HospitalInspections.org

The Condition of Patient Rights has not been met.

Based on clinical record review and interview for 1 (P#200) of 4 patients who received care in the Behavioral Health area of the Emergency Department (ED) the facility failed to ensure that the patient was free from physical abuse, that the Security Officer (SO) had updated training on crisis prevention and failed to ensure that the hospital policy included guidance as to notification of local law enforcement when a crime occurred.


Please see A144 and A467

Based on clinical record review and interview for 1 (P#200) of 4 patients who received care in the Behavioral Health area of the Emergency Department (ED) the facility failed to ensure that the patient was free from physical abuse, that the Security Officer (SO) had updated training on crisis prevention and failed to ensure that the hospital policy included guidance as to notification of local law enforcement when a crime occurred. The findings include:

A. P#200 was evaluated in the ED, medically cleared and placed in the behavioral health area of the ED for a crisis evaluation. P#200's history included antisocial personality disorder, bipolar disorder and schizophrenia. According to facility documentation P#200 was experiencing paranoid delusions. On 11/27/17 at 6:30 AM P#200 was belligerent, agitated and verbally abusive to staff. He/she was reevaluated and Geodon 20 milligrams intramuscular (used to treat Schizophrenia and the manic symptoms of bipolar disorder) was ordered.

During an interview with RN#100 on 12/11/17 at 12:00 PM, RN#100 indicated when he/she first encountered P#200 he/she was verbally loud and refused to be evaluated by the physician. The physician ordered P#200 to receive an intramuscular injection (IM) of Geodon. RN#100 called security for assistance because of P#200's behaviors. SO#10 and SO#20 responded to assist as per usual routine in that situation. RN#100 indicated when SO#10 and SO#20 entered the room P#200 was in bed with a blanket covering his/her head. When P#200 saw SO#10, P#200 immediately jumped out of bed and became louder and stood in front of SO#10 in a "fighting stance". RN#100 proceeded to stand behind SO#10. RN#100 indicated he/she was not familiar with P#200 therefore he/she consulted with SO#20 who instructed RN#100 that P#200 was not usually assaultive and would back down when authority showed control of the situation. SO#10 removed the radios from his/her person and positioned him/herself in a "fighting stance" in front of P#200. SO#10 and P#200 continued to argue back and forth. RN#100 indicated he/she signaled for staff to call for assistance because the situation was continuing to escalate. When he/she turned around RN#100 saw SO #10 lunge at P#200 and push P#200 onto the bed at which time both P#200 and SO #100 rolled off the bed onto the floor of the opposite side of the bed. P#200 was on the floor up against the bed and wall. RN#100 saw SO#10 strike P#200 in the face with a closed fist. Upon surveyor inquiry RN#100 did not recall the number of times SO#10 struck P#200 and he/she did not recall seeing P#200 strike SO#10 at any time.

During an interview with Crisis Clinician (CC) #10 on 12/11/17 at 1:00 PM he/she indicated while evaluating a patient in another room (Room 8) he/she overheard loud voices and an altercation coming from P#200's room (Room 12). CC#10 indicated SO#10 was loudly saying "Come on". "Are you going to make this day". CC#10 then proceeded to P#200's room. Upon arrival he/she saw SO#10 with his/her arms around P#200 rolling over P#200's bed to the floor on the opposite side of the bed. CC#10 indicated he/she did not see P#200 strike SO#10. CC#10 then saw SO#10 make closed fist punching gestures towards P#200. CC#10 did not see SO#10's fist make contact with P#200. CC#10 then loudly yelled for SO#10 to stop however SO#10 continued to strike P#200 a total of 3-4 times. CC#10 indicated SO#10 stopped striking P#200 when additional emergency staff arrived within minutes.

During an interview with Security Officer (SO) #20 on 12/11/17 at 2:00 PM, he/she indicated a medical assist was called to P#200's room and SO#10 and SO#20 responded to the room. RN#100 needed to administer medication to P#200 and he/she was threatening violence. Upon arrival, when P#200 saw SO#10 he/she immediately stood up and got into SO#10's face yelling and cursing. At first SO#10 did not respond to P#200. SO#10 proceeded to inform P#200 that he/she needed to get back in bed. SO#10 began assisting P#200 back to bed at which time both P#200 and SO#10 rolled off the bed opposite side of the bed onto the floor. SO#20 indicated he/she did not see P#200 strike SO#10. SO#10 then proceeded to strike P#200 3-4 times in the face.

According to a written report by SO#10 dated 11/27/17 at 8:30 AM, SO#10 indicated P#200 had stood in a fighting stance in front of SO#10 with his/her fist balled up, threatening to hang and kill SO#10. SO#10 indicated he/she attempted to deescalate the situation and distance him/herself from P#200. Initially P#200 sat back on the bed however when RN#100 approached P#200 with the injection P#200 stood up in RN#100's face with a balled fist, threatening him/her. RN#100 ran behind SO#10 and SO#10 instructed P#200 to lie back in bed. P#200 continued to approach SO#10 swinging his/her fist, striking SO#10 several times in the face. The report indicated SO#10 attempted to subdue P#200 by placing P#200 on the bed, while P#200 continued to strike SO#10 on the nose and right eye. SO#10 indicated in the report he/she then struck P#200 in an attempt to defended him/herself and stop P#200 from assaulting SO#10. SO#10 was eventually able to hold P#200's arms and stop him/her from striking SO#10.

According to medical record documentation subsequent to the incident, P#200 was moved to the main ED for medical evaluation and treatment. P#200 suffered from a nasal bone fracture and left orbital floor fracture. His/her injuries did not require surgical intervention and P#200 was transferred to Inpatient Behavioral Health for admission.

The hospital's Patient Rights policy indicated the patient has the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. In addition, the Employee behavior policy indicated behaviors including: fighting or assault on a patient, visitor, supplier and/or a fellow employee are prohibited.


B. During a review of SO#10's employee file with the Vice President (VP) of Regulatory Readiness on 12/11/17 it was identified that SO#10 previously had non-violent crisis prevention (CPI) training however his/her annual training had expired 4/20/16 and SO#10 had not received his/her annual competency training for 2017.


C. Health Stream Patient Assault and Abuse training indicated patient abuse by a healthcare worker is a breach of medical ethics. In addition assault and abuse are crimes punishable by jail time and fines.

During a review of hospital policies (Patient Rights and Workplace Violence with the Vice President (VP) of Regulatory Readiness and the Executive Nursing Director of the ED om 12/11/17 and 12/12/17 it was identified that the policies did not address the notification of local law enforcement in the case of an alleged/witnessed assault or abuse of a patient, visitor or employee occurs. Additionally review of the hospital policies did not identify the procedure to implement should an allegation or witnessed incident of assault or abuse occur.

Based on clinical record review and interview for 1 (P#200) of 5 patients reviewed for the use of restraints the hospital failed to ensure restraints were applied based on an accurate physicians order. The findings include:

P#200 was evaluated in the ED for a crisis evaluation. P#2's history included antisocial personality disorder, bipolar disorder and schizophrenia.

A physicians order entered on 11/27/17 at 10:55 AM by Registered Nurse (RN) #100 and cosigned by Medical Doctor (MD) #100 on 11/27/17 at 11:19 AM indicated an order for the use of four side rail restraints however according to progress notes and assessments on 11/27/17 at 8:30 AM P#200 was placed in bilateral double secure hard locked wrist and ankle restraints.

During a review of the physician orders with the Executive Nursing Director of the ED on 12/12/17 at 9:00 AM he/she indicated the documentation of the MD order for restraints was inaccurate because side rails are not used/available in the Behavioral Health area of the ED. He/she indicated RN#100 must have chosen the wrong option when entered the order in the electronic medical record during the emergent incident subsequently there was no order for the restraint.