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.

TENNOVA HEALTHCARE 900 EAST OAK HILL AVENUE KNOXVILLE, TN 37917 Nov. 21, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of facility investigation docmentation, review of facility training documentation, and interview, the facility failed to protect and/or promote patient rights for one patient (#2) of five sampled patients.

The findings included:

Review of facility policy titled, "Abuse ..." dated March 22, 2011, revealed, " ...strives to the best of its ability to prohibit and protect patients from real or perceived abuse ...further protected from any form of abuse ...unreasonable confinement ...Associates will be instructed to observe for, intervene in, and report any incidents of abuse ...documented in the medical record ...All observed or reported incidents ...will be entered into the electronic incident reporting system. The Risk Manager and Administrator-on-call must be notified immediately ...If the alleged abuser is a staff member:..All associates with information regarding the alleged incident will be asked to document their observations individually prior to leaving the facility ..."
Review of facility policy titled "Restraints" dated March 1, 2011, revealed, " ...Restraint is any manual method ...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ...Seclusion is the involuntary confinement of a person alone in a room or area from which the patient is physically prevented from leaving ...All restraint use requires a physician's order ...All staff who implement, apply, and remove restraints or utilize seclusion will be trained and have demonstrated competency in the safe and proper technique and procedure ..."
Review of facility policy titled, "Disruptive Behavior (Code Green/Security Stat (without delay) dated September 6, 2011, revealed, " ...to provide a safe environment ...When verbal intervention techniques have failed and the person is becoming a danger to themselves or others, two procedures have been established: Disruptive Behavior for Patients - "Code Green" ...Definitions: 1. Code Green Team: Designated associates trained in Crisis Intervention ...Code Green Team Leader: Associate with relationship with patient ...A licensed associate initially involved with the patient who is a danger to themselves or others may make the decision that a "Code Green" is called ...The associate(s) involved with the patient remains with the patient and attempts to de-escalate ...Another associate may take over the attempts to de-escalate the patient if the patient is too angry or hostile with the involved associate ...The Code Green team leader is the ONLY person to communicate with the patient and other associates ...Security should not be asked to touch the patient unless there is imminent danger of harm to the patient or associates ...The "Code Green" team leader informs the patient is not a punishment but is carried out to assure the safety of that the intervention all concerned ...The RN associate assists ...in assessing the need for restraining the patient or placing the patient in seclusion ...team members: Position themselves to control their assigned limb ...Maintain their holds until the "Code Green" team leader signals ...Upon verbal command, all "Code Green" team members proceed in a quick manner to restrain their assigned limb ...The head must be protected from injury ...The RN must complete the restraint order form and insure that the Restraint Policy and Procedure is followed ..."

Patient #2 presented to the facility's emergency room (ER) on November 6, 2011, at 5:33 p.m. with diagnosis of Hand Laceration.

Medical record review of an Emergency Department (ED) Triage Record dated November 6, 2011, at 7:02 p.m. revealed, "pt (patient uncooperative...Chief Complaint...lac (laceration) to R (right) hand refuses to say how done...Is this patient presenting with an emotional or behavioral complaint? No..." (Time was changed to Eastern Standard time on November 6, 2011, and based on the remainder of the medical record the time of this entry appeared to have been 6:02 p.m.)

Medical record review of an ED Nursing assessment dated [DATE], at 6:06 p.m. revealed, "...lac R palm...AAO x 3 (alert and oriented times three)...Respiratory: Unlabored...Cardiac NA (not applicable)...Functional ADL (activities of daily living) WNL (within normal limits)..."

Medical record review of an ED Nursing Record dated November 6, 2011, revealed, "...6:09 p.m...hand cleaned...bleeding controlled...6:11 p.m...to/from x-ray with tech (calm at present) - security..." Continued review revealed no documentation regarding behavioral issues and/or rationale regarding inclusion of "security" in the medical record.

Medical record review of an Emergency Provider Record Hand or Wrist Injury dated November 6, 2011, at 6:35 p.m. revealed, "...chief complaint: injury to: right hand...severity of pain mild...appears well alert/oriented x 3...Neuro...nml (neurological...normal)...Skin warm lac L (left) hand...lac over bridge nose...mood/affect nml..."

Medical record review of an ED Nursing Record dated November 6, 2011, at 6:58 p.m. revealed, "...Dr...at bedside suturing pt's (patient's) hand...7:44 p.m. Pt laceration drg (dressing) applied to wound. Steri-strips applied to bridge of nose after being cleaned."

Review of facility investigation documentation completed by Registered Nurse (RN #1) and dated November 6, 2011, at 5:30 p.m. revealed, "...In room 19 the patient sat on the bed, then jumped up and pushed me and remained within six inches of me behaving in a threatening manner. I had to push the patient away to protect myself...patient started to flee the ER (emergency room ) and security was called. I informed security I was filing charges for assault and battery. The patient was restrained, hand-cuffed and taken to Room 9 (factual error, Room was 19)..."

Review of facility investigation documentation completed by Security Officer #1 and dated November 6, 2011, revealed, "...at approximately 5:35 p.m...dispatched to an irate patient in...ED lobby...identified...(patient #2) in the driveway of the ambulance bay entrance...trying to leave...(RN #1) informed me (RN #1) had been assaulted by (patient #2) and wanted to press charges...(patient #2) continued to be irate and uncooperative...attempted to escalate in aggression so the staff and I took (patient #2) to the ground...resisted more. After handcuffed (patient #2) was escorted...to ED...(patient #2) stated that (RN #1) was disrespectful to (patient #2) and eventually shoved (patient #2) causing (patient #2) to trip and almost fall...then (patient #2) attempted to walk out of the ED...(RN #1) stated...(patient #2) attempted to leave but was stopped by staff..."

Medical record review revealed no physician's order for use of physical restraint.

Review of security video provided by and interview with the ER Clinical Leader on November 15, 2011, at 3:28 p.m., revealed ED Technician (ED Tech) #2 on his knees and over the patient who was lying on the ground face down. The patient's feet were between ED Tech #2's legs and Security Officer #1 on the ground on the patient's right side. Continued review revealed Security Officer #2, RN #1, ED Tech #3, and another employee at the scene. The patient was handcuffed and assisted to stand; ED Tech #2 held the neck of the patient's shirt in his hand as the patient walked toward the ER accompanied by facility staff.

Review of facililty training records provided by the facility on November 16, 2011, revealed ED Tech (technician) #1 was certified in Nonviolent Crisis Intervention. Continued review revealed no documentation regarding training/certification for other facility employees at the scene involving physical restraint of Patient #2 on November 6, 2011.

Telephone interview with Patient #2 on November 10, 2011, at 3:02 p.m., revealed, "...person who assaulted me was an ex-cop named (RN #1)...They tackled me outside, took me in like (a) false imprisonment situation..."

Interview with RN #1 on November 15, 2011, at 1:27 p.m., in the ER Clinical Leader's office, revealed RN #1 escorted the patient to ER Room 19. RN #1 stated, "...told (patient #2) to sit down...got up in my face about six inches from my face. I told (patient #2) to sit down and step away. (Patient #2) was yelling. (Patient #2) pushed me about three feet backwards and took one step toward me and I pushed (patient #2) away from me. (Patient #2) then left the room and I called security. I don't remember how (patient #2) got through the double (exit) doors. By the time (patient #2) got out (before the x-ray) several staff were in the area and they detained (patient #2)..."

Interview with ED Technician (ED tech #1) on November 15, 2011, at 12:47 p.m., in the ER Clinical Leader's office, revealed he observed Patient #2 outside the facility on November 6, 2011, and he stated, "...The patient was near the area where ambulances park, approximately forty feet from the exit doors. (RN #1)...pointing at (patient #2) and stated stop (patient #2). I proceeded to (patient #2). (Patient #2) stopped and was no longer walking away from us...I reached up and touched (patient's) arm and said we don't want you to leave. I'm not proud of this...(ED Tech #2) ...grabbed (patient's) shirt from behind...which agitated the patient...Patient asked (ED Tech #2) 3-4 times to let go of shirt...There is a camera out there. This was agitating the patient...security showed up ...was getting more agitated because (patient ) just wants to leave...wasn't physically agitated and not trying to strike anyone...(ED Tech #2) instructs patient to get to...knees. Security officer had not intervened. (ED Tech #2) started to force (patient) to the ground...Patient was now fighting to keep this from occurring. It should not have occurred...I teach for the hospital. Need to know how to verbally defuse. The reason (patient was) detained was for arrest...What I saw was unnecessary force..."

Interview with ED Tech #3 on November 15, 2011, at 3:00 p.m., in the ER Clinical Leader's office, revealed a security officer and ED Tech #2 "took (patient) down..."

Interview with Security Officer #1 on November 15, 2011, at 3:12 p.m., in the ER Clinical Leader's office, revealed security responded to a call regarding an "irate" patient in the ER lobby and when security arrived the patient was outside the facility. Security Officer #1 stated, "...bunch of staff...(RN #1) told me he wanted (patient) arrested...patient probably intoxicated. I said everyone stop...Patient said (patient) was treated badly and wanted to leave. Staff got more involved than they should have. After looking at camera the staff was trying to grab hold...I tapped (patient) on chest and (patient) was compliant. Staff grabbed (patient) and were yelling at (patient)...after looking at tapes staff should have kept their hands off...patient was not violently aggressive so staff reacting (was) not in defense of selves or others - think they got tired of the situation."

Telephone interview with ED Tech #2 on November 16, 2011, at 1:37 p.m., revealed he participated in restraining the patient on the ground outside the ER on November 6, 2011.

Telephone interview with the facility's Security Manager on November 16, 2011, at 9:32 a.m., revealed the security video in his possession differed from the video provided on November 15, 2011, with regard to when the taping began. The Security Manager stated, "As I looked at the video saw subject walked out, nurse and tech walked out after (patient)..."

Telephone interview with Patient #2 on November 21, 2011, at 9:13 a.m., revealed the patient presented to the facility with an injury to the left hand on November 6, 2011. Continued interview revealed,"...(RN #1)...took me to room...I was trying to leave...I told (RN #1) I don't want your help anymore. I'd like to leave. (RN #1) said no you're not...I stood up...As soon as I squeezed out the door it closed...(RN #1) followed and called get security...They came behind me and said you need to come back inside and I said no I'm going to leave. I had walked out the front. I was not a harm to myself or others...they tackled me...was on my knees, three to four people on top of me. (They) cuffed me while I was down..." Continued interview revealed the patient was returned to a room and the patient stated, "...As (they) were walking me back in I told them I didn't need cuffs and I wanted to leave. They told me I was going to be arrested...I didn't lay a hand on anybody..."

Interview with the ER Clinical Leader on November 15, 2011, at 12:30 p.m., in his office, revealed the patient wanted to leave and had the right to leave without treatment. Continued interview confirmed the facility failed to provide the right to refuse treatment and ensure staff did not physically restrain Patient #2 from leaving the hospital grounds on November 6, 2011.

Refer to A131 and A154.

C/O: #
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, review of facility investigation documentation, and interview, the facility failed to provide the right to refuse treatment for one patient (#2) of five sampled patients.

The findings included:

Patient #2 presented to the facility's emergency room (ER) on November 6, 2011, with diagnosis of Hand Laceration.

Medical record review of an Emergency Department (ED) Triage Record dated November 6, 2011, revealed, "pt (patient uncooperative...Chief Complaint...lac (laceration) to R (right) hand refuses to say how done...Is this patient presenting with an emotional or behavioral complaint? No..."

Medical record review of an ED Nursing assessment dated [DATE], revealed, "...lac R palm...AAO x 3 (alert and oriented times three)...Respiratory: Unlabored...Cardiac" NA (not applicable)...Functional ADL (activities of daily living) WNL (within normal limits)..."

Medical record review of an Emergency Provider Record Hand or Wrist Injury dated November 6, 2011, revealed, "...chief complaint: injury to: right hand...severity of pain mild...appears well alert/oriented x 3...Neuro...nml (neurological...normal)...breath sounds nml...heart sounds nml...mood/affect nml..."

Review of facility investigation documentation completed by Registered Nurse (RN #1) and dated November 6, 2011, revealed, "...patient started to flee the ER (emergency room ) and security was called. I informed security I was filing charges for assault and battery. The patient was restrained, hand-cuffed and taken to Room 9 (factual error - was Room #19)..."

Review of facility investigation documentation completed by Security Officer #1 and dated November 6, 2011, revealed, "...dispatched to an irate patient in...ED lobby...identified...(patient #2) in the driveway of the ambulance bay entrance...trying to leave...after handcuffed (patient #2) was escorted...to ED...(patient #2) stated that (RN #1) was disrespectful to (patient #2) and eventually shoved (patient #2)...then (patient #2) attempted to walk out of the ED...(RN #1) stated...(patient #2)attempted to leave but was stopped by staff...(RN #1) no longer wanted to press charges and told (patient #2)...was not placed under arrest...discharged without incident..."

Interview with RN #1 on November 15, 2011, at 1:27 p.m., in the ER Clinical Leader's office, revealed RN #1 escorted the patient to ER Room 19. RN #1 stated, "...told (patient #2) to sit down...got up in my face about six inches from my face. I told (patient #2) to sit down and step away. (Patient #2) was yelling. (Patient #2) pushed me about three feet backwards and took one step toward me and I pushed (patient #2) away from me. (Patient #2) then left the room and I called security. I don't remember how (patient #2) got through the double (exit) doors. By the time (patient #2) got out several staff were in the area and they detained (patient #2)..."

Interview with ED Tech #1 on November 15, 2011, at 12:47 p.m., in the ER Clinical Leader's office, revealed he observed Patient #2 outside the facility on November 6, 2011, and he stated, "...The patient was near the area where ambulances park, approximately forty feet from the exit doors. (RN #1)...pointing at (patient #2) and stated stop (patient #2). I proceeded to (patient #2). (Patient #2) stopped and was no longer walking away from us...(Patient #2) said...wanted to leave...(RN #1) said (RN #1) wanted (patient #2) arrested for assault...was getting more agitated because (patient #2) just wants to leave..."

Interview with the ER Clinical Leader on November 15, 2011, at 12:30 p.m., revealed the patient had the right to leave, was detained by the facility and confirmed the facility failed to provide the patient the right to refuse treatment. He stated, "The techs detained the patient on the orders of (RN #1). The patient wanted to leave."

C/O: #
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of facility policy, medical record review, review of facility investigation documentation, review of facility security video, and interview, the facility failed to ensure staff did not physically restrain a patient from leaving the hospital grounds for one patient (#2) of five sampled patients.

The findings included:
Review of facility policy titled "Restraints" dated March 1, 2011, revealed, " ...Restraint is any manual method ...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ...Seclusion is the involuntary confinement of a person alone in a room or area from which the patient is physically prevented from leaving ...All restraint use requires a physician's order..."

Patient #2 presented to the facility's emergency room (ER) on November 6, 2011, at 5:33 p.m. with diagnosis of Hand Laceration.

Medical record review of an Emergency Department (ED) Triage Record dated November 6, 2011, at 7:02 p.m. revealed, "pt (patient uncooperative...Chief Complaint...lac (laceration) to R (right) hand refuses to say how done...Is this patient presenting with an emotional or behavioral complaint? No..." (Time was changed to Eastern Standard time on November 6, 2011, and based on the remainder of the medical record the time of this entry appeared to have been 6:02 p.m.)

Medical record review of an ED Nursing assessment dated [DATE], at 6:06 p.m. revealed, "...lac R palm...AAO x 3 (alert and oriented times three)...Respiratory: Unlabored...Cardiac NA (not applicable)...Functional ADL (activities of daily living) WNL (within normal limits)..."

Medical record review of an ED Nursing Record dated November 6, 2011, revealed, "...6:07 p.m. Tid 0.5 cc/IM (intramuscular) L (left) deltoid...6:09 p.m...hand cleaned...bleeding controlled...6:11 p.m...to/from x-ray with tech (calm at present) - security..." Continued review revealed no documentation regarding behavioral issues and/or rationale regarding inclusion of "security" in the medical record.

Medical record review of an Emergency Provider Record Hand or Wrist Injury dated November 6, 2011, at 6:35 p.m. revealed, "...chief complaint: injury to: right hand...severity of pain mild...appears well alert/oriented x 3...Neuro...nml (neurological...normal)...Skin warm lac L (left) hand...lac over bridge nose...mood/affect nml..."

Medical record review of aa ED Nursing Record dated November 6, 2011, at 6:58 p.m. revealed, "...Dr...at bedside suturing pt's (patient's) hand...7:44 p.m. Pt laceration drg (dressing) applied to wound. Steri-strips applied to bridge of nose after being cleaned."

Review of facility investigation documentation completed by Registered Nurse (RN #1) and dated November 6, 2011, at 5:30 p.m. revealed, "...patient started to flee the ER (emergency room ) and security was called. I informed security I was filing charges for assault and battery. The patient was restrained, hand-cuffed and taken to Room 9..."

Review of facility investigation documentation completed by Security Officer #1 and dated November 6, 2011, revealed, "...at approximately 5:35 p.m...dispatched to an irate patient in...ED lobby...identified...(patient #2) in the driveway of the ambulance bay entrance...trying to leave...(RN #1) informed me (RN #1) had been assaulted by (patient #2) and wanted to press charges...(patient #2) continued to be irate and uncooperative...attempted to escalate in aggression so the staff and I took (patient #2) to the ground...resisted more. After handcuffed (patient #2) was escorted...to ED...(patient #2) stated that (RN #1) was disrespectful to (patient #2) and eventually shoved (patient #2) causing (patient #2) to trip and almost fall...then (patient #2) attempted to walk out of the ED...(RN #1) stated...(patient #2) attempted to leave but was stopped by staff..."

Medical record review revealed no physician's order for use of physical restraint.

Review of security video provided by and interview with the ER Clinical Leader on November 15, 2011, at 3:28 p.m., revealed ED Technician (ED Tech) #2 on his knees and over the patient who was lying on the ground face down, with patient's feet between ED Tech #2's legs and Security Officer #1 on the ground on the patient's right side. Continued review revealed Security Officer #2, RN #1, ED Tech #3, and another employee at the scene, the handcuffed patient was assisted to stand; ED Tech #2 held the neck of the patient's shirt in his hand as the patient walked toward the ER accompanied by facility staff.

Telephone interview with Patient #2 on November 10, 2011, at 3:02 p.m., revealed, "...person who assaulted me was an ex-cop named (RN #1)...They tackled me outside, took me in like false imprisonment situation..."

Interview with RN #1 on November 15, 2011, at 1:27 p.m., in the ER Clinical Leader's office, revealed RN # #1 escorted the patient to ER Room 19. RN #1 stated, "...told (patient #2) to sit down...got up in my face about six inches from my face. I told (patient #2) to sit down and step away. (Patient #2) was yelling. (Patient #2) pushed me about three feet backwards and took one step toward me and I pushed (patient #2) away from me. (Patient #2) then left the room and I called security. I don't remember how (patient #2) got through the double (exit) doors. By the time (patient #2) got out (before the x-ray) several staff were in the area and they detained (patient #2)..."

Interview with ED Technician (ED tech #1) on November 15, 2011, at 12:47 p.m., in the ER Clinical Leader's office, revealed he observed Patient #2 outside the facility on November 6, 2011, and he stated, "...The patient was near the area where ambulances park, approximately forty feet from the exit doors. (RN #1)...pointing at (patient #2) and stated stop (patient #2). I proceeded to (patient #2). (Patient #2) stopped and was no longer walking away from us...I reached up and touched (patient's) arm and said we don't want you to leave. I'm not proud of this...(ED Tech #2) ...grabbed (patient's) shirt from behind...which agitated the patient...Patient asked (ED Tech #2) 3-4 times to let go of shirt...There is a camera out there. This was agitating the patient...security showed up ...was getting more agitated because (patient ) just wants to leave...wasn't physically agitated and not trying to strike anyone...(ED Tech #2) instructs patient to get to...knees. Security officer had not intervened. (ED Tech #2) started to force (patient) to the ground...Patient was now fighting to keep this from occurring. It should not have occurred...I teach for the hospital. Need to know how to verbally defuse. The reason (patient was) detained was for arrest...What I saw was unnecessary force...When the patient was in the room (after returned into the ER)...was handcuffed..."

Interview with ED Tech #3 on November 15, 2011, at 3:00 p.m., in the ER Clinical Leader's office, revealed a security officer and ED Tech #2 "took (patient) down..."

Interview with Security Officer #1 on November 15, 2011, at 3:12 p.m., in the ER Clinical Leader's office, revealed security responded to a call regarding an "irate" patient in the ER lobby and when security arrived the patient was outside the facility. Security Officer #1 stated, "...bunch of staff...(RN #1) told me he wanted (patient) arrested...patient probably intoxicated. I said everyone stop...Patient said (patient) was treated badly and wanted to leave. Staff got more involved than they should have. After looking at camera the staff was trying to grab hold...I tapped (patient) on chest and (patient) was compliant. Staff grabbed (patient) and were yelling at (patient)...after looking at tapes staff should have kept their hands off...patient was not violently aggressive so staff reacting (was) not in defense of selves or others - think they got tired of the situation."

Telephone interview with ED Tech #2 on November 16, 2011, at 1:37 p.m., revealed he participated in restraining the patient on the ground outside the ER on November 6, 2011.

Telephone interview with the facility's Security Manager on November 16, 2011, at 9:32 a.m., revealed the security video in his possession differed from the video provided on November 15, 2011, with regard to when the taping began. The Security Manager stated, "As I looked at the video saw subject walked out, nurse and tech walked out after (patient)..."

Interview with the ER Clinical Leader on November 15, 2011, at 12:30 p.m., in his office, revealed the patient had the right to leave and confirmed the patient was physically restrained and detained while hand-cuffed on November 6, 2011.

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