HospitalInspections.org

Based on record review and staff interviews the facility failed to respect the right to personal privacy for one patient by failing to restrict access to the patient to only those staff members involved in the direct care of the patient. (Patient #1). Findings include:

Per record review Patient #1 was admitted on 2/28/14, following a nontraumatic cerebral hemorrhage (stroke) requiring neurosurgery, and a post operative course complicated by seizures, impaired cognition, and swallowing and mobility deficits. The patient was admitted to inpatient acute rehabilitation services from a subacute unit where s/he had sustained a number of falls secondary to ataxia (an inability to coordinate voluntary muscular movements) and where s/he had displayed some evidence of mood lability,anxiety and agitation with paranoid thoughts, problematic enough to have required physical and chemical restraints.
The record revealed that a Code 8, (The emergency phrase used to alert other staff to a violent or potentially violent situation - according to the policy, dated 8/2/2011, called when: 1) a patient is behaving in a way which places him/her at risk for hurting him/herself or othes and/or 2) the team members need additional assistance in establishing and maintaining safety), was called on two separate occasions in March of 2014 as a result of the patient's agitated and threatening behavior. Despite the lack of policy regarding the role of law enforcement in a Code 8 situation, and the fact that the police were not directly involved in the medical intervention/treatment for which the code was initiated, they responded to and were physically present during some of the ongoing interventions by staff to de-escalate the patient's behavior during each of the Code 8's, on both 3/13/14 and 3/15/14, respectively. A nursing progress note on 3/13/14 indicated that the patient was displaying "hallucinations, delusions, aggression, posturing and threatening harm to objects and people in room." The patient's behavior escalated, a Code 8 was called and although security arrived, the patient continued to be challenging. The note further indicated that local law enforcement arrived and, "police entered room and pt immediately became cooperative and dropped the object [s/he] was threatening to harm others with, actually offered to be restrained but did not need to be at this point. Pt able to calm down..." A subsequent nursing progress note, dated 3/15/14 at 12:44 AM, revealed the patient was agitated and threatening to harm a staff member with a telephone. A Code 8 was again called. Security arrived and nursing remained with the patient who still had possession of the phone. The patient became agitated again and stood up to close the door to his/her room when s/he fell and hit his/her head on the trash can. A decision was made to transfer the patient to the Emergency Department (ED) for evaluation after his/her fall. The phone was taken away when the patient "was on the ground and at this time police arrived and pt. seemed happy to see the police stating, "I am glad you guys are on my team, these people are trying to kill me. Police and nursing quickly packed pts. belongings and pt was placed in the wc by police and transported downstairs..." Patient #1 was then transferred via ambulance to the ED.
Despite the evidence to support the likelihood that Patient #1's agitated and aggressive behaviors were related to his/her medical condition, and despite the lack of evidence to suggest criminal activity, the local police, who were not employed by the facility were physically present during some part of each of the Code situations, had unnecessary access to the patients personal information, including his/her identity, medical condition and treatment provided by staff during the Codes.
During interview, on 5/21/14 the Nurse Manager confirmed that the facility's Code 8 policy did not include notification of law enforcement personnel and that there was no policy to direct and guide the use of law enforcement during a Code 8 event. S/he stated that a Code 8 is initiated through a central call center where notification is then made to the facility's security department, as well as predetermined nursing staff, to respond to the event. S/he further stated that local law enforcement personnel are also notified, by the call center, of any Code 8 and respond to the facility to assist in the event criminal activity has occurred. The Nurse Manager acknowledged that law enforcement personnel should not be present in a patient care area, where they have potential access to a patient's personal information unless the patient has been involved in criminal activity.

Based on record review and staff interviews the facility failed to assure that each patient's right to receive care in an emotionally safe setting was maintained when law enforcement personnel were notified of and responded to an inpatient behavioral emergency. (Patient #1). Findings include:
Per record review Patient #1 was admitted on 2/28/14, following a nontraumatic cerebral hemorrhage (stroke) requiring neurosurgery, and a post operative course complicated by seizures, impaired cognition, and swallowing and mobility deficits. The patient was admitted to inpatient acute rehabilitation services from a subacute unit where s/he had sustained a number of falls secondary to ataxia (an inability to coordinate voluntary muscular movements) and where s/he had displayed some evidence of mood lability,anxiety and agitation with paranoid thoughts, problematic enough to have required physical and chemical restraints.
A nursing progress note, on 3/13/14 at 4:46 PM, indicated that the patient was displaying "hallucinations, delusions, aggression, posturing and threatening harm to objects and people in room." Despite the evidence to support the likelihood that Patient #1's agitated and aggressive behaviors were related to his/her medical condition, the local police were notified of, and responded to the Code 8 (The emergency phrase used to alert other staff to a violent or potentially violent situation - according to the policy, dated 8/2/2011, called when: 1) a patient is behaving in a way which places him/her at risk for hurting him/herself or othes and/or 2) the team members need additional assistance in establishing and maintaining safety) that was called. The record indicated that although security arrived, the patient continued to be challenging. and that when local law enforcement arrived, "....police entered room and pt immediately became cooperative and dropped the object [s/he] was threatening to harm others with, actually offered to be restrained but did not need to be at this point. Pt able to calm down..", indicating that the presence of police created an environment in which the patient may have felt intimidated and fearful.
During interview, on 5/21/14 the Nurse Manager confirmed that although the facility's Code 8 policy did not include notification of law enforcement personnel, and there was no policy to direct and guide the use of law enforcement during a Code 8 event, it was the policy to notify local law enforcement of all Code 8 events. S/he stated that when a Code 8 is initiated a central call center notifies the facility's security department, as well as predetermined nursing staff to respond to the event. S/he further stated that local law enforcement personnel are also notified of any Code 8 and respond to the facility to assist in the event criminal activity has occurred. The Nurse Manager acknowledged that law enforcement personnel should not be present in a patient care area, where they have the opportunity to see patients and witness medical interventions or treatment unless the patient has been involved in criminal activity.

Based on staff interviews and record review the facility failed to assure that staff consistently implemented the use of physical restraints in accordance with their policies and procedures and in a manner that would reduce the risk of injury for one patient. (Patient #1). Findings include:

Per record review Patient #1 was admitted on 2/28/14, following a nontraumatic cerebral hemorrhage (stroke) requiring neurosurgery, and a post operative course complicated by seizures, impaired cognition, and swallowing and mobility deficits. The patient was admitted to inpatient acute rehabilitation services from a subacute unit where s/he had sustained a number of falls secondary to ataxia (an inability to coordinate voluntary muscular movements) and where s/he had displayed some evidence of mood lability,anxiety, impulsivity and agitation with paranoid thoughts, problematic enough to have required physical and chemical restraints.

A nursing progress note, dated 4/15/14, indicated that Patient #1 began exhibiting behaviors, at about 5:50 AM on that date, that included anxiety, confusion, agitation and aggressiveness towards staff, throwing a walker at and threatening further harm to staff. Despite attempts by staff, over a period of approximately 1 hour and 25 minutes, to utilize less restrictive measures to de-escalate the patient, a Code 8, (The emergency phrase used to alert other staff to a violent or potentially violent situation - according to the policy, dated 8/2/2011, called when: 1) a patient is behaving in a way which places him/her at risk for hurting him/herself or othes and/or 2) the team members need additional assistance in establishing and maintaining safety) was called at approximately 7:15 AM and the patient was placed in 4 point restraints on his/her bed. The patient then agreed to take medication, and was released from restraints after approximately 25 minutes when s/he was able to contract for safety. At approximately 8:15 AM the patient complained of pain in the left side of his/her rib cage and verbalized, at other times throughout that day that; "[his/her] ribs hurt because [s/he] thought someone had jumped on [him/her] and s/he became agitated when offered shower by male caregiver, stating " [s/he] is one of the people who hurt me and I don't want [him/her] taking care of me." An x-ray was obtained during the day, on 4/15/14, which revealed that the patient had sustained a fractured rib.

The facility policy for Restraints for Medical/Surgical and Behavioral Health Indications on Non-Psychiatric Units, dated 11/20/2013 directed staff in the application of Locked Velcro Restraints: "H.....1) Position the patient supine on the bed, with each arm and leg securely immobilized at the joints. Notewell: This minimizes combative behavior, preventing injury to patient/others without using excessive force; 2) Apply device securely to each wrist and ankle. Notewell: you should be able to slip 1 or 2 fingers between the restraint and the patient's skin. Slight flexion prevents contracture and dislocation; 3) Patient must be under constant observation when in these restraints.

During interview, at 11:52 AM on 5/19/14, Staff Member #1 stated that s/he had assisted with the application of 4 point restraints on Patient #1 on the morning of 4/15/14. S/he stated that s/he was in the patient's room at the time the patient threw his/her walker at another staff member and Staff Member #1 held onto each of the patient's hands, which were raised over the patient's head, and assisted him/her to lay on the bed. The staff member stated that s/he continued to hold the patient's arms and laid his/her body across the mid-section area of the patient's body to immobilize him/her while another staff member applied restraints to each of the patient's extremities. The Unit Nurse Manager stated, during interview on the afternoon of 5/21/14 that the technique utilized by Staff Member #1, including laying across the patient's body, to restraint Patient #1 was not an appropriate and safe technique and not in accordance with the facility's policy and procedure for use of restraints. S/he further stated that the staff members involved in the restraint of Patient #1 all received training and re-education regarding the facility's policies and procedures for use of restraints, following the event of 4/15/14.

Based on staff interview and record review the facility failed to fully implement timely preventive actions after identifying opportunities for improvement and changes that would lead to improvement following an adverse event involving the use of physical restraints for one patient. (Patient #1). Findings include:

Per record review Patient #1 was admitted on 2/28/14, following a nontraumatic cerebral hemorrhage (stroke) requiring neurosurgery, and a post operative course complicated by seizures, impaired cognition, and swallowing and mobility deficits. The patient was admitted to inpatient acute rehabilitation services from a subacute unit where s/he had sustained a number of falls secondary to ataxia (an inability to coordinate voluntary muscular movements) and where s/he had displayed some evidence of mood lability,anxiety, impulsivity and agitation with paranoid thoughts, problematic enough to have required physical and chemical restraints.
During the course of the patient's hospitalization staff initiated the Code 8 process (The emergency phrase used to alert other staff to a violent or potentially violent situation - according to the policy, dated 8/2/2011, called when: 1) a patient is behaving in a way which places him/her at risk for hurting him/herself or others and/or 2) the team members need additional assistance in establishing and maintaining safety) on a number of occasions in response to Patient #1's escalating agitated and aggressive behaviors. Although there was no policy regarding the role of law enforcement in a Code 8 situation, and despite the evidence to support the likelihood that Patient #1's agitated and aggressive behaviors were related to his/her medical condition, and there was no evidence to suggest criminal activity, the local police, who were not employed by the facility, were physically present during some part of each of two separate Code situations, on 3/13/14 and 3/15/14 respectively. Because of their presence the police had unnecessary access to the patients personal information, including his/her identity, medical condition and treatment provided by staff during the Codes, which violated the patient's right to privacy. In addition, the record indicated that during the Code 8 on 3/15/14 although security arrived, the patient continued to be challenging. and that when local law enforcement arrived, "....police entered room and pt immediately became cooperative and dropped the object [s/he] was threatening to harm others with, actually offered to be restrained but did not need to be at this point. Pt able to calm down..." This suggests that the presence of police could have created an environment in which the patient may have experienced feeling intimidated and unsafe.
A nursing progress note, dated 4/15/14, indicated that Patient #1 began exhibiting escalating behaviors, at about 5:50 AM on that date, that included anxiety, confusion, agitation and aggressiveness towards staff, throwing a walker at and threatening further harm to staff and eventually required the use of 4 point restraints to maintain the safety of the patient and others. There was evidence that inappropriate technique was used by one staff member, who laid his/her body across the patients body, to subdue the patient while his/her extremities were restrained by another staff member, and the patient subsequently sustained a fractured rib.

The Director of Security Services stated, during interview at 1:35 PM on 5/20/14, that security was not present on site at the facility between the hours of 11:30 PM and 7:30 AM Monday through Friday. S/he stated that a security officer, employed by the facility and trained in the use of restraints and hands on techniques to subdue aggressive and threatening patients, is assigned during those hours to conduct routine assessment of the exterior grounds by vehicle and to respond to and support staff during any Code 8 at the facility. S/he also stated that local law enforcement is notified of and responds to all Code 8 events because of the potential that the event could involve criminal activity. The Security/Parking Supervisor for the facility, also present during the interview, further stated that although security is notified of the Code 8 events, the responding officer might be otherwise involved in a separate off site location which could delay their response to the Code 8 for a period of time.
During interview, on the afternoon of 5/21/14, although the Unit Nurse Manager and the Director of Accreditation and Regulatory Affairs both stated that during an internal review of the event of 4/15/14, involving use of physical restraints, staff had identified a lack of role definition for response of local law enforcement to a Code 8, both confirmed that, to date, no policy had been developed or clarification made to appropriately define and direct the role of local law enforcement who continue to respond to Code 8 events at the facility. The Unit Manager stated that use of inappropriate technique during restraint application had also been identified including: the way in which the patient had been subdued and that action to restrain the patient had occurred by the two staff members present with the patient, without waiting for the support of the maintenance or security staff as well as nursing staff to respond to the Code 8. S/he further stated that following the internal review although some education and trainings had occurred and a plan identified to provide further training in the use of hands on techniques to appropriately subdue an aggressive patient while placing restraints, that plan, has not, to date, been implemented. Although some action had been identified and implemented by the facility, staff training had not been completed. In addition, although staff had been instructed to await response by the facility's security staff prior to initiating any restraints, no plan had been identified to assure timely response at all times by security staff.