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.

TRINITY ROCK ISLAND 2701 17TH ST ROCK ISLAND, IL 61201 Aug. 1, 2018
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
Based on document review and interview, it was determined for 5 of 6 (MD (Medical Doctor) #1, MD#2, MD#3, MD#4 and PA (Physician Assistant) #1) Emergency Department (ED) Medical Providers authorized to order restraints or seclusion, the Hospital failed to ensure the Medical Providers were knowledgeable of the restraint policy or qualified to order restraints. This has the potential to affect approximately 350 patients per month who present to the ED for a medical screening examination.

Findings include:

1. The policy titled "Restraints, Patient" (revised 1/29/18) was reviewed on 8/1/18. The policy noted on page 6 and page 9 that physicians... and other LIP (Licensed Independent Practitioners) authorized to order restraints or seclusion must have have knowledge of the restraint and seclusion policy. The policy lacked documentation of the training requirements to determine how the medical providers were "knowledgeable" based on their competence level and the needs of the population they serve.

2. During a review of the credentialing file on 8/1/18 at approximately 12:00 PM, MD#1, MD#2, MD#3, MD#4, PA#1 and APN (Advanced Nurse Practitioner) #1's were ED Medical Providers authorized to order restraints or seclusion. The following Hospital Learning Transcripts (software utilized to track completed education) lacked documentation the providers were informed, educated or assessed for competence regarding restraint and seclusion use:
a) MD#1- Physician/Psychiatrist
b) MD#2- Physician/Psychiatrist
c) MD#3- Physician/Medical Director of Emergency Services
d) MD#4- Physician/Psychiatrist
e) PA#1- Physician Assistant

3. During an interview on 8/1/18 at approximately 12:00 PM, E#4 (Manager of Medical Records) verbally agreed MD#1, MD#2, MD#3, MD#4, PA#1 and APN #1 were active staff members authorized to order restraints and seclusion.

4. During an interview on 8/1/18 at approximately 12:30 PM, E#3 (ED Nurse Manager) stated that the ED Medical doctors and LIPs (APN and PAs) do not receive restraint and seclusion training. E#3 stated "The only reason APN#1 had the training is because he/she was a nurse before he/she became an APN."

5. During an interview on 8/1/18 at approximately 2:00 PM, E#1 (Director of Emergency Services) stated Medical Providers authorized to order restraints and seclusion were not required to review the Hospital's Restraint policy or demonstrate competence of their knowledge and should have been.