HospitalInspections.org

Based on the review of two open Cardiac Critical Care Unit (CCU) medical records, policies and procedures, and other pertinent documents it was determined that the hospital failed to ensure that 1 of 2 surgical patients medical record consents were signed by the patient with decision making capacity and failed to document changes in capacity prior to going to surrogate decision makers for one of the two surgical records.

Patient # 1 was an almost 80 year-old patient that was transferred to this tertiary hospital due to complex cardiac surgical needs. On arrival p# 1 was evaluated by a cardiologist who completed the history and physical (H&P). In the H&P the patient was documented as being alert and oriented x 3 (person, place, and time) and the plan was for the patient to undergo a cardiac catheterization on day two of hospitalization. Review of p# 1 consents indicated that a surrogate and the patient were signing consent for invasive and surgical procedures. On admission the Important Message from Medicaid was signed by the patient. On day two of admission the Cardiac Catheterization consent and Sedation consent were signed by the spouse. On day four of admission the ICU consent and Blood consent were signed by the patient. On day 7 of this admission a Thoracentesis consent was sign by the spouse.

It was found that 3 of the 5 consents in p# 1 medical record were signed by someone other than the patient. No statement of capacity nor advance directives were found within the patient's medical record to justify why p# 1 was denied the right to make decisions for care and providing consent for invasive and surgical procedures as evidence by the lack of p# 1's signature nor was documentation found to identify why the surrogate was used.

Based on review of the security officer job description and the hospital "Continuum of Force" (May 6, 2019) policy, it was determined that the hospital failed to authorize security to use restraints while at the same time allowing security personnel to choose the level of force to be used on patients or others irrespective of restraint training, clinical direction, and clinical oversight.

Review of the hospital security officer job description identified no listed duty which included the possibility of having to restrain patients. This meant that the job description lacked authorization for security to have the close contact with patients that possible manual/hands-on restraint, or providing assistance to clinical staff, would entail.

Review of the hospital Continuum of Force policy revealed levels of force starting with the security officer "Presence" and ending with "Deadly Force." Some of the levels included:

5. "Hard Hands Control: Includes take-downs, strikes and pain compliance techniques to be used to overcome active physical resistance."

6. "Defensive Impact Weapon: The ASP 26" expandable police baton..." (Certified and used only by security supervisors only)

7. "Deadly Force: the use of the ASP 26" expandable police baton to strike lethal areas on a subject's body. The Security Officer may NEVER strike any area of a subject that might cause lethal injury unless such strike would be authorized by Security Department policy and Maryland State Law."

It is not known under what conditions security officers could use a baton to lethal end. No other Security Department policy or Maryland State Law was provided by staff which allowed for deadly force. Further, the policy failed to describe to whom the levels of force would be applied when it only identified a "Subject." However, since it was beyond the scope of a Security Officer to determine who is a patient, a subject could be any individual for whom a Security Officer independently and without clinical direction or oversight determined required a level of force.

While review of documents related to retrospective quality reviews of security/patient interactions identified no patient injuries, the policy and job description failed to meet healthcare restraint safety requirements where it allowed security officers to forego clinical oversight and decision-making and to independently determine a level of force and a course of action.

Based on interviews conducted with security and clinical staff on 8/13 and 8/14/12019, review of restraint training for security, and hands on demonstration, it was determined that disparate training between nursing, security officers and contracted security staff failed to meet requirements for consistent training between restraining staff and for clinical oversight of restraints.

Interviews conducted with security and clinical staff revealed that behavioral health nurses in the emergency department and in the inpatient behavioral health units all had restraint training including manual restraints. However, interview with the emergency department Nurse Manager on 8/13/2019 at approximately 0930 revealed in part that emergency department nurses only received training for mechanical restraints, not manual restraints. Further discussion revealed that nursing was currently deciding on what type of restraint training to use for manual restraint education.

Interview with security administrators revealed in part that during a clinical event, restraint might be requested by a clinician. For instance, a clinician might ask that security hold the arm of the patient. However, the administrator when asked, indicated no expectation of training on how to safely conduct that hold. Further, the Administrator stated that the hospital training had multiple versions, but that security staff were not currently using the component for "holds training." Review of current training revealed that to date, 35% of all security guards had no restraint training, and 26% had not had training since 2017, which was the approximate time when the contracted security staff were initiated.

The hospital had a contracted security service for approximately two years. Interview with a hospital security officer, an emergency department behavioral health RN, and the administrator of hospital security all variously stated that (contracted security staff) were contacted when hands on was required, when behaviors were beyond the scope of RN's to manage, and/or when behaviors were beyond the scope of hospital-employed security to manage.

Attempts to clarify with all interviewees what constituted behaviors "beyond the scope" of RNs and security were unsuccessful, This confusion may have been attributed to the fact that restraint training was inconsistent over those departments, thus decreasing confidence overall to manage patient outbursts.

Interview with a contracted security staff (CSS) on 8/13/19 revealed in part that all efforts were made to deescalate individuals prior to placing hands on individuals. The CSS was asked to demonstrate a manual restraint. The CSS demonstrated one hold which gently bent the surveyor wrist (an escort hold), but effectively caused some wrist pain. The CSS indicated that CSS employed a type of martial arts in the management of escalated individuals, including patients, but also stated that since CSS did not know what was medically wrong with patients, CSS staff tried to keep holds to a minimum. Documentation regarding the CSS service was obtained sometime later stated in part, "...the techniques officers CSS are being trained to utilize have been optimized with a combined 105 years of Martial Arts training to be effective, without applying any pain compliance...."

In summary, interviews and review of restraint training and methodologies identified four types of restraint training for behavioral health nurses, non-BH emergency department clinical staff, hospital employed security personnel, and CSS. No standardized training on safe and clinically appropriate health care restraint practices could be identified which allowed for consistent clinical oversight when placing patients in manual restraint.

Based on interview, it was determined that no hospital-employed security staff had training in cardiopulmonary resuscitation.

Interview with the hospital security manager on 8/13 at approximately 1400 revealed that no security officer was required at that time to have cardiopulmonary resuscitation certification.