HospitalInspections.org

Based on observation during inspection tours, review of procedures and records, and staff interviews, it was determined the facility 's Governing Body did not ensure effective accountability for all hospital operations as required.

Findings include:

The governing body did not exercise its responsibility for the monitoring and implementation of effective operations and clinical services in the facility as evidenced by non compliance with the following Conditions of Participation and regulatory requirements:

?482.13 Condition of Participation: Patient's Rights
?482.55 Condition of Participation: Emergency Services .

1. Condition level non compliance was identified for Patient's Rights.

The facility failed to provide a safe environment of care in accordance with patients' rights requirements.

The facility failed to establish a policy and procedure for the use of chemical restraints.

The facility failed to evaluate the need for use of the least restrictive restraint for patients in the Emergency Department.

The facility failed to provide monitoring of a patient who was restless and agitated and was restrained in the Emergency Department.

The facility did not conform to regulatory requirements for the mandatory reporting of a patient death while in restraints to the Centers for Medicare and Medicaid Services (CMS).

Refer to findings detailed under Tag #A115, A144, A160, A164, A175 and A214.

2. Condition level non compliance was identified for Emergency Services.

The facility failed to provide emergency care that met general standards of practice.

The facility did not develop or implement effective procedures in the emergency department consistent with accepted practice standards. Specifically, the facility failed to:
1) formulate and implement an (ED) emergency department triage policy and procedure that accurately reflects the triage practice and ensures triage is performed by qualified staff, 2) implement a policy and procedure that ensures effective supervision of patients who require special monitoring for their safety, 3) failed define "reasonable physical force" in existing policy to be used by Hospital Security to prevent patients from exiting the ED without reference to what constitutes such reasonable force and 4)maintain a comprehensive Emergency Department (ED) Log that was easily retrievable.

Cross-refer also to citations noted under tag A1100, A1101 and A1104.
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Based on review of records , procedures, and staff interviews, the facility did not comply with requirements for the protection and promotion of patients' rights as required.

Findings include:

The facility failed to meet the Condition of Participation for Patient Rights due to non-compliance with requirements as follows:

1. The facility did not provide a safe and secure environment for patients in the psychiatric emergency room . (MR #1, #3, and #4)
Refer to findings detailed under Tag #A144.

2. The facility has no policy and procedure in place for the use of chemical restraints.
Refer to findings detailed under Tag #A160.

3. The facility failed to evaluate the need for use of the least restrictive restraint for patients in the Emergency Department.
Refer to findings detailed under Tag #A164.

4. The facility failed to provide monitoring of a patient who was restless and agitated and was restrained in the Emergency Department.
Refer to findings detailed under Tag #A175.

5. The facility did not conform to regulatory requirements for the mandatory reporting of a patient death while in restraints to the Centers for Medicare and Medicaid Services (CMS).
Refer to findings detailed under Tag #A214.
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Based on review of medical records and other documents, it was determined that the facility did not effectively ensure a safe environment as per facility policy. This deficiency is evident in three medical records reviewed (MR#s1, #3 and #4).
Findings include:
1) Review of MR#1 on 5/29/13 found that the patient who had presented to the ED with altered mental status was placed in 2 point arm restraints on 5/11/03 at 0335 hours (3:35AM) . However, the restraint record did not indicate its discontinuance. The surveyor reviewed three security reports, written by three different officers which were all dated 5/11/13 and timed at 0405 hours (4:05 AM).

The first security report stated that the patient who was on close observation in stretcher #1 kept falling out of her stretcher during the eight hour tour. At one point, the officer was asked to pick the patient up and called a worker from Emergency Medical Services, who "grabbed the patient under her arms from her back and pulled her up."

Security report #2 at 4:05 AM stated that the patient fell out of her stretcher to the floor and that he and and a security guard #1 put her back to the stretcher and the patient was placed in wrist restraints by nursing staff. This report stated that fifteen minutes later the patient got out the restraints and fell out of the stretcher again.

Security report #3 noted that the patient fell out of the stretcher and that this officer assisted the other two officers and one emergency medical worker to put the patient back on the stretcher .

There was no evidence that the medical staff assessed the patient's agitation or persistent vomiting. The patient was administered an antiemetic. The patient was restrained ( 2 point ) to keep her from " falling ". An order for Versed 4mg IV was ordered at 0225 (2:25AM) on 5/11/13 and was administered at 0229 (2:29AM). There was no evidence that the patient's vomiting was taken into consideration in the use of restraints. There was no evidence that the patient's history of being found at the foot of a staircase was re-examined for delayed signs of trauma. There was no evidence of re-assessment of the patient even after she fell out of the stretcher even while restrained to rule out further head trauma. The medical record indicated that the patient had been on "security monitoring. " At interview with the administrative and clinical ED staff on 5/28/13 at 10 AM it was stated that this the patient was on "close observation. " However, this level of close security monitoring permits an assignment of 1 security officer to 13 patients.

This patient's creatine phospokinase (CPK) result at 1659 hours found it to be 531 IU/L which is high out of range (38-174 IU/L ). There was no evidence this matter was promptly addressed and hence this patient did not receive an appropriate level of monitoring.

The record stated that the patient was on "cardiac monitoring " . There were, however, no rhythm strips or record of any alarm going off when the patient went into ventricular fibrillation.

The patient was found in cardiac arrest in a prone position at 0500 (5:00AM) . The patient was pronounced dead at 5:34 AM on 5/11/13. It is evident that there was no documentation of monitoring from 4:20 AM to 5:00 AM , when the patient was found prone and in cardiac arrest.

2) Review of MR #3 on 5/30/13 noted this 16 year old female, who was accompanied by her mother, arrived on 2/22/13 at about 10:42PM to the Emergency Department (ED) via Emergency Medical Services (EMS). Per EMS "patient is having anxiety attack. Wants to kill herself."
Vital signs were taken at 10:42PM and noted to be T: 98.9, HR: 99, RR:18, B/P: 130/85. The patient was seen at 11:22 PM and examined by the physician and urine toxicology was done. The attending physician documentation indicated that the patient was medically cleared pending psychiatric consult and close observation.
The patient had a psychiatric consult on 2/23/13 at 12:46 AM which recommended that the patient remain in the ED on close observation and psychiatric re-evaluation on 2/24/13.
This record did not reflect that staff considered the need for one to one arms length monitoring, given the patient's suicidal ideation.
Department of Emergency Medicine Security Guard Close Observation Form indicated that the patient (MR#3) was started on close observation on 2/22/13 without indication to time.
Review of an incident/situation report on 5/30/13 dated 2/25/13 by a security officer, documentation indicated that on 2/24/13 about 8:40 pm he "caught" a male patient (MR#4) and this female patient (MR#3) in the same bathroom at the same time, "they were just talking".
According to the Psychiatric Patient Treatment Observation policy, last revised on 1/21/11, it was noted: "until the Close Observation order is rescinded, the security officer will remain outside of the Psychiatric room, and will prevent the exit of the patient from this room, except to escort the patient to the bathroom". The facility therefore, did not follow its procedure that requires the officer to escort patients to the bathroom.
Furthermore, a follow up incident of sexual encounter between these two patients was noted. On 2/24/13 about 10:30PM documentation indicated that the female patient in MR #3 was engaged in an observed sexual encounter with a male patient referenced in MR #4.
3) Review of MR #4 on 5/30/13 noted this 15 year old male was brought in by emergency medical service (BIBEMS) and NYPD on 2/24/13 following a confrontation with his father, his mother called the police. Physician's documentation indicated that the patient's mother requested psych evaluation for behavioral concerns at home. The past medical history is significant for Attention- Deficit/ Hyperactivity Disorder (ADHD) and two inpatient admissions.
Vital signs on 2/24/13 at 1:04 AM were noted to be T: 97.8, HR: 69, R: 20, B/P: 127/79. The patient was seen and examined by the physician on 2/24/13 at 1:37 AM. The plan was for psychiatric consult and continuous observation.
The patient had a psychiatric consult on 2/24/13 at 7:32 pm and recommendation was made to remain in the ED on close observation and for re-evaluation on 2/25/13. The Security Guard Close Observation form indicated that the patient was placed on close observation on 2/24/13 at 1:07am.
Review of an incident/situation report on 5/30/13 dated 2/25/13 by a security officer, documentation indicated that on 2/24/13 about 8:40 pm he "caught" this male patient (MR#4) and a female patient (MR#3) in the same bathroom at the same time, "they were just talking".
According to the Psychiatric Patient Treatment Observation policy, last revised on 1/21/11, it was noted: "until the Close Observation order is rescinded, the security officer will remain outside of the Psychiatric room, and will prevent the exit of the patient from this room, except to escort the patient to the bathroom". The facility therefore, did not follow its procedure that requires the officer to escort patients to the bathroom.
Furthermore, a follow up incident of sexual encounter between these two patients was noted. On 2/24/13 about 10:30PM documentation indicated that the patient in MR #3 was engaged in an observed sexual encounter with a male patient referenced in MR #4.
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Based on review medical records,policy and procedures and staff interview, the facility administered medications as a chemical restraint in 2 out of 10 patients and failed to develop policies and procedures for the use of chemical restraints. (MR #1 and #2)

Findings include:

Review of MR #1 and MR#2 document the use of medications as a restraint. Refer to findings under A144.

Review of the facility procedure titled, "Use of Seclusion and Restraint for Behavioral purposes" on 5/28/13 found it did not reference any use of chemical restraints or drugs used to manage patient behavior. However, at interview with the ED nursing manager on 5/28/13 it was stated that chemical restraint is used in the emergency room.

Refer to findings detailed under Tag #s A164 and A175.
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Based on record review and interview, it was determined that the hospital failed to evaluate the need for use of the least restrictive restraint for the patients. This finding was identified in 2 out of 5 applicable Emergency medical records reviewed. (MR #1 and MR#2)

Findings include:

1) Review of MR #2 on 5/28/13 found that the patient arrived on 5/27/13 at 2125 hours (9:25PM) per the ambulance call report and was triaged at 2135 (9:35PM).
Review of the ACR (ambulance call report ) indicated that the patient was in a "restraining bag". The ACR noted the patient had been in a fight, was bleeding from his face and head, and had "AOB" (alcohol on breath). Further the ACR noted the patient was "cooperative" with EMS crew.

The patient was a 21 year old male transported to the ED on 5/28/13 by EMS (Emergency Medical Service ) and NYPD (New York City Police Department) officers under arrest, handcuffed, and in a full body restraint applied by the NYPD Emergency Services Unit (ESU).

The ED triage note dated 5/27/13 at 9:38 PM noted "as per PD ( Police Department) patient violent and spitting at officer". The patient was assigned a triage level of ESI-3 (Emergency Severity Level) which is "urgent" but not emergent.

The triage note did not document the information recorded in the ACR with reference to the forehead laceration with the right eye swollen shut. Further the triage note, records under the section titled "Assessments/Screening" that the patient is combative. No vital signs were recorded in triage.

At 9:35 PM on 5/27/13, the nurse documented that: "Patient placed in burrito bag by ESU. Patient fighting and spitting at PD."

The facility staff applied a 4 point restraint without documented justification for the use of restraint. The physician restraint order at 2000 on 5/27/13 noted the 4 point restraint was started at 2000 (8 PM) for "verbally aggressive/threat of harm/combative/violent". There was no documented evidence that this patient was observed by staff to be violent in the hospital.

The time of the Restraint order and initiation of the 4 point restraint was recorded as 2000 hours (90 minutes prior to the patient's actual arrival at the hospital.) No restraint flow sheet was found in the medical record.

Chemical restraints were concurrently utilized. The Medication Administration Record (MAR) documented that between 9:52 PM and 10:01 PM on 5/27/13 dated, that the patient was administered Versed (a benzodiazepine used for sedation) 6mg IV Push and Haldol (an antipsychotic drug) 5 mg IM (intramuscuular) by the ED resident defined as "chemical sedation."
The nursing note written at 10:15 PM on 5/27/13 documented the "patient was chemically sedated for patient and other safety."

The physician note documented at 12:43 AM on 5/28/13 noted Versed and Haldol were administered in the ED for agitation.

The initial set of documented vital signs were entered as taken at 0437 hours, 7 hours after arrival.

During interview on 5/29/13 with the staff ED RN assigned to the patient it was stated that the patient was placed into 4 point restraints on arrival. It was stated by the nurse that the second upper extremity 4 point restraint was not placed as that arm had a forensic restraint already applied (handcuffs).

At interview with the RN on 5/28/13 at 1PM, who documented initial care provided to the patient, stated that the patient presented to the ED in a "burrito bag," in a prone position and handcuffed to his back. The RN stated that after 5 minutes, the bag was unzipped to the waist, the bag was removed by Police and ED staff, the patient was unhandcuffed, and then administered Versed 6 mg IVP (intravenous push) and Haldol 5 mg. IM (intramuscular) by the ED resident. He stated that the patient was turned to the supine position, from the prone position by ED staff. There was no documentation of the sequence of events described during the interview except the administration of Versed 6mg IVP (intravenous push) and Haldol 5mg IM (intramuscular) at 2201 hours. (10:01 PM ).

There was no progress note in the medical record by nursing or medical staff as to how long the body bag was on place prior to its removal. There was no reference as to the position of the patient on arrival (prone, supine, or side-lying ) and whether additional forensic restraints were in place and the time that the patient remained in the prone position in the body bag while in the ED. There was no record of the sequence of events in the transition from the body bag with patient in prone position and handcuffs to the back to supine.

Review of the record on 5/28/13 determined the the physician failed to provide an individualized clinical assessment of the need for restraints that were subsequently applied by hospital staff immediately upon arrival. There was no evidence that less restrictive alternatives were considered.

It was stated at interview with nursing staff on 5/29/13 that the patient had arrived in a full body bag in a prone position and handcuffed to the back. It was also stated this bag is made of a heavy burlap type material and is meant for transport, not for long term use.

2) Review of MR#1 on 5/29/13 found that the patient who had presented to the ED with altered mental status was placed in 2 point arm restraints on 5/11/03 at 0335 hours (3:35AM) . However, the restraint record did not indicate its discontinuance. The surveyor reviewed three security reports, written by three different officers which were all dated 5/11/13 and timed at 0405 hours (4:05 AM).

The first security report stated that the patient who was on close observation in stretcher #1 kept falling out of her bed during the eight hour tour. At one point, the officer was asked to pick the patient up and called a worker from Emergency Medical Services, who "grabbed the patient under her arms from her back and pulled her up."

Security report #2 at 4:05 AM stated that the patient fell out of her stretcher to the floor and that he and and a security guard #1 put her back to the stretcher and the patient was placed in wrist restraints by nursing staff. This report stated that fifteen minutes later the patient got out the restraints and fell out of the stretcher again.

Security report #3 noted that the patient fell out of the stretcher and that this officer assisted the other two officers and one emergency medical worker to put the patient back on the stretcher bed.

There was no evidence that the medical staff assessed the patient's agitation or persistent vomiting. The patient was administered an antiemetic. The patient was restrained ( 2 point ) to keep her from " falling " . An order for Versed 4mg IV was ordered at 0225 AM on 5/11/13 and was administered at 0229. There was no evidence that the patient's vomiting was taken into consideration in the use of restraints. There was no evidence that the patient's history of being found at the foot of a staircase was re-examined for delayed signs of trauma. There was no evidence of re-assessment of the patient even after she fell out of the stretcher even while restrained to rule out further head trauma. The medical record indicated that the patient had been on "security monitoring. " At interview with the administrative and clinical ED staff on 5/28/13 at 10 AM it was stated that this the patient was on "close observation. " However, this level of close security monitoring permits an assignment of 1 security officer to 13 patients.

Despite security documentation of falling out of the stretcher while in restraints, there was no documentation of this course of events in the patient record. Review of MR#1 found no reference to the patient removing her restraints and them having to be re-applied.
Security officers' reports documented on 5/11/13 at 0405 AM noted the patient had gotten out of restraints and had fallen off of the stretcher in the emergency room at that time. It was noted on this report " an unknown Emergency Medicine Technician (EMT) asked us to move out of the way while he placed his arms under the patient and lifted her." Security placed the patient back on the stretcher and the patient was placed in wrist restraints by nursing staff. A security supervisory report at 0405 AM on 5/11/13 stated that fifteen minutes after this incident (about 4:20 AM on 5/11/13) the patient got out the restraints and fell out of the stretcher again.

The record stated that the patient was on "cardiac monitoring " . There were, however, no rhythm strips or record of any alarm going off when the patient went into ventricular fibrillation.

The patient was found in cardiac arrest in a prone position at 0500 (5:00AM) . The patient was pronounced dead at 5:34 AM on 5/11/13. It is evident that there was no documentation of monitoring from 4:20 AM to 5:00 AM , when the patient was found prone and in cardiac arrest.

Cross reference associated findings noted under tag # A1100 and A1101.
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Based on record review, documents, and interviews, it was evident that the hospital failed to provide monitoring of a patient who was restless and agitated and was restrained. This finding was identified in 1 out of 10 applicable Emergency medical records reviewed. ( MR#1)


Findings include:

Review of MR#1 on 5/29/13 found that the patient who had presented to the ED with altered mental status was placed in 2 point arm restraints on 5/11/13 at 0335 hours (3:35AM) . However, the restraint record did not indicate its discontinuance. The surveyor reviewed three security reports, written by three different officers which were all dated 5/11/13 and timed at 0405 hours (4:05 AM).

The first security report stated that the patient who was on close observation in bed #1 kept falling out of her bed during the eight hour tour. At one point, the officer was asked to pick the patient up and called a worker from Emergency Medical Services, who "grabbed the patient under her arms from her back and pulled her up."

Security report #2 at 4:05 AM stated that the patient fell out of her bed to the floor and that he and and a security guard #1 put her back to bed and the patient was placed in wrist restraints by nursing staff. This report stated that fifteen minutes later the patient got out the restraints and fell out of the bed again.

Security report #3 noted that the patient fell out of bed and that this officer assisted the other two officers and one emergency medical worker to put the patient back to bed.

There was no evidence that the medical staff assessed the patient's agitation or persistent vomiting. The patient was administered an antiemetic. The patient was restrained ( 2 point ) to keep her from " falling " . An order for Versed 4mg IV was ordered at 0225 AM on 5/11/13 and was administered at 0229. There was no evidence that the patient's vomiting was taken into consideration in the use of restraints. There was no evidence that the patient's history of being found at the foot of a staircase was re-examined for delayed signs of trauma. There was no evidence of re-assessment of the patient even after she fell out of the stretcher even while restrained to rule out further head trauma. The medical record indicated that the patient had been on "security monitoring. " At interview with the administrative and clinical ED staff on 5/28/13 at 10 AM it was stated that this the patient was on "close observation. " However, this level of close security monitoring permits an assignment of 1 security officer to 13 patients.

This patient's creatine phospokinase (CPK) result at 1659 hours found it to be 531 IU/L which is high out of range (38-174 IU/L ). There was no evidence this matter was promptly addressed and hence this patient did not receive an appropriate level of monitoring.

Despite security documentation of falling out of bed while in restraints, there was no documentation of this course of events in the patient record. Review of MR#1 found no reference to the patient removing her restraints and them having to be re-applied.
Security officers' reports documented on 5/11/13 at 0405 AM noted the patient had gotten out of restraints and had fallen out of bed in the emergency room at that time. It was noted on this report " an unknown Emergency Medicine Technician (EMT) asked us to move out of the way while he placed his arms under the patient and lifted her." Security placed the patient back on the bed and the patient was placed in wrist restraints by nursing staff. A security supervisory report at 0405 AM on 5/11/13 stated that fifteen minutes after this incident (about 4:20 AM on 5/11/13) the patient got out the restraints and fell out of the bed again.

The record stated that the patient was on "cardiac monitoring " . There were, however, no rhythm strips or record of any alarm going off when the patient went into ventricular fibrillation.

The patient was found in cardiac arrest in a prone position at 0500 (5:00AM) . The patient was pronounced dead at 5:34 AM on 5/11/13. It is evident that there was no documentation of monitoring from 4:20 AM to 5:00 AM , when the patient was found prone and in cardiac arrest.
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Based on record review and staff interview, it was determined that the facility did not conform to regulatory requirements for the mandatory reporting of a patient death while in restraints to the Centers for Medicare and Medicaid Services (CMS). Specific reference is made to MR#1, where this patient was restrained within a 24 hour period prior to death .

Findings include:

Review of MR #1 on 5/28/13 at approximately 10 AM found this patient with noted altered mental status was taken to the emergency room by Emergency Medical Services on 5/10/13 after having been found on the floor. The patient received chemical restraints during the course of the ED encounter: A chemical restraint (Versed 4 mg IVP) was ordered and administered. Versed 4mg IVP was ordered at 0225 (2:25AM) on 5/11/13 and was administered at 0229AM. The patient was also restless and a 2 point restraint was ordered at 0324 (3:24AM) and was implemented at 3:35 AM on 5/11/13. Security officers' documented three reports dated 5/11/13 at 0405 (4:05AM) which noted the patient had fallen out of bed in the emergency room at that time. It was noted on this report " an unknown Emergency Medicine Technician ( EMT) asked us to move out of the way while he placed his arms under the patient and lifted her." Security placed the patient back on the bed and the patient was placed in wrist restraints by nursing staff. A security supervisory report at 0405 (4:05AM) on 5/11/13 stated that fifteen minutes after this incident the patient got out the restraints and fell out of the bed again.
Of note, the medical record did contain a restraint monitoring flow sheet entered at 3:35 AM on 5/11/13. However, this form did not measure specific observations at each key time interval as required , such as safety, respiratory status, vital signs, fluids, toileting, position of restraints, and mobility. Consequently, there was no evidence to demonstrate when or if the physical restraints were removed.

The patient was found in cardiac arrest at 5:00 AM and expired at 5:34 AM.

The medical record did not document evidence of required reporting to the Centers for Medicare and Medicaid Services (CMS) within 24 hours.

Regulatory requirements mandate that the hospital must report information to CMS for each death that occurs while a patient is in restraint or seclusion, including " each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. "

At interview with Nursing Quality Assurance Director on 5/29/13 at approximately 9:30 AM, it was stated this report was not essential.
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Based on record review and interview, it was determined that the hospital did not meet the needs of its patients in that the emergency department failed to provide emergency medical care that conforms with accepted standards of practice.


Findings include:

1. The hospital failed to provide emergency medical care that conforms with general standards of practice. This was evident in 4 of 10 medical records reviewed. (MRs #1, #2, #3, and #4).
See tag #A1101.

2. facility did not develop or implement effective procedures in the emergency department consistent with accepted practice standards. Specifically, the facility failed to:
1) formulate and implement an (ED) emergency department triage policy and procedure that accurately reflects the triage practice and ensures triage is performed by qualified staff, 2) implement a policy and procedure that ensures effective supervision of patients who require special monitoring for their safety, 3) failed define "reasonable physical force" in existing policy to be used by Hospital Security to prevent patients from exiting the ED without reference to what constitutes such reasonable force and 4)maintain a comprehensive Emergency Department (ED) Log that was easily retrievable.
See tag #A1104.
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Based on record review and interview, it was determined that the emergency department was not organized and directed in accordance with requirements in that the hospital failed to provide emergency medical care that conforms with general standards of practice. This was evident in 4 of 10 medical records reviewed. (MRs #1, #2, #3, and #4)

Findings include:

1) MR#1 reviewed on 5/28/13 is a 38 year old female patient who was noted to be 290 lbs. and approximately 5'9" in height who was transported to the ED (emergency department) on 5/10/13 by EMS, after having been found on a floor with altered mental status and was arousable to pain only. The Ambulance Call Report (ACR) did not state if this event occurred at home or in a public place

The patient presented with minimal responsiveness and did not receive a complete assessment to rule out traumatic brain injury in the setting of persistent restlessness and vomiting that developed late in the course of the ED visit.

The ED triage note on 5/10/13 at 4:57 pm records that "patient states: pt. found unresponsive, cold, clammy and diaphoretic." The triage acuity level was noted as (2), which is categorized as very urgent by ESI (Emergency Severity Index )
triage guidelines. This nursing triage note does not reference the information as documented in the ACR about the patient being found on the floor. The resident physician note at 5:56 PM on 5/10/13 noted the presented to the ED "after being found on ground". Subsequent documentation from the physician attending on 5/10/13 at 6:05 PM references a discussion with the resident and documents the patient presented to the ER "after being found on the bottom of the stairs".Consequently, documentation of the circumstances of the injury varied between the EMS documentation on the ACR and hospital triage records. There is no documented evidence in the medical record as to how the ED staff ascertained that the patient was found at the foot of a staircase.

There was no evidence in the medical record that the patient was ruled out for any trauma other than brain injury by a CT scan. The CT (CAT) scan of the brain was performed at 8:06 PM on 5/10/13. The interpretation of this exam, dated 5/11/13 at 4:15 AM noted "markedly limited evaluation due to motion artifact".

The patient developed several episodes of vomiting during the course of the ED visit. The nurse noted at 2:57 AM on 5/11/13 that patient vomited in bed, pulling her sheets off and exposing herself. The physician noted several vomiting episodes at 4:30 AM on 5/11/13.

The hospital also failed to provide proper monitoring of this patient, who was restless and agitated and was restrained. The patient who had presented to the ED with altered mental status was placed in 2 point arm restraints on 5/11/03 at 0335 hours (3:35AM) . However, the restraint record did not indicate its discontinuance. The surveyor reviewed three security reports, written by three different officers which were all dated 5/11/13 and timed at 0405 hours (4:05 AM).

The first security report stated that the patient who was on close observation in bed #1 kept falling out of her stretcher during the eight hour tour. At one point, the officer was asked to pick the patient up and called a worker from Emergency medical Services, who "grabbed the patient under her arms from her back and pulled her up."

Security report #2 at 4:05 AM stated that the patient fell out of her stretcher to the floor and that he and and a security guard #1 put her back on the stretcher and the patient was placed in wrist restraints by nursing staff. This report stated that fifteen minutes later the patient got out the restraints and fell off of the stretcher again.

Security report #3 noted that the patient fell out of bed and that this officer assisted the other two officers and one emergency medical worker to put the patient back to the stretcher.

There was no evidence that the medical staff assessed cause of the patient's agitation or persistent vomiting. The patient was administered an antiemetic at 1:57 AM on 5/11/13. The patient was restrained (2 point ) to keep her from " falling ". There was an order for Versed 4 mg IV was ordered at 0225 (2:25AM) on 5/11/13 and was administered at 0229 (2:29AM). There was no evidence that the patient's vomiting was taken into consideration in the use of restraints. There was no evidence that the patient's history of being found at the foot of a staircase was re-examined for delayed signs of trauma. There was no evidence of re-assessment of the patient after she fell out of the stretcher, even while restrained to rule out further head trauma. The medical record indicated that the patient had been on "security monitoring. " There was no evidence of neurological monitoring of this patient given the finding the patient had fallen repeatedly off the stretcher and given that the CT of the brain was inconclusive.

At interview with the administrative and clinical ED staff on 5/28/13 at 10:00 AM it was stated that this the patient was on "close observation. " However, this level of close security monitoring permits an assignment of 1 security officer to 13 patients.

This patient's CPK result at 1659 hours found it to be 531 IU/L which is high out of range (38-174 IU/L ). There was no evidence this matter was promptly addressed and hence this patient did not receive an appropriate level of monitoring. The record stated that the patient was on "cardiac monitoring. " There were, however, no rhythm strips or record of any alarm going off when the patient went into ventricular fibrillation.

Despite security documentation of falling out of bed while in restraints, there was no documentation of this course of events in the patient record. Review of MR#1 found no reference to the patient removing her restraints and them having to be re-applied.
Security officers' reports documented on 5/11/13 at 0405 AM noted the patient had gotten out of restraints and had fallen off the stretcher in the emergency room at that time which required help from an unknown Emergency Medicine Technician ( EMT).Security placed the patient back on the stretcher and the patient was placed in wrist restraints by nursing staff. A security supervisory report at 0405 AM on 5/11/13 stated that fifteen minutes after this incident (about 4:20 AM on 5/11/13) the patient got out the restraints and fell out of the stretcher again.

The patient was found in cardiac arrest in a prone position at 0500 (5:00AM) .
At 5:00AM was found prone, unresponsive and in cardiac arrest, unable to be resuscitated. The patient was pronounced dead by the ED resident at 5:34 AM on 5/11/13. It is evident that there was no documentation of monitoring of the patient from 4:20 AM to 5 AM , when the patient was found prone and in cardiac arrest.

Review of the document on 5/28/13, titled "ME-2016, "Report to the Office of the Chief Medical Examiner" prepared by the ED physician on 5/11/13 stated: "The patient was brought by EMS after being found at the foot of a staircase." The Medical Examiner accepted the case for autopsy. The results are still pending as of 6/13/13.

Review of the ED MR #1 on 5/30/13 found the ED resident noted at 6:10 AM on 5/11/13 that " Patient was noted getting out of bed and pulling IV line. Patient was attempting to lay on the ground but was helped back to her bed. Was placed in bed supine. The patient turned herself to the prone position. I went to place an IV, however, we noted the patient to be unresponsive. We immediately returned her to the supine position and initiated ACLS. "

Interview of the ED resident physician on 5/30/13 by telephone, the physician acknowledged the above written statement. On 6/14/13 follow-up communication with the facility staff and the ED resident physician , and the ED Medical Director it was stated that the resident "found the patient prone". The physician stated that he did not see the patient turn herself prone and that he required the assistance of security officers to turn her supine. This statement was at variance with the chart entries in the medical record.

2. The hospital failed to evaluate the need for use of the least restrictive restraint for 2 out of 5 emergency medical records reviewed (MR#1 and MR#2).
See tag #A164.

3. The hospital failed to provide a safe environment to two minor patients who were both assigned in the emergency department to continuous observation status and who were found to be engaged in sexual contact on 2/24/13 (MR#3 and MR#4).
See Tag #A144.
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Based on interview, observation, and review of policies and records, it was evident that the facility did not develop or implement effective procedures in the emergency department consistent with accepted practice standards. Specifically, the facility failed to:
1) formulate and implement an (ED) emergency department triage policy and procedure that accurately reflects the triage practice and ensures triage is performed by qualified staff, 2) implement a policy and procedure that ensures effective supervision of patients who require special monitoring for their safety, 3) failed define "reasonable physical force" in existing policy to be used by Hospital Security to prevent patients from exiting the ED without reference to what constitutes such reasonable force and 4)maintain a comprehensive Emergency Department (ED) Log that was easily retrievable.

Findings include:

1. The facility did not formulate and implement an (ED) emergency department triage policy and procedure that accurately reflects the triage practice. The existing triage practice did not include the functions of the ED registrar or the PCT (patient care technician). Review found that triage was not provided by qualified staff in that patients are seen first by a registrar.

Review of emergency department triage policy Titled T.10 - Triage of Patients ( Adult and Pediatrics ) revised 3/4/13 on 5/29/13 found that the policy addresses the ESI system (1 to 5) and re-assessments as well as patients who require immediate isolation. Reference is made to only the RN performing triage. There is no policy that references the actions of the ED registrars or the PCT (patient care technician ).

At interview with the nurse manager on 5/28/13 it was stated that the initial interaction with the patient is made in a mini-registration process that includes the ED Registrar asking for picture ID and the patient's complaint. This is recorded by the registrar in the intake record. The next phase is the patient being called by the PCT ( Patient Care Technician ) who takes vital signs and these results are transcribed into the RN triage notes as the patient's vital signs. The PCT stated that if the vital signs are " abnormal " this is reported to the triage nurse so that the patient can be triaged more urgently. At interview with the ED Nurse Manager, the Registrar and the PCT on 5/28/13, this information was verified.

On 5/28/13 at 11:00 AM in the ED waiting room it was observed that the patients were being requested to provide a chief complaint to the registrar and had their vital signs taken by the PCT at a point further in the process.

At interview with the nurse manager on 5/28/13 , when discussing the documentation of patients who leave before triage, it was stated that if a patient leaves before triage, the registrar's notes of the chief complaint are retained but the vital signs taken by the PCT are not retained or affixed to any record and disposed of.

2. The hospital failed to implement a policy and procedure that ensures effective supervision of patients who require special monitoring for their safety. The facility did not establish and implement an effective or safe procedure to manage patients who require require close observation.
Review of facility policy titled " Security Procedural Guide " on 5/28/13 it was found that patients who require special observation secondary to behavioral issues and potential for safety issues are placed under " Close Observation " by the RN and is implemented by security staff. This policy, reviewed on 5/28/13, permits 1 security guard to "observe" up to 13 patients at a time. The patients under this level of observation are scattered in the ED and the guard must make continuous rounds in order to survey the assigned patients.

Existing procedure for the Psychiatric Patient Treatment Observation policy, last revised on 1/21/11, was not followed during an identified incident of sexual contact between two minor patients in the psychiatric emergency room. This procedure notes: "until the Close Observation order is rescinded, the security officer will remain outside of the Psychiatric room, and will prevent the exit of the patient from this room, except to escort the patient to the bathroom". The facility did not follow its procedure.

3. The facility failed define "reasonable physical force" to be used by Hospital Security to prevent patients from exiting the ED without reference to what constitutes such reasonable force.
Review of security department policy titled, "Close Observation" on 5/28/13, documented that the facility permits the security officers to use "reasonable physical force" to prevent patients from leaving the ED and other situations including causing injury to self and others, and destruction of property. The policy does not define "reasonable physical force" to be applied if a patient attempts to leave the ED.



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4. The facility failed to maintain a comprehensive Emergency Department (ED) Log that was easily retrievable.
The Emergency Department log was requested on 5/28/13 approximately 10:00 am. An electronic log was presented approximately 3:35 pm. The ED log was not presented to surveyors in a timely manner for review.
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