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 staff interview and record review, the hospital's Quality/Performance Improvement Department failed to have a formal, effective review process related to patient restraint occurrences, to identify problems, prevention strategies and and on-going analysis of data. Findings include:

Per staff interview and record review, ED nursing staff failed to use the hospital's Quantros Event Reporting System effectively and in accordance with written policy/procedures related to restraint use in the ED on 3 occasions during Patient #1's stay in the ED. Based on the review of restraints utilized for Patient #1 in the ED on 1/20/19 (medical use restraint) and 1/23/19 (behavioral use restraint), ED nursing staff failed to follow hospital policy for event reporting. Per review, the policy entitled Incident/Adverse Event Reporting, # QM-101, stated under the section titled Procedure: "IV. All events and near misses should be reported within 24 hours using the Safety Event Reporting link founds on Gifnet. The event reporting and management system will automatically notify Quality Management and the appropriate department managers."
During interview on 4/2/19 at 10:05 AM, the Director of QA confirmed that there was a delay in notifying h/her regarding the restraint procedures for Patient #1 due to nurses' lack of completing the required event reports. S/he stated that upon learning of the restraint events weeks after the events occurred, s/he commenced a quality review of the patient's care provision by staff related to the restraint processes. The review included ED nurses and providers and nursing leadership staff. A corrective action plan was implemented on 3/6/19. Although significant progress had been made, the plan had not been fully implemented as of the date of the survey (4/2/19). Areas needing correction reviewed with the Dir. of QA include the following: The forms used for restraint provider orders and nursing flow sheet monitoring forms had inaccurate language that did not meet the regulatory requirements for the maximum duration of behavioral restraint orders; flow sheets had inaccurate language for documentation; and there were no existing flow sheets for use with restraints ordered for medical use. The review also revealed that there was no adopted hospital policy to address the use of law enforcement assistance in assuring safety in the ED. (Refer also to 0253 and 0271)