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Based on interviews and records review, the hospital failed to ensure 1 of 1 patient (Patient #1) was provided a safe environment. (Patient #1) was found on the floor in the ED (Emergency Department) after being physically restrained with soft wrist restraints. (Patient #1) had removed the tracheostomy tube while residing in the nursing home and was at the hospital for for re-insertion of the tracheostomy tube. (Patient #1) had a known history of TBI (Traumatic Brain Injury) and was not identified as a fall risk. The assigned nurse, Personnel #13, failed to initiate the ED Fall Protocol. This failure contributed to (Patient #1) falling out of bed and sustaining injuries.

Findings included:

Patient #1's hospital medical record reflected, "Admit 12/27/11 at 04:26 AM to the ED (Emergency Department)...per EMS (emergency medical system) report, pt (Patient) pulled out his trach (tracheotomy)...TBI (traumatic brain injury)...discharged at 2:52 PM..."

The nursing note dated 12/27/11 timed at 10:07 AM reflected, "Pt (patient) is awaiting social worker to help decide where pt will go and where they will receive further ongoing treatment. 1:1 sitter present at bedside....at 14:11...pt instructed not to pull out trach tube...soft restraints removed, 1:1 sitter at bedside..." The above medical record was Patient #1's first admission to the ED (Emergency Department) for tracheostomy tube replacement.

The physician provider note dated 12/28/11 timed at 11:00 AM on Patient #1's second admit medical record reflected, "24M (Male)...TBI (Traumatic Brain Injury) with trach (Tracheotomy)...returns to ED (Emergency Department) after pulling out trach...patient not vent dependent...past medical diagnosis...traumatic brain injury and unspecified mental or behavioral problem schizophrenia...responds yes to any questioning...well healed scars to head..."

The physician orders dated 12/28/11 timed at 11:54 AM and acknowledged by the nurse at 12:52 PM reflected, "Soft wrist restraints...reason...pulling/dislodging essential medical devices."

The nursing note dated 12/28/11 timed at 13:32 PM reflected, "Upon entering room, found pt (patient) on floor. When asked if pt climbed out of bed, pt responds "yes." Pt in no obvious distress. Pt returned to stretcher by staff...pt removed restraints, is refusing to have them put back on, states "I do not like them." 1:1 sitter now present. Pt smiling says "I know what I like; I know what I don't like." Awaiting scan, will continue to monitor..."

The physician consult note dated 12/28/11 timed at 19:51 PM reflected, "CT of the head shows left sided squamous temporal bone fx (fracture)...CT cervical-spine shows C6 (Cervical) lamina fx (fracture) and C7 lateral mass fx (fracture)...neurosurgery consulted for evaluation of temporal bone fracture...encephalomalacia of the left temporal lobe and left occipital lobe, compatible with this patient's history of traumatic brain injury...no neurological intervention or follow-up needed...continue c-collar. Cervical fracture mgmt (management) per ortho (orthopaedic) spine..."

The physician note dated 12/28/11 timed at 18:50 PM, reflected, "Pt (patient) was found down in his room despite being in soft wrist restraints. He is unable to provide any history given his TBI (traumatic brain injury). He has no signs of external trauma, but was clutching at his left hip repeatedly. No palpable spine deformity or tenderness with palpation. Given his mental status, CT head and CT spine as well as XR (X-Ray) hip were ordered. A sitter was assigned ...CT head revealed L (left) temporal bone fx (fracture) read as acute, as well as C5-C6 fx (fracture)..."

The nursing note dated 12/29/11 timed at 02:09 AM reflected, "Patient continues to be combative/aggressive pulling at cervical-collar/trach (tracheotomy), patient not maintaining cervical-spine precautions despite repeated verbal reminders...1:1 sitter at bedside....will continue to monitor..."

No documentation was found indicating fall protocol precautions were initiated for Patient #1 upon his arrival and during his stay in the Emergency Department 12/28/11.

On 01/17/12 at 1:00 PM Personnel #12 was interviewed. Personnel #12 stated the nurse should have initiated the ED (emergency department) fall protocol, especially due to the patient's history of traumatic brain injury. Personnel #12 reviewed the medical record for documentation from the nurse indicating the ED (emergency department) fall protocol was not initiated and/or followed. He stated the patient was placed in a private room instead of a bed in view of the nursing station. Personnel #12 said with the patient's history of pulling his tracheotomy out he should have had a sitter.

On 01/17/12 at 2:00 PM Personnel #13 was interviewed. Personnel #13 was asked to review Patient #1's medical record. She stated she was informed by one of the nurses the patient was on the floor. Personnel #13 was asked if she initiated the ED fall protocol for Patient #1. Personnel #13 did not offer a response to the surveyor's question.

The Emergency Services Department Modified Fall Protocol for Emergency Services with a revision date of 06/11 reflected, "All patients in the emergency room are considered a fall risk due to the nature of the environment. However, patients with the following should be identified as a fall risk and placed on fall protocol...patient who presents to Emergency Services with the following are considered as High Risk for fall: altered mental status...post-ictal, intoxicated, dementia or any other reason patient is unable to comply with instructions...inability to perform activities of daily living...unsteady gait, motor/sensory deficits, or history of previous fall...if a patient has any of the identified risk factors, that patient will be placed on the modified fall protocol, and documentation will be placed in the medical record...patients on fall protocol will have rounds every hour to confirm: bed is in low position...call light/Bell are in reach, toileting offered if awake and allowed by treatment plan/condition...fluids offered if awake and allowed by treatment plan/condition ...rounds will be documented...patient on Fall Protocol should be placed in close proximity to the nurse's station..."

Based on interviews and records review, the hospital failed to ensure that a POC (Plan of Care) was initiated for 1 of 1 patient (Patient #1) who was physically restrained with soft wrist restraints on 12/28/11 in the hospital's Emergency Department in order to stop Patient #1 from pulling out or dislodging his tracheotomy tube.

Findings included:

The physician provider note dated 12/28/11 timed at 11:00 AM reflected, "24M (Male)...TBI (Traumatic Brain Injury) with trach (Tracheotomy)...returns to ED (Emergency Department) after pulling out trach...patient not vent dependent...past medical diagnosis...traumatic brain injury and unspecified mental or behavioral problem schizophrenia...responds yes to any questioning...well healed scars to head..."

The physician orders dated 12/28/11 timed at 11:54 AM and acknowledged by the nurse at 12:52 PM reflected, "Soft wrist restraints...reason...pulling/dislodging essential medical devices."

The nursing note dated 12/28/11 timed at 13:32 PM reflected, "Upon entering room, found pt (patient) on floor. When asked if pt climbed out of bed, pt responds "yes." Pt in no obvious distress. Pt returned to stretcher by staff...pt removed restraints, is refusing to have them put back on, states "I do not like them." 1:1 sitter now present. Pt smiling says "I know what I like; I know what I don't like." Awaiting scan, will continue to monitor..."

The physician consult note dated 12/28/11 timed at 19:51 PM reflected, "CT of the head shows left sided squamous temporal bone fx (fracture)...CT cervical-spine shows C6 (Cervical) lamina fx (fracture) and C7 lateral mass fx (fracture)...neurosurgery consulted for evaluation of temporal bone fracture...encephalomalacia of the left temporal lobe and left occipital lobe, compatible with this patient's history of traumatic brain injury...no neurological intervention or follow-up needed...continue c-collar. Cervical fracture mgmt (management) per ortho (orthopaedic) spine..."

The physician note dated 12/28/11 timed at 18:50 PM, reflected, "Pt (patient) was found down in his room despite being in soft wrist restraints. He is unable to provide any history given his TBI (traumatic brain injury). He has no signs of external trauma, but was clutching at his left hip repeatedly. No palpable spine deformity or tenderness with palpation. Given his mental status, CT head and CT spine as well as XR (X-Ray) hip were ordered. A sitter was assigned ...CT head revealed L (left) temporal bone fx (fracture) read as acute, as well as C5-C6 fx (fracture)..."

The nursing note dated 12/29/11 timed at 02:09 AM reflected, "Patient continues to be combative/aggressive pulling at cervical-collar/trach (tracheotomy), patient not maintaining cervical-spine precautions despite repeated verbal reminders...1:1 sitter at bedside....will continue to monitor..."

No documentation was found indicating that a plan of care was initiated for Patient #1 which addressed patient safety and the use of soft wrist restraints.

On 01/17/12 at 1:00 PM Personnel #12 was interviewed. Personnel #12 was asked to review (Patient #1's) medical record for documentation indicating that a plan of care was initiated for (Patient #1) after being placed in wrist restraints. Personnel #12 said he did not find any documentation with a plan of care that addressed patient safety and wrist restraints.

The policy entitled, "Non-Violent/Non-Self Destructive and Violent/Self Destructive Restraints" with a revision date of 07/11 reflected, "Modification of the plan of care and achievement of goal...results of all monitoring, reassessments and related interventions related to restraint use..."