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Based on observation, staff interview, and document review, it was determined that the facility failed to ensure development and implementation of policy and procedure for the safe management of violent or agitated patients and ensure appropriate training for staff members who assist with the application of restraints.



Findings include:

See citations:
Tag A0144.
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Tag A0206

Based on observation, record review and interview, it was determined that the facility did not ensure safe observation and supervision of patients receiving continuous observation in the Emergency Department (ED).


Findings include:


During tour of the ED on 9/2/15 at 11:00 AM it was noted that the security guard was stationed at an overbed table. At interview with this employee it was stated that he was "observing" patients on "security watch " and the guard showed a list of 7 patients. Three (3)of the seven (7) patients he was assigned to observe could not be visualized directly from the guard's post.
The security guard was asked to point out the patients on this "watch". From his table, curtains were drawn on other patients which blocked his view. In order to observe 3 of the 7 patients, he had to be relieved at that post by another guard (the supervising lieutenant) so that he could accompany the surveyor.
At interview, he security guard stated that he did not actually have to "see" the patients that he was "watching."

Review of 2 of the medical records (MR#C ,MR#D) identified;
On 7/17/15 at 7:45 PM, patient MR#C was on security watch and close observation for an overdose secondary to a suicide attempt and walked out of the ED without being noticed. On 6/19/15 patient MR#D with suicidal ideation walked out of the ED without being noticed.


During the ED tour on 9/2/15 two (2) patients (MR#E and MR# F), were noted to be on "continuous observation" and were watched by the Patient Care Technician (PCT).
Review of the Continuous Observation Log for 9/2/15 found that patient MR#E was in the bathroom at 9:15 AM and patient MR#F was in the bathroom at 8:15 AM. There was no record of who was observing each of the patients during these periods
At interview with the PCT watching the patients, it was stated that she was not required to be at arms length but that this type of watch was like watching two one to one patients simultaneously.

Based on observation, review of document, and staff interview, it was determined the facility failed to provide patients the right to be free of unsafe restraints. Specific reference is made to the use of handcuff restraints by security staff to manage the behavior of non-forensic combative patients in the medical emergency room.
This finding was noted in two (2) of ten (10) records reviewed.


Findings include:

Review of the facility's Incident Report on 09/02/2015 identified:
Patient MR#A, on 07/19/2015 at approximately 1140 hours (11:40 AM ) was handcuffed by security guards when he became agitated and combative with medical and security staff. The medical record for patient MR#A did not document the use of handcuffs.

Patient MR#B, 07/17/15 at approximately 1845 hours ( 6:45 PM ) was handcuffed by security guards when be became agitated. The medical record for patient MR#B did not document the use of handcuffs.

Both patients were on security watch at the time of these interventions.

At interview with the Staff #1 (Director of Security), on 09/04/15 at approximately 11:00 AM , it was reported that the supervisory security guards carry and use standard metal handcuffs and they are the only staff authorized to use these handcuffs on patients. He further stated that the officers take a "handcuffing course" titled "Specialized Handcuffing Training Course."

The policy titled "Security Department's Policy Regarding the Use Of Handcuffs " (issued 8/28/2013 and revised 03/19/2015) states that while these cuffs should not be used to restrain patients, that they can be used when there is no other means available to gain control of a violent, combative, and uncooperative patient.
Review of MR#A and MR#B identified there was no documented use of other means to gain control of these agitated patients.

At interview with Staff #2 (Lieutenant), on 9/5/15 at approximately 11:00 AM, she confirmed that she placed the patient MR#A in handcuffs.

At interview with Staff #3 (Patient Care Technician) on 9/8/15 at approximately 2 PM, it was stated that he was the PCT who assisted with the patient MR#A and observed the security guard handcuff the patient to the side rail of the stretcher.

At interview with the Emergency Department (ED) Nursing Director on 09/08/15 at approximately 3 PM, it was stated that while she was not aware that handcuffs were being utilized by security staff, but the type of clientele of patients seen at this hospital might require different types of restraints.

Based on review of document and interview, it was determined that the hospital permitted handcuffs to be used as form of restraint.

Findings include:

Review patient MR#A on 9/2/15 at 2 PM, identified documentation by the medical staff that on 7/19/15 at 1140 hours (11:40 AM) the restrained patient escaped out his restraints and became violent in the ED and security had to intervene and the patient was restrained 4 points by clinical staff.
Review of the security Incident Report identified that the patient MR#A was handcuffed by security guards when he became agitated and combative with medical and security staff.
At interview with the PCT ( Patient Care Technician ) on 9/8/15 at 3 PM who assisted in the application of the restraints for this incident, it was stated that he observed security guards handcuffing the patient's wrist to the side rail after he was subdued.

Review of security Incident Report identified that the patient MR#B, on 7/17/15 at approximately 1845 hours ( 6:45 PM ) was handcuffed by security staff when he became agitated. Review of his medical record found no reference to being handcuffed.

Both patients were on security watch at the time of these incidents.

At interview with the Lieutenant, on 9/4 /15, it was stated that she applied metal handcuffs for patient MR#A. She did not report that she handcuffed the patient to the siderail.

At interview with the Director of Security on 9/4/15, it was stated that supervisory security guards carry and are authorized to use standard metal handcuffs and they are the only staff permitted to use these handcuffs.
The policy titled "Security Department's Policy Regarding the Use Of Handcuffs," states that while cuffs should not be used to restrain patients, that they could be used when there is no other means available to gain control of a violent, combative or uncooperative patient.
There was no documentation in the medical record for MR#A and MR#B that other means were used to gain control of these agitated patients.

Based on review of document and interview, it was determined that the hospital failed to formulate and implement a safe policy and procedure to govern the use of chemical restraints.

Findings include:

Review of MR#A on 9/2/15 found that on 7/18/15 at 3 PM the patient was restrained with 3 point restraint by verbal order of the physician. No corresponding written order was found in the record. Further review of MR#A identified that the patient had a combination of 4 point and chemical restraint on 7/19/15 at 6 PM but the drugs used were not documented. There was no documentation of ony observation while the patient was physically and chemically restrained.

The facility's policy, "Medication Used As Restraints," states that persons in chemical restraints are to be observed every half hour. The policy fails to note what specific assessments are required at each interval. CMS giudelines are every 15 minutes observations..

Based on interview, and review of personnel files, it was determined that the facility failed to ensure security staff members who are used to assist in restraining patients, receive ongoing restraint training.
This finding is noted in 10 of 10 security staff credential files reviewed.

Findings include:

On 9/4/2015, review of ten of ten security staff credential files found no recent training or education for restraints or for the management of violent and/or combative patients.

During interview on 09/04/2015 with the Director of Hospital Security, it was stated that none of hospital security officers had any current training in restraints and how to manage violent or self destructive patients.

Based on interviews, and the review of personnel files, it was determined the facility failed to ensure all staff who apply restraints receive education and training in the use of first aid techniques as well as training and certification in the use of cardiopulmonary resuscitation. This finding was noted for 10 of 10 security staff files reviewed.

Findings include:

Ten of ten Security staff 's personnel files reviewed on 09/08/2015 lacked evidence of training and education in the use of first aid technique and certification in the use of cardiopulmonary resuscitation. All staff members were security personnel.

During interview on 09/04/2015 with the Director of Hospital Security, it was stated that none of the 60 hospital security officers had any training in the use of first aid technique and certification in the use of cardiopulmonary resuscitation.