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-SHELBYVILLE 2835 HWY 231 N SHELBYVILLE, TN 37160 Sept. 9, 2013
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, record review, observation and interview, it was determined the Chief Executive Officer (CEO) failed to be responsible for the management of the hospital, ensure staff provided care in a safe environment and patients' rights were promoted for 1 of 1 (Patient #1) sampled patients who rights were violated.

The findings included:

1. Review of the emergency department (ED) record for Patient #1 revealed the patient (MDS) dated [DATE] with the diagnosis of Suicidal Ideations. The patient was placed in the seclusion room.

2. Observation of the hospital's video recording of the seclusion room by the surveyor revealed on 6/10/13 Medical Doctor (MD) #2 and the security guard entered the seclusion room and forcefully pushed and restrained Patient #1 against the wall. The MD was observed talking in a loud voice to the patient. On 6/11/13 the security guard was observed opening the door to the seclusion room and forcefully pushed the patient backwards, causing the patient to be bolted into the air. The patient's head was observed to hit the floor and wall which resulted in a pool of blood around the patient's head. The patient was observed to lay on the floor motionless for a few seconds. During this time the security guard grabbed the patient's arm and drug the patient across the floor. The video recording revealed the RNs and MD #2 failed to appropriately respond to the patient and perform appropriate assessments and treatments.

As a result of the incident, Patient #1 sustained fractures to the cervical spine and a head laceration. The hospital staff failed to immediately stabilize the patient. The patient had to be transferred to a higher level of care as a result of the incident.

3. There was no documentation the CEO had investigated the incident to determine the root cause in order to implement appropriate interventions to ensure patients' received care in a safe environment.
Refer to A 144, A 145, A 164, A 286 and A 392.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy review, record review, observation and interview, it was determined the Governing Body failed to assume responsibility and provide oversight of the hospital's quality of care, patient rights, QAPI program and nursing services. The failure of the Governing Body to assume responsibility and provide oversight resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in an IMMEDIATE JEOPARDY and at risk for serious injuries and/or death.

The findings included:

1. The Governing Body failed to ensure the Chief Executive Officer Chief Executive Officer (CEO) was responsible and ensured the safety of the patients in the hospital.
Refer to A057.

2. The Governing Body failed to be responsible and ensure all contracted services provided appropriate care and services in a safe environment.
Refer to A083.

3. The Governing Body failed to ensure policies were implemented, all patients received appropriate care and services in a safe setting, were protected at all times, and their patient rights, dignity, and well-being was preserved.
Refer to A115, A144, A145 and A164.

4. The Governing Body failed to ensure the Quality Assessment Performance Improvement (QAPI) committee analyzed and reviewed all adverse patient events and implemented preventative actions to ensure the events did not reoccur.
Refer to A 286.

5. The Governing Body failed to ensure nursing services provided appropriate interventions, performed assessments and provided timely stabilization to all patients that sustained cervical fractures and a head laceration while receiving care in the emergency department.
Refer to A 392.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, record review, observation and interview, it was determined the Governing Body failed to assume responsibility for the management of the hospital in order to ensure staff provided care in a safe abuse free environment. The failure of the governing body to be responsible for contracted services resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and abuse.

The findings included:

1. Review of the emergency department (ED) record for Patient #1 revealed the patient (MDS) dated [DATE] with the diagnosis of Suicidal Ideations. The patient was placed in the seclusion room.

2. A hospital recorded video of Room 7, a seclusion room in the ED revealed on 6/10/13 and 6/11/13 contracted MD #2 and the contracted security guard physically and forcefully restrained Patient #1 against the wall. The contracted security guard was observed forcefully pushing Patient #1 backwards causing the patient to bolt in the air and hit his head.
Patient #1 was diagnosed with a head laceration and transferred to a higher level of care.

3. Review of the hospital contracts revealed MD #2 and the security guard had contractual agreements with the hospital.

4. There was no documentation the Governing Body investigated the incident and reviewed the care provided by the contracted services in order to determine the root cause and implement appropriate interventions.

There was no documentation the Governing Body disciplined or counseled contract MD #2 who was involved in the patient incident.

There was no documentation the Governing Body implemented interventions to ensure contracted security guard services preserved the patients' right to be free from abuse.
Refer to A 144, A 145, A 164, A 286 and A 392.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on facility policy, record review, observation and interview, it was determined the facility failed to follow policies for patient environmental safety and security, and protected the patients' emotional health and safety as well as their physical safety. The failure of the facility to protect the emotional health and physical safety resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in an IMMEDIATE JEOPARDY and at risk for serious injuries and/or death.

The findings included:

1. The facility failed to follow policies and ensure all patients received appropriate care and services in a safe and protected environment.
Refer to A 144

2. The facility failed to ensure all patients were free from abuse or harassment.
Refer to A 145

3. The facility failed to ensure restraint and seclusion were only used as a last resort for patient safety.
Refer to A 164
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, record review, observation and interview, it was determined the facility failed to follow policies and ensure all patients received appropriate care and services, were protected at all times, and their patient rights, dignity, and well-being were preserved for 1 of 1 (Patient #1) sampled patients whose rights were violated. The failure of the facility to follow policies, protect patients and ensure all patients were treated with dignity and respect resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and/or death.

The findings included:

1. Review of the facility's "Suicide Risk Assessment and Interventions in a Non-Behavioral Health Setting" policy documented, "...All patients...will receive an initial assessment to determine suicide risk...to identify patients at risk for suicide and provide safety interventions...Suicidal Ideation; Thoughts of harming or killing oneself. Intensity determined by assessing the frequency, duration and intensity of these thoughts; in addition to the presence of a plan...Levels of Supervision...Continuous visual surveillance. Patient is under direct observation at all times and observer must be able to respond to the patient rapidly...Observer must have direct line of sight to patient. If de-escalation techniques are ineffective, patient will be escalated to Acuity 1..."
The policy designated the Registered Nurse (RN) would "...identify the appropriate acuity...that correlates with the HIGHEST level of observed or reported factors...From highest acuity (Acuity 1) to lowest-acuity (Acuity 5)...Selection of the applicable acuity box identifies the interventions that are being implemented...The level of suicide risk and need for suicide precautions must be reassessed by the qualified medical provider or Registered Nurse if there is an observed or stated change in behavior...Use verbal de-escalation techniques for the agitated patient Orient the patient; tell them who you are. Emphasize you want to keep them safe, you won't let any harm come to them, and you will help them gain control...Use positive reinforcements and listen...Communicate in an empathetic and concerned way...Be non-provocative, do not argue...Demonstrate a calm demeanor, voice and facial expression...Relaxed stance, hands open, normal eye contact...position self at 1 - 2 times arm length from patient (approximately 2 - 4 feet)...Consider the safety of yourself and patient when determining appropriate distance and adjust accordingly to individual situation...High-Risk Patients (Level 2): Probable risk of danger to self or others. As evidenced by observed extreme agitation/restlessness, physically/verbally aggressive, confused/unable to cooperate, hallucinations/delusions/paranoia, if unable to de-escalate may require restraint or seclusion, high risk for eloping and not waiting for treatment and/or reported attempt to self-harm ...and unable to wait safely. LEVEL OF SUPERVISION: Continuous visual surveillance..."

Review of the facility's "Verbally and Physically Abusive Patients and Guests" policy documented, "...To ensure that all [Hospital #1's name] patients receive medical care in a safe environment...The degree of care that a hospital owes a patient is higher than the degree of care a hospital owes to other persons that may enter the hospital...[Hospital #1's name] policy provides that patients have the right to be free from...restraint unless such restraint is required to prevent injury to the patient...If a Hospital patient...becomes verbally or physically abusive while...receiving or waiting for treatment, Hospital personnel contact hospital Security and the Administrative Liaison. Security takes the actions described below. This policy is enforced regardless of the cause of abusive behavior. Security will call for assistance, if needed, which may include additional Security Officers, [the County Sheriff's Department's name], [the city's name] City Police, and/or Facilities Management staff...A Security Officer makes him or herself visible to the person and stands nearby...If a person's abusive behavior continues, the Security Officer issues a statement to the patient...similar to the following verbal warning: 'This is a hospital and the hospital staff are here to provide medical care. Your behavior is disruptive and is making it difficult for our staff to provide quality care. If you behave in this manner, the physician may be forced to restrain you, refuse or discontinue treatment, contact the police, or ask that you are removed from the hospital'...If the verbal warning is ineffective as to a patient or individual seeking treatment for a medical condition, the attending physician evaluates whether restraints are necessary...If the patient...assaults or attempts to assault a member of the Hospital's staff, the Security Officer follows the procedures outlined in the Hospital's Use of Force and Security Procedures..."

Review of the facility's "Patient Restraints and Seclusion" policy documented, "...This facility creates an environment that helps hospital staff focus on the patient's well being...Our goal is an organization - wide approach to restraints that protects the patient's health and safety and preserves his or her dignity, rights and well-being...Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior...It is the policy of this facility to...Protect the patient and preserve the patient's rights, dignity and well-being during the restraint use by...Respecting the patient as an individual...maintain a clean and safe environment...The nurse...should concentrate on attempts at preventing the need for restraint by initiating the items listed in Limiting the Use of Restraint or Seclusion in this policy...The intervention should not cause or inflict harm to the patient...When the patient is awaiting transfer to a psychiatric unit, the transfer is accomplished as rapidly as possible. If the patient is in restraint or seclusion, emergency department staff...shall collaborate with psychiatric staff to ensure appropriate evaluation of the patient, until the transfer occurs...A. STAFF TRAINING AND COMPETENCE Our facility ensures staff, who have direct care responsibilities, including contract or agency personnel...are competent to minimize the use of restraint and seclusion, and to use them safely when their use is indicated...how staff behavior can affect the behavior of the patients they serve...the use of alternative and/or nonphysical interventions...the use of least restrictive intervention...the initiation, safe application, and removal of restraints to include monitoring and assessment...recognize signs of physical and psychological distress in patients who are restrained or secluded and application of first aid techniques...monitoring of the physical and psychological well-being of a patient in restraint or seclusion...Physicians and LIP's [licensed independent practitioner] authorized to order restraint and seclusion must have working knowledge of hospital policy regarding restraint and seclusion...A comprehensive assessment of the patient must determine that the risks associated with the use of restraint outweigh the risk of not using it...Planning for being proactive rather than reacting to the patient's behavior, protects the patient's health and safety...Situations in which restraints/seclusion are clinically justified include...harmful to self or others and alternative measures have been attempted...patient is unable to follow directions to avoid self-injury and protective, alternative measures have been attempted...LIMITING THE USE OF RESTRAINTS OR SECLUSION Our facility believes nonphysical techniques are the preferred intervention in the management of behavior. Attempts should be made to evaluate and use interventions/alternatives when possible and in response to the patient's assessed needs: Monitoring...companionship; staff or family to stay with patient...close, frequent observation, one-to-one when necessary...Comfort Measures...gentle touch, soothing voice...Interpersonal Skills...pleasant, consistent interaction... actively listening to patient; calm reassurance...Staffing ...flexibility to allow for assignment changes as per patient needs / behavior...Diversion Activities...distract patient with videos, TV, reading materials; engage in conversation...purposeful activities such as puzzles...listening to music...Reality Orientation and Psychological Intervention...involve the patient in conversation. Do not talk over him/her...explain procedures to reduce fear and convey a sense of calm...use relaxation techniques (warm bath, warm drink, ect.)...attempt to verbally redirect behavior...DOCUMENTATION Each episode of restraint is documented in the patient's medical record, consistent with policies and procedures...Consideration or failure of alternative interventions...Any injury to the patient..."

Review of the facility's "Code White" policy documented, "...It is the policy of [Hospital #1's name] to follow written procedures in the event of a security incident when a patient...becomes disruptive...to provide and maintain a safe environment for patients...The hospital 'Code White' alert is utilized in emergency situations when a patient...becomes disruptive and demonstrates the potential to: Inflict physical harm on themselves or others...Damage the physical property...The decision to implement 'Code White' alert is made by any employee or any individual who feels there is immediate threat of harm or injury to themselves, the patient or others...The telephone operator is informed by dialing extension 8988...The telephone operator will announce 'Code White'...three times... Members of the Code White team and the Security Officers on duty will respond immediately...Administration/Department Head/Nursing Supervisor or staff involved will assume control of the situation and direct team members as needed. Team members will not act to handle or physically restrain the patient/visitor unless directed...In the event the patient...is otherwise uncontrollable...remove all patients and employees from danger and notify the Police to handle the situation..."

Review of the facility's "Patient Fall Prevention" policy documented, "...a fall is defined as...Any observed fall of a patient from one surface level to another...Assessment of the Fallen Patient...The RN will assess the patient for obvious injury...report all falls to the attending physician...The RN will document fall, the post fall nursing assessment, notification of the physician and any treatment/tests ordered in the medical record..."

2. Medical Record review for Patient #1 revealed the [AGE] year old patient was transported via emergency medical services (EMS) to Hospital #1's emergency department (ED) on 6/10/13 at 13:59. The patient's chief complaint was suicidal ideations. The ED record documented the patient's weight was 131 pounds. The patient was placed in ED seclusion room #7 with the door unlocked.

Review of the laboratory results revealed the ED admission drug screen was positive for methamphetamine.

The ED "INITIAL ASSESSMENT FORM" revealed the patient's chief complaint was, "SUICIDE IDEATION...Told police and neighbors he wanted to kill himself." The form documented "UNK [unknown]" as to if the patient had a plan or means.

Review of Patient #1's Suicide Risk/Behavior Disorder Assessment form revealed the patient was defined as a Level 2 High-Risk situation, a "probable risk or danger to self or others and/or Severe behavioral disturbance." The assessment documented the patient was a "Threat to harm self or others" and "Suicidal Ideation [thoughts of suicide] with or without a plan."

Review of the 6/10/13 "CERTIFICATE OF NEED FOR EMERGENCY INVOLUNTARY ADMISSION" form completed at 20:00 revealed the patient required direct transportation to an admitting psychiatric facility related to "suicidal ideation (plan to shoot himself)...suicidal plan homicidal speech..."

Review of the 6/10/13 ED nurse's notes revealed the following:
"14:11...Patient's behavior appears suicidal ideations...Patient is not at risk for fall as evidenced by: being alert and oriented at presentation, no predisposing medical history..."
"15:41...Bedrails are up to protect patient from fall. Call light within reach and patient or family was instructed on use. Bed height is at the lowest position."
Surveyor observation of the hospital's video recording of the patient in the seclusion room revealed there was not a bed with side rails or a call light in the room.
"17:05...crisis called...stated she would have someone enroute, no ETA [estimated time of arrival] given..."
"18:38...Report was given...[to] crisis worker."
"20:38...reassessed at 20:05. Crisis worker completed eval [evaluation] with patient."
"20:39...Patient is alert and oriented x [times] 3..."
"21:02...patient reassessed ..."
"22:36...patient was reassessed..."
"22:51...Report was given...Person receiving report was [name of RN #1]."
"2350...PT YELLING, SLAMMING DOOR, SECURITY CONTACTED"
"2352...[County Police Department's name] NOTIFIED THAT PT ATTEMPTING TO HIT MD...Physician [MD #2] was at the bedside..."

Review of the 6/11/13 ED nurse's notes revealed:
"0207...PT [Patient #1] BEATING ON DOOR AND YELLING. SECURITY GUARD ON PT AND PT BEGAN YELLING AT SECURITY GUARD. PT THEN PUT HIS HANDS ON SECURITY GUARD'S SHOULDER AND SWUNG AT HIM AS REPORTED BY SECURITY GUARD. SECURITY GUARD RAISED HIS HANDS TO DEFEND HIMSELF AND THE PT fell BACKWARDS HITTING THE BACK OF HIS HEAD ON THE WALL AND fell TO THE GROUND. PT DID NOT HAVE LOC..."
"0215...c- [cervical] collar applied to pt neck and pt put on spine board ...put in ER room 5..."
"02:18...IM [intramuscular] haldol 5 mg [milligrams] initiated..."
"02:20...Pain: Patient rates pain as 8 on a one to ten scale with ten as the worst pain ever. Pain is located in the head, neck. Onset of pain was sudden, within the last hour. Patient describes the pain as constant aching...The patient is alert and oriented times 3 (person, place & time)...No deficits noted to upper or lower extremities. Sensation is intact...Musculoskeletal: Denies musculoskeletal pain, numbness or tingling. No swelling or deformity noted...Integumentary...Patient presents with laceration 1-2 cm [centimeters], superficial, that is linear..."
"03:30...IV [intravascular] Insertion started to the L [left] -anticube..." and "IV Ativan 1 mg [milligram] in the left AC [anticubical], given for therapeutic reasons..."
"03:42...Normal Saline 100 cc/hr [cubic centimeters/hour]..."
"03:57...Transfer...[to a higher level of care hospital's name]...for: SPECIALIZED CARE-TRAUMA...Patient left the department at 06/11/2013 04:37."

Review of the 6/10/13 ED MD notes revealed:
"14:20...Chief Complaint-SUICIDE IDEATION Exam time: 14:20. History obtained from patient...Pt A/O [alert and oriented] x [times] 4, calm, cooperative. States he has thought of shooting himself x 2 years b/c [because] lives alone and is lonely. Reports no family in town."
"14:34...Psychological: positive suicidal thoughts...All systems have been reviewed and are negative...Past Medical and Surgical histories reviewed..."

Review of the 6/11/13 ED MD notes revealed:
"02:54...Pt became agitated and very aggressive when he was asked to get back into room 7 [seclusion room] he became more aggressive and tried to push and hit myself and security. Local PD [police department] was called...Pt was given dose of IM [intramuscular] Haldol and rested for a while then got up and banged on the door again. When security responded, he again became aggressive and tried to hit security about the face and head. Security reacted, pushed him back and patient hit the ground striking his head. Bleeding noted from posterior scalp. Pt was placed on a backboard after a c-collar was placed..."
The patient was transported to ED room #5 and then to radiology for an emergent (STAT) computerized tomography scan (CT scan).

Review of the CT scan dated 6/11/13 02:20 revealed "...Impression...Odontoid base fracture with mild retrolisthesis of the odontoid tip in a fracture through the anterior C2 [cervical spine] body. Comminuted fracturing involving the C2 spinous process extending to the posterior arch and mild posterior sublaxation of the left C1 [cervical spine] facet with respect to the left C2 facet/lateral mass. Moderate/severe multilevel degenerative disc disease with generalized osteopenia..."

Review of the 6/11/13 ED MD note revealed, "03:30...CLINICAL IMPRESSION...Major Depression, Acute Exacerbation 2. Fracture C2 3. Dementia...03:32...will be transferred to [Hospital #2]...Patient's condition was emergent..."
"03:34...CT of c-spine remarkable for fx [fracture] of base of odontoid, base of C2, fx C2 spinous process extending into posterior arch..."

Review of the "Patient Transfer Form" dated 6/11/13 at 03:50 revealed the patient was being transferred to Hospital #2, "...that provides a different level of care and/or services which this hospital does not provide..." The "Expected Benefits of Transfer" were documented to be "advanced care - trauma center." The "Specific Risks of Transfer" was "deterioration of condition."

Review of the 6/11/13 EMS trip report revealed Patient #1 "was found in ER #5 [of Hospital #1] on spine board [without] straps or head blockers..." The patient was transported to Hospital #2.

Review of the ED records for Patient #1 at Hospital #2 revealed the patient arrived at the hospital ED on 6/11/13 at 05:46.
The ED History and Physical documented the patient had fallen, "...Unsure of loss of consciousness...A CT scan was done [at Hospital #1]...described misalignment...which our radiologist think may be...Pt rotation..."
The Drug screen results at Hospital #2 were negative. The ED Social History documented, "...No history of illicit drug use..."
The patient's weight was documented as 154.3 pounds.
The CT report from Hospital #1 was submitted to Hospital #2 for interpretation and documented, "...The described misalignment of the lateral mass of C1 on C2 may be secondary to patient rotation..."

The 6/11/13 CT Head and Cervical Spine, performed at Hospital #2 revealed, "...IMPRESSION: 1. Type II dens fracture. There is 3 mm [millimeter] retrolisthesis of the dens with respect to the C2 vertebral body, slightly increased compared to the exam performed 9 hours previously [at Hospital #1]. The anterior inferior C2 endplate fracture and comminuted fracture of the C2 spinous process and right lamina are unchanged..."
The patient was admitted to inpatient status at Hospital #2 on 6/11/13 at 13:49.

3. Review of Hospital #1's investigative summary completed by the the RM and CQO of the events that occurred in the ED seclusion room on 6/10/13 and 6/11/13 revealed, "...He [Patient #1] became more aggressive and tried to push and hit the ED physician and the security guard. Local police department...were unable to transport the patient to jail because he had an involuntary committal. The room was secured where the patient could not leave at that time and was monitored via camera...0220 The patient began banging on the door and was yelling. The security guard responded to the patient by opening the door, and he became aggressive and tried to hit the security guard about the face and head when the door was opened. He put his hands on the guards shoulder and swung at him. The security raised his hands to defend himself and the patient fell backwards hitting his head on the wall...The physician went into the room immediately and examined the patient. The patient had a 1-2 cm [centimeter] laceration to the back of the head that was superficial and linear...0437 patient left the ED and was transferred to [name of Hospital #2]...Restrain and Seclusion Per documentation, after the patient was identified as a suicide risk, he was assessed every 15 minutes during the stay and recorded Appropriately in the medical record..."

There were no observations of the hospital's video recordings viewed by the surveyor that the patient attempted to hit the security guard about his face or swing at the security guard.
The video did not reveal the security guard was attempting to defend himself.

Review of the Security Guard's first written statement obtained by Hospital #1 regarding the incident on 6/10/13 at 23:44 revealed, "Called to ER [emergency room ] for combative and disruptive patient in room 7. Patient was beating on door and screaming that he wanted to go home. I tried to calm the patient down, and told him to lay down and be calm. He continued without calming down, and Nurse Supervisor [name] said she was going to call the Police Depart. Dr. [MD #2's name] came over to the room and told me to unlock the door. We stepped into the room and Dr. [name] told the patient he was going to jail [the patient had been involuntary committed to a psychiatric unit and was awaiting transfer]. The patient then grabbed Dr. [name] and Dr. [name] spun him around and put him against the wall. At this point, I grabbed the patient's arms and told him to let go of the Dr. and to lay down. Police came and would not take the patient to jail. The police stayed with him while the nurse gave him a shot to calm the patient down until placement could be found. Patient lay down and the police left."

Review of the Security Guard's second written statement obtained by Hospital #1 regarding the incident on 6/11/13 at 01:58 revealed, "Called to watch intoxicated patient in Room 10...At approximately 1:30 a.m. [01:30], patient in Room 7 [Patient #1] started banging on door...I instructed patient to lay down and go to sleep...After a few moments, patient complied. Patient in Room 10 was being very vocal...stating when he got out of jail he was going to, 'come up in here and kill us all'...the patient in Room 7 began banging on the door and screaming that he wanted to go home. I told the patient several times he could not go home, and he continued to get louder. I then unlocked the door and asked him to calm down and lay down. He stated he wanted to go home. Again, I told him that he could not go home. At this point, he advanced on me and grabbed my shoulder. I told him to get off me and he swung at my face. I shoved the patient away from me, and he hit the wall striking his head. I called to [nurse assigned to patient #1], nurse, that I needed help in the room. [Nurse's name] assessed the patient's needs and then Dr. [MD's name] came in and said to put a collar and backboard on him and take him to Room 5."

There were no observations on the hospital video recordings reviewed by the surveyor that Patient #1 grabbed MD #2, advanced toward the security guard and swung at the security guard.

Review of RN #1's written statement obtained by Hospital #1 regarding the incidents that occurred on 6/10/13 at 23:44 and at 01:58 revealed, "[the 23:44 incident] The patient began beating on the door and yelling around midnight so security went to the door...to speak with the patient. The patient became combative towards the security guard and the doctor so [County's name] County Police Dept. was called. Police arrived and calmed the patient down. [6/11/13 01:58 incident] The patient then began beating on the door and yelling again around 0200 in the morning. Security then went to the door to check on the patient again. The patient continued to yell and put his hands on the security guard. The patient was being combative towards the guard so he put his hands up to defend himself. The patient was then seen to Fall backwards and hit his head. The patient did not lose consciousness and was immediately assessed by the doctor. A c- [cervical] collar was applied, and the patient was log-rolled onto a spinal board."

There were no observations on the hospital video recordings reviewed by the surveyor the patient was combative with the security guard and no observations the MD immediately assessed the patient.

Review of RN #2's written statement obtained by Hospital #1 regarding the incident that had occurred on 6/11/13 at 01:58 revealed, "Pt in Room 7 was screaming, yelling, banging on the door. Did not eye witness event, noticed on security camera that pt was lying supine, RN [RN #1's name assigned to care for the patient] & Security guard [security guard's name] in room to assess pt C-collar, supine board applied, XR [Xray] ordered."

Review of RN #3's written statement obtained by Hospital #1 regarding the incident that had occurred on 6/11/13 at 01:58 revealed, "I was sitting at nurse's station when pt started beating on door and yelling Security went to door to try and calm him. Security opened door and was talking with pt. out of the corner of my eye I saw pt lunge forward then security raised arms up and pt fell backwards. Went into room, pt lying on back, bleeding from head. Pt was asked if he knew where he was and he said no then said he thought he was in jail. MD entered room C-collar placed on pt [patient] and pt placed on back board then lifted onto stretcher."

There were no observations on the hospital video recordings reviewed by the surveyor the patient had lunged at the security guard. Observations revealed the patient was attempting to exit the seclusion room door.

Review of a summarized statement obtained by Hospital #1 from MD #1 who treated the patient from 07:00 - 19:00 revealed, "Pt was calm cooperative but was high energy. He knew why he was here. He was lucid and & alert...he said he just was old & just wanted to die...He seemed lucid & then went off on tangits [tangents]. Uncertain if he was confused r [or] just wanted to talk. Dr. [MD #1's name] told staff to let him come out to the desk some."

Review of a summarized statement obtained by Hospital #1 from MD #2 who treated the patient from 19:00 - 07:00 revealed, "He [patient #1] became agitated because had been there so long- Before fall he [MD #2] went in to calm him...he went in c [with] SG [Security Guard] & [and] they pushed him against wall med [medicated] him & was ok for a while. Later SG went back in pt tried to hit SG & SG pushed him back...."

There were no observations on the hospital video recordings reviewed by the surveyor that the MD attempted to calm the patient or of the patient attempting to hit the security guard.

Review of the Police report, provided by the hospital, dated 6/11/13 documented the victim to be the security guard and the suspect to be Patient #1. The report documented the patient weighed 157 pounds and was 5 foot 6 inches. The "NARRATIVE" documented, "...I was at the [Hospital #1's name] keeping watch on a suicidal subject [in Room 10]...I observed a male subject by the name of [Patient #1's name] being held in room #7...start screaming and beating on the door. The hospital security guard...then walked over to room #7 and opened the door....[The security guard told Patient #1] he needed to calm down and sit down and relax. I then noticed [Patient #1] reach towards [security guard's] face then start pushing him in attempt to get out of the room. [Security guard] then grabbed [Patient #1] and pushed him back into the room...I then went into the room and saw [Patient #1] laying on his back on the floor of the room..."

There were no observations on the hospital video recordings reviewed by the surveyor the patient reached towards the security guard's face.

4. Observation of the hospital video recordings of Patient #1 in the ED at Hospital #1 revealed on 6/10/13 at 18:34 the patient was laying on a floor mat in the seclusion room. At 19:53 a counselor walked into the room, talked with the patient and then left the room.
The next observation of the video recordings revealed on 6/10/13 at approximately 23:40 the patient was standing at the seclusion room door, looking through the window. The patient started slapping the door with his open hands, pointed out through the window and was asking why he couldn't go home. At approximately 23:44 the seclusion room door opened, MD #2 appeared in the doorway, advanced towards the patient, and said in a loud voice, "Congratulations, you gonna go to jail." The MD then reached his right hand out towards the patient. The patient began questioning why he was going to jail and what had he done to have to go to jail. The patient stepped forward and attempted to go out the door. The MD pushed the patient forcefully back into the seclusion room. A large in statue security guard then entered the seclusion room. The MD and security guard pushed the patient forcefully against the wall and the patient's head was observed bumping the wall. The patient's arms were at his side during this. After the patient was restrained against the wall by the MD and security guard, the patient raised his right arm and slapped toward the area of the MD's left shoulder/neck area. The MD had his left arm across the patient's chest, and the security guard had both his hands against the patient restraining the patient against the wall. The patient placed his left hand on top of the MD's right forearm arm attempting to move the MD's arm off his chest. The MD pointed his finger at the patient then at the floor mat. The MD then let go of the patient and left the seclusion room. The security guard continued to keep the patient restrained against the wall for a few more seconds before he too exited the seclusion room. The patient walked towards the closed seclusion room door and looked out the window.
There was no observation the patient was aggressive.

At approximately 00:14 two policemen entered the seclusion room. The policeman calmly talked with the patient, and the patient was calmly talking with the policeman. RN #1 then entered the room and was observed administering a shot to the patient. The patient remained calm.

Observations of the video recordings for 6/11/13 from 01:28 to 01:56 revealed Patient #1 was laying on a floor mat in the seclusion room. At 01:56 the patient was observed moving slow and unsteady to a standing position. At 01:57 the patient walked to the door and stood looking out the door window. Around 01:58 the patient began slapping on the door with opened hands and loudly asking why he couldn't go home. At this time the seclusion room door opened, the security guard stood in the doorway and reached his right hand out towards the patient. The security guard then placed his right hand up toward the patients chin area. The patient slapped at the security guards right hand and the security guard pointed toward the floor mat. The patient stepped forward and placed his right arm across the security guard's chest and his left arm out toward the door. The security guard then grabbed the patient, forcefully leaned into the patient and pushed the patient backwards. The patient was bolted into the air by the security guard's force and landed on the floor with his head forcefully hitting the baseboard and wall area. The patient was observed to be laying on the floor motionless for a few seconds. The security guard then went to the patient's side, grabbed the patient's left arm and drug the patient 6 - 12 inches across the floor before letting go of the patient.
At this time RN #1 entered the room, stood beside the patient for a few seconds and then exited the room. RN #1 did not perform an assessment of the patient. As the RN was leaving the room, the patient brought his hands to his head and turned onto his right side. A pool of blood was observed around the patient's head. RN #1 returned to the room, donned a pair of gloves, and remained in a standing position beside the patient. The patient remained on the floor moving around. RN #2 entered the room for a few seconds, stood beside the patient, then left and returned with 4 x 4s. RN #2 held pressure to the back of the patient's head for approximately 10 - 15 seconds, then left the 4 x 4s on the patients head and walked away from the patient. The patient then rolled onto his back. RN #2 did not perform an assessment of the patient. RN #1 then brought a stretcher into the seclusion room and stood beside the patient. The RN was observed to step over the patient as the patient continued to lay on the floor unattended. RN #1 left the room again. At 02:00 the security
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, record review, observation and interview, it was determined the facility failed to ensure patients were free from all forms of abuse for 1 of 1 (Patient #1) sampled patients who sustained abuse while in the care of the hospital. The failure of the facility to ensure patients were free from all forms of abuse resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries.

The findings included:

1. Medical Record review for Patient #1 revealed the [AGE] year old patient was transported via emergency medical services (EMS) to Hospital #1's emergency department (ED) on 6/10/13 at 13:59. The patient's chief complaint was suicidal ideations. The patient stated that he lived alone, was lonely and threatened to shoot himself with a gun. The patient was placed in ED room #7, a seclusion room.

The 6/10/13 MD order at 23:10 documented Patient #1 was placed in seclusion related to "Agitated...Combative...Danger to self or others as demonstrated by aggressive behavior..Threatening actions toward staff as demonstrated by: physically abusive to MD..."

2. Observation of the video recordings of Patient #1 in the ED at Hospital #1 revealed on 6/10/13 at approximately 23:40 the patient was standing at the seclusion room door, looking through the window. The patient started slapping the door with his open hands, pointed out through the window and was asking why he couldn't go home. At approximately 23:44 the seclusion room door opened, MD #2 appeared in the doorway, advanced towards the patient, and said in a loud voice, "Congratulations, you gonna go to jail." The MD then reached his right hand out towards the patient. The patient began questioning why he was going to jail and what had he done to have to go to jail. The patient stepped forward and attempted to go out the door. The MD pushed the patient forcefully back into the seclusion room. A large in statue security guard then entered the seclusion room. The MD and security guard pushed the patient forcefully against the wall and the patient's head was observed bumping the wall. The patient's arms were at his side during this. After the patient was trapped against the wall by the MD and security guard, the patient raised his right arm and slapped toward the area of the MD's left shoulder/neck area. The MD had his left arm across the patient's chest, and the security guard had both his hands against the patient restraining the patient against the wall. The patient placed his left hand on top of the MD's right forearm arm attempting to move the MD's arm off his chest. The MD pointed his finger at the patient then at the floor mat. The MD then let go of the patient and left the seclusion room. The security guard continued to keep the patient restrained against the wall for a few more seconds before he too exited the seclusion room.
There was no observation on the hospital's video recording viewed by the surveyor of the patient being aggressive.

Observations of the video recordings for 6/11/13 from 01:28 to 01:56 revealed Patient #1 was laying on a floor mat in the seclusion room. The patient, unsteady and slow, got up off the mat and walked to the door. Around 01:58 the patient began slapping on the door with opened hands and loudly asking why he couldn't go home. At this time the seclusion room door opened, the security guard stood in the doorway and reached his right hand out towards the patient. The security guard then placed his right hand up toward the patients chin area. The patient slapped at the security guards right hand and the security guard pointed toward the floor mat. The patient stepped forward and placed his right arm across the security guard's chest and his left arm out toward the door. The security guard then grabbed the patient, forcefully leaned into the patient and pushed the patient backwards. The patient was bolted into the air by the security guard's force, flew backwards and landed on the floor with his head forcefully hitting the baseboard and wall area. The patient was observed to be laying on the floor motionless.
The video recordings verified the patient was forcefully restrained and assaulted by the MD and security guard.

3. Hospital #1's investigation of the incidents revealed statements obtained from the Security Guard, MD #1, MD #2, RN #1, RN #2 and RN #3.
The hospital video recordings of the events in the seclusion room with Patient #1 on 6/10/13 and 6/11/13 contradicted the statements that wee made by the hospital staff.

4. During an interview on 8/28/13 at 16:30 the CQO stated the incident was not identified as abuse because there was no "willful" intent.

Refer to A144 and A164
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on facility policy, record review and interview, it was determined the facility failed to implement less restrictive devices and protect and preserve the patient's right to be free from restraint and seclusion for 1 of 1 (Patient #1) sampled patient who was in seclusion.

The findings included:

1. Review of the facility's "Patient Restraints and Seclusion" policy documented, "...This facility creates an environment that helps hospital staff focus on the patient's well being...Our goal is an organization - wide approach to restraints that protects the patient's health and safety and preserves his or her dignity, rights and well-being...Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior...A. It is the policy of this facility to: i) Protect the patient and preserve the patient's rights, dignity and well-being during the restraint use by: a) Respecting the patient as an individual. b) maintain a clean and safe environment...The nurse...should concentrate on attempts at preventing the need for restraint by initiating the items listed in Limiting the Use of Restraint or Seclusion in this policy...The intervention should not cause or inflict harm to the patient...viii) When the patient is awaiting transfer to a psychiatric unit, the transfer is accomplished as rapidly as possible. If the patient is in restraint or seclusion, emergency department staff...shall collaborate with psychiatric staff to ensure appropriate evaluation of the patient, until the transfer occurs...A. STAFF TRAINING AND COMPETENCE Our facility ensures staff, who have direct care responsibilities, including contract or agency personnel...are competent to minimize the use of restraint and seclusion, and to use them safely when their use is indicated...how staff behavior can affect the behavior of the patients they serve...the use of alternative and/or nonphysical interventions...the use of least restrictive intervention...the initiation, safe application, and removal of restraints to include monitoring and assessment...recognize signs of physical and psychological distress in patients who are restrained or secluded and application of first aid techniques...monitoring of the physical and psychological well-being of a patient in restraint or seclusion...Physicians and LIP's authorized to order restraint and seclusion must have working knowledge of hospital policy regarding restraint and seclusion...A comprehensive assessment of the patient must determine that the risks associated with the use of restraint outweigh the risk of not using it...Planning for being proactive rather than reacting to the patient's behavior, protects the patient's health and safety...Situations in which restraints/seclusion are clinically justified include: i) harmful to self or others and alternative measures have been attempted...patient is unable to follow directions to avoid self-injury and protective, alternative measures have been attempted...C. LIMITING THE USE OF RESTRAINTS OR SECLUSION Our facility believes nonphysical techniques are the preferred intervention in the management of behavior. Attempts should be made to evaluate and use interventions/alternatives when possible and in response to the patient's assessed needs: Monitoring...companionship; staff or family to stay with patient...close, frequent observation, one-to-one when necessary...3. Comfort Measures...gentle touch, soothing voice 4. Interpersonal Skills i) pleasant, consistent interaction...ii) actively listening to patient; calm reassurance 5. Staffing i)...flexibility to allow for assignment changes as per patient needs / behavior...Diversion Activities i) distract patient with videos, TV, reading materials; engage in conversation ii) purposeful activities such as puzzles...listening to music...10. Reality Orientation and Psychological Intervention i) involve the patient in conversation. Do not talk over him/her...explain procedures to reduce fear and convey a sense of calm iv) use relaxation techniques (warm bath, warm drink, ect.) v) attempt to verbally redirect behavior...I. DOCUMENTATION Each episode of restraint is documented in the patient's medical record, consistent with policies and procedures...ii) Consideration or failure of alternative interventions ...xiii) Any injury to the patient..."

2. Medical Record review for Patient #1 revealed the patient was transported via emergency medical services (EMS) to the emergency department (ED) at Hospital #1 on 6/10/13 at 13:59 with the chief complaint of Suicidal Ideations. The patient was placed in an ED seclusion room.

The ED MD order dated 6/10/13 at 23:10 for Patient #1 revealed the patient was to be placed in seclusion. The documented reason for seclusion was "...physically abusive to MD...", yet there was no documentation the patient was abusive to the MD.
Hospital #1's video recording of the seclusion room revealed on 6/10/13 at 23:44 PM MD #2 and the security guard had entered the seclusion room due to Patient #1 slapping at the door and asking to go home. MD #2 was observed talking in a loud voice to the patient saying, "Congratulations, you gonna go to jail." The MD and security guard were observed to forcefully restrain the patient.

There was no observation on the hospital video recording viewed by the surveyor of the patient had been physically abusive to the MD.

There was no documentation less restrictive devices had been used prior to the patient being placed in the seclusion room. There was no documentation to justify why the patient had been placed in the seclusion room.

3. During an interview on 8/28/13 at 9:15 AM the Chief Quality Officer (CQO) stated Patient #1 arrived in the ED on 6/10/13 at 13:59 after a suicidal threat with a gun. The patient was taken to a locked seclusion room "after becoming increasingly agitated and aggressive."

During an interview on 8/28/13 at 8:55 PM MD #2 (caring for Patient #1 during both incidents) stated the patient was put in seclusion because he became "more agitated...wandered...He had already tried to come out in the hall...became increasingly agitated...He put his hands on my chest...I think there was 3" psych patients that needed monitoring during this time.
Refer to A144 and A145
VIOLATION: QAPI Tag No: A0263
Based on record review, observation and interview, it was determined the facility failed to ensure it maintained an effective and on-going Quality Assessment and Performance Improvement (QAPI) program that involved all hospital departments including contracted services and focused on improved outcomes in the delivery of care and in the prevention of adverse patient events. The failure by the facility to recognize the need for improvement in care areas resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in an IMMEDIATE JEOPARDY and at risk for serious injuries and/or death.

The findings included:

1. The facility failed to ensure the QAPI committee analyzed adverse patient events and the care associated with the events in order to implement preventative actions and mechanisms to ensure the event would not re-occur.
Refer to A-0286
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on facility policy, record review and interview, it was determined the Quality Assessment Performance Improvement (QAPI) committee failed to ensure an ongoing hospital-wide program that identified, addressed and analyzed all contributing causes related to adverse events resulting in serious injuries for 1 of 1 (Patient #1) sampled patients who received serious injuries related to an adverse event. The failure of the QAPI committee to identify adverse patient events and analyze the causes resulted in the facility's failure to implement corrective actions to ensure these events did not reoccur, this resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and/or death.

The findings included:

1. Medical record review for Patient #1 revealed the patient presented to the emergency department (ED) on 6/10/13 at 13:59 per emergency medical services (EMS) with the diagnosis of Suicidal Ideations. The patient stated he lived alone, was lonely and had threatened to shoot himself. The patient was assessed as a Level 2 suicide threat and the need for continuous visual surveillance. The patient was placed in ED room #7, a seclusion room. At 20:00 the ED MD documented the patient was to be involuntarily admitted to an inpatient psychiatric facility.

2. Observation of the hospital's video recording of the seclusion with Patient #1 revealed at approximately 23:44 the patient was slapping on the door with open hands and loudly asking why he couldn't go home. MD #2 was observed entering the seclusion room and saying in a loud voice to the patient, "Congratulations, you gonna go to jail." MD #2 and a security guard were then seen forcefully restraining the patient against the wall causing the patient's head to bump the wall. MD #2 and the security guard let the patient free and walked out of the room.

The video recording revealed on 6/11/13 at approximately 01:57 the patient was again slapping the door with open hands and asking to go home. The security guard was observed opening the seclusion room door, stood in the doorway, and the patient attempted to go around the security guard and out the door. The security guard grabbed the patient, forcefully pushed the patient, causing the patient to bolt in the air and landing with his head hitting the base board of the wall. The patient was observed to be motionless laying supine on the floor. The security guard then grabbed the patient's left arm and drug the patient across the floor. RN #1 and RN # 2 both entered the room, stood beside the patient and never performed an assessment of the patient. A 4 x (by) 4 was held to the patient's head laceration for approximately 10 -15 seconds by RN #2 and then she left the 4 x 4 on the patient's head and left the room. There was no observation of any other care or treatment performed by the 2 RNs. MD #2 entered the room and bent down beside the patient, who remained on the floor, and applied a cervical collar around the patient's neck. The patient was transferred onto a back board but was strapped securely on the board.

The patient sustained cervical fractures of the neck and a laceration to the head. The patient had to be emergently transferred to a higher level care hospital.

3. The hospital's investigation determined the only cause of the incident was the security guard. The only intervention the hospital had taken was to request that the security guard not be allowed to come back to the hospital.

There was no documentation the QAPI committee had intervened and analyzed the adverse event that led to the patient's serious injury, or an investigation into the physical assault by the MD and security guard. There was no documentation the QAPI had analyzed or reviewed the care provided by the ED RN staff in order to determine if appropriate care and services had been provided. There was no documentation QAPI had implemented measures to ensure the adverse events were corrected and would not re-occur.

4. An interview was conducted on 8/28/13 at 13:20 with Hospital #1's CQO, CNO, EDD and Risk Manager (RM). They were asked to identify all problems that were identified and interventions implemented as a result of the events with Patient #1. The RM stated, "No one saw the event occur...We called the Security Company and asked to not send that security guard back...The security guards are not supposed to touch the patients...We started the investigation...We did not know there was a video of the incident until Friday [6/14/13]. We are changing security companies effective 9/15/13. We developed a power point to address as an in-service...to be done this week...We have a Code White system in place [in place prior to the incidents]..." During this interview the CQO and RM both agreed and verified the only problem identified during this investigation was "the security guard."

After these interviews Hospital #1 was informed by the surveyor there were concerns related to the security guard being the only problem identified, the lack of interventions implemented with the incidents that occurred with Patient #1 which had occurred over two and a half months prior to the surveyor investigation. The RM then stated, "We do have a concern" related to how MD #2 handled the situation with the patient. The CQO then stated they were unable to provide any documentation and "We will go ahead and start some in-servicing for the staff." The CNO stated the video camera doesn't provide a "good view" of what is actually occurring.

During an interview on 8/28/13 at 16:30 the CQO stated the incident was not identified as abuse because there was no "willful" intent.

During an interview on 8/29/13 at 7:50 AM when asked for the root cause analysis and corrective action plans for the incidents the CQO stated, "but we have given you all the information and what we gleamed from the investigation."

During an interview on 8/29/13 at 08:30 the CQO stated any problems identified with restraint/seclusion is reported to the Medical committee on a "Quarterly" basis.
Refer to A115, A144, A145, A164
VIOLATION: NURSING SERVICES Tag No: A0385
Based on policy review, record review, observation and interview, it was determined nursing services failed to perform appropriate assessments and provide necessary stabilization and care for 1 of 1 (Patient #1) sampled patients who sustained an injury in the hospital ED. The failure of nursing to perform assessments and provide appropriate nursing interventions resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in an IMMEDIATE JEOPARDY and at risk for serious injuries and/or death.

The findings included.

1. Nursing services failed to perform appropriate assessments of patient's needs and provide appropriate interventions and care in order to stabilize patients who had sustained a serious injury form an adverse event which occurred in the hospital environment.
Refer to A 0392
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on facility policy, record review, observation and interview, it was determined nursing services failed to provide appropriate interventions, perform assessments and provide timely stabilization to patients who had suffered from a fall resulting in a head injury while in the emergency department (ED) for 1 of 1 (Patient #1) sampled patient that received a serious injury in the ED. The failure of nursing services to provide assessments, interventions and stabilization resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and/or death.

The findings included:

1. Review of the facility's "Suicide Risk Assessment and Interventions in a Non-Behavioral Health Setting" policy documented, "...All patients...will receive an initial assessment to determine suicide risk...to identify patients at risk for suicide and provide safety interventions...Suicidal Ideation...If de-escalation techniques are ineffective, patient will be escalated to Acuity 1..." The policy designated the Registered Nurse (RN) would "...identify the appropriate acuity...that correlates with the HIGHEST level of observed or reported factors...From highest acuity (Acuity 1) to lowest-acuity (Acuity 5)...Selection of the applicable acuity box identifies the interventions that are being implemented...The level of suicide risk and need for suicide precautions must be reassessed by the qualified medical provider or Registered Nurse if there is an observed or stated change in behavior...Use verbal de-escalation techniques for the agitated patient Orient the patient; tell them who you are. Emphasize you want to keep them safe, you won't let any harm come to them, and you will help them gain control...Use positive reinforcements and listen...Communicate in an empathetic and concerned way...Be non-provocative, do not argue...Demonstrate a calm demeanor, voice and facial expression...Relaxed stance, hands open, normal eye contact...position self at 1 - 2 times arm length from patient (approximately 2 - 4 feet)...Consider the safety of yourself and patient when determining appropriate distance and adjust accordingly to individual situation... if unable to de-escalate may require restraint or seclusion, high risk for eloping and not waiting for treatment and/or reported attempt to self-harm ...and unable to wait safely. LEVEL OF SUPERVISION: Continuous visual surveillance..."

Review of the facility's "Patient Fall Prevention" policy documented, "...a fall is defined as...Any observed fall of a patient from one surface level to another...Assessment of the Fallen Patient...The RN will assess the patient for obvious injury...The RN will document fall, the post fall nursing assessment..."

2. Medical Record review for Patient #1 revealed the patient was transported via emergency medical services (EMS) to the emergency department (ED) at Hospital #1 on 6/10/13 at 13:59 with the diagnosis of Suicidal Ideation.

Review of the ED nurses notes dated 6/10/13 from 1411 - 2251 revealed the patient was in a seclusion room in the ED. There was no documentation the patient had experienced behaviors. On 6/11/13 at 2350 the nurse documented the patient began yelling and slamming the door of the seclusion room. There was no documentation the nurse used de-escalation techniques or attempted to calm the patient. At 0207 the nurse documented the patient was, "beating the door and yelling." There was no documentation the nurse used de-escalation techniques or attempted to calm the patient.

3. Observation of the video recordings of Patient #1 in the ED at Hospital #1 on 6/10/13 at approximately 11:40 PM the patient was standing at the seclusion room door, looking through the window. The patient started slapping the door with his open hands, pointed out through the window and was asking why he couldn't go home.
There was no documentation the nursing staff assessed the patient, attempted to calm the patient or use de-escalation techniques.

Observations of a hospital video recording dated 6/11/13 at 01:58 revealed the hospital security guard entered the seclusion room of Patient #1. The security guard grabbed the patient and forcefully pushed the patient backwards, causing the patient to bolt thru the air and hitting his head against the wall and baseboard. A pool of blood was observed around the patient's head. The patient was observed to be unattended as RN #1 and RN #2 walked in and out of the seclusion room without performing assessments of the patient and providing nursing interventions. There was no observation RN #1 and RN #2 stabilized the patient's back, neck or spine immediately following the incident.

4. Review of the CT scan dated 6/11/13 at 02:20 revealed the patient had suffered a fractured cervical spine as a result of the incident.

5. During an interview on 8/28/13 at 4:00 PM the Director of Information Systems (DIS) stated there were hours of video that was recorded on Patient #1 and that he had watched all of the videos. The DIS stated between 19:53 until the incident occurred at 23:44 incident there was no observations of nursing providing care to Patient #1 during that time. Review of the nursing documentation reflected that nursing care was provided during that time.

During an interview on 8/28/13 at 8:00 PM RN #1 stated Patient #1 arrived by ambulance and was "cooperative...as the night went on he became more agitated...The door to his room was not locked when I arrived to work...There was no one sitting in front of the monitor all the time..."
When questioned about the first incident that occurred at 11:44 PM the nurse stated, "...he started beating on the door and yelling...The doctor told me not to go to the door by myself...I do not know why he [MD#2] went in [the room]..."
When questioned about the second incident at 1:58 AM the nurse stated, "...I was behind the nurse's station. I couldn't see the patient at that time. I saw the patient trying to get out the door. The security guard's hands went up. I don't know why he [security guard] went in there..."
RN #1 stated, "No one ever called a Code White...Sometimes people respond better to someone in a uniform. They're [security guards] not supposed to push or hold...The [County Police name] are called when we can't handle it..." RN #1 stated, "I never moved him to a different level [higher], to move to a Level 1 you have to have an attempt [suicide]..."

During an interview on 8/28/13 at 8:30 PM RN #2 stated Patient #1 did "a lot of yelling, he was agitated." The RN stated that there was "no one to help her [RN#2] watch him...I saw him lying down...he was agitated, it came and went..."
RN #2 was asked if they have someone assigned to watch the monitors when there was someone locked in the seclusion room. RN #2 stated, "...On nights we don't have that, No...even security have to make rounds [leave to make hospital rounds]..."
RN #2 was asked if she called a Code White. RN #2 stated, "I've never heard of a Code White..." RN #2 stated there are "3 nurses until 11:00 PM and 2 after 11:00 PM."

During a telephone interview on 9/4/13 at 3:30 PM RN #3 stated, "...He [Patient #1] had some aggressive behaviors, because he wanted to go home. I saw the guard put his hands up and then I saw [Patient #1's name] on the floor. [Patient #1's name] didn't know what happened, he just asked, what had happened...The doctor directed the care, he was at the nursing station and said to do cervical stabilization, back board and get him to CT."

Refer to A-0115, A-0144, A-0145, A-0164