HospitalInspections.org

Based on record review and interview the hospital failed to ensure the patient was free from all forms of abuse and neglect for 1 (#14) of 30 sampled patients (#1 - #30) as evidenced by failing to ensure the nursing staff attempted all least restrictive methods of restraint for a psychiatric patient (#14) by failing to intervene when police tactics were used on a patient not in police custody. This resulted in the patient #14 being tasered once and threatened with further use of the tasered and calling the local police department to the Emergency Room (ER) for a psychiatric patient (#14) exhibiting disrupting behavior. The local police told the patient "if you do not calm down we will handcuff you." Findings:

Review of a hospital policy titled "Restraints - Behavioral Management", Date Effective: 7/9/03, Date Revised: 10/2011, presented as current hospital policy, revealed in part: "Purpose: To ensure patient's rights while providing adequately for their safety in an emergency or crisis situation when patient's behavior becomes aggressive or violent, presenting an immediate, serious danger to his/her safety or that of others. To provide an environment that seeks to reduce and/or eliminate the use of restraints. Definitions: Restraint includes manual method or physical or mechanical device, material, or equipment attached to or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement and is not a standard treatment for the patient's medical condition. A drug used for restraint is a medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical condition. Least restrictive measures, in order of restriction from least to most restrictive: soft mittens, vest restraint, one limb soft restraint, bilateral soft limb restraints, four-point soft limb restraint, four-point plus vest restraint, leather restraints. Policy: American Legion Hospital supports the patient's right to be free from both physical restraints and drugs that are used as a restraint when these are not medically necessary or used as a means of coercion, discipline, convenience, or retaliation by staff. Restraints will only be implemented after alternatives have been considered and were deemed inadequate to promote patient safety and health. Patients will be restrained with the least restrictive measure that is adequate to promote patient safety and health. Restraints will be applied only by those staff members who have been trained and determined to be competent to do so. Staff involved in direct patient care will have ongoing education and training in proper and safe use of restraints...Restraints for behavior management will only be used as an emergency measure and is reserved for those occasions when severely aggressive or destructive behavior places the patient or others in imminent danger. Scope: This policy applies to the use of restraints in the situation of an unanticipated outburst of severely aggressive or destructive behavior that poses an imminent danger to the patient or others...Training: Staff responsible for care of patients with restraints will receive training on American Legion Hospital's policy and procedure on restraints. All staff members involved in direct patient care will receive training in the proper and safe use of restraints, restraining techniques, as well as alternatives to restraints...Safe Application and Removal of Restraints: The nurse responsible for the patient's nursing plan of care will select the correct size of restraint for the patient..."

Review of a hospital policy titled "Patients Presenting with Complaints of Suicidal and/or Homicidal Ideation", Date Effective: 7/15/13, Date Revised: 01/06/12, presented as current hospital policy read in part: "Purpose: To assist with protecting all patients, visitors and staff in the Emergency Dept. Policy: Patients with Suicidal and/or Homicidal Ideation. Procedure:...In the event a patient should elope the E.D. staff will call city police with the description of the patient and the direction the patient was last seen heading. E.D. staff will not attempt to physically subdue the patient."

Review of a hospital policy titled "Code White (Security Alert - Violence/Hostage), no date effective or revised, presented by S18RN as current hospital policy, revealed in part: "General Overview: This plan addresses the situation of a violent person in or about the facility. In the case of an angry person who doesn't appear violent, security should be contacted in the normal method. (via radio or PBX). The intent of this plan is to prevent harm to staff, patients or visitors. The number of persons interacting with the violent person should be minimal...Response Phase: Problem/Situation. A. Person acting violent. If you are in direct contact with a person who is acting violently or has a weapon, do the following: 1. Attempt to leave the area if possible. 2. If you cannot get away, cooperate with the person, but try to keep some distance between you. 3. Call the operator as soon as you can. The operator will send help to the area and call 911. 4. Do not attempt to subdue the person. B. Notification/Announcement of the situation - PBX staff. When PBX receives a call there is a violent person...they will: 1. Immediately call 011. 2. Announce a Code White location". Notify Security..." Review of the entire policy revealed it does not address the any de-escalation and/or Crisis Prevention Intervention interventions for the psychiatric patient.

Review of the medical record of patient #14 revealed the following document: "American Legion Hospital One to One Guidelines. There are a number of reasons why a patient is ordered to be one to one. The three main reasons would be that a patient has either threatened or attempted suicide, they may be at risk for falling, or it may be behavioral. For whatever reason there are certain guidelines that must be followed for the safety of the patient and perhaps the safety of the staff and other patients. 1. One to one means to be arms length away at all times. It does not matter if the patient is in bed, in a chair, ambulating in the hall, in the bathroom, or bathing. Staff must be able to reach out and touch the patient at all times. 2. A patient who is one to one has limited privileges:...d. The patient is not allowed to have personal items on their person or in their room, such as combs, toothbrushes, etc...e. The patient cannot use the bathroom with the door closed and a staff member must be inside the bathroom with them. There is no privacy allowed...h. One to One Guidelines must be signed by all staff that is sitting with the patient. The above guidelines have been carefully explained to me. I understand and accept guidelines." The above document is signed on a separate form by S4House Supervisor and S17RN, S8RN, S10LPN, S14CNA, S9RN, S5LPN, S16RN, and S6ER Tech.

Review of Louisiana Revised Statutes Title 40. Public Health and Safety
Chapter 11. State Department of Health and Hospitals ?2009.2. Definitions (Excerpt) (3) "Department" shall mean the Department of Health and Hospitals.
(4) "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. ?2009.20. Duty to make complaints; penalty; immunity A. As used in this Section, the following terms shall mean: (1) " Abuse " is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. (2) " Neglect " is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. B. (1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report...(2) Any person who knowingly or willfully violates the provisions of this Section shall be fined not more than five hundred dollars or imprisoned for not more than two months, or both. C. Any person, other than the person alleged to be responsible for the abuse or neglect, reporting pursuant to this Section in good faith shall have immunity from any civil liability that otherwise might be incurred or imposed because of such report. Such immunity shall extend to participation in any judicial proceeding resulting from such report. D. All hospitals shall permanently display in a prominent location in their emergency rooms..."
Review of the medical record for patient #14 revealed the following documentation: "4/26/13 21:53 (S10LPN) 2151 - Pt bolted out of back door of ER. Pt has been agitated and upset. Pt stated she was served soup hat [sic] tasted like "crap." Pt stated she was tired of waiting using profanities several times stating in any other time we would have found placement for anyone else. Pt told that the kitch [sic] has been closed for a while. Pt also informed that (EMS) has been called twice for transfer. (EMS) called back stating it could be over an hour for an available unit for transport due to several emergencies in the area. Pt also offered Ativan PO (by mouth) and refused medication. (PD1) contacted to inform of pt elopement. Dispatch stated a unit could not come at this time because all units are tied up with calls and/or emergencies. ALH security has been in ER for the last 20-30 minutes due to pt agitation. Security ran after pt as soon as pt bolted from ER. Upon return by security, they stated she ran across the street and she is nowhere to be found at this time. House Supervisor (S4House Supervisor) contacted as soon as pt left ER. 4/26/13 22:19 (S10LPN) 2218 - Pt arrived back in ER with (PD1). Pt still agitated and upset. Pt states she is giving us 10 minutes to find transportation or she will run away again. 4/26/13 22:42 (S10LPN) (PD1) in room with pt entire time since rearrival. All clothing and belongings removed from pt as soon as pt arrived. Pt placed in 4 point restraints due to noncompliance with orders and refusing to remove clothing. Pt agitated and yelling continuously for mother. Pt demanding to call mother. Pt informed she does not have phone privileges at this time and cannot use the phone. Offered pt several times for ER staff to call mother and continuously refused. Ativan 2 mg ordered and given IM (intramuscular). 4/26/13 23:13 (S10LPN) Restraints applied for the second time to pt after getting out of arms restraints. Pt yelling continuously for mother and obsenaties [sic] out loud in the ER. Pt yelling at staff and crying continuously. 4/26/13 23:30 (time of documentation) (S10LPN) 2310 - Pt has agreed to stay calm and stop yelling if we remove the restraints and allow her to sit up. 2330 - (EMS) on site for pt transfer to PFC. Pt calm and collected at this time and causing no more disturbances. 4/26/13 23:42 (S9RN) 2235 - Ativan 2 mg IM given in right dorsogluteal."

Review of a document titled "Physician's Orders for Restraints" revealed the following: "Date Ordered: 4-26-13. Time: 2235. 1. Alternative considered prior to restraints include: Verbal Instructions. 2. Purpose of Restraints: High-risk for injury to self. 3. Type of restraint to be implemented: Ankle: right, left. Wrist: right, left. 4. Patient to be restrained for ____ hours* (left blank). *Explanation:...Patients restrained for behavioral management may have orders written for the following time limits: 4 hours for adults"...the document is signed by the ER Physician with no documented time of signature.

Review of the nursing notes dated/timed 4/26/13 22:35 by S10LPN revealed: "Reason for restraint: Impulsive, Unable to follow Directions. Alternatives Prior to Application: Verbal Instructions, Frequent Pt Checks, Distraction Techniques, Frequent Re-Orientation. Location: Left Arm, Right Arm, Right Leg, Left Leg. LOC (level of consciousness): Alert. Behavior: Uncooperative, Anxious, Agitated, Impulsive, Combative..."

Review of the medical record of patient #14 revealed no documentation of patient #14 being tasered by PD1, threatened to be tasered again while the taser was held on her by PD1 while she was in 3 point restraints, or being threatened with the use of handcuffs by PD1.

In an interview on 6/13/13 at 3:00 p.m. with S1Administrator he stated "The police have said they will use all options to protect themselves and the public if they are called once they enter the hospital."

In an interview on 6/14/13 at 9:00 a.m. with S1Administrator the video of the Emergency Room was reviewed. This video is from the first arrival of patient #14 under police escort due to an OPC (Order of Protective Custody) at 16:10:50 to her elopement at 21:55:54. This is the only video reviewed by S2DON prior to the survey. No person other than S1Administrator had viewed the video of the initial arrival of patient #14 to elopement and the second video of patient #14's return with police escort at 22:24 until her departure with EMS at 23:39:40.

Review of Video #1 revealed the following: At 16:10:50 patient #14 is escorted in to the front lobby of the hospital by police officer. The officer and patient #14 speak to the admit clerk separately. Patient #14 appears calm and cooperative. She then takes a seat in the lobby. At 16:16 patient #14 is taken to triage by S17RN. At 16:16:56 patient #14 is placed in ER Bay #3. S17RN is in and out of room #3 three times over the next 26 minutes. At 16:42:27 S16RN enters room #3 to begin 1:1 observation of patient #3 as assigned by S4House Supervisor. At 16:44:10 S16RN escorts patient #14 to the restroom and allows her to enter the restroom with a door that can be locked from the inside. S16RN confirmed in an interview on 6/17/13 at 9:50 a.m. that this violated the LOS (line of sight/within arms reach) observation. At 16:57:48 S11MD entered Bay #3 for the first time, she exited the room at 16:58:48, one minute after entering. At 18:25:36 patient #14 is again escorted to the restroom and the 1:1 LOS Observation is broken when the patient is allowed to enter and is not kept in sight by the RN. At 19:44:26 S9RN enters Bay #3 for 46 seconds. At 19:58:06 Security enters the ER, briefly speaks to the patient in ER bay #5 (next to Bay #3) and exits at 19:59:44. (1 minute and 38 seconds). Further review of the video revealed that at 20:02:40 three policemen entered the ER. At 20:03:02 all three officers entered Bay #5. S5LPN was now in Bay #3 doing the 1:1 Observation. Between 20:03:10 and 20:07:36 the officers were in and out of Bay #3. There was 3 male police officers and one female police in the ER. At 20:07:36 all 4 officers exited the ER. At 20:15:23 S9RN entered Bay #3 for 6 seconds. At 20:28:20 S9RN entered Bay #3 for 1 minute and 13 seconds. At 20:31:10 S8RN, Charge Nurse entered Bay #3 for 14 seconds. At 21:46:30 S7Security and S12Security entered the ER. At 21:47:10 and 21:47:30 S7Security looked into Bay #3 then stepped away. At 21:50:44 patient #14 can be seen through an opening in the curtain as she approaches the front of Bay #3 (the open ER side). Patient #3 looks to her left outside of the curtain where S7Security is standing with his back to the patient. Patient #14 goes back into Bay #3. At 21:50:51 S12Security is looking directly at the curtain where patient #14 just stuck her head out. S12Security then walks away from Bay #3 towards the nursing station. At 21:54:56 S8RN, Charge Nurse, enters Bay #3 for 54 seconds. S7Security is outside of Bay #3 with his back turned to Bay #3. S12Security is at the end of the nursing station looking towards Bay #3. At 21:55:54 patient #14 exits Bay #3 and leaves the camera view towards the rear ER doors (ambulance bay). S5LPN, S7Security, and S12Security all exit the ER doors 6 seconds later.

Review of Video tape #2 (from patient #14's return to the ER escorted by PD1 until her departure with EMS) revealed in part: "At 22:23:58 S5LPN (assigned 1:1 by S4House Supervisor), S6ER Tech, and S10LPN were at the nursing station. At 22:24 PD1 entered the ER with patient #14. She was walking in front of PD1 and there was no contact by PD1, nor was there handcuffs on patient #14. At 22:24:22 S6ER Tech, S5LPN, patient #14, and one police officer are in Bay #3. S10LPN, ER, (large male) is seated at the nursing station. At 22:24:42 S6ER Tech exits Bay #3, leaving S5LPN and one police officer in Bay #3 with patient #14. At 22:25:52 S6ER Tech dons gloves, gets a gown and enters Bay #3 at 22:25:56. At 22:26:22 S4House Supervisor enters the ER. At 22:26:44 S9RN enters Bay #3, 22 seconds later she exits. At 22:27:08 a second police officer enters Bay #3. S4House Supervisor, S8RN Charge Nurse, and S10LPN are at the nursing station. S9RN is near Bay #2 and Bay #4 (across the center hall of the ER).At 22:28:12 the police exit Bay #3. S6ER Tech, S5LPN, and S14CNA (the 1:1 replacement for S5LPN) are in Bay #3 with patient #14. At 22:28:36 S8RN, Charge Nurse, is in the office at the rear of the ER, S4House Supervisor, and S5LPN, and S10LPN are at the nursing station. S9RN is in either Bay #2 or Bay #4 (can't tell which she entered). S6ER Tech and S14CNA are the only staff in Bay #3 with patient #14. At 22:28:51 S8RN, Charge Nurse, exits the office and enters Bay #3. At 22:29:32 two more police officers enter the ER (for a total of 4 now in the ER). At 22:29:53 there are 3 police officers, S4House Supervisor, S10LPN, S9RN at the nursing station. At 22:30:41 the curtain to Bay #3 opens and 3 officers look towards Bay #3. At 22:30:46 2 officers enter Bay #3 and the 3rd is at the curtain. 3 ER Nurses (S4, S9, and S10) remain at the nursing station. At 22:31:08 2 police officers exit Bay #3. At 22:31:16 3 police officers are at the curtain to Bay #3, S10LPN, S9RN, and S4House Supervisor remain at the nursing station. At 22:31:21 2 police officers enter Bay #3. S6ER Tech, S14CNA, and S8RN, Charge Nurse, are also in Bay #3. S4House Supervisor is moving toward the ER exit door and exits 24 seconds later. At 22:31:51 S8RN, Charge Nurse; and S14CNA exit Bay #3. 2 police officers and S6ER Tech are in Bay #3 with patient #14. 2 RN's (S8, S9), 1 LPN (S10), 1 CNA (S14), and one police officer are outside the room. (the location of the 4th officer is unknown at times due to there being one camera angle).At 22:31:55 S9RN enters Bay #3. At 22:31:57 S8RN, Charge Nurse, and the third police officer re-enter Bay #3. There are now 3 police officers, S9RN, S8RN, and S6ER Tech in Bay #3. S10LPN remains at the nursing station. At 22:34:41 S11MD exits the office and enters Bay #3 5 seconds later. She exits Bay #3 19 seconds later. At 22:39:01 there are three police officers, S6ER Tech, and S14CNA in Bay #3. 3 RN's (S4, S8, S9), 1 LPN (S10) and 1 Security Officer (S12) are at the nursing station. Between this time and 23:06:10 there were usually at least two police officers in the room. Hospital staff in Bay #3 were primarily S6ER Tech and S14CNA. (S4House Supervisor was in Bay #3 for 4 seconds and 6 seconds; S9RN was in Bay #3 for 28 seconds; S10LPN was in Bay #3 for 28 seconds) Observation of the video revealed the nursing staff primarily remained at the nursing station. Patient #14 left the ER at 23:38:25 with (EMS).

Review of a document titled "Confidential Hospital Occurrence Report to HSLI and the Hospital Attorney" revealed the following: "Patient #14's name was at the top of the form." Section 1...Hospital: American Legion. Diagnosis Prior to Occurrence: Depression/Suicidal. Date of Occurrence: 4-26-13. Time: 2150. Date of Report: 4-26-13. Age: 30. Female. Room Number: Bay 3. Unit/Department: ER. Location of Occurrence: Emergency Department. Type of Occurrence: Other: Elopement...Brief Factual Description: Argumentative. Wanting to leave. She was PEC'd and waiting on EMS for transport to PFC. (Pauline Faulk Center - offsite In-patient Psychiatric Hospital) Her clothes had been returned to her for transport and she was dressed. Upset because EMS taking so long. Patient jumped up and ran out back door. Police Dept. notified per ER staff. Pt returned per (PD1) @ 2218. Physician's Treatment: S11MD ER notified at 2051 by ER Staff...Names...of witnesses: S5 LPN,S9RN ER, S7 Security Officer, S12 Security Officer, S8 RN ER, S10 LPN ER,S6ER Tech. Result of Occurrence: No Apparent Injury. Patient Condition Prior to Occurrence: Alert-Oriented. Patient or Visitor Attitude After Occurrence: Uncooperative. Name, title, Department, and Signature of Person Preparing Report: S8RN, ER. Signature and Date of Department Head: S3ER Director 4/29/13 (3 days after occurrence). Signature and Date of Risk/Safety Manager Reviewing Report: (??RN) whose signature on report 5/7/13; S1Administrator 5/11/13.

Statements attached to the above Occurrence Report are as follows:

S5LPN

"4/26/13. Sitting with one on one patient. Agitated and wanting to leave. (EMS) notified of need to transport to PFC. They (EMS) called ER staff and stated they were all busy with emergencies and would be here as soon as possible. This was told to pt. Pt. got up and stood in room for a short time and said she was hungry and needed to go get something to eat. Security notified and in room. She then bolted for back door and ran after her unsuccessful in stopping her. Police Dept. notified per ER staff. Signed by (S5LPN)."

S6ER Tech

"4/26/13. @ 21:51 PEC pt., patient #14, eloped from ER using the rear exit. @ 22:18 (PD1) brought pt. back to ER. Pt was placed in Bay 3. Pt was refusing to get back into a hospital gown, started demanding to speak with her mother. The charge nurse S8RN ER, came into the room and explained to pt. that she could not call her mom or see her mother because she was PEC'd and S8RN ER explained what a PEC was but pt was still uncooperative and getting violent, so PD came into room and helped restrain pt so we could remove her clothing. Kicking and refusing to remove shorts so her shorts were cut off......Pt was very violent. Pt broke one of the restraints and swung at the cop and myself. Pt would not calm down and kept thrashing and making threatening comments to nursing staff as well as the PD. PD tazzed [sic] pt in the right upper chest. PD only tazzed [sic] pt. once." Signed by (S6ER Tech.)

S4RN House Supervisor

"4-26-13. Went to the ER and noted that PED pt (patient # 14) was now in 4 point restraints that (PD1) was assisting staff to restrain pt. I also saw that one officer had a black device in his hand and had it near shoulder of pt and said "do you want me to do it again" - Pt had been thrashing about in the bed. I walked over to ER staff and asked did he taze her and they said yes. S6ER Tech. was the only one who said she actually saw the patient being tazed - S6ER Tech. said it was done once. I immediately called S2DON to notify her of this." Signed by (S4RN House Supervisor) S8RN ER "4/26/13. Re: (patient #14) Visit ID (number listed). From the time of our arrival at 1900 patient was combative and abusive with staff and other ER Pt's. She was cursing and hollering using 4-letter words. She had numerous complaints and stated she wasn't staying. Many other ER patients wanted to leave because they were afraid of her. We had gotten acceptance at PFC (Pauline Faulk Center) and had called (EMS) but they were not immediately available to transport her. She continued to be combative and abusive. When we were told that (EMS) would be here soon we gave her clothes to her so she could dress for the trip. After getting dressed she bolted out back door. We notified security and the city police. She was only gone a few minutes and was then returned to ER by (PD1). Upon returning she continued to be combative and refused to remove her clothing. With the police present at the bedside we were able to remove her clothing and place her in a gown. She continued to be combative and verbally and physically abusive. At that time we obtained an order for restraints and placed her in restraints. She was only in restraints a short time and then agreed to cooperate if we would leave restraints off. At that time restraints were removed. Not long after (EMS) arrived and patient was transferred to PFC." Signed (S8RN ER) There is no documentation that patient #14 was tasered by PD1 while in 3 point restraints in the incident report of the S8RN ER

S10LPN

"4/26/13. Pt: patient #14 Visit ID : (number). patient #14 was under PEC order upon arrival for shift at 1900. At this time pt was resting quietly with 1:1 observer in room at arm's length. PFC called to state they will be accepting pt to their facility for treatment at 2011. Pt informed of acceptance. (EMS) called for transport once chart was complete. During wait for (EMS) pt began getting agitated and making loud comments in ER mainly about being transported and length of time waiting. Pt also stated several times she was hungry and what she was given stated [sic] like "crap". (EMS) called back stating the unit would be tied up for at least another hour due to multiple calls in the area. Pt began getting more and more agitated as time went on. Security had to be called to speak with pt and calm her down. (EMS) dispatch called back again stating they could be another hour before transport to receiving facility. At 2151 pt was seen running out of back door of ER with 1:1 observer and security in pursuit. Security returned stating they could not find pt on the premises. (PD1) contacted once pt left ER. (PD1) returned with pt at 2218 (27 minutes after elopement). Upon arrival pt was still agitated and upset, still making loud comments and shouting profanities. All clothing and belongings taken back again and placed in bag with pt label. (PD1) officers remained in room with pt due to pt acting out. Pt began getting louder and louder using profanities. Pt had to be placed in 4 point restraints after several attempts to calm pt. (PD1) remained in room at this time. Pt continuously yelling for mother to come meet her in the room and that this hospital is an "animal hospital." Pt continuously stating she was going to sue ALH. ER staff offered several times to contact mother for her but pt refused and continued yelling for mother. Such a disturbance was caused that several pt's in the ER stated they wanted to be d/c' d because they were scared for their safety. Other pt's wanted to leave simply because they could not go one [sic] hearing the screaming and yelling. This went on for roughly 45 minutes until pt stated she would calm down if the four point restraints were removed. At this point the pt has broken through 3 pairs of wrist restraints. Restraints released and pt remained calm until arrival of (EMS). Pt left in gown and given back all belongings in bag with label on bag." Signed (S10LPN, ER). There is no mention of the taser being used by PD1 on patient #14 while the patient was in 3 point restraints. Review of the video tape revealed S10LPN, ER, was in Bay #3 where patient # 14 was for a total of 11 seconds during the incident.

S9RN, ER

"4/26/12 (year incorrect). On arrival to work @ 1900 patient #14 was in Bay 3 as a PEC. Around 2030 patient became agitated using profanity asking when she would be transferred because the bed was not comfortable and that she couldn't sleep due to the noise in the ER. Explained to patient of the wait time for (EMS) arrival. At 2151 patient ran out of back doors of ER. (PD1) called. At 2218 patient returned escorted per (PD1) still agitated and cursing and threatening staff. All clothing and belongings removed from patient and placed in a hospital gown. Patient still belligerent and yelling. 4-point restraints applied. @ 2300 patient still yelling and cursing, asking for her mother. (PD1) in the room entire time assisting while patient was violent. Restraints reapplied due to patient escaping from restraints. @ 2310 patient agreed to stay calm if I removed her restraints. Restraints removed. Patient sitting up in bed, 1:1 sitter at bedside. @ 2330 (EMS) here for transport. Patient calm and cooperating at time of transport to Pauline Faulk." Signed by S9RN ER. (There is no mention of patient #14 being tasered while in 3 point restraints by PD1).

Review of a second document titled "Confidential Hospital Occurrence Report to HSLI and the Hospital Attorney" revealed the following: "Hospital: American Legion. Diagnosis Prior to Occurrence: Depression/Suicidal. Date of Occurrence: 4-26-13. Time: 2235. Date of Report: 4-26-13. Age: 30. Female. Room Number: ER Bay 3. Unit/Department: ER. Location of Occurrence: Emergency Department. Type of Occurrence: Restraint Use...Possible Related Cause(s): Combative. Possible Patient Factor: Combative...Physicians Orders Prior To Occurrence: PEC...Brief Factual Description: Patient is PEC and had eloped from ER. Returned by (PD1) to Bay 3. Combative and argumentative. Uncooperative. Fighting with all staff. Order written by S11MD, ER, to restrain patient...Physician's Treatment Given: Restrain pt. S11MD ER notified at "present at time of incident." Examined by Physician? Yes is circled. Names...of witnesses: S5LPN, S8RN, ER; S9RN, ER; S10LPN, ER; S6ER Tech. Result of Occurrence: No Apparent Injury. Patient Condition Prior to Occurrence: Combative. Patient or Visitor Attitude After Occurrence: Uncooperative, Angry, Combative. Name, title, Department Head and Signature of Person Preparing Report: S8RN, ER. Signature and Date of Department Head: S3RN, ER Unit Manager, (no date documented) Signature and Date of Risk/Safety Manager reviewing report: (S1Administrator) 5/11/13." There is no mention that patient #14 was tasered while in 3 point restraints by PD1."

Review of the individual incident reports attached revealed they were copies of the incident reports from the elopement of patient # 14.

Review of an e-mail sent by S1Administrator dated April 26, 2013 at 10:31 p.m. revealed: "(S2DON) just called me. I asked how this happened with on even one (1:1?) and she told me that security was also in the ER at the time. She told me that we are not allowed to tackle them and then abuse them. I stayed (stated?) that I thought we should have stopped them. She stated that the policy is not to physically restrict or stop them but to call police as was done. I think we need to define our responsibilities in this with our attorneys and review policies. O don't think this is a reportable event if it is our policy and we followed it. I do remember this happening before cane (?) the procedure is to call the police. I don't think this is neglect either. What do you think?"

Review of an e-mail response from S31CFO dated Saturday, April 27, 2013 at 6:56 a.m. read: "Subject: Re: PEC ER patient elopement. I agree if this is our policy. I definitely agree we need to review the policy. Thank You."

Review of an e-mail from S1Administrator to S2DON, S3ER Unit Manager and S31CFO dated Saturday, April 27, 2013 at 10:05 a.m. revealed: "(S2DON) I have recorded and placed in my DropBox the video of the elopement. The patient is in Bay 3 right next to the desk behind the security guard. It appears to me that I can see the 1:1 person in the room right after the patient leaves. She is sitting next to the wall closest to the desk. It appears that the 1:1 person is there with the patient and the patient exits the room on the other side of the bed. We need to review our policies as to how we handle these situations. It is my understanding from you that we do not attempt to prevent them from leaving by using force and call the police to locate the patient. I wou

Based on record review and interview the facility failed to ensure a registered nurse (RN) assigned nursing care of each patient according to the needs of the patient and the qualifications and competency of the nursing staff as evidence by:
A) Failing to ensure nursing staff assigned to the care of a patient placed in restraints were competent in the application of restraints for 6 out of 6 emergency department personnel S8RN, S9RN,S5LPN, S10LPN, S6ER Tech.& S14CNA records reviewed.
Findings:
Review of the facility's policy titled Competency Assessment and Staff Development revealed Nursing service personnel at the hospital includes RN's, LPN's, nurse assistants, mental health worker, and unit secretaries. All nursing staff members are assigned duties and responsibilities consistent with their educational preparation and experience. ..Competence is maintained and enhance through a combination of the above mentioned tool and regular continuing education and in-service opportunities. Nursing competency that is specific to the area of assignment is evaluated on an annual basis. An individualized staff developed plan and/or tailored orientation program is developed for personnel based on feedback for the competency assessment process ...Unit specific competencies that are necessary for that patient population are utilized by each patient care unit ... Each Nursing Unit Manager is responsible for ensuring the ongoing competence of employees assigned to that desk ...Areas of competence that have been identified as necessary for nurses to demonstrate competence are listed below:
Complies with safety and emergency procedures.
Complies with nursing service policies.
Performs critical/frequent procedures correctly.
Uses equipment required for implementing patient care safely and effectively.
An interview was conducted with S18 RN/Infection Disease Nurse/Educator on 6/17/13 at 11:30 a.m. She reported during general orientation to the hospital she showed a film on restraints to nursing personnel. When S18 RN/ Infection Disease Nurse/Educator was questioned if the nursing personnel did a return demonstration on restraints to check their competencies on restraints, she reported the Unit Managers were responsible for checking skill competencies specific for their unit.
An interview was conducted with S3RN/Unit Manager of Emergency Department on 6/17/13 at 10:30 a.m. She reported competencies for restraint applications were not conducted with the emergency department nursing personnel. She further reported CNA's, nurses and/or Emergency Room technicians can apply restraints.
Review of the personnel record for S6ER Technician , with a date of hire of 1/2/13 as a Emergency Department Technician, revealed no competencies for the applications of restraints.
Review of the personnel record for S5LPN (Licensed Practical Nurse),with a date of hire of 11/13/95, revealed no competencies for the application of restraints.
Review of the personnel record for S10LPN, with a date of hire of 12/15/11, revealed no competencies for the application of restraints.
Review of the personnel record for S8RN, ER, with a date of hire of 8/11/11, revealed no competencies for the application of restraints.
Review of the personnel record for S9RN, ER, with a date of hire of 2/9/12, revealed no competencies for the application of restraints.
Review of the personnel record for S14CNA(Certified Nursing Assistant) with a date of hire of 8/9/12, revealed no competencies for the application of restraints.
Review of the facility's policy titled Orientation-Nursing revealed all nursing staff will be oriented by the nursing unit manager of the responsibilities to which they are assigned.

Based on observations and interview, the hospital failed to ensure medical records were properly retained by failing to protect 3 year's worth of medical records from water damage in the event the sprinkler system became activated in the medical record department.
Findings:
Review of the Hospital Policy titled Access to Medical Records, Revised 7/17/12, stated in part: Medical Records and other information will be protected against loss, destruction, or tampering...
In an observation on 6/12/13 at 11:00 a.m. of the medical records department, 12 cardboard boxes of medical records were stacked on the floor. 25 sets of open shelving approximately 6 1/2 feet high and 8 feet long contained paper medical records. Sprinklers were observed in the ceiling of the room.
In an interview on 6/12/13 at 11:10 a.m. with S22Medical Records Director, she said the medical records at the hospital were electronic since July of 2010. She also said approximately 3 year's worth of paper medical records that had not been copied were stored in the medical records room on the open shelves. S22Medical Records Director stated if the sprinklers were activated, there was no way to protect the medical records from water damage.

Based on interview and record reviews, the hospital failed to provide patient safety and to control and distribute drugs and biological in accordance with acceptable standards of practice. This failure is evidenced by not having a system in place to review all first dose medications ordered at night before the first dose had been dispensed and administered for 3 (#7, #9, #10) of 3 (#7, #9, #10) patients reviewed for medications ordered at night out of a total of 30 sampled residents.
Findings:
Patient #7
Review of the medical record for Patient #7 revealed she was admitted on 6/12/13 at 2:56 a.m. with diagnosis which included an intentional overdose of Lithium. A PEC was dated 6/12/13 at 2:35 a.m. Further review revealed she was admitted to the ICU because she was medically unstable to be transferred to a psychiatric facility.
Review of the Physician's Orders for Patient # 7 revealed the following order:
6/12/13 at 6:30 p.m.- Flexaril 10 mg 1 po bid, Tylenol 325 mg (2) po q 4 hrs prn pain
Review of the MAR for Patient #7 revealed Cyclobenzaprine (Flexaril) 10 mg was documented as having been given on 6/12/13 at 6:51 p.m. and 6/13/13 at 6:03 a.m. Tylenol 325 mg was documented as having been given on 6/12/13 at 11:40 p.m.

Patient #9
Review of the medical record for Patient #9 revealed she was admitted to the hospital on 6/12/13 at 11:42 a.m. with diagnosis which included dysphasia, salivation, and sore throat.
Review of the Physician ' s Orders for Patient #9 revealed an order dated 6/12/13 at 6:08 p.m. for a Tylenol Suppository 650 mg PR x 1 now.
Review of the MAR for Patient #9 revealed Acetaminophen (Tylenol) Suppository 650 mg was documented as having been given on 6/12/13 at 6:38 p.m.

Patient #10
Review of the medical record for Patient #10 revealed he had been admitted to the hospital on 6/12/13 at 1:08 p.m. with diagnosis which included chronic obstructive pulmonary disease and apparent pulmonary fibrosis.
Review of the Physician's Orders dated 6/12/13 at 6:00 p.m. for Patient #10 revealed an order for Levaquin 500 mg IVPB qd.
Review of the MAR for Patient #10 revealed Levofloxacin 500 mg had been charted as having been given on 6/12/13 at 8:09 p.m.


In an interview on 6/12/13 at 9:40 a.m. with S19RPH, she stated the pharmacy hours were from 7:30 a.m. until 6:00 p.m. Monday through Friday and 8:00 a.m. until 4:00 p.m. on weekends and holidays. S19RPH said if first dose medications were ordered after the pharmacy was closed, the medications were pulled from floor stock by the nursing staff and given to the patients. If the medications were not in the floor stock, she said the night supervisor would obtain the medications from a locked room in the pharmacy. She said a pharmacist would not review the first dose medications for appropriateness until the next morning when the pharmacy was open. S19RPH verified this was a retrospective review since the first dose would have already been given.
In an interview on 6/13/13 at 9:15 a.m. with S19RPH she stated Patient #7, Patient #9 and Patient #10 received the above mentioned medications before they were reviewed by a pharmacist.

In an interview on 6/12/13 at 2:00 p.m., S18RNInfection Control stated the pharmacy had no policies on first dose review of medications.

Based on observation and interview the hospital failed to ensure outdated drugs/biological's were not available for use as evidenced by having drugs/biological's with no date of first puncture and/or expired vials available for use. Findings:

Based on observation and interview the hospital failed to ensure outdated drugs/biological's were not available for use as evidenced by having drugs/biological's with no date of first puncture and/or expired vials available for use. Findings: In an observation on 6/12/13 at 9:53 a.m. of the contents of the medication refrigerator the following were found: One vial of PPD (Purified Protein Derivative) used for TB (Tuberculosis) skin test, lot # C3948AA, with a documented date of first puncture of 5/5/13. One vial of Xylocaine 1% 10 mg/ml (milligrams/milliliter) 20 ml vial with no date of first puncture.

In an interview with S24DON (Pauline Faulk Center offsite) she confirmed the above listed medications expire 28 days after first puncture and should not be available for patient use.

Based on observation, policy review, and interview the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1) infection control officer failed to maintained a hospital wide surveillance system for controlling infection by failing to ensure housekeeping and nursing staff maintained a sanitary hospital environment. This was identified throughout the hospital in the Emergency Room, Medical-Surgical patient areas, Intensive Care Unit, Operating Room, Kitchen, and Laboratory. (see findings at A0749)

Based on observation and interviews, the hospital failed to ensure that the infection control officer failed to maintained a hospital wide surveillance system for controlling infection by failing to ensure housekeeping and nursing staff maintained a sanitary hospital environment. This was identified throughout the hospital in the Emergency Room, Medical-Surgical patient areas, Intensive Care Unit, Operating Room, Kitchen, and Laboratory. Findings:
Review of the hospital policy presented as current titled Cleaning Emergency Room, Revised 1/15/03, said in part:
The emergency room will be cleaned every day or as needed ...Area will be cleaned by the men and women in the environmental department.

Review of the hospital policy presented as current titled Standards, Subject: Environmental Services, Revised 1/15/03, said in part:
Floors: No dust, litter, debris ...
Furniture: In good condition ...with no spots, lint, dust, rips or tears.
Storage areas/Closets: Free of unnecessary items, floors cleaned; space kept in a neat and orderly manner.
Beds and frames: Disinfected on checkouts.

In an observation on 6/11/13 at 1:00 p.m. of the triage room in the ED (Emergency Department), a slit lamp used by ophthalmology was observed in the corner partially covered. Clean supplies were observed on an open shelving unit in the room. When supplies were removed from the top shelf, dust and lint fell into the air. Also, the base of the blood pressure machine in the room was observed to have hair and dirt on the surface.

In an observation on 6/11/13 at 1:25 p.m., the trauma room was observed to have dust on the tops of the paper towel dispenser, bed frame, and cabinets. An uncovered, open shelving unit with clean supplies was located in the trauma room. A chair at the bedside had 2 rips in the vinyl seat approximately 2-3 inches each.

In an observation on 6/11/13 at 1:30 p.m. of exam room #3, the defibrillator and crash cart had a visible layer of dust on their tops. The vinyl mattress on the patient bed had a tear approximately 2 inches long.

In an observation at 6/11/13 at 1:35 p.m. of exam room #6 revealed dust on the cabinets, bed frame, and the hand sanitizer. The base of an intravenous pole was noted to have dirt and hair on the surface.

In an observation on 6/12/13 at 1:45 p.m. in the ED, a clean linen cart was noted to be inside of an alcove in the ambulance entry hall. The cart had a covering with gaps on both sides which exposed the linen. 3 blankets were on top of the cart wrapped in plastic which had approximately a 10 inch tear in the plastic. In the doorway and on the ceiling of the alcove were 6 spiders and cobwebs. A large amount of lint and dust was observed on the floor around and under the linen cart.

In an interview on 6/11/13 at 1:40 p.m. with S18RN Infection Control she stated she was the infection control officer for the hospital. She stated the triage room was used to examine patients when they were being admitted to the emergency department. She verified the slit lamp was partially covered and was considered a piece of clean equipment, but the triage room was not considered clean. She also verified there was an open shelving unit with clean supplies in the triage room with a layer of dust the top shelf of the clean supplies. S18RN Infection Control stated the emergency department did not have a clean supply or clean equipment room. She also verified the trauma room had dust on the surfaces of the cabinets, furniture, and supplies. S18RN Infection Control verified an uncovered, open shelving unit with clean supplies for the entire ED was located in the trauma room because storage space was limited. She also said most surfaces in the ED seemed to have a layer of dust on them and they did not appear to have been cleaned recently. She said housekeeping was supposed to clean the ED at night, but it did not appear that they had cleaned the unit well.

In an interview on 6/12/13 at 1:45 p.m. with S3ER Director stated the linen cart had been moved to the above in the ED about six months ago. She said to her knowledge, the above had not been cleaned since the linen cart was placed there.

In an interview on 6/12/13 at 2:00 p.m. with S23Housekeeping Supervisor, he stated the ED was cleaned once per day by housekeeping on the night shift. He said the housekeeper was supposed to mop the floors, dust the walls and equipment, and empty the trash. He said since it was only 1 person for the hospital, the cleaning was not getting done like it should have been.

During a tour of the Medical Surgical Unit (3rd floor) on 6/11/13 at 1:00 p.m. through 1:20 p.m. S20 RN Unit Manager the following were noted:

Observation of room (empty) #338 located on the corner across from the family waiting room there was a housekeeping cart parked near the bed. The cart contained a bag of trash, trash bags, open box of gloves, liquid cleaning supply, can of disinfectant, mop, mop bucket with gray colored water, and rolls (did not count) of toilet paper.

Observation of the soiled utility room located on the 300 hallway revealed 4 large clear plastic bags with contents of soiled items(linens, patient gowns) on the floor. There was 1 large plastic container on 4 wheels which contained one large plastic bag of soiled items and 3 free standing 3 wheelers plastic lined containers which were empty.

Interview on 6/11/13 at 1:25 p.m. with S20RN Unit Manager confirmed the above findings stating the cart should not have been in room #338 as this was a clean room ready for patient use. According to S20RN Unit Manager the soiled plastic bags should have been placed in the plastic bags and not on the floor. She stated room #338 would have to be re-cleaned and she would speak to the housekeeping supervisor concerning both issues.

Review of the hospital policy tilted: Cleaning Soil Utility Rooms with revised date of 1/15/03 reads in part:
Laundry will be contained in a hamper and in a large clear liners.

During a tour of the Intensive Care Unit (3rd floor) on 6/11/13 at 1:30 p.m. through 1:45 p.m. the following were noted:

Observation of the crash cart located outside of the door next to ICU #2 revealed a layer of dust on top of the cart.

Observation of a 3 tier alumni cart located in the area where the supplies are kept next to the Unit Managers office revealed:
a) 1st tier a portable cardiac monitor with a cable wire connecting EKG lead wires, & pulse oximeter with the top of the monitor covered with visible layer of dust and strands of hair on the surface of the tier.
b) 2nd tier 2 kangaroo feeding pumps with tags on each, dust was on the surface of the tier.
c) 3rd tier 2 pairs of pneumatic hose without the pumps were cover with dust as evidence by the surveyor running her fingers over the surface of the hoses.

Observation of ICU #2 revealed an IV pump on the pole with white substance on the back of the pump and dust and dirt on the base of the IV pole stand, and the pole which the MAPP(electronic blood pressure machine on a stand) had dirt on the base as evidence by the dirt on the surveyor's hand after touching the base. There was a visible layer of dust on the cardiac monitor. Requested policy for cleaning of equipment and ICU. According to S20RN Unit Manager the hospital did not have a policy for cleaning the equipment in the ICU such as the monitor, cables and etc . just for the IV pump She stated they are wiped down with an approved germicidal,with the exception of the IV pumps, the hospital had a policy.

Review of the hospital policy title : Cleaning of Intensive Care Units with revised date of 1/15/03 reads in part:
Clean the pantry area.
Clean the countertops.

Review of the hospital policy title: Cleaning IV pumps and Poles with revised date of 1/15/03 reads in part:
Upon discharged of IV pumps, maids will disinfect, clean,....
IV pumps will be sprayed with vesphine germicidal and wiped dry.
Nursing may assist in cleaning after hours if the pumps are needed......

Interview on 6/11/13 at 1:47 p.m. with S20 RN Unit Manager confirmed the above were all infection control issues. According to S20RN Unit Manager housekeeping is responsible for cleaning the equipment after discontinued use and or discharge.

During a tour of the Operating Room with S20RN Unit Manager on 6/12/13 at 8:45 a.m. through 9:00 a.m. the following was noted:

Observation of Operating Room #3 which was an empty room which had been cleaned from an earlier case. The base of the Da Vinci 9443A Surgical System ( used for Robotic Laparoscopic Hysterectomy) had a layer of dust and dirt noted on the base. Foot pedal, monitor arm, Unit patient consult monitor bracket all had dust present as evidenced by the dust on the hand of the surveyor.

Interview on 6/12/13 at 9:00 a.m. with S20RN Unit Manager confirmed dust and dirt were presented on the equipment and should not have been. According to S20RN the equipment would have to be cleaned again. She also stated this was not an acceptable practice and S18Infection Control Nurse would be notified along with Operating Room Manager.

Interview on 6/12/13 at 9:42 a.m. with S18Infection Control Nurse confirmed that housekeeping issues were problems throughout the hospital however she was not aware of the dust/dirt in ICU and OR.

During a tour of the Dietary Department with S21Registered Dietician on 6/12/13 at 10:15 a.m. through 10:45 a.m. the following was noted :

a) Fans in both of the walk-in cooler and walk-in freezer were caked with thick layer of dust.
b) Dry storage area with 5 bottles of salad dressing with dust noted on the bottles and on the surface of the tray.
c) Hood over the stove with grease and dust on the fan unit.
d) A pitcher located in the refrigerator located in the cooking area (cooks refrigerator) with label "Pat's tea."

An interview on 6/12/13 at 10:55 a.m. with S21Registered Dietician confirmed the fans, hood, and tray needed to be cleaned. She stated that the pitcher should not have been stored in the refrigerator as this was not for employees use. S21Registered Dietician removed the pitcher and disposed of the pitcher and its content in the trash can. According to S21Registered Dietician, maintenance is responsible for cleaning the fans and the stove hood however she will monitor her area more closely.

Review of the cleaning duties presented by S21Registered Dietician revealed the hood should be cleaned weekly, no personal items allowed in the kitchen, and the walk in freezer and cooler are straighten up daily.

During a tour of the Laboratory Department with S32Laboratory Directory on 6/12/13 at 1:20 p.m. through 1:35 p.m. the following was noted :
a) Visible dust on Napco machine, and hood located in the Microbiology Room.
b) Visible dust on Hematology Analysis machine located in main section of the laboratory(front).
c) Storage refrigerator used for reference lab samples, fresh frozen plasma had a green striped dish cloth on the top shelf.

An interview on 6/12/13 at 1:35 p.m. with S32Laboratory Director confirmed the above observations. According to S32Laboratory Director housekeeping is an issue in all departments and he is trying to have his staff do more in the ways of cleaning their areas more often and checking up behind one another.

An interview on 6/14/13 at 9:00 a.m. with S23Housekeeping Supervisor confirmed his awareness of some of the housekeeping issues however he was not aware of the issues in the OR, ICU, Dietary, and Laboratory.


31206