HospitalInspections.org

Based on record review, document review, policy review and interview, the Hospital failed to ensure they meet the requirements for the Patient's Rights, Condition of Participation, when staff failed to obtain informed consent; failed to protect a patient from all forms of abuse or harassment; and failed to ensure staff followed policy and training on how to interact with patients who are aggressive or have inappropriate behaviors. The cumulative effects of this deficient practice has the potential to place patients at risk for abuse, harm, and unsafe care.

Findings Include:

1. The Hospital failed to ensure informed consent for treatment was obtained for 1 of 7 patients (Patient 2) reviewed. (Refer to Tag A-0131)

2. The Hospital failed to ensure a patient was free from all forms of abuse or harassment and failed to ensure staff followed policy and training on how to interact with patients who are aggressive or have inappropriate behaviors for 1 of 7 patients (Patient 2) reviewed. (Refer to Tag A-0145)

Based on record review, document review, and interviews, the Hospital failed to ensure informed consent for treatment was obtained for 1 of 7 patients (Patient 2) reviewed. This deficient practice has the potential to affect all patients and violate the patients right to request or refuse treatment.


Findings Include:


Review of the Hospital's document titled "Patient Rights and Responsibilities" reviewed 12/2017 showed, ....9. Consent: The Patient has the right to informed participation in decisions involving his/her healthcare plan and treatment. To the degree possible, informed consent will be based on a clear concise explanation of his/her condition and of all proposed technical procedures, including the possibilities of any risk of mortality or serious side effects, problems related to recuperation and probability of success. The patient should not be subject to any procedure without a voluntary, competent, and understand consent or consent by a legally authorized representative. Where medically significant alternatives for care or treatment exist, the patient will be informed. The patient has a right to request treatment that is medically necessary.

Review of the document titled "Patient Rights Acknowledgement" showed there is a designated area where hospital staff can document the medical reason why the patient was unable to sign.


Patient 2


Review of Patient 2's discharged medical record showed, a 31-year-old brought to the Emergency room on 10/31/22 by his significant other with a chief complaint of Altered mental status (change in mental status), substance use (use of alcohol, illegal drugs, or misuse of prescription drugs), and agitation (nervous excitement). The Patient admits to ingesting 6 Xanax (treat anxiety or panic disorders) pills. The patient was somnolent (drowsy) but arousable with noxious (unpleasant) stimuli.

Review of Staff R, Doctor of Osteopathy (DO) document titled "History of present illness" dated 10/31/22 at 11:21 PM showed " ...Patient oriented to person, place, time, and situation."

Further review of the record showed no evidence of an informed consent for treatment in Patient 2's medical record. The "Patient Rights Acknowledgement" form was not available in the record and there was no documentation of an attempt to obtain informed consent or any documented medical reason why Patient 2 was unable to sign the informed consent.

During an interview on 12/08/22 at 1:25 PM Staff H, RN stated that Patient 2 was slurring his words and not able to talk in complete sentences, he wasn't sure where he was going, didn't know the date or the time. Patient 2 was not able to make sound decisions. Patient 2 has a history of substance abuse, and that he had a history of substance abuse and his significant other drop him off and stated, "here you treat him." Staff H RN stated "No, we did not have informed consent to treat, "in an emergency it is implied the patient wants to be treated if they are unconscious."

The facility failed to obtain an informed consent for Patient 2 and failed to document any subsequent attempts to obtain or any medical reason why Patient 2 was unable to sign an informed consent for treatment.

Based on policy review, record review, document review, and interviews, the Hospital failed to ensure a patient was free from all forms of abuse or harassment and failed to ensure staff followed policy and training on how to interact with patients who are aggressive or have inappropriate behaviors for 1 of 7 patients (Patient 2) reviewed. This deficient practice places patients at risk for potential abuse, harm, or neglect.


Findings Include:


Review of Hospital Policy titled, "Combative Patient Code Gray" last revised 10/2019 showed: "A Code Gray situation is an occurrence in which any PATIENT present in a patient care or a non-patient care area has lost all rational thinking and is now a threat to him/herself or others which may result to violent and/or an immediate dangerous event, requiring a response by Security Officers.
... In an attempt to diffuse and avoid a potential violent or physical act the Security Officers shall use the following techniques and others which are taught in the Behavioral Violence Prevention Training:
c. Isolate the Aggressor to a place away from others to prevent any harm to self or others.
d. Use distraction techniques."


Review of Hospital Policy titled, "Abuse, Neglect, Harassment and Exploitation within the Facility" last reviewed 12/2018 showed, "In - service programs shall be presented at new employee orientation and at least annually thereafter which will encompass... ... Training in appropriate interventions to deal with aggressive and/or inappropriate behaviors or reactions of patients. Training to recognize the signs of employee burnout, frustration and stress that may jeopardize patient safety. Training on what constitutes violations of patient safety and misappropriation of patient property. ...It is the responsibility of all supervisors to supervise employees in a manner to improve their effectiveness in dealing with aggressive and/or inappropriate behaviors or action of patients and to ensure that needed care is provided in accordance with the plan of care."


Patient 2

Review of Patient 2 discharged medical record showed that Patient 2, a 31-year-old was brought to the Emergency room on 10/31/22 by his significant other with a chief complaint of Altered mental status (change in mental status), substance use (use of alcohol, illegal drugs, or misuse of prescription drugs), and agitation (nervous excitement). The Patient admits to ingesting 6 Xanax (treat anxiety or panic disorders) pills. The patient was somnolent (drowsy) but arousable with noxious (unpleasant) stimuli. Patient then became Alert and Oriented x 4 to Person, place, time, and situation. During the patient course of treatment, a Code Gray (management of combative patients) was called at 1:26 AM. Patient 2 was discharged on 11/01/22 at 11:50 AM to home with self-care.


Review of Hospital document titled "Incident Report" dated 11/01/22 showed; at about 1:20 AM When the Security Guard arrived Patient 2, was standing in the hallway partially in the nurse's station and Staff I EMT, Staff H RN, Staff F RN, and Staff E, MD were attempting to talk to Patient 2 and have him return to his room. Patient 2 was on his feet and talking and stating he wanted to leave but did seem a little confused and dazed. When Staff G, Security Guard walked up, the first thing heard was Staff E, MD say "if you don't go back into your room in 15 seconds we will put you back in that room, sedate you, and put you in 4- point restraints." Patient 2 did not like that and said if anyone touched him, he would hit them. Staff H, RN and Staff F, RN had touched his shoulder and arm and he did not hit anyone even after he made those threats. Medical staff attempted to talk him into going back into ER Room 21, but Patient 2 continued to refuse. After about a minute of this back-and-forth Staff E, MD forcefully pushed Patient 2 back into his room and into his bed and ordered medication to be given to calm Patient 2 down and 4- point restraints to be put on him. A Code Gray is to be called as restraints were being used. A Code Gray was called at 1:26 AM. Staff J RN and Staff Q, Nursing Supervisor, all of them along with Staff H RN, Staff F RN, and Staff G, took turns holding down the patient's limbs while 4-point restraints were being applied. Patient 2 was verbally abusive toward staff especially Staff E MD and made several threats of physical harm towards staff. Staff E, MD ordered the patient's right arm to be restrained upwards instead of the downward position. When Security attempted to explain about the risks of restraining a patient that way the doctor said he still wanted the patient's arm to be restrained upwards. After 4-point restraints were placed on the patient and medicine given Staff Q, Nursing Supervisor cleared Security and the Code Gray ended at 1:39 AM.


Review of Hospital video camera footage dated 11/01/22 at 1:20 AM showed; Staff H Registered Nurse (RN) and Staff F (RN) standing in the hallway and staff I Emergency Medical Technician (EMT) sitting outside Patient 2's room. At 1:21 AM Patient 2 comes out of the room, walks past Staff I, Emergency Medical Technician (EMT) assigned to monitor Patient 2 for one to one. Staff I, EMT stands up as Patient 2 walks by and follows the patient. Patient 2 stops in the hallway by the nurses' station and is encountered by Staff H RN and Staff E MD. Staff I EMT is standing behind Patient 2. Patient 2 is shirtless, with shorts and one sock on. Patient 2 is standing with his arm's folded demeanor is calm. Staff E, MD, Staff H RN, and Staff I EMT are talking with the Patient, at 1:22 AM Staff H RN goes behind the patient and gets gloves. At 1:22:32 AM Staff G Security arrives to the unit and stands behind Staff E MD. Patient 2 is engaging with both the nurse, EMT and the physician, Patient 2 steps towards Staff E, MD. Staff E, MD touches Patient 2's shoulder appears to stomp feet and uses two hand gesture. At 1:23 AM Patient 2 throws his hands up and turns around in a complete circle. Staff E, MD is using hand gestures and is pointing toward the patient's room. Patient 2 begins pointing toward the doctor. Staff F RN is walking down the hall and talks with Patient 2, she points toward the patient's room, gesturing for Patient 2 to go to his room. At 1:23:16 AM, 4 staff members (Staff E MD, Staff H RN, Staff F RN and Staff I EMT) surrounding Patient 2 and Staff G security is standing a small distance away behind Staff E MD. At 1:23:29 Staff E, MD pushed and shoved Patient 2 toward his room. Camera footage ends and you are not able to see inside Patient 2 room.


Review of Staff H, RN nursing notes dated 11/01/22 at 1:24 AM showed, "Code Grey was called due to patient being aggressive with staff. Patient 2 would not stay in bed and refused to keep leads on. Patient 2 decided to remove his intravenous (IV) line and go to the bathroom. Patient 2 became argumentative with staff and the Physician (Staff E MD). Patient 2 stated that we could not stop him from leaving and he wanted to go home. Patient 2 was incoherent and could not stand up straight. ...Patient 2 became aggressive and refused to go sit in his room. Security was then called and placed Patient 2 back into his room."

Review of Staff E, MD physician progress note dated 11/01/22 "Patient became more awake and wanted to leave the Emergency Department (ED) but still had impaired attention. Could not spell "WORLD" backwards. He had no relations that were willing to pick him up. He then stated ''I am going to leave, and no one can stop me." Concerned about his ability to manage his own affairs with significant attention impairment I somewhat forcefully encouraged him to get back in bed. We then put him in four-point restraints and gave him chemical sedation 50 mg of Benadryl (used to relieve symptoms of allergy) 2 mg of Ativan (used to treat anxiety), 5 mg of Haldol (used to treat certain mental/mood disorders). This made him somewhat somnolent (sleepy), but he continued to be restless in bed for approximately 20 to 30 minutes.

During an interview on 12/07/22 at 10:06 AM Staff E, MD stated, "I spent about 30-40 min talking with this patient and bargaining with this patient. I explained to [Patient 2] he wasn't ready to go and ask him to spell the word "WORLD" backwards, and he couldn't do it." "I offered him food." Staff E, MD stated that Patient 2 has thrown punches before, and he had made threats. I didn't push him, but I put my hands out and moved him like a shopping cart. Staff E, MD stated that just shortly after that incident I initiated the restraints orders.

During an interview on 12/07/22 at 3:44 PM Staff G, security guard stated, "I was very surprised about this kind of behavior, I have never really had a doctor say get in the room, or I am going to sedate you, you have about 15 seconds or I am going to put you back in that room and sedate you." Patient 2 expressed he wanted to leave against medical advice (AMA) and he knew he could leave AMA and knew what AMA was. He knew he had the right to leave. Staff G, security guard stated that Patient 2 stated "If anyone puts their hands on him, I will punch them." Staff G Security Guard stated that Patient 2 didn't want to try hurt anyone else but was angry with the doctor. Staff G, stated, "I have been in working in security a little over 5 years and haven't seen this type of treatment." Staff G, security guard stated that once getting the patient in his room half forcing Patient 2's body over the bed railing, the upper body went over the bed railing. He put him in the bed. Staff G stated that Staff Q, RN, Nursing Supervisor, arrived after Patient 2 was escorted to the bed.

During an interview on 12/08/22 at 1:25 PM Staff H, RN stated "I tried on multiple occasion to have him go back into his room." Staff H RN stated that Patient 2 said that he was going to leave and that he wanted to leave against medical advice (AMA). Staff H RN stated "but he was impaired due to substance use. Patient 2 was slurring his words and not able to talk in complete sentences. Patient 2 came out into the hall, he wasn't sure where he was going, didn't know the date or the time. Patient 2 was not able to make sound decisions." Staff H RN stated that Patient 2 has a history of substance abuse, and his significant other drop him off and stated, "here you treat him."


During an interview on 12/09/22 at 9:31 AM Staff Q, RN, Nursing Supervisor stated that, she responded to the incident when the "Code Gray" was called. Patient 2 was belligerent, not cooperative, cursing and threatening. Staff Q stated that there was a concern about the physician's response to the patient, that the physician put his hand on the patient and that Patient 2 was pushed over the bed railing. Staff Q, RN, nursing supervisor stated that, she notified Staff D, RN Director of Nursing (DON) and explained the situation and was encouraged to contact Staff C, RN, Area Chief Nurse Officer (CNO). She stated that had she witnessed the alleged behavior of a physician handling a patient inappropriately, the physician would have been removed from the situation, taken off the schedule and asked to leave.

The Hospital failed to follow their "Code Gray" policy of isolating the aggressor or creating a non-combative atmosphere that caused the situation to escalate into a physical altercation between Staff E, MD, and Patient 2. The surrounding hospital staff's failure to immediately intervene during initial incident placed the patient at risk for abuse and harm.