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.

Based on document review, observation and interview, the Critical Access Hospital (CAH) failed to follow acceptable standards of practice within the scope of care for an Emergency Department (ED) patient in one (1) instance (Patient # 1).

Findings include:

1. Review of the hospital policy titled, "Scope of Care and Standards of Practice for the ED", reference number 078.618.1, effective date 08/22/2017, indicated the following:
A. Standards of practice within the scope of care will be followed in the ED.
B. The goal of the Critical Access Hospital's ED "is to provide all patients with excellent healthcare services in a caring and compassionate manner."
C. The RN (Registered Nurse) and Paramedic serve as a patient advocate, "preserving the basic rights of the patient".

2. Review of the hospital policy titled, "Patient Rights", reference number 151.115.1, effective date 10/24/2017, indicated the following:
A. It is the policy of the Critical Access Hospital to promote and protect each patient's rights as outlined by the Conditions of Participation. Protection of patient's rights is demonstrated through a variety of modalities, which include safety.
B. The patient has the right to receive care in a safe setting.
C. The patient has the right to be free from all forms of abuse or harassment.
D. The patient has the right to be free from physical or mental abuse.

3. Review of the OC # 1 (Emergency Physician Services) and CAH's contract titled "CONTRACT FOR EMERGENCY DEPARTMENT STAFFING SERVICES", dated/signed on 03/15/2017, indicated the following: Quality Assurance and Risk Management-2.2.1-Each physician shall accept the duties as determined by the medical staff of the hospital and shall abide by the bylaws and the rules and regulations as set forth by the medical staff of the hospital.

4. Review of the document titled "Applicant's Consent and Release", dated 07/28/2017, indicated MS # 1 (Physician Emergency Department) signed acknowledgment "I have received and had an opportunity to read a copy of the medical staff bylaws and such facility policies and directives as are applicable to appointees to the medical staff, including bylaws and rules and regulations of the medical staff presently in force. I specifically agree to abide by all such bylaws, policies, directives and rules and regulations as are in force, and as they may hereinafter be amended, during the time I am appointed or reappointed to the medical staff or exercise my clinical privileges at the facility".

5. Review of the letter from the CAH to MS # 1, dated 10/26/2017, indicated the request for the application of courtesy staff with privileges in emergency medicine was approved by the Board of Trustees, and would be effective 10/24/2017 to 10/23/2018, and "are subject to the bylaws and rules and regulations of the medical staff".

6. Review of the "Medical Staff" of the Critical Access "Hospital Bylaws", reference number 300.112.1, effective date 02/27/2018, indicated the following:
A. The courtesy medical staff qualification meet the general qualifications set forth in Section five (5).
B. Section five (5) titled "basic responsibilities of applicants and medical staff members", indicated the following basic responsibilities and representations shall be applicable to every applicant for appointment and member for reappointment as a condition of consideration for their application and as a condition of continued membership if granted.
C. Section 5.1.1 indicated providing patients with the "quality of care meeting the professional standards of the medical staff of this hospital".
D. Section 5.1.2 indicated abiding by the medical staff bylaws and the hospital bylaws and hospital policies.
E. Section 5.1.5 indicated abiding by the lawful and ethical principles of the American Medical Association.

7. The "AMA (American Medical Association) Code of Medical Ethics", copyright date 2016, located on the website, the principles adopted by the American Medical Association "were not laws", but standards of conduct that define the essentials of "honorable behavior for the physician", indicated the following:
A. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
B. A physician shall uphold the standards of professionalism, be honest in all professional interactions.
C. A physician shall respect the law.
D. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

8. On 05/15/2018 at approximately 1:04 pm, an observation of PO # 1's (Police Officer) body camera footage from the evening of 05/03/2018, provided by PD # 1 (Police Department), was viewed with administrative staff members A # 1 (Chief Executive Officer-CEO), A # 2 (ED Manager), A # 3 (RN Director of Acute Patient Services), A # 4 (Director of Quality & Regulatory Affairs), and A # 5 (Chief Nursing Officer) confirmed the following:
A. At approximately 05:12 (five minutes twelve seconds into the body camera footage) patient # 1 shouted "don't fuckin grab me like that man". At that time patient # 1 was sitting on the side of the cart with their hands cuffed behind their back in room number nine (9) of the emergency department.
B. At approximately 05:13 MS # 1 (Physician ED) shouted at patient # 1 that MS # 1 would put a "tube up your ass and your dick and everything else"..."gonna put your mother fucking picture on facebook mother fucker".
C. At approximately 05:25 MS # 1 stated "I wish they would take the cuffs off you I would beat the shit out of you".
D. At approximately 05:29 patient # 1 shouted "don't fuckin touch me dude".
E. At approximately 05:30 a commotion was heard on the body camera footage.
F. At approximately 05:33 the body camera footage showed all four (4) police officers (PO # 2, PO # 3, PO # 4, and PO # 5) holding patient # 1 down on the cart. At this time patient # 1 was still handcuffed behind the back but lying flat on the cart.
G. At approximately 05:35 the body camera footage showed MS # 1 leaning over patient # 1's face shouting "this is my house dude don't you ever forget that mother fucker" and MS # 1's left hand appeared to be on patient # 1's chest, neck, face area.
H. At approximately 05:38 MS # 1 shouted "I'll fuck you up you piece of shit".
I. At approximately 05:50 MS # 1 exits room number nine (9).
J. At approximately 14:50 patient # 1 requested the physicians name. PO # 1 told patient # 1 the physicians name.
K. At approximately 15:16 patient # 1 stated that MS # 1 had grabbed their throat.
L. At approximately 16:21 patient # 1 was placed in the police vehicle outside the facility.
M. At approximately 16:25 the body camera footage showed PO # 1 walking toward the other four (4) police officers (PO # 2, PO # 3, PO # 4 and PO # 5) who were standing outside the front of the facility.
N. The body camera footage ended at 16:26.

9. Interview with ED # 1 (Emergency Department Personnel) on 05/15/2018 at approximately 3:05 pm, confirmed MS # 1 grabbed patient # 1 by either the "throat or the shirt" and pushed the patient down on the bed". The behavior of MS # 1 was "unprofessional and the language was inappropriate".

10. Interview with PO # 2 (Police Officer) on 05/15/2018 at approximately 3:35 pm, confirmed that MS # 1's behavior was unprofessional.

11. Interview with LB # 1 (Lab Technician) on 05/16/2018 at approximately 9:40 am, confirmed that nothing that patient # 1 did justified the way that MS # 1 spoke or treated the patient.

12. Interview with ED # 2 (Emergency Department Personnel) on 05/16/2018 at approximately 10:30 am, confirmed MS # 1 was shouting directly in patient # 1's face "not in my house mother fucker".

13. Interview with PO # 3 (Police Officer) via telephone on 05/16/2018 at approximately 2:20 pm, confirmed MS # 1 "was out of hand and the language was inappropriate". MS # 1 grabbed the patient not sure where, and then "pushed the patient down on the cart".

14. Interview with PO # 4 (Police Officer) via telephone on 05/16/2018 at approximately 2:35 pm, confirmed MS # 1 "went hands on", and was using "vulgar descriptive language". MS # 1 "put hands on patient # 1 and not to examine the patient". The "measures used by MS # 1 were unnecessary".

15.. Interview with administrative staff member A # 1 (Chief Executive Officer) on 05/17/2018 at approximately 1:30 pm, confirmed after A # 1 viewed the body camera footage, A # 1 "believed MS # 1 was verbally and physically abusive to patient # 1" on the evening of 05/03/2018.

16. Interviewed PO # 5 (Police Officer) via telephone on 05/18/2018 at approximately 8:50 pm. PO # 5 was returning a call from a message that was left on 05/16/2018 at 1:30 pm with the dispatcher at PD # 2 (Police Department). PO # 5 confirmed "MS # 1 had jumped on top of the patient and grabbed the patient by the throat". I was positioned at the patient's right shoulder and could see "MS # 1's hand around patient # 1's throat".
Based on document review and interview, the Critical Access Hospital (CAH) failed to ensure the quality assurance program evaluated, identified, and monitored the treatment outcomes and corrective actions, by failure of the completion of a Variance (Incident) report in one (1) instance.

Findings include:

1. Review of the hospital policy titled, "Variance Reporting", reference number 170.050, effective date 09/26/2017, indicated the following:
A. Variance was anything that happens in the facility or on the facility premises that "is not consistent with routine patient care or with the routine operation of the facility and/or that adversely affects or threatens to affect the health, life or comfort of a patient, visitor or employee."
B. All employees of the CAH will be accountable for recognizing and reporting variances.
C. It "is vital that employees report errors and other unexpected occurrences as they become aware of them."
D. The CAH "adopted this policy concerning the reporting of Variances to ensure systems are in place to identify risk to patient."

2. Interview with administrative staff member A # 3 (Registered Nurse-RN Director of Acute Patient Services) on 05/15/2018 at approximately 2:40 pm, confirmed that a variance report had not been completed in the electronic reporting system.

3. Interview with administrative staff member A # 1 (Chief Executive Officer-CEO) on 05/15/2018 at approximately 4:10 pm, confirmed that the staff member ED # 1 (Emergency Department Personnel) had been instructed not to fill out a variance report in the electronic system. ED # 1 was instructed to "write down what happened and if the variance report needed to be put in the electronic reporting system at a later time, A # 1 would enter the data in the system.

4. No further documentation was provided prior to exit related to a Variance report being completed for the Variance that had occurred on 05/03/2018 in the Emergency Department.