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Based on record review, video review, staff interviews and policy review, it was determined that the Medical Director failed to assure that adequate psychiatric and medical care was provided for a patient in seclusion (adolescent patient E-18). This patient was physically held and given IM [intramuscular] medications two different times and secluded five additional times in a span of fewer than 21 hours between 8/6/11 and 8/7/11 without being evaluated by the attending psychiatrist or the covering psychiatrist or medical physician. The Physician Assistant who was to evaluate the patient did not do so. Instead, medical staff ordered that the patient be transferred to an emergency department for evaluation. Because the staff did not feel comfortable in evaluating the patient, the patient was transferred to an ER, with one staff member in attendance, and eloped from the ER. The patient, who was on a 1:1 because of aggressive behavior, and who had a history of homicidal ideation, eloped from the Emergency Room and was discharged from the facility subsequent to this. Failure to provide adequate psychiatric and medical care puts all patients at risk. The facility was informed on 8/10/11 at 1:30PM that an IMMEDIATE JEOPARDY status existed during the Exit Conference with the hospital's Executive Team. (Refer to B144)

Based on record review, video review, staff interviews and policy review, the Medical Director failed to assure that adequate psychiatric and medical care was provided for a patient in seclusion (adolescent patient E-18). This patient was physically held and given IM medications two different times and secluded five different times in a span of fewer than 21 hours between 8/6/11 and 8/7/11 without being examined by the attending psychiatrist or the covering psychiatrist or medical physician. The Physician Assistant who was to evaluate the patient did not do so. Instead, medical staff ordered that the patient be transferred to an emergency department for evaluation. Because the staff did not feel comfortable in evaluating the patient, the patient was transferred to an ER, with one staff member in attendance, and eloped from the ER. The patient, who was on a 1:1 because of aggressive behavior, and who had a history of homicidal ideation, eloped from the Emergency Room and was discharged from the facility subsequent to this. Failure to provide adequate psychiatric and medical care puts all patients at risk.


Findings include:

A. Record Review

1. Patient E-18, an adolescent (under 18 years old) was admitted on 8/4/11 at 4:30AM with the diagnosis of Psychosis NOS (not otherwise specified), upon telephone order from the Medical Director. Patient was admitted under care of Physician 2.
2. Initial Nursing Assessment on 8/4/11 at 4:30AM noted, "Patient has auditory hallucinations and visual hallucination, also patient is prone to get aggressive." The patient was transferred from the community hospital ER and his "K[potassium] level was 3.3 [low]". High Risk Notification Alert form at the time of admission had "Homicidal" box checked off for "HI [homicidal ideation] directed toward family."
3. Daily Nursing Progress Note on 8/4/11at 6:36PM noted patient's vital signs to be normal, but with "0" percent breakfast, "0" percent lunch and "5" percent dinner eaten.
4. History and Physical Examination with exam date of 8/4/11 noted urine drug screen to be negative and a plan to repeat Basic Metabolic Profile and intervene medically.
5. There was no note by any psychiatrist on 8/4/11, a weekday. Attending Psychiatrist Assessment dated 8/5/11 noted "No overt aggression" and "Positive" hallucinations with plan to offer Risperdal to address psychotic symptoms and diagnosis of Psychosis NOS (Not Otherwise Specified). Medications were ordered at 9:00AM.
6. Progress Notes on 8/5/11 stated the patient refused lab work and EKG. Daily 24 Hour RN Progress note described patient to be isolative, refusing program and sleeping most of the day. Nursing Progress Note at 11:30PM noted patient had eaten 100 percent breakfast, lunch and dinner, but refused vital signs.
7. According to the nurses notes on 8/6/11, on Saturday, 8/6/11 the patient was placed in physical hold for eleven minutes from 12:20PM to 12:31PM, escorted to quiet room, given 25mg of Thorazine (antipsychotic) IM (intramuscular), and continued in seclusion until 6:00PM. Telephone Orders for Physical Hold at 12:20PM, Seclusion at 2:30PM and Seclusion at 4:30PM were obtained from the treating psychiatrist (Physician 2), who was out of state at the time (see interview below). The medical record showed no evidence of a psychiatrist or any other physician personally evaluating this patient during the entire time between 12:20PM and 6:00PM. A nursing note indicated inability to get vital signs throughout this period. The nursing note at 6 pm on 8/6/11 noted, "no longer striking out, vitals WNL...." Daily Nursing Progress Note dated 8/6/11 indicated patient ate 85 percent breakfast, refused lunch and ate 70 percent of dinner.
8. According to the nurses' notes on 8/7/11, on Sunday 8/7/11, the patient was placed in a physical hold at 6 AM, given 25mg of Thorazine IM, and continued in seclusion until 9:08AM. Telephone orders for Physical Hold continuing into seclusion were obtained from Physician 2. At 8:15AM, Physician 2 gave another telephone order to "continue seclusion for another 2 hours." The medical record showed no evidence of a psychiatrist or any other physician personally evaluating this patient during this entire episode between 6:00AM and 9:08AM on 8/7/11, at which time the patient was released from seclusion. A nurses' note at 9:08 stated the patient was "calmer and cooperative," but refused breakfast.
9. The nursing note on 8/7/11 at 10:10am stated that Physician 2 asked the nursing staff to "contact Medical staff to notify of refusal to eat X 3days and administration of stat thorazine medications X 2."
10. The Doctor's orders on 8/7/11 at 1:40PM had an entry by RN "T.O. (Telephone Order) (name of PA) PA-C, transfer to [community hospital] to be evaluated for possible dehydration and anorexia for 3 days with a staff escort."
11. There was no evidence in the medical record that a Medical Physician or PA-C. personally examined the patient on 8/6/11 or 8/7/11.
12. The patient was transferred to a community hospital emergency department for evaluation of dehydration and anorexia at 3:10PM on 8/7/11. Staff stated that the patient was in five point restraint on a gurney; there was no order in the chart for restraint.
13. According to the nursing note on 8/7/11 at 4:15PM, "patient eloped from ER."

B. Staff Interviews

1. In an interview with Physician 2 on 8/10/11 at 10:15AM, he reported that he did not know how many times exactly he was called for the telephone orders for the seclusions and physical holds for patient E-18 on 8/6/11 and 8/7/11. He further stated that he never saw the patient E-18 on 8/6/11 or 8/7/11, as "I was in Michigan." He stated that he was responsible for his patients at all times and that he had called the Medical Director, who was also covering for him, about patient E-18 and talked with the Medial Director about his (Physician 2's) plan to send the patient to an emergency department for medical evaluation as a way to get the lab work done, and evaluate the patient's status after having been given IM Thorazine. When asked about under what circumstances a physician would return to the hospital to see a patient, Physician 2 said he has returned to see his patients but admitted most of the contact was via phone. Physician 2 stated, "I actually talk to patients having difficulty via phone because filtering through the nurse may not be the most accurate."

When asked to comment about patient E-18's eloping from the ER, Physician 2 responded, "I thought the patient would be secured" and "they [the facility] need firm guidelines for high risk patients that are being transferred to [community hospital]."

2. In an interview with Director of Medical Affairs (the head of the medical team) on 8/10/11 around 10:35am, he stated that his medical team, rather than a psychiatrist, was responsible for all the post-seclusion evaluations, as well as any medical problems for all the patients in the hospital. He reported that the PA-C on his medical team who was on call on 8/7/11 and asked to see the patient did not document anything in the medical record of patient E-18. The Director reported that he was called about this patient and felt that the patient needed lab work and since he was refusing all lab work in the hospital. The patient was sent to an ER, where staff "looking like bouncers in the club" could get patient cooperation.

3. In an interview on 8/10/11 around 11:45AM, LPN2 stated that he had accompanied (PA-C) to evaluate the patient on 8/7/11 in the morning. "[PA-C] did not enter the seclusion room" where the patient E-18 was, as "patient was lunging at staff and internalizing/hallucinating."

4. In an interview on 8/10/11 around 11 AM, the Medical Director was asked about the coverage during off hours and weekends, and he mentioned that each psychiatrist was responsible for his or her patients around the clock, seven days a week. He also stated that he and Physician 2 always covered each other and that he was covering for Physician 2 on 8/7/11. He stated that Physician 2 had talked about his plans to send the patient E-18 to the Medical ER. In light of this plan, he (Medical Director) did not feel the need to change his schedule in the morning of 8/7/11. "I was going to see the patient in the evening". When asked if he was aware of the seclusions of this patient on 8/6/11, he responded that he was aware.

C. Video Review

Video of the 8/7/11 seclusion of patient E-18 was reviewed around 1 PM on 8/10/11.
It revealed that LPN2 entered the seclusion room alone while PA-C waited outside the seclusion room at 8:39AM. The patient was sitting in the room without exhibiting any agitation. There was no sound for the video. As noted above, the nurse's note at 9:05AM stated patient was noted to be "calmer and cooperative," and was released from seclusion at that time, but refused to eat.

D. Policy Review

Hartgrove Hospital Policy NO: PC 615 revised 07/11 on Restraint and Seclusion, under Physician Order stated: "If an emergency order to restrain is initiated by a RN, a physician must examine the patient as soon as possible but at least within 24 hours and document such in the progress note or restraint/seclusion record and co-sign the order."

Based on record review, video review, staff interviews and policy review, the Medical Director failed to assure adequate medical staffing to provide psychiatric and medical care for a patient in seclusion (adolescent patient E-18). This patient was physically held and given IM medications two different times and secluded five different times in a span of fewer than 21 hours between 8/6/11 and 8/7/11 without being examined by the attending psychiatrist or the covering psychiatrist or medical physician. The Physician Assistant who was to evaluate the patient did not do so. Instead, medical staff ordered that the patient be transferred to an emergency department for evaluation. The patient, who was on a 1:1 because of aggressive behavior, and who had a history of homicidal ideation, eloped from the Emergency Room and was discharged from the facility subsequent to this. Failure to provide adequate medical staffing for psychiatric and medical care puts all patients at risk.

Findings include:

A. Record Review

1. Patient E-18, an adolescent (under 18 years old) was admitted on 8/4/11at 4:30AM with the diagnosis of Psychosis NOS (not otherwise specified), upon telephone order from the Medical Director. Patient was admitted under care of Psychiatrist Physician 2. The Initial Nursing Assessment on 8/4/11 at 4:30AM noted, "Patient has auditory hallucinations and visual hallucination, also patient is prone to get aggressive." The patient was transferred from the community hospital ER and his "K[potassium] level was 3.3 [low]." A "High Risk Notification Alert" form at the time of admission had "Homicidal" box checked off for"HI [homicidal ideation] directed toward family."

2.According to the nurses notes on 8/6/11, on Saturday, 8/6/11 the patient was placed in physical hold for eleven minutes from 12:20PM to 12:31PM, escorted to quiet room, given 25mg of Thorazine (antipsychotic) IM (intramuscular), and continued in seclusion until 6:00PM. Telephone Orders for Physical Hold at 12:20PM, Seclusion at 2:30PM and Seclusion at 4:30PM were obtained from the treating psychiatrist (Physician 2), who was out of state at the time (see interview below). The medical record showed no evidence of a psychiatrist or any other physician personally evaluating this patient during the entire time between 12:20PM and 6:00PM. A nursing note indicated inability to get vital signs throughout this period. The nursing note at 6 pm on 8/6/11 noted, "no longer striking out, vitals WNL...." Daily Nursing Progress Note dated 8/6/11 indicated patient ate 85 percent breakfast, refused lunch and ate 70 percent of dinner.

3. According to the nurses' notes on 8/7/11, on Sunday 8/7/11, the patient was placed in a physical hold at 6AM, given 25mg of Thorazine IM, and continued in seclusion until 9:08AM. Telephone orders for Physical Hold continuing into seclusion were obtained from Physician 2. At 8:15AM, Physician 2 gave another telephone order to "continue seclusion for another 2 hours." The medical record showed no evidence of a psychiatrist or any other physician personally evaluating this patient during this entire episode between 6:00AM and 9:08AM on 8/7/11, at which time the patient was released from seclusion. A nurses' note at 9:08AM stated the patient was "calmer and cooperative," but refused breakfast.

4. A nursing note on 8/7/11 at 10:10AM stated that Physician 2 asked the nursing staff to "contact Medical staff to notify of refusal to eat X 3days and administration of stat thorazine medications X 2." There was no evidence in the medical record that a Medical Physician or PA-C personally examined the patient on 8/6/11 or 8/7/11. The Doctor's orders on 8/7/11 at 1:40 PM had an entry by RN "T.O. (Telephone Order) (name of PA) PA-C, transfer to [community hospital] to be evaluated for possible dehydration and anorexia for 3 days with a staff escort."

5.The patient was transferred to a community hospital emergency department for evaluation of dehydration and anorexia at 3:10PM on 8/7/11. Staff stated that the patient was in five point restraint on a gurney; there was no order in the chart for restraint.

6. According to the nursing note on 8/7/11 at 4:15PM, "patient eloped from ER."

B. Staff Interviews

1. In an interview with Physician 2 on 8/10/11 at 10:15AM, he reported that he never saw the patient E-18 on 8/6/11 or 8/7/11, as "I was in Michigan." He stated that he was responsible for his patients at all times and that he had called the Medical Director, who was also covering for him, about patient E-18 and talked with the Medial Director about his (Physician 2's) plan to send the patient to an emergency department for medical evaluation as a way to get the lab work done, and evaluate the patient's status after the patient having been given IM Thorazine. When asked about under what circumstances a physician would return to the hospital to see a patient, Physician 2 said he has returned to see his patients but admitted most of the contact was via phone.

2. In an interview with Director of Medical Affairs (the head of the medical team) on 8/10/11 around 10:35am, he stated that his medical team, rather than a psychiatrist, was responsible for all the post-seclusion evaluations, as well as any medical problems for all the patients in the hospital. He reported that the PA-C on his medical team who was on call on 8/7/11 and asked to see the patient did not document anything in the medical record of patient E-18.

3. In an interview on 8/10/11 around 11AM, the Medical Director was asked about the coverage during off hours and weekends and he mentioned that each psychiatrist was responsible for his or her patients around the clock, seven days a week. He also stated that he and Physician 2 always covered each other and that he was covering for Physician 2 on 8/7/11. He stated that Physician 2 had talked about his plans to send the patient E-18 to the Medical ER. In light of this plan, he (Medical Director) did not feel the need to change his schedule in the morning of 8/7/11. "I was going to see the patient in the evening". When asked if he was aware of the seclusions of this patient on 8/6/11, he responded that he was aware.

C. Video Review

Video of the 8/7/11 seclusion of patient E-18 was reviewed around 1 PM on 8/10/11.
It revealed that LPN2 entered the seclusion room alone while PA-C waited outside the seclusion room at 8:39AM. The patient was sitting in the room without exhibiting any agitation. There was no sound for the video. As noted above, the nurse's note at 9:05AM stated patient was noted to be "calmer and cooperative," and was released from seclusion at that time, but refused to eat.

D. Policy Review

Hartgrove Hospital Policy NO: PC 615 revised 07/11 on Restraint and Seclusion, under Physician Order stated: "If an emergency order to restrain is initiated by a RN, a physician must examine the patient as soon as possible but at least within 24 hours and document such in the progress note or restraint/ seclusion record and co-sign the order."

Based on observation, record review, and interview, the Chief Nursing Officer (CNO) failed to provide proper training for registered nurses completing the physician order form in the medical record. Specifically, the CNO failed to ensure proper documentation of seclusion and restraint procedures for 1 of 12 sample patients (B1) and 4 of 17 non-sample patients (E1, E4, E11 and E18) chosen for review of seclusion and restraint procedures. Registered nurses rather than the physicians dated and timed the physician signatures for the telephone orders. Therefore, the timeline of events during the 24 hour period after restrictive procedures were employed could not be verified. This practice potentially results in a failure to ensure the proper documentation of seclusion and restraint procedures, and can impact patients' rights to the use of least restrictive measures.

Findings include:

1. Patient B1 was restrained on 8/07/11. The "Restraint/Seclusion/Physical Hold Physician Order" (RSPHPO) form documented a physical hold episode with a start time of 7:38PM and an ending time of 7:40PM. The form had a date and time of "8/7/11/7:38 PM" written by the registered nurse in the space for the physician signature, with the same date and time as the time the order was received and read back to the physician by phone.

2. Patient E1 was placed in a physical hold on 8/1/11. The RSPHPO form documented a physical hold episode with a start time of 9:32PM and ending at 9:34PM. The form had the date and time of "8/1/11/9:32PM" written by the registered nurse in the space for the physician signature, at the same time the order was received and read back over the phone.

3. Patient E4 was placed in a physical hold on 8/2/11. The RSPHPO form documented the physical hold episode with a start time 12:55PM and ending at 12:58PM. The form had the date and time of "8/2/11/12:55 PM" written by the registered nurse in the space for the physician signature, at the same time the order was received and read back over the phone.

4. Patient E11 was placed in a physical hold on 6/13/11. The RSPHPO form documented the physical hold with a start time of 10:25AM and ending at 10:35AM. The section designated for the physician signature contained a physician signature, but the date and time documented was the actual date and time (6/13/11/10:25AM) that the registered nurse documented as receiving and reading back the telephone order.

5. On 8/7/11 Patient E 18 was placed in a physical hold for 1 minute, given 25mg intramuscular Thorazine, and then secluded between 6:00 AM and 9:05AM. The RSPHPO for this physical hold and seclusion had date of "8/7/11(no time)" written by the nurse who took the telephone order in the space where the physician signature should have been.

B. Staff Interviews

1. In an interview on 8/09/11at 3:40PM with the Chief Nursing Officer (CNO) and the Director of Staff Development (DSD) the documentation for sample B1 and non-sample patients E1, E2, E4, E8, E9 and E11 was reviewed. CNO and DSD looked at the RSPHO forms and confirmed the date and time were written on some forms by the registered nurse receiving the order and admitted this was a training issue. The CNO stated the nurses were confused and were writing in the date and time they received the orders in the area where the physician should be co-signing and recording the date and time the telephone order was signed by the physician.

2. In an interview on 8/9/11 at 5:15PM, RN2 confirmed that registered nurses were inserting the date and time in the area designated for the physician's signature.