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Based on staff interview and record review, the hospital failed to provide a written to response to a grievance regarding patient care, in accordance with it's Grievance Policy/Procedure, for 1 of 10 patients in the total sample. (Patient #1). Findings include:

Per record review and staff interviews, Patient #1's spouse filed a grievance with the hospital on 1/28/15. The grievance was delivered verbally during a meeting between the patient's spouse and the Quality Consultant. The grievance detailed numerous aspects of patient care during a lengthy hospital stay, commencing on 1/12/15. Although the Quality Consultant and the Physician Director of Hospitalists each confirmed during interviews that they had verbally discussed many of the concerns directly with the spouse multiple times after receipt of the grievance, there had been no written letter from the Director of Quality stating the steps taken to investigate the issues, the actions implemented , the names of hospital staff who may be contacted in case of questions, the results of the grievance process and the date of completion.
Per review, the hospital's Grievance Policy, effective 5/22/14, stated " 5. Managers will draft a letter of response to the grievance.....The written notice to the complaintee must be communicated to the patient/patient's representative in a language and manner ....understands and shall include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. A letter from the Chief Medical Officer (CMO) dated 2/10/15 stated that "We are continuing to review -------'s case........ Either myself or one of my colleagues will give you feedback regarding the findings of this review".
Per interview on 9/8/15 at 4:50 PM, the CMO confirmed that although the physician review was completed in March, 2015, no further written contact with the complaintee had been completed, as required by the grievance process.

Based on staff interview and record review, the hospital failed to assure that a Patient's right for the safe implementation of a restraint by trained staff was protected for 1 of 5 applicable patients treated in the Emergency Department. (Patient # 2). Findings include:

Per record review and staff interview, Patient #2 was physically restrained by Staff Nurse #1 in a non-therapeutic hold during an intervention to prevent an elopement, resulting in a risk of injury to the patient and a minor injury to the staff member. On 8/3/15, Patient #2 presented to the Emergency Department (ED) with suicidal ideation. Prior to arriving, the patient had engaged in self-harming behaviors that included causing a small wrist wound and placing a strangulation device around the neck. At 1539 hours, the ED physician determined that s/he was in a "mental health crisis" and would remain in the ED until suitable disposition was determined following an emergency psychiatric evaluation.
On the morning of 8/4/15, Patient #2 wanted to leave the ED AMA (Discharge Against Medical Advice). A code green (Behavioral Crisis Intervention) was called and s/he returned to his/her room with a show of staff. S/he became tearful and attempted to exit again, but was redirected back to his/her room. Per interviews on the afternoon of 9/8/15, the Director of Inpatient Psychiatry (Dir IPP) reported that s/he was called to the ED to assist the staff in their attempts at de-escalation when the patient made another elopement attempt. After 10 minutes without success from de-escalation efforts, s/he reported that Patient #2 was combative and physically agitated and attempted to pry a metal sign from the exit door, a safety hazard posing a risk of harm to the patient and/or others in the area. A decision was made to use a manual J-hook restraint to escort the patient back to his/her room with the Dir IPP on one side and Nurse #1 on the other. When almost to the patient's room, Patient #2, struggling and kicking, bit Nurse #1 on the hand. The Dir IPP reported that Nurse #1 was angry and reacted to the bite, and per report, contacted the back of Patient #2's head with an open hand, forcing his/her head downward in a non-therapeutic hold. When told to stop, Nurse #1 stated, s/he's "not going to f ....ing bite me." Nurse #1 was directed to "step back." The incident was reported to APS (Adult Protective Services).

Per interview with Nurse #1 on 9/8/15 at 3:00 PM s/he reported that s/he does not use the J-hold often and was not able to demonstrate the hold correctly after several attempts; s/he recollected that the hold was taught in his/her original training (s/he reported working in the ED for approximately 10 years). Nurse #1 also reported that since the incident no further training re the use of restraints has occurred though s/he has returned to work in the ED.

Later at 4:16 PM, the Nurse Manager of the ED reported that per discussions with the Dir. of IPP after the incident, Nurse #1 did not demonstrate the use of a proper J-hold; if the hold was properly done, [the staff member] may not have been bitten. S/he confirmed that the ED staff have been identified as needing training in the provision of care for patients with Mental Health needs. Refer also to A 0196.

Based on staff interview and record review, the hospital failed to assure that staff who work in the Emergency Department (ED) were trained and demonstrated competency in the application of restraints for 1 of 5 patients in the sample (Patient #2). Findings include:

Per record review and interview, Patient #2 was physically restrained by Staff Nurse #1 in a non-therapeutic hold during an intervention to prevent an elopement attempt posing a risk of injury to the patient and staff member. Following an internal review of the incident, a lack of ED staff training to deal with mental health behavioral emergencies was identified. On 8/3/15 Patient #2 presented to the Emergency Department (ED) with suicidal ideation. Prior to arriving, the patient had engaged in self-harming behaviors that included causing a small wrist wound and placing a strangulation device around the neck. At 1539 hours, the ED physician determined that s/he was in a "mental health crisis" and would remain in the ED until suitable disposition was determined following an emergency psychiatric evaluation.
On 8/3/15 at 15:39, the ED physician, who performed a medical screening examination determined that s/he was in a "mental health crisis" and would remain in the ED until suitable disposition was determined following an emergency psychiatric evaluation.
On the morning of 8/4/15, Patient #2 wanted to leave the ED AMA (Discharge Against Medical Advice). A code green (Behavioral Crisis Intervention) was called and s/he returned to his/her room with a show of staff. S/he became tearful and attempted to exit again, but was redirected back to his/her room. Per interviews on the afternoon of 9/8/15, the Director of Inpatient Psychiatry (Dir IPP) reported that s/he was called to the ED to assist the staff in their attempts at de-escalation when the patient made another elopement attempt. After 10 minutes without success from de-escalation efforts, s/he reported that Patient #2 was combative and physically agitated and attempted to pry a metal sign from the exit door, a safety hazard posing a risk of harm to the patient and/or others in the area. A decision was made to use a manual J-hook restraint to escort the patient back to his/her room with the Dir IPP on one side and Nurse #1 on the other. When almost to the patient's room, Patient #2, struggling and kicking, bit Nurse #1 on the hand. The Dir IPP reported that Nurse #1 was angry and reacted to the bite, and per report, contacted the back of Patient #2's head with an open hand, forcing his/her head downward in a non-therapeutic hold. When told to stop, Nurse #1 stated, s/he's "not going to f ....ing bite me." Nurse #1 was directed to "step back." The incident was reported to APS (Adult Protective Services).

On 9/8/15 at 3:00 PM, Nurse #1 reported during interview that s/he does not use the J-hold often and was not able to demonstrate the hold correctly after several attempts; s/he recollected that the hold was taught in his/her original training (s/he reported working in the ED for approximately 10 years). Nurse #1 also reported that since the incident no further training re the use of restraints has occurred though s/he has returned to work in the ED.

The hospital's policy, Evaluation and Care of Patients Presenting in Imminent Danger of Harm to Self and Others in the Emergency Department (Policy # ED-216, rev 8/27/12), under the heading Staff Training and Competence, section 2. stated: Annual competency training in the safe use of restraint should be provided to clinical staff in the application and documentation of restraints as well as training on the technical aspects of care of the behavioral health patient including causes of behavior, medical condition that may cause behaviors, de-escalation and self protection techniques and how to recognize physical distress in the restrained patient.

Per interview on 9/8/15 at 4:16 PM, the Nurse Manager (NM) of the ED stated that per discussions with the Dir. IPP. after the incident, Nurse #1 did not demonstrate the use of a proper J-hold; if the hold was properly done, [the staff member] may not have been bitten. S/he confirmed that the ED staff have been identified as needing training in the process of appropriate and safe provision of care when working with Mental Health patients. In a later interview, the NM reported that through informal discussions, the ED staff reported they want more training and that not all staff are comfortable dealing with mental health behavioral emergencies.
Refer also to A 0194.

Based on staff interview and record review, the hospital's Quality Assurance and Performance Improvement (QAPI) staff failed to conduct a thorough and effective review of an adverse patient event and failed to implement timely preventive actions for learning throughout the hospital. This investigation was the result of a patient event that occurred in the Emergency Department (ED) regarding use of an improper manual restraint hold of 1 applicable patient in the sample. (Patient #2). Findings include:

Per review of a self-report filed by the hospital with APS, and confirmed during interviews with QAPI committee members and nursing staff throughout the 3 days survey, the QAPI review of a patient adverse event that included use of an improper manual restraint hold of Patient #2 on 8/4/15, was not thorough, and an effective and timely corrective plan was not implemented post event.

Per record review, Patient #2 presented to the Emergency Department (ED) on 8/3/15 with suicidal ideation. Prior to arriving, the patient had engaged in self-harming behaviors that included causing a small wrist wound and placing a strangulation device around the neck. At 1539 hours, the ED physician determined that s/he was in a "mental health crisis" and would remain in the ED until suitable disposition was determined following an emergency psychiatric evaluation.

On the morning of 8/4/15, Patient #2 wanted to leave the ED AMA (Discharge Against Medical Advice). A code green (Behavioral Crisis Intervention) was called and s/he returned to his/her room with a show of staff. S/he became tearful and attempted to exit again, but was redirected back to his/her room. Per interviews on the afternoon of 9/8/15, the Director of Inpatient Psychiatry (Dir IPP) reported that s/he was called to the ED to assist the staff in their attempts at de-escalation when the patient made another elopement attempt. After 10 minutes without success, s/he reported that Patient #2 was combative and physically agitated and attempted to pry a metal sign from the exit door, a safety hazard posing a risk of harm to the patient and/or others in the area. A decision was made to use a manual J-hook restraint to escort the patient back to his/her room with the Dir IPP on one side and Nurse #1 on the other. When almost to the patient's room, Patient #2, struggling and kicking, bit Nurse #1 on the hand. The Dir IPP reported that Nurse #1 was angry and reacted to the bite, and per report, contacted the back of Patient #2's head with an open hand, forcing his/her head downward in a non-therapeutic hold. When told to stop, Nurse #1 stated, s/he's "not going to f ....ing bite me." Nurse #1 was directed to "step back."

Per interview on 9/8/15 at 4:16 PM, the Nurse Manager (NM) of the ED and the Dir. IPP. had determined through their review of the incident that Nurse #1 did not demonstrate the use of a proper J-hold; if the hold had been properly done, [the staff member] may not have been bitten [and the use of a non-therapeutic intervention prevented]. Following the identification of an improper, non-therapeutic hold, the NM failed to assure that Nurse #1 received retraining in manual hold procedures prior to returning to work in the ED. This was confirmed during interview with Nurse #1 on 9/8/15 at 3 PM.

During interview, the NM also confirmed that following the incident, there was no formal debriefing process held for the key staff involved to assist the group to review the situation and discuss what worked well and/or opportunities for improvement and other strategies that might have been used. During informal discussions, the ED staff identified a need for training in the process of appropriate and safe provision of care when working with Mental Health patients, as not all staff reported being comfortable dealing with mental health behavioral emergencies. However, though the hospital had previously identified the training need and in conjunction with the Dir. IPP. established a plan for staff to receive ProACT (Professional Assault Crisis Training) by December 31, 2015, there was no plan to expedite the training date even though the staff would be expected to handle similar types of emergencies as this one, prior to the training's implementation.

Per review of the hospital's adverse event investigation, witness statements were taken. Staff Nurse #2 identified that the incident may have been prevented by having Patient #2 changed out of street clothes and into a gown. During interviews, both the NM and Dir IPP confirmed that the hospital's policy Evaluation and Care of Patients Presenting in Imminent Danger of Harm to Self and Others in the Emergency Department, (last revised on 8/27/12) states that a patient should be asked to disrobe and should be given hospital issued clothing and the patient's belongings should be removed from the room. During an interview on 9/9/15 at 10:00 AM, the NM stated there was no formal investigation as to why the policy was not followed and no documentation in the medical record to explain the exception.

Based on the information obtained, although the hospital had taken some actions to ameliorate the potential for recurrence of a similar incident, they failed to conduct a thorough review and failed to identify all the needs and implement a timely corrective action plan. Though identified as a need, the hospital had yet to provide training to the all ED staff to ensure that they had the tools to de-escalate patient behaviors and if unsuccessful, to safely use hands on restraints to reduce the likelihood of a similar incident from occurring and reduce the risk for patient and staff injury.
Refer also to A-0194 and A-0196