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.

RUTLAND REGIONAL MEDICAL CENTER 160 ALLEN ST RUTLAND, VT 05701 May 11, 2011
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on staff interview and record review, the hospital failed to ensure a policy for the potential use of weapons to include pepper foam and handcuffs were not intended for use on patients by security staff. Findings include:

1. Per telephone interview on 5/10/11 at 4:40 PM the Manager for Security and Safety confirmed security staff are authorized to carry pepper foam and handcuffs, describing them as law enforcement tools. S/he further stated they would not be used on patients but may be used during a violent act on the hospital premises involving individuals who are not patients and where a person's safety was in jeopardy. S/he further acknowledged any potential use would also require immediate contact with law enforcement requesting emergency assistance. However, per review of the hospital policy Authority of the Security Department effective 1/96 and Oleo-Capsicum , effective 10/95, the circumstances for use does not exclude their use on patients, which is prohibited by federal regulation.

Further review of the policy and CMS regulations were discussed on 5/11/11 at 11:35 AM with the Vice President of Support Services who confirmed the policy did not protect patients from the potential use of pepper foam by security guards and confirmed use of such weapons is a law enforcement action not a healthcare intervention.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and staff interview, the hospital failed to ensure that staff consistently implemented the Event Reporting policy and failed to ensure that an adverse patient event was effectively analyzed for causes and preventive actions and mechanisms were initiated to ensure a patient on 1:1 observations is monitored appropriately and medications are properly administered to patients for 1 of 10 applicable patients. ( Patient #2) Findings include:

1. Per record review, Patient #2 was admitted to the Psychiatric Services Inpatient Unit (PSIU) on 11/06/10 with a diagnosis of suicidal ideation with a history of suicide attempts. On 11/7/10 a psychiatrist ordered Patient #2 to be on 1:1 supervision at 1420 and further added 1:1 with staff at 1550 after being allowed out of seclusion following an assault and threatening incident. Per 'Patient Chart Summary Report' for 11/08/10 entered at 2216 "....Patient has continuous 1:1 supervision. Patient mood labile and affect depressed. Patient is medication compliant. Patient was given bedtime medications and then was in the bathroom for a long time. Staff found (Patient #2) with some pills crushed on sink attempting to snort them.....". Per interview on 4/19/11 at 11:15 AM the PSIU nurse manager confirmed 1:1 supervision means 1:1 observation. Per review of the hospital policy Levels of Observation last approved 1/7/11, addresses 3 levels of observation to include: Intermittent (every 15 minutes); Constant (patient must be in constant view of staff unless attending psychiatrist writes an order to modify this, such as when a patient is using the rest room; and Highest level (Patient must be in constant view of the staff, staff will accompany patient when the patient needs to use the rest room and staff must be an arms length of patient at all times). The psychiatrist had not specified the patient should not be in constant view, even while in the bathroom nor had the nurses verified the exact level ordered by the psychiatrist and if there were exceptions to the constant 1:1 observation for Patient #2.

Per telephone interview on 4/20/11 at 11:25 AM the Nursing Director for PSIU confirmed s/he had reviewed the adverse event report regarding Patient #2 and at that time felt staff had an awareness of the differences in observations. However, the Nursing Director of PSIU was unable to provide an explanation how Patient #2 who is on 1:1 continuous observation (who has a history of snorting Clonazepan) was able to confiscate medication and proceed to go into their bathroom, spend time crushing medications and then attempting to snort the medications while under constant 1:1 observation. Additional interview with the Nursing Director, on 5/9/11 at 2:15 PM, confirmed although s/he had discussed the incident with the nurse in charge who had documented the event on 11/08/10, s/he failed to interview the nurse responsible for the 1:1 constant observation on 11/08/10 to ensure this nurse understood their responsibilities when providing 1:1 observation on PSIU. Until the concerns regarding the incident were brought to the attention of PSIU staff, by the surveyor, on 4/19/11, there was no further follow up to ensure compliance by staff regarding the policy and procedure for levels of observation; assurance nurses are maintaining standards of practice when administering medications to patients on PSIU or review of the policy and expectations of the psychiatrists on staff who are ordering 1:1 observations.

Per interview on the morning of 5/10/11, the Director of Performance Improvement confirmed there is a process by the Performance Improvement staff to triage and review all adverse patient events. The Director confirmed that, although contact was made with the PSIU Nursing Director, no further analysis of the cause of the event was conducted by Performance Improvement staff. As a result, neither department recognized the need for corrective action to ensure the safety of the patients, staff compliance with policies and procedures and verification of proper medication administration to patients on PSIU.

2. Per record review staff failed to complete an Event Report following an incident where Patient #9, who had a history of self harming behavior, had used a plastic eating utensil in an attempt to self harm. A nurse's note, dated 5/4/11 at 5:06 PM stated that patient #9, "has superficial laceration on left wrist which (patient) admitted was self inflicted with plastic knife....." A subsequent nurse's note, dated 10/4/11 at 9:50 PM, stated that at approximately 3:30 PM on that date the patient had been "yelling, crying, appears angry ....cut left wrist with plastic knife. Stated ...........told me to kill myself so I tried to do it......" The note further revealed that the patient was hitting self in the head with his/her hands with much force, and was verbalizing suicidal ideation. Although the note indicated that the Charge nurse and MD had been notified of the incident there was no evidence that an Event Report had been completed in accordance with the facility's Event Reporting policy,which stated: Event reporting is an important part of the organization's patient safety program, the reports are used to identify events and situations that have the potential to cause patient harm and by "helping to identify these risks, the hospital has the opportunity to improve patient safety within the organization." During interview, at 9:37 AM on 5/10/11, the Director of Performance Improvement confirmed an Event Report had not been completed regarding this incident and further stated that if there had been a report it would have been reviewed to determine the risk level and, because it was an incident of self injury, they "would have opened that up." The Nurse Manager of the unit on which Resident #9 resided at the time of the incident, stated, during interview at 3:00 PM on 5/10/11, that Event Reports "should be completed by whoever was directly involved in the incident", and confirmed that an Event report had not been completed. The RN who had been present and identified Resident #9's injury at the time of the incident on 5/4/11 stated, during the 5/10/11 3:00 PM interview, that s/he had not completed an Event Report.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on staff interview and record review, Emergency Department nursing staff failed to document the implementation of suicide precautions and the continued use of restraints for 1 applicable patient who expressed suicidal ideation. ( Patient #2 ) Findings include:

Per record review, Patient #2 was brought to the Emergency Department (ED) on 11/5/10 at 2155 escorted by the Vermont State Police and accompanied by the patient's mother with a chief complaint of suicidal and homicidal ideation. Patient #2 reported to the Crisis Screener s/he became upset at home due to unstable living situations and "...grabbed a belt and threatened to hang her/himself........also took a kitchen knife from the drawer and put it to her/his wrist, and threatened to cut her/himself." The patient informed the screener "If she (the mother) did not take the belt and knife away, I would be dead". The patient would not contract for their own safety. The patient has a past history of suicide attempts.

Per review of Suicide Risk Screening and Precaution Policy approved 12/6/09, ED staff are required to immediately implement suicide precautions when a patient presents with a chief complaint of suicidal ideation. The nurse is expected to assess the physical environment for all patients who require the initiation of suicide precautions to ensure all "...identifiable environmental risks have been addressed." To reduce self -harm, the nurse would need to make modifications to the environment if necessary; all patient possessions would be inspected for safety risk and then items would be removed and secured. The provision of adequate supervision would then be assigned to this patient, generally using hospital security staff. Per record review, Patient #2 was first placed in Triage room #2, a room equipped with medical equipment providing a potentially unsafe environment for a patient with suicidal ideation. The nurse failed to document whether any modifications were made to the room prior to Patient #2 being assigned to the room nor was their evidence possessions were inspected and the patient's clothing removed with the option of the patient wearing a hospital gown.

At 0602 on 11/6/10 Patient #2, whose room was changed to a more secure observation area, became aggressive and violent throwing furniture and causing physical damage to walls. Bilateral wrist and ankle restraints were applied and emergency medications to include Haldol 5 mg IM (intramuscular) and Ativan 2 mg. IM were administered. Per review the Violent and Self-Destructive Restraint and/or Seclusion Doctor's order and Daily Record nursing documentation identified the initiation of restraints but does not include when the restraints were removed nor does the 'Continuation Nurses Note' document removal and/or ongoing monitoring of their use. Per interview on 5/9/11 at 3:35 PM, the ED nurse manager confirmed "..of course you would expect to see documentation " specific to the provision of care related to the use of restraints that were applied to Patient #2.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on staff interview and record review, the hospital failed to provide care in a safe setting for 1 applicable patient who required continuous 1:1 supervision. (Patient #2) Findings include:

1. Per record review, Patient #2 was admitted to the Psychiatric Services Inpatient Unit (PSIU) on 11/06/10 with a diagnosis of suicidal ideation with a history of suicide attempts. On 11/7/10 a psychiatrist ordered Patient #2 to be on 1:1 supervision at 1420 and further added 1:1 with staff at 1550 after being allowed out of seclusion following an assault and threatening incident. Per 'Patient Chart Summary Report' for 11/08/10 entered at 2216 "....Patient has continuous 1:1 supervision. Patient mood labile and affect depressed. Patient is medication compliant. Patient was given bedtime medications and then was in the bathroom for a long time. Staff found (Patient #2) with some pills crushed on sink attempting to snort them.....". Per interview on 4/19/11 at 11:15 AM the PSIU nurse manager confirmed 1:1 supervision means 1:1 observation. Per review of the hospital policy Levels of Observation last approved 1/7/11, addresses 3 levels of observation to include: Intermittent (every 15 minutes); Constant (patient must be in constant view of staff unless attending psychiatrist writes an order to modify this, such as when a patient is using the rest room; and Highest level (Patient must be in constant view of the staff, staff will accompany patient when the patient needs to use the rest room and staff must be an arms length of patient at all times). The psychiatrist had not specified the patient should not be in constant view, even while in the bathroom nor had the nurses verified the exact level ordered by the psychiatrist and if there were exceptions to the constant 1:1 observation for Patient #2.

Per telephone interview on 4/20/11 at 11:25 AM, the Nursing Director of PSIU was unable to provide an explanation how Patient #2 who is on 1:1 continuous observation (who has a history of snorting Clonazepan) was able to confiscate medication and proceed to go into their bathroom, spend time crushing medications and then attempting to snort the medications while under constant 1:1 observation. Until the concerns regarding the incident were brought to the attention of PSIU staff, by the surveyor, on 4/19/11, there was no further follow up to ensure care in a safe setting was maintained to include: compliance by staff regarding the policy and procedure for levels of observation; assurance nurses are maintaining standards of practice when administering medications to patients on PSIU; and/or review of the policy and expectations of the psychiatrists on staff who are ordering 1:1 observations.