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.

HIGHLINE MEDICAL CENTER 16251 SYLVESTER ROAD SW BURIEN, WA 98166 Nov. 4, 2011
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on interview and review of medical records, it was determined that the hospital failed to ensure that all restraints and/or seclusion was utilized only after less restrictive interventions had been determined ineffective to protect the patient, or others, from harm. The hospital's failure to do so placed all ED patients at risk for restraint and/or seclusion when less intrusive or harmful interventions may have been effective.

See citation written at Tag A0144
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on interview and review of medical records, it was determined that the hospital failed to ensure that all patients in restraints and/or seclusion were released from restraints and/or seclusion at the earliest possible time. The hospital's failure to do so resulted in 3 of 3 ED patients who were identified as having been restrained and/or secluded, not having documented evidence that they were released at the earliest possible time, and potentially placed all ED patients who were restrained and/or secluded, at risk for the same.

Reference citation written at Tag A0144
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of the hospital's policies and procedures, document review, and interview, it was determined that the hospital's governing body failed to ensure that the rights of all patients in the hospital's Emergency Department (ED) were protected.

The cumulative effect of these systemic problems resulted in the governing body failing to ensure that the rights of all patients in the hospital, and specifically the ED, were protected.

Reference citation written under Tag A 0084

Reference citation written under Condition of Participation Patients' Rights, Tag A - 0115
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on interview and review of credentialing files, it was determined that the governing body failed to ensure that all services performed under a contract were provided in a safe and effective manner. The hospital's failure to do so resulted in 4 of 4 physicians and 1 of 1 physician's assistants, who worked in the Emergency Department (ED), not having training and education regarding the safe and appropriate utilization of restraints and/or seclusion. The hospital's failure subsequently placed all patients in the ED at risk for unnecessary loss of freedom, privacy and dignity as well as physical harm from the unsafe and incorrect use of restraints.

Findings include:

The Chief Nursing Officer confirmed that all of the ED physicians and physicians' assistants were contracted with the hospital to provide medical staff services in the ED, and were not hospital employees.

Review of the hospital's policy "Restraint and Seclusion - Staff Training" revealed the following statements:

"Policy:
In accordance with Highline Medical Center's philosophy on restraint and seclusion which espouses the creation of an environment that minimizes circumstances that give rise to restraint and seclusion use and that maximizes safety when they are used, initial and ongoing education for direct care staff is heavily supported and provided.

-All Licensed Independent Physicians [as well as physicians' assistants per the Chief Nursing Officer] authorized to order restraints or seclusion by Highline Medical Center policy and in accordance with state law shall have, at a minimum, a working knowledge of hospital policy regarding the use of restraint and seclusion.
-All patients have the right to the safe implementation of restraint and/or seclusion by trained staff...


Staff Training:
Staff must have restraint and/or seclusion training and demonstrate competency before applying restraints, implementing seclusion, monitoring, assessing, and providing care for a patient in restraint and/or seclusion. The viewpoints of patients who have been restrained or secluded are included in staff education to help the staff understand all aspects of restraint and seclusion...annually, per hospital policy."

MD #1
MD #1 was interviewed on 11/2/2011. MD #1 was the physician who had provided care to Patient #1. The physician stated that s/he had not participated in the hospital's training regarding the safe and appropriate utilization of restraints because the hospital provided training for employees, the physicians were not employees of the hospital and the training was not required for the physicians in the ED group.

MD #1 stated that s/he had been board-certified in Internal Medicine and Emergency Medicine since 1975 and had been at the hospital for approximately 31 years. S/he stated s/he had received some training regarding the use of restraints as a resident, and had taken "courses over the years", but had no formal training relative to the use of restraints/seclusion, had no "hands on" training relative to the use of restraints/seclusion and had not received training relative to "how to assess and defuse [patients]".

When questioned about the use of restraints specific to Patient #1, the physician stated that s/he "...would do it again if [s/he] came in tonight."

Review of the physician's credentialing file, in the company of the Manager of Medical Staff Services, revealed no documentation of training or education relative to the safe and appropriate utilization of restraints/seclusion.

MD #2
MD #2, was interviewed on 11/2/2011, and was the Emergency Department Medical Director. MD #2 stated that s/he was board-certified in Emergency Medicine and had been at the hospital for approximately 7 years.

MD #2 stated that s/he had reviewed the hospital's new restraint policy [last update to the restraint/seclusion policy was 3/10/2010], but had not received any formal training relative to the safe and appropriate use of restraints/seclusion. MD #2 also stated that s/he was not familiar with the Medicare regulations specific to the utilization of restraints/seclusion, and was provided a copy of same.

MD #2 stated that the usual practice in the ED was for either no restraints or 4-point restraints; s/he also stated that if the same patient situation that had occurred with Patient #1 were to occur in the ED at the present time, the patient might have been placed in seclusion instead of restraints, but still might have been forcibly catheterized.

MD #2 stated that there had been no change in her/his utilization of restraints/seclusion since the events involving Patient #1, and s/he had not attended any education or training relative to the safe and appropriate use of restraints or seclusion.

Review of the physician's credentialing file, in the company of the Manager of Medical Staff Services, revealed no documentation of training or education relative to the safe and appropriate utilization of restraints/seclusion.

MD #3
MD #3 was an ED physician who was interviewed during a tour of the ED on 10/20/2011. The physician stated that restraint of patients in the ED would be utilized if the patient was a danger to themselves or others and a Posey [a brand of restraint] would usually be tried first. The physician also stated that there was not always enough staff to keep patients and staff safe.

Review of the physician's credentialing file, in the company of the Manager of Medical Staff Services, revealed no documentation of training or education relative to the safe and appropriate utilization of restraints/seclusion.

MD #4
MD #4 was a ED physician who was interviewed during a tour of the ED on 10/20/2011. The physician stated that s/he was unsure, given the scenario described for Patient #1, why less than 4-point restraints could not have been tried or utilized.

Review of the physician's credentialing file, in the company of the Manager of Medical Staff Services, revealed no documentation of training or education relative to the safe and appropriate utilization of restraints/seclusion.

Physicians' Assistant (PA)
The PA#1 was interviewed on 11/2/2011 and stated that he had been working at the hospital for 6 years and had been a Navy medic prior to that time. The PA#1 had been involved in the care of Patient #1, and had some recall of the patient and events in the ED on the night of 9/23/2009.

PA#1 stated that s/he recalled that the patient had been "...uncooperative, loud, screaming...". Review of the medical record revealed that the patient had been evaluated and transported to the ED by EMS services who documented that the patient "...moves all extremities with purpose unable to stand r/o [rule out] intoxication".

PA#1 stated that when the patient arrived in the ED, s/he had been asked to go into the bathroom and provide a urine specimen, but had instead, gone into the bathroom and locked the bathroom door. PA#1 stated that when the bathroom door was eventually opened, the patient had thrown the urine specimen at the staff and subsequently been placed in 4-point restraints for the safety of the staff and other patients in the ED, and forcibly catheterized for the urine specimen.

Review of the medical record for Patient #1 revealed that the "Emergency Physician Record", signed by MD#1, noted that the patient had been admitted for "altered mental status" and "intoxication". Further review of the medical record revealed a physician's order for a "tox" screen, which staff reported was understood to be a clean catch [patient urinates into a cup] urine specimen, to be analyzed for the presence of toxic substances.

When asked to describe alternatives to restraints, PA#1 stated that s/he had seen 3-point restraints used in the ED on occasion, but not 2-point restraints due to safety concerns. The PA also stated that if patients were grossly impaired and would not "listen to the sitters", they might be restrained to make sure they did not fall.

PA#1 stated that s/he "could not recall" whether or not s/he had received any education or training relative to the safe and appropriate use of restraints/seclusion", but was sure that s/he had received no formal education or training regarding same since the incident involving Patient #1.

Review of the physician assistant's credentialing file, in the company of the Manager of Medical Staff Services, revealed no documentation of training or education relative to the safe and appropriate utilization of restraints/seclusion.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, review of medical records and document review, it was determined that the hospital failed to protect and promote each patient's rights.

The hospital failed to assure safe care to 8 of 12 ED patients by the following actions or omissions:

-Failure to assure that all restrained patients were not covered by sheets or blankets, so that the patient's physical condition could be easily ascertained

-Failure to develop and implement a policy and procedure to guide practice regarding when a patient should have a blood alcohol test drawn, and when a test for urine toxicity done

-Failure to develop and implement a policy and procedure to guide practice regarding obtaining urine specimens under forced conditions, such as while the patients were restrained

-Failure to develop and implement a policy and procedure to guide practice regarding physician/PA evaluation of laboratory results prior to patient discharge, and documentation of same

-Failure to assure that all restraints and/or seclusion were ordered by practitioners who had training in the safe and appropriate use of restraints
Reference citation at Tag A 084

-Failure to assure that all restraints and/or seclusion, were implemented and all patients assessed and monitored, by staff who had demonstrated current competencies.
Reference citation at Tag A 196

-Failure to assure that staff considered the least possible restrictive alternatives to restraints and/or seclusion
Reference citation at Tag A 064

-Failure to assure that all patients were released from restraints and/or seclusion at the earliest possible time
Reference citation at Tag A 174

On November 4, 2011, the survey team met with hospital leadership and identified that the hospital was in "Immediate Jeopardy" status with the Patients Rights Condition of Participation.

The hospital submitted a credible abatement plan and a revisit survey by the State Agency on November 8, 2011 confirmed that the immediacy was abated but the Condition of Participation was still Not Met.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview, review of policy and procedure and review of grievance files, it was determined that the hospital failed to provide 4 of 4 patients/complainants with complete written notice of its decision regarding a grievance. The hospital's failure to do so deprived patients of their rights to complete information regarding the processing of their grievances.

Findings include:

A list of grievances received by the hospital in August, September and October, 2011 was reviewed and 4 files were selected for review. All of the files selected contained grievances which pertained to patients who had received care in the hospital's Emergency Department (ED). Files were reviewed with the Director of Quality and Risk Management, who confirmed the investigator's findings.

Patient #13
Review of the file revealed that the hospital had received a complaint on 9/15/2011. The hospital's response letter to the complainant was dated 10/4/2011, and did not gives the steps taken to resolve the grievance, what the resolution was and the date the resolution was completed.

Patient # 14
Review of the file revealed that the hospital had received a complaint on 9/20/2011 and had sent an initial letter of acknowledgement to the complainant, which was dated 9/28/2010. The file did not contain a final letter of resolution.

Patient # 15
Review of the file revealed that the hospital had received a grievance on 8/8/11. The file contained a final letter to the complainant, dated 8/15/2011, which did not contain the steps taken to resolve the complaint, what the resolution was, when the complaint was resolved or who the complainant should contact with questions.

Patient # 16
Review of the file revealed that the hospital had received a complaint on 8/10/2011. An acknowledgement letter dated 8/26/11 was sent to the complainant, and another letter was sent on 8/29/11. The second letter appeared to be identical to the first, with the exception of a corrected typographical error. The initial letter(s) outlined the complainant's concerns; however, no final resolution letter was found in the file.

Review of the hospital's policy and procedure regarding the processing of grievances revealed the following directives:

"Procedure:
"5. Based on the findings of the investigation, the Director of Quality Services will notify the patient, in writing, within 7 days of receipt of the grievance of the outcome.
6. If the investigation is not able to be completed within 7 days, the patient will be notified in writing, including approximately when the outcome of the investigation will become available..."

Three (3) of 4 files did not have a response to the complainant that was consistent with the hospitals' policy for timelines and 4 of 4 files either had an incomplete resolution letter to the complainant or were missing the resolution letter. The policy and procedure did not include directions on what information was to be contained in the final, or resolution, letter to the complainant.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, review of medical records and document review, it was determined that the hospital failed to assure that all patients received care in a safe setting. The hospital's failure to do so resulted in potentially unsafe practices for 8 of 12 patients who had received care in the Emergency Department (ED) for treatment of intoxication and/or drug overdose.

Findings include:

The sample of medical records for review included those patients whose admitting diagnosis had been intoxication or overdose. The review included the medical record of Patient #1, who had received care in the ED in September 23, 2009; all other records were selected from a list of patients who received care in the hospital ED during the months of July, August, September and October, 2011.

Review of documentation revealed that 2 of 12 patients (Patients #1 and #3) who had been admitted for intoxication and/or overdose, had been placed in 4-point restraint and had also been forcibly catheterized to obtain a urine specimen.

One (1) of 12 patients (Patient #2) admitted with diagnosis of intoxication and/or overdose had been placed in seclusion.

Patient #1:

Use of Restraints
Review of the patient's medical record revealed that the patient had been admitted to the ED after/he had been evaluated by Fire and Rescue/Emergency Services (EMS) who subsequently transported the patient to the hospital's ED. Documentation by EMS personnel revealed that the patient "...extrem moves all with purpose unable to stand r/o [rule out] intoxication". The documentation also revealed that the patient's vital signs had been checked a total of 4 times by the EMS prior to the patient being admitted to the ED in Sept. 23, 2009.

Review of the medical record revealed that Registered Nurse (RN) #4, the RN assigned to primary care of the patient, documented at 1:20 am, "ETOH [alcohol] little response but will answer questions correctly." The nurse also documented that vital signs had been obtained.

MD #1, who was the physician who provided medical care to the patient, documented at 1:50 am that the patient was "intoxicated" and also documented "4 pt. restraints/locking self bathroom, throwing urine, verbally abusive".

The medical record documented that at 2 am, the patient had locked her/himself in the bathroom, had been given a cup in which to provide a urine specimen, but the patient had twice thrown the specimen "...cup on the floor".

Documentation by RN #4, the RN assigned to primary care of the patient, revealed that the RN checked the box on the restraint order form for the section that stated:
"All alternative and least restrictive measure have been considered and documented, and the patient is unable to comply with specific requests that ensure safety creating the potential to self or others. Document this behavior."

In the section provided for documentation, the RN wrote:
"pt has decided [s/he] will not cooperate with ordered medical tx [treatment]. Fighting staff and security. ETOH [alcohol] aboard. Throwing UA [urine specimen] at staff."

The RN also checked the box on the restraint order form for the section that stated:
"Patient's behavior became out of control so quickly there was not time to trial less restrictive measures..."

In the section provided for documentation the RN documented:
"Became out of control anger [sic] when asked for urine".

Documentation also revealed that subsequent to throwing the the urine cup on the floor, the patient was placed in 4-point restraints [all 4 limbs restrained] and was then catheterized by RN #1 (who had been the Charge RN in the ED that shift). Placing the patient in the restraints required the assistance of a male technician and 2 male security guards. In addition, documentation revealed that the patient had "...cooperated with blood draw..." but it was not clear if the blood draw had been obtained before or after the patient had been placed in 4-point restraints.

MD #1 stated on 11/2/2011 that s/he did not recall the patient or the situation, but had reviewed the medical record, and believed that the patient had been perceived to be a threat to any and all members of the team and that was why the patient had been restrained.

PA #1, who also provided care to Patient #1, stated that s/he did recall the patient. The PA stated that the patient had come to the ED via the EMS, had been in restraints and had been "uncooperative, loud and screaming". The PA stated that the patient had been released from restraints to go into the bathroom to provide a urine specimen, but had locked the bathroom door. When the patient came out of the bathroom, s/he had thrown urine and was determined to be a danger to others.

Interview with MD #1 and PA #1 revealed that the physician and PA believed that the patient had thrown a urine specimen cup at staff; documentation by RN #4 revealed that the patient had thrown the urine specimen cup on the floor. In addition, RN #4 failed to document why the patient continued to be in 4-point restraints when the patient was asleep.

Further documentation by RN #4 revealed that at 2:20 am, a friend had come to the ED for the patient, and was angry that the patient was unclothed. The RN documented "...pt. was totally covered with sheet. In restraints. Calm. Sleeping. Pt. coop with removal of restraints, given clothes by tech..."

On 11/2/2011, the PA #1 stated that it was the usual practice in the ED to strip patients who were in 4-point restraints and then cover them with a blanket.

Review of the hospital's policy and procedure "Proper Use of Restraints and/or Seclusion" revealed the following directive:

"PROCEDURE:
General
...All restraints are to be kept in full view and not covered with sheet or bedspread..."

Documentation did not explain why Pt #1 had previously cooperated with 5 sets of vital signs and a blood draw, and then became "out of control" when asked to provide a urine specimen.

Documentation did not explain why the patient had to be placed in 4-point restraints, as opposed to be placed in a seclusion room and given the opportunity to possibly calm her/himself. Interview with hospital leadership revealed that in 2009, the hospital ED had not had seclusion rooms, and so patients who might not have actually required restraints had to be restrained due to lack of adequate facilities. The present ED does have 2 seclusion rooms, neither of which have locking bathroom doors.

Documentation did not explain why the patient's medical status warranted a urine specimen, particularly when obtaining the specimen required placing the patient in 4-point restraints and forcibly catheterizing her/him, thereby placing the patient at risk for injury during the restraint process and as well as while the patient remained in restraints.

Laboratory Tests and Evaluation of Same

Review of Pt #1's medical record revealed that the physician had circled the pre-printed order for "ETOH" [alcohol] which staff reported was understood to be a request for a blood alcohol level and "TOX" which was reportedly understood by staff to be the order for a clean catch urine specimen [the patient urinates into the specimen cup] to determine the presence, or lack, of toxic substances which could not be determined by a blood specimen. No MD or PA order was found for a urinary catheterization of the patient.

Further review of the medical record revealed that the patient's blood alcohol level (BAL) was determined to be 415. The medical record revealed that the results of the BAL were available in the computer at 2:05 am, and that the results had been called to the ED at 2:41 am because of the high level of alcohol in the patient's bloodstream.

The medical record documented the results of the urinalysis had also been in the computer system at 2:05 am, but had not been called to the ED. Review of the policy "Critical Panic Values" revealed that the laboratory was to call ED staff with critical values, but no directions were given to call the ED staff with normal or negative results. Pt #1's medical record contained the urinalysis report, which reported no toxic substances in the urine.

The medical record also documented that the patient had been discharged from the ED at 2:30 am, approximately 10 minutes before the BAL of 415 had been called to the ED.

Review of the hospital's policy and procedure "Critical Panic Values" revealed that the "critical panic value" of blood alcohol was considered to be greater than 300 MG/DL, because levels at that rate or higher could have the possible effect of "coma, death". The hospital policy also directed laboratory staff to call reports "...which contains results in the LOW or HIGH critical ranges will be phoned to the patient's nurse or the ordering physician...ER [ED] patient results must be phoned to the nursing unit within 30 minutes of the report from the analyzer...it is the responsibility of the "Licensed Caregiver" to follow up and respond appropriately to the critical values."

On 11/2/2011, the PA stated that not all intoxicated patients got a "tox" screen. S/he stated that if a patient admitted to alcohol ingestion and "cooperated", they would probably not get a tox screen. The PA also stated that s/he was not aware that a BAL of 415 was considered a critical panic value.

The PA was also asked to review the medical record to determine who, if anyone, had reviewed the results of the BAL and urinalysis prior to Pt #1 being discharged . The PA stated that s/he was unable to tell if anyone had.

MD #1 was interviewed on 11/2/2011 and also stated that not all intoxicated patients received a "tox screen". The MD stated that there was no policy and procedure regarding which patients should have a urinalysis for toxic substances, which substances should be looked for and under what circumstances a patient should be restrained to obtain the urine specimen; the MD stated that the decision was made by the provider, [MD or PA], and was a clinical decision.

MD #1 stated that s/he was the provider who determined that Patient #1 was medically stable for discharge. The MD was asked to review the medical record to determine if any provider had seen the BAL prior to discharge of the patient. The MD stated s/he could not determine that from the medical record. S/he also stated that if the patient appeared to be "medically stable" they might be discharged prior to a review of the laboratory results.

Based on review of documentation and interview, MD #1 did not give a rationale for obtaining the patient's urine specimen by force, when the laboratory results were not documented as having been reviewed prior to discharging the patient.

The ED Medical Director confirmed on 11/2/2011 that the hospital did not have a policy and procedure to guide clinicians regarding when, and for which patients, they should order urine toxicology screens and under what circumstances, if any, laboratory values should be reviewed prior to discharge of the patient.

Patient #2

Use of Seclusion
Review of the medical record for Patient #2 revealed that the patient had been admitted to the ED in Oct. 11, 2011 at 2:42 am, with a drug overdose, as well as homicidal ideation.

The RN documented at 6:00 am that the patient was "actively homicidal..." and at 7:07 am, was sleeping in bed in an isolation room and the Charge RN had been informed of the need for a sitter due to the patient's homicidal ideation.

At 11:12 am, a social worker documented that the patient was being held as an involuntary treatment admit due to her/his homicidal thoughts. At 2:30 pm, a physician documented that the patient was sleeping comfortably in a locked room. It was not clear when the seclusion of the patient had begun.

No physician orders were found in the medical record for the seclusion of the patient, nor was any documentation found in the record that the patient had been monitored during the unknown number of hours s/he had been secluded.

Review of the hospital's policy and procedure revealed the following directive:
"Patients who are in behavioral health restraints or seclusion should be assessed at the initiation of restraint or seclusion, and every 15 minutes thereafter..."

The hospital failed to assure that seclusion was ordered by a physician/provider, with the required evaluation of the patient, and that the patient had ongoing monitoring and evaluation while in seclusion.

Patient #3

Use of Restraints
Patient #3 was admitted to the ED July 27, 2011 and seen by triage at 11:53 am. The physician's documentation revealed that the patient had been brought to the ED after being found intoxicated, but was "easily arrousable [sic] unremarkable physical exam".

Review of the medical record revealed that the RN documented at 11:55 that the patient refused to put on a gown and the patient's clothes were cut off of her/him, due to patient "...being aggressive with staff. Suicide precautions initiated; one on one supervision, clothing...removed".

The order for restraints, was timed at 11:55 am, and the RN had checked the box on the restraint order form for the section that stated:
"Patient's behavior became out of control so quickly there was not time to trial less restrictive measures..."

The RN documented the behavior as: "Pt arrived restrained by EMS, pt. yelling and kicking staff. Uncooperative."

At 12:14, while in 4-point restraints and approximately 15 minutes after arriving in the ED, the patient was forcibly catheterized.

At 12:20 pm, the RN documented "...alert. oriented. appears anxious. The patient appears agitated and is hostile and combative. patient's speech is loud. Patient's mood/affect appears angry. Patient's mood/affect appears abnormal (pt. yelling at staff profanities, attempting to kick staff on arrival)...

Further review of the medical record revealed that the results of the patient's urinalysis for toxicology and BAL were in the computer system. The patient's urine toxicology screen came back normal, except for the presence of marijuana, and the BAL was approximately 200.

At 3:27 pm, a social worker documented "...officer reports pt. had no identification on [her/him] and refused to provide any information...ED staff were unable to confirm pts. name as pt. was uncooperative and intoxicated requiring 4 pt. restraints".

At 6 pm, the patient was removed from restraints and was subsequently discharged to home with family members at 8:26 pm.

Documentation did not explain why the patient required 4-point restraints, as opposed to be placed in a seclusion room and given the opportunity to possibly calm her/himself. Interview with hospital leadership, and a tour of the ED, revealed that the current ED does have 2 seclusion rooms, neither of which have locking bathroom doors.

Documentation did not explain why the patient required 4-point restraints for 6 hours, when s/he was documented to be sleeping at 12:59 pm, 15:36 pm (at which time the patient was requesting to be released from restraints), at 5:20 pm.

Documentation did not explain why the patient's medical status warranted a catheterized urine specimen, particularly when obtaining the specimen required placing the patient in 4-point restraints and forcibly catheterizing her/him, thereby placing the patient at risk for injury during the restraint process and while the patient remained in restraints.

Nine (9) additional medical records were reviewed for patients who had been admitted to the ED with diagnoses of intoxication and/or drug overdose, but were not placed in restraints/seclusion. The patients were admitted to the ED during the months of July, August, September and October, 2011.

Findings include:

Laboratory Tests and Evaluation of Tests

Patient # 5
Patient was admitted to the ED on July 12, 2011 at 11:35 pm by EMS after being found in her/his car at a convenience store. The patient was brought to the ED with smell of alcohol on breath and slurred speech. No tests were ordered for blood alcohol or urine toxicology screening.

Patient #8
The patient was admitted to the ED on July 9, 2011 at 3:53 am by EMS after being found lying in the street. Documentation by the RN revealed that the patient had the patient "appears in pain and anxious. Patient smells of alcohol...patient's speech is slurred". No tests were ordered for blood alcohol or urine toxicology.

Patient #9
The patient was brought to the ED on Sept. 16, 2011 at 7:59 pm by EMS after being found in the community attempting to "(...get into people's house to stay out of the rain) and intoxication. No tests were ordered for blood alcohol or urine toxicology.

Patient #10
The patient was brought to the ED on August 6, 2011 at 8:38 pm by EMS after being found by the police. RN documentation revealed that the [AGE] year-old patient was "...pale, has slurred speech and smells of alcohol..."
Documentation by the physician revealed that the patient admitted to consumption of alcohol and ingestion of marijuana. No tests were ordered for blood alcohol or urine toxicology.

Patient #12
The patient had been brought to the ED on Oct. 12, 2011 at 9:20 pm by EMS after being found "...appearing intoxicated at seatac airport...pt has long hx [history] of ETOH abuse..."
The physician documented that a history from the patient was "unobtainable due to patient's altered status...the patient's speech is slurred and odor of alcohol is present..altered mental status...(somnolent but easily arrousable). No tests were ordered for blood alcohol or urine toxicology.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0176
Based on interview, review of hospital policy and review of credentialling files, it was determined that the hospital failed to ensure that independent practioner training requirements were specified in hospital policy. The hospital's failure to do so resulted in 4 of 4 physicians and 1 of 1 physician's assistants, who worked in the Emergency Department (ED), not having training and education regarding the safe and appropriate utilization of restraints and/or seclusion. The hospital's failure subsequently placed all patients in the ED at risk for unnecessary loss of freedom, privacy and dignity as well as physical harm from the unsafe and incorrect use of restraints.

Review of the hospital's policy "Restraint and Seclusion - Staff Training" revealed the following directive:

"POLICY:
In accordance with Highline Medical Center's philosophy on restraint and seclusion, which espouses the creation of an environment that minimizes circumtances that give rise to restraint and/or seclusion use and that maximizes safety when they are used, initial and ongoing education for direct care staff is heavily supported and provided.

-All Licensed Independent Physicians [sic] authorized to order restraints or seclusion by Highline Medical Center policy and in accordance with state law shall have, at a minimum, a working knowledge of hospital policy regarding the use of restraint and secusion..."

No further reference was made to Licensed Independent Practitioners or physicians and the rest of the policy refereneced only "staff".

Reference citation written at Tag A0084
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on interview and review of personnel files, it was determined that the hospital failed to assure that 5 of 5 Emergency Department (ED) Registered Nurses had documented current competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. The hospital's failure to do so placed all patients in the ED at risk for loss of freedom, privacy and dignity as well as physical harm from the improper and incorrect use of restraints.

Findings include:

RN #1

RN#1 was interviewed on 11/2/2011 and stated that s/he had been the Charge Nurse on September 23, 2009, when Patient #1 was admitted to the ED. The RN stated that, while s/he had not had primary care for the patient, s/he had participated in the care of the patient and had also documented in the patient's record.

RN #1 stated that her/his understanding of restraint use was that if certain patients could not be verbally de-escalated, they were to be placed in restraints for the safety of the patient as well as the staff. The RN stated that the hospital's policy was that patients were put in "four point restraints [all 4 limbs restrained] or nothing".

The RN was also asked about the decision to place any patient in 4-point restraints and then do a urinary catheterization. The RN stated that s/he had not seen the "Clinical Pathway for Intoxicated Patients". [The clinical pathway did not note the need to obtain urine samples, clean catch or catheterized, from intoxicated patients.]

RN #1 stated that s/he took a "restraint quiz" every year, but could not recall participating in any "hands on" demonstrations relative to the use of restraints, and was unable to describe any de-escalation techniques or less intrusive alternatives to the 4-point restraints.

The personnel file for RN #1 was reviewed in the presence of the Chief Nursing Officer (CNO) and found to contain documentation that the last on-line training regarding the use of restraints was 5/26/2010, and the last return demonstration had been 6/5/2010. The hospital's policy required yearly training regarding the appropriate use of restraints and seclusion.


RN#2

RN #2 was an ED RN who was interviewed on 10/20/2011. The RN stated that part of the restraint protocol was to attempt a less restrictive alternative. The RN also stated that if the patient was unable to make a decision for themselves and the ED staff was forced to make a decision, an attempt would be made to call family or friends of the patient to obtain their help.

The RN was asked to describe when the ED staff justified the use of 4-point restraints to obtained a forced catheterization of the patient. The RN stated that sometimes the urine sample was needed to determine the cause of a patient's mental status. When asked how the determination was made to proceed to a forced catheterization, the RN stated it was "very tough" to make that decision.

The RN stated that seclusion could be an alternative to restraints, and that if the patient was "up and breathing" their condition would not be considered emergent enough to warrant the use of restraints.

The RN's personnel file was reviewed with the CNO and found to contain no documentation of online training relative to the use of restraints. A return demonstration regarding the use of restraints was last completed on 8/2/2010. The hospital's policy required yearly training regarding the appropriate use of restraints and seclusion.

RN #3

RN #3 was an ED RN who was interviewed on 10/20/2011. The RN stated that there was no specific standard for when an intoxicated patient was asked to provide a urine specimen, but her/his understanding was that urine specimens were necessary to ascertain if a patient had "co-ingestion" or if there was a need to obtain a specimen to obtain permission for post-discharge placement.

The RN stated that a patient might be restrained to obtain a urine specimen if one was needed to place a patient in a detoxification setting after discharge from the ED. S/he stated that the usual process would be to wait for an hour to an hour and a half, offer a bedpan and then, if the patient still had not produced a urine specimen, the staff would explain that they did not want to have to do a catheterization while the patient was restrained, but they would.

The RN was asked if there were any alternatives between not getting the specimen and forcing the patients into restraints and then doing a catheterization. The RN stated that the usual procedure would be to call a "show of force" [security and male staff arrive at the patient's door to "show force"] and then explain in a "calm " way what the process would be if the patient did not cooperate. The RN stated that after 2 or 3 unsuccessful attempts to get the patient to comply, then the patient would be put into restraints and forcibly catheterized.

The RN's personnel file was reviewed in the company of the CNO and found to contain no documentation that the online course for the appropriate utilization of restraints had been completed, and the return demonstration for the appropriate utilization of restraints had last been completed on 5/28/2010. The hospital's policy required yearly training regarding the appropriate use of restraints and seclusion.

RN #4

RN #4 was an agency nurse who had been assigned primary care of Patient #1 on September 23, 2009. The RN was not available for interview.

Review of the agency nurse's personnel file was reviewed in the company of the CNO and was found to contain no documentation that any training or education had been held relative to the appropriate use of restraints.

RN #5

RN #5 was the Interim Director of Nursing Services for the Emergency Department and s/he was interviewed on 10/13/2011. The Director stated that it was the usual practice of the ED to obtain urine specimens from patients who were intoxicated, to check for the presence of potentially dangerous substances, that could not be revealed with a blood test. When asked why it was critical to have the information, and if the potential risks of restraints might outweigh the information obtained, the Director stated s/he did not know.

The specific events around the use of 4-point restraints for Patient #1, as well as the forced catheterization of the patient, and potentially other patients in the same or similar circumstances, were discussed with the Director. When asked if s/he could assure that the same situation would not occur with any other patient that same night, s/he stated that s/he could not.

The Director's personnel file was reviewed in the company of the CNO. Review of the file revealed no documentation of a return demonstration relative to the appropriate use of restraints and seclusion, but did document that an online class had been taken by the Director on 10/28/2011. The CNO confirmed that the online training had been prompted by the initial onsite hospital visit by the Department of Health investigator, which had revealed issues around the ED staff, and ED physicians and one Physicians' Assistant, not having evidence of current training and competencies regarding the appropriate utilization of restraints and seclusion.