/2013 (36 days ago). Continued observation revealed 17 Culture Swabs on the supply shelve with an expiration date of 09/30/2013 (4 months, 5 days ago).

Interview during tour on 02/05/2014 at 1035 with RN #16 revealed "yes, our culture swabs are outdated ...these are used for MRSA (Methicillin-resistant Staphylococcus aureus) cultures. Yes the kits are outdated too." Interview confirmed the facility failed to ensure safe medical supplies.

Based on review of hospital policy and procedure, cleaning and humidity logs, round reports, meeting minutes, work orders, closed medical record reviews, and staff interview, the hospital staff failed to prevent and control the spread of hospital-acquired infections and surgical site infections.

The findings include:

1. The hospital's infection control officer failed to (A) mitigate risks contributing to hospital-acquired infections (HAI) for 1 of 3 patients on isolation precautions (Patients #50) and 1 of 1 patient receiving dialysis (Patient # 29) ; (B) the infection control preventionist failed to identify and investigate 6 of 7 surgical patients (Patient #43, #44, #45, #46, #47, #48) who had surgery in OR #3 and developed surgical site infections (SSI); and (C) Failed to monitor the humidity and terminal cleaning in the hospital's operating rooms.

~cross refer to 482.42(a)(1) Standard: Tag A0749 Infection Control Program.

Based on review of hospital policy and procedure, cleaning and humidity logs, round reports, meeting minutes, work orders, closed medical record reviews, observations and staff interview, the hospital's infection control officer failed to (A) mitigate risks contributing to hospital-acquired infections (HAI) for 1 of 3 patients on isolation precautions (Patients #50) and 1 of 1 patient receiving dialysis (Patient # 29) ; (B) the infection control preventionist failed to identify and investigate 6 of 7 surgical patients (Patient #43, #44, #45, #46, #47, #48) who had surgery in OR #3 and developed surgical site infections (SSI); and (C) failed to monitor the humidity and terminal cleaning in the hospital's operating rooms.

(A) Review of the hospital's "MANAGEMENT OF THE PATIENT WITH EPIDEMIOLOGICALLY SIGNIFICANT AND ANTIBIOTIC-RESISTANT ORGANISMS POLICY: D-51-06 REVIEW/REVISE DATE: 03/12/2013" revealed, "III. GENERAL CONTROL MEASURES A. Hand Hygiene - Healthcare workers should wash their hands for at least 15 seconds or use an alcohol hand rinse product before leaving the patient room whether or not gloves were worn ...B. Precaution measures: 5. Nursing staff will ensure that an orange precaution bracelet is placed on the patient's right arm indicating "Contact" precautions or the specific transmission based precaution type. 6. The patient's chart should be labeled with a precaution label ...C. Communication: ... 4. The microbiology staff will notify the specific unit by phone when a positive result is identified on an inpatient and will edit the Clinical Data Screen for MRSA (methicillin-resistant staphyloccus aureus) and VRE (Vancomycin-resistant enterococci). 5 ...Any patient identified as having a positive MRSA history, will be placed on contact precautions ...6. Contact Precautions should be followed for patients with a positive test result for MRSA, current or previous history of VRE ... "

Review of the hospital's "CONTACT PRECAUTIONS Policy: D-51-16, Review/Revise Date: 1/27/13" revealed, "Background: Contact Precautions are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact ...B. Gloves and Hand Hygiene, Wear gloves when entering the room or cubicle, and/or when touching patient's intact skin, surfaces, or articles in close proximity ...Remove gloves before leaving the patient's room and perform hand hygiene immediately making sure not to touch potentially contaminated environmental surfaces in the patient's room ..."

Review of the hospital's "PERSONAL PROTECTIVE EQUIPMENT - GLOVES Policy: D-51-11, Review/Revise Date: 1/27/13" revealed, "PROCESS: 1. Perform hand hygiene by hand washing or use of an alcohol hand rinse product before donning gloves ...6. Wash hands a minimum of 15 seconds with soap and water or use a hand rinse product following glove removal."

Review of the hospital's "HAND HYGIENE Policy: D-51-10 Review/Revise Date: 5/25/12" revealed, "II. Hand antisepsis using an alcohol-based hand rinse: a) before having direct contact with patients ...d) after contact with a patient's intact skin. e) after contact with body fluids or excretions, mucous membranes ...g) after contact with inanimate objects in the immediate vicinity of the patient. h) after removing gloves ... "

Review of the hospital's "INFECTION PREVENTION GUIDELINES" Policy: D-51-02, Review/Revise Date: 02/01/13" revealed, " PROCESS: I. Medical Asepsis: A. Hand Hygiene including hand washing and use of hand sanitizers should be done before and after contact with a patient, even if gloves are used ...VIII. Personal Protective Equipment: A. 2. Perform hand hygiene before entering isolation area ...IX. Hand Hygiene: Indication for hand washing and hand antisepsis B. 1. Before having direct contact with patients ...7. After contact with inanimate objects in the immediate vicinity of the patient. 8. After removing gloves."

Review of the hospital's "EXPOSURE CONTROL PLAN", POLICY: D-51-04, Revised March 14, 2012" revealed, "I. INTRODUCTION: C. Epidemiology of Blood-borne Pathogens: In the health care setting it is appropriate to use personal protective equipment (PPE) such as gloves, gowns, and face protection to prevent skin or mucous membrane contact with blood or other potentially infectious materials ...III. COMMUNICATION OF HAZARDS TO WORKERS: B. Infection prevention Training for Hospital Employees: Each Hospital employee is required to participate to receive infection prevention education when starting work at named Hospital and annually thereafter ...IV. PROTECTION FROM EXPOSURE: A. Standard Precautions: ...employees, ...should assume that each patient harbors blood-borne pathogens (regardless of available screening test data) and should always follow " Standard Precautions " with every patient specimen, and contaminated item to minimize the risk ...I. Personal Protective Equipment (Barrier Techniques): a. Gloves Hand hygiene should be performed before and after contact with every patient, even if gloves are worn. If gloves are worn, they must be changed between patients, and hand hygiene performed whenever gloves are removed. Hand hygiene should be performed immediately or as soon as feasible after removal of gloves and other PPE ... "

1. Open medical record review of Patient #50 revealed a patient admitted to the hospital on 01/29/2014 with "shortness of breath x (times) 1 month". Record review revealed the patient had a positive MRSA (Methicillin resistant Staphylococcus Aureus) screen on 01/30/2014. Record review revealed the patient had a positive VRE (Vancomycin resistant Enterococcus) on 01/31/2014. Record review revealed isolation precautions were initiated 02/05/2014 at 0850. Record review revealed the patient was placed on contact precautions for MRSA. Record review revealed the patient was educated on isolation precautions. Record review revealed , "...Following performed: chart labeled ...orange bracelet placed on patient's wrist...".

Observation on 02/06/2014 at 1213 of the chart for Patient #50 revealed the chart was not labeled with a contact precautions sticker. Observation on 02/06/2014 at 1213 of Patient #50 revealed she did not have an orange wrist band.

Observation on 02/06/2014 at 1213 revealed a staff member entered Patient #50's room. Observation revealed the staff member did not perform hand hygiene before entering the room. Observation revealed the staff member did not wear a gown or gloves before entering the room. Observation revealed the staff member did not perform hand hygiene when exiting the room. Observation revealed the staff member spoke to surveyor in the hallway. Observation revealed the staff member entered another isolation room without performing hand hygiene.

Interview with ED director on 02/07/2014 at 1250 revealed, "Isolation precautions are initiated as soon as the patient is identified. The caddy is placed on the door and a bracelet is placed on the patient. All staff should follow isolation procedures."

2.) Review of the hospital's contract dialysis policy, "Acute Services Policy & Procedure Manual, #1 Policy: 7-03-01, TITLE: INFECTION CONTROL IN THE HOSPITAL DIALYSIS SETTING, Revision Date: September 2013" revealed, "POLICY: 1. Named "dialysis teammates will follow hospital policies for infection control, as mandated by hospital/facility ...TEAMMATE PERSONAL PROTECTIVE EQUIPMENT (PPE) 8. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces".

Review of the hospital 's contract dialysis policy, "Acute Services Policy & Procedure Manual, #1 Policy: 7-06-04, TITLE: ANTICOAGULATION Revision Date: March 2012" revealed, "POLICY: 2. Named policies and procedures for Dialysis Precautions, aseptic technique and infection control will be used when administering anticoagulation ...USE OF SALINE FLUSHES: 18. The use of saline flushes involves periodically rinsing the dialyzer with 50-100ml of saline while occluding the blood inlet line, usually every 15-30 minutes. The periodic rinsing is necessary to allow for inspection of the dialyzer for evidence of clotting ...The blood flow prescribed should be as high as possible to reduce potential clotting. "

1. Open medical record review of Patient # 29 revealed a dialysis patient admitted to the ICU (intensive care unit) on 02/03/2014 for fluid overload. Medical record review revealed the patient received saline flushes during dialysis treatment.

Observation on 02/05/2014 at 1010 revealed Patient #29 receiving dialysis. Observation revealed administrative staff #2 as Patient #29's primary nurse. Observation revealed administrative staff #2 did not perform hand hygiene prior to donning gloves. Observation revealed no gown or face shield being worn during treatment. Observation revealed no hand hygiene between glove changes.

Interview with administrative staff #2 on 02/05/2014 at 1200 revealed staff are required to wear face shield and gown, "whenever at risk of blood splashing. "

(B) Review of the hospital's, "INFECTION PREVENTION PROGRAM", POLICY: D-51-01, Revised 1/31/13" revealed, "C. Duties 1. Infection Prevention Monitor and evaluate healthcare associated infections in an effort to facilitate and improve patient outcomes and promote efficient utilization of medical resources...Review results of any anti-microbial susceptibility resistance trend studies...D. Authority Statement The Infection Prevention Committee of named hospital is granted authority to initiate those procedures to control measures deemed necessary to protect the hospital population, patients, and staff from danger of infectious disease...4. The initiation of Infection Prevention procedures to prevent the spread of infectious disease(s). III. INFECTION SURVEILLANCE SYSTEM B. Mechanism for Identification, Assessment, and Classification of Healthcare associated Infections...The Infection Prevention Practitioner shall seek to identify other possible cases of healthcare associated infection (HAI) through ongoing surveillance...IV. CRITERIA FOR IDENTIFICATION AND CLASSIFICATION OF INFECTIONS B. Criteria for Identification and Classification of Healthcare associated infections at specific focused sites: 3. SURGICAL SITE INFECTION (SSI) V. DATA COLLECTION, ANALYSIS, AND UTILIZATION A. Infection Prevention Meeting Data The Infection Prevention Practitioner will prepare HAI summary reports for presentation to the Infection Prevention Committee. These reports may include, but not be limited to, the following based on the surveillance plan for each year: ...Performance improvement process measures, current review of evidence based practices...B. An epidemiological investigation... Additionally, certain healthcare associated infections are either so sufficiently important that the occurrence (multiple drug resistant microorganisms, group A streptococcus) of one or two or more HAI almost invariably suggests an infection problem and this may call for an epidemiological assessment."

Review of the hospital's infection control surveillance log revealed 6 surgical patients (Patients #43, #44, #45, #46, #47, #48) who had surgery in OR #3 and developed surgical site infections (SSI).

1. Closed medical record review of Patient #43 revealed the patient had a "RT (RIGHT) OPEN COLECTOMY" in OR #3 on 06/26/2013.

Review of the infection control log revealed Patient #43 ..."INF (infection) Date 7/15/2013, Pathogen CORNEBACTERIUM."

2. Closed medical record review of Patient #44 revealed the patient had an "AXILLARY NODE DISSECTION" in OR #3 on 7/9/2013.

Review of the infection control log revealed Patient #44 "INF (infection) Date 8/5/2013, Pathogen MRSA (METHICILLIN RESISTANT STAPHLOCOCCUS AUREUS)."

3. Closed medical record review of Patient #45 revealed the patient had a "RIGHT HEMICOLECTOMY" in OR #3 on 8/21/2013.

Review of the infection control log revealed Patient #45 "INF (infection) Date 8/26/2013, Pathogen ENTEROBACTER."

4. Closed medical record review of Patient #46 revealed the patient had a "COLON RESECTION" in OR #3 on 08/11/2013.

Review of the infection control log revealed Patient #46 "INF (infection) Date 8/19/2013, Pathogen ENTEROBACTER, E. COLI (ESCHERICHIA COLI)."

5. Closed medical record review of Patient #47 revealed the patient had a "LUMPECTOMY WITH SENTINAL NODE BIOPSY" in OR #3 on 10/8/2013.

Review of the infection control log revealed Patient #47 "INF (infection) Date 10/30/2013, Pathogen STAPH AUREUS."

6. Closed medical record review of Patient #48 revealed the patient had an "OPEN LAPARATOMY, ILEOCECECTOMY WITH PRIMARY REANASTOMOSIS" in OR #3 on 11/19/2013.

Review of the infection control log revealed Patient #48 "INF (infection) Date 11/19/2013, Pathogen STREP, E. COLI, BACTEROIDES OVATUS."

Review of the "Infection Prevention Committee Meeting Minutes" for 08/20/2013 revealed, "Operating Room Issues/concerns There have been no reported events or recalls affecting the Operating Room for the past quarter."

Interview on 02/07/2014 at 1100 with the infection control practitioner revealed the practitioner did not recognize a trend with surgical site infections in OR #3. Interview revealed, "I screwed up. The columns on my tracking sheet were hidden." Interview confirmed the infections were not identified and were not reported to the Infection Control Committee.

C. Review of the hospital's, "INFECTION PREVENTION GUIDELINES" Policy: D-51-02, Review/Revise Date: 02/01/13 revealed, "POLICY: The staff of named hospital, under the direction of the Infection Prevention Committee, will share in the responsibility for controlling the transmission of infectious diseases....PROCESS: I. Medical Asepsis: C. Approved housekeeping procedures are followed based on Environmental Services policy...II. Identification of Patient Infections: A. The Director of Infection Prevention or designee will monitor for communicable diseases, elevated temperatures, surgical site infections, evidence of antibiotic resistant organisms, and evidence of HAI as determined by the Infection Prevention plan and microbiology culture reports..."

Review of the hospital's "OPERATING ROOM POLICY: D-50-S-F-13 ENVIRONMENTAL CONTROL REVISED 6/13" revealed, "POLICY: To establish a surgical environment that minimizes bacterial growth and enhances fire safety. PROCESS: I. Gauges for humidity and temperature will be present in every Operating Room. A. Desired ranges. 1. 20% - 60% humidity as recommended by AORN (Association of Perioperative Registered Nurses) and ASHRAE (American Society of Heating, Refrigerating and Air Conditioning Engineers)...II. Anything outside of these desired ranges will be reported to the Director of Surgery/designee, who will take appropriate action..."

Review of the hospital's "EXPOSURE CONTROL PLAN", POLICY: D-51-04, Revised March 14, 2012" revealed, "IV. PROTECTION FROM EXPOSURE: 3. Housekeeping and Waste Management: a. Environmental Surfaces and Work Surfaces: All environmental and work surfaces shall be cleaned and decontaminated after contact with blood and other potentially infectious materials...Contaminated or potentially contaminated work surfaces shall be decontaminated at the end of each procedure or at the end of the work shift if the surfaces may have become contaminated since the last cleaning."

Review of the hospital's "Operating Room terminally cleaning tasks to be done daily: List A: OR staff to complete and document in the Terminal Cleaning Log as being done List B: Environmental staff to complete and document in the Terminal Cleaning Log as being done List A: OR staff Clean OR beds...Clean all horizontal surfaces. Clean boive machine (cautery) and other equipment in the room...Include wheels and casters if applicable....List B: Environmental Staff: Clean ceilings... Clean cords. Clean doors, walls and vents...Wet Vac Floors...Clean hallways and scrub sink areas."

Review of the hospital OR's "TERMINAL CLEANING LOG" for the days procedures were completed revealed no documentation available for review for January 2013 - August 2013. Review revealed the operating rooms were not terminally cleaned per hosptial policy for the following dates the operating rooms were used for procedures: 09/03/2013, 09//04/2013, 09/06/2013, 09/10/2013, 09/13/2013, 09/17/2013, 09/20/2013, 09/27/2013 and 09/30/2013, 10/04/2013, 10/18/2013, 10/25/2013, 10/29/2013, 10/30/2013, 11/01/2013, 11/08/2013 and 11/15/2013.

Interview with EVS (environmental service) staff #1on 02/07/2014 at 1305 revealed, "The days that surgeries are not done, terminal cleaning is still done." Interview confirmed the cleaning log revealed no documentation that terminal cleaning was done in the operating rooms on the following dates: 09/03/2013, 09//04/2013, 09/06/2013, 09/10/2013, 09/13/2013, 09/17/2013, 09/20/2013, 09/27/2013 and 09/30/2013, 10/04/2013, 10/18/2013, 10/25/2013, 10/29/2013, 10/30/2013, 11/01/2013, 11/08/2013 and 11/15/2013.

Review of the OR "Temp/Humidity" log for June 2013 revealed 13 days OR #1, #2, #3, #4, or #5 had high humidity (greater than 60%) documented:

Review of the log revealed the following high humidity in the operating rooms:
Temp/Humidity LogJun-13OR 1OR 2OR 3OR 4OR 5362.5462.5106467.562.56176.51163.566.5741262.562.576.51365.060.562651462.560.567.5176161.51860.560.561.5621961622061.52463.52561.560.561.52661.562.5276162.52861.567.5
Review of the log for July 2013 revealed 18 days OR #1, #2, #3, #4, or #5 had temperatures and/or humidities out of range. Review of the log revealed the following high humidity in the operating rooms:
Temp/Humidity LogJul-13OR 1OR 2OR 3OR 4OR 516162.56162.56426361.562.561.5362.560.560.563.571561.56270708621061.51160.561.51561.561166262.5177162.5186119612262.52360.561.52460.6365256863.56529636361.5793060.53161
Review of the log for August 2013 revealed 22 days OR #1, #2, #3, #4, or #5 had temperatures and/or humidities out of range. Review of the log revealed the following high humidity in the operatiing rooms:
Temp/Humidity LogAug-13OR 1OR 2OR 3OR 4OR 5161616364.526362626379.53646656263636270662646565687646673.567.586163.577639666668801263.56370.5136163.56860.5146162.562.5611561626316616262.51963646120637161.52163.5647062226563.5696262263.564.5626881276463.5626377.5286464.5626629707070653068.568.57075.579.5
Review of the log for September 2013 revealed 20 days OR #1, #2, #3, #4, or #5 had temperatures and/or humidities out of range. Review of the log revealed the following high humidity in the operating rooms:
Temp/Humidity LogSep-13OR 1OR 2OR 3OR 4OR 537165.572674687370686657076.569696666875.56967.5659686355.57075.510706870.570.579.5117166.5707178.5126866.57072.5791367.565.57077.580.51667.56670.57774.5176866.56974.57818666169.57472196865697077206865.5697273.5236866697269.52468.565.568.5727225696566.57970.52667656980.5702767686370306566.564.572.566.5
Review of the log for October 2013 revealed 9 days OR #1, #2, #3, #4, or #5 had temperatures and/or humidities out of range. Review of the log revealed the following high humidity in the operating rooms:
Temp/Humidity LogOct-13OR 1OR 2OR 3OR 4OR 516365.56475622686263.57666.5366.5626575.562.54666663.575.562.5762.56466.570708636464.56771.51162.5616361.51561.586.560.590.51780
Review of "(Named Hospital) Summary of Operation Room Closings Due to HVAC (Heating, Ventilation, Air Conditioning)"no review/revision dates revealed, "Closed: 09/06/2013 (Friday) @ 1530, Re-Open: 09/09/2013 (Monday) @ 0700. Closed: 09/29/2013 (Sunday) @0700, Re-Open: 09/30/2013 (Monday) @ 0700. Closed: 10/11/2013 (Friday) @1530, Re-Open: 10/14/2013 (Monday) @ 0700."

Review of the hospitals "ENVIRONMENTAL, SAFETY, AND INFECTION PREVENTION ROUNDS" in the OR revealed on 8/28/2013, "Vents rusty in instrument room beside room 3." Review of round report for 10/16/2013 (49 days later) revealed, "Vents rusty in instrument room beside room 3." Review of round report for 11/27/2013 (91 days since first noted) revealed, "Vents rusty in supply room OR and PACU (Pre/Post Anesthesia Care Unit)." Review of round report for 12/19/2013 (113 days since first noted) revealed, "Rusty vent covers throughout department need to be replaced." Review of OR round report for 01/31/2014 (156 days since first noted), "Vents rusty in several places."

Review of the hospital's work order #FAC-19460 request placed on 12/3/2013 (77 days after first noted) at 7:14:11 AM revealed, "Reason: paint rusty air vents throughout the department PLEASE NOTIFY (ZZZ) OR (YYY) WHEN THIS HAS BEEN COMPLETED thanks." Further review revealed, "Work Order #FAC-19460 (Closed), paint rusty air vents throughout the department ..., Date 12/4/2013."

Interview with the hospital's infection control practitioner on 02/07/2014 at 0854 revealed when environmental rounds are performed, staff are questioned on documentation in the logs and their knowledge of when a process is completed. Interview revealed, "I know the humidity gets high at times and the staff make adjustments to help with the issue. The maximum humidity is 60%. I have not seen the logs. We believed the chillers would fix the problem. We were disappointed when it did not work. We have placed the issue about the high humidities on the agenda for the February 2014 (infection control) meeting" Interview revealed, "I'm not sure if they have terminal cleaning logs." Interview revealed, "I do not remember if there was a plan in place to minimize infection risk from the humidities and construction." Interview confirmed the infection control practitioner was not monitoring the terminal cleaning or humidity in the operating rooms.

Based on the hospital policy and procedure reviews, Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training material review, Quality Care Control Report review, Daily Security Report reviews, closed medical record review, video surveillance footage review, education training transcript reviews, staffing schedule reviews, and staff interviews, the hospital failed to meet the emergency needs of behavioral health patients in accordance with acceptable standards of practice.

The findings include:

The hospital failed to ensure 3 of 7 registered nurses (RN #2, RN #3, RN #4) and 1 of 2 Security Officers (SO #1) were qualified and trained to meet the needs of behavioral health patients that presented to the hospital's emergency department who were physically restrained for the management of violent and/or self-destructive behaviors.

~cross refer to 482.55(b)(2) Standard: Tag A1112.

Based on the hospital policy and procedure reviews, Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training material review, Quality Care Control Report review, Daily Security Report reviews, closed medical record review, video surveillance footage review, education training transcript reviews, staffing schedule reviews, and staff interviews, the hospital failed to ensure 3 of 7 registered nurses (RN #2, RN #3, RN #4) and 1 of 2 Security Officers (SO #1) were qualified and trained to meet the needs of behavioral health patients that presented to the hospital's emergency department who were physically restrained for the management of violent and/or self-destructive behaviors.

The findings include:

Review of current hospital policy "Restraint Management Program" Policy: D-50-D42, revised 09/2012, revealed "...The USE OF ANY RESTRAINTS FOR VIOLENT/SELF DESTRUCTIVE BEHAVIOR REQUIRES ONE-TO-ONE STAFF. AND MONITORING EVERY 15 MINUTES ...VI. TRAINING OF STAFF Hospital and medical staff members shall receive training in the following subjects as it relates to duties performed under this policy. Such training shall take place during departmental or medical staff orientation (before the trainee is asked to implement the provision of this policy) and shall be repeated periodically as indicated in the hospital's training plan, which is based on the results of quality monitoring activities. Individuals trained shall exhibit their knowledge of the subject matter through the consistent implementation of the matters taught. The training programs will include return demonstrations and post-training tests a the discretion of the trainer. A. Physicians (or designees, PA's NP's) who order restraint or seclusion shall be trained in the requirements of this policy and shall demonstrate a working knowledge of this policy through ongoing compliance. B. Hospital staff members who assess patients need for restraint or who apply restraint shall receive training in the following: (It is acceptable to have separate training for staff who deal with Behavioral Health and Medical restraint.) 1. The impact of restraints on the rights and dignity of the patient. 2. Risks associated with the use of restraint to vulnerable populations, such as pediatric, emergency and cognitively or physically challenged patients. 3. Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. 4. The use of nonphysical intervention skills. 5. Alternatives to restraint-choosing the least restrictive intervention based on an individualized assessment of the patient's medical, or behavioral status or condition. 6. The safe application and use of all types of restraint or seclusion used by the staff member, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). 7. Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. 8. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to respiratory and circulatory status, skin integrity, and vital sings. 9. Staff members who are authorized to monitor patients in restraint also receive training in: a. taking vital signs and interpreting their relevance to the physical safety of the patient in restraint. b. recognizing nutritional and hydration needs c. checking circulation and range of motion in the extremities d. addressing hygiene and elimination e. addressing physical and psychological status and comfort f. helping patients meet behavior criteria for discontinuing restraint or seclusion g. criteria for early release and criteria for removal of restraint h. recognizing readiness for early release and/or discontinuing restraint or seclusion i. recognizing incorrect application of restraints j. recognizing when to contact a medically trained licensed independent practitioner, designee, PA or NP to evaluation and or treat the patient's physical status 10. The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic re-certification. C. Annually, Hospital staff members who assess, monitor or apply restraint in the Emergency Department or the Behavioral Health Unit are required to complete the Non-Violent Crisis Intervention Program (NCI). These staff members also receive training in the following: 1. The underlying causes of threatening behaviors exhibited by the patients. 2. Medical conditions that may lead to aggressive or threatening behavior 3. Influence of staff behavior on patients 4. Alternative techniques such as de-escalation, mediation, self-protection, and other techniques such as time-out 5. Staff members who are authorized to apply restraint or seclusion also receive training on the safe use of restraint, including physical holding techniques, take-down procedures, and the application and removal of mechanical restraint. 6. Staff members shall demonstrate competence in: a. Recognizing how age, developmental considerations, gender issues, ethnicity, and history of sexual or physical abuse may affect the way in which a patient reacts to physical contact b. Using behavior criteria for discontinuing restraint or seclusion and how to help patients in meeting these criteria ...V. PERSONNEL AUTHORIZED AND QUALIFIED TO APPLY RESTRAINTS * Patient Care Services Personnel who have demonstrated competency by annual completion of....Restraint Management Program. ..."

Review of current hospital policy "Security Measures" Policy S-121-201, revised 02/18/2013, revealed "...TRAINING: All Security personnel shall receive security training adequate to perform their job functions. ...RESPONSIBILITIES: * Security personnel stationed at the hospital shall be responsible for the following: ...* Staff assistance with patient restraint and intervention in disruptions by patients, visitors or staff ...."

Review on 02/07/2014 of Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) training materials, copyright 2009 (reprinted 2013), revealed "Unit I: The CPI Crisis Development Model." Review revealed "...Definitions 1. Anxiety: A noticeable increase or change in behavior. A nondirected expenditure of energy; e.g., pacing, finger drumming, wringing of the hands, or staring. ...2. Defensive: The beginning stage of loss of rationality. At this stage, an individual often becomes belligerent and challenges authority. ...3. Acting-Out Person: The total loss of control, which results in a physical acting-out episode. ...4. Tension Reduction: A decrease in physical and emotional energy that occurs after a person has acted out, characterized by the regaining of rationality. ...Review of "Unit II: Nonverbal Behavior" revealed "...The CPI Supportive Stance" and "Reasons for using the CPI Supportive Stance 1. Communicates respect by honoring personal space. 2. Is nonthreatening/nonchallenging. 3. Contributes to staff's personal safety if attacked/offers an escape route." Review of "Unit VIII: Nonviolent Physical Crisis Intervention and Team Intervention" revealed "The Nonviolent Crisis Intervention program is a safe, nonharmful behavior management system designed to help human service professional provide for the best possible care and welfare of disruptive, assaultive, and out-of-control persons--even during tier most violent moments. In Nonviolent Crisis Intervention training, the emphasis is always on your primary responsibility: the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint is recommended only when all less restrictive methods of intervening have been exhausted, and when the individual presents a danger to self or others. ...Risks involved with physical intervention can be minimized when staff members regularly practice and rehearse procedures for team interventions. Further review revealed "CPI TEAM CONTROL POSITION" and "The CPI Team Control Position is used to manage individuals who have become dangerous to themselves or others. Two staff members hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist, if needed. During the intervention, staff members who are holding the individual should: *Face the same direction as the acting-out person while adjusting, as necessary, to maintain close body contact with the individual. * Keep their inside legs in front of the individual. ...*Bring the individual's arms across their bodies securing them to their hip areas. ...*Place the hands closest to the individual's shoulders in a C-shape position to direct the shoulders forward. ...Control Dynamics 1. Reduce upper-body strength by controlling the arms as weapons. 2. Reduce lower-body strength by controlling the back incline. 3. Reduce mobility by close body contact." Further review revealed "CPI TRANSPORT POSITION" and "The CPI Transport Position will assist you in safely moving an individual who is beginning to regain control. Prior to moving an individual, assist the person into a more upright position and remove your hand from the individual's shoulder. Reach under the individual's arm to grab your own wrist. This cross-grain grip better secures the individual between staff during transport. Remove your leg from directly in front of the individual prior to transport while maintaining close body contact. ...Further review revealed "CPI INTERIM CONTROL POSITION" and "The CPI Interim Control Position is a temporary control position that allows you to maintain control of both of the individual's arms, if necessary, for a short time. Starting from the CPI Transport Position, maintain control of the individual's arm, but release the cross-grain grip. Use your free arm to reach across and gain control of the opposite arm. ...If the individual attempts to strike, use your free arm to block, and safely move away. ..." Review of "Appendix: A Practical Approach for Managing Violent Behavior" revealed "...Team Intervention All of the intervention concepts are best utilized when a team of professionals intervenes. ...Why Nonviolent Crisis Intervention Training? A fundamental purpose of the Nonviolent Crisis Intervention training program is to help people understand the process of behavior escalation and to recognize that people don't act out in a vacuum. The staff member who intervenes with the potentially violent person must realize that her behavior has a tremendous impact on that individual. In any cases, the subsequent escalation or defusion of the person's behavior may depend entirely on how that staff member reacts. Nonviolent Crisis Intervention training stresses that crisis interventions is an integrated process. ...In an effort to maximize the chance of calming the person, it is best to balance or offset the person's behavior with therapeutic responses by staff. The therapeutic environment should be maintained continually, even during the most violent moments. ...By using safer, nonharmful techniques taught in the Nonviolent Crisis Intervention program, it is more likely that the therapeutic relationship you have worked so hard to develop can be maintained." Review of "Appendix: Understanding the Risks of Restraints" revealed "...Dangers of Restraints ....restraints should only be used when a person's behavior is MORE dangerous than the danger of using restraints. Some restraints are more dangerous than others. For example, facedown (prone) floor restraints and positions in which a person is bent over in such a way that it is difficult to breathe are extremely dangerous. This includes a seated or kneeling position in which the person being restrained is bent over at the waist and any facedown position on a bed or mat. Restraint-related positional asphyxia occurs when the person being restrained is placed in a position in which he cannot breathe properly and is not able to take in enough oxygen. Death can result from this lack of oxygen and consequent disturbance in the rhythm of the heart. Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breathe. This includes sitting or lying across a person' back or stomach. When someone is lying facedown, even pressure to the arms and legs can impact the person's ability to breathe effectively. ...When confronted with an emergency situation, always consider the option of disengaging. If the persons is not a danger to self or others while on the floor, staff may make the decision to move away and give a clear directive. Reducing the Risks of Restraints ...Staff members should be trained in and regularly practice safer ways of restraining. ...A physical restraint is an emergency procedure...As with any emergency response procedure, staff members need to practice these skills on a regular basis. ...Key elements of Nonviolent Physical Crisis Intervention responses include: * No element of pain involved. * The intent is to calm the individual. * The intent is to keep the individual off the floor, thus reducing risks of restraint-related positional asphyxia and other injuries. * Team interventions are used when necessary. * Nonviolent Physical Crisis Intervention is used only as a last resort when someone presents a danger. * Nonviolent Physical Crisis Interventions is used to protect - not to punish. The goal is for staff....is to eliminate the need for restraints at all."

Review on 02/05/2014 of a Quality Care Control Report completed by the ED Director on 08/15/2013 regarding a "Behavioral Variance" occurring on 08/07/2013 at 2310 in ED III, involving Patient #37, revealed "Pt (patient) yelling + (and) swearing at staff....(RN name) called for assistance to help with situation. Pt pacing in room. Staff went into give pt. medication shot. Pt refused shot. Pt backed up into corner. 3 male staff tried to secure pt for shot. Pt hit RN....Pt held + shot given. Pt verbally + physically resistant to staff. Handcuffs from security placed on pt by RN. Pt put in sitting position. Police arrived. Spoke to patient. Pt assisted to stretcher, handcuffed to stretcher. Handcuffs removed, pt placed in 4 point soft restraints. Pt became calm. MD assessed pt. Restraints removed one at a time." Review revealed the staff involved were identified as RN #1, RN #2, RN #3, RN #4, RN #5, RN #6, RN #7, SO #1 and SO #2.

Review on 02/07/2014 of a "Daily Security Report" dated 08/07/2013 from 1600 to 0030 completed by SO #1 revealed "...2330 patient in and out of room many times Nurse ask him to go back in the room and stay. Patient refused and started cussing nurse asked patient to get quiet. And was asked if he wanted a shot to help to rest and he refused said they could not give him the meds in the shot called for help to give injection and patient became combative and RPD (local police department). Was called. patient knocked hole in wall with elbow. ..."

Review on 02/07/2014 of a "Daily Security Report" dated 08/08/2013 from 0000 to 0800 completed by SO #2 revealed "2340 (08/07) Went to ED III Room #2 to assist with a patient that RPD was called on. ...0006 (08/08) Started one on one ED III Room #2 ref (reference) subject was placed in restraint 0115 Assisted in removing Restraint one limb at a time every 15 minute last one removed on Thursday 8 of August 0230 Clear one on one. ..."

Closed emergency department (ED) record review on 02/05/2014 for Patient #37 revealed a 26 year old male who presented to the hospital's ED on 08/03/2013 under involuntary commitment (IVC) petition for psychiatric evaluation. Review revealed the patient was diagnosed with "substance abuse disorder." Review revealed the patient was held in the ED from 08/03/2013 until 08/13/2013 (11 days), awaiting placement at a psychiatric hospital. Review revealed on 08/13/2013 the patient was reassessed by the ED physician as "...no longer meets criteria for inpatient treatment" and was subsequently released from IVC petition and discharged from the ED. Review of nursing documentation by RN #6 on 08/07/2013 at 2329, revealed "Approximately 2310 patient went from washing his hands in room to hall sink to wash hands back to room to wash hands and to sink again to wash hands, at the sink he looked at this RN and looked like he was asking a question, this RN asked what he needed but couldn't here [sic] him, this RN then went to doorway of nurses station and asked, '(Patient #37 name), I couldn't hear you, what did you need?' At that point patient started yelling 'I'm singing a Marilyn Manson song, can't someone just sing a song without you f**king getting in their face.' (RN #2 name), RN spoke to patient and asked him to stop yelling and to stop swearing, patient started yelling more and posturing, this RN called on radio that assistance was needed in ED III--(RN #1 name), RN, (RN #4 name), RN, (SO #1 name)--Security, (RN #3 name), RN came to assist, patient starting yelling more and swearing louder. Patient was told he was going to get a shot of Geodon (antipsychotic) if he did not settle down, he just kept yelling, this RN called communications and used hand radio again to notify charge RN (RN #7 name) that communications was called, patient kept yelling and swearing, the other RNs continued to try to talk patient down but patient kept yelling, this RN got the Geodon and prepared it, medication was given while male nurses secured patient, patient remained secured until officers (Law Enforcement Officers) arrived to help with situation, officers requested patient's IVC papers and discussed this with patient, patient did hit (RN #2 name), RN in the jaw and kicked in the shins--report filed, ....(SO #2) from security came on shift and is now present also--sheets have been removed from bed and officers have patient handcuffed to bed, (RN #7), RN talking to officers about handcuffs and (ED Physician #1 name) has walked in at 2345 to assess patient and speak to officers and staff. 1:1 in place with (SO #2 name)--security, restraint orders in place, verified with (RN #7), RN and (RN name), RN from BH (Behavioral Health)." At 0035, revealed "(RN #2 name), RN is being checked for injuries....there is a bruise on patient's l-arm (left arm)--discussed with (SO #1 name) from security--stated the patient had that bruise prior to incident, VS (vital signs) checked as ordered and patient, patient continues to argue that he does not need restraints, when he asked when restraints would be removed, this RN explained when it was safe for him and staff restraints would be removed--patient slammed the bed rail and complained again about his 'f**king situation'. Explained to him that type of behavior would keep him in the restraints. Patient has been offered and given ice water, he is currently being assisted by security to help with urinal." At 0106, revealed "....patient was moved up in bed with assistance from (SO #2 name) from security....patient appeared to be sleeping, VS taken but when patient started to kick a little and argued about being in restraints, is able to turn from l-to-r (left to right), patient did urinate 425 mL (milliliters) with assistance by (SO #2 name), security, patient has continually been offered ice water and given when requested, patient remains agitated but not as noticeable at this time." At 0119, revealed "patient is sleeping but restless with sleep--pulling at restraints at times--this RN called (RN name), RN BH and (RN #7 name), Charge RN to verify taking restraints off--advised to remove one restraint at a time--opposite of each other--l-wrist (left wrist) is removed at this time--1:1 continues with (SO #2 name), Security--he assisted with removing first restraint." At 0131, revealed "r-ankle (right ankle) restraint removed, (SO #2 name) from security is assisting patient with urinal, explained to patient that two restraints have been removed and will continue to remove one at a time if patient remains cooperative, patient did request to urinate--was ambulated by (SO #2 name) from security to BR (bathroom) and returned to room where two restraints were reapplied, patient fell asleep during reapplication." At 0152, revealed "spoke to (RN #7), Charge RN and (ED Physician #1 name) that patient is restless only when VS are checked but is sleeping otherwise--3rd restraint to r-wrist (right wrist) removed, last restraint will be removed at 0200 if patient continues to sleep and remain cooperative, patient sleepily stated he did not want anything to drink at this time." At 0207, revealed "(ED Physician #1) and (RN #7), RN notified that patient's 4th restrain [sic] has been removed, 1:1 will continue until 0230 by (SO #2 name) from security as is ordered in paperwork, patient verbally stated during 0145 VS that he understood, (RN name), RN BH notified as well and advised to continue 1:1 for 30 minutes--advised this is being done, patient is completely self turning at this time--l-arm (left arm) noted earlier as having a bruise--also noted at this time that it is a healing scar with bruising about it." At 0233, revealed "restraints remain off, 1:1 discontinued...." At 0402, revealed "Sergeant (name) arrived at 0400--advised ED staff that patient has one misdemeanor injury to real property and one felony for assault on ED staff--(RN #2 name), RN, we are to notify communications dept (department) when patient is to be dc'd (discharged) from (hospital) or after transfer and release from additional facility....that patient is to be arrested for these charges." Record review revealed the patient was discharged to jail on 08/13/2013.

Review on 02/05/2014 at 1615 with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Quality and Risk Management, Director of Security, Emergency Department Director, and the hospital's Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) Certified Instructor (CI #1) of video surveillance footage without audio; dated 08/07/2013, time interval 23:10:00 to 23:55:00; from hospital security camera, ED III Room 2 revealed at:
23:10:00 to 23:17:59 - Patient #37 observed in treatment room. Holding book in hands. Placing book on and off counter top. Exits and re-enters room two times. Speaking towards doorway. Drinking from container with straw. Pacing within room. Shadows observed at doorway. No physical aggression observed.
23:18:00 - Patient observed standing in room with left side of body adjacent to cabinet/countertop with left hand on countertop. Patient is facing direction of door. Male staff member (RN #1) enters room and goes over to patient's right side. RN #1 carrying medication syringe (Geodon). RN #1 begins to swab/wipe the patient's right shoulder with antiseptic/alcohol wipe. Two male staff members (RN #2, RN #3) appear in doorway. No physical aggression is observed by patient towards staff.
23:18:14 - Patient walks away from cabinet/countertop and RN #1. Patient walks across room to left rear corner of room and turns his back towards the wall, facing staff members. Patient and staff members engaging in verbal communication. Three male staff members are present inside room (RN #1, RN #2, RN #3). No physical aggression is observed by the patient towards staff.
23:18:29 - A fourth male staff member (SO #1) appears at doorway of room.
23:18:38 - SO #1 reaches into room and turns lights on. Patient stands in left rear corner of room with back towards wall. Patient has his hands behind his back. Patient and staff engaging in verbal communication. No physical aggression is observed by the patient towards staff.
23:19:19 - Patient in left rear corner of room with back towards wall. RN #1, RN #2, and RN #3 start moving closer towards patient from three sides (in a corralling stance). No physical aggression is observed by the patient towards staff.
23:19:24 - A fifth male staff member (RN #4) enters room. Patient remains in left rear corner of room with his back to wall, facing staff members. RN #1, #2, #3, #4 in room. SO #1 at doorway.
23:19:47 - Patient remains in left rear corner of room with back towards wall. Facing staff. No physical aggression is observed by the patient towards staff.
23:19:50 - Patient steps backward further into left rear corner of room (away from staff). Patient's arms are crossed in front of chest. No physical aggression is observed by patient towards staff. RN #2 and RN #3 begin approaching patient.
23:19:51 - Patient with back against wall in left rear corner of room, facing staff. Patient arms crossed in front of chest. No physical aggression observed by patient towards staff. Staff observed in a "corralling stance" and then rapidly advance towards patient. RN #2 reaches towards patient and appears to make physical contact with left chest/axilla area of patient. Patient extends left arm outward towards RN #2 and appears to make contact with RN #2. Patient swings right arm and appears to strike RN #2 in left side of face/jaw area. RN #3 reaching towards patient and appears to make contact with the patient's right shoulder. Patient appears to be pushed up against wall of room. Two additional male staff members (RN #4 and RN #5) enter room to assist.
23:19:52 - Patient appears to strike RN #2 in back of neck two times with his right arm. Patient is held against rear wall by male staff members.
23:19:54 - Patient held against wall by male staff members. SO #1 and RN #1, #2, #3, #4 in room. RN #6 enters room and stands at door.
23:19:59 - Patient is held against wall by male staff members.
23:20:03 - SO #1 is observed grabbing patient's left leg and pulling/holding the leg up off the floor. RN #2, RN #3, and RN #4 observed holding patient up against wall.
23:20:05 - RN #3 is observed with his left arm around patient's neck in a "head lock" type position pulling downward.
23:20:11 - The patient is held against the wall. RN #3 is observed with his left arm around patient's neck in a "head lock" type position. RN #2 is observed holding the patient's extended left arm up against the wall. SO #1 is observed holding the patient's left leg up off the floor. RN #1 is observed approaching the patient with a medication syringe in his left hand.
23:20:12 - A male staff members gloved hand is observed covering the patient's chin/mouth area. The patient's neck is observed being hyper-extended backwards.
23:20:13 - The patient is observed being held against the wall. RN #3 is observed with his left hand around the patient's neck. A gloved hand is covering the patient's chin and his neck is hyper-extended backwards. The patient's left arm is bent behind his back by RN #2. SO #1 is holding the patient's leg off the floor. The patient appears to be in a contorted/flexed position.
23:20:14 - RN #1 is observed with a syringe in his left hand.
23:20:21 - Patient is observed to be pulled down onto floor with staff on top of patient.
23:20:28 - RN #1 is observed administering the IM medication to the patient's left arm.
23:20:45 - Patient with head held to floor by gloved hand of RN #3. Gloved hand pushing head downward to floor. Patient body appears contorted/flexed. Staff over patient.
23:20:55 - Patient observed on floor, on left side. RN #2 observed with his left knee against small of patient's back. Staff holding patient down on floor.
23:21:19 - SO #1 is observed removing handcuffs from belt case.
23:21:33 - Staff holding patient down on floor. Three staff members on top of patient, RN #5 enters room.
23:21:38 - SO #1 is observed handing handcuffs to RN #2.
23:21:42 - Patient remains on floor. RN #7 enters room.
23:21:46 - RN #7 exits room.
23:21:53 - Patient on floor on lateral right side, torso is bent forward at waist (fetal like position). Pants pulled down and entire buttocks exposed.
23:21:57 - RN #2 is observed over the patient with his leg over the patient's leg. Patient is held down to floor by male staff members. Patient appears to be on side.
23:22:04 - Patient on floor. Appears to be on right side/facing downward on floor. RN #2 is observed placing a handcuff on patient's left wrist.
23:22:07 - RN #2 is observed placing a handcuff on patient's right wrist.
23:22:08 - Patient's is observed with hands handcuffed behind back. Lying on right lateral side. Facing downward to floor.
23:22:10 - Patient is observed lying face down (Prone position) on floor with hands handcuffed behind back.
23:22:32 - RN #2, RN #5 and SO #1 exit room. Patient remains lying face down on floor with hands handcuffed behind back. Knees bent. RN #3 and RN #4 remain in room.
23:23:00 Patient remains lying face down on floor with hands, handcuffed behind back.
23:24:00 Patient remains lying face down on floor with hands, handcuffed behind back. Patient is moved to sitting position ("Indian style") with staff assistance.
23:24:20 - RN #3 and RN #4 exit room. SO #1 remains in room. Patient remains sitting on floor with hands handcuffed behind back.
23:24:27 - Law enforcement officers (LEO) enter room.
23:31:20 - LEOs present. Remains on floor, with hands handcuffed behind back.
23:38:35 - Patient assisted up off the floor by LEOs into standing position.
23:38:48 - 5 LEOs present. Patient escorted over to bed by LEOs. SO #1 in room.
23:39:35 - 7 LEOs and 1 SO in room with patient. Patient in standing position with hands handcuffed behind back.
23:40:08 - Sheets removed from stretcher by LEO/Staff.
23:40:37 - Patient assisted onto bed by LEOs with hands handcuffed behind back.
23:41:09 - Patient handcuffs removed from back by LEOs. Patient's left and right hand individually handcuffed to left and right bed siderail by LEOs.
23:42:08 - Patient in room alone. Handcuffed to bed siderails. LEO at door.
23:45:00 - Remains on bed handcuffed to siderails.
23:46:28 - Remains in room on bed handcuffed to siderails.
23:47:03 - ED Physician #1 enters room. Stands beside counter. No physical contact with patient observed.
23:47:47 - ED physician #1 exits room.
23:47:49 - RN #7 enters room, goes over to bed. Patient appears to be crying. Remains handcuffed to bed siderails.
23:47:54 - RN #7 exits room.
23:50:06 - RN #7 enters room.
23:50:08 - SO #2 enters room with soft wrist restraints.
23:51:00 - Soft restraints applied to bilateral feet by RN#7 and SO #2.
23:51:54 - Soft restraints applied to bilateral hands by RN #7 and SO #2.
23:54:26 - Handcuffs removed by SO #2.
23:55:00 - Patient observed on bed in 4 point soft restraints. End video.

Continued record review of a "Medical/Surgical Restraint Order Form" dated 08/07/2013 revealed a verbal order for restraint was obtained by RN #7 at 2350 from ED Physician #1. Review revealed ED Physician #1 signed the verbal order on 08/08/2013 at 0030. Review of the order form revealed "A. Reason-based on Nursing Assessment: (check all that apply)." Review revealed under the heading "Medical Surgical/Restraint....5._[hand written check mark on line]_Other_[Violent Behavior handwritten on line]_." Further review revealed under the heading "Violent/Self-Destructive Behavior Restraint **IF ANY OF THE BELOW APPLY-VIOLENT/SELF-DESTRUCTIVE BEHAVIOR RESTRAINT ORDER FORM MUST BE USED** ...Patient needs protection from injuring himself/herself either intentionally or accidentally secondary to cognitive impairment resulting in the following: a. primary psychiatric diagnosis b. Substance abuse c. Suicidal ideation/behaviors d. In an emergency situation (there must be accompanying documentation) e. If the patient's condition warrants ANY restraints ...Others need to be protected from being injured by the patient, either intentionally or accidentally secondary to cognitive impairment. ...Serious disruption to the therapeutic milieu is occurring because of out of control aggressive behavior." Further review revealed "B.__[RN #7 and RN #6 name handwritten on line]__" above "Collaboration with/and Correct Restraint Application Verified by" dated 08/07/2013 at 2350. Review revealed the hand written signature of RN #6 on the line above "Signature of RN assessing patient/applying restraint:" dated 08/07/2013 at 2350. Further review revealed "C. Type of restraint (check all that apply)" with "Soft Limb Holder" right wrist, left wrist, right ankle and left