HospitalInspections.org

Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to require that seclusion be ordered by a licensed practitioner authorized by state statute to practice independently for 1 of 1 patient who was secluded in the Emergency Department due to violent and/or self-destructive behavior (Pt # 39).

Findings include:

Review of hospital policy titled Restraints and Seclusion Policy revealed: "...The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner (LIP) who is responsible for the care of the patient...LIPs include...Physician Assistants with the privilege to practice at YRMC...."

Review of Medicare State Operations Manual Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals 482.13(e)(5) Interpretive Guidelines revealed: "...Licensed Independent Practitioner- (LIP) For the purpose of ordering restraint or seclusion, an LIP is any practitioner permitted by State law and hospital policy as having the authority to independently order restraints or seclusion for patients...."

Review of Arizona Revised Statute (ARS) 32-2531 revealed: "...A supervising physician may delegate health care tasks to a physician assistant...The physician assistant may perform those duties and responsibilities...that are delegated by the supervising physician...."

Review of ARS 32-2501 revealed: "...Physician assistant means a person who is licensed pursuant to this chapter and who practices medicine with physician supervision...Supervising physician means a physician who holds a current unrestricted license, who supervises a physician assistant and who assumes legal responsibility for health care tasks performed by a physician assistant...Supervision means a physician's opportunity or ability to provide or exercise direction and control over the services of a physician assistant...."

Review of Pt # 39's ED record for ED admission on 10/19/13 revealed:

Documentation by PA # 16 in the ED Note-Physician on 10/19/13 at 1933: "...Due to the patient's mania I decided to give the patient an injection of IM (Intramuscular) Haldol. Patient was also put into seclusion for safety...."

PA # 16 entered and electronically signed an order 10/19/13 at 2057 for Seclusion. The supervising physician electronically signed the order.

The Director of Risk/Quality Management confirmed during an interview conducted on 11/1/13 that PA's are required to work under the supervision of a physician who delegates health care tasks to the PA. The hospital administration had considered the order for seclusion and/or restraint to be a task that could be delegated to the PA by the supervising physician.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require documentation of a face-to-face evaluation of the patient conducted within one hour after the initiation of seclusion for the management of violent or self-destructive behavior for 1 of 1 patient secluded during two separate ED admissions (Pt # 39).

Findings include:

Review of hospital policy/procedure titled Restraints and Seclusion Policy revealed: "...When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be evaluated face-to-face within 1 hour after the initiation of the intervention by a Physician or other LIP (Licensed Independent Practitioner). The evaluation must include: a. The patient's immediate situation; b. The patient's reaction to the intervention; c. The patient's medical and behavioral condition; and d. The need to continue or terminate the restraint or seclusion...."

Review of hospital policy/procedure titled Emergency Services behavioral health: Seclusion or Patients Operating Practice revealed: "...a face-to-face evaluation must be completed and documented within 1 hour of initiation of seclusion...."

The CNO confirmed, on 10/30/13, that the face-to-face evaluation must be completed within one hour after the seclusion is initiated.

Review of Pt # 39's medical record for ED visit on 10/19/13, revealed:

The ED registration form was completed for Pt # 39's ED visit, on 10/19/13 at 1906. At 2101, an RN documented: "...agitated combativeness, verbalizing or attempting to harm others...."

Pt # 39's medical record contained documentation that seclusion was initiated on 10/19/13 at 2101 and discontinued on 10/20/13 at 0130.

Physician's Assistant (PA) # 16 documented an ED Physician Note "performed" 10/19/13 at 1933. He documented "...as of 2229 patient is relaxed. She has been accepted for mental health transfer we are still pending labs tox screen and an ultrasound to evaluate fetal status...."

The medical record did not contain documentation of a face-to-face evaluation conducted within one hour after the patient was placed in seclusion to include evaluation of Pt # 39's immediate situation, reaction to the seclusion, her medical and behavioral condition after the seclusion and the need to continue or terminate the seclusion. Pt # 39 remained in seclusion until 10/20/13 at 0130. PA # 16 documented that she was relaxed as of 10/19/13 2229.

RN # 39 confirmed during interview conducted on 10/30/13, that Pt # 39's medical record for ED visit of 10/19/13, did not contain documentation of a face-to-face evaluation completed by a physician or other LIP, within 1 hour after the initiation of seclusion and containing the required elements.

Review of Pt # 39's medical record for ED visit on 10/21/13, revealed:

The ED registration form was completed for Pt # 39's ED visit, on 10/21/13 at 0006.

At 0100, an RN documented that the patient was in seclusion; was agitated and "...not making any sense...." An RN also completed an electronic form to indicate that a face to face evaluation was performed and included: "...The patient's immediate situation; The patient's reaction to the intervention; The patient's medical and behavioral condition, and The need to continue or terminate the restraint or seclusion...." The electronic form was electronically signed by a physician.

The medical record did not contain documentation by an LIP of a face-to-face evaluation conducted within one hour after the patient was placed in seclusion to include evaluation of Pt # 39's immediate situation, reaction to the seclusion, her medical and behavioral condition after the seclusion and the need to continue or terminate the seclusion.

RN # 39 confirmed that Pt # 39's medical record for ED visit in 10/21/13 did not contain documentation of the one hour face-to-face evaluation as required by hospital policy/procedure.