The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

KOOTENAI HEALTH 2003 KOOTENAI HEALTH WAY COEUR D'ALENE, ID 83814 June 10, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on staff interviews and review of medical records, hospital policies, and grievance documents, it was determined the hospital failed to protect and promote patients' rights. This resulted in patients restrained 1) without evidence of necessity to protect the patient or other from harm 2) without physician authorization 3) on an as-needed basis 4) longer than necessary and/or permitted 5) and without incorporating the intervention into each patients' POC. It also resulted in delayed investigation of a patient's allegations of mistreatment by hospital employees. Findings include:

1. Refer to A145 as it relates to the hospital's failure to ensure a process had been developed for the prompt reporting and investigation of allegations of abuse.

2. Refer to A154 as it relates to the hospital's failure to ensure restraint was only imposed to ensure the immediate physical safety of the patient or others and/or was discontinued at the earliest possible time.

3. Refer to A166 as it relates to the hospital's failure to ensure patients' written plans of care were modified to reflect the use of restraints.

4. Refer to A168 as it relates to the hospital's failure to ensure restraints were utilized in accordance with physician orders.

5. Refer to A169 as it relates to the hospital's failure to ensure orders for chemical restraints were not written on an a prn basis.

6. Refer to A171 as it relates to the hospital's failure to ensure orders for restraint used for the management of violent or self-destructive behavior were renewed every 4 hours.

7. Refer to A174 as it relates to the hospital's failure to ensure restraints were discontinued at the earliest possible time.

8. Refer to A187 as it relates to the hospital's failure to ensure medical records documented the symptoms that warranted the use of restraint.

9. Refer to A188 as it relates to the hospital's failure to ensure medical records documented the rationale for the continued use of restraints.

The cumulative effect of these negative systemic practices resulted in the inability of the hospital to ensure the rights of restrained patients were protected.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, staff interview, review of grievance documentation and review of policies, it was determined the hospital failed to ensure a process was in place for the prompt reporting and investigation of allegations of abuse. This directly impacted 1 of 8 patients (#2) whose records were reviewed and had the potential to impact all hospital patients. This resulted in a lack of direction to staff and a delay in the investigation of abuse allegations. Findings include:

1. Patient #2 was a [AGE] year old male admitted on [DATE] at 6:55 PM for schizophrenia. The ED physician dictated a progress note on 1/26/13 at 22:55 stating Patient #2 presented to the ED hearing voices and having thoughts about harming others. The note stated that during his ED stay, Patient #2 became increasingly combative and attempted to hit security staff with a metal stool. The note documented that Patient #2 was then physically restrained by security staff and given an injection of an antipsychotic medication. The note stated that Patient #2 was to be transferred to the behavioral health unit of the hospital but would remain in the ED until a bed became available. Patient #2 was transferred to the behavioral health unit on 1/27/13 at approximately 1:55 PM.

On 1/27/13 at 9:42 PM, a Mental Health Specialist documented that Patient #2 believed he had been abused by security during his time in the ED and wanted to meet with administration to file a grievance. The note went on to state that Patient #2 felt undue force had been used on him causing injuries to his arm and back and he felt the security staff was laughing at him. There was no documentation to indicate the Mental Health Specialist had reported this incident or responded to Patient #2's request to file a grievance. A grievance was later filed by the manager of the behavioral health unit on 1/31/13, four days after the initial allegation of abuse by Patient #2, and an investigation was initiated at that time.

The Mental Health Specialist referenced above was interviewed at 11:25 AM on 6/07/13. She stated that she had not reported the incident nor had she responded to Patient #2's request to file a grievance. She stated that she had not been told to report these kinds of allegations. She also stated that she did not think he really had been abused and therefore did not feel the need to report it. She stated that if she had thought Patient #2 had been abused, she would have reported it to her supervisor and the house supervisor. She also stated that because the incident did not happen on her unit, she felt her only responsibility was to document it in the record.

The policy "Abuse and Neglect of Patients at Kootenai Medical Center," dated 5/13/13, stated "All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the employee's director and in accordance with state law." The policy did not address when or how to report allegations of abuse nor did it outline a process for staff to follow when reporting abuse.

The DQRM was interviewed at 11:05 AM on 6/07/13. She confirmed there was no written process to provide direction to staff regarding the reporting of abuse allegations.

The hospital did not have a process for reporting abuse.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the hospital failed to ensure restraint was only imposed to ensure the immediate physical safety of the patient or others and/or was discontinued at the earliest possible time for 2 of 4 patients (#3 and #7) who were restrained and whose records were reviewed. This resulted in the potential for the unnecessary use of restraint. Findings include:

1. Patient #7's medical record documented a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED]

A physician order, dated 5/10/13 at 9:10 PM, called for Patient #7 to be placed in "four point leather restraints."

Patient #7's nursing notes, beginning at 9:07 PM on 5/10/13, stated these restraints were in place. At 12:00 midnight on 5/11/13, a nursing progress note stated "right upper and lower leather restraints removed." At 2:55 AM on 5/11/13, a nursing progress note stated only Patient #7's left arm was restrained. At 3:30 AM on 5/11/13, a nursing progress note stated Patient #7's last restraint was removed.

Nursing notes documented 30 minute checks while Patient #7 was restrained. The notes documented Patient #7 "Appears to sleep" on 5/10/13 at 11:20 PM, 11:50 PM, and on 5/11/13 at midnight, 12:25 AM, 12:55 AM, 1:16 AM, 1:45 AM, 2:15 AM, 2:45 AM, and 3:15 AM. Patient #7 was restrained for 3 hours and 50 minutes while he was asleep. No nursing notes documented that he was a threat to himself or others from 11:20 PM through 3:15 AM.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed Patient #7 was restrained while he was asleep and he did not appear to be a threat to himself or others.

There was no documentation to support that Patient #7 was restrained to protect himself or others.





2. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

A physician order, dated 3/09/13 at 10:00 PM, called for Patient #3 to be placed in "four point soft restraints." The order did not state what specific behaviors Patient #3 exhibited that construed a threat to safety.

On 3/09/13 at 9:36 PM, a nursing progress note included wrists and legs were restrained. The note did not include the specific behaviors which may have warranted the restraints. At 1:30 AM on 3/10/13, Patient #3's nursing note stated " ...IS SLEEPING ON AND OFF, WHEN AWAKE PT HAS TO BE REDIRECTED FROM HIS WRIST RESTRAINTS, ONLY WRIST RESTRAINTS ARE APPLIED." There was no nursing documentation to indicate when the leg restraints were discontinued. Subsequent nursing notes included no further reference to Patient #3 being restrained. No documentation was found to indicate when the restraints were discontinued or the rationale for the restraints.

The DQRM was interviewed at 6/05/13 at 12:40 PM. She reviewed Patient #3's medical record and confirmed there was no documentation to indicate Patient #3 was physically aggressive or exhibited violent behavior, requiring the use of restraints.

There was no documentation to support that Patient #3 was restrained to protect himself or others.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the hospital failed to ensure treatment plans reflected the use of restraints and seclusion for 3 of 4 patients (#3, #7, and #8) whose records were reviewed and who were restrained and/or secluded. This resulted in a lack of direction to staff regarding ways to decrease restraint usage and ways to keep the patient safe. Findings include:

1. Patient #8 was a [AGE] year old male admitted on [DATE] for severe intoxication and suicidal behavior. He was discharged on [DATE].

An RN assessment note, dated 5/15/13 at 3:52 PM, stated Patient #8 had been placed in soft wrist and ankle restraints due to his intoxication level and increasing combativeness. A "RESTRAINT NON-VIOLENT/SELF DESTRUCTIVE (MEDICAL) PHYSICIAN ORDERS," signed by the ED physician on 5/15/13 at 5:00 PM, documented orders for soft ankle and wrist restraints. A nursing note dated 5/15/13 at 7:25 PM documented that Patient #8 had been removed from restraints and was calm and cooperative. A plan of care that included the restraints was not documented in Patient #8's medical record.

The DQRM was interviewed on 6/10/13 beginning at 12:40 PM. She stated POCs, including POCs for restraints, were not documented for Patient #8.

Patient #8's plan of care was not reflective of the use of restraints.

2. Patient #2 was a [AGE] year old male admitted through the ED on 1/26/13 for schizophrenia. He was discharged on [DATE].

The ED physician's progress note, dictated 1/26/13 at 10:55 PM, stated Patient #2 had been physically restrained after attempting to hit security staff with a metal stool.

In addition, a "Case Report," completed by security staff on 1/27/13 at 11:50 PM, documented that security officers were in place at the door to Patient #2's room to "make sure (patient) didn't leave or injure himself." The security officer that documented the report was interviewed on 6/07/13 at 7:35 AM and confirmed he and another officer stood at the door of Patient #2's room and did not allow him to leave to protect Patient #2 and ED staff. The medical record did not document the length of time the security gaurds were positioned at Patient #2's doorway to prevent him from leaving.

In an interview with the Manager of Patient Advocacy on 6/06/13 at 8:45 AM, he confirmed the security guards did not allow Patient #2 to leave the room and this qualified as seclusion, in addition to the physical restraint by security staff. A plan of care that included physical restraints and seclusion was not documented.

The DQRM was interviewed on 6/10/13 beginning at 12:40 PM. She stated POCs, including POCs for restraints, were not documented for Patient #2.

Patient #2's plan of care was not reflective of the use of restraints.





3. Patient #7's medical record documented a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED]

At 9:07 PM on 5/10/13, a nursing progress note stated Patient #7 was placed in 4 point restraints. At 12:00 midnight on 5/11/13, a nursing progress note stated "right upper and lower leather restraints removed." At 2:55 AM on 5/11/13, a nursing progress note stated only Patient #7's left arm was restrained. At 3:30 AM on 5/11/13, a nursing progress note stated Patient #7's last restraint was removed. A plan of care that included restraints was not documented in his medical record.

The DQRM was interviewed on 6/10/13 beginning at 12:40 PM. She stated POCs, including POCs for restraints, were not documented for Patient #7.

A POC that included the use of restraints was not documented in Patient #7's medical record.




4. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

At 9:36 PM on 3/09/13, a nursing progress note stated Patient #3 was placed in 4 point restraints. A POC that included restraints was not documented in Patient #3's medical record.

The DQRM was interviewed on 6/05/13 beginning at 12:40 PM. She stated POCs, including POCs for restraints, were not documented.

A POC for Patient #3 which included the use of restraints was not found in his medical record.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the hospital failed to ensure restraint was used in accordance with the order of a physician or an authorized licensed independent practitioner for 4 of 4 patients (#2, #3, #7, and #8) whose records were reviewed and who were restrained. This resulted in the use of restraints without orders. Findings include:

1. Patient #2 was a [AGE] year old male admitted through the ED on 1/26/13 for schizophrenia. He was discharged on [DATE].

The ED physician's progress note, dictated 1/26/13 at 10:55 PM, stated Patient #2 had been physically restrained after attempting to hit security staff with a metal stool. There were no orders documented for the physical restraint.

In addition, a "Case Report," completed by security staff on 1/27/13 at 11:50 PM, documented that security officers were in place at the door to Patient #2's room to "make sure (patient) didn't leave or injure himself." The security officer that documented the report was interviewed on 6/07/13 at 7:35 AM and confirmed he and another officer stood at the door of Patient #2's room and did not allow him to leave to protect Patient #2 and ED staff. The medical record did not document the length of time the security officers were positioned at Patient #2's doorway to prevent him from leaving.

In an interview with the Manager of Patient Advocacy on 6/06/13 at 8:45 AM, he confirmed the security guards did not allow Patient #2 to leave the room and this qualified as seclusion. He confirmed there were no orders in the medical record for seclusion. He also confirmed that there were no orders for the physical restraint.

Patient #2 was physically restrained and placed in seclusion without an order.

2. Patient #8 was a [AGE] year old male admitted on [DATE] for severe intoxication and suicidal behavior. He was discharged on [DATE].

An RN assessment note, dated 5/15/13 at 3:52 PM, stated Patient #8 had been placed in soft wrist and ankle restraints due to his intoxication level and increasing combativeness. The RN also documented that a valid order for restraints was in the chart.

A "RESTRAINT NON-VIOLENT/SELF DESTRUCTIVE (MEDICAL) PHYSICIAN ORDERS," signed by the ED physician on 5/15/13 at 5:00 PM, documented orders for soft ankle and wrist restraints as well as chemical restraints, one hour and eight minutes after Patient #8 had been placed in restraints. The order form contained a place for the RN who initiated the restraints to sign, date, and time when restraints had been placed. This portion of the form was left blank. There was no documentation to explain why the order was delayed after initiating the restraints.

The DQRM was interviewed on 6/06/13 at 4:15 PM. She confirmed the documentation indicated Patient #8 had been placed in restraints prior to the ED physician's order.

Patient #8 was physically restrained without an order.





3. Patient #7's medical record documented a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED]

A physician's order, dated 5/10/13 at 9:10 PM, called for Patient #7 to be placed in "four point leather restraints."

Patient #7's nursing notes, beginning at 9:07 PM on 5/10/13, stated these restraints were in place. At 12:00 midnight on 5/11/13, a nursing progress note stated "right upper and lower leather restraints removed." At 2:55 AM on 5/11/13, a nursing progress note stated only Patient #7's left arm was restrained. At 3:30 AM on 5/11/13, a nursing progress note stated Patient #7's last restraint was removed.

An order was not present in the medical record for the 2 point restraints which were documented at 12:00 midnight on 5/11/13 or the 1 point restraint which was documented at 3:30 AM on 5/11/13.

Also, a nursing progress note dated 5/11/13 at 8:00 AM stated Patient #7 had a "trunk" restraint. The trunk restraint was also documented in place on 5/11/13 at 10.00 AM, 12:00 noon, 1:42 PM, and 5:00 PM. An order for the trunk restraint was not documented.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed Patient #7's medical record did not include orders for the restraints.

Patient #7 was placed in restraints which were not in accordance with the orders of a physician or other LIP.





4. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

A physician order, dated 3/09/13 at 10:00 PM, called for Patient #3 to be placed in "four point soft restraints."

On 3/09/13 at 9:36 PM, a nursing progress note included wrists and legs were restrained, it did not include any specific behaviors. At 1:30 AM on 3/10/13, Patient #3's nursing note, stated " ...IS SLEEPING ON AND OFF, WHEN AWAKE PT HAS TO BE REDIRECTED FROM HIS WRIST RESTRAINTS, ONLY WRIST RESTRAINTS ARE APPLIED." There was no nursing documentation to indicate when Patient #3's ankle restraints were removed. The medical record did not contain an order for wrist restraints only.

The DQRM was interviewed on 6/05/13 beginning at 3:40 PM. She acknowledged a specific order for Patient #3 to be in wrist restraints only was not documented.

Patient #3 did not have a specific order for wrist restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, it was determined the hospital failed to ensure orders for chemical restraints were not written on a prn basis for 1 of 4 patients (#3) who were restrained and whose medical records were reviewed. This resulted in the potential for patients to be unnecessarily restrained. Findings include:

Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. Diagnoses included progressive dementia and GLF.

An order titled "RESTRAINT/SECLUSION VIOLENT/SELF-DESTRUCTIVE(BEHAVIORAL) INITIAL PHYSICIAN ORDERS AND ASSESSMENT," dated 3/09/13 at 9:33 PM, stated "medication: Haldol + Ativan." A subsequent order, dated 3/10/13 at 12:29 AM, stated "Ativan 1 mg IV/IM/PO Q1h PRN agitation, Haldol 1-4 mg IV/IM PRN agitation."

Patient #3's MAR indicated PRN Haldol was given 3/09/13 at 9:33 PM and at 3/10/13 at 4:17 PM. Patient #3's MAR indicated PRN Ativan was given on the following dates and times for "AGITATION":

- 3/09/13 at 10:51 PM

- 3/10/13 at 9:17 AM, 11:39 AM, 12:37 PM, 3:28 PM, 6:33 PM, 9:53 PM, 11:33 PM.

The DQRM was interviewed on 6/13/13 beginning at 2:00 PM. She confirmed Patient #3's medical record contained orders for PRN chemical restraints.

PRN chemical restraints were ordered for Patient #3.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the hospital failed to ensure orders for restraint used for the management of violent or self-destructive behavior were renewed every 4 hours for 1 of 4 adult patients (#7) who were restrained for violent and destructive behavior and whose records were reviewed. This resulted in the use of restraint without continued authorization. Findings include:

1. Patient #7's medical record documented a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED]

A physician order, dated 5/10/13 at 9:10 PM, called for Patient #7 to be placed in "four point leather restraints."

Patient #7's nursing notes, beginning at 9:07 PM on 5/10/13, stated these restraints were in place. At 12:00 midnight on 5/11/13, a nursing progress note stated "right upper and lower leather restraints removed." At 2:55 AM on 5/11/13, a nursing progress note stated only Patient #7's left arm was restrained. At 3:30 AM on 5/11/13, a nursing progress note stated Patient #7's last restraint was removed.

Patient #7 was restrained from at least 9:07 PM on 5/10/13 until 3:30 pm on 5/11/13, a total of 6 hours and 23 minutes. No orders for restraints were documented after 5/10/13 at 9:10 PM.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed restraint orders for Patient #7 were not renewed after 4 hours.

Restraint orders for Patient #7 were not renewed after 4 hours.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the hospital failed to ensure restraints were discontinued at the earliest possible time for 1 of 4 patients (#7) who were restrained and whose records were reviewed. This resulted in the continued use of restraint that was not necessary to keep the patient and others safe. Findings include:

Patient #7's medical record documented a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED]

A physician order, dated 5/10/13 at 9:10 PM, called for Patient #7 to be placed in "four point leather restraints."

Patient #7's nursing notes, beginning at 9:07 PM on 5/10/13, stated these restraints were in place. At 12:00 midnight on 5/11/13, a nursing progress note stated "right upper and lower leather restraints removed." At 2:55 AM on 5/11/13, a nursing progress note stated only Patient #7's left arm was restrained. At 3:30 AM on 5/11/13, a nursing progress note stated Patient #7's last restraint was removed.

Nursing notes documented 30 minute checks while Patient #7 was restrained. The notes documented Patient #7 "Appears to sleep" on 5/10/13 at 11:20 PM, 11:50 PM, and on 5/11/13 at midnight, 12:25 AM, 12:55 AM, 1:16 AM, 1:45 AM, 2:15 AM, 2:45 AM, and 3:15 AM. Patient #7 was restrained for 3 hours and 50 minutes while he was asleep. A reason why the restraints were not discontinued when Patient #7 was asleep and did not present a danger to himself or others was not documented.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed Patient #7 was restrained while he was asleep.

Restraints for Patient #7 were not discontinued at the earliest possible time.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0187
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the hospital failed to ensure medical records documented the symptoms that warranted the use of restraint for 3 of 4 patients (#2, #3 and #7) who were restrained and whose records were reviewed. This resulted in the inability of the hospital to justify the use of restraints. Findings include:

1. Patient #7's medical record documented a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED]

A nursing progress note dated 5/11/13 at 7:38 AM stated Patient #7 was "...very restless [with] lap belt in place. Pulls and [sic] garments, linens, cables/cords." No other specific behaviors or reasons why the lap belt was applied were documented." The trunk restraint was also documented in place on 5/11/13 at 8:00 AM, 10.00 AM, 12:00 noon, 1:42 PM, and 5:00 PM. An order for the trunk restraint was not documented. None of these note explained why Patient #7 needed a trunk restraint. In addition, no physician note was present in the record which explained why the restraint was applied.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed Patient #7's medical record did not include documentation of symptoms that warranted the use of the restraint.

Patient #7's medical record did not document the behaviors that warranted the use of the lap belt restraint.





2. Patient #2 was a [AGE] year old male admitted through the ED on 1/26/13 for schizophrenia. He was discharged on [DATE].

The ED physician's progress note, dictated 1/26/13 at 10:55 PM, stated Patient #2 had been physically restrained after attempting to hit security staff with a metal stool. There were no orders documented for the physical restraint. However, no nursing notes documented the behaviors that led to the restraint or the restraint itself. The length of time Patient #2 was restrained was not documented.

A "Case Report," completed by security staff and dated 1/27/13 at 11:50 PM, documented that security officers were in place at the door to Patient #2's room to "make sure (patient) didn't leave or injure himself." The "Case Report" was an internal report and was not part of the medical record.

The security officer that documented the report was interviewed on 6/07/13 at 7:35 AM. He confirmed he and another officer stood at the door of Patient #2's room on the evening of 1/26/13 and did not allow the patient to leave in order to protect Patient #2 and ED staff. The length of time the security guards were positioned at Patient #2's doorway to prevent him from leaving was not documented. There was no nursing documentation to include the rationale for the seclusion of Patient #2.

In an interview with the Manager of Patient Advocacy on 6/06/13 at 8:45 AM, he confirmed the security guards did not allow Patient #2 to leave the room and this qualified as seclusion. He confirmed there was no nursing documentation to include the rationale for seclusion of Patient #2

Patient #2's medical record did not contain the rationale for seclusion.





3. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

On 6/05/13 at 9:25 AM, Patient #3's medical record was reviewed. Patient #3's Emergency Admit note, section Emergency Department Course stated, "He has been violent with other staff at (assisted living) earlier, but has not been so yet with the emergency department. He was given Haldol IM in the emergency department. As this was not effective enough, he was given 1 mg Ativan IM." The medical record did not document that Patient #3 was violent or combative at the hospital. A physician order titled "RESTRAINT/SECLUSION VIOLENT/SELF-DESTRUCTIVE(BEHAVIORAL) INITIAL PHYSICIAN ORDERS AND ASSESSMENT," dated 3/09/13 at 10:00 PM, stated "medication: Haldol + Ativan." The order also stated to place Patient #3 in 4 point soft restraints. The order stated Patient #3 was a danger to himself and others. However, the order did not state what specific behaviors Patient #3 exhibited that construed a threat to safety. There was no documentation in nursing notes to indicate Patient #3 was violent or combative.

The DQRM was interviewed at 6/05/13 at 12:40 PM, she reviewed Patient #3 medical record and confirmed there was no documentation to indicate Patient #3 was physically aggressive or combative.

Patient #3's medical record did not include documentation to support the need for the restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the hospital failed to ensure medical records documented the rationale for continued use of restraints for 2 of 4 patients (#7 and #8) who were restrained and whose records were reviewed. This resulted in the inability of the hospital to justify the continued use of restraints. Findings include:

1. Patient #7's medical record documented a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED]

A physician order, dated 5/10/13 at 9:10 PM, called for Patient #7 to be placed in "four point leather restraints."

Patient #7's nursing notes, beginning at 9:07 PM on 5/10/13, stated these restraints were in place. At 12:00 midnight on 5/11/13, a nursing progress note stated "right upper and lower leather restraints removed." At 2:55 AM on 5/11/13, a nursing progress note stated only Patient #7's left arm was restrained. At 3:30 AM on 5/11/13, a nursing progress note stated Patient #7's last restraint was removed.

Nursing notes documented 30 minute checks while Patient #7 was restrained. The notes documented Patient #7 "Appears to sleep" on 5/10/13 at 11:20 PM, 11:50 PM, and on 5/11/13 at midnight, 12:25 AM, 12:55 AM, 1:16 AM, 1:45 AM, 2:15 AM, 2:45 AM, and 3:15 AM. Patient #7 was restrained for 3 hours and 50 minutes while he appeared to be asleep. The rationale for continued use of the restraints while Patient #7 was asleep was not documented.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed Patient #7's medical record did not document the reason for his continued restraint while he was sleeping.

Patient #7's medical record did not document the rationale for continued use of the restraints .





2. Patient #8 was a [AGE] year old male admitted on [DATE] for severe intoxication and suicidal behavior. He was discharged on [DATE].

An RN assessment note, dated 5/15/13 at 3:52 PM, stated Patient #8 had been placed in soft wrist and ankle restraints due to his intoxication level and increasing combativeness. The RN also documented the clinical justification for restraints, less restrictive alternatives used prior to restraints and that an assessment and observation of Patient #8 had been done. The next assessment and observation was documented by the RN at 5:42 PM, one hour and 50 minutes after the first assessment. There was no documentation during this time of the rationale for the continued use of restraints.

The policy "Non-Violent/Self Destructive Restraint and Seclusion (Non-Behavioral)," revised March 2013, stated "Direct observation must be performed at a minimum of every one-hour."

The DQRM was interviewed on 6/06/13 at 4:15 PM. She confirmed the documentation indicated Patient #8 had not been directly observed every hour in accordance with hospital policy. She also confirmed the lack of documentation for the continued use of restraints.

Patient #8's record did not document the rationale for the continued us of restraints.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, it was determined the hospital failed to ensure medical records were properly retained and accessible for 7 of 8 ED patients (#2-#8) whose medical records were reviewed. This failure resulted in an inability to review the complete medical record and had the potential to prevent medical providers from obtaining information about courses of treatment. Findings include:

1. The Medical Records Manager was interviewed in 6/05/13 at 1:30 PM. She stated that the hospital had a scheduled downtime period of the EMR in order to change servers. The downtime was scheduled to end on the morning of 5/30/13. However, the servers stayed down for several more hours and as a result, certain data within the EMR from the period of 10/01/12 to the time of the survey had been lost. Some data had been retrievable, but ED physician orders and narrative notes were not.

The DQRM confirmed in an interview on 6/05/13 at 11:40 AM that clinical data could not be pulled from the EMR. While attempting to review the EMR of Patient #6, the DQRM was unable to access nursing or physician notes, orders, and other clinical data. She stated that some of this information was available in the legal record, but could not be accessed by using the EMR. She confirmed that the ED physicians orders and some ED nursing notes were not retrievable, even in the legal record. She also confirmed that staff could not access the legal record easily from computer portals. The DQRM also stated the hospital could not access lists or logs that were generated by the EMR, such as the restraint log, as a result of the server crash. The number and name of patients that had been restrained could only be determined by examining each handwritten note completed by the house supervisors over a 24 hour period.

The complete medical record could not be accessed for the following patients:

a. Patient #2 was a [AGE] year old male admitted through the ED for schizophrenia on 1/26/13 and discharged on [DATE]. His medical record was missing ED physician orders and nursing POCs.

The DQRM was interviewed on 6/06/13 beginning at 8:15 AM. She confirmed the missing documentation.

b. Patient #8 was a [AGE] year old male admitted through the ED for extreme intoxication and suicidal behavior on 5/13/13 and discharged on [DATE]. His medical record was missing ED physician orders and nursing POCs.

The DQRM was interviewed on 6/06/13 beginning at 8:15 AM. She confirmed the missing documentation.

c. Patient #6 was a [AGE] year old female admitted on [DATE]. She was discharged on [DATE]. Her medical record was missing ED physician orders and nursing POCs.

The DQRM was interviewed on 6/06/13 beginning at 8:15 AM. She confirmed the missing documentation.

d. Patient #4 was a [AGE] year old male admitted on [DATE] for alcohol intoxication, aspiration pneumonia, and hepatitis. He was discharged on [DATE]. His medical record was missing ED physician orders, ED nursing notes, and nursing POCs.

The DQRM was interviewed on 6/06/13 beginning at 8:15 AM. She confirmed the missing documentation.

e. Patient #5 was a [AGE] year old female admitted on [DATE] for an acute drug overdose. She was discharged on [DATE]. Her medical record was missing ED physician orders, ED nursing notes, and nursing POCs.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed the missing documentation.

f. Patient #7 was a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED].

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed the missing documentation.

g. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed the missing documentation.

The complete medical record was not accessible.
VIOLATION: FIVE-YEAR RETENTION OF RECORDS Tag No: A0439
Based on staff interview and review of medical records, it was determined the hospital failed to ensure the medical records of 7 of 8 patients (#2-#8) whose records were reviewed were maintained for a period of at least 5 years. This prevented the hospital from promptly retrieving the complete medical records of patients. Findings include:

1. The Medical Records Manager was interviewed on 6/05/13 beginning at 1:30 PM. She stated the national servers which stored electronic medical records for the hospital had been corrupted on 5/29/13. She stated medical record information may have been lost for all patients treated at the hospital from October 2012 through 5/29/13. She stated electronic physician orders in the ED, nursing POCs, and some nursing notes had been lost. She stated this information may be lost forever as the corrupted servers were back-up servers and no servers contained usable data.

2. Medical records of Patients #2-#8 were reviewed on 6/5/13 and 6/17/13. All of these records were of patients who had been admitted through the ED and had been admitted as inpatients for more than 24 hours. All of these records were missing ED physician orders and nursing POCs.

The DQRM was interviewed regarding each of the above medical records from 6/05/13 to 6/07/13. She confirmed each record contained missing information.

The hospital did not maintain complete medical records for at least 5 years.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the hospital failed to ensure medical records contained sufficient information to describe the progress and response to services for 3 of 8 patients (#3, #7, and #8) whose records were reviewed. This resulted in incomplete medical records.
Findings include:

1. Patient #7's medical record documented a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED]

A physician's order, dated 5/10/13 at 9:10 PM, called for Patient #7 to be placed in "four point leather restraints." The medical record documented the restraints were applied. At 12:00 midnight on 5/11/13, a nursing progress note stated "right upper and lower leather restraints removed." The left side remained restrained. At 2:55 AM on 5/11/13, a nursing progress note stated only Patient #7's left arm was restrained. At 3:30 AM on 5/11/13, a nursing progress note stated Patient #7's last restraint was removed. No orders were present in the record to utilize either 1 or 2 extremity restraints. No nursing documentation was present explaining why Patient #7 was placed in 2 point restraints and then in 1 point restraint. In addition, a nursing POC was not present in Patient #7's medical record.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed Patient #7's medical record did not include orders for the use of 1 or 2 extremity restraints. She confirmed Patient #7's medical record did not include a rationale for the different types of restraints. She was interviewed again on 6/10/13 beginning at 12:40 PM. She confirmed Patient #7's nursing POC was not present in the medical record. She stated, due to a computer problem, ED physician orders and nursing POCs written between 10/12/12 and 5/29/13 were not accessible by the hospital.

Patient #7's medical record did not contain complete documentation of services and the rationale for them.

2. Patient #2 was a [AGE] year old male admitted through the ED on 1/26/13 for schizophrenia. He was discharged on [DATE].

The ED physician's progress note, dictated 1/26/13 at 10:55 PM, stated Patient #2 had been physically restrained after attempting to hit security staff with a metal stool. There were no orders documented for the physical restraint and no nursing notes documented the behaviors that led to the restraint or the restraint itself. The length of time Patient #2 was restrained was not documented.

A "Case Report," completed by security staff and dated 1/27/13 at 11:50 PM, documented that security officers were in place at the door to Patient #2's room to "make sure (patient) didn't leave or injure himself." The "Case Report" was an internal report and was not part of the medical record.

The security officer that documented the report was interviewed on 6/07/13 at 7:35 AM. He confirmed he and another officer stood at the door of Patient #2's room on the evening of 1/26/13 and did not allow the patient to leave in order to protect Patient #2 and ED staff. This seclusion of Patient #2 to his ED room was not documented. The length of time the security guards were positioned at Patient #2's doorway to prevent him from leaving was not documented.

In an interview with the Manager of Patient Advocacy on 6/06/13 at 8:45 AM, he confirmed the security guards did not allow Patient #2 to leave the room and this qualified as seclusion. He confirmed there were no orders in the medical record for seclusion. He also confirmed that there were no orders for the physical restraint.

Patient #2's medical record did not completely describe interventions and his responses to them.





3. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

a. A physician order, dated 3/09/13 at 10:00 PM, called for Patient #3 to be placed in "four point soft restraints."

Patient #3's nursing notes, beginning at 9:36 PM on 3/09/13, stated his wrists and legs were restrained. A nursing note,dated 3/10/13 at 1:30 AM stated Patient #3 " ...IS SLEEPING ON AND OFF, WHEN AWAKE PT HAS TO BE REDIRECTED FROM HIS WRIST RESTRAINTS, ONLY WRIST RESTRAINTS ARE APPLIED." Subsequent nursing notes did not state Patient #3 was restrained. It was not documented when the restraints were discontinued. Nursing notes did not include specific behaviors that justified the use of restraints.

Patient #3's Emergency Admit note dictated, dated 3/09/13 at 11:20 PM stated, he had been violent at an assisted living facility earlier that day but he had not been violent in the emergency department. The note stated Patient #3 was given Haldol IM in the emergency department and then was given Ativan IM as chemical restraints.

The medical record did not document that Patient #3 was violent or combative in the hospital. The medical record did not document the rationale for the use of restraints.

The DQRM was interviewed at 6/05/13 at 12:40 PM. She reviewed Patient #3 medical record and confirmed there was no documentation of physically aggressive behavior. She was also interviewed on 6/05/13 beginning at 3:40 PM. She acknowledged an order for the decrease in Patient #3's extremity restraints from 4 to 2 was not documented. She confirmed specific behaviors to justify the use of restraints were not documented.

b. At 5:28 PM on 3/15/13, Patient #3's physician's progress note stated "This afternoon (Patient #3) was left unattended in the bathroom and sustained a GLF. There was no loss of consciousness." There was no documentation by nursing that Patient #3 had fallen.

Prior to Patient #3's fall, the physician had ordered a 1:1 staff sitter for patient safety on 3/11/13, untimed. There was no documentation in the nursing notes on 3/15/13, the day Patient #3 fell , that he was accompanied by a sitter at all times

After Patient #3 sustained the fall, neurochecks were ordered by the physician on 3/15/13 at 12:22 PM. The medical record did not include documentation that neurochecks had been done.

The DQRM was interviewed on 6/05/13 beginning at 12:40 PM. She confirmed the medical record was missing nursing documentation that Patient #3 had fallen. She also confirmed the medical record was missing documentation related to the 1:1 staff sitter and neurochecks being performed as ordered. She stated the missing documentation was the result of nursing staff's failure to document rather than the server crash.

Patient #3's medical record did not include documentation verifying services provided and his response to those services.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the hospital failed to ensure medical records contained all practioners orders, nursing notes, and POCs for 7 of 8 ED pateints (#2-#8) whose records were reviewed. This failure resulted in an incomplete medical record and had the potential to prevent medical providers from obtaining information about courses of treatment. Findings include:

The Medical Records Manager was interviewed in 6/05/13 at 1:30 PM. She stated that the hospital had a scheduled downtime period of the EMR in order to change servers. The downtime was scheduled to end on the morning of 5/30/13. However, the servers stayed down for several more hours and as a result, certain data within the EMR from the period of 10/01/12 to the time of the survey had been lost. Some data had been retrivable, but ED phsyician orders and narrative notes were not. In addition, the restraint log and other logs that were generated in the EMR were no longer accessible. The following medical records did not contain ED orders as a result of the servers going down:

1. Patient #2 was a [AGE] year old male admitted through the ED for schizophrenia on 1/26/13 and discharged on [DATE]. His medical record was missing ED physican orders and nursing POCs.

The DQRM was interviewed on 6/06/13 beginning at 8:15 AM. She confirmed the missing documentation.

Patient #2's medical record was missing information.

2. Patient #8 was a [AGE] year old male admitted through the ED for extreme intoxication and suicidal behavior on 5/13/13. His medical record was missing ED physician orders and nursing POCs.

The DQRM was interviewed on 6/06/13 beginning at 8:15 AM. She confirmed the missing documentation.

Patient #8's medical record was missing information.

3. Patient #6 was a [AGE] year old female admitted on [DATE]. She was discharged on [DATE]. Her medical record was missing ED physicain orders and nursing POCs.

The DQRM was interviewed on 6/06/13 beginning at 8:15 AM. She confirmed the missing documentation.

Patient #6's medical record was missing information.





4. Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE] and was discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]

The DQRM was interviewed on 6/06/13 beginning at 8:15 AM. She confirmed the missing documentation.

Patient #3's medical record was missing information.





5. Patient #4 was a [AGE] year old male admitted on [DATE] for alcohol intoxication, aspiration pneumonia, and hepatitis. He was discharged on [DATE]. His medical record was missing ED physician orders, ED nursing notes, and nursing POCs.

The DQRM was interviewed on 6/06/13 beginning at 8:15 AM. She confirmed the missing documentation.

Patient #4's medical record was missing information.

6. Patient #5 was a [AGE] year old female admitted on [DATE] for an acute drug overdose. She was discharged on [DATE]. Her medical record was missing ED physician orders and ED nursing notes.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed the missing documentation.

Patient #5's medical record was missing information.

7. Patient #7's medical record documented a [AGE] year old male who was admitted to the hospital through the ED at 9:03 PM on 5/10/13. He was discharged on [DATE]. His diagnoses included [DIAGNOSES REDACTED]

Patient #7's medical record did not contain ED physician orders and nursing notes from the ED.

The DQRM was interviewed on 6/06/13 beginning at 3:40 PM. She confirmed Patient #7's medical record was not complete.