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.

MONTEFIORE MEDICAL CENTER 111 EAST 210TH STREET BRONX, NY 10467 March 22, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, document review, and interview it was determined that the facility failed to meet regulatory requirements for compliance with the Condition of Participation for Patient's Rights.

Specifically, the facility failed to:
1. Provide a safe environment in the Emergency Department (ED), for Pediatric patients assessed to be suicidal.
2. Ensure patients who are assessed to be suicidal are searched for items that pose a potential risk for harm and to provide monitoring by appropriate clinical staff.
3. Ensure the appropriate use of the facility Seclusion/Observation Room and that the room is appropriately maintained and monitored.
4. Ensure the rights of patients to be free from restraints/ seclusion.
5. Ensure that a patient was free from abuse.

These failures placed all patients at risk of harm.

These findings were evident in fifteen (15) of nineteen (19) Medical Records reviewed (Patient #s 1, 2, 3, 4, 5, 6, 7,8, 9, 11, 12, 13, 14, 15 & 16).

These failures placed all patients at risk for harm.

Findings include:

Review of medical record for Patient #2 revealed this 11 year was brought to the facility's Emergency Department (ED) on 02/06/17 at 1:15 PM, precipitated by an attempted suicide by overdose. The physician ordered Constant Observation (CO), but the CO was not conducted by Care Providers as per policy.
Instead, the patient was maintained under a Security Watch. The patient was able to obtain a knife from another patient while on Constant Observation under the Security Officers.

Similar finding was found for Patient #3, a [AGE]-year-old female who (MDS) dated [DATE] at 4:13 PM, for recent suicide attempt. The Psychiatrist evaluated the patient and documented that the "Patient is at chronic risk for suicide and is actively suicidal." On 02/06/17, Patient #3 was placed on Constant Observation (CO) and was able to provide a knife to Patient #2.

Observation tour of the ED on 3/20/17 at 3:30 PM, identified Patient #16 was lying on a stretcher in the overflow area. Next to the patient and within arm's reach was an unattended lab cart with unsecured sharps lying on top of the cart. Review of medical record identified Patient #16 as schizophrenic and his presentation on 3/19/17 was precipitated by taking an overdose of Seroquel (Antipsychotic medicine) and Tylenol.

Leaving the unattended cart with sharps, within reach of the patient, posed a potential risk for harm to this patient.

See Tag 0144


Medical record review identified Patient #1 presented to the facility's Emergency Department (ED) on 2/13/17 at 2:37 PM and was triaged by the nurse at 3:35 PM. The triage Nurse documented, "Patient is on 1:1 with security in the ED Observation Room and is pending further evaluation and assessment." The patient was placed in seclusion for over two and a half hours, there was no physician order, and no documentation of monitoring for the patient while in seclusion, as required by regulation and by hospital policy.
On 2/13/17 at 5:13 PM, the psychiatrist documented "Patient was placed in Seclusion. The floor has visible blood. The patient has facial contusions."
Interview with facility security staff on 3/20/17 at 2:15 PM, identified improper techniques were used during physical take down and application of manual restraints, during an attempt to disrobe the patient. The patient later alleged facial injury occurred during the event. CT (computed tomography) scan revealed multiple facial fractures, requiring surgical interventions.


During observation of the ED on 3/20/17, it was identified the facility's Observation Room was being used as a Seclusion Room. This room was not appropriately furnished to meet the criteria for a Seclusion Room. It was also identified that the security camera was not functioning (on 02/13/17), due to facility's failure to monitor this equipment.

See Tag 0145


Review of medical records revealed that the facility did not document the monitoring of patients when placed in Seclusion or on Constant Observation (CO).

See Tag 0154

Review of medical records revealed that the facility did not obtain physician orders for the medical management of violent aggressive patients who were placed in Seclusion, and did not obtain physician orders for patients placed on Constant Observation (CO).

See Tag 0162
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on observation, document review and interview the facility failed to provide a face-to-face assessment by a physician for the patient after seclusion was initiated. This was found in two (1) of 10 medical records reviewed (Patient #1).

Findings include:

Review of hospital policy titled, "Restraint or Seclusion, Care of the patient requiring," last revised 10/16 documents, "The RN must document the circumstances requiring the use of seclusion and must notify the prescriber (provider) immediately.
The patient must be supervised and assessed at least every thirty minutes until the prescriber arrives.
The nurse is responsible for ensuring a written order within thirty minutes of seclusion initiation. Seclusion requires an order from a provider after a face-to-face assessment of the patient. The prescriber is required to review the patient's medical record, evaluate mental and physical status with assessment, evaluate the patient's medication and treatment plan, assure there are no medical/psychological contraindications, discuss alternatives attempted and document the face-to-face assessment and plan in a progress note. Note, a simple statement that the patient is agitated or dangerous to self or others is not adequate."


Medical record review for Patient #1 indicated on 02/13/17 at 2:37 PM, this 28 year - old male arrived into the facility's Emergency Department (ED). On 2/13/17 at 3:35 PM, the triage nurse documented, "Patient is on 1:1 with security in the ED Observation Room Pending further evaluation and assessment." There is no nursing documentation in the medical record to state the clinical rationale for seclusion or that the physician was notified.

On 2/13/17 at 5:13 PM, approximately two hours and thirty-six minutes after the patient's arrival, the physician documented consultation note.

On 2/14/17 at 9:18 AM, approximately eighteen hours after the patient's arrival to the ED, there is the first documentation of the patient's vital signs. There is no documented evidence of nursing monitoring while the patient was in seclusion.

There is documentation in the medical record that the patient was placed in seclusion while in the ED and there is no documentation of a face-to-face assessment of the patient.

These findings were confirmed during interview conducted on 3/21/17 with Staff E, Medical Director. Staff E acknowledged that the documentation was not there to show a timely physician to patient "face to face" evaluation.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, it was determined that the facility did not afford the patients' rights to be free from restraint and/or seclusion. This was found in one (1) of nineteen (19) medical records (Patient #1).

This placed all patients at risk for harm.

Findings Include:

Medical Record review for Patient #1 indicated on 02/13/17 at 2:37 PM this [AGE] year old male arrived into the facility's Emergency Department (ED). On 2/13/17 at 3:35 PM, the Triage nurse documented, "Patient is on 1:1 with security in the ED Observation Room. Pending further evaluation and assessment."
On 2/13/17 at 3:45 PM, the Nurse documented, "Patient brought in from transitional living for aggressive behavior. Patient was uncooperative with security during initial safety check. Patient began to spit at officers and would not change into hospital garb. Patient is currently in ED Observation Room resting on mattress pending further evaluation."

There is documentation in the medical record that the patient was placed in seclusion in the ED Observation Room for approximately two hours and forty minutes pending evaluation by a physician. There is no documentation detailing the purpose for seclusion to include patient safety and/or behavior management.

Review of hospital policy titled, "Restraint or Seclusion. Care of the patient requiring, "last revised 10/16 documents. "All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraints or seclusion may only be imposed to ensure the immediate physical safety of the patient and must be discontinued at the earliest possible time. Seclusion is an involuntary confinement of a patient apart and separate from others in an area or room from which the patient is physically prevented from leaving. Seclusion may be used for the management of violent or self-destructive behavior."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview, it was determined the facility failed to ensure
there was a physician order and documentation of monitoring for the patient while in seclusion. This was found in one (1) of ten (10) medical records reviewed. (Patient #1).

This placed all patients at risk for harm.

Findings include:

Medical Record review for Patient #1 indicated on 02/13/17 at 2:37 PM this [AGE] year-old male arrived into the facility's Emergency Department (ED). On 2/13/17 at 3:35 PM, the triage nurse documented, "Patient is on 1:1 with security in the ED Observation Room. Pending further evaluation and assessment." On 2/13/17 at 3:45 PM, The Nurse documented, "Patient brought in from transitional living for aggressive behavior. Patient was uncooperative with security during initial safety check. Patient began to spit at officers and would not change into hospital garb. Patient is currently in ED Observation Room resting on mattress pending further evaluation." There is documentation that the patient was taken to the Observation Room and security officers attempted to remove his clothing.
Documentation in the medical record noted on 2/14/17, the patient reported to the physician that on 2/13/17, while in the emergency Department (ED), he was assaulted by Staff members (Security Officers) during a physical takedown. The patient reported that he was punched in the face and had pain in the left side of his face. A CT Scan (diagnostic imaging) of the patients head, showed multiple facial fractures including to the left orbital base, requiring surgical intervention.

During interview on 3/20/17 at 2:15 PM, Staff K, Security Officer stated, on 2/13/17 at around 3:00 PM, he arrived at the scene. Patient had his legs Stretched out and he was sat in a chair. He refused to pull his legs in. He was spitting at people. I asked him to take his jacket off so the nurse could get his Vital signs. He refused and used an expletive at me. The nurse directed me to take the patient to the Psychiatric observation area. Staff K stated he and three other officers took him to the seclusion room while the nurse waited outside the room. Patient refused to change out of his clothes and the officers attempted to remove the patient's clothing. Staff K stated: 'the four of us were on the floor with him. Two on one side and two on the other side, he was on his stomach, I was at his head, and another officer had his legs. The Patient was struggling and we were trying to take his pants off ... ...He was still on his stomach and his face was down in the mattress. Staff K stated a doctor did not enter the room during that time.

There is no nursing documentation in the medical record to state the clinical rationale to forcibly remove the patients clothing by physical takedown and manual restraint by four security officers.



Review of Montefiore Crisis Management Program effective date 2015, states, "Staff responses to deescalate physically aggressive behavior in patients includes, always providing choices to the patient, if physical interventions are necessary, provide the patient a way out. Physical interventions are used as a last resort. Face down restraints are not allowed."

The facility Crisis Prevention Training Manual of the two and three person take down procedure does not include head holding, or placing the patient in a prone position on their stomach or placing a gag covering the airway.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, document review, medical record review and interview, it was determined the facility failed to provide a safe environment in the Emergency Department for patients with Mental Health Disorders.

Specifically, staff did not ensure:
a) all patients were searched, monitored and provided ongoing surveillance. As a result of this failure, an actively suicidal pediatric patient was able to secure a box cutter knife from another actively suicidal pediatric patient.
b) a potentially suicidal adult patient was protected in a safe environment and was not left within arm's reach of unattended sharps.
c) timely physicians' orders were obtained after patients were placed on Constant Observation.
d) pediatric and adult patients placed on Constant Observation were assigned Care Providers, as required by facility's policy.
e) safe and protective rooms for patients placed in seclusion.
f) consistency in the standard of care and observation provided for psychiatric patients who were located in the overflow area.

These findings were evident in eight (8) of nineteen (19) medical records reviewed (Patient #2, 3, 4, 5, 7, 8, 9 & 16).

Findings include:

Review of the facility's Occurrence Report dated 02/08/17 documented; "the mother of Patient #2 informed me (Security Officer) that her daughter had a switch blade given to her by another patient. The blade was allegedly handed to her by Patient #3 as she was being transferred."

Review of Medical Record for Patient #2 revealed an [AGE]-year-old female who was housed in the Emergency Department (ED) Pediatric Psychiatric Observation Suite (POS) from 2/6/17 to 2/11/17, after she (MDS) dated [DATE] at 1:51 PM. This encounter was precipitated by an attempted suicide by overdose with Oxycodone tablets. The patient had an evaluation on 02/06/17 at 11:18 AM and the Psychiatric Consultant noted, "This was an intentional overdose with oxycodone to end her life." The physician ordered the child to be monitored on "Constant Observation". The ED nurse noted on 2/6/17 at 2:00 PM, that constant observation was initiated and maintained by security.
On 2/9/17 at 1:07 AM, the ED Provider documented, "Patient (#2) is very frustrated because was given a knife in Room 8 by another patient (#3) who has since been transferred out."

Review of medical record for Patient #3 revealed this [AGE]-year-old female presented to the facility's Emergency Department (ED) on 02/06/17 at 3:52 PM. The encounter to the facility ED was precipitated by an attempted suicide by hanging. Patient #3 stated at Triage, "I tried to commit suicide yesterday. I put a telephone cord around my neck." The patient was examined by a psychiatrist on 02/06/17 who documented, "...[AGE]-year-old female with past psychiatric history of suicidality. This Patient is at chronic risk for suicide and is actively suicidal. "
On 02/06/17 at 4:13 PM, Patient #3 was placed on Constant Observation (CO) as per physician's order.
Nursing documentation stated that the patient was provided observation by Security Watch on 2/6/17 through 2/8/17, when patient was transferred to an inpatient psychiatric facility.

Review of the hospital's Policy titled, "Security Patient Watch- emergency room s," last revised 11/16, states, "Patients are assigned to "Security Patient Watch" due to psychological issues and violent/aggressive behavior by the triage nurse, in-charge nurse or physician .... Upon being assigned to guard a patient under "Security Patient Watch", scan (with hand held detector) the patient for harmful objects and medications upon arrival and again before admission to the POS (Psychiatric Observation Suite)."

Review of the hospital's Policy titled, "Searching and Monitoring of Patients under Security Patient Watch," last revised 11/16, states, "All patients that are placed under "Security Patient Watch" will be searched." The policy also states security will routinely monitor the behavioral activity of the patient.

During interview on 3/15/17 at 12:55 PM, Staff D, Site-specific Security Manager stated, "We don't know whether either patient was searched or wanded (scanned). They probably weren't because they are minors."
During interview on 3/16/17 at 11:15 AM, Staff B, System Security Director stated, " The patients were not wanded (scanned) because they are minors and the one found with the knife had a history of sexual assault, so we didn't search her."

During Observation of the Psychiatric Overflow Area in the Adult Emergency Department, on 3/20/17 at approximately 3:40 PM, it was noted that a laboratory phlebotomist cart with venipuncture equipment (including sharps) lying on top of the cart, was left unattended. The cart was within arm's reach of Patient #16. Review of medical record identified Patient #16 was diagnosed with schizophrenia. His presentation on 3/19/17 was precipitated by taking an overdose of Seroquel (antipsychotic medicine) and Tylenol.
Leaving the unattended cart with sharps, within reach of the patient, posed a potential risk for harm to this patient.

This finding was discovered and confirmed in the presence of Staff Q, Director of Nursing, on 3/20/17 at 3:40 PM.


Review of the hospital's Policy and Procedure titled "Behavioral Management of Patients on Non-Psychiatric units: Risk of Harm to Self /Others", last reviewed 10/16, states, "Constant Observation (CO) requires a physician order and the physician's order must be renewed every 24 hours."

Review of the medical record for Patient #4 identified, a [AGE]-year-old boy was brought in by police to the hospital ED on 3/14/17 at 6:25 PM, with a chief complaint of acting out at home after running out of antipsychotic medication. Patient with past history of Attention-Deficit Hyperactivity Disorder (ADHD), Pervasive Development Disorder (PDD) and Opposition Defiant Disorder (ODD). Review of nursing progress notes for 3/14/17 revealed that the patient was placed on Constant Observation (CO) for potential for self-harm.
On 3/15/17 at 7:23 AM, the physician wrote an order for Constant Observation, which was twelve hours after the CO was initiated by nurses.

Review of the medical record for Patient #5 identified, this [AGE] year old boy with history of asthma (MDS) dated [DATE] at 10:23 PM for evaluation of auditory and visual hallucinations. Nursing noted on 3/12/17 at 11:05 PM that, "Security Observation was initiated, awaiting physician's evaluation." The patient was evaluated by psychiatry on 3/13/17 at 12:32 AM. The psychiatrist noted that the patient is not psychiatrically clear and will stay overnight for re-evaluation by the psychiatrist in the morning. The psychiatrist plan was to hold the patient overnight, place on Constant Observation in the Pediatric ED.
Review of nursing progress notes for 3/13, 3/14 and 3/15/17 revealed that the patient was maintained on Constant Observation by security.
The physician did not re-order Constant Observation every twenty-four hours as per policy. There is no physician's order for constant observation in the medical record for 3/14 and 3/15/17.

Review of medical record for Patient #9 (an Adult) revealed on 10/19/16 at 9:59 PM, the patient arrived to the emergency room via Emergency Medical Services, with a chief complaint of aggressive and violent threatening behavior. Nurses documented Patient #9 was on Constant Observation from 10/20/16 at 10:00 PM through to 10/21/16 at 9:45 AM. There was no documented evidence of a physician's order for the Constant Observation.

Similar finding was identified for Patient #8, who was placed on Constant Observation without a physician's order. Nurses documented Patient #8 had "Constant Observation" maintained by security on 3/13/17 through 3/16/17, and there was no documented evidence of a physician's order for Constant Observation (CO).

During interview on 03/22/17 at 11:20 AM, Staff M, Vice President of Nursing and Patient Services stated, "Every patient in the Pediatric Psychiatric Holding area (Psychiatric Observation Suite) is placed on Constant Observation that is ordered by the Attending, whether they need it or not. That's how we have always done it."



Review of the hospital's Policy and Procedure Titled "Behavioral Management of Patients on Non-Psychiatric units: Risk of Harm to Self/Others" (B9), last reviewed 10/16, states that: "Constant Observation is a level of Observation in which a designated Care Provider monitors a selected patient who is kept within arm's reach at all times. The Caregiver ratio is 1 Caregiver to 1 patient." This policy did not define Security Officers as Care Providers.

On 3/15/17, observations by surveyors at 11:30 AM confirmed pediatric patients being watched by the two Security Officers, and not by Care Providers as per the facility policy.

Surveyor inspection of the Pediatric ED, POS (Psychiatric Observation Suite) on 3/15/17 at 11:30 AM, showed the Constant Observation monitoring for Pediatric patients was conducted by Security Officers and not Care Providers as per the facility policy. Two (2) hospital Security Officers were sitting at the doorway entrance of Room 8 (POS). During the interview conducted at the time of this observation the officers stated that they were responsible for monitoring the psychiatric pediatric patients. "We are positioned here to prevent the patients from trying to leave (elope) and to prevent the patients from hurting themselves or each other." There were five (5) pediatric patients housed in the ED pediatric POS at the time of this observation. This is not in keeping with facility's policy that the Caregiver ratio is 1 Caregiver to 1 patient for constant observation.

Review of the medical record for Patient #8 revealed this 7-year-old male presented to the pediatric Emergency Department (ED) on 3/13/17 at 12:33 PM with a history of auditory hallucination and thoughts of suicide. The Psychiatrist evaluated the child at 4:35 PM, noted that the patient was under foster care for one week and had exhibited aggressive behavior, suicidal thoughts, and depression, and recommended inpatient admission.
The nurses documented in the medical record that constant observation was conducted by security.

Patients #4, #5 and #7 were also among the five pediatric patients housed in the Pediatric ED, POS (Psychiatric observation Suite), Room #8, and observed by the Surveyor as being watched by the two Security Officers
Clinical Staff did not provide monitoring of patients on constant observation in the Pediatric ED, POS (Psychiatric observation Suite).


During interview on 3/16/17 at 11:30 AM, Staff F, Nurse Manager of Pediatric ED stated, "We assign the psychiatric peds patients to the pediatric nurses in the ED. We don't have adolescent/child psychiatric nurses because we don't have inpatient psychiatric services for pediatrics. We hold them here in Room 8, sometimes for a few days until we can transfer them out."
There was no evidence of this practice during observation of the pediatric patients in Room 8.
The facility does not have a clinical policy specific to the Emergency Department for the management of Pediatric Psychiatric patients.


On 3/20/17 at 3:30 PM, during tour of the Psychiatric Overflow Area (POS) in the Adult ED, patients were observed in the west side of the ED outside of the POS area. Staff H, Registered Nurse was assigned to the area and during the interview stated, "I work twelve hour shifts and I am the Nurse that is assigned to take care of the adult psychiatric overflow patients in the main ED. When the five rooms in the POS gets full then all the psychiatric patients who come to the ED are assigned to me. But the patients will still appear on the POS daily census and they are still under psychiatry (services). These patients are in the west side of the ED outside the POS area. There are also medical patients commingled in that area but I am assigned only to be the nurse for the psychiatry patients. I have six patients today. But some days it can be as many as twelve." Staff H identified the six patients who were sitting in chairs and/or stretchers intermingled with medical patients.


Staff H was asked about the frequency of monitoring the patients under his care and stated, "We don't have the same close environment like we do in the POS .... We don't do the fifteen-minute "Periodic Awareness" checks out here like they do in the POS. Maybe because the patients aren't as acute. I am not sure why."
On 3/20/17 at 3:30 PM, these findings were confirmed in the presence of Staff Q, Director of Nursing for Medical Services.

During interview on 3/20/17 at 3:50 PM, Staff P, Psychiatric ED POS Nurse stated, that all the patients in the Psychiatric Observation Suite are monitored by a nurse and/or tech. The patients there are automatically checked by nurses every fifteen minutes and the observation checks are documented.

This process is not done in the psychiatric overflow area of the ED.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, staff interview and in two (2) of 10 medical records reviewed, the hospital failed to ensure that a physician order was obtained immediately after patients were placed in seclusion. (Patents#1 & #6).


Findings:

Medical Record review for Patient#1 indicated on 02/13/17 at 2:37 PM, this [AGE]-year-old male arrived into the facility's Emergency Department (ED). The patient refused to disrobe for the Triage Staff and was taken to the ED Observation Room at approximately 3:35 PM, and his clothing was forcible removed by four (4) Security Officers. After the patient was disrobed, he was left alone in the room with Security Officers standing outside the room.
On 2/13/17 at 5:13 PM, The Psychiatrist noted, "While here is the ED the patient was placed in Seclusion as he was spitting and aggressive." There was no documented evidence of a physician's order for the seclusion.

Review of the Medical Record for Patient #6 identified a Registered Nurse documented on 12/28/16 at 8:35 AM, "the patient was restless and was not responding to intervention and he was placed in seclusion at 8:30 AM." There was no documented evidence of physician's order for the seclusion.

The hospital policy titled, "Restraint or Seclusion, (Care of patient requiring)," last revised 10/16 revealed, "Seclusion required written order by the physician. The physicians order must be placed within thirty minutes (30) of seclusion initiation by the RN."
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on observation, document review and interview, the facility failed to conduct a thorough investigation of patient incidents and implement corrective actions and learning throughout the facility.
This finding was found in three (3) of 19 medical records reviewed (Patient #1, 2, & 3).

Findings include:

Medical record review for Patient #1 documented, on 2/14/17, the patient reported to the physician that on 2/13/17, while in the emergency Department (ED), he was assaulted by Staff members (Security Officers) during a physical takedown. The patient reported that he was punched in the face and had pain in the left side of his face. A CT Scan (diagnostic imaging) of the patients head, showed multiple facial fractures including to the left orbital base, requiring surgical intervention.

During interview on 3/16/17 at 10:15 AM, Staff E, Medical Director stated that he had spoken with the lead Security Officers, Staff K, post event on 2/14/17 and he recollected being told, "The patient was escorted back to the Psychiatric Observation Suite (POS) area and placed into a seclusion room (Room 112) where his clothes were removed and then the Nurse triaged him. The patient alleged he was assaulted in that room."

Review of Occurrence Reports dated 2/14/17 for Patient #1, documented that interviews with five security officers took place after the patient reported the allegations of assault. Documentation showed that all the Security Officers involved in the incident admitted a physical takedown using manual holds (restraints) of the patient to disrobe him. This occurred in the ED in Room 112 on 2/13/17 at approximately 2:37 PM. The Security Officers all denied physical assault or punching the patient during the incident. The investigation was closed and the officers were permitted to continue working. Quality Assurance did not pursue the incident any further and the case was closed.


Hospital incident report dated 2/9/17 revealed: Patient #2 has been in Room 8 for several days awaiting inpatient psychiatric bed transfer. This evening, the patient's mother visited, and found her daughter in possession of a knife that was given to her by Patient #3, either today or yesterday. The other patient was already transferred out of here. The patient's mother found the knife and filled out this report. No evidence of harm."

No further investigation was conducted to detail the root cause of how Patient #2 was able to obtain the knife from Patient #3. Quality Assurance/Performance Improvement department took no further actions.

This was confirmed during interview on 3/22/17 at 11:20 AM with Staff A, Director Regulatory Affairs, who stated, "We didn't do a root cause analysis of this incident."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
Based on observation, document review and staff interview, the facility failed to provide a policy to guide staff in the seclusion of patients in the Emergency Department Psychiatric Observation Suite (POS). This was found in one (1) of 20 medical records reviewed (Patient#1).

This placed all patients at risk for harm.

Findings Include:

On 3/20/17 at 3:30 PM, inspection of the Emergency Department and Psychiatric Observation Suite (POS) Observed Room 112, which is outside the POS area and signposted "ED Observation Room." Staff H stated. "This is where Patient#1 was on 2/13/17. I saw him in here, he was by himself in this room. The door was closed but I could look through this window in the door and see him on the mattress. There was a security guard outside the room watching him. We don't call it a seclusion room. It's called a private room or isolation room. We don't use it often. We use it for disruptive patients, intoxicated patients or patients who request to be themselves. Room 112 is not part of the POS, so the geographic location prohibits it from being called a seclusion room. I have seen patients physically restrained in that room by the security." Staff H was asked what is the definition of seclusion and stated, "It's when a patient is locked in a room and can't leave."

During interview on 3/22/17 at 10:20 AM, Staff R, Adult ED Nurse Manager, stated that Rooms A, B, C, D and E in the POS area are used as seclusion rooms "when necessary."

On 3/20/17 at 3:30 PM, Staff Q, Director of Nursing was asked for the policy that includes the criteria for use of Room 112 and stated, "We don't have a policy for this room"

During interview on 3/21/17 at 1:45 PM, Staff N, Director of Environmental Safety Stated, "The ED doesn't have seclusion rooms." This statement was confirmed in the presence of Staff A, Director of Regulatory.


Review of hospital policy titled, "Restraint or Seclusion, Care of the patient requiring," last revised 10/16 documents, "Seclusion: Treatment of the patient requiring seclusion necessitates consultation with the inpatient psychiatry attending. Children's Hospital at Monty doesn't have rooms designated for seclusion."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
Based on observation, document review and interview, the facility failed to document the least restrictive interventions used prior to seclusion.
This finding was found in one (1) of 10 medical records reviewed (Patient #1).

Findings include:

Medical record review for Patient #1 revealed the Nurse, Staff H documented on 2/13/17 at 3:45 PM, "Patient brought in from transitional living for aggressive behavior. Patient was uncooperative with security during initial safety check. Patient began to spit at officers and would not change into hospital garb. Patient is currently in the Emergency Department (ED) "Observation Room" resting on mattress pending further evaluation."

There was documentation in the medical record that the patient was placed in seclusion while in the ED.

There was no documentation that the least restrictive interventions, including de-escalation was used prior to placing the patient in Seclusion.

.