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 interview and record review the hospital failed to ensure that physical and chemical restraints were applied in accordance with physician's orders for 1 of 10 applicable patients (Patient #1). Findings include:

Per review of nursing notes for Patient #1, on 10/12/18 at 10:28 PM, "Patient sitting on the floor at this time at the head of the bed hitting him/her-self in the head with a metal IV pole. The patient was instructed to stop but s/he continued to hit him/her-self in the head ....This nurse grabbed the pole to prevent further injury to the patient. At this time the patient struck his/her head on the bed frame .....The physician arrived to the room and moved the bed allowing the patient to get to a standing position and the patient retreated to the corner of the room making remarks of fighting the staff". At 10:30 PM, "Police arrive to the facility and with the patient continuing to verbalize that s/he was going to fight the police at which time the police deployed their tazers. The patient was taken to the ground via police and placed into handcuffs. The police then helped the patient get into the bed". At 10:40 PM, "Patient placed into 4 point restraints at this time and was given sedatives for his/her safety". The physician progress notes from 10/12/18 at 11:07 PM read, "Pt yanking on restraints, trying to get out, remains agitated. Ordered for additional Haldol". Per review of the Medication Administration Record (MAR) on 10/12/18 at 11:19 PM, 5 mg of Haldol was given IM to Patient #1. There was no evidence in the record that physician's orders were written for the 4 point physical restraints and the additional IM Haldol that was given to Patient #1. Per interview on 11/20/18 at 10:39 AM with the Manager of Regulatory Affairs, s/he confirmed that there were no physician orders for the physical restraints (4 points) or additional chemical restraint (IM Haldol) for Patient #1.
Based on observations, interviews, and record reviews during the course of the follow-up survey and complaint investigation, the Condition of Participation: Quality Assurance and Performance Improvement was not met as evidenced by the failure of the hospital to effectively evaluate, fully analyze, and fully implement activities that focused on high-risk and problem prone areas to ensure that patient rights were protected and staff were adequately trained.
Based on staff interview and record review, the hospital failed to ensure that performance improvement activities included an analysis of adverse patient safety events and implementation of preventive actions after a significant adverse patient event occurred for 1 applicable patient (Patient #1). Findings include:

The Quality Assurance and Performance Improvement department failed to fully analyze all the potential causes of an adverse patient safety event and did not identify opportunities for improvement or implement corrective actions in a timely manner. On 10/12/2018, Patient #1 presented to the Emergency Department and was assessed to meet criteria for psychiatric hospitalization due to suicidal ideation and risk of harm to self . During an episode of self-injurious behavior and escalation which included threats of harm to others, Patient #1 was tazed by local law enforcement in order to be physically subdued. The Manager for Regulatory Affairs and the Director of Quality confirmed during an interview at 3:45 PM on 11/20/2018 that the event had been discussed during a case review at the hospital's Patient Care Committee and had been reviewed by members of hospital staff who were on-call and working on 10/13/2018. Per interview, the Patient Care Committee had, "determined the use of law enforcement and response to the event was appropriate". There was a failure to identify that the use of police and utilization of a tazer was not in compliance with regulatory requirements or identify opportunities for the hospital to implement training or protocols for managing the healthcare needs of patients exhibiting behavioral symptoms.

As of the time of the investigation, there had not been a formal review of the significant chain of events which included the use of a law enforcement weapon to manage patient behavior, the practice of calling local law enforcement for assistance with the management of patient behavior, or training needs and direction needed for hospital staff regarding the management of the patients in psychiatric crises.