HospitalInspections.org

Based on record review and confirmed through staff interviews the CAH failed to assure that care was provided in accordance with established Policies and Procedures for 4 of 13 patients. (Patients #13, 15, 19, 20 ). Findings include:

1. Per review, the CAH's Restraint and Seclusion Policy, with an approval date of 1/10/2013 and identified by staff as the currently used policy, stated under Methods of Restraint and Application of Restraint: Handcuffs: 1. Handcuffs are only applied by Police Officers/Correctional Officers for Patients in their custody. Under Restraint and Seclusion Procedure for Violent and Self - Destructive Patient (formerly known as Acute Behavioral Management): A. Restraint for the violent and self-destructive patient will ONLY be used in an emergency situation if needed to ensure the patient's physical safety AND only if less restrictive interventions have been found to be ineffective to protect the patient and others from harm; B. Restraint for the violent and self-destructive patients is an emergency measure to be taken ONLY when unanticipated, severely aggressive or destructive behavior takes place. Assessment for early release of the violent and self-destructive patient: B. Reduction or removal of restraint will be considered when the patient demonstrates a change in the behavior that was the reason for the initial application of the restraint. C. Assessment should include: 2. if the behavior has decreased so that the risk to the patient and others is no longer present, the restraint may be removed.

Per record review Patient #19, who presented to the ED (Emergency Department) on 5/8/13, and remained there on involuntary status, awaiting bed placement in an inpatient psychiatric unit, was subjected to involuntary procedures, including application of handcuffs and leg cuffs, as a result of an action that occurred by nursing during administration of oral medications, and was not released from restraints at the earliest possible time in accordance with the facility's Policy and Procedures. A nurse's note, dated 5/19/13, indicated that at 10:20 AM that morning, Patient #19 had escalated when Nurse #2 had attempted to administer scheduled oral medications. The note stated, "Pt was keeping meds in [his/her] mouth and became combative when the RN had to pinch nose to get pt to swallow meds. Pt was upset when RN had "outsmarted" [him/her]"and had stated...."I was just playing, it was a game"...then was swinging (punching) at RN.......grabbing at my waist.....attempted to hit my back as I was exiting the room.....following me out of the room swinging....The sheriffs that were outside the door then intervened, holding [patient] as [s/he] began to curse and swing at all people around[him/her], [s/he] then threw [himself/herself] onto the floor, and was banging [his/her] head onto the floor." The note further stated the patient began kicking and biting at staff, and "(Pt was placed in handcuffs and leg cuffs)". The record indicated the patient also had a spit hood applied, and received intranasal and intramuscular (IM) involuntary medications. There was no evidence in the record that Patient #19 was in police custody, warranting the need for use of handcuffs or leg cuffs in accordance with the stated policy, at the time of the incident. The order for use of 4 point restraints indicated they were applied at 10:30 AM and released at 12:36 PM. Despite the fact that there was no evidence that the patient continued to pose a threat of immediate danger to self or others and despite documentation, at 10:45 AM, that indicated the patient was "cooperative after medications" the patient remained in 4 point restraints for a period of approximately 2 hours.

During interview, at 8:20 AM on the morning of 5/23/13, Nurse #2, who had been responsible for the care of Patient #19 at the time of the incident, stated s/he had been told during report on the morning of 5/19/13 that Patient #19 was court ordered to be there, that s/he had the mentality of a 4 year old and should be treated like a pediatric patient. Nurse #2 also stated that s/he did not fully understand what involuntary hospitalization status meant and thought it included that the patient had to take all his/her meds. The nurse confirmed that, s/he had used a technique to "pinch" the nose of Patient #19 to elicit a swallow reflex during administration of some PO (by mouth) medications because there was a question in mind about whether the patient had swallowed his/her meds. The nurse stated that s/he had enlisted the help of a sheriff, who was present in the room, and told him/her to make sure the patient didn't swing at the nurse during the act of pinching his/her nose. Nurse #2 further stated that after pinching the patient's nose, the patient became angry and assaultive towards staff and engaged in self - harming behavior, which led to the administration of chemical restraints and the application of physical restraints. The nurse confirmed that handcuffs and leg cuffs had been applied at some point and stated s/he did not know why they were used. S/he stated the patient had been cooperative with the removal of handcuffs and leg cuffs and replacement with soft restraints. Nurse #2 further stated that the patient's behavior calmed shortly after the administration of involuntary meds and that, although the patient at times cried and expressed remorse for his/her actions, s/he remained cooperative until all restraints were removed at 12:36 PM. The Director of Patient Care Services confirmed, during interview on the afternoon of 5/23/13, that handcuffs and leg cuffs should only be applied by law enforcement personnel for patients in their custody.

2. Per CAH policy titled Patients Seeking Care in the Emergency Department approved 4/16/12 states: "...all patients presenting to Springfield Hospital Emergency Department who request examination and/or treatment for a medical condition must be provided with a Medical Screening Exam (MSE) by a qualified practitioner. A MSE is defined by law to mean a medical history, physical exam and diagnostic evaluation sufficient to determine if an emergent medical condition exists. Triage of the patient does not met the criteria of a medical screening. This policy includes all patients.......".

However, on 3/13/13 at 13:12 Patient #13 was brought to the Emergency Department (ED) by the police and left in the patient waiting room. The patient's initial complaint was anxiety and depression with a diagnosis of Schizophrenia . Prior to arrival, the police had removed the patient from a office of HCRS (Health Care and Rehabilitation Services/the agency which provides psychiatric support and housing) after Patient #13 had tossed a chair at support staff at HCRS. Per the Emergency Department Clinical Report-Nurse documents the patient was unable to state what medications s/he was on. The nursing note states " Onset: prior to arrival. The patient has had anxiety and sleeping difficulties, describes feelings of depression and has been confused. Has been feeling agitated. Denies hallucinations". During the self harm assessment performed by the Triage nurse, Patient #13 answered "yes" to feeling "...down,depressed and hopeless".

Per interview at 4:15 PM, the Physician Assistant (PA) confirmed s/he was working in the ED on 3/13/13 when Patient #13 was brought for treatment. S/he confirmed his/her interaction was brief with Patient #13 and became involved after hearing nurses screaming to call the Springfield Police Department (SPD). The PA stated s/he got up from a desk and walked around a corner and saw the patient standing in the doorway holding the collar of the security guard. The PA stated s/he attempted to calm Patient #13, asking him/her what was happening and s/he placed a hand on the patient's chest meanwhile the patient continued to draw back his/her fist at the security guard. The PA further stated s/he grabbed the patients free arm and twisted behind the patient's back and placed the patient prone on the floor. The patient eventually went limp and the SPD arrived, got the patient up on a stretcher and 4 point restraints applied.

The PA stated as soon as the patient was restrained, s/he choose to relieve himself/herself from further care of Patient #13, fearing his/her presence would escalate the patient's behaviors. When asked if another member of the ED medical staff conducted a Medical Screening Exam (MSE) for Patient #13, the PA thought another member of the medical staff may have screened the patient but was unsure. The PA also confirmed s/he had not reviewed the patient's record (nursing and Triage notes) prior to his/her interaction with Patient #13. After a discussion with other ED staff including the Nurse Manager it was decided to press charges and allow the police to detain Patient #13 at a correctional facility.

Although Patient #13 responded readily when restrained by the PA and security guard and shortly after by the SPD, the PA stated s/he was not sure why the patient did not remain in the ED, treated with emergency medications and provided a crisis screening. S/he stated in their opinion the patient had committed a criminal act of assault and thus it was determined s/he should be discharged and removed by the police. The PA stated s/he had not been aware of the patient's diagnosis of Schizophrenia.

When asked if s/he felt a MSE was conducted to determine if Patient #13 was experiencing a emergency medical condition, as required per CAH policy and Federal regulation, the PA agreed a Medical Screening Exam was not conducted. Patient #13 was cited for a simple assault but was returned to the ED within 3 hours when a judge refused to allow Patient #13 to be incarcerated and ordered the patient to return to the hospital ED for evaluation. Upon Patient #13's second admission on 3/13/13 a MSE was conducted. The Emergency Evaluation for Involuntary Admission to a inpatient psychiatric unit states Patient #13 as lacking insight, danger to self and others, delusional and paranoid and required hospitalization.

2. Per State Statute 1852. Patients' Bill of Rights for Hospital Patients: " (5) The patient has the right to refuse treatment to the extent permitted by law. In the event the patient refuses treatment, the patient shall be informed of the medical consequences of that action and the hospital shall be relieved of any further responsibility for that refusal." and CAH Patient Rights and Responsibilities approved 10/13/11 " F). Participate actively in decisions regarding his/her medical care. To the extent permitted by law, this includes the right to refuse treatment."

Per record review, Patient #20 was brought to the ED on 5/1/13 with a chief complaint of being in need of a medical clearance for a potential involuntary inpatient psychiatric admission. The patient's past history includes Bipolar Disorder. Per the "Application for Warrant for Immediate Exam" for 5/1/13, Patient #20 was "...paranoid, angry, delusional and manic". Per Emergency Department Physician/PA Clinical Report, the PA states " PT refused to get out of street clothes. S/he is yelling in the doorway and refusing labs and all work up...s/he was placed in restraints." The "Order Sheet for Violent or Self-Destructive Patient Restraint" signed by the PA for 4 point restraints states at 1855 on 5/1/13 "..won't allow labs and other required test." Although the patient has a right to refuse treatment, specifically having labs drawn, CAH ED staff provided no options or discussed medical consequences of Patient #20's actions when refusing to have blood drawn for testing. In addition, per CAH's Restraint and Seclusion Policy approved 1/10/2013 states "The Registered Nurse and PA-Cs in the Emergency Department are responsible for .....Protecting and preserving the patient's rights, dignity and well-being".

3. CAH Patient Rights and Responsibilities approved 10/13/11 states ".... the patient's right to: Considerate and respectful care with consideration of his or her personal values and beliefs". However, Patient #15, treated in the ED on 3/4/13 at 21:26 on a involuntary warrant for possible inpatient psychiatric hospitalization, was not provided considerate and respectful care. The patient's chief complaint was depression, hallucinations, delusions and bizarre behavior and had a past history of Paranoid Schizophrenia and Bipolar Disorder. Patient #15 was brought via EMS after threatening a case worker from HCRS. The nursing assessment describes the patient as "...disoriented to place, time and situation...behavior is abnormal, including paranoid behavior and having apparent visual hallucinations. Appears animated ". On 3/5/13 at approximately 10:30 AM upon return from the bathroom, Patient #15 accessed the Physician Assistant's office and threw coffee at computer equipment.. The patient then walked away and returned to his/her assigned room and was cooperative. The "Crisis Evaluation/Screening" report by HCRS staff on 3/4/13 states prior to ED first admission, Patient #15 "..engages in several delusions, and yells and sings. Patient attempting to get police to shoot him or cut off his head". Patient #15's mental status "flow of thought" was described as"psychotic" with "poor insight" and "poor judgement".

Despite the Crisis screening evaluation, and patient's active psychosis, the ED Medical Director agreed to have the patient charged with destruction of hospital property and removed from the ED. Per the Medical Directors "Clinical Impression" written on 3/4/13 Patient #15 was experiencing a "Exacerbation of bipolar disorder (manic state) after a warrant for an immediate exam was ordered and it was later determined the patient was in need of inpatient psychiatric hospitalization" . Further interview on 5/23/13 at 10:10 AM, the ED Medical Director commented on the incident involving Patient # 15 stating s/he ".. know right from wrong". Subsequently the patient was returned to the ED 7 hours later by police still in need of psychiatric services and intervention.