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.

ST JOSEPH HOSPITAL 2901 SQUALICUM PARKWAY BELLINGHAM, WA 98225 July 11, 2019
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure emergency department (ED) staff created or modified a patient's plan of care after placing him in seclusion. (Patient #1001)

Failure to create or modify a plan of care for a patient placed in seclusion could lead to physical deterioration and delay in obtaining appropriate treatments.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint for Violent, Self-Destructive Patients," policy number 200.2.102, effective 12/24/18, showed that once the patient is placed in restraints or seclusion, the registered nurse (RN) documents in the electronic health record, the patient's assessment and a revision to the plan of care.

2. Record review of Patient #1001's medical record showed a [AGE] year old patient transported to the ED on 04/24/19 at 9:49 AM after he physically assaulted his caregivers. Review of the physician's encounter note showed that the patient has a history of autism and assaulting behavior. ED staff are familiar with this patient due to his 8 previous ED visits (7 month period) for agitation and aggression. Records showed that upon admission to the ED, the patient was aggressive, violent, screamed, hit and kicked individuals, injured several staff members. On two occasions a Code Grey was initiated (process to communicate & mobilize a response team to manage an individual who is combative or displays abusive behavior). Review of a physician's note at 11:24 AM, described the patient as agitated, assaultive, punched staff, grabbed a staff member by the arm, causing pain and swung her around the room. The patient was monitored immediately upon entry into the ED, at 9:54 AM, he was monitored by AV video, at 10:00 AM, a caregiver was assigned to observe the patient 1:1 and at 6:20 PM, he was determined to be medically cleared and moved to the Special Emergency Care Unit (SECU) within the department. In the SECU, the patient was evaluated by a mental health profession (DMHP) who determined that the patient did not fit the criteria for commitment and he remained on a voluntary status. On 05/14/19 records showed that while the patient was escorted to the bathroom, he turned and approached the fire door, pushed it opened and ran out of the department through the lobby. The local police and mother were notified. Police officers returned the patient to the ED, staff returned him to the SECU and seclusion. Then, after a second mental health (DCR) evaluation was done the patient was detained and placed on an involuntary status under a 14 day commitment order. On 5/16/19, the patient was noted to be on hold for a Single Bed Certification after he eloped from the department and he may accidentally harm himself or others if he eloped again.

Record review of restraint/seclusion documentation revealed that the patient was initially placed in locked restraints upon admission to the ED at 11:49 AM and released at 4:40 PM. After his move to SECU, staff kept him under continuous seclusion, plus 1:1 observation, noting that this was for the protection of patient, staff, caregivers, and others. Review of nurse's notes showed that the patient was physically assessed and re-evaluated hourly. ED technicians observed and documented notes every 15 minutes and offered the patient fluids (juice in his room), food (snacks), and bathroom/shower time. However, a review of all nursing documentation showed that staff did not initiate or revise a plan of care according to hospital policy. Also, the patient's plan of care could not be found in the medical record after the patient was admitted under a Single Bed Certification status.

3. During an interview on 07/10/19 at 10:50 AM, the ED Director (Staff #1001) confirmed the missing documentation.

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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure ED staff did not utilize seclusion preemptively on a patient who exhibited aggressive and/or violent behavior initially (Patient #1001).

Failure to remove a patient from seclusion after staff observed him to be re-directable or without significant disruptive behavior, can lead to physical and emotional harm to the patient.

Findings included:

1. Review of the hospital's policy and procedure titled, ""Restraint for Violent, Self-Destructive Patients," policy number 200.2.102, effective 12/24/18, showed that restraints or seclusion cannot be utilized preemptively due to a concern that the patient might become self-destructive or place others at risk of harm sometime in the future. The policy directs staff to use seclusion only in emergency situations to ensure immediate safety for the patient exhibiting violent/self-destructive behavior, and less restrictive interventions have been determined to be ineffective.

2. Record review of Patient #1001's medical record showed a [AGE] year old patient transported to the ED on 04/24/19 at 9:49 AM after he physically assaulted his caregivers. Review of the physician's encounter note showed that the patient has a history of autism and assaulting behavior. Records showed that upon admission to the ED, the patient was aggressive, violent, screamed, hit and kicked individuals, injured several staff members. On two occasions a Code Grey was initiated (process to communicate & mobilize a response team to manage an individual who is combative or displays abusive behavior). The patient was monitored immediately upon entry into the ED, at 9:54 AM, he was monitored by AV video, at 10:00 AM, a caregiver was assigned to observe the patient 1:1 and at 6:20 PM, he was determined to be medically cleared and moved to the Special Emergency Care Unit (SECU) within the department. In the SECU, the patient was evaluated by a mental health profession (DMHP) who determined the patient did not fit the criteria for commitment and he remain on a voluntary status. On 05/14/19 records showed that the patient eloped the department and after a mental health (DCR) evaluation was performed, the patient was on an involuntary admission and a 14 day commitment order. On 5/16/19, the patient was noted to be on hold for a Single Bed Certification after he eloped from the department and was waiting placement disposition.

Record review of restraint/seclusion documentation revealed that ED staff provided care to the patient in the SECU and kept him under continuous seclusion while an assigned staff member observed him 1:1 twenty-four hours per day. One licensed provider entered a note dated 04/27/19, that secondary to multiple episodes of aggression and assault to the staff (who continued to feel unsafe) orders were to continue the patient's seclusion for staff safety. Review of nurse's seclusion documentation showed that the patient was physically assessed and re-evaluated hourly. ED technicians observed and documented notes every 15 minutes and offered the patient fluids (juice in his room), food (snacks), and bathroom/shower time. Caregivers notes showed that the patient, at times was "re-directable, resting in bed, sleeping ..." A review of a behavioral health provider note dated 05/18/19 showed that the patient slept through the night and woke up early in the morning requesting television, plus a snack. That the patient had a positive day and without significant disruptive behavior.

3. During review of Patient #1001's medical record on 07/11/19 at 9:15 AM, the ED Director (Staff #1001), and Investigator #10 reviewed a seclusion checklist dated 05/10/19 that showed hourly checks describing the patient as asleep. The investigator asked Staff #1001 if the patient's seclusion was at any time discontinued. The Director stated that the patient was kept in seclusion due to his potential for aggressive behavior and harm inflicted on her staff. She added, if the patient awoke and needed something, he would "knock" on the seclusion door to inform staff.

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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on interview, medical record review, and review of policies and procedures, the hospital failed to ensure staff performed and documented a one-hour face-to-face evaluation after initiation of restraint or seclusion for patients exhibiting violent behavior, as observed in 3 of 7 patient records reviewed (Patients #1001, #1002, 1003).

Failure to perform or document a one-hour post application, evaluation on a patient during use of physical restraints or seclusion for violent behavior can lead to possible abuse, assault, and self-injury or poor patient outcome.

Findings included:

1. Review of the hospital's policy titled, "Restraint for Violent, Self-Destructive Patients," Policy #200.2.102 effective 12/24/18, showed that restraints or seclusion will be utilized only when the patient is unable or unwilling to stop behavior that interferes with medical treatment, and necessary for the safety of the patient, care givers, or others. The patient must be seen face-to-face within one (1) hour after the initiation of restraint or seclusion by a physician, or trained nurse and complete an assessment. The policy outlines specific documentation included in the one-hour assessment, which includes: the patient's immediate situation, patient's reaction to the intervention, patient's medical/behavior condition, and the need to continue or discontinue restraints.

2. Review of Patient #1001's medical record showed a [AGE] year old who was transported to the emergency department (ED) by local police, on 06/24/19 at 3:38AM. The patient exhibited aggressive behavior toward staff at his group home and police were notified. It was noted that his caregivers were traumatized by his behavior. Review of his diagnosis list includes autism spectrum disorder (ASD) and aggression. The patient's record showed that he was cleared medically by the emergency department (ED) physician and was waiting discharge placement (family unable to care for patient at home due to his aggressive behavior). The patient was being cared for in the ED's Specialized Emergency Care Unit (SECU) awaiting discharged disposition, this was day 14 of his ED visit.

The patient's initial notes showed that upon entry to the ED, he began to exhibit aggressive behavior toward staff and after trying less restrictive alternatives, the patient was placed in seclusion, at 9:15 AM. Further review showed that the patient was placed into seclusion six (6) separate additional events. However, the physician's or a trained nurse's completed one-hour face-to-face post initiation assessment, for 6 of the 7 seclusion events, could not be found in the medical record.

Review of Patient #1002's medical record showed a [AGE] year old who was transported to the ED by emergency medical services for evaluation of a mental health disorder. The patient was medically cleared and then evaluated by a Designated Crisis Responder (DCR) who officially detained the patient. The patient was receiving care in the SECU and under observation. On 06/16/19 at 8:45 AM, the patient was observed hitting his head on the wall but staff were unable to redirect the patient and a Code Grey was initiated, at 9:30 AM. The patient was placed into 4-point locked restraints. At 10:48 AM, the patient's behavior improved and the restraints were discontinued. A physician order for restraints was observed in the record, however, the physician's or trained nurse's face-to-face one-hour physical assessment after the initiation of seclusion could not be found in the medical record."

Similar findings were observed in Patient #1003's seclusion records.

3. During an interview on 07/09/19 at 3:00 PM, the ED Director (Staff #1001) confirmed the missing one-hour post initiation documentation for each event.

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VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on interview, record review and review of hospital policies and procedures, the hospital failed to ensure emergency department (ED) staff performed a complete initial assessment for patients presenting for care, as observed in 3 of 6 patient records reviewed (Patients #1004, #1005, #1006).

Failure to perform a complete initial assessment can lead to obtaining inaccurate patient information resulting in an ineffective plan of care, treatment, or services.

Findings include:

1. Record review of the hospital's policy titled, "Emergency Department Nursing Care Standard (NCS)," reviewed 04/30/18 showed that after a rapid triage assessment, each patient presenting to the ED for care, will undergo an initial complaint based focused assessment to include the patient's comfort level, safety (fall risk, suicide/violence risk, signs of abuse/self-harm, skin integrity - risk for skin breakdown), and psychosocial (include family or other representative).

2. Record review of 3 patients who were restrained and/or secluded in the ED showed:

a. Review of Patient #1006's medical record showed an [AGE] year-old patient (MDS) dated [DATE] at 5:53 PM, claiming he has thoughts of harming himself, depressed, and increased anxiety. Review of the ED physician's encounter note revealed that the patient has attempted suicide in the past. The patient was accompanied by family members and they requested he undergo a psychiatric evaluation. The patient was evaluated, monitored, diagnostic testing performed, and then discharge later that night.

Review of the ED nurse's initial assessment showed that the safety assessment did not include a documented suicide risk assessment as part of the initial assessment. The patient was placed under one-one observation at 7:00 PM, approximately 60 - 70 minutes after he entered the ED.

b. Review of Patient #1005's medical record showed a [AGE] year-old patient transported to the ED on 07/03/19 at 7:25 PM, by Police Officers after she left her assisted living facility (ALF), but became aggressive when the officers attempted to return her to her ALF. The ED provider's encounter note showed that the patient had a medical history of cancer, arthritis, and dementia. After the patient was evaluated, assessed, and underwent diagnostic testing, she was then medically cleared. The patient was diagnosed with dementia and aggressive behavior. She remains in the ED, currently being cared for in the Specialized Emergency Care Unit (SECU). A review of the ED social worker's note showed that the patient was placed on a 14 day court ordered hold on 07/09/19, and will remain in the SECU until an inpatient psychiatric bed is available.

Review of the ED nurse's initial assessment showed that some elements of the safety assessment were incomplete, specifically suicide screen and skin integrity.

c. Similar findings were observed in Patient #1004's records.


3. During an interview on 07/10/19 at 10:50 AM, the ED Director (Staff #1001) confirmed the missing documentation.

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