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Based on observation, interview, and document review, the hospital failed to protect and promote patient rights for 1 of 10 patients (P1) reviewed for behavioral disturbances. A security officer used a taser (a law enforcement tool) to restrain P who fell to the ground, and sustained a laceration on his head which required sutures.

As a result, the hospital was found NOT in compliance with Condition of Participation Patient Rights at 42 CFR 482.13.

The IJ began on 11/30/24 when a facility security officer used a taser on P1, who then fell and sustained a laceration on his head requiring sutures. The Vice President (VP) of Medical Affairs, VP of Nursing, Mental Health Director, Mental Health Manager, Security Director, Security Manager, Risk Manager, Accreditation Specialist, Accreditation Strategist, Safety Quality Director were notified of the IJ findings on 12/12/24 at 4:10 p.m. The IJ was removed on 12/17/24 at 12:30 p.m., after verification of an acceptable removal plan, but a condition level deficiency was issued.

A condition level deficiency was issued. See A-0154

Based on observation, interview, and document review, the hospital failed to protect and promote patient rights for 1 of 10 patients (P1) reviewed for behavioral disturbances. A security officer used a taser (a law enforcement tool) to restrain P1. P1 fell to the ground, and sustained a laceration on his head which required sutures.

Findings include:

P1's emergency department (ED) admission record indicated P1 presented to the ED on 11/12/24. P1's diagnoses from this visit included schizoaffective disorder, paranoia, psychosis, and substance abuse.

P1's Physician Order dated 11/14/24 directed "Assault Precautions" (undefined) with the following interventions: Document reason for precaution in staff alerts, communicate assault precautions in report, review behavioral expectations for no violence at start of shift, assist patient to identify triggers to violence and develop a plan to de-escalate, consider a private room near the nursing station, consider space restriction from other patients, consider use of increased security presence on unit, consider removing items in the lounge that could be thrown.

On 11/30/24 at 2:00 p.m., a progress note indicated P1 was observed on camera throwing an object and a chair. There was a show of support call (when security officers, nursing staff or other staff are summoned to be present as a visual deterrent to decrease the likelihood of physical confrontation, and to support de-escalation efforts to prevent physical contact with the patient prior to requiring to call a (Code Green) was initiated. P1 was saying he would be violent if staff entered his secured area. A Code Green (overhead announcement for immediate staff assistance for a patient who is presenting, through behavior or threats, a danger of harm to self or others) was initiated. Security officers were on the unit and tried to verbally de-escalate P1, and encouraged him to sit down. P1 continued to escalate and was non-redirectable. P1 was yelling and kicking the doors. Security officers then opened the doors to the closed observation area. P1 was holding a cordless phone and threw it at the security officers. In response, P1 was tased and fell to the ground sustaining a laceration to the right temporal region. The as needed medications were administered, and P1 was moved to the seclusion area and placed in four-point restraints. The rapid response team and internal medicine physician were paged. The physician determined P1 required a CT scan, and would need to be transported to the emergency department (ED) for suturing of the laceration. P1 was in restraints for a total of 15 minutes. P1 was transported to the CT scan without incident, and was calm and cooperative.

On 11/30/24 at 12:44 p.m., a video recording (without audio) was reviewed. P1 was observed pacing around his room, the hallway, and lounge area. There were no other patients or staff in the secured area. P1 repeatedly slammed a door and threw a weighted chair across the room. From 12:47 p.m. through 12:54 p.m. P1 sat on the chair and talked on a cordless phone. At 12:55 p.m. P1 moved two chairs to make a partial barricade in front of the door. At 12:56 p.m. four security officers (SO) entered the area. P1 moved towards them, made verbal threats, and threw the phone at them. The phone did not strike any of the SOs. The SO-A immediately deployed his taser hiting P1 who fell and hit his head on the wall. Nursing staff entered the area, and both nursing and SO attended to P1. Two taser darts were removed from P1's shoulder and groin area. Approximately 15-30 minutes later, SO brought P1 to the ED where he required four sutures to his forehead and a CT as a result of the fall.

On 12/9/24 at 11:57 a.m., P1 stated no de-escalation techniques were used during the incident. His shoulder and neck were still sore from the fall, and he still had bruises on right shoulder and groin area from the taser. He had four sutures on his forehead. He was upset about how he was treated. P1 was not able to provide a succinct answer for why he was upset on 11/30/24. P1 stated staff did not try de-escalation techniques with him.

On 12/9/24 at 12:29 p.m., registered nurse (RN)-A stated she was present during the incident. She showed up for the show of support and was not able to see the taser deployment. She was not able to specify what type of de-escalation techniques were used, or to what extent they were tried. She suggested calling the police. There was a debrief following the incident.

On 12/10/24 at 12:30 p.m., RN-B (the patient care manager of the mental health unit) stated nursing staff and security officers had a plan to administer medications to P1, move the chairs out of the area and then leave the area, but plans changed due to the continued verbal threats and the phone being thrown. Nursing staff and security officers were trying to verbally de-escalate the patient by talking through the window between the secured area and the nursing station. The patient was in a secured area to make sure the other patients were safe.

On 12/10/24 at 2:19 p.m., SO-C stated SOs arrived to the unit for a show of support, and the nurses did not have a plan besides administering medications for P1's agitation. P1 could see the SOs through the window and was making verbal threats. Security determined it should be called a Code Green to obtain more staff support. None of the nursing staff wanted to assume the role of Code Green director. Although SO-C did not deploy the taser on P1, tasers could be used on patients if there was a threat of harm. Following the incident, he did a debrief with the security manager, and discussed having a Code Green director.

On 12/10/24 at 2:34 p.m., SO-D stated SOs arrived to the unit for a show of support, which turned into a Code Green. The SOs went into the secured area, and were telling P1 to go to his room. He threatened to throw the phone several times before he threw it, and we tased him. SO-D was unable to state if there was a plan to obtain the cell phone from P1, or if the four SOs had designated roles before entering the secure area. SO-C reviewed the incident with leadership, and the suggestion was to make sure there was a Code Green director identified before SOs could do anything.

On 12/10/24 at 2:42 p.m., RN-C stated she called for a show of support so she could administer P1 his medications for his agitation. P1 was agitated because the family members he was trying to call were not answering the phone. When the SOs arrived, they decided to call a Code Green. P1 started throwing the chairs and the tables, so the SOs decided to go in and try to hold him down to administer his medications via intramuscular injection.

On 12/10/24 at 2:56 p.m., the security manager (SM)-A stated the SO's response to the incident was rushed. The SOs could have waited it out, entered when P1 wasn't escalated, which may have led to a better outcome. Following the taser deployment, a debriefing was held with the SOs. They discussed concerns with identifying the director of the code green. There was no indication the debriefing discussed SM-A's concern the incident was rushed.

On 12/11/24 at 11:09 a.m., SO-A stated de-escalation did not work on P1, and clinical staff had asked security to take control. P1 was making threats, had created a barricade, and threw the phone. That is when he deployed the taser.

On 12/11/24 at 11:33 a.m., medical doctor (MD)-A stated she responded to the incident since she was called about P1's forehead laceration. She did not have concerns about the use of the taser on P1. She responded to assess the forehead laceration.

On 12/11/24 at 11:40 a.m., SO-B stated the use of a taser was indicated when a patient was posing substantial to great bodily harm to others. He observed P1 throw the chair on camera, and felt the Code Green should have been called a lot sooner.

On 12/11/24 at 4:00 p.m. risk manager (RM)-A stated SOs made attempts to verbally de-escalate P1 through the door. The hospital determined the use of the taser on P1 was appropriate because of the potential for a significant threat of injury to the four security officers, and P1's throwing of the phone was considered criminal activity. There was no better way to deal with this, and all four SOs acted within their scope. All actions were reasonable.

The facility policy Use of Security Interventions dated 5/24, directed law enforcement weapons may be used only on the rare occasion where there is immediate risk of substantial or great bodily harm, after available de-escalation techniques have been utilized. Law enforcement tools must not be used as a clinical intervention including to gain patient compliance or subdue a patient to place them in restraint or seclusion.

The IJ was removed on 12/17/24 at 12:30 p.m. after the following actions were completed: Facility policies Use of Security Interventions, System-wide policy: Code Green and Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior were reviewed with no changes. Education was provided to all relevant staff on the policies and procedures. Examples were provided to security staff to determine when additional assistance would be required. The education included Know Why and Comply Behavioral Escalation and Clinical Interventions, De-escalation tip sheet, Agitation Protocol, Violence Prevention Program - Situational Awareness, Mercy Hospital Code Green Officer Guidance and Scenarios. A new admission form, How I Cope, was created to identify patient specific de-escalation techniques. Audits were completed using the Violent Restraint/Seclusion Documentation Audit form. This was verified through interview and document review.