Banner Thunderbird Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 52995 Based on a review of hospital record and interviews, it was determined that the hospital failed to ensure that a provider order was received when patient #11 required a physical restraint. This deficient practice poses the risk of patients being restrained unnecessarily, the use of restraint as a punishment, increased risk of injury to the patient being restrained, and the right of the patient to have an environment free from abuse. Findings include: The policy titled, “Restraint use for Non-violent and Violent situations revealed”: Behavioral/Violent Restraint: Restraint or Seclusion used to manage violent or self-destructive behavior; i.e. danger to self (DTS) or danger to others (DTO) that poses an imminent danger to the physical safety of the patient, staff or others, regardless of the patient ’ s location...B. Physical Holding: Patients may be physically held for the purpose of conducting physical examinations or tests. However, patients do have the right to refuse treatment, including the right to refuse physical examinations or tests. Holding a patient in a manner that restricts the patient ’ s movement against the patient ’ s will is considered a restraint. The use of force in order to medicate a patient against their will, even when court ordered, is considered a restraint. Staff may only use Banner approved physical hold techniques as taught per Workplace Violence Prevention training. C. A physician/LIP order is required prior to the initiation of Restraints or Seclusion. Exception: In emergency situations, Restraints and Seclusion may be applied prior to the Registered Nurse (RN) obtaining the order; however, an order must be obtained duringor immediately (within a few minutes) after the application of Restraints....” During review of Patient #11 medical record was revealed that on 07/30/2025 at 2135 patient became confused agitated, and aggressive towards staff. Attempting to kick, bite and headbutt staff. Security staff was called to intervene. Further review of Patient #11 medical record revealed that patient was physically restrained to prevent injury or harm to patient #11 and staff. Further review of Patient #11 revealed that patient #11 did sustain skin tear to left and right arms during the physical hold. Further review of Patient #11 medical record revealed that there was no restraint order for the physical hold that occurred on 07/30/2025. An interview with employee #4 on 08/19/2025 confirmed that the policy for restraint use was not followed and there was no order for restraint in Patient #11 medical record.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the hospital did not reassess two (2) out of 20 patients (Patient #1 and #10) who presented to the ED per the hospital’s policies and procedures, that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases. Findings include: Hospital policy titled, “Emergency Department Patient Care”, revealed: “ ...Guidelines of Care ...Triage assessment ...1. Completed by a RN, Paramedic or QMP ....2. An Emergency Severity Index (ESI) score is assigned when the triage assessment is completed ...ESI 2 = High risk situation or confused/lethargic/disoriented or severe pain distress ...ESI = 3 Two or more resources may be needed ...3. ED triage documentation may include, but is not limited to: Chief complaint, vital signs, pain, and oxygenation, Mode arrival and mechanism of injury, Triage assessment and ESI scoring ...Medical Screening Exam ...1. A medical screening exam (MSE) is completed by an Emergency Physician or QMP. When applicable, the ED Medical Provider and/or QMP will complete the MSE in conjunction with an RN or Paramedic as a joint assessment. Both the ED Medical Provider and/or QMP and RN or Paramedic perform a complaint specific assessment to prioritize, treat and evaluate for emergent, urgent, and non-urgent patients ....Assessment/Reassessment ...4. Occurs according to the patient’s clinical presentation or any significant clinical event with the minimum requirements as follows: ...ESI 2 = Documented reassessments every 1 hour under hemodynamically stable, then minimally every 4 hours or per admitting unit guidelines of care ...ESI 3 = Documented reassessments every 4 hours ...5. Reassessments may include, but are not limited to: Patient’s current condition/status; Pain; Response to interventions ...Vital Signs ...1. To be completed at a minimum with every ED assessment/reassessment ...2. Vital signs include: Heart Rate, Blood Pressure, Respiratory rate, Temperature, Oxygen Saturation ...Pain ....Left Without Treatment (LWOT): If a patient is seen leaving, expresses desire to leave or is unobserved leaving prior to a MSE ...Elopement: If a patient that has had a MSE and does not complete care who leaves the hospital without knowledge of the family, physician, or hospital personnel ....” Hospital document titled, “ED Huddle” dated 05/15/2024, revealed: “ ...Regardless of ESI score, all patients in the lobby are required to have vital signs retaken. ESI 2 q1 hr and all others documented every 2 hours. This can be done by an EDT {sic}(ED technician), the Zoomer, or a triage nurse ....” Review of Patient #1’s medical record dated 05/28/2024 identified an ED triage note, and it revealed: “ ...Date/Time of Service: May 28, 2024 12:24 ...Chief complaint: pt on the phone last night and then “came to” hunched over in chair and left arm was shaking for approx. 15 secs; pt states [he] remembers events; hx of 1 seizure 12 yrs ago while playing video games; pt reports having HAs {sic}(headaches) a few times a week for past yr ...Systolic Blood Pressure: 125mmHg, Diastolic Blood Pressure: 79mmHg, Heart Rate Monitored: 85bpm, Respiratory Rate: 18br/min, SpO2: 97%...Tracking Acuity: 3 ...Pain Assessment ...1 = Mild pain ....” Review of Patient #1’s medical record revealed they remained in the lobby, and no laboratory or diagnostic imaging were ordered, and no treatment initiated. Review of Patient #1’s medical record dated 05/28/2024, revealed no reassessment between triage at 12:24 ESI of 3, and discovery of Patient #1’s elopement at 16:54, with 4 hours and 30 minutes elapsed. Review of Patient #10’s medical record dated 05/08/2024 identified an ED triage note, and it revealed: “ ...Date/Time of Service: May 08, 2024 17:26 ...Chief complaint: SOB {sic}(shortness of breath), shakiness, HA {sic}(headache), BG {sic}(blood glucose) of 300 at home. Audible wheezing. Hx DM1 {sic}(diabetes mellitus type 1), COPD {sic}(chronic obstructive pulmonary disease), PE {sic}(pulmonary embolism), BG 336 in triage ...Systolic Blood Pressure: 156mmHG (H), Diastolic Blood Pressure: 91mmHg (H) ...Peripheral Pulse Rate: 106bpm (H), Respiratory Rate: 24br/min (H), SpO2: 99%....” Review of Patient #10’s medical record dated 05/08/2024, revealed no reassessment between triage at 17:26 ESI of 2, and Patient #10’s LWOT at 19:36, with 2 hours and 10 minutes elapsed. Employee #7 confirmed during an interview conducted on 07/16/2024 that patients who are in ED beds are reassessed per policies and procedures, and patients in the lobby with ESI of 2 are to have their vital signs retaken every hour and patients with other ESI to have vitals retaken every two hours. Employee #6 confirmed Patient #1 and Patient #10 did not have documented reassessment or vital signs retaken for changes of condition, per the facility’s policies and procedures and standards.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interviews, it was determined the Hospital delayed examination and treatment for four (4) out of 20 patients (Patients #1, #10, #16, and #20), who presented to the ED seeking medical treatment. Findings include: Hospital policy titled, “EMTALA - Medical Screening Examination and Stabilization Treatment”, revealed: “ ...III. Policy: A. Medical Screening Examination (“MSE”) ....2. An appropriate MSE will be offered to individuals in the Hospital’s Dedicated Emergency Department who request emergency medical services ...4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE. 5. An MSE will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient’s needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred. 6. An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals regardless of their ability to pay ...8. Where an individual comes to the Hospital’s Dedicated Emergency Department and requests services for a medical condition that is not of an emergency nature, the Hospital will perform such screening as would be appropriate to determine that the individual does not have an EMC ....12. The MSE includes ancillary services routinely available to the Hospital along with available personnel, which includes on-call physicians, in determining whether an EMC exists ....B. Stabilizing Care. 1. If the MSE demonstrates that an EMC exists, the Hospital will provide Stabilizing Treatment within the Hospital’s Capabilities, even if the Hospital must transfer the Patient ....2. A Patient with an EMC is stabilized when the physician/QMP determines that: a. The Patient is Stable for Discharge (i.e., when, within reasonable clinical confidence, the physician or QMP determines that the Patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as in inpatient) ....” Hospital policy titled, “Emergency Department Patient Care”, revealed: “ ...Guidelines of Care ...Triage assessment ...1. Completed by a RN, Paramedic or QMP ....2. An Emergency Severity Index (ESI) score is assigned when the triage assessment is completed ...ESI 2 = High risk situation or confused/lethargic/disoriented or severe pain distress ...ESI = 3 Two or more resources may be needed ...3. ED triage documentation may include, but is not limited to: Chief complaint, vital signs, pain, and oxygenation, Mode arrival and mechanism of injury, Triage assessment and ESI scoring ...Medical Screening Exam ...1. A medical screening exam (MSE) is completed by an Emergency Physician or QMP. When applicable, the ED Medical Provider and/or QMP will complete the MSE in conjunction with an RN or Paramedic as a joint assessment. Both the ED Medical Provider and/or QMP and RN or Paramedic perform a complaint specific assessment to prioritize, treat and evaluate for emergent, urgent, and non-urgent patients ....Assessment/Reassessment ...4. Occurs according to the patient’s clinical presentation or any significant clinical event with the minimum requirements as follows: ...ESI 2 = Documented reassessments every 1 hour under hemodynamically stable, then minimally every 4 hours or per admitting unit guidelines of care ...ESI 3 = Documented reassessments every 4 hours ...5. Reassessments may include, but are not limited to: Patient’s current condition/status; Pain; Response to interventions ...Vital Signs ...1. To be completed at a minimum with every ED assessment/reassessment ...2. Vital signs include: Heart Rate, Blood Pressure, Respiratory rate, Temperature, Oxygen Saturation ...Pain ....Left Without Treatment (LWOT): If a patient is seen leaving, expresses desire to leave or is unobserved leaving prior to a MSE ...Elopement: If a patient that has had a MSE and does not complete care who leaves the hospital without knowledge of the family, physician, or hospital personnel ....” Review of Hospital’s Emergency Department (ED) Log for May 2024, revealed Patient #1 checked in on 05/28/2024 at 11:47, acuity of 3, doctor assessment completed at 11:50, and checked out at 17:35 with disposition as eloped and left unannounced. Review of Patient #1’s medical record dated 05/28/2024 identified an ED triage note, and it revealed: “ ...Date/Time of Service: May 28, 2024 12:24 ...Chief complaint: pt on the phone last night and then “came to” hunched over in chair and left arm was shaking for approx. 15 secs; pt states [he] remembers events; hx of 1 seizure 12 yrs ago while playing video games; pt reports having HAs {sic}(headaches) a few times a week for past yr ...Systolic Blood Pressure: 125mmHg, Diastolic Blood Pressure: 79mmHg, Heart Rate Monitored: 85bpm, Respiratory Rate: 18br/min, SpO2: 97%...Tracking Acuity: 3 ...Pain Assessment ...1 = Mild pain ....” Review of Patient #1’s medical record dated 05/28/2024 identified an ED provider note, and it revealed: “ ...Provider patient care initiated: 05/28/24 11:50 ...Medical Decision Making ...The patient was evaluated in Triage in conjunction with the Triage RN. I performed a brief Medical Screening evaluation and examination of the patient. No orders have been placed as the patient left shortly after their triage evaluation, but I considered including CBC, Comprehensive Metabolic Panel. Patient was informed that they will need to wait for the next available bed and that additional testing may be indicated if subsequent ED Provider determines appropriate based on more through {sic}(thorough) history and physical exam. The patient returned to the lobby but unfortunately eloped ...Disposition ...Eloped ....” Review of Patient #1’s medical record revealed they remained in the lobby, and no laboratory or diagnostic imaging were ordered, and no treatment initiated. Review of Patient #1’s medical record identified a completed form for patients who left without informing staff prior to completion of care. The form revealed three attempts were made to locate the patient without success at 16:54, 17:11, and 17:35. Review of Patient #1’s medical record revealed no reassessment between triage at 12:24 as ESI of 3, and discovery of Patient #1’s elopement at 1654 hours, with 4 hours and 30 minutes elapsed. An additional 19 ED medical records were randomly selected for review including patients who were transferred, admitted, discharged home, left before treatment, and eloped. Review of 19 ED medical records revealed three (3) patients had a delay in examination or treatment: 1. Patient #10, arrived 05/08/2024 17:16 for shortness of breath, triaged 17:26 with ESI 2, no MSE, LWOT 19:36, time elapsed from arrival: 2 hours 20 minutes 2. Patient #16, arrived 06/01/2024 18:31 for fall, triaged 18:34 with ESI 3, MSE 18:33, no labs or imaging completed, eloped 20:39, time elapsed from arrival: 2 hours and 8 minutes 3. Patient #20, arrived 06/27/2024 21:37, no triage completed, LWOT 23:30, time elapsed from arrival: 1 hour 53 minutes Employee #6 confirmed during an interview conducted on 07/16/2024 that Patient #1 had a MSE initiated at triage, and returned and remained in the lobby. Employee #6 also confirmed no laboratory or diagnostic imaging were ordered, and no treatment provided for Patient #1. Employee #6 also confirmed there was no documentation that Patient #1 was reassessed for changes of condition while waiting in the lobby for four and a half hours.”