HospitalInspections.org

The facility was not in compliance with the CMS (Center for Medicare/Medicaid Services) Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 176, 12/29/17). Specifically, the facility was not in compliance with 482.13 Patient Rights. Significant corrections evidencing compliance will be required.

The CONDITION is not met as evidenced by:
Based on the nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

Findings include:

These following standard(s) were cited and show a significant nature of non-compliance with regards to patient's rights as follows:

(142.13 Tag A-117)
A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.

(482.13 Tag A-0154)
The information reviewed during the survey provided evidence the facility did not provide an environment where the patient was free from unnecessary restraint for one medical record reviewed (MR1).

(482.13 Tag A-167)
The information reviewed during the survey provided evidence the facility did not follow their policy in accordance with the use of weapons (Tasers) against facility patients for one medical record reviewed (MR1).

(482.13 Tag A-168)
The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §481.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

During review of facility policy and procedure, medical records (MR), and staff interview (EMP) it was determined the facility failed to provide patient's the notice of patient rights for eight of nine medical records reviewed (MR2, MR3, MR4, MR6, MR7, MR8, MR9, and MR10).

Findings include:

Review of facility policy and procedure "Patient Rights and Responsibilities" last approved September 2018, revealed "2. Patients will be informed of their rights and responsibilities at the earliest opportunity in the course of their treatment or hospitalization."

Review of MR2, MR3, MR4, MR6, MR7, MR8, MR9, and MR10 revealed no documentation the patients were informed of their rights and responsibilities.

Interview with EMP5, on April 23, 2019, at 9:32 AM confirmed the above findings and revealed "I don't see it was documented."

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility engaged in a law enforcement action by deploying a taser against a patient without charges being filed or the patient being taken into legal custody for one medical record (MR1).

Findings include:

Review of facility policy "Restraint and Seclusion" last revised September 2018 revealed "...Weapons, The use if weapons in the application of restraint or seclusion is not considered a safe, appropriate health care intervention. the use of weapons by security staff is considered a law enforcement action, not a health care intervention , and their use on a patient , employee or visitor will be handled as criminal activity and the perpetrator will be placed in the custody of local law enforcement. The use of weapons will not be used as a means of subduing a patient in order to place that patient in restraint or seclusion. The following are considered weapons included, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols.

Review of MR1 physician note dated March 13, 2019 at 4:51 AM revealed "Code Grey...At approximately 0430 on 3/19 patient became very agitated. MR1 left his room and grabbed a pair of metal scissors from a nursing station. MR1 cut his IV line and cardiac monitor lines and entered another patient's room. When nurses approached MR1 he threatened them with the scissors and made stabbing motion. On my arrival MR1 was in room...seated with pair of scissors in is hand. The...usual occupant was in the room. Security was present and attempting to orient MR1 and calm him down. He continued becoming more and more agitated and aggressive. He was making threatening motions with the scissors towards the other patient, who he was very close to in proximity. He was making ominous threats about "not going down alone." This continued for about 30 minutes. At around 5:00 AM, the patient belonging to room...was evacuated from the room. MR1 continued being very aggressive and threatening with his scissors. Security was forced to subdue MR1 by using a Taser device..."

During Interview on April 22, 2019, at 10:30 AM EMP4 confirmed the above findings and revealed seeing a facility police officer deploy a taser against MR1 to subdue the patient to place in restraints.

Cross reference with:
482.13(e)(4)(ii) Standard: Restraint or Seclusion

Based on a review of facility documentation, medical records (MR) and staff interview(s), it was determined the facility used a weapon against a patient that was not in accordance with facility policy for one medical record reviewed (MR1).

Findings include:

Review of facility policy "Private Police/special Officers for Highmark Health" last reviewed 10/2018 revealed "..F. Taser Guidelines...Additional and specific procedures pertaining to TASER use, such as warnings prior to TASER deployment, where to aim the device, maintenance of TASER devices and the like are addressed and presented during the TASER training and certification process and is found in the Use of Tasers Procedure..."

Review of "Use of Taser Procedure" last reviewed 10/2018 revealed "...Use of Taser Device: The Taser device is only to be used by a (Facility) Police Officer or Supervisor when he/she has identified an imminent physical threat in accordance with the (Facility Police) Use of Force Procedure and in accordance with the (Facility ) police training. In addition, a verbal warning should be given if possible prior to deployment. The TASER is NEVER to be used on anyone that is known to be a patient of AHN. Additionally, Taser deployment is never an option on anyone who exhibits the following characteristics...Elderly individuals: Elderly or other individuals who are or appear fragile, weak and could suffer significant collateral injury from being subjected to Taser deployment..."

Review of MR1 revealed 78-year-old...presented to facility ED on March 15, 2019 with SOB, anemia, WBC's 11.43, H& H 5.5/17.9 on March 15, 2019. On March 19, 2019, at 0430 the patient walked out of his/her room and attempted to enter another patient's room. The patient in the other room was yelling and moaning. Staff intercepted MR1 and were able to prevent the patient from entering this patient's room. The patient then walked into the nursing station on B Team and sat down. Staff attempted to de-escalate the patient. MR1 stood up and stated, " hold on, I want to see this " and grabbed scissors from the container. MR1 became aggressive, lunging and swinging at staff with scissors. A code grey was activated. The patient walked towards a patient room again, staff pushed a cart towards him and the patient reversed his course. MR1 attempted to walk into another patient ' s room, but staff was successful in redirecting him from that room. Staff began to close patient doors to safeguard the other patients. The patient proceeded to walk into another patient room and sat on the bed continuing to hold the scissors in a threatening manner verbally threatening staff, security, and police. The patient used the scissors to cut...IV tubing and the cardiac monitor cable continuing to lunge at staff and make verbal threats of harm. The patient assigned to this room was in a recliner. Staff were able to extract this patient from the room unharmed. Security police attempted to de-escalate the patient for approximately 25 minutes unsuccessfully. The police officer conferred with the MHO about the patients medical history, returned to the room and again requested the patient to drop the scissors, informing the patient he would need to use his taser if...did not comply. The patient continued to exhibit aggressive behavior, making threatening remarks. The officer deployed the taser once, the patient dropped the scissors. The patient was assisted to the hallway, placed in a bed, restraints were applied and patient was medicated with 1 mg of Haldol.. The physician assessed the patient ordered EKG, lab work. The patient was returned ot his room with a a sitter and security officer. Psych consult was ordered. Family was notified. The patient has no previous documented psychiatric history. Patient was not formally taken into custody by police or charged with a crime.

During interview on April 23, 2019 at 1:30 PM EMP2 confirmed the above finding and revealed the facility police action did not comply with facility policies regarding the use of Tasers against patients.

Cross reference with:
142.13(e) Standard: Restraint or Seclusion

Based on review of facility policy and procedure, medical records (MR), and interview with staff (EMP), it was determined the facility failed to use restraints in accordance with the order of a physician for three of five medical records reviewed (MR3, MR4, and MR6).

Findings include:

Review of facility policy and procedure, "Restraint and Seclusion" last approved September 2018, revealed "Restraint ... F. Hand mitts (when tethered/pinned to the bed, chair or other object ... Guidelines/Procedures: ... The use of restraint or seclusion must be: ... C. In accordance with the order of a physician or other licensed independent practitioner, who is responsible for the care of the patient (but not a standing or PRN order). ...

Review of MR3 on April 22, 2019, revealed documentation from April 20, 2019, at 0800 AM thru April 21, 2019, at 1600 "Mitt Secured" Review of Physician order dated April 19, 20, and 21, 2019, revealed a physician order "Bilateral soft wrist restraints" Further review revealed no physician order for hand mitts.

Interview with EMP5 on April 22, 2019, at 11:00 AM confirmed the above findings and revealed "I don't see one."

Review of MR4 on April 22, 2019, revealed documentation on 4/5/2019 at 2000, 4/6/2019 at 0400 and 1200, 4/7/2019 at 0000, 0800, 1200, and 2100 "full side rails" and bilateral wrist restraints. Review of physician order dated 4/5/2019, 4/6/2019, and 4/7/2019 revealed "Soft restraint Bilateral Wrists" Further review revealed no physician order for full side rails.

Review of MR5 on April 23, 2019, revealed documentation on 4/17/2019 at 2319, 4/18/2019 at 0800 and 2000, 4/19/2019, at 0400, 1200, and 2033, 4/20/2019 at 0400, 1709, and 2000 "full side rails" Further review revealed no physician order on April 18, 2019. Review of Physician order dated April 17, 2019, April 19, 2019, and April 20, 2019 revealed "Soft restraint Bilateral Wrists". Continued review revealed no order for full side rails.

Interview with EMP5 on April 23, 2019, at 10:40 AM confirmed the above findings and revealed "Correct."