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CHRISTUS GOOD SHEPHERD MEDICAL CENTER- LONGVIEW 700 EAST MARSHALL AVENUE LONGVIEW, TX 75601 April 4, 2013
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on documentation and interview the facility failed to protect 1 of 1 patient's from abuse during assessment in the Emergency Department.

On 4/4/2013 in the conference room the Medical Record for Patient #1 was reviewed and revealed the following documentation taken from the nurses notes. 3/14/2013 20:05 hours. Psychological Assessment: "Psych precautions taken including patient placed in closest available room to the nurses station, patient placed in a snap gown, ..."

On 4/4/2013 at 10:00 AM, in the conference room, the Director of the Emergency Department (ED) was interviewed regarding the privacy of a patient, brought in on an Emergency Detention Warrant (EDW), when "Psych precautions" are implemented and a patient's clothing is removed to dress them in a "Snap gown". When asked, did the Police officers remain in the room during the undressing of this [AGE] year old female patient and the reply was "probably". Staff #4 continued by saying when patients are brought in (to the ED) in handcuffs and continue to show aggression, the police officer stayed with them. Continued questioning revealed no attempt to provide modesty for the female patient was made.

Further review of the MR for Pt#1, found in the physician's documentation, Patient #1 behavior was aggressive, angry, affect was animated, Patient had no thoughts to harm self or others. However, Nursing documentation revealed the patient was stripped of her personal clothing and placed in a snap gown for "psych precautions". The above interview implies this [AGE] year old female patient was fully exposed to police officers who remained in the room. No explanation was found to indicate the nature of Patient #1 combative or threatening behavior exhibited while in the ED. The time of arrival documented by nursing staff was 20:05. The time documented for Patient #1 to be placed in a snap gown was 20:05. No time was documented allowing patient #1 to calm herself before she was placed in a snap gown and having all her personal belongings removed from the room.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview the facility failed to insure the least restrictive restraints for 1 (#1) of 5 (#1-#5) patient identified.

On 4/4/2013 in the conference room the Medical Record (MR) for Patient #1 was reviewed and revealed the following: 3/14/2013 at 2005 hours, Nursing documentation reflected the following. "Patient brought in on Emergency Detention Warrant (EDW) for medical clearance to geri-psychiatric unit. Patient extremely agitated at this time. Combative prior to arrival. Patient #1 was unkempt, behavior was agitated, anxious, combative toward staff inappropriate for age and uncooperative".

Further review of Physician's documentation reflected the following: 3/14/2013 at 2016 hours, "this [AGE] year old black female presents to the ED (Emergency Department). Presents with persecutory delusions. Severity of symptoms, at the worst symptoms were severe, in the emergency department the symptoms are unchanged. Pt here on EDW reportedly already accepted to geri-psychiatric unit for psychosis/delusions/violent behavior. Pt arrived with handcuffs in place after being violent to police". Further review of the MR for Patient #1, found in the physician's documentation, "Patient #1 behavior was aggressive, angry, affect was animated, Patient had no thoughts to harm self or others".

Further review of physician's documentation reflected the following: 3/14/2013 at 2015 hours the physician recorded the following orders: "Ativan 2 mg (milligram) IM (Intramuscular) one time only and Geodon 10 mg IM one time only".

Review of Nursing documentation reflected the Ativan and Geodon were administered in left deltoid on 3/14/2013 at 20:20. Nursing documentation reflected at 21:02 Anxiety was improved after IM doses of Ativan and Geodon.

Review of Physician's documentation reflected an order for Restraint up to 4 hours. (There was no documentation why the restraint was ordered after administration of Ativan and Geodon IM)

Review of the Nursing documentation reflected an order dated 3/14/2013 for restraint, was initiated at 21:19, however the Nurses notes reflected that the Restraint order, leather wrist and leather ankle restraint and Restraint Application Assessment was conducted on 3/14/2013 at 20:30 hours, 49 minutes before the order was documented as given by the physician.. The Restraint Application Assessment documented the following clinical justification support the decision for use of restraint: "Patient is at risk for harm to self and others. Patients behavior disrupts the environment so that treatment can not take place". Behaviors are listed as agitation, combative behavior that interfere with treatment. Alternate interventions listed were, "medications were given". (Ativan and Geodon).

Further review of the MR revealed the Ativan and Geodon were given IM at 20:20 only 10 minute before leather wrist and ankle restraints were applied. There was no descriptive documentation of combative or agitated behaviors continuing after the use of IM medication to calm this [AGE] year old patient.

Further review of the every 15 minute assessment documented in the nurses assessment reflects the following. Restraint were initiated at 20:30 hours. "Patient #1 continues restless" at 20:45 and "is agitated and restless" at 21:00. At 21:19 the patient was restless and from 21:30 through 21:45 nursing documentation reflected the patient was "asleep". At 22:04 the MR documentation reflected the patient was transferred "upstairs to the psychiatric unit" There was not documentation patient was awake. There was no documentation the patient was released from restraint or how the patient was transferred to the psychiatric unit.

On 4/4/2013 in the conference room and interview with staff #2 confirmed the nursing documentation did not describe how the patient left the ED, if the patient was awake and went by wheel chair or if the patient remained asleep and restrained and was transported via the bed.

Staff #2 was questioned as to whether she felt the staff released Patient #1 from the wrist and ankle restraint once she fell asleep and she responded "Probably not".

Pt #1 was restrained with both Ativan and Geodon administered IM and leather wrist and ankle restraint for at least 30 minutes while asleep. Documentation indicated Patient #1 was asleep, secondary to IM medication and mechanically restrained to both her wrist and ankles at the time of transport from the ED to the Psychiatric unit.