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Tag No.: C0253
Based on interview and record review, the Critical Access Hospital (CAH) failed to ensure that there was sufficient staff available at all times to respond to and address behavioral precautionary safety measures in the Emergency Department (ED) by requesting presence from a local police department to assist in the provision of patient care for 1 of 5 patients in the total sample. (Patient #3) Findings include:
Patient #3 arrived to the ED on 3/9/19 at 19:31 accompanied by police under warrant after it was determined Patient #3 required mental health evaluation and hospitalization. Patient #3 presented as delusional and paranoid and had been refusing medications for schizophrenia since January 2019. Patient #3 denied suicidal or homicidal ideations; at times refused meals due to fear of being poisoned; often mumbled but would respond to staff questions. At 20:00 Patient #3 was informed by staff s/he would have to remove all clothing and change into a hospital gown and pants. Per nursing progress note Patient #3 refused to change and informed staff " ...its my right to keep my clothes on, I'm not in jail". Although hospital security was assigned to observe Patient #3 and sufficient staff was present in the ED to assist in a clothing search, per telephone interview on 4/24/19 at 11:15 AM, the nurse assigned to Patient #3 on 3/9/19 confirmed s/he was directed by the PA-C (physician assistant) and ED charge nurse to call police to come to the ED for the purpose of searching Patient #3.
At 20:30 Patient #3 consented to have his/her clothing searched. While hospital staff performed the search, 2 police officers arrived to the ED and remained stationed outside the patient's room in full view of the patient, creating a police presence and potential availability for intervention during the search of the patient's clothing.
Tag No.: C0271
Based on staff interview and record review, the CAH failed to assure that all hospital policies and procedures included consistent definitions related to emergency treatment for patients exhibiting self-harming and/or other types of behavior. This practice had the potential to affect applicable patients in inpatient units and the ED (emergency department). There was also a failure by staff to provide services in accordance with existing policies and procedures. Findings include:
1. Per review of hospital policies and procedures related to treatment of patients with mental health issues, including self harming/risk of harming others, and violent, aggressive actions, hospital policies were not consistent with definitions related to frequency of observations and documentation in related policies and procedures. This failure resulted in staff inconsistency of documentation of care and treatments regarding some Emergency Department patients who were restrained and or secluded . Examples of 2 reviews related to the inconsistent implementation of the policy/procedure processes are included as follows:
a. Per interview with the security staff providing monitoring for 2 patients in the seclusion area on 4/23/19 at 1:30 PM, the staff member stated that every 15 minutes, they have 'eyes on' (visualize) the patients in the room (s) in that area. On 4/23/19, both rooms had patient occupants, both had the window blinds closed. For 1 room (rm. #6), the patient was alone in the room at the time of the observation. The security staff demonstrated that they could open the window blinds to observe the patient in the room every 15 minutes, and document the safety check on the Constant Observation Log Flow Sheet.
The hospital nursing policy entitled Restraint and Seclusion Policy, approval date of 3/11/19, stated on Pg. 4, under DEFINITIONS, "Continuous Monitoring, staff will maintain the ability to appreciate the activities of the patient at all times while also maintaining proximity and access to the patient to allow immediate physical intervention if necessary." On Pg. 2, it stated under DOCUMENTATION, "shall include" at "(4) ongoing monitoring by trained staff;" It was not clear based on the policy definitions and the Constant Observation Log Flow Sheet whether patients should have 'eyes on' continuously or only every 15 minutes, per the documentation log reviews. A nurse interviewed on 4/24/19 indicated that if patients were restrained or in seclusion, then the patient would always be on continuous 1:1 observation. Although the security staff indicated that s/he could open the blinds to see into the patient room as needed, the fact that the blinds were closed at the time of the observation, was not in accordance with the policy. The lack of clarity regarding the specific monitoring requirements for patients in restraints or in seclusion was confirmed during interviews with the RN ED Director of Clinical Operations and the ED Charge RN on 4/24/19 at 12:55 PM.
b. Per record reviews, ED nursing staff also failed to adhere to the ED policy entitled Patients with Potential for Self-Harm, Suicide, or Harm of Others in the ED.
Patient #1 arrived in the ED on 4/21/19 at 23:03 with chief complaint of depression and suicidal thoughts. Per review, The Self-Harm Assessment performed by ED nurse at the time of triage noted the following: Patient ...answered "yes" to questions related to being depressed; hopeless; and having thoughts of killing himself/herself. Patient consented to changing into hospital gown and was placed in a "Safe room" after a safety sweep of the room was performed by staff. Patient #1 informed the ED provider that s/he wanted to commit suicide and the plan would be to overdose on medications or drive or jump into a dam. Per review, a nurses progress note stated: Suicide precautions initiated and " ...continuous one on one supervision, checks performed every 15 minutes ..." Per review, the Policy and Procedure Patients with Potential for Self-Harm, Suicide, or Harm of Others in the ED, approved on 3/1/19, stated that patients with increased risk for harm will be placed on 1:1 "continuous" visual observation .....". It further stated "F. If the PA-C/MD, after assessing the patient decides that there is not a risk for harm and there has been no sign of escalation of behavior, the continuous observation status may be discontinued." Per review, the Crisis Screener Emergency Services Progress Note/Evaluation of 4/22/19 stated related to Suicidal ideation, that Patient #1: " ...has access to his/her car and medications and clear intent to carry out his/her plan to take his/her life".
On 4/23/19 at 1:45 PM a security guard was observed sitting in the entry of the hallway between rooms #5 & #6. During interview, the security guard confirmed that once every 15 minutes s/he checks on Patient #1, (located in Room #6) however, "continuous observations" were not being followed. There was also no documented evidence in the medical record that the ED provider had made a change in the determination of suicide precautions and the level of observation since admission.