HospitalInspections.org

Based on document review and interview, the facility failed to ensure: 1) the use of appropriate restraints and, 2) all staff who assist and monitor patients in restraints receive training in the use of First Aid, and certification in the use of Cardiopulmonary Resuscitation (CPR).

These failures place all patients at risk for potential harm.


Findings include:

See Tag A 154
See Tag A 206

Based on document review and staff interview, the facility did not ensure that: 1) staff adhere to its policy /procedure established for the resolution of grievances, 2) an allegation of patient abuse was investigated.
This was found in (1) of (8) grievance records reviewed. (Patient #2)


Findings:

Review of the Hospital Police Incident Log Book identified an unsigned written entry on 4/23/2016 at 11:02 PM, which stated that at 11:55 PM, the operation manager at the Juvenile detention Center called to state that detainee, a 15 year old (Patient #2), was placed in a choke hold by a hospital police officer (Staff I) and that he would like to speak with a supervisor. It was documented that Staff H, Hospital Police Sergeant, was notified.

During interview with Staff E, Director of Regulatory Affairs, on 6/22/16 at approximately 10 AM, she stated that there was no complaint reported on behalf of Patient # 2. This was confirmed by Staff# G, the Interim Assistant Director of Patient/Guest Relations.

During interview with Staff H, Hospital Police Sergeant on 6/22/16, at approximately 3:00 PM, she stated that she received a phone call and spoke to a staff from the Juvenile Justice Center who informed her that Patient #2 alleged that during his hospital stay, he was choked by a police officer (Staff I). She indicated that the staff from the Juvenile Center stated he wanted to make a formal complaint. Staff H stated that she informed her Lieutenant that the Juvenile Center Staff would like to make a formal complaint. She stated that her Lieutenant spoke with the Juvenile Center staff and told him that he would have to make the formal complaint to the director.
There was no documentation that this phone call was documented by Staff H.


An interview was conducted with Staff A, Director of Hospital Police on 6/22/16, at approximately 2:51 PM. The Director of Hospital Police was asked whether he was informed of the complaint, he stated that no one from his staff informed him of this complaint.

During interview with Staff D, Assistant Director of Hospital Police on 6/22/16, he stated that he reviewed the log book and followed up with interview of the officers. Staff D stated that he could not substantiate the complaint. When asked if there is any documentation of the complaint investigation or whether he referred the complaint to Patient/Guest Relations Department, the Assistant Director of Police answered no.



Review of facility Complaint and Grievance Log from January 2016 to June 2016, found there was no documentation of an allegation of abuse against Patient #2.


Review of the Hospital Policy and Procedure titled, "Patient Complaints/Grievances Mechanism," last revised May 2015 stated the following: "All verbal and written complaints/grievances regarding abuse, neglect, care or Hospital Non -Compliance with CMS Condition of Participation (COP's) CMS 482.13 (2) requirements are to be considered a grievance."
The policy also stated, "Upon receipt, the complaint is documented into the written Complaint Summary Report Log as a tracking mechanism in the close of the complaint process." A copy of the grievance is forwarded to the appropriate senior staff/director of services for review and response. The department head must conclude its review/investigation with findings, and indicate the outcome according to the Summary Response Mechanism Form"

There was no documented evidence that facility staff identified the patient's verbal complaint as a grievance, and followed the mechanism of documenting, reporting, and investigating a verbal complaint.

Based on document review and staff interview, the facility failed to ensure: 1) the appropriate use of health care restraint; and 2) the development and implementation of written policy and procedure to guide the medical and surgical units staff on the management of patients with aggressive behavior. These findings were noted in one (1) of one (1) medical record reviewed. (Patient #1)


Findings include:


Review of the medical record for Patient #1 identified a 35 year patient was admitted from the Emergency Department (ED) on 1/6/16 with a diagnosis of hypoglycemia; history of hypertension, lupus, and End Stage Renal Disease (ESRD).

Review of an Occurrence Reporting Form dated 1/21/16 at 2:50 PM, documented Patient #1 was missing from the medical unit (D6N/Medical). At 4:45 PM, the patient returned to the unit accompanied by family member and a one-to-one observation was put in place.

Review of Occurrence Reporting Form documentation, dated 1/22/16 at 11:40 AM, identified that patient #1 was observed walking off unit followed by nursing staff. The physician, hospital police, and Associate Director of Nursing (ADN) were notified. Documentation indicated that the hospital police stopped the patient. Patient was returned to the unit with handcuffs to wheelchair. Patient arrived with injury to right 4th and 5th digits. Gauze dressing placed to right hand. One-to-one observation continued.

Documentation on the Hospital Incident Log, from the Hospital Police Department, identified that on 1/22/16 at 4:15 PM, this patient was found by hospital police on S5 Labor and Delivery Unit. Reportedly, patient was aggressive and threatening to the hospital police staff. The patient was returned to the unit where the cuffs were removed.


The staff's action was not in compliance with facility policy which prohibits use of handcuffs. The facility's policy and procedure on Restraints, last revised on 12/2014, documented: "Handcuffs as restraints must never be ordered by clinical personnel. Handcuffs or other restrictive devices applied by law enforcement officials who are not HHC (Health and Hospital Corporation) employees for custody, detention, and public safety reasons are not covered by this Guideline. HHC Special Officers shall not handcuff a patient unless the patient is under arrest."


The facility failed to ensure that patient on the medical unit, received appropriate management and interventions for aggressive behavior. It was noted by the surveyor that the facility has no written policy and procedure to guide staff on the management of patients with aggressive behavior outside behavioral health service units.

This was confirmed during interview with Staff E and F, on 6/21/16 and 6/22/16, in which staff acknowledged that the facility does not have a written guidance specific to the management of patients with aggressive behavior in medical and surgical services, outside the behavioral health units.

Based on document review and staff interview, the facility failed to ensure that hospital police staff who assist in the application of restraint received appropriate training. This was noted in one (1) of one (1) medical record reviewed. (Patient #2)


Findings include:


Review of the entry from the Hospital Police Incident Log, identified that a patient (Patient #2) was handcuffed by hospital police as a means to manage a patient who was aggressive and threatening.

Review of the medical record for Patient #2 identified a 15 year old who presented to the Pediatric ED on 4/22/16 at 11:09 PM, with a chief complaint of a left eye injury sustained after inadvertently sticking his finger to his left medial eye while playing basketball. The documentation noted that the patient lives in a home for children with behavioral issues, and the patient was agitated and was handcuffed with two counselor/personnel from the juvenile center.
There was no documentation in the medical record to reflect how the ED staff managed the patient's aggressive behavior.

During an interview with Staff I, a hospital police, on 06/22/2016, at 14:27(2:27 PM), Staff I stated that he assisted counselors in handling the patient in the emergency room. Staff I stated, "I was just assisting Juvenile Center Officers. We received a call that the counselors needed assistance to keep patient on bed. If a patient needs to be restrained, the policy is to place a cable (an extension device that connects handcuff to bed) on the patient. That day we ran out of cable but another hospital police found one cable and brought it to the room. I got involved because I was asked to assist. I helped to hold the patient. I held his left hand. One counselor held the right hand, the other counselor held both legs. He was combative. He was not still. Both hands were cuffed. After the other hospital police applied the cable to the bed, less than five minutes, we left."

The Director and Assistant Director of Hospital Police confirmed on 6/22/16 at approximately 1:00 PM that hospital police assist in the application of restraint including the use of cables, and were not trained.

The hospital has no written protocol on the use of cables for restraint, and no documented evidence of training of hospital police in the application of restraint including the use of cables.

Based on document review and interview, the facility did not ensure that Hospital Police, who assist in the application of restraints and cables, including the use of manual hold, are trained in the use of first aid techniques, and are certified in the use of cardiopulmonary resuscitation. This finding was noted in five (5) of six (6) personnel files reviewed. (Staff A, B, C, D, and I).


Findings include:


Review of personnel file for Staff I, Hospital Police identified there was no evidence of training in the use of First Aid, and certified in the use of Cardiopulmonary Resuscitation.
Similar findings were identified for personnel staff files A, B, C, and D.

During interview with Staff A, Director of Security, on 6/21/16 at approximately 12:30 PM, staff acknowledge that Hospital Police received no training on First Aid Techniques and Cardiopulmonary Resuscitation.