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Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure a bathroom in the Emergency Department (ED) utilized by patients was maintained in good repair and equipment stored on patient stretchers did not place patients at risk for harm. Findings include:

1. Accompanied by the ED Nurse Manager, a tour of the ED conducted on 1/22/19 at 1:20 PM included observation of a bathroom identified by the Nurse Manager for patients assigned to Rooms #5 & 6. The rooms are considered "safe rooms" frequently occupied by patients awaiting crisis screening for psychiatric hospitalization, often with a diagnosis of suicidal ideation or attempted suicide; acute psychosis or behavioral symptoms. Observation of the bathroom noted the toilet tank was missing the ceramic tank cover. The Nurse Manager confirmed the cover had been broken and replacement parts were on order. However, the toilet remained in operation for patient use despite the exposure of multiple parts contained inside the toilet tank. A temporary cover had not been applied and attention to safety risks had not been considered. Further review of the incident noted the tank top had been broken by a patient on 12/25/18. Further observation of the patients' bathroom noted the shower had an installed grab bar that was razor sharp on the end where the bar had been cut to fit the shower stall. The Nurse Manager was unaware of the safety concern that existed within the shower stall, but acknowledged the grab bar had the potential to cause patient injury whether self-inflected or accidental.

2. During a tour of the ED on 1/22/19 at 1:16 PM, the ED Nurse Manager stated that Rooms #5 & 6 were "safe rooms". Room #5 was observed to have a stretcher with an unsecured pole at the head of the stretcher. The top of this pole had a hook that was used to hang bags of intravenous fluids; and the edge of the hook had a sharp edge. Per interview with the ED Nurse Manager at this time, s/he confirmed that the hook on the pole was sharp, the pole could be used to inflict self-harm and/or be used as a ligature point.

Based on interview and record review, the CAH failed to ensure that there was sufficient staff available at all times to respond to and address behavioral health emergencies in the ED and failed to prevent non-employees from delivering support and/or patient care for 2 of 10 applicable patients (Patient #5 and Patient #7). Findings include:

1. Per review of a nursing triage note, on 9/13/18 at 3:29 PM, Patient #5 came to the ED with depression and suicidal thoughts. S/he had been at an outpatient crisis clinic and started to punch his/her head. S/he was then brought to the ED by police. Per review of physician progress notes from 9/13/18, the patient had been meeting with Health Care and Rehabilitation Services (HCRS) and became angry and starting punching him/her-self. S/he would not state what was upsetting him/her. S/he had a history of paranoid delusions and had suicidal thoughts. Per review of a nursing progress note from 9/14/18 at 11:06 AM, it read, "Suicide precautions maintained. Hospital security officer at bedside, checks performed every 15 minutes. (lights remain dimmed, door open, body moves, pt sleeping)". On 9/14/18 at 1:45 PM, "(pt awake, asked for gum, coffee, medication, went in to the rest room came out yelling sex comments to a nurse walking by. Brought in the med, coffee, gum, medication, pt took the medication and throw them against the wall, yelling, hitting" him/her-self "in the head, punching walls, then turned and ran and fist in the air at the nurse, after I moved to the hallway" s/he "moved and fist in the air after the security personal, code orange and police called, police and code team arrived pt yelling bad language and names at everyone)". At 3:15 PM, "(pt remains anger yelling, hitting" him/her- self "spitting, police have redirected pt which does not last. When nurses try" s/he "calls them names, states that should be dead)". At 3:50 PM, "Suicide precautions maintained. Hospital security officer at bedside, checks performed every 15 minutes. (police left, pt calm, resting in bed)". Per interview on 1/23/19 at 10:07 AM with the ED Nurse Manager, s/he confirmed that the police should not have been called to help manage Patient #5's behavior. S/he further stated that the police should not be called to assist with any behavioral health emergencies; and that it was the responsibility of the staff to manage the patients that come to the ED.

2. On 12/19/18 Patient #7 was brought to the ED by the sheriff's department for a medical screening exam and clearance for court ordered psychiatric hospitalization. Per Clinical Report - Nurses Progress Notes states on 12/19/18 at 16:20 "Sheriffs turned patient over to us per their protocol and left. Code Orange (a request for assistance/show of force to bring appropriate help to a location where a threatening situation from a patient, visitor has the potential to exist) was activated for patient behavior. Springfield Police called for help with patient due to his/her posturing behavior toward staff and refusing to stay in his/her room". The interactions of the police with Patient #7 were not documented. However, per interview on 1/23/19 at 10:07 AM with the ED Nurse Manager, s/he confirmed that the police should not have been called to help manage Patient #7's behavior. S/he further stated that the police should not be called to assist with any behavioral health emergencies; and that it was the responsibility of the CAH staff to manage the patients that come to the ED.

Based on observations, interviews and record review, the CAH failed to ensure that care and services were provided in accordance with currently established written policies and procedures regarding the provision of care provided to patients treated in the Emergency Department for 2 of 10 applicable patients (Patient #1 and Patient #7). Findings include:

1. Per review of a nursing triage from 7/2/18 at 4:11 PM, Patient #1 was at his/her physician's office and assaulted his/her caregiver because s/he did not receive his/her as needed medications as s/he had requested. The patient had been shouting and making threats in the office triage area; and was found stapling him/her-self with a stapler. S/he was brought to the ED by police. Per review of a nursing progress note from 4:16 PM, it read, "Reassurance given to the patient. Two patient identifiers checked. Call light placed in reach. Side rails up x 1. Bed placed in lowest position. Brakes of bed on. (Patient remains with police guard-in police handcuffs, one arm attached to the stretcher.)". A case management note written at 6:31 PM read, "spoke with" patient "upon arrival" s/he "was agitated. angry about the case worker that" s/he "assaulted" the nurse and nurse manager worked with the patient and the "SPD (Springfield Police Department) x 2 to calm and settle ... ...Pt had handcuffs removed over time as" s/he "agreed to not hurt" him/her-self "or others .....The police stayed until 6:15 PM ...."SPD and" the Nurse Manager "spoke to" the patient "and" s/he "agreed to stay here and not hurt" him/her-self "or others.". Per interview on 1/22/19 at 2:00 PM with the ED Nurse Manager, s/he confirmed that handcuffs were a restraint; and that the handcuffs on Patient #1 should have been removed immediately when s/he presented to the ED. Per interview on 1/23/19 at 2:30 PM with the Chief of Quality and Systems Improvement, s/he stated that as soon as Patient #1 was registered s/he was a patient of the CAH and that the handcuffs should have been removed.

Per review of the Restraint and Seclusion Policy (approved 12/5/18) under the Violent or Self Destructive section, it read, "Appropriate Use-Restraint or Seclusion must be discontinued at the earliest possible time .....Assessment- Registered Nurses (RN's) are responsible for conducting comprehensive individualized patient assessments as part of initiating an intervention, and on an ongoing basis to determine the least restrictive interventions, review potential medical problems that may be causing behaviors changes, assess the risks of the intervention, and to ensure that the patient is released at the earliest possible time.".

2. Upon admission to the ED on 12/19/18, it was determined Patient #7 required Constant Observations for elopement and suicide precautions, and 1 on 1 supervision was provided by assigned hospital contracted security officers. Per ED policy Patients with Potential for Self Harm, Suicide, or Harm of Others in the ED (last approved 4/18/18) states when it is determined by RN (Registered Nurse) or PA-C (Physician's Assistant) a patient is at increased risk for harm, the patient will be placed on 1:1 continuous observation in a "Safe Room" #5 or #6. In addition, the policy further states "C. The officer is responsible only for the direct observation and physical safety of the patient....." D. The suicide patient will be observed directly or indirectly during the time they are in any bathroom". Patient #7 was assigned to Safe Room #5 and during the course of his/her ED admission s/he was permitted to use the bathroom located in the designated "Crisis" corridor utilized by those patients occupying the Safe Rooms. Despite being on 1 on 1 Constant Observations, Patient #7 was permitted to use the bathroom "unobserved", and at approximately 11:30 AM on 12/25/18 s/he went into the bathroom, closed the door, removed and broke into several pieces the porcelain toilet tank cover. Although the potential for harm existed, Patient #7 did not sustain an injury from the sharp porcelain pieces. As of 1/23/19 the tank top had not been replaced, exposing other patients to multiple toilet tank parts. The ED nurse manager confirmed the bathroom observations on 1/22/19 at 1:30 PM, and acknowledged the present observation policy permits patients to use the bathroom without direct observation which was the case on 12/25/18. The patient remained unattended behind the closed bathroom door when the toilet tank top was broken by Patient #7. It was also confirmed the part for the toilet had been on order; however, a temporary repair had not been initiated, despite the open tank in this patient bathroom.

3. After arriving in the ED on 12/19/18 for a medical clearance prior to court ordered psychiatric hospitalization, Patient #7's behavior escalated and documentation in both nursing and physician clinical report notes Patient #7 was administered Zyprexa (antipsychotic) 10 mg and Ativan (anxiety/sedation) 2 mg. IM (intramuscular). Per Clinical Report - Nursing Progress Note states at 16:45 "PO (oral) medication was not chosen due to level of agitation and the slow onset. Out of concern for patient safety, IM medications were chosen and patient agreed to IM medications....". Per review of ED provider's orders for Patient #7, no orders were written for the administration of either of the medications. Per CAH policy Medication Administration for Clinical Staff last approved 12/05/2018 states: "4. A medication may be administered only if the order specifies: the medication, dose, route, time, and patient. This must accompany the right nursing documentation as well." Per interview at 1:15 PM on 1/23/19, the ED Nurse Manager confirmed no order was written for the administration of Zyprexa or Ativan IM.

Based on staff interview and record review, the CAH failed to ensure that patient care records were legible,complete and accurate, and the provision of care conducted by providers was consistently documented for patients experiencing behavioral health crises for 2 of 10 applicable patients (Patient #1 & 7) Findings include:

1. Per review of nursing progress notes from 7/7/18 at 9:00 PM, "Lorazepam (medication for anxiety) PO (by mouth) 1 mg (milligram) given ...information reviewed with patient including reason for taking this medication and sedative warning. Verbalizes understanding .... (Walked patient to the bathroom. Patient tolerated well. Patient provided a recliner chair and a cup of coffee per request.)". On 7/8/18 at 4:20 PM, "Lorazepam IM (intramuscular) 1 mg given. Given in the right deltoid ..... (injection given by PAC (Physician's Assistant))". There was no evidence in the medical record that indicated that Patient #1 had any behaviors and/or any need for the Lorazepam to be given IM. Per interview on 1/22/19 at 2:58 PM with the Physician's Assistant who administered the medication, s/he stated that s/he confirmed that there was no reason documented as to why the Lorazepam was given to Patient #1 IM. Per interview on 1/22/19 at 3:27 PM with the Nurse Manager, s/he also confirmed that there was no reason documented as to why Patient #1 received the Lorazepam IM.

2. After being admitted to the ED on 12/19/18 for medical screening and clearance for court ordered psychiatric hospitalization, Patient #7 was prescribed medication for increased agitation. Per Clinical Report - Nursing Progress Note states at 16:45 "PO (oral) medication was not chosen due to level of agitation and the slow onset. Looking after the patient safety IM medications were chosen and patient agreed to IM medications..." At 17:41 a second Nursing progress note states: " Reassessment after medication administered (Patient is much more calm and is now laying in the stretcher in and out of sleep)". Review of Physician Clinical Report for 12/10/18 a PA-C states: " S/he accepted administration of Zyprexa (antipsychotic) 10 mg and Ativan (used for anxiety/sedation) 2 mg IM without physical altercation." Per review of the Medication Administration Record the medications were never documented as given and per the ED provider's orders, there is no order documented for the IM injections administered to Patient #7. The ED Nurse Manager confirmed on the afternoon of 1/23/19, no written order existed for the IM medication administered to Patient #7 nor was it documented by the ED nurse in the Medication Administration Record.

Based on interview and record review, the CAH failed to effectively analyze and evaluate the use of restraints and police presence in the Emergency Department, resulting in a failure to identify opportunities for improvement in patient care for 3 of 10 applicable patients (Patient #1, Patient #5, and Patient #7). Findings include:

1. Per review of a nursing triage from 7/2/18 at 4:11 PM, Patient #1 was at his/her physician's office and assaulted his/her caregiver because s/he did not receive his/her as needed medications as s/he had requested. The patient had been shouting and making threats in the office triage area; and was found stapling him/her-self with a stapler. S/he was brought to the ED by police. Per review of a nursing progress note from 4:16 PM, it read, "Reassurance given to the patient. Two patient identifiers checked. Call light placed in reach. Side rails up x 1. Bed placed in lowest position. Brakes of bed on. (Patient remains with police guard-in police handcuffs, one arm attached to the stretcher.)". A case management note written at 6:31 PM read, "spoke with" patient "upon arrival" s/he "was agitated. Angry about the case worker that" s/he "assaulted" the nurse and nurse manager worked with the patient and the "SPD (Springfield Police Department) x 2 to calm and settle ... ...Pt had handcuffs removed over time as" s/he "agreed to not hurt" him/her-self "or others .....The police stayed until 6:15 PM ...."SPD and" the Nurse Manager "spoke to" the patient "and" s/he "agreed to stay here and not hurt" him/her-self "or others." Per interview on 1/23/19 at 2:30 PM with the Chief of Quality and Systems Improvement, s/he stated that events like the application of restraints were entered in the event reporting system. The Quality Department assigns the appropriate department managers to review these events to evaluate and identify any potential opportunities for improvement. Per interview on 1/23/19 at 9:25 AM with an ED Charge Nurse, s/he stated that s/he reviewed all behavioral health cases as part of the ED's quality program. S/he stated that s/he was aware that on 7/2/18, Patient #1 was in the ED restrained in handcuffs. S/he stated that there was a question regarding whether or not Patient #1 was going to be arrested; and that was why Patient #1 remained in handcuffs in the ED. The ED Nurse Manager confirmed at that time that handcuffs should not have been used in the ED and that the case should have been further analyzed and evaluated to identify opportunities for improvement.

2. Per review of a nursing triage note, on 9/13/18 at 3:29 PM, Patient #5 came to the ED with depression and suicidal thoughts. S/he had been at an outpatient crisis clinic and started to punch his/her head. S/he was then brought to the ED by police. Per review of physician progress notes from 9/13/18, the patient had been meeting with Health Care and Rehabilitation Services (HCRS) and became angry and starting punching him/her-self. S/he would not state what was upsetting him/her. S/he had a history of paranoid delusions and had suicidal thoughts. Per review of a nursing progress note from 9/14/18 at 11:06 AM, it read, "Suicide precautions maintained. Hospital security officer at bedside, checks performed every 15 minutes. (lights remain dimmed, door open, body moves, pt sleeping)". On 9/14/18 at 1:45 PM, "(pt awake, asked for gum, coffee, medication, went in to the rest room came out yelling sex comments to a nurse walking by. brought in the med, coffee, gum, medication, pt took the medication and throw them against the wall, yelling, hitting" him/her-self "in the head, punching walls, then turned and ran and fist in the air at the nurse, after I moved too the hallway" s/he "moved and fist in the air after the security personal, code orange and police called, police and code team arrived pt yelling bad language and names at everyone)". At 3:15 PM, "(pt remains angry yelling, hitting" him/her- self "spitting, police have redirected pt which does not last. when nurses try" s/he "calls them names, states that should be dead)". At 3:50 PM, "Suicide precautions maintained. Hospital security officer at bedside, checks performed every 15 minutes. (police left, pt calm, resting in bed)". Per interview on 1/23/19 at 10:07 AM with the ED Nurse Manager, s/he confirmed that the case was not analyzed and evaluated to further identify opportunities for improvement with the use of police in the ED.

3. On 12/19/18 Patient #7 was brought to the ED by the sheriff's department for a medical screening exam and clearance for court ordered psychiatric hospitalization. Per Clinical Report - Nurses Progress Notes states on 12/19/18 at 16:20 "Sheriffs turned patient over to us per their protocol and left. Code Orange (a request for assistance/show of force to bring appropriate help to a location where a threatening situation from a patient, visitor has the potential to exist) was activated for patient behavior. Springfield Police called for help with patient due to his/her posturing behavior toward staff and refusing to stay in his/her room". The interactions of the police with Patient #7 were not documented. However, per interview on 1/23/19 at 10:07 AM with the ED Nurse Manager, s/he confirmed that the police should not have been called to help manage Patient #7's behavior. S/he further stated that the police should not be called to assist with any behavioral health emergencies; and that it was the responsibility of the staff to manage the patients that come to the ED. The use of police in the ED was not evaluated through the Quality Assurance program to determine the impact on patient health and safety.