HospitalInspections.org

Based on policy and procedure review, medical record review, video observation, direct observation, and staff interviews, Emergency Department (ED) staff failed to provide care in a safe setting by failing to ensure policy was followed to prevent an IVC (involuntary commitment) patient from leaving the ED (Patient #3), and failing to monitor according to policy in 2 of 2 ED patients who needed a sitter for continuous observation. (Patients #3, 11)

The findings include:

1. Review of a policy titled "Crisis Intervention Emergency Mental Health Care", last revised March 2017, revealed "...PURPOSE: Patients who present to the Emergency Department with emotional or behavioral disorders must be screened for risk of suicide while under (hospital initials) care. There exists a subset of patients who are at risk of harming themselves or others and others who are risk of eloping from the department. To protect and plan for care of at-risk individuals, consistent management of these patients to is necessary assure [sic] the safety of the patient...PROCEDURE:....D. Involuntary Emergency Patients (by family, EMS [Emergency Medical Services], or law enforcement) 1. Will be placed in a room visible from the nurse's station when possible with a dedicated sitter assigned to the room. 2. Clinical staff will assure that the patient completely disrobes and is provided blue paper scrubs....5. All belongings will be bagged, labeled with the patient's name, and removed from the patient room for safekeeping where the patient is not allowed easy access to these items....6. The patient will be monitored closely via security camera or a sitter posted near the door for continuous observation. ..."

Review on 07/07/2017 of a policy titled "Safety Attendant Policy" revealed "...1. Safety Attendants are utilized for patients who are potentially dangerous to themselves or others......2. A Safety Attendant may be utilized based on a physician's order......Due to the level of patient care provided by the attendant, the attendant must minimally be a Certified Nursing Assistant...

Closed medical record review of Patient #3, on 07/05-06/2017, revealed the 42 year-old patient presented to the ED on 03/31/2017 at 0441 with a chief complaint of anxiety. Review revealed the patient was examined and discharged at 0518 with a diagnosis of anxiety and ear infection. Review revealed Patient #3 was reregistered at 0939. Review of ED Provider Notes, dated 03/31/2017 at 1016, revealed "...he was here last night and then discharged home with a diagnosis of anxiety disorder. Patient's family is requesting mental health evaluation....Behavior health services has come in to evaluate the patient.... Patient seen and evaluated by behavioral health services and is cleared by behavioral services to follow up as an outpatient. ..."Further review revealed Patient #3 was discharged at 1129. ED record review revealed Patient #3 returned again to the ED at 1442 under IVC and was placed in an ED room at 1443. At 1550, ED notes revealed "Pt [patient] sitting on bed, resting comfortably. Pt talking on phone. ...". ED notes, at 1645, revealed "Pt moved to hallway bed for safety. Pt sitting on hallway bed, quiet, calm. ..." Review of ED Notes Addendum, at 1728, revealed "Pt not noted in bed at this time. Parking lots searched and hospital security notified. [Police Department] notified of same. ..." Further review revealed at 1750 "Pt noted walking back thru ed [ED] lobby returning to bed. Pt calm and cooperative....promises 'not to do it again.' pt agreeing to change clothes at this time. ..." At 1800, ED Notes revealed "Pt escorted back to [ED room]. Pt dressed out in blue scrubs. Belongings bagged by [Name], CNA [Certified Nursing Assistant]....Pt states that he ran 'because you weren't paying attention to me.'" Record review failed to reveal a Patient Observation flow sheet to document the sitter observation while Patient #3 was in the ED. Review revealed a flowsheet was started when the patient was admitted to the behavioral unit.

Observation of an ED video, on 07/07/2017 at 1520, revealed a time period of 03/31/2017 at 1722. Video review revealed a male in street clothes [not blue scrubs], identified as Patient #3, walk down the ED hallway and exit out to the right. Further video observation revealed Patient #3, at 1747 [25 minutes later] enter the doorway into the ED from the outside.

Observation of the ED, on 07/07/2017 at 1530, revealed the door Patient #3 exited was now equipped with a delayed exit and loud alarm should someone try to leave through that door. Observation revealed a second door had also been added between registration and the ED hallway to deter anyone attempting to leave.

Telephone interview with RN #7, on 07/06/2017 at 1210, revealed RN #7 was the primary nurse for Patient #3 on the third visit. Interview revealed the patient was an IVC patient and in an ED room with another patient. Interview revealed the second patient became belligerent and Patient #3 was moved to the hallway for safety. A patient across the hall also became argumentative, RN #7 stated, and she went into the third patient's room to try and settle the patient. When RN #7 got out of the other room, she stated, Patient #3 was not there. Interview revealed RN #7 was not sure who was watching the patient at that time.

Interview with Certified Nursing Assistant [CNA] #1, on 07/07/2017 at 1355 revealed CNA #1 did not know if Patient #3 was IVC when caring for the patient. Interview revealed CNA #1 was assigned to sit with the two patients in the room when the second patient became disruptive. Interview revealed CNA #1 shifted focus to the second patient and was not aware of what happened with Patient #3. Further interview revealed CNA #1 did not receive instruction on documenting the Patient Observation flowsheet until after the event.

Interview with the Director of Emergency Services [DES], on 07/06/2017 at 1435, revealed Patient #3 was not placed in blue scrubs until after the patient returned to the ED and confirmed a policy that stated personal belongings would be removed from IVC patients.






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2. Review on 07/07/2017 of a policy titled "Suicide Precautions for Patients Admitted to Non-Behavioral Health Unit" revealed "...1. All patients will be assessed for Risk for suicide. 2. A sitter/attendant will be provided based on physician order (see safety attendant policy)..."

Review on 07/07/2017 of a policy titled "Safety Attendant Policy" revealed "...1. Safety Attendants are utilized for patients who are potentially dangerous to themselves or others......2. A Safety Attendant may be utilized based on a physician's order......Due to the level of patient care provided by the attendant, the attendant must minimally be a Certified Nursing Assstant...

A. Closed medical record review of Patient #3, on 07/05-06/2017, revealed the 42 year-old patient presented to the ED on 03/31/2017 at 0441 with a chief complaint of anxiety. Review revealed the patient was examined and discharged at 0518 with a diagnosis of anxiety and ear infection. Review revealed Patient #3 was reregistered at 0939. Review of ED Provider Notes, dated 03/31/2017 at 1016, revealed "...he was here last night and then discharged home with a diagnosis of anxiety disorder. Patient's family is requesting mental health evaluation....Behavior health services has come in to evaluate the patient.... Patient seen and evaluated by behavioral health services and is cleared by behavioral services to follow up as an outpatient. ..." Further review revealed Patient # 3 was discharged at 1129. ED record review revealed Patient #3 returned again to the ED at 1442 under IVC and was placed in an ED room at 1443. At 1550, ED notes revealed "Pt [patient] sitting on bed, resting comfortably. Pt talking on phone. ...". ED notes, at 1645, revealed "Pt moved to hallway bed for safety. Pt sitting on hallway bed, quiet, calm. ..." Review of ED Notes Addendum, at 1728, revealed "Pt not noted in bed at this time. Parking lots searched and hospital security notified. [Police Department] notified of same. ..." Further review revealed at 1750 "Pt noted walking back thru ed [ED] lobby returning to bed. Pt calm and cooperative....promises 'not to do it again.'..." At 1800, ED Notes revealed "Pt escorted back to [ED room]....Pt states that he ran 'because you weren't paying attention to me.'" Record review failed to reveal a Patient Observation flow sheet to document the sitter observation while Patient #3 was in the ED. Review revealed a flowsheet was started when the patient was admitted to the behavioral unit.

Observation of an ED video, on 07/07/2017 at 1520, revealed a time period of 03/31/2017 at 1722. Video review revealed a male in street clothes, identified as Patient #3, walk down the ED hallway and exit out to the right. Further video observation revealed Patient #3, at 1747 [25 minutes later] enter the doorway into the ED from the outside.

Telephone interview with RN #7, on 07/06/2017 at 1210, revealed RN #7 was the primary nurse for Patient #3 on the third visit. Interview revealed the patient was an IVC patient and in an ED room with another patient. Interview revealed the second patient became belligerent and Patient #3 was moved to the hallway for safety. A patient across the hall also became argumentative, RN #7 stated, and she went into the third patient's room to try and settle the patient. When RN #7 got out of the other room, she stated, Patient #3 was not there. Interview revealed RN #7 was not sure who was watching the patient at that time.

Interview with Certified Nursing Assistant [CNA] #1, on 07/07/2017 at 1355 revealed CNA #1 did not know if Patient #3 was IVC when caring for the patient. Interview revealed CNA #1 was assigned to sit with the two patients in the room when the second patient became disruptive. Interview revealed CNA #1 shifted focus to the second patient and was not aware of what happened with Patient #3. Further interview revealed CNA #1 did not receive instruction on documenting the 15 minute observation sheet until after the event.

B. Review on 07/07/2017 of Patient # 11's closed medical record revealed a 26 year old female who arrived to the emergency room (ER) on 03/31/2017 at 1250 with a chief complaint of suicidal thoughts. Continued review revealed Patient #11 was triaged at 1253 and a "Triage Note" written by RN #6 at 1254 revealed "PT (patient) TO TRIAGE AMBULATORY WITHOUT ANY DIFFICULTY. PT C/O (complains of) HAVING SUICIDAL THOUGHTS. THESE SYMPTOMS STARTED THIS MORNING. PT HAS HX OF SUICIDAL THOUGHTS AND 1 ATTEMPT (sic)..." Continued review revealed Patient #11 was transferred to a semi private room in the ER at 1258. Further review revealed a nursing note written at 1413 by RN #5 revealed "AMBULATORY TO BATHROOM OUT IN THE LOBBY WITH HER VISITOR AT SIDE, RETURNS WITH UA, (urinalysis) ? (sic) WHETHER PT OR HER FRIEND ACUTALLY GAVE SPECIMIN (sic)." Continued review revealed "Safety precautions" were ordered at 03/31/2017 at 12:59 per standing orders. Continued review of safety precaution order revealed "ON Unit Supervision Within Eyesight (ED (Emergency Department) Only). Continued medical record review failed to reveal a "Patient Observation Flow Sheet" for Patient #11 while in the ER. Continued review revealed a "Patient Observation Flow Sheet" was started at 1750 on 03/31/2017 when Patient #11 was transferred to the Behavioral Health Unit. Further review revealed Patient #11 was transferred to a behavioral health unit at 1751.

Interview on 07/07/2017 at 1350 with CNA #1 revealed she sat in a semi-private room with Patient #11 and Patient #3 to make sure they stayed in their room. Further interview revealed if Patient #11 had to use the restroom then CNA #1 would call for another tech or sitter to sit with Patient #3 while she took Patient #11 to the bathroom. Continued interview revealed Patient #11 would have to be escorted to the bathroom with a staff member so she would remain in eyesight of facility staff. Further interview revealed
CNA #1 did not know she was supposed to document on a "Patient Observation Flow Sheet" and could not remember what time she started sitting with Patient #11.

Interview on 07/07/2017 at 1430 with RN #5 revealed if a patient was suicidal and had 1:1 sitter then the sitter would document in the EMR or on the Patient Observation Flowsheet 15 minute checks. Continued interview revealed if Patient #11 had to use the restroom a staff member would have to escort her so she would remain in sight. Further review of nursing notes with RN #5 revealed "I don't remember the note about the bathroom but I didn't know she went to the bathroom until she came back she didn't go to the bathroom with permission." Continued interview revealed she did not know when CNA #11 started sitting with Patient #11 and there was no documentation to reveal when she started sitting with Patient #11.

Based on policy and procedure review, medical record review, and staff interviews the facility's nursing staff failed to monitor the patient during a physical and chemical restraint.

The findings include:

Review on 07/07/2017 of a policy titled "Restraint: Physical and Chemical Restraint for Behavioral Health Care (Violent or Self-Destructive Behavior)" revealed "...Physical Restraint a. The patient will be monitored by a competent staff member under the direction of an RN (Registered Nurse) for at least the following six parameters of care at intervals not to exceed two hours and results will be documented on the violent restraint flow sheet in the EMR (electronic medical record). i. Response to restraint (e.g., level of distress and agitation, mental status, cognitive functioning); ii. Circulation and skin integrity; iii. Need for nutrition and fluids; iv. Toileting; v. Repositioning; and vi. Range of motion exercises to restrained extremities. The Registered Nurse is responsible to ensure that: a. The patient's vital signs will continue to be monitored according to the most recent vital signs order or more frequently if indicated by the patient's condition. b. Neurological evaluations should be initiated as appropriate. c. For safety, the restrained patient requiring Human Transboards and 6 point Humane restraints must have continuous 1:1 monitoring. Chemical Restraint The patient will be monitored by a competent staff member under the direction of an RN a. signs of any injury/adverse reactions associated with chemical restraint every 15 minutes for one hour, then every one hour for three hours; b. nutrition/hydration every four hours; c. vital signs every 30 minutes for one hour, then every one hour for three hours; d. hygiene and elimination every four hours; 3. comfort every one hour; and. f. monitor for safety every 15 minutes..."

Review on 07/07/2017 of Patient # 11's closed medical record revealed a 26 year old female who arrived to the emergency room (ER) on 03/31/2017 at 1250 with a chief complaint of suicidal thoughts. Review revealed a note written on 03/31/2017 at 1645 by RN #5 which stated "PT (patient) OUTSIDE ROOM LOUD AND CURSING, ESCALATING AND STATING OVER AND OVER "I DON'T WANT TO STAY HERE", VERBALIZED UNDERSTANDING BUT IS DISGRUNTLED. PT RELUCTANTLY RETURNS TO ROOM AND PROVIDER GIVES ORDERS FOR MEDICATION. PT BECOMES TEARFUL AND DE-ESCALATES. SECURITY AT BEDSIDE AND MEDS HELD BECAUSE PT IS CONTROLLED AT THIS TIME (sic)." Further review revealed a "VIOLENT, SELF-DESTRUCTIVE BEHAVIOR RESTRAINT AND SECLUSION ORDER" that started at 03/31/2017 at 1710. Further review revealed "RESTRAINT ORDER" with a check on "Transboard Restraint" and "...D. Chemical: Medication name Geodon (anti-psychotic medication)-Route IM (intramuscular)-Dose 20 mg Frequency x1" signed by PA #1. Continued review revealed a note written on 03/31/2017 at 1715 by RN #5 "PT ESCALATES UNTIL NEEDING MEDICATION, GIVEN GEODON AS ORDERED AND PLACED ON BEHAVIOR BOARD ALL WHILE SCREAMING AND CURSING AT THE SECURITY AND NURSING STAFF, PT IS INCONSOLABLE." Further review revealed 20 mg IM Geodone was given at 1730 by RN #5. Continued review revealed a note at 1732 written by RN #5 that stated "BECOMING MORE CONTROLLED, PCT (patient care technician) AT BEDSIDE AND GETTING GOOD RAPPORT WITH PT, ALLOWED TO LET ONE ARM OFF BOARD AND EAT APPLE AS SHE HAS NOT HAD FOOD 'ALL DAY.'" Further review revealed documented vitals at 1734 by CNA #1. Continued review revealed a note written at 1736 by RN #5 which stated "COMING OFF BEHAVIOR BOARD, PT IS GROGGY AND TEARFUL BUT COMPLAINT, PCT AND SECURITY REMAIN AT SIDE 1:1." Further review revealed documented vitals at 1741 by CNA #1. Further review revealed Patient #11 was transferred to the "Behavioral Health Unit" at 1751. Review failed to reveal documentation of Patient #11's response to restraint, circulation, skin integrity, need for nutrition and fluids, toileting, repositioning, and range of motion exercises to restrained extremities. Continued review failed to reveal debriefing with patient and staff. Further review revealed documentation was not done in violent restraint flow sheet but through notes. Further review of "Behavioral Restraint/Seclusion Physician Assessment" revealed Patient #5 was completely off board at 1736.

Interview on 07/07/2017 at 0955 with NM (Nurse Manager) #1 revealed documentation for restraints goes in the restraint tab in the EMR. Review of Patient #11's chart with NM #1 failed to reveal documentation in the restraint tab on monitoring Patient #11 during the restraint.

Interview on 07/07/2017 at 1350 with CNA #1 revealed she sat with Patient #11 to make sure she stayed in her room. Further interview revealed Patient #11 became agitated after her friend left and she was put on the transboard and medication was given. Further interview revealed CNA #1 was told to take Patient #11's vital signs every 15 minutes and documented them.

Interview on 07/07/2017 at 1430 with RN #5 revealed that she saw Patient #11 become agitated after her Patient #11's friend left. Further interview revealed Patient #11 was on the behavior board for a brief amount of time. Continued interview revealed RN #5 knew about restraint tab in EMR. Continued interview revealed RN #5 stated she preferred to document with notes but she would usually use the restraint tab in the EMR.

Based on policy and procedure, medical record review and staff interview the facility nursing staff failed to feed 1 of 2 sampled patients needing one to one assistance (Patient # 8) and failed to assess and reassess pain in 2 of 3 sampled patients with complaints of pain (Patient #4 and Patient #6).

The findings include:

1. Review of the procedure on 07/07/2017 "Feeding, Lippincott Manual; revised May 12, 2017" revealed "Introduction...Meeting the nutritional needs of such a patient requires determining the patient's food preferences; feeding the patient in a friendly, unhurried manner; encouraging self feeding to promote independence and dignity, when possible; and documenting intake and output..."Implementation....Document oral intake, as ordered; Document the procedure..."

Review of closed medical record of Patient #8 on 07/06/2017 revealed a 83 year old female admitted to the hospital on 02/21/2017 for a diagnosis of Influenza A. Record review revealed a past medical history of functional quadriplegia, dementia and diabetes. Review of Speech Language Pathology Clinical Swallow Assessment Evaluation on 02/22/2017 at 0844 revealed "... RECOMMENDATIONS: ...3) Compensatory Swallowing Strategies: Upright as possible for all oral intake; Remain upright for 20-30 minutes after meals; One to one assist with meals; External pacing; No straws d/t (due to) confusion; Small bites/sips; Eat/feed slowly; Check for pocketing of food on the right; Check for pocketing of food on the left". Record review of intake/output flowsheet on 03/05/2017 at 0940 revealed the patient ate 100% of meal. Record review revealed next documented meal was on 03/06/2017 at 0945 (24 hours 5 minutes later).

Interview on 07/06/2017 at 1040 with Nurse Manager #2 revealed she did "at the moment" education with staff about documentation with meals and feedings in March. Interview revealed if staff does not document the task, it is unknown if patients are fed.

Interview on 07/06/2017 at 1200 with CNA #2 revealed she documents every time she feeds a patient. Interview revealed she documents the percentage of the meal that was eaten and how much fluids the patient drank. Interview revealed she documents patient care task she performs in the medical record.

Telephone interview on 07/06/2017 at 1415 with RN #6 revealed she was floated from her home unit to work on the 3rd floor on 03/05/2017. Interview revealed she remembers caring for Patient #8. Interview revealed during the morning of 03/05/2017 while passing medications she spoke to the daughter of Patient #8 about the someone was coming back to feed the patient lunch. Interview revealed no one came to feed the patient lunch. Interview revealed she should have called to confirm no one was coming and she was to feed the patient. Interview revealed another family member returned later in the afternoon and was upset the patient has not eaten since breakfast. Interview revealed she apologized for not feeding the patient and she should have called the family. Interview revealed time passed and she became busy and the patient was not fed.





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2. Review on 07/06/2017 of a policy titled "Pain Management" revealed "...A. All patients will be assessed for the presence/absence of pain using an objective rating scale, which is specified for each patient...2. Pain in the pediatric population will be assessed using the following scales:......3-12 years: FACES Scale (The scale shows a series of faces ranging from a happy face at 0, No hurt to a crying face at 10 Hurts worst).......B. Pain assessments will be performed at the time of admission, reassessment of pain will be performed every shift, at the time of a patient's self-report of pain, and within one hour of any intervention that has been provided for relief of pain..."

A. Review on 07/05/2017 of Patient #4's medical record revealed an 11 year old male who came to the Emergency Room (ER) for a chief complaint of abdominal pain. Continued review revealed Patient #4 arrived at 1548 on 05/23/2017 and was discharged home at 2023. Continue review revealed a "Wong-Baker FACES" pain scale was done on 05/23/2017 at 1600 during triage by RN #4 where Patient #4 scored his pain as an 8/10. Continued review revealed Patient #4 was given 2 mg morphine (pain medication) IV (intravenous) at 1616 by RN #1. Review failed to reveal a post medication pain assessment one hour after morphine administration. Further review revealed Patient #4 was given 2 mg IV morphine at 1931 by RN #2. Continue review revealed "Wong-Baker FACES" pain scale was done on at 2020 during Patient #4's discharge by RN #3 where he scored a 2/10. Continued review failed to reveal a reassessment of pain done prior to administration of morphine at 1931.

Interview with RN #1 on 07/06/2017 at 1330 revealed pain assessments should be done during triage, every hour, and at discharge. Further interview revealed pain reassessments should be done within 1 hour after medication administration. Review of Patient #4's chart with RN #1 failed to reveal a pain reassessment after morphine administration "I know I'm suppose to do a reassessment I don't see it though."

Interview with RN #2 on 07/06/2017 at 1420 revealed pain reassessments are done within 1 hour of medication administration. Further interview revealed pain reassessments are also done prior to discharge.

Interview with RN #3 on 07/06/2017 at 1425 revealed pain reassessments are suppose to be done prior to discharge.

Interview with Director of Emergency Services (DES) revealed the pain assessments were to be done anytime pain medication was given, pain must be reassessed within 60 minutes. Further interview revealed patients must have documented vital signs including pain assessment within 30 minutes of discharge. Further interview revealed weekly pain assessment audits were done and if nurses were found non-compliant they would have to do 10 pain audits.

B. Review on 07/05/2017 of Patient #6's medical record revealed a 4 year old male who arrived to the ER on 06/03/2017 at 2324 with a chief complaint of abdominal pain. Continued review revealed a FACES pain rating was done on 06/03/2017 at 2326 by RN #6 during triage and Patient #6 scored an 8/10. Review failed to reveal another pain assessment prior to Patient #6's discharge on 06/04/2017 at 0224.

Interview with RN #1 on 07/06/2017 at 1330 revealed pain assessments should be done during triage, every hour, and at discharge. Further interview revealed pain reassessments should be done within 1 hour after given medication.

Interview with RN #2 on 07/06/2017 at 1420 revealed pain reassessments are done within 1 hour of medication administration. Further interview revealed pain reassessments are also done prior to discharge.

Interview with RN #3 on 07/06/2017 at 1425 revealed pain reassessments are suppose to be done prior to discharge.

Interview with Director of Emergency Services (DES) revealed the expectation for pain assessments to be done were anytime pain medication was given pain must be reassessed within 60 minutes. Further interview revealed patients must have documented vital signs including pain assessment within 30 minutes of discharge. Further interview revealed weekly pain assessment audits were done and if nurses were found non-compliant they would have to do 10 audits.

NC00127863, NC00128720