HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on clinical record review, hospital policy, observation, and staff interview for 3 of 5 sampled patients reviewed for continuous observation (Patients #3, #47 and #48), the hospital failed to ensure a safe environment when patients were not visible to staff observers, for 2 of 3 sampled patients reviewed for the delivery of oxygen (Patients #1 and #2), the hospital failed to ensure a safe environment when the patients did not receive oxygen as ordered when the oxygen tanks ran dry, failed to ensure that ligature risks within the Emergency Department's behavioral health unit were monitored to ensure care in a safe setting, and failed to ensure that supplies used in the behavioral health setting were safe for use.

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Based on clinical record reviews, review of hospital documentation, review of hospital policies, and interviews for six of six sampled patients (Patients # 12, 13, 14, 15, 16, 17) who were reviewed for the use of restraints, the hospital failed to ensure that the least restrictive device was utilized prior to the initiation of restraints and failed to ensure that patients were not restrained by multiple means or double restrained.


Please see A144 & A164

Based on observation, clinical record review, staff interviews, and policy review, for 3 of 5 sampled patients reviewed for continuous observation (Patients #3, #47 and #48), the hospital failed to ensure a safe environment when patients were not visible to staff observers, for 2 of 3 sampled patients reviewed for the delivery of oxygen (Patients #1 and #2), the hospital failed to ensure a safe environment when the patients did not receive oxygen as ordered when the oxygen tanks ran dry, failed to ensure that ligature risks within the Emergency Department's behavioral health unit were monitored to ensure care in a safe setting, and failed to ensure that supplies used in the behavioral health setting were safe for use. The findings include:

1a. Patient #3 was admitted to the Emergency Department (ED) on 10/29/22 for worsening depression with Suicidal Ideations (SI) and had a plan. Physician orders dated 10/29/22 at 7:44 PM directed the patient to be on continuous observation for suicidal ideation. Observations during a tour of the ED on 10/31/22 at 10:15 AM noted Patient #3 lying on a stretcher in the hallway with Patient Safety Staff #3 standing in between 2 stretchers. The Patient Safety Staff was observed to be turning her head from side to side from Patient #3 towards another patient down the hallway, taking her eyes off Patient #3. Interview with Patient Safety Staff #3 at that time stated that she is watching both patients but is supposed to be watching Patient #3 at all times. Interview with the ED Nurse Manager on 10/31/22 at 10:30 AM stated that when a patient is on continuous observation, the staff is to be monitoring and watching the patient at all times to ensure they are safe.

b. Patient #47 was admitted to the ED on 10/28/22 with depression and anxious mood. Physician orders dated 10/28/22 directed continuous observation.

c. Patient # 48 was admitted to the ED on 10/31/22 for evaluation of suicidal ideation. Physician orders dated 10/31/22 directed continuous observation.

Observations in the behavioral unit within the ED on 11/1/22 at 10:20 AM noted Patient Safety Monitors #1 and #2 sitting in the alcove area. Upon inquiry, the Safety Monitors identified they were doing continuous observations on Patient's #47 and #48. Observations at that time noted that both Patient #47 and #48's rooms to be dark and the patients were not in full line of sight of the Patient Safety Monitors. Interview with the Nurse Manager at 10:35 AM stated that when staff are doing continuous observation, they are to be watching the patient at all times to ensure they are safe. The Nurse Manager further stated after sitting where the Patient Safety Monitors were positioned that staff could not fully see the patient to ensure patient safety, and she would be repositioning staff to ensure patients are viewed fully when monitored.

Review of the hospital policy for continuous observation noted that staff must remain attentive to the needs of the patient at all times and keep their eyes on patient at all times.


2a. Patient #1 was admitted to the hospital on 9/16/22 following a laparoscopy with lysis of adhesions. Diagnoses included obstructive sleep apnea and on CPAP. Patient #1 was transported from the Post Anesthesia Care Unit (PACU) on 2 Liters of oxygen to an inpatient unit. Nurse's notes dated 9/16/22 at 3:30 PM noted that the patient arrived on the unit at 3:25 PM and vital signs were stable. Review of hospital documentation dated 9/26/22 noted that on 9/16/22 at 3:30 PM Patient #1 arrived on the unit and the portable oxygen tank was empty. The documentation noted the patient was assessed immediately and found to have a pulse oxygen saturation rate of 95% on room air. The documentation further identified that the oxygen in the portable tank was not checked prior to the patient leaving the PACU. Interview with RN #3 on 11/8/22 at 10:50 AM stated that Patient #1 came up to the floor from the PACU on portable oxygen. RN #3 stated that she looked at the tank to see how many liters of oxygen the patient was on and noted that the gauge was in the red and the tank was empty. RN #3 stated that she assessed the patient, and the patient was in no respiratory distress. Interview with RN #4 on 11/8/22 at 11:00 AM stated that she left Patient #1 on oxygen for transport because the patient was sleepy after anesthesia. RN #4 stated that although the RN is to disconnect the patient from the wall oxygen, the transport person unhooked the oxygen, and she could not remember if she or the transport person hooked the oxygen tubing to the portable tank or if she checked the oxygen gauge to ensure there was oxygen in the tank.

Interview with the VP of Therapy Services and Director of Respiratory Services on 11/8/22 at 12:10 PM stated that it is the responsibility of the clinical staff to unhook a patient from the wall oxygen, checking the portable tank to ensure there is enough oxygen and connect them to the portable tank.

b. Patient #2 was admitted to the hospital on 2/25/21 for acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and acute/ chronic Congestive Heart Failure (CHF). Review of the Pulmonary Consult Report dated 2/26/21 noted the patient was admitted for increased shortness of breath and increased lower extremity edema. The note identified an increased right sided pleural effusion, moderate in size and that the patient would benefit from diagnostic/ therapeutic thoracentesis. Review of physician orders dated 2/25/21 directed oxygen at 3 liters via nasal canula (NC). Review of hospital documentation dated 2/26/21 at 4:00 PM noted the patient was transported to Interventional Radiology for a scheduled thoracentesis and upon arrival the RN noted the patient was short of breath. The documentation identified that the RN checked the portable oxygen tank the patient was transferred with and observed that the tank was empty. The patient was then connected to the wall oxygen, the oxygen saturation level was at 91%, and the patient was breathing easier.

Interview with the Safety Manager on 11/8/22 at 12:30 PM stated that she reviewed the incident with Patient #2 and identified that when the patient arrived at Interventional Radiology, they were short of breath, were unable to speak, and it was discovered by the RN in Interventional Radiology that the portable oxygen tank the patient was connected to was empty. The Safety Manager stated that Patient #2 was assessed, placed on the wall oxygen, and began breathing easier.

Interview with RN #6 on 11/8/22 at 1:00 PM stated that RN #5 reported to her that when the patient arrived in Interventional Radiology, they were short of breath and having difficulty breathing. RN #6 stated that RN #5 reported to her that when she checked the portable oxygen tank it was empty. RN #5 was unavailable for interview.

Interview with RN #7 on 11/8/22 at 1:45 PM stated that she disconnected Patient #2 from the wall oxygen and connected the patient to a portable tank but did not look at the tank to see how much oxygen was in tank.

Interview with the VP of Therapy Services and Director of Respiratory Services on 11/8/22 at 12:10 PM stated that it is the responsibility of the clinical staff to unhook a patient from the wall oxygen, checking the portable tank to ensure there is enough oxygen, and connect them to the portable tank.

Interview with the Safety Manager and Chief Nursing Officer (CNO) on 11/8/22 at 2:00 PM stated that since the two oxygen incidences the hospital has implemented procedures for staff to follow when a patient is on portable oxygen. The CNO stated that staff have been educated, competency will be completed, and random audits are in place.



3a. Observations during a tour of the behavioral unit within the ED on 10/31/22 at 11:00 AM noted the following ligature risks: The doors to rooms #13, #14 #15 had large magnets on top of the doors, a telephone had a long phone cord and a cord to a jacket on the counter, a Workstation on Wheels (WOW) cart with several long cords in the alcove, 2 step garbage pales, one in the bathroom and one in the alcove, and 4 unlocked tackle boxes on top of the counter containing numerous restraint straps.

Interview with the ED RN Director and the Nurse Manger of the ED at that time identified that they do not do environmental rounds in the ED behavioral health unit. The Nurse Manager stated that they do fifteen-minute rounding on patients and that staff are to check the patients and their surroundings.

b. Observations during a tour of the behavioral health secure holding unit within the emergency department on 11/01/2022 at approximately 9:30 AM noted that the ligature risks identified on 10/31/2022 had not been mitigated. The doors to patient rooms #13, #14 #15 continued to have magnetic locking hardware on the tops of the doors with flanges that could pose a potential hanging hazard and not designed to a behavioral health / psychiatric institutional standard. Subsequent interview with the Emergency Department Medical Director and Nurse Manger identified that they do not do environmental rounds in the Behavioral Health Secure Holding Area for the Emergency Department and that the magnetic door locking had never been enabled. The Nurse Manager stated that they do fifteen-minute rounding on patients and that staff are to check the patients and their surroundings and this had not been identified as a hazard. Subsequent to this interview and observation, the facility will be removing the magnets and flanges and will be contacting the facilities design professional for a solution that's is designed to a behavioral health / psychiatric institutional standard for safely securing these doors for use when needed.

Review of the hospital policy for environmental safety rounds for inpatient psychiatry identified that environmental safety rounds are performed every fifteen minutes to maintain a safe environment and mitigate environmental risks. The policy failed to include environmental safety rounds in the behavioral health unit within the ED.


4. Observations during a tour of the behavioral health secure holding unit within the emergency department on 11/01/2022 at approximately 9:30 AM noted that the toilets / bathrooms and common areas utilized by patients had trash receptacles that had frames and plastic receptacles not designed to a behavioral health / psychiatric institutional standard. Subsequent interview with the Emergency Room Medical Director and Nurse Manger identified that they were not aware of trash/waste receptacles that were designed to and for use in a behavioral health / psychiatric setting. Subsequent to this interview and observation the facility will be reviewing the 2022 Behavioral Health Design Guide for solutions and resources for products designed for use in a behavioral health / psychiatric institutional setting.


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Based on clinical record reviews, review of hospital documentation, review of hospital policies, and interviews for six of six sampled patients (Patients # 12, 13, 14, 15, 16, 17) who were reviewed for the use of restraints, the hospital failed to ensure that the least restrictive device was utilized prior to the initiation of restraints and failed to ensure that patients were not restrained by multiple means or double restrained. The findings include:

1. Patient #12 was admitted to the hospital on 10/19/2022 with diagnoses that included pneumonia, sepsis, acute respiratory failure, and alcohol withdrawal. A fall risk assessment dated 10/20/2022 at 12:00 AM identified the patient was a moderate risk for falls. A Nurse's progress note dated 10/20/2022 at 12:30 AM identified a continuous visual monitor showed Patient #12 attempting to get out of bed. Two nurses responded, entered the Patient's room, and placed a vest restraint (restraint #1) on the Patient. The patient then attempted to pull off the vest restraint and bilateral wrist restraints (restraint #2) were applied. A Physician's order dated 10/20/2022 at 12:42 AM directed the use of a vest restraint for unsafe ambulation and bilateral upper soft wrist restraints for pulling on lines. At 1:24 AM the restraint order increased to soft restraints on all four extremities. Review of the nursing flow sheets identified that Patient #12 was in a vest restraint for unsafe ambulation and bilateral lower extremity soft restraints and from 12:00 AM on 10/20/22 until 6:00 AM on 10/20/22. Although the flow sheets indicate a bed alarm and continuous observation were attempted prior to the application of the vest and soft restraints, the clinical record lacked documentation that a bed alarm was applied, and that the patient was on continuous observation. Review of the clinical record identified the vest restraint was discontinued at 6:00 AM.

Interview, review of the clinical record, review of hospital documentation and policy on 11/8/2022 at 10:00 AM with the Chief Nursing Officer, the Manager of Patient Safety and Compliance, and the Vice President of Patient Care stated that nursing flow sheets populate alternative measures that staff are to utilize prior to the use of a restraint application, but the clinical records lacked documentation that the interventions were implemented or actually tried.
In addition, when more than one restraint is used, one is typically for medical reasons such as pulling lines and the other to prevent getting out of bed and the use of two restraints was a solution to two different problems. Staff had not perceived that using double restraints was an issue.

Review of the hospital policy for restraints identified that restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time. The policy identified that staff would use the least restrictive form of restraint that protects the physical safety of the patient and staff, and restraints will be used only when alternative and/or less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The policy failed to identify if the utilization of more than one type of restraint at the same time (double restraint) was an acceptable practice. Also, a net bed is considered a medical restraint.

Review of the fall prevention policy identified that patients are assessed and identified as at risk for falling and to ensure that adequate interventions are in place to reduce falls. The policy notes that all patients will have standard universal fall precautions in place during their hospitalization and patients assessed who are at high risk for falling will have additional fall prevention interventions in place. Further review of the hospital policy for falls did not include a vest restraint an approved intervention utilized for a patient with unsafe ambulation.



2. Patient #13 was admitted to the hospital on 10/26/2022 at 1:21 PM with diagnoses that included a urinary tract infection, bacteremia, syncope, diverticulosis, and dementia. A fall risk assessment dated 10/27/22 at 4:00 PM identified the patient as a high fall risk. Physician orders dated 10/27/22 at 5:38 PM directed to apply a vest restraint (restraint #1) for unsafe ambulation and bilateral soft upper wrist restraints (restraint #2) for pulling of lines. Nurse's notes dated 10/27/22 at 7:16 AM noted the patient continued to try and get out of bed during the night with vest restraint on and now has continuous video monitoring. Nurse's notes dated 10/28/22 at 6:33 AM noted the patient was frequently attempting to climb out of bed, patient pulled vest restraint off and attempted to pull out peripheral line, new order for bilateral soft upper restraints obtained and applied. Review of the nursing flow sheets dated 10/27/22 at 12:00 AM through 10/29/22 at 8:00 AM (a total of 32 hours) identified the patient remained in a vest restraint for unsafe ambulation. The flow sheets identified although other interventions were populated and included continuous observation and bed/ chair alarms, the clinical record lacked documentation that these interventions were tried and for how long. Additionally, the flow sheets indicated the vest restraint was the least restrictive restraint for the patient.



3. Patient #15 was admitted to the hospital on 10/10/22 with diagnoses that included chest pain, shortness of breath and malaise. The fall assessment dated 10/15/22 at 4:00 PM noted Patient #15 was at high risk for falling. Physician orders dated 10/15/22 at 4:28 PM directed to apply a vest restraint due to unsafe ambulation and at 5:36 PM directed to apply bilateral upper soft restraints (restraint #1) for pulling on lines. Physician orders dated 10/16/22 at 9:27 AM directed to place the patient in a net bed (restraint #2) for unsafe ambulation. Nurse's notes dated 10/15/22 at 5:52 PM noted that Patient #15 pulled out the Intravenous (IV) line, was agitated, walking around room unassisted, and was reminded to call for assistance. The note identified that the patient requested a knife to cut the IV tubing and upon flushing the IV, a hole was noted in the tubing. The MD was notified, and a new order was obtained for a vest restraint. The note further identified the nurse was called back into the patient's room and the patient was sitting on the edge of the bed without the vest restraint on. The MD was notified and a new order for wrist restraints was obtained. Review of the flow sheets dated 10/15/22 noted the patient was in a vest restraint and soft wrist restraints from 4:00 PM until 8:00 PM when the patient was placed in a net bed with bilateral wrist restraints. Further review noted that although alternate interventions were populated on the flow sheets prior to the application of the vest and bilateral soft wrist restraints, the clinical record lacked documentation of when and how long the alternate interventions were tried.



4. Patient #16 was admitted to the hospital on 10/1/22 with abdominal pain, and sigmoid diverticulitis with micro perforation. The fall risk assessment dated 10/2/22 at 8:00 AM identified the patient at a high risk for falling. Physician orders dated 10/2/22 at 3:02 AM directed to use a vest restraint (restraint #1) for unsafe ambulation. Physician orders dated 10/2/22 at 1:02 PM directed the use of a net bed for unsafe ambulation and bilateral upper soft restraints (restraint #2) for pulling on lines. Nurse's notes dated 10/2/22 at 3:09 AM noted Patient #16 was confused, continuously trying to climb out of bed, staff were unable to redirect patient, a bed alarm in place and a posey vest placed on the patient per order. Review of the medical restraint flow sheets dated 10/2/22 from 4:00 AM through 12:00 PM noted the patient was in a vest restraint. The documentation noted that on 10/2/22 at 10:00 AM the patient was removed from the vest restraint and placed in a net bed with bilateral soft wrist restraints. Further review noted that although alternate interventions were populated on the flow sheets prior to the application of the vest restraint, net bed and bilateral soft wrist restraints, the clinical record lacked documentation of when and how long the alternate interventions were tried.



5. Patient #17 was admitted to the hospital on 10/20/22 for possible subacute stroke. The fall risk assessment dated 10/23/22 at 8:00 AM identified the patient as a moderate fall risk. Physician orders dated 10/23/22 at 8:19 PM directed to utilize a vest restraint (restraint #1) for unsafe ambulation and 4- point soft restraints (restraint #2) for pulling lines. Nurse's notes dated 10/23/22 at 11:40 PM noted that Patient #17 was found sitting upright at the edge of the bed with restraints off. The Patient combative, kicking, resistive to care and difficult to communicate with due to a language barrier. The note further identified the patient removed the restraints, IV catheter and tele monitor/ cables. The patient was placed in 4- point soft restraints with a posey vest. Review of the medical restraint flow sheets dated 10/23/22 at 8:00 PM through 10/25/22 at 6:00 AM (a total of 34 hours) noted the patient was in a vest restraint and 4- point soft restraints. Further review noted that although alternate interventions were populated on the flow sheets prior to the application of the vest restraint, the net bed and bilateral soft wrist restraints, the clinical record lacked documentation of when and how long the alternate interventions were tried.



6. Patient #14 was admitted to the hospital on 10/13/22 with diagnoses that included increased shortness of breath with cough. The fall risk assessment dated 10/14/22 at 4:00 PM noted the patient was a low fall risk. Nurse's notes dated 10/15/22 at 8:11 AM noted that at 3:30 AM they heard Patient #14 calling for the nurse and found the patient on the floor. A rapid response team was called, the patient was assessed and a small abrasion to the patient's right flank was observed. The note indicated the patient was placed on high fall precautions, bed alarm was on, continuous video monitoring put into place and all post fall protocol was followed. Physician orders dated 10/15/22 at 4:14 AM directed the patient to be on continuous observation for patient safety. Physician orders dated 10/15/22 at 2:24 PM directed to apply a vest restraint for unsafe ambulation. Review of the nursing flow sheets for continuous observation noted the patient was on continuous observation from 10/15/22 at 10:20 AM through 10/16/22 at 4:00 PM. Review of the flow sheets dated 10/15/22 at 4:00 PM through 10/16/22 at 8:00 PM identified the patient was in a vest restraint for a total of 28 hours. The flow sheets identified although other interventions were populated and included continuous observation and bed/ chair alarms, the clinical record lacked documentation that these interventions were tried and for how long. Additionally, the flow sheets indicated the vest restraint was the least restrictive restraint for the patient.