HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure that a patient was free from abuse for one (1) of two (2) patients reviewed (Patient A).

Finding includes:

A "Reportable Incident Form for Certified, Licensed or Registered Providers", dated August 16, 2017, indicated that on August 10, 2017, Patient A arrived in the hospital Emergency Department (ED) with a suspected overdose. The incident form indicated the patient was "not combative or uncooperative"; he/she was attempting to answer the physician's questions to the best of his/her ability; and the physician grabbed and pulled on the patient's hair and repeatedly asked the patient what substances he/she had taken. The Incident Form also indicated that the physician was saying "Don't lie to me. You're lying to me. Tell me what you took or I will pull your hair again."

During a telephone interview on August 25, 2017 at 7:01 AM, a Registered Nurse (RN). who provided patient care to Patient A on August 10, 2017, reported the following: "the patient was very calm and cooperative as well as non-combative" and "the patient was coming out of unconsciousness and was trying to understand what the doctor was asking". The RN reported "The doctor said 'You better tell me what you took' and then grabbed the patient's hair and said 'Don't lie to me' and continued to call the patient a liar and pulled the patient's hair, stating 'Do you want me to pull your hair again' three more times while grabbing the patient's hair".

The hospital's Incident Reporting system was reviewed on August 23, 2017 at approximately 2:22 PM. This system contained information that on August 10, 2017 at approximately 5:30 PM a patient was brought to the ED after snorting Percocet. The patient received Narcan prior to arrival and was described in the report as cooperative and non-combative. The Incident Reporting system indicated that a nurse had reported that the ED physician grabbed the patient's hair and pulled it while asking what drugs the patient took while stating "Don't lie to me". The report also indicated that the physician pulled the patient's hair three times.

The information provided on the Reportable Incident Form was confirmed by one of the Emergency Department Co-Medical Directors on August 23, 2017 at approximately 9:20 AM, and was re-verified on August 23, 2017 at approximately 2:45 PM by the second Emergency Department Co-Medical Director.

Based on document reviews and interviews, the hospital failed to ensure the patient's medical record contained documentation of the patient's symptoms that warranted the use of restraint/seclusion for two (2) of five (5) restraint/seclusion records reviewed (Patients C and D).

Finding includes:

The hospital's Policies 06.001 and 06.001.01 regarding Non-Violent or Non-Self Destructive and Violent or Self Destructive Restraint Management, both state the following: "EMMC believes all patients have the right to be free from physical or mental abuse and corporal punishment. All patients have the right to be free from restraint or seclusion of any form ... Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others ..." These policies include a definition from the Code of Federal Regulation for Restraint and Seclusion, which states: " ... Seclusion: a. Is the involuntary confinement of a patient ... b. May only be used for the management of violent or self-destructive behavior ..."

1. Patient C's record indicated a restraint order was entered on July 30, 2017 at 2:40 AM. The rationale for the restraint, which was selected from a drop down list, indicated the patient "can't reason/persuade/contain/delay/deny, Net".

Documentation in Patient C's record indicated he/she was placed in a restraint (net) on July 30, 2017 from 2:40 AM to 4:17 AM.

A review of documentation in the patient's record staff was conducted. There was no documentation that the patient was displaying behavior that would place the immediate physical safety of the patient, a staff member, or others at risk to warrant the use of the restraint. The documentation indicated the following:

- The patient arrived in the Emergency Department (ED) on July 30, 2017 at approximately 2:40 AM, following a reported ingestion of an unknown toxin. The medical record described patient as follows: "Patient hallucinating and talking gibberish. [He/She] is unable to have a conversation. Laughs uncontrollably ... Patient is sweating ... is red in the face. Pupils are dilated." Physical examination: ...Neurological: "Alert and oriented to person, place, time and situation ..., Psychiatric: Cooperative, appropriate mood & affect." Under Medical Decision Making: indicated, "[He/she] required medical and physical restraints for [his/her] medical staff safety".

- The security documentation, dated July 30, 2017 at 2:40 AM, indicated " ... Pt placed in full restraints on arrival ... Pt lying in bed talking to himself, appears calm." At 3:15 AM the security note reported. "Pt calm in bed". At 3:30 AM: "No change"

- The Nursing note, dated July 30, 2017 at 2:54 AM, indicated "pt. making nonsensical statements. Pt is able to state name ... Does not know what [he/she] ingested tonight ... Pt netted for behavioral discontrol after failing to contract for safety."

On August 24, 2017 at approximately 11:00 AM., the Assistant Nurse Manager Emergency Department and the Director of Nursing for Professional Practices and Administrative Services confirmed that Patient C's records contained no information that the patient presented with violent or self-destructive behaviors during their stays in the Emergency Department.

2. Patient D's record contained orders for "Seclusion Behavioral Management" dated June 29, 2017 at 1:46 PM. One order indicated the rational for use of seclusion was the patient "can't reason/persuade/contain/delay/deny, 1:1 care" and the second order indicated "has homicidal or suicidal ideation." The second order was rewritten the exact same way again at 3:46 PM, 5:46 PM, and 7:46 PM.

Patient D's record indicated that he/she was placed in seclusion on June 29, 2017 from 1:46 PM until 9:04 PM when he/she was discharged from the Emergency Department (ED).

A review of documentation by the physician, nursing staff, and security staff showed no evidence that the patient was displaying violent or self destructive behavior to warrant the use of seclusion. The documentation indicated the following:

- The physician progress note indicated "the patient presents with agitation. The onset was chronic. The course/duration of symptoms is episodic ... Self injury: None... Risk factors consist of age." The physical examination report stated: "Psychiatric; Cooperative, appropriate mood & affect."

- The nursing documentation on June 29, 2017 at 2:16 PM, stated: "pt. reports intermittent SI [suicidal ideation], denies at this time. Intermittent HI [homicidal ideation] towards [relative] who 'raped me' [relative not in current community] ... pt. reports feeling unsafe at home. Pt. calm and polite with this RN."

- The Security documentation of "continuous observation" from 12:20 PM to 9:05 PM on June 29, 2017, reported the patient as predominately; "calm", "watching TV", or "laying on bed". Only agitation was documented at 8:20 PM, report indicated: "Pt verbalizes violence towards [Crisis] staff - he will punch them and make them bleed if they ask him any more questions." At 8:30 PM again described as "Pt. calm in room".

On August 24, 2017 at approximately 11:00 AM., the Assistant Nurse Manager Emergency Department and the Director of Nursing for Professional Practices and Administrative Services confirmed that Patient D's record failed to contain information that the patient presented with violent or self-destructive behaviors during his/her stay in the Emergency Department. The Assistant Nurse Manager Emergency stated that patient D probably needed to be secluded to keep him/her safe in the ED due to his/her age and to prevent the patient from eloping from the ED.