HospitalInspections.org

Based on observation, interview, record review, policy review and video recording review, the hospital's Governing Body failed to:
- Ensure the Chief Executive Officer (CEO) effectively managed the hospital in order to meet applicable regulatory requirements (A-0057);
- Ensure Patient #30 was not allowed to wear sweatpants that had a drawstring around her waist on the Center for Psychiatric Services (CPS, the hospital's behavioral health unit) Unit (A-0144)
- Ensure 11 shower curtains were psychiatric (relating to mental illness) safe and not easily pulled away.(A-0144);
- Ensure 33 chairs with wooden frames on the CPS Unit were psychiatric safe and could not be used as weapons. (A-0144);
- Recognize ligature risks on the CPS Unit, when Patient #23 was on suicidal precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) and had two hospital gowns on, one was covering her front and the other covered her back. Both hospital gowns had long ties near the neck and waist (A-0144);
- Recognize ligature risks on the CPS Unit when there were three hospital gowns that had long ties near the neck and waist, in a patient room and both patients occupying that room were on suicidal precautions (A-0144);
- Recognize ligature risks on the CPS Unit when 30 hospital gowns with long ties near the neck and waist were found in the clean utility room (A-0144);
- Ensure staff appropriately followed Mandt (an approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others) training and utilized appropriate de-escalation techniques and physical holds during a restraint (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for two patients (#37 and #38) of two patients observed in restraints (A-0145);
- Ensure Public Safety Officer's (PSOs) completed Mandt training as outlined in the action plan from the root cause analysis (RCA) completed after a Taser incident on 11/03/22 (A-0145);
- Ensure PSOs followed hospital policy and used Tasers as a last, non-lethal resort to defend themselves or others against a threat of serious physical injury or death on two patients (#37 and #38) of two patients observed (A-0145);
- Ensure PSOs followed hospital policy and removed and secured their Tasers prior to entering the CPS Unit. (A-0145)
- Ensure Leadership recognized that a Taser was considered a weapon and not allowed to be brought into the CPS unit (A-0145);
- Ensure staff medically assessed and obtained vital signs on two patients (#37 and #38) of two patients observed that had been tased (A-0145); and
- Ensure all physicians and other licensed practitioners (LPs) who ordered restraints and seclusion, completed required training and put a policy in place regarding restraint and seclusion physician and LP training requirements (A-0176).

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body and resulted in the hospital's failure to ensure quality health care and safety.

The hospital census was 92.

Based on observation, interview, record review, policy review and video recording review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.12 Condition of Participation (CoP): Governing Body and 482.13 CoP: Patient's Rights This failure had the potential to affect the quality of care and safety of all patients. The hospital census was 92.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 09/27/17, showed that the CEO was the individual named by the Board of Trustees to act on behalf of the Board in the overall management of the hospital.

Review of the hospital's document titled, "Board of Trustees Special Closed Session Minutes," dated 07/21/21, showed that a motion was made and the Board of Trustees approved, to offer Staff III, CEO, the position of CEO.

The CEO failed to ensure compliance with the COP of Governing Body as evidenced by failure to effectively manage the hospital in order to meet applicable regulatory requirements. (A-0057)

The CEO failed to ensure compliance with the COP of Patient's Rights as evidenced by failure to:
- Ensure Patient #30 was not allowed to wear sweatpants that had a drawstring around her waist on the Center for Psychiatric Services (CPS, the hospital's behavioral health unit) Unit. (A-0144)
- Ensure 11 shower curtains were psychiatric (relating to mental illness) safe and not easily pulled away.
- Ensure 33 chairs with wooden frames on the CPS Unit were psychiatric safe and could not be used as weapons. (A-0144)
- Recognize ligature risks on the CPS Unit, when Patient #23 was on suicidal precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) and had two hospital gowns on, one was covering her front and the other covered her back. Both hospital gowns had long ties near the neck and waist. (A-0144)
- Recognize ligature risks on the CPS Unit when there were three hospital gowns that had long ties near the neck and waist, in a patient room and both patients occupying that room were on suicidal precautions. (A-0144)
- Recognize ligature risks on the CPS Unit when 30 hospital gowns with long ties near the neck and waist were found in the clean utility room. (A-0144)
- Ensure staff appropriately followed Mandt (an approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others) training and utilized appropriate de-escalation techniques and physical holds during a restraint (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for two patients (#37 and #38) of two restraints viewed. (A-0145)
- Ensure Public Safety Officer's (PSOs) completed Mandt training as outlined in the action plan from the root cause analysis (RCA) completed after a Taser incident on 11/03/22. (A-0145)
- Ensure PSOs followed hospital policy and used Tasers as a last, non-lethal resort to defend themselves or others against a threat of serious physical injury or death on two patients (#37 and #38) of two patients viewed. (A-0145)
- Ensure PSOs followed hospital policy and removed and secured their Tasers prior to entering the CPS Unit. (A-0145)
- Ensure Leadership recognized that a Taser was considered a weapon and not allowed to be brought into the CPS unit. (A-0145)
- Ensure staff medically assessed and obtained vital signs on two patients (#37 and #38) of two patients viewed that had been tased. (A-0145)
- Ensure all physicians and other licensed practitioners (LPs) who ordered restraints and seclusion, completed required training and put a policy in place regarding restraint and seclusion physician and LP training requirements. (A-0176)

During an interview on 05/11/23 at 3:15 PM, Staff III, CEO, stated that he was responsible for the entire hospital and responsible for the oversight of regulatory compliance with the CoPs for Governing Body and Patient's Rights. He agreed that there should be no ligature risks on the CPS Unit and the PSOs should have completed Mandt training as outlined in the 11/08/22 RCA.

Based on interview, record review, policy review and review of digital video recording, the hospital failed to provide a safe environment, free from potential abuse, when they:
- Failed to remove a drawstring from the waist of Patient #30's sweatpants, which was considered a ligature risk on the Center for Psychiatric Services (CPS, the hospital's behavioral health unit) unit (A-0144);
- Had 11 shower curtains, on the CPS unit, that were not psychiatric safe and were not easily pulled away (A-0144);
- Failed to remove 33 chairs on the CPS unit, with wooden frames that were not psychiatric safe chairs and could be used as weapons to harm themselves or others, from patient rooms, the television room and the hallways (A-0144);
- Failed to ensure staff appropriately followed Mandt (an approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others) training and utilized appropriate de-escalation techniques and physical holds during a restraint (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for two patients (#37 and #38) of two restrained patients viewed (A-0145);
- Failed to ensure Public Safety Officers (PSOs) completed Mandt training as outlined in the action plan from the root cause analysis (RCA) completed after a Taser incident on 11/03/22 (A-0145);
- Failed to ensure PSOs followed hospital policy and used Tasers as a last, non-lethal resort to defend themselves or others against a threat of serious physical injury or death on two patients (#37 and #38) of two patients viewed (A-0145);
- Failed to ensure PSOs followed hospital policy and removed and secured their Tasers prior to entering the CPS Unit (A-0145);
- Failed to ensure Leadership recognized that a Taser was considered a weapon and allowed to be brought into the CPS unit (A-0145);
- Failed to ensure staff medically assessed and obtained vital signs on two patients (#37 and #38) of two patients viewed that had been tased (A-0145); and
- Failed to ensure all physicians and other licensed practitioners (LPs) who ordered restraints and seclusion, completed required training and to put a policy in place regarding restraint and seclusion physician and LP training requirements (A-0176).

These failures created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. The hospital census was 92.

The severity and cumulative effect of these systemic practices resulted in the overall noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights, which resulted in a condition of Immediate Jeopardy (IJ).

As of 05/17/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- Removed the drawstring from Patient #30's sweatpants;
- Provided education to all staff regarding ligature risk, and potentially dangerous mobile items that could be used as weapons;
- Removed the chairs from Patient rooms on the CPS unit;
- Secured chairs together with psychiatric safe screws in the hallways and television room;
- Removed shower curtain hooks except the ones on each end and one in the middle making it unable to hold weight;
- Ensure PSOs would not be allowed to work until Mandt training was completed;
- Ensure upon hire, PSO employees completed Mandt training prior to completion of orientation.
- Ensure every PSO employee completed Mandt training annually.
- Develop a Post Use of Force Policy, which included vitals and physical assessment of the patient after any use of force utilized beyond de-escalation to be completed by nursing or provider. Patient to have assessment completed and documented in the medical record, in addition to Fit for Confinement. Medical Treatment was to be offered for injuries as needed.
- Ensure education to all nursing department staff and PSO staff of post-event assessment to be completed by nursing or provider and documented in the medical record. Assessment to include physical findings and vital signs. Providers to complete Fit for Confinement prior to the patient being discharged from the hospital.
- Ensure education to all nursing department staff and PSO staff of the need to escalate all events in which Use of Force beyond de-escalation was utilized by notifying Nursing Supervisor, who will notify Hospital Leadership.
- Update Use of Force policy to notify law enforcement as soon as possible by the PSO/designee in the event a Taser was drawn.
- Ensure education to PSO staff regarding use of Taser and shall only be utilized for the use of imminent threat of physical harm to patient, visitors. or staff after all Mandt training resources have been used.





41474

Based on observation, interview, record review and policy review, the hospital failed to provide care in a safe setting where multiple ligature (anything which could be used for the purpose of hanging or strangulation) risks and mobile items were present in the Center for Psychiatric Services (CPS, the hospital's behavioral health unit) that could be used to harm themselves and others when:
- Patient #30 was allowed to wear sweatpants that had a drawstring around her waist.
- 11 Shower curtains were not psychiatric (relating to mental illness) safe and were not easily pulled away.
- There were 33 chairs with wooden frames that were not psychiatric safe chairs and could be used as weapons to harm themselves or others, in patient rooms, the television room and in the hallways.
- Patient #23 was on suicidal precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) and had two hospital gowns on, one was covering her front and the other covered her back. Both hospital gowns had long ties near the neck and waist.
- There were three hospital gowns that had long ties near the neck and waist, in a patient room and both patients occupying that room were on suicidal precautions.
- 30 hospital gowns with long ties near the neck and waist were found in the clean utility room on the CPS.

The failure to remove ligature risk and mobile items had the potential to put all patients on the CPS unit at risk for their health and safety. The hospital census was 92.

Findings included:

Review of the hospital's policy titled, "Suicide Risk Precautions," revised 03/2021, showed the following:
- It is the policy of the hospital to provide a safe environment and appropriate care for patients who have been determined to be at risk for suicide (to cause one's own death) or self-harm through early identification and initiation of precautions.
- When a person expresses feelings of sadness, hopelessness, despair or grief, it is important to assess any possible risk of physical harm to him or herself. Staff will use evidence based risk assessments to identify the appropriate safety precautions needed for each patient.
- Potentially harmful objects should be removed from patient rooms, items included shoes with shoestrings and clothing with long strings on them.
- Potentially harmful items are not allowed in patient rooms.

Review of the hospital's policy titled, "Q15 Minute Safety Checks," revised 02/2019, showed it was the policy of the hospital to provide a safe environment and appropriate care for patients who have been determined to be at risk for suicide or self-harm, impulsive, violent or an elopement (when a patient makes an intentional, unauthorized departure from a medical facility) risk through early identification and initiation of precautions as well as perform safety checks every 15 minutes to ensure their safety and a safe environment.

Review of the hospital's policy titled, "Safety Searches," revised 03/2021, showed that room searches would be performed in the interest of patient, staff and visitor safety. The desired outcome of all searches was to minimize risk in the environment and to secure harmful and potentially harmful items if they were found. Necklaces and bracelets were not allowed for safety reasons. Room searches were conducted several times throughout each day and as needed.

Review of the hospital's policy titled, "Patient Sitter," revised 06/2022, showed staff performing patient room safety checks should remove any extra furniture from the patient room as they could be used as potential weapons. Remove all unused linen from the room including towels, sheets, and patient gowns as they can be strangulation risks.

Review of the hospital's handbook titled "The Center for Psychiatric Services, Patient/Legal Guardian Handbook" dated 06/15/22, showed the following were permitted:
- Patients will only need three changes of comfortable clothes, undergarments and sleeping attire.
- No hooded garments, scarves/bandanas, or hats/headgear or revealing attire are allowed.
- No drawstrings or belts, and no laces on shoes.

Review of the hospitals handbook titled "Phelps Health Center for Psychiatric Services. Mandatory Guidelines for Direct Care Staff to Maintain a Safe and Therapeutic Environment," dated 11/12/20, showed the following:
- Safe Practices included knowing where your patients are and what they are engaged in even between safety checks.
- Safety checks must be performed by direct visual eyesight (not through camera usage) and must be conducted at least every 15 minutes. Document the exact time you directly observed the patient and location of patient in the patient's records.
- Report any variation in behavior immediately to RN Shift Manager. During the night shift, it is important that you observed respirations and any changes in patient behavior or location to the RN Shift Manager.

Observation on 05/16/23 at 9:37 AM, on the CPS unit, showed Patient #39 had on gray sweat pants with a draw string around the waist.

Review of patient #39's medical record showed the following:
- She was a 25-year-old female who presented to the Emergency Department (ED) on 05/13/23, with shortness of breath and dizziness, she also complained of feeling anxious (a feeling of fear or worry experienced intermittently).
- Past medical history included self-harm by cutting herself.
- Physician documentation showed she reported paranoia (excessive suspiciousness without adequate cause) and some delusional (false ideas about what is taking place or who one is) thoughts. She believed people were out to harm her and she had been running away from family members.
- On 05/13/23 she was admitted to the CPS Unit with a 96 hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others), and a diagnosis of paranoid schizophrenia (a mental illness that involves mistaken beliefs that one or more people are plotting against them or their loved ones).
- Admission orders included every 15 minute safety checks (15-minute visualization and documentation of the safety of each patient) be performed and continued throughout her stay.
- On 05/14/23, a short term goal included the patient's verbalization of control of suicidal thoughts/behaviors, and had not been documented as met.

Review of the hospital's document titled, "Hold/Guardian Precautions," dated 05/10/23, showed Patient #23 and Patient #24 were on suicide precautions.

Observation on 05/10/23 at 9:30 AM, on the CPS Unit, showed Patient #23 and #24's room with three hospital gowns folded on a shelf that had long ties at the neck and waist. Patient #23 was walking down the hallway wearing two hospital gowns, one to cover her front and one put on backwards to cover her back. Both hospital gowns had long ties at the neck and waist.

Observation on 05/10/23 at 9:40 AM, on the CPS Unit, showed the shower curtains in patient rooms did not come down from the hooks when pulled on. There were chairs with wooden frames that were not psychiatric safe chairs and could be used as weapons to harm themselves or others, in patient rooms, the television room and in the hallways.

Observation on 05/11/23 at 2:30 PM, on the CPS Unit, in the clean utility room, showed 30 gowns with strings on a linen cart.

During an interview on 05/10/23 at 1:15 PM, Staff GG, Director of CPS, stated that Patient #23 was wearing two hospital gowns from the intensive care unit (ICU, a unit where critically ill patients are cared for). There should not have been hospital gowns in Patient #23's room, hospital gowns with ties were a risk to safety. There were around 30 chairs on the Unit, and the chairs had been used in violent ways in the past. Heavy weighted chairs were in the budget to order, but the order hadn't been placed yet. The shower curtain hooks were fairly new and she did not realize that they could not be pulled down. The shower curtains should easily break away from the hooks. She planned to order new shower curtain hooks that were seven pound break away hooks that day.

During an interview on 05/17/23 at 9:32 AM, Staff GG, Director of CPS, stated that all the shower curtain hooks had been taken care of.

During an interview on 05/16/23 at 9:32 AM, Staff N, Risk Manager, stated the CPS unit ordered seven pound break away shower curtain hooks, when they arrived they were not the seven pound break away shower curtain hooks and those were on back order. She did not know when they would arrive, staff went to each room and removed the shower curtain from every other break away hook while waiting for the correct hooks to arrive.





39354

Based on interview, record review, policy review, and video recording review, the hospital failed to ensure:
- Staff appropriately followed Mandt (an approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others) training and utilized appropriate de-escalation techniques and physical holds during a restraint (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for two patients (#37 and #38) of two patient restraints reviewed.
- Public Safety Officer's (PSOs) completed Mandt training as outlined in the action plan from the root cause analysis (RCA) completed after a Taser (weapons designed to disrupt an individual's central nervous system by means of deploying battery powered energy sufficient to cause neuro muscular incapacitation and override an individual's voluntary motor responses) incident on 11/03/22.
- PSOs followed hospital policy and used Tasers as a last, non-lethal resort to defend themselves or others against a threat of serious physical injury or death on two patients (#37 and #38) of two patients reviewed.
- PSOs followed hospital policy and removed and secured their Tasers prior to entering the Center for Psychiatric Services (CPS, the hospital's behavioral health unit) Unit.
- Leadership recognized that a Taser was considered a weapon and not allowed to be brought into the CPS unit.
- Staff medically assessed and obtained vital signs on two patients (#37 and #38) of two patients reviewed that had been tased.

These failures had the potential to place all patients at risk for abuse and their overall safety. The hospital census was 92.

Findings included:

Review of the hospital's policy titled, "Use of Force," revised 04/2021, showed the following directives for staff:
- Hospital Department of Public Safety (DPS) Officers should immediately assess each situation and determine which techniques will effectively de-escalate the situation and bring it under control with the least risk of injury to all involved. These techniques could include: calling for assistance, use of verbal nonviolent crisis intervention techniques, use of defensive skills and physical strength, use of defensive tools or instruments such as batons or Taser, use of lethal force such as side arms or long guns in situations when presented with a lethal force threat.
- In the event that assistance is requested in the CPS Unit, armed hospital DPS Officers and any local law enforcement officers who respond must remove and secure their weapons prior to entering CPS.
- During rapidly escalating situations, officers should utilize the minimum level of force available to safely deal with the threat presented.
- The patient must be medically assessed and be deemed "Fit for Confinement" prior to release for police custody.

Review of the public Center for Medicare and Medicaid Services (CMS) online document titled, "CMS.gov, State Operations Manual, Appendix A - Regulations for Hospitals," revised 02/21/20, showed that a weapon includes pepper spray, mace, nightsticks, Tasters, cattle prods, stun guns and pistols. CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention.

Review of the hospital's policy titled, "Workplace Violence Training Program," revised 10/2022, showed the following:
- The workplace violence training program helps staff avoid or mitigate the risk of workplace violence through a combination of training and preparation.
- The workplace violence training program is a proactive approach to assessing for risk and preventing harm in all care settings.
- Job roles requiring workplace violence training include the Public Safety Department.
- Workplace violence includes the following: bullying, intimidating or harassing another person; the act of threatening to inflict physical harm or unwanted physical contact which causes fear of such contact that will be painful and injurious, and behavior that causes another person emotional distress and creates a reasonable fear of injury.

Review of the hospital's policy titled, "Abuse and Neglect," revised 04/2023, showed the following:
- Phelps Health recognizes that each patient has the right to be free from mistreatment, neglect, and misappropriation of property.
- This policy applies to all departments including, but not limited to, hospital departments, physician clinics, ancillary departments, all outpatient areas, and business offices.
- All patients have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and neglect.
- Patients must not be subjected to abuse by anyone, including facility staff, other patients, consultant or volunteers, staff of other agencies servicing the patient, family members or legal guardians, friends, and/or other individuals.
- Initiate action to provide a safe environment for the patient.

Review of the hospital's policy titled, "Taser Usage," revised 04/2023, showed the following:
- A Taser is a conducted energy weapon.
- The Taser shall not be utilized on a patient except as a last, non-lethal resort by officers to defend themselves or others against a threat of serious physical injury or death.
- In the event that a subject who has been energized refuses to comply, and continues to present a threat, the officer is authorized to re-energize the subject in five second increments until sufficient assistance has arrived to apply restraints and control the threat.
- The Taser is not to be used to subdue or restrain anyone who is a patient unless all other means of control have either been exhausted and proven ineffective or the patient is escalating to higher levels of violence too quickly to attempt some basic or intermediate de-escalation techniques.
- In exigent circumstances (circumstances that require immediate action), the Taser may be deployed in a 'Drive Stun" mode (the process of using the Taser as a pain compliance technique; this is done by activating the Taser and placing it against the person's body without a cartridge in place and is intended to cause pain without incapacitating the subject).

Review of the hospital's document titled, "The Mandt System, Student Workbook," dated 1975 - 2022, showed the following:
- The Mandt System is a comprehensive, integrated approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others.
- The focus of the Mandt System is on building healthy relationships between all the stakeholders in human services settings in order to facilitate the development of an organizational culture that provides the emotional, psychological, and physical safety needed to teach new behaviors to replace behaviors that are labeled challenging.
- The Mandt System provides a framework that empowers staff to do their work in a way that minimizes the use of coercion in behavior change methodologies.
- The Mandt System prohibits these practices: pain compliance, trigger points, pressure points, any technique that forces the person to the floor, and any manual restraint that maintains a person on the floor in any position (prone, supine, side-lying).
- Pain (physical or emotional) should never be used to make a person comply with directions or demands. It is abuse and will destroy therapeutic treatment and rapport between the person and the staff.

Review of the hospital's policy titled, "Root Cause Analysis," revised 12/2022, showed the following:
- Root cause analysis (RCA) is a systems-based approach, for identifying the factors or system level causal underlying factors that contributed to variation in performance, including the occurrence or possible occurrence of a sentinel, or other adverse event or condition.
- Variation in performance can produce unexpected and undesired adverse outcomes.
- When trying to solve a problem/system failure, the team member identifies the root cause of the problem/system failure and then finds ways to eliminate or mitigate the identified system hazards or vulnerabilities and prevent them from recurring.
- Develop and implement an action plan for improvement and make adjustments as needed.

Review of the hospital's policy titled, "Restraint and Seclusion - Violence and Self Destructive Indications," revised 01/2020, showed the following:
- Leadership is committed to providing effective and efficient care in a safe environment, with the respect for the rights and dignity of the individual receiving care. To this end, leaders communicate this philosophy on the use of restraint and seclusion to all direct care staff.
- This philosophy includes the following principles: the least restrictive and non-physical techniques are always considered as the preferred intervention; the commitments to problem solve potentially dangerous situations and avoid or eliminate restraint; and the commitment to utilize an approved de-escalation training to enhance personal safety within the context of patient rights and needs.
- Staff who have completed an approved de-escalation program are considered competent to implement the principles and standards for manual redirection and manual restraint.

Review of the medical record for Patient #37, showed he was a 44 year old male who presented to the emergency department (ED) on 10/26/22 via law enforcement for a 96 hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) after his mother, the patient's legal guardian, reported he had made suicidal (thoughts of causing one's own death) and homicidal (thoughts or attempts to cause another's death) statements to her, with recent erratic behavior (grabbed steering wheel while driving). The patient had a past medical history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly). The ED clinical impression for Patient #37 was psychosis (a serious mental illness characterized by defective or lost contact with reality). On 10/28/22, Patient #37 was admitted to the CPS unit for suicidal ideation, homicidal ideation, schizophrenia, opiate use and marijuana use. On 11/03/22, physician documentation indicated Patient #37 was verbally agitated, threatening to engage in violence and reported a desire to go to jail. The patient appeared to respond to internal stimuli; judgement and insight poor secondary to psychosis. Security was called to the unit. Patient #37 punched a nurse and he was then discharged to jail. Nursing documentation on 11/03/22 indicated that Staff RRR, PSO, reported that he "dry stunned" the patient with his Taser for three seconds. After the incident, there was no documentation that Patient #37 was medically assessed or that vital signs were obtained prior to discharge into police custody. Nursing documentation indicated that a physician completed a fit for confinement form for Patient #37; this was not found in the patient's medical record.

Review of the hospital's video recording titled, "CPS - 4 Nurses Station," dated 11/03/22, showed the following:
- The video time stamp began at 12:26:29 PM.
- At 12:26:55: Patient #37, Staff QQQ, PSO, Staff RRR, PSO, Staff HH, Registered Nurse (RN) and four other CPS staff were seen standing at the nurses station, in front of the opened seclusion room door.
- At 12:27:01: Staff QQQ appeared to be talking with Patient #37.
- At 12:27:05: Patient #37 walked down the hallway past the seclusion room, an RN stood in front of the patient and tried to direct him into the seclusion room.
- At 12:27:10: Patient #37 hits the RN in the face and she fell to the ground.
- At 12:27:11: Patient #37 ran down the hallway and both Staff QQQ and Staff RRR grabbed the patient and tackled him to the ground.
- At 12:27:17: Patient #37's legs were moving.
- At 12:27:24: Staff HH held the patient's legs, Staff QQQ held the patient's right arm and Staff RRR held the patient's left arm. The patient was lying supine (lying on the back with the face and torso facing upward).
- At 12:29:00: The patient was not resisting and continued to be held in a supine position by Staff HH, QQQ and RRR.
- At 12:30:00: Staff HH released hold on Patient #37's legs; Staff QQQ and RRR assisted the patient to a standing position and ambulated the patient to the seclusion room.
- The video ended at 12:30:30.
- Due to the angle of the video, the surveyor was unable to view when Staff QQQ used the Taser to drive stun Patient #38.

Review of the hospital's document titled, "Department of Public Safety Incident Report #2022-321," dated 11/03/22, showed that Staff RRR, PSO was the investigating officer of an event that occurred on the CPS unit on 11/03/22 involving Patient #37. He and Staff QQQ, PSO, were assisting staff with a patient that was uncooperative and disruptive. Patient #37 punched a nurse in the face with his right fist. Staff RRR and Staff QQQ tackled Patient #37 to the floor to prevent him from attacking the nurse any further. Patient #38 continued to struggle. Staff RRR, pulled his Taser and applied a drive stun to the lower right rear flank of Patient #37. The patient stopped fighting and said he was done. The police were called and took custody of the patient.

Review of the hospital's document titled, "Root Cause Analysis Tool, Event Report ID: DEC18165371," dated 11/08/22, showed the following:
- The date of the first meeting was 11/08/22. There was no date documented for a second or third meeting.
- A description of the event that occurred on 11/03/22, indicated Patient #37 became verbally agitated, threatened to engage staff in violence and reported a desire to go to jail. Staff ambulated with the patient down the hall and requested him to go into room 435, the seclusion room, to be medicated. The patient stated he would rather go to jail than stay in the hospital. The patient then took a step towards the nurse and punched her in the right side of the face. Security then took the patient to the floor and physically restrained him. Staff RRR, PSO, stated he had dry stunned the patient for three seconds. When additional staff arrived to the unit to assist, the patient was requested to comply and walk to the locked seclusion room. The patient complied. The local police department was contacted due to the assault. The patient was taken to jail on 11/03/22 at 1:06 PM.
- The Taser policy needed some updating.
- Staff RRR had not received any de-escalation training through Phelps Health at the time of the incident.
- Security was escorting the patient with the nurse; security was wearing a Taser.
- The Taser was deployed during the course of handling the patient after the patient had physically assaulted a staff member and continued to display assaultive behaviors. The Taser worked as designed.
- The root cause and action plan indicated that certifications for PSO Mandt training was not showing up on staff "to do list." Mandt certification was a two part process (online training followed by hands on training). Staff had only completed the online training, so they were not certified. All PSO staff to be certified in the Mandt training. The person responsible was Staff EEE, Chief of Public Safety and date completed was 12/26/22.

On 05/11/23, the state surveyor's requested the list of PSO's employed by the hospital and dates of completed Mandt training. Documentation showed that only 13 out of 26 PSOs employed by the hospital had completed Mandt training.

During an interview on 05/11/23 at 12:11 PM, Staff RRR, PSO, stated that on 11/03/22, he was called to the CPS unit because Patient #37 was being obnoxious with the physicians and the staff. The patient would not listen. When PSO arrived on the unit the patient was in the physician office, yelling at the physician, and yelling he wanted to go to jail. The patient was informed he had done nothing to go to jail for. PSO walked the patient down the hall and informed the patient he needed to go to the seclusion room for a while. The patient started walking toward the seclusion room. The patient side stepped and the RN informed the patient he needed to go into the seclusion room. The patient punched the RN in the face, and then started down the hallway. PSO did not know where the patient was headed, so they took him to the floor. The patient was asked several times to get his arm out and he would not, so he used his Taser to drive stun the patient. The patient yelled out and quit moving. Staff RRR stated that the patient verbailzed to him that "he was done", he then started to cooperate, and the patient was walked to the seclusion room without further incident. When the drive stun was used on the Taser, it was less harm to the patient. The drive stun hurts, but it was not a lasting hurt. The Taser was used on the patient while on the floor because he was moving around like he was trying to get away. After the patient hit the RN, the officers still felt the patient was a danger to staff and other patients. He had not had Mandt training. He had not received a class date for the training. He had worked part time at the hospital for two or three years. He was also an active law enforcement officer. This was the only time he had used his Taser. The only thing carried onto the CPS unit was a Taser. He could carry a Taser at all times.

During an interview on 05/11/23 at 10:38 AM, Staff QQQ, PSO, stated that he recalled the event regarding Patient #37 that occurred 11/03/22 on the CPS unit. Staff RRR, PSO, was already on the unit. Security was called for a patient that was out of control and argumentative towards the doctor and nurses. He carried a Taser and firearm. Before PSO staff entered the CPS unit, firearms were secured in a lock box. PSO staff were allowed to carry a Taser at all times. When he arrived to the CPS unit on 11/03/22, Patient #37 was hollering and said he was not going to stay anymore. Staff were trying to direct the patient to the seclusion room to medicate the patient. Security staff were several feet behind him. A nurse stepped in front of the patient to direct him into the seclusion room and the patient struck her. He and Staff RRR made contact with the patient by taking him to the ground. It was easier to handle someone when they were off their feet. The patient was resisting, struggling. He did not recall when Staff RRR used the Taser on Patient #37; he did not hear Staff RRR say he was going to use the Taser. When the Taser was used in the drive stun mode, it was an "attention getter." The patient complied and then walked to the seclusion room. He was certified in Mandt training.

During an interview on 05/11/23 at 11:13 AM, Staff HH, RN, CPS Shift Manager, stated that on 11/03/23, Patient #37 had been extremely agitated all day. The goal was to get the patient to the seclusion room to medicate him because he had been threatening violence and would do whatever he needed to do to go to jail. She called security when the patient started making threats. After Patient #37 hit the nurse, the PSO's got on top of him and controlled his upper body. She held the patient's feet. Staff RRR, PSO, reported that he had drive stunned the patient. PSO's were required to secure their guns before entering the unit. They were allowed to carry Tasers onto the unit. She felt the takedown of Patient #37 was appropriate. Abuse was causing undo harm to a patient, either physical or verbal. A Taser if misused could be a form of abuse.

During an interview on 05/11/23 at 8:37 AM, Staff EEE, Chief PSO, stated that videos were reviewed after every occurrence. He was notified immediately after each time a Taser was used. The officer that used the Taser wrote a report, and the video was reviewed. He then contacted the Director of Security and the Risk Director. He tracked the usage of the Tasers. A Taser was the least amount of force. The officers normally carried a Taser, handcuffs, and a firearm. Pepper spray and a baton were optional to carry. The first goal was to keep the staff, patients, and visitors safe. The word "weapon" referred to the firearm the officers' carried. Verbal de-escalation was always used. The absolute minimal amount of force was always used for any situation. All officers received abuse and neglect training, and restraint training. A Taser would be used if the verbal de-escalation did not work, the situation still escalated, all other means of de-escalation had failed, and there was still immediate danger. This happened very rarely. In the 11/03/22 Taser incident, the officer felt the only way for the patient to go from a "no" person to a "yes" person was to use the Taser. After each Taser incident, the PSO staff involved were educated, and the situation was reviewed.

During an interview on 05/11/23 at 8:37 AM, Staff DDD, Director of Security, stated that the PSOs left their firearms in a secure locker before entering the CPS unit. When the PSO used the Taser on patient #37, on 11/03/22, the officer had to make a split decision of what to do in the "heat of the moment". The officer made the appropriate choice. After the incident, no actual changes were made to the wording of the Taser policy, other than it was reviewed and the model of the Taser was updated. The officers always took their weapon off before entering CPS. A Taser was not considered a weapon. To be a security officer, the qualifications were Mandt training with in the first year. All PSOs were current law enforcement officers. A Taser could be used as a form of abuse if used inappropriately.

Review of Patient #38's medical record showed that he was a 57 year old male that arrived to the ED on 01/25/23 at 6:41 PM with a diagnosis of alcohol intoxication. He had a past medical history of alcohol abuse, cardiac murmur, psychosis and seizures (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or levels of consciousness). The patient was agitated, restless, verbally abusive and delusional (false ideas about what is taking place or who one is). Ativan (a medication that has a calming effect, used to treat anxiety or sleep difficulties) and Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) were ordered to be given and administered to the patient at 7:38 PM. Blood work resulted at 9:41 PM, indicated a critical lab value of ethanol (alcohol) at 368 mg/dl. Normal ethanol level was less than 299. The patient slept from 8:00 PM until the patient was awakened and rechecked by the medical provider on 01/25/23 at 2:22 AM and concluded the patient was stable for discharge. Nursing documentation at 2:21 AM indicated the patient was verbally aggressive with staff, the patient was being discharged and was asked to get dressed. Security was called for support. Nursing documentation at 2:27 AM, indicated the patient continued to be verbally aggressive with security and started walking toward security aggressively. The patient was advised by security to stop or he would be tased. The patient backed off and sat in the wheelchair to put his shoes on. Nursing documentation at 2:30 AM, indicated the patient started cursing and threatening security again. The patient walked aggressively toward security and the patient was tased. The patient turned around, took a few steps and fell to the ground. The patient was placed in handcuffs and awaited for local police to respond. After the incident there was no documentation that Patient #38 was medically assessed or that vital signs were obtained prior to discharge into police custody. The patient was discharged on 01/25/23 at 2:41 AM.

Review of the hospital's video recording titled, "Emergency Room #5," dated 01/25/23, showed the following:
- The video time stamp began at 02:19:59.
- At 02:20:08: Patient #38 was lying on his right side, three staff members in the room. The curtain was closed.
- At 02:20:39: The curtain was opened, one RN and Staff KKK, PSO and Staff MMM, PSO were outside of the room.
- At 02:21:04: Staff member placed the patient's shirt and pants next to him on the bed.
- At 02:21:22: Patient #38 appeared agitated, sat up in bed, raised his middle finger at the staff member, and pointed his finger at staff.
- At 02:21:42: Patient #38 removed his paper scrub top, threw the scrub top at a staff member, the staff member threw the scrub top back at the patient. The patient put his shirt on. The curtains were open, the patient was exposed.
- At 02:22:55: Patient #38 removed his paper scrub pants, while the curtains were open, and PSO staff were standing outside the patient's room. The patient's genitals were exposed.
- At 02:24:39: Patient #38 got up out of bed and stood by the doorway. Staff KKK had Taser pointed at the patient.

Review of the hospital's video recording titled, "ER-4 Rooms 4-5-6-7-8," dated 01/25/23, showed the following:
- The video time stamp began at 02:19:59.
- Patient #38 was not visible on the screen until he exited Room Five.
- At 02:20:48: Staff KKK, PSO, Staff MMM, PSO and Staff NNN, PSO were in close proximity of ED, Room Five.
- At 02:20:59: All three PSOs stood at the entrance of Room Five.
- At 02:24:41: All three PSOs backed away from Room Five; Staff KKK had his Taser out and pointed at the patient.
- At 02:24:50: Staff MMM also had his Taser out and pointed at the patient. The PSOs continued to back up.
- At 02:25:39: Staff KKK and Staff MMM have Tasers pointed at the patient. The hallway was not cleared of equipment. There was a metal table and three computer on wheels in the hallway by Room Five.
- At 02:26:16: Staff KKK stepped toward the entrance of Room Five, Taser still pointed.
- At 02:26:23: Patient #38 stepped out of Room Five and walked down the hallway. Staff MMM put his Taser away. Staff NNN redirected the patient and the patient turned and walked towards Room Five. The patient stopped and pointed his finger at Staff KKK; Staff KKK pointed his finger at Patient #38.
- At 02:26:54: Three PSOs and three ED staff were in the hallway by Room Five. Staff KKK continued to have his Taser pointed in the direction of Patient #38.
- At 02:28:08: Patient #38 sat in a wheelchair outside of Room Five, attempted to put his shoes on. Three PSOs were in close proximity.
- At 02:29:37: All three PSOs, a large male ED employee and Staff JJJ, RN were in close proximity of Patient #38. Patient #38 stood up, walked toward Staff KKK.
- At 02:29:38: Patient #38 was tased by Staff KKK. Patient #38 fell to the ground and was lying on his right side. Staff KKK had his Taser pointed at the patient.
- At 02:29:50: Patient #38 rolled onto his stomach; Staff KKK continued to point his Taser at the patient.
- At 02:30:05: Patient #38 was handcuffed by Staff MMM.
- After the patient was tased, video review showed that the patient was not touched by any medical or nursing staff. A physician bent over the patient, but did not touch the patient.
- At 02:33:50: Local law enforcement arrived.
- At 02:39:37: Law enforcement wheel Patient #38 out of view.

Review of the hospital's document titled, "Department of Public Safety Incident Report #2023-26," dated 01/25/23, showed that Staff KKK, PSO, was the investigating officer and on 01/25/23 at approximately 2:18 AM, Staff MMM, PSO, Staff NNN, PSO and Staff KKK responded to the ED, Room five, in reference to an uncooperative individual, Patient #38, who appeared to be intoxicated. Patient #38 was yelling obscenities at the nursing staff and refused to get dressed. Staff KKK asked the patient to get dressed so he could leave. The patient advised Staff KKK to "fuck off" and that he would "beat his ass". At this time, Staff KKK believed he was faced with an immediate or imminent threat of physical injury, unholstered his Taser and powered it on. The local police department was asked to respond to aid in averting unnecessary danger to or harm to anyone involved. Patient #38 asked Staff KKK to get the lasers off of him (referring to Staff KKK's assigned Taser). The lasers were pointing at the ground, in front of the patient's feet. The patient kicked his shoe off and again threatened bodily harm to Staff KKK. Patient #38, got up from the wheelchair and went towards Staff KKK in an aggressive manner. In response to the threat that was presented by Patient #38's actions, Staff KKK deployed his Taser and delivered a five second charge. Patient #38 fell to the ground and kept his arms under his body. Staff KKK instructed the patient to put his hands behind his back; the patient did not comply. Staff KKK recharged his Taser and delivered a two second shock to the patient, instructing him to place his hands behind his back; the patient complied with the order. Staff MMM and Staff NNN placed the patient in handcuffs. The local police arrived, removed the Taser barbs from the patient's body and left with him.

Review of the hospital's document titled, "Root Cause Analysis Tool, Event Report ID: QBB18299793," dated 01/26/23, showed the following:
- The type of event was agitated discharge ED patient - tased.
- The event occurred on 01/25/23 and involved Patient #38 who arrived to the ED on 01/24/23 at 6:53 PM via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) for alcohol intoxication.
- On 01/25/23 at 2:18 AM, the patient was currently sleeping and an order for discharge was placed.
- The patient became verbally aggressive and security was contacted for support.
- The patient became aggressive with security and the PSO pulled his Taser.
- The patient noted the Taser red light was still on the floor in front of the wheelchair where the patient was sitting and Patient #38 told the officer to turn it off; security refused and advised the patient to get dressed so he could leave.
- The patient then got out of the wheelchair and aggressively advanced toward the PSO, the patient was tased.
- The patient was instructed to place his hands behind his back; he did not comply, the Taser was recharged and a two second shock was given. The patient then complied.
- The patient was placed in handcuffs and police were contacted.
- Policies were reviewed and no concerns were identified regarding this event.
- No vital signs were documented after 9:29 PM on 01/24/23.
- The patient was reevaluated by the provider after being tased, but no documentation was in the patient's medical record.
- Security was trained on de-escalation and the use of tasers.

On 05/11/23, the state surveyor's requested the list of PSO's employed by the hospital and dates of completed Mandt training. Documentation showed that Staff KKK, PSO and Staff MMM, PSO had not completed Mandt training.

During an interview on 05/15/23 at 2:00 PM, Staff KKK, PSO, stated that he and two other PSOs were called to the ED for Patient #38 who was discharged and was being combative. Patient #38 was lying on the bed and appeared to be very intoxicated. He was belligerent. Security asked him to get his clothes on. Staff KKK stated that Patient #38 verbalized that he "would kick his ass." Staff KKK felt that there was an imminent threat due to Patient #38's behavior and verbal assault, so he drew his Taser and powered it on. A nurse helped Patient #38 find his shoes. The Taser was not pointed toward Patient #38, but he became upset. Staff KKK explained that the Taser was pointed in a safe direction. Patient #38 kicked off his shoe, said "let's do this" and stepped toward Staff KKK. Staff KKK felt there was imminent threat and deployed his Taser. The Taser delivered a five second energized round, and Patient #38 was given commands to put his arms behind him to place him in handcuffs. He refused, and Staff KKK reenergized the Taser for about two seconds, and Patient #38 then complied and was placed in handcuffs. Security did try verbal de-escalation prior to the Taser being deployed. There would not have been time to put Patient #38 in a physical hold between the time Patient #38 got out of the wheelchair and when he was tased. Law enforcement was called prior to the Taser deployment. Staff KKK felt that Patient #38's behavior indicated he was going to assault someone. Staff KKK was not Mandt trained. Per the hospital's use of force continuum policy, it was not necessary to follow the order of the continuum depending on the threat presented. Security staff were usually able to talk to patients refusing to discharge and they become agreeable to leaving. Homeless patients were able to sit out in the

Based on interview, record review and policy review, the hospital failed to ensure all physicians and other licensed practitioners (LPs) who ordered restraints and seclusion, completed required training. The hospital also failed to put a policy in place regarding restraint and seclusion physician and LP training requirements. These failures had the potential to adversely affect all patients placed in restraints. The hospital census was 92.

Findings included:

Review of the hospital's document titled, "Medical Staff Rules and Regulations," revised 11/2019, showed that the medical staff will conform to the hospital wide policy on restraints and seclusion.

Review of the hospital's policy titled, "Restraint and Seclusion-Violence and Self Destructive Indications," revised 01/2020, showed that staff competency requirements included Physicians/Certified Advanced Practice Nurses have working knowledge in the use of Restraint and Seclusion according to hospital policy.

Even though requested, the hospital failed to provide training requirements on restraint/seclusion for physicians and a copy of training completion.

During an interview on 05/11/23 at 4:04 PM, Staff A, Quality Executive Director, stated that physicians have not had restraint training since 2020.