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|SPRINGFIELD HOSPITAL||PO BOX 2003 SPRINGFIELD, VT 05156||Jan. 23, 2019|
|VIOLATION: QUALITY ASSURANCE||Tag No: C0337|
|Based on interview and record review, the CAH failed to effectively analyze and evaluate the use of restraints and police presence in the Emergency Department, resulting in a failure to identify opportunities for improvement in patient care for 3 of 10 applicable patients (Patient #1, Patient #5, and Patient #7). Findings include:
1. Per review of a nursing triage from 7/2/18 at 4:11 PM, Patient #1 was at his/her physician's office and assaulted his/her caregiver because s/he did not receive his/her as needed medications as s/he had requested. The patient had been shouting and making threats in the office triage area; and was found stapling him/her-self with a stapler. S/he was brought to the ED by police. Per review of a nursing progress note from 4:16 PM, it read, "Reassurance given to the patient. Two patient identifiers checked. Call light placed in reach. Side rails up x 1. Bed placed in lowest position. Brakes of bed on. (Patient remains with police guard-in police handcuffs, one arm attached to the stretcher.)". A case management note written at 6:31 PM read, "spoke with" patient "upon arrival" s/he "was agitated. Angry about the case worker that" s/he "assaulted" the nurse and nurse manager worked with the patient and the "SPD (Springfield Police Department) x 2 to calm and settle ... ...Pt had handcuffs removed over time as" s/he "agreed to not hurt" him/her-self "or others .....The police stayed until 6:15 PM ...."SPD and" the Nurse Manager "spoke to" the patient "and" s/he "agreed to stay here and not hurt" him/her-self "or others." Per interview on 1/23/19 at 2:30 PM with the Chief of Quality and Systems Improvement, s/he stated that events like the application of restraints were entered in the event reporting system. The Quality Department assigns the appropriate department managers to review these events to evaluate and identify any potential opportunities for improvement. Per interview on 1/23/19 at 9:25 AM with an ED Charge Nurse, s/he stated that s/he reviewed all behavioral health cases as part of the ED's quality program. S/he stated that s/he was aware that on 7/2/18, Patient #1 was in the ED restrained in handcuffs. S/he stated that there was a question regarding whether or not Patient #1 was going to be arrested; and that was why Patient #1 remained in handcuffs in the ED. The ED Nurse Manager confirmed at that time that handcuffs should not have been used in the ED and that the case should have been further analyzed and evaluated to identify opportunities for improvement.
2. Per review of a nursing triage note, on 9/13/18 at 3:29 PM, Patient #5 came to the ED with depression and suicidal thoughts. S/he had been at an outpatient crisis clinic and started to punch his/her head. S/he was then brought to the ED by police. Per review of physician progress notes from 9/13/18, the patient had been meeting with Health Care and Rehabilitation Services (HCRS) and became angry and starting punching him/her-self. S/he would not state what was upsetting him/her. S/he had a history of paranoid delusions and had suicidal thoughts. Per review of a nursing progress note from 9/14/18 at 11:06 AM, it read, "Suicide precautions maintained. Hospital security officer at bedside, checks performed every 15 minutes. (lights remain dimmed, door open, body moves, pt sleeping)". On 9/14/18 at 1:45 PM, "(pt awake, asked for gum, coffee, medication, went in to the rest room came out yelling sex comments to a nurse walking by. brought in the med, coffee, gum, medication, pt took the medication and throw them against the wall, yelling, hitting" him/her-self "in the head, punching walls, then turned and ran and fist in the air at the nurse, after I moved too the hallway" s/he "moved and fist in the air after the security personal, code orange and police called, police and code team arrived pt yelling bad language and names at everyone)". At 3:15 PM, "(pt remains angry yelling, hitting" him/her- self "spitting, police have redirected pt which does not last. when nurses try" s/he "calls them names, states that should be dead)". At 3:50 PM, "Suicide precautions maintained. Hospital security officer at bedside, checks performed every 15 minutes. (police left, pt calm, resting in bed)". Per interview on 1/23/19 at 10:07 AM with the ED Nurse Manager, s/he confirmed that the case was not analyzed and evaluated to further identify opportunities for improvement with the use of police in the ED.
3. On 12/19/18 Patient #7 was brought to the ED by the sheriff's department for a medical screening exam and clearance for court ordered psychiatric hospitalization . Per Clinical Report - Nurses Progress Notes states on 12/19/18 at 16:20 "Sheriffs turned patient over to us per their protocol and left. Code Orange (a request for assistance/show of force to bring appropriate help to a location where a threatening situation from a patient, visitor has the potential to exist) was activated for patient behavior. Springfield Police called for help with patient due to his/her posturing behavior toward staff and refusing to stay in his/her room". The interactions of the police with Patient #7 were not documented. However, per interview on 1/23/19 at 10:07 AM with the ED Nurse Manager, s/he confirmed that the police should not have been called to help manage Patient #7's behavior. S/he further stated that the police should not be called to assist with any behavioral health emergencies; and that it was the responsibility of the staff to manage the patients that come to the ED. The use of police in the ED was not evaluated through the Quality Assurance program to determine the impact on patient health and safety.