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BAYFRONT HEALTH - ST PETERSBURG 701 6TH ST S SAINT PETERSBURG, FL 33701 Dec. 20, 2018
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on record review, and interviews it was determined the facility failed to honor patient rights for one (#1) of three records reviewed,

Findings include:

A review of Patient #1's medical record, including physician assessment, progress notes and orders, nursing assessment notes and flowsheets document the patient was placed in restraints without a physician order and baker acted.

The facility policy titled, "Restraint and Seclusion" page 8 of 12 states, "orders for restraints for violent/self-destructive behavior that jeopardizes the immediate physical safety of the patient or team member requires:
1) A face-to-face assessment by the qualified LIP [licensed Independent Practitioner] within one [1] hour of restraint application.
2) The face to face evaluation must be done on new restraint episodes by the Prescriber and include an evaluation of the patient's immediate situation:
a) The patients reaction to the intervention
b) The patient's medical and behavioral condition
c) Determine the need to continue or terminate the restraint or seclusion and place appropriate order.
3) Every twenty-four [24] hours, a LIP must conduct a face-to-face evaluation before writing a renew order for restraint or seclusion used for the management of violent or self-destructive behavior.
Orders for restraints for non-violent behavior requires to ensure the physical safety of non-violent or non-self-destructive patient requires:
1) A face-to-face assessment by a qualified LIP within twenty-four [24] hours of restraint application
2) A renewal of the restraint order every calendar day
3) No additional face-to-face evaluation for the non-violent behavior for a renewal order; a TORB [telephone order read back] order may be used.

Review of the restraint documentation shows the patient was in bilateral soft wrist restraints on the following dates:
11/29/2018, 11/30/2018. 12/01/2018, 12/02/2018, 12/03/2018, 12/04/2018. 12/05/2018, 12/07/2018, 12/08/2018, 12/11/2018, 12/12/2018.
However, no orders for restraints were documented for dates 11/29/2018, 11/30/2018, or 12/05/2018 per record review with facility staff.

The facility policy titled, "Patient Rights and Responsibilities Policy", page 3 of 4 states,in part, "Upon admission, each patient will receive a written copy of the patient's rights and responsibilities. Patients' rights include, but not limited to:
1) Know the risks, benefits and alternative to proposed treatments or procedures
2) Be informed about the outcomes of care treatment and service
3) Refuse care, treatment and services in accordance with law and regulation
4) Leave the medical center against the advice of the physician

A review of Patient #1's medical record, specifically the attending physician notes nursing notes and psychiatrist notes, document the Subject was seen by a psychiatrist on the following dates and notes state:
11/30/2018 -Patient was intubated and not available for metal status examination at this time. Please re-consult us when patient has been extubated and can engage us verbally.
12/06/2018 -diagnostic impressions: Alcohol use disorder, early withdrawal oral, Adjustment disorder with mixed emotional features, rule our bipolar disorder. Recommendations: discussed with nursing, no medication recommendations at this time, and No other specific treatment recommendations at this time. If patient begins to describe or complain of anxiety symptoms and/or other mood, symptoms please re-consult.
12/10/2018 - Patient states, I get irritated sometimes. I feel trapped at times and that increases my irritability, Psychiatrist documents, Patient is aware that she gets irritated at times, especially when she starts to feel trapped. Her thinking is currently logical and goal oriented with no evidence of either delusions or hallucinations. She denies all past depression and suicidally issues. She denies any past mental health history. The mood lability she describes and observed by nursing is consistent with personality disorder. There is no specific medication treatment for personality disorder. So far, today mood lability has been absent which would frequently occur if this were a personality disorder. I have asked the patient to be aware of her irritability as she starts to become uncomfortable and ask me.
12/14/2018 - Patient seen in her room. She was sitting up about to have lunch. She is considerably more alert and awake than previously. Patient is alert and awake and denies any desire to hurt herself or anyone else. Her thought process is logical and goal directed. No delusions elicited and patient is not experiencing hallucinations. She is oriented, aware of her situation, and ready for discharge. Affect was full range. Therefore, patient is not displaying any psychotic or mood disorder symptoms. Diagnostic impressions: Alcohol use disorder, currently in remission. Adjustment disorder with mixed emotional features. Recommendations: Discontinue BA-52 [baker act]. Patient cleared by psychology for discharge.

A review of the Nursing Notes document the following:
11/28/2018 - Mother, Father, and Boyfriend at bedside, updated on patient's condition.
11/29/2018 - Call from boyfriend regarding concerns about patient's wait to be extubated [4 hours] even though she was having pain from ET [endotracheal] tube, as well as anxiety and no medications given because her oxygen level was low. Also concerned that she was about to be re-intubated prior to arrival of him to the unit, where he states he "calmed her down and she didn't need it". He states worried about PTSD [post-traumatic stress disorder] and feels she wants transferred to another hospital. I informed him that transfer process requires the patient/representative to find an accepting physician at the desired facility, at which point this facility will coordinate transfer. Advised patient that we will make every effort to accommodate transfer, however, we cannot guarantee acceptance from another hospital. Boyfriend states patient is of her own free will and they will walk out of here if not transferred to another facility. Advised him that due to patient's condition [post cardiac arrest]; this is highly ill advised and could result in serious harm to the patient. He states that staying here will cause more PTSD and that her mind needs taken care of, too. Informed charge nurse of these events, patient was hyperventilating due to anxiety and was not oxygenating, requiring possible intubation. Ativan ordered as well as precede drip and patient is calmer now.
11/30/2018 - 0900 - Patient woke up very agitated and increasingly more confused. I was at the besides attempting to de-escalate the situation and patient. Patient started to threaten me and stated, "I'm going to punch you in the face if you don't get off me". She became increasingly more agitated and began pulling at all of her lines. Ativan 1 mg [milligram] IV [intraveneous] push given. Patient's boyfriend and Registered Nurse at bedside. 0930 - Patient on 15 liters of oxygen via high-flow nasal cannula before she took off both the high flow nasal cannula and oxygen probe off her finger. Patient immediately began desaturating and went down into the 40's. Patient placed back on oxygen via non-re-breather mask at 100 percent and did not respond to therapy. Respiratory therapy and intensive care physician assistant at bedside, Pulmonologist call stat to beside for re-intubation. Boyfriend refusing reintubation. 1005 - Patient's mother agreed to intubation.
12/11/2018 - Patient assessed earlier by attending, patient restless, agitated and wanting to leave hospital and care. Attending Baker acted patient, Security and management notified. 12/14/2018 - Patient discharged to home self-care. The discharge packet reviewed with the patient and her father, both verbalized understanding of the packet that included education, follow-up instructions, and prescriptions. The patient wheeled off the floor in stable condition to the west entrance.

The facility policy titled, "Baker Acted Patients admitted ", Page 3 of 11 states, "Patients that are Baker-Acted may not sign out AMA [against medical advice unless seen by a psychiatrist/psychologist first and the Baker Act rescinded. [Only a psychiatrist or psychologist can rescind a Baker Act.

A review of the attending physician's notes on 12/11/2018 at 1130 - document the patient is at least partially confused, expresses lack of insight and understanding of her medical conditions and has displayed inability to follow even simple instructions. She repeatedly tries to get up on her own to leave the hospital. Given her medical issues, she is at high risk for recurrence of cardiac arrest and death if she leaves the hospital prematurely. She currently requires medical management in the intensive care unit. Therefore, the patient will be Baker Acted for her own safety to comply with medical recommendations. She is not actively suicidal as far as I can tell, but is at risk of serious medical illness and complications including death, without the above medical treatment.

A review of the Pulmonologist notes on 12/11/2018 at 1226 - document The patient is agitated today, though generally cooperative. Insistent on going home soon. On exam, the patient is awake, alert, oriented to person, and place. The patient remains hemodynamically stable and I can see no further critical care needs at this time. Stable for transfer to medical telemetry.

A review of facility policies document the Subject's rights were not honored as followed:
1) The review failed to show documentation of physician orders to restrain patient every calendar day Subject was in restraints.
2) The review failed to show documentation less restrictive interventions tried and failed.
3) The review failed to show documentation Baker Acted patient examined by a psychiatrist to document and complete the certificate of person's competence to provide express and informed consent.

An interview on 12/19/2018 with chief nursing officer, chief quality officer and regulatory compliance leader confirmed the above findings.