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HARRIS HEALTH SYSTEM 2525 HOLLY HALL HOUSTON, TX 77054 Feb. 16, 2017
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on observation, interview, and record review, the facility failed to investigate an allegation of abuse per its policy.

(citing Patient # 1 )

Findings include:

TX 493

Record review of complaint intake # TX 493 revealed allegations that Patient # 1 arrived at the facility via ambulance on 10-18-16 at approximately 2 a.m. Allegations included "nurses took multiple ammonia inhalants and placed them into a 30 cubic centimeter (cc) syringe, inserted into the patient's nares (nostrils) , causing him to become violently combative and confused..." .

During an interview on 02-16-17 at 9:30 a.m. with Registered Nurse (RN) # 9 she stated she was the charge nurse in ER the night (10-18-16) Patient # 1 was brought in by ambulance.

She went on to say the Emergency Medical Technician (EMT) who brought the patient in, came to talk with her that night. "The EMT told me: 'a nurse had put a bunch of the ammonia ampules through a syringe and this was not appropriate.' He said the patient was calm when he was brought in then became agitated after the ammonia. He said they used excessive ammonia caps." RN # 9 went on to say when something like that happened at night "we usually just send the ER Director an email, which I did". She said she did not complete an incident report or notify anyone of the allegations.

Record review of facility "Multiple Issues Feedback" form revealed the following documentation:

1. Documentation of a telephone call received 10-18-16 (2:09 p.m.) from a Houston Fire Department (HPD) firefighter "called to file a patient right/abuse complaint..He turned over a patient last night and witnessed what he states was 'patient abuse' from our staff members. He would like to speak to our Patient Rights Officer to discuss what he witnessed..."

2. Documentation dated 10-18-16 (4:35 p.m.) by Patient Advocate # 11 read: "...Houston firefighter called to complain about what he observed and categorized as "patient abuse". Documentation included a detailed description of techniques used by the Triage nurse and other nurses to elicit a response from Patient # 1, including "sternum rub..trap squeeze... little twister" and pressure on patient's cuticle bed. In addition there was an allegation "the nurses took 5 ammonia inhalants and put them in a syringe and put it in the patient's nose. The patient became combative and agitated."

3. "Follow-up" documentation dated 11-10-16 (11:39 a.m.) by ER Director # 3 revealed a synopsis of the techniques used to arouse Patient # 1, including 'noxious stimulation with ammonia'. "These techniques were all acceptable according to the literature." ER Director documented the medic was upset about his wait time...he eventually unloaded the unresponsive patient to the floor..."

During an interview on 02-16-17 at 2:00 p.m. with ER Director # 3 she reported she did not take witness statements from the staff or view the surveillance video from the Triage hallway for the date of the alleged abuse. She stated when there was an allegation of abuse, Risk took over the investigation. She went on to say the Charge Nurse should have entered an incident report when the EMT made the allegation of abuse. The ER Director said the Triage nurse completed an incident report concerning actions by the EMT. In this incident report, she documented the different techniques used on Patient # 1 , including the ammonia inhalants in the syringe.

During an interview on 02-16-17 at 3:00 p.m. with Director Risk Management/Patient Safety # 12, she stated when there was an allegation of abuse, there was a collaborative investigation: risk and the department director. The department director conducted preliminary interviews, etc. The Patient Safety Director coordinated and ensured the investigation had been completed. He was responsible for checking for attachments related to the investigation, including witness statements, etc....She said in reviewing this complaint, there was no attached investigation.

During a telephone interview on 03-01-17 at 12:53 pm. with Director of Accreditation & Regulatory Affairs # 2 she stated the "facility Abuse & Neglect policy has a clearly established process for persons to be notified when an allegation of abuse was made; that did not happen in this case. If the process had been followed, a proper investigation would have been initiated".

Record review of facility policy titled " Abuse, Neglect, and Exploitation of Patients Occurring at Harris Health System Facilities",dated 01/1998, read: "...B. Identification of Allegations Requiring Investigation and Reporting...2 Reports of abuse, neglect of a patient shall be entered into Harris Health's electronic incident reporting system and shall be made to the immediate supervisor...C. 1. Upon identification of a suspicion of abuse, neglect, the following shall be notified immediately: a. Immediate supervisor ...if the most immediate supervisor is not available, escalate notification to one of the following individuals: 1. Unit director, 11. Hospital supervisor, etc...2. When the alleged perpetrator named by the...visitor in the allegation is a Staff member, that Staff member shall be removed immediately from direct patient care or from the area where the patient is located...3. g. Risk Management Department shall provide review, oversight, and coordination of the investigative process..."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview and record review, the facility failed to ensure medication was administered in a safe manner to Patient # 1.

Nursing supervision failed to ensure a "Adverse Drug Event" form was completed after becoming aware that ammonia inhalants were administered via a syringe to Patient # 1.

Nursing supervision failed to investigate the scope of Emergency Center (EC) nursing practice of administering ammonia inhalants via a syringe & implement possible preventative measures.

Findings include:

TX 493

Record review of complaint intake # TX 493 revealed allegations that Patient # 1 arrived at facility via ambulance on 10-18-16 at approximately 2 a.m. Allegations included "nurses took multiple ammonia inhalants and placed them into a 30 cubic centimeter (cc) syringe, inserted into the patient's nares ( nostrils) , causing him to become violently combative and confused...".

Review of manufacturer's label for "Ammonia Inhalant, aeromatic, 0.3 milliliter (ml) ampule" , read: Warnings: For external use only..Directions: Hold inhalant away from face and crush between thumb and forefinger. Carefully approach crushed inhalant to nostrils of affected person. "

During a telephone interview on 03-01-17 at 4:30 pm with Emergency Center (EC) Pharmacist # 14, she stated based on her research and experience , "administering ammonia inhalants via a syringe was not something she would recommend". EC Pharmacist # 14 acknowledged there was a glass ampule inside the inhalant. She went on to say she was unaware that nurses in the EC were administering ammonia inhalants in this manner.

During a telephone interview on 03-01-2017 at Noon with Triage Registered Nurse (RN) # 13, she reported she remembered Patient # 1 who came by ambulance on 10-18-16. "The police had found this patient semi-responsive on the street and called Emergency Medical Services (EMS) to bring him in. My main concern was trying to get this patient to respond. If we could get some information from him and get him to respond, he might have been able to wait in the waiting room..".

Triage RN # 13 said the charge nurse informed her that night of the EMS's concerns. She said "yes, the paramedic's main concern was the ammonia. He wanted our protocol for administering ammonia. We don't have a protocol but it is a common item to use in the ER." Triage RN # 13 stated the ammonia inhalant was administered either "under the nose or in a syringe." The syringe method involved "getting some inhalants and placing them in a 30 cubic centimeter (cc) syringe and directing them up toward the nares and injecting." RN # 13 said the number of inhalants placed in the syringe would depend upon how many the ER staff retrieved from the box.

She said she used both methods (under the nose and syringe) on Patient # 1 in the ER on 10-18-16. RN # 13 said she "used multiple ammonia inhalants in the syringe on Patient # 1 ...more than one but less than 4." She went on to say "not all current ER nurses at the hospital administered ammonia inhalants via a syringe; some do; some do not". Triage RN # 13 stated no one from the hospital discussed this patient or issue with her other than the charge nurse on the night the paramedic was upset.

During an interview on 02-16-17 at 9:30 a.m. with RN # 9 she stated she was the Charge Nurse in ER the night Patient # 1 was brought in.

She went on to say the Houston Fire Department (HFD) EMT came to talk with her. He informed her 'the nurse had put a bunch of the ammonia ampules through a syringe. He said this was not appropriate.' He said "the patent was calm when he was brought in then became agitated after the ammonia. He said they used excessive ammonia caps.' "I told him I would talk with the Triage nurse."

Charge Nurse RN # 9 said she spoke with Triage RN # 13 that night. The Triage nurse admitted she administered the ammonia inhalants through the syringe. The Charge Nurse stated she did not complete an incident report; "at nights, we usually just send the ER Director an email, which I did".

During an interview on 02-16-17 at 2:00 p.m. with EC Director # 3 she stated she was aware the Triage Nurse # 13 had administered ammonia inhalants via a syringe to Patient # 1 on 10-18-16. She went on to say this was not an acceptable practice. EC Director said she had not counseled the Triage Nurse, as she had relocated to a sister hospital. In addition, she said that Risk took over the investigation; she was unsure of the outcome or the actions taken. She further reported the incident with Patient # 1 was discussed informally with the staff. She did not interview other EC nurses or provide formal in-services.

Interviews on 02-16-17 between 9:30 and 10:30 a.m. with four (4) current EC nurses ( RNs # 4, #5, # 6, # 7) revealed 4 of 4 stated no one from EC or pharmacy had spoken with them about the practice of the administration of ammonia inhalants via a syringe.

Record review of facility policy titled "Medication Administration", dated 01/2004, read: "Policy Statement: It is the policy of Harris Health System through the implementation of the measures outlined, to ensure accuracy during medication administration and enhance patient safety...G. medications shall be administered utilizing the "eight rights: 1. Right Drug ; 2. Right Dose ; 3. Right Route; 4. Right Time; 5. Right Patient; 6. Right Reason; 7. Right Documentation; and 8. Right Assessment for administration and response to medication. H. Medications administered contrary to any of the first five 'rights' ( G1-G5 above) shall be documented exactly as administered to the patient and an Adverse Drug Event Form completed..."