HospitalInspections.org

Based on clinical record review, staff interview and review of facility documents and documentation, the facility failed to ensure patient rights of three (3) of three (3) patients (Patient #11, 12, and #13) who presented to the facility for treatment were protected as evidenced by: failure to adhere to facility policy for determining patient capacity for treatment (A-0131), failure to monitor patients after being administered a chemical restraint (A-0160), failure to use least restrictive interventions to protect patients and others (A-0164) and failure to obtain orders for chemical and physical restraints (A-0168). The cumulative effect of these findings led to violation of patient rights.

Cross references:
§482.13(b)(2) Patient Rights: Informed Consent
§482.13(e)(1)(i)(B) Patient Rights: Chemical Restraint
§482.13(e)(2) Patient Rights: Use of Restraint or Seclusion
§482.13(e)(5) Patient Rights: Restraint or Seclusion Order


42929

Based on clinical record review staff interview, and facility document review, the facility staff failed to ensure each patient was permitted to exercise their rights. Patient #11 was:

1. "Held" in the Emergency Department without being informed of their status/ability to leave.
and
2. Was administered medications (Intramuscular injection- IM) over refusal/objection.

The findings included:

1. Patient #11 presented to the Emergency Department (ED) on 12/13/23, according to the "ED Provider Note" with complaints of increased depression...some auditory hallucinations...no s/h (suicidal/homicidal) ideations...would like to have thyroid level drawn...Medical Decision Making: medically stable for psychiatric evaluation..."

A "ED Triage" note dated 12/13/23 at 2:00 p.m. evidenced: "...sad, withdrawn and cooperative...Is the patient an ECO (Emergency Custody Order)? No..."

At 3:40 p.m. it was documented in the RN (Registered Nurse) note: "Is the patient an ECO? No".

On 12/13/23 at 5:07 p.m., the documentation in the clinical record evidenced: "During AES (Adult Emergency Services) assessment pt (patient) became agitated, through (sic) ipad, attempted to leave department...Per AES TDO (Temporary Detaining Order) is recommended...Patient prevented from leaving ED by Carilion PD (Police Department)..."

At 15:40 p.m. on 12/13/23 there was documentation under the "Behavioral Health Assessment - Is the Patient an ECO? No."

On 12/13 at 5:23 p.m., the Mental Health Therapist had entered a note: "recommended TDO...City Magistrate has agreed to issue TDO, however pt cannot be served or transported on a TDO without bed placement..."

On 12/14/23 it was documented at 7:00 a.m. in the "Behavioral Health Assessment : Is the patient an ECO? No..."

The only documentation about the issuance of an ECO was in the Physician Assistant note 12/14/23 at 1:17 p.m. "...ECO issued this a.m...."

The clinical record evidenced on 12/14/23 at 17:16 (5:16 p.m.) "Carilion PD exit annex due to ECO ending at 1700 (5:00 p.m.)."


Patient #11 remained in the ED until 11:56 p.m. (12/14/23) when it was documented that "PD arrived to transfer patient to psych facility...Pt left in PD custody." There was no documentation of when the ECO nor TDO were formally served to the patient, only that the patient had been "prevented" from leaving the department.

In an interview with SM #5 on 2/5/24 at 3:10 p.m., the SM stated: "The ECO was started at 0900 (9:00 a.m. 12/14/23) and lasts for eight (8) hours...the TDO was recommended but when we call the magistrate they will not issue the TDO until we have a bed confirmed, but they tell us that they will issue it. It takes time to find a bed..." The surveyor inquired about the legality of holding the patient without the ECO or the TDO, the rights of the patient and whether the patient was informed they were able to leave. SM #5 stated "Legally they can leave but we are not willing to let them leave due to the risk to the patient and the community..." The surveyor asked, in this case with Patient #11, why the ECO was allowed to elapse and the patient still held. SM #5 stated, "We could have had the Magistrate list the bed of last resort on the papers but we do not like to dump on the state hospital..." The surveyor asked if the patient was informed of their right to leave. SM #5 stated the patient was not told they could leave because they were on a recommended TDO.

The facility policy and procedure "Patient rights and Responsibilities" effective 11-2021 evidenced, in part: "...IV. Procedure: A. Patient Rights- held when the individuals treating physician, clinical psychologist or clinical social worker has made a part of the individuals record a written statement that , in the exercise of their professional judgement the furnishing to ...would be reasonably likely to endanger the life or physical safety of the individual or another person...reasons must be clearly documented...c. Information may not be withheld from a patient in the belief that providing the information will cause the patient to forgo the treatment...4. The right to obtain complete, current information concerning diagnosis...treatment...7. The right to reasonable informed participation in decisions involving his/her care, treatment and services...13. Receive care in a safe setting free from all forms of harassment or abuse. This includes freedom from restraint or seclusion that is not indicated for safety or medical indications...15. The right to refuse treatment to the extent permitted by law..."

The Facility policy "ECO, TDO, and Judicial Authorization - Obtaining and Care of Patient effective 9-2023" evidenced, in part: "...III. Policy Statement: A. An ECO is issued by a magistrate when upon sworn petition of any responsible person, treating physician or upon his/her won motion to facilitate a face-to-face meeting with the person and a designee of the Community Services Board to determine if the patient needs further hospitalization or treatment...B. A paperless ECO may be obtained in certain situations...C. The purpose of a psychiatric TDO is to require short term detention of a patient who is believed to be suffering from a mental illness, at risk of harm, and is unwilling or incapable of consenting to treatment...Procedure: Emergency Custody Order:...3. Process: a. The magistrate issues the ECO. The ECO is served through law enforcement...b. The patient will be taken into custody for a period not to exceed 8 (eight) hours. An ECO cannot be extended...4. Paperless ECO : A Carilion Police Officer, based on their own observations or the reliable reports of others...may take a person into custody...The period of custody shall not exceed 8 (eight) hours. b. If a patient is voluntary needing mental health treatment and requests to leave the hospital, staff will notify the practitioner/ACP(Advanced Care Practitioner) or nurse and Carilion Police for further evaluation. A decision will be made by the practitioner/ACP in collaboration with Carilion Police to determine if criteria is met for ECO. c. All reasonable attempts should be made to enlist the patients cooperation in remaining in the ED or hospital. Carilion Police will apply the least restrictive means of physical restraint may only be used as a last resort...B. Temporary Detention Order...c. The TDO will not be formally issued until bed placement has been arranged..."

The surveyor discussed the concerns with facility administration on multiple occasions throughout the survey 2/4 through 2/6/24 (SM # 5, 25, 28, 29, 31 and 32.)

2. Review of the clinical record for Patient #11 revealed the patient was administered "Haldol (an antipsychotic) 5mg (milligrams), Ativan 2mg, and Benadryl 50mg IM (intramuscular injection) on 12/13/23 at 7:58 p.m. for (7:52 p.m.) "verbally aggressive, hateful and disrespectful to staff, continued to push the code button over and over". It was also documented the "Police Department was at the bedside."

The surveyor was unable to locate in the clinical record evidence detailing the medication administration to the patient who was displaying agitation and whether or not the patient accepted the medication, however in an interview with Staff Member (SM) #22 on 2/6/24 at 2:50 p.m. the SM stated: "We tried to talk to (patient) and calm (them)...I let (patient) know I was giving the med and (patient) put up a fuss so the officers stood on each side of (patient) and each officer placed their one hand on the upper arm and one on forearm below on both of the (patient's) arms and (patient) didn't struggle. (Patient) voiced some derogatory words but (patient) didn't jerk or struggle. (Patient) did say 'you are not going to do that to me', but (patient) didn't struggle when the police officers placed their hands on (patent's arms)."

It was again documented Patient #11 received the same "cocktail" of medications IM on 12/14/23 at 9:28 a.m. for "severe agitation". The note documented in the clinical record at 12/14/23 0930 (9:30 a.m.) evidenced, "Pt in hallway speaking to Carilion security...requesting to know when (patient) will be leaving...9:00 a.m. Pt currently on phone agitated..Carilion PD called and are at bedside. Pt currently calling 911 and Carilion PD at bedside. 9:03 a.m. This tech distress badge activated." There was no further documentation as to what the distress situation was or interventions from the facility other than the documentation of medication administration.

On 2/6/24 at 12:50 p.m. the surveyor interviewed SM #21 who stated, "I administered the IM...(patient) was agitated and violent at that time and assaulted a police officer. (Patient) did need to be physically restrained by PD who responded to the assault; I will say subdued (patient) would be more accurate. I tried to talk (patient) down...I can't really remember but I think (patient) might have agreed to submit, but I don't really know..."


The facility presented a document from the Carilion Police dated 12/13/23 and timed at 7:33 p.m. start - 8:00 p.m. ended: "...dispatched to annex to stand by while medical gave medication to a disorderly patient...when medication was ready (name of officer) and I tried to talk to (Patient #11) to get (patient) to roll up (their) sleeve and take the medication. After a few minutes (Patient) did not comply and with a nod from (name of officer) I took control of (Patient #11's) left arm...(Patient) did not resist, pull away or tense up. I rolled up (patient) sleeve and medical administered the medication. After that (patient) started crying..."

An interview with SM #29 (Carilion Chief of Police) on 2/5/24 at 2:45 p.m., evidenced: "We are both police and security for the facility...in 2015 the General Assembly made a path to privatize eight police departments, Carilion being one of them...we are Carilion Employees and we go through the main orientation and follow the policies that all employees receive. We also have our own specialized departmental orientation...patients have the right to refuse...we do not hold any patients unless we have an order to do so..."



The facility policy "Patient rights and Responsibilities effective 11-2021" documented: "...15. The right to refuse treatment to the extent permitted by law..."

The Facility policy "Patient Decision Making: Informed Consent to Treatment effective 11-2021" evidenced, in part: "...Refusal of treatment to which a normally prudent patient would normally agree does not by itself indicate lack of capacity sufficient to demonstrate that a patient is incapable of making an informed decision..."

The surveyor discussed the concerns with facility administration on multiple occasions throughout the survey 2/4 through 2/6/24 (SM # 5, 25, 28, 29, 31 and 32.)

Based on clinical record review, staff interview and facility document review, the facility failed to follow facility procedure for determining capacity of Patient #11.

The findings include:

Failure to follow facility determination of capacity procedure.

Review of facility policy titled "Patient Decision Making: Informed Consent to Treatment" dated August 2021 revealed in pertinent part: "Refusal of treatment to which a reasonable prudent patient would normally agree does not by itself indicate lack of capacity sufficient to demonstrate that a patient is incapable of making an informed decision." The policy further revealed, "Determination that a patient is incapable of making an informed decision regarding health care must be documented in the patient's chart by the patient's attending physician and also documented in the chart by a second physician or licensed clinical psychologist. The second physician or licensed clinical psychologist should not otherwise be involved in the treatment of the patient being assessed unless an independent reviewer is not reasonably available." The scope of the policy revealed it " ... includes all Carilion facilities where approval has been granted;" no departmental exclusions were identified.

Review of Patient #11's medical record titled "ED (Emergency Department) Provider Note" dated December 13, 2023, timed 1356 (1:56 PM) indicated the patient presented voluntarily for increased depression with auditory hallucinations; the patient denied suicidal or homicidal ideation and was deemed medically stable for psychiatric evaluation. The ED Psychiatric Provider documented in Patient #11's medical record on 12/13/2023 at 2:32 p.m. ,"(patient) requires psychiatric admission and (patient) is impulsive, aggressive and does not have capacity at this time ..." There was no documentation by the ED provider related to Patient #11's decision making capacity. On 12/13/23 at 8:38 p.m., an "Emergency Psychiatric Consultation" was documented and evidenced: "...While (patient) denies any SI (suicidal ideations) or HI (homicidal ideations), (patient) requires inpatient admission as (patient) is impulsive, aggressive and does not have capacity at this time..."

The surveyor interviewed Staff Member #25 on February 6, 2024 at 10:46 AM. Staff Member #25 stated: "...in the spirit and context of doing capacity assessments, in the ED, the volume of patients we see in a twenty-four hour period is, by nature, a good volume...we have held to the interpretation that the capacity is a component of the mental health evaluation...as far as a capacity consult, we don't have that in ED...we have the attending and the mental health evaluation...the determination of capacity is done differently on the units..." Staff Member #25 confirmed that the above noted facility policy "Patient Decision Making: Informed Consent to Treatment" applies to all facility departments and the ED department didn't have at the time of survey and/or Patient #11's visit a different written policy for this process.



42929

Based on clinical record review, staff interview and facility document review, the facility staff failed to follow the policy and procedure for the ordering and monitoring of a chemical restraint for three (3) of three (3) patients, Patient #11, #12, and #13.

All three (3) patients were administered a combination of medications Haldol 5mg, Ativan 2mg and Benadryl 50mg aka "B52" intramuscularly in order to control their behavior which was not a standard treatment or dosage for the patient's condition(s).

The findings include:

Review of the facility policy: "Restraints/Seclusion, Use of" revealed in part: "...Violent/Self Destructive (Behavioral) Manual hold or Chemical: Assessment- 1. A comprehensive Assessment...2. Less restrictive alternatives..C. Restraint Orders - Determine order type of restraint per clinical indication and justification for patient safety...Documentation: Includes the physician, NP (Nurse Practitioner), PA (Physician Assistant) patient evaluation and findings to support the use of restraint or seclusion....Monitor the physical and psychological well being of the patient every 15 (fifteen) minutes including respiratory,and circulatory status, skin integrity. Vital signs will be assessed as often as needed taking into consideration the patient's condition. cognitive status and intervention risk. Additional monitoring q2 (every two) hours while awake and PRN (as needed)...Required: A description of the patient's behavior and the intervention used. Any alternatives or other less restrictive interventions attempted. The patient's condition or symptom(s) that warranted the use of the restraint. The patients response to the intervention used...the intervals for monitoring, revisions to the plan of care and education to the patient and family...Chemical Restraint: A drug or medication when it is used as a restriction to manage the patients behavior or restrict the patients freedom of movement and is not a standard treatment or dosage for the patient's condition [CMS 482.13 (a)]...a face to face evaluation must be performed in person..."

Patient #11
Review of the clinical record for Patient #11 revealed the patient was administered Haldol (an antipsychotic) 5mg (milligrams), Ativan 2mg (sedative), and Benadryl 50mg (antihistamine) IM (Intramuscular injection) aka "B52" on December 13, 2023 at 7:58 PM due to being "verbally aggressive, hateful and disrespectful to staff, continued to push the code button over and over". This medication combination wasn't a part of Patient #11's maintenance medication regiment of their psychiatric condition. Following the administration of B52, the medical record evidenced patient was asleep until 11:38 PM when they briefly awoke for 6 minutes, made a phone call and slept until 6:39 AM on December 14, 2023.

Review of Patient #11 medical record evidenced that patient received "B52" IM (Intramuscular Injection) again on December 14, 2023 at 9:28 AM for "severe agitation". The medical record didn't contain further documentation as to what the distress situation was or what interventions staff performed before administering this medication combination to patient.

Patient #11's medical record contained orders documented on December 13, 2023 at 1639 (4:35 PM) for Haldol 5mg, Benadryl 50 mg, Ativan 2mg once PRN (as needed) for agitation, psychosis and a second order for the same medication combination on December 13, 2023 at 1643 (4:43 PM) Q8H PRN (every 8 hours as needed) for agitation. The medical record didn't contain documentation the medication combination was used as a chemical restraint. Review of Patient #11's medical record didn't reveal documentation of patient's condition and or monitoring after "B52" IM administration, except a tech note on December 14, 2023 at 10:35 AM, "Due to aggressive behavior, group is deferred at this time. Will continue to follow patient." and a nurse's note on December 14, 2023 at 10:45 AM, "appears asleep" and at 1:00 PM when patient refused to take oral medications.

Patient #12
Patient #12 presented to the ED on December 16, 2023 with "suicidal ideations and a plan to jump off a bridge". On December 16, 2023 at 4:38 PM it was documented the patient was "hitting self in face and screaming", being verbally abusive to staff and police officers and security were present in the annex. The patient was administered at 4:31 PM Haldol 5mg, Ativan 2mg, and Benadryl 50 mg via intramuscular injection without a manual hold. There was no order for the use of a chemical restraint nor any documentation of interventions prior to the medication administration or monitoring after administration of "B52". The medical record documented patient #12 was sleeping until they were transferred to another unit at 8:37 PM.

Patient #13
Patient #13, according to the clinical record, presented to the ED via EMS (Emergency Medical Services) on December 19. 2023 for a Mental Health evaluation from (another community setting) where they had been therapeutically managed for "alcohol abuse". On December 20, 2023, at 4:50 a.m. it was documented, "Patient keeps coming up to the nurses station getting agitated and saying inappropriate words. Patient given B52 (Haldol, Ativan and Benadryl) at this time..." There was no order for a chemical restraint and no documentation of any interventions prior to the medication administration or monitoring, nor further description of the patient's behavior warranting the use of the medication combination per facility policy. The medical record documented patient #13 was sleeping until 5:00 PM.

On February 6, 2024, at approximately 2:00 PM the surveyor interviewed Staff Member # 26 about the use of the "B52", a medication combination in this Emergency Department. SM #26 indicated, "We use different medications in the ED for agitation...this combination of medication is used to treat the underlying condition because the patient is hostile and aggressive or violent...I do not like the term chemical restraint because it infers that I am harming a patient...I am treating the underlying condition so they can interact better and help them regain control..."

The surveyor interviewed Staff Member # 23 (Senior Director of Pharmacy) regarding the use of the medications combination aka "B52" on February 6, 2024, at 1:15 PM. SM #23 stated they were not familiar with this combination of medications, its therapeutic effects, frequency of use in the ED and that the medication was not "commonplace".

The surveyor requested any literature from the facility regarding the national standards of practice and/or clinical studies related to the use of this medication combination in treating acute agitation. The facility didn't provide such information by the end of the survey.

Based on clinical record review, staff interview and review of facility documents, the facility staff failed to ensure evidence that least restrictive interventions were attempted or ineffective at protecting the patient or others from harm prior to administering an intramuscular (IM) medication for one (1) patient, Patient #13 and prior to placing one (1) patient, Patient #11 in a manual hold.

The findings include:

Review of the facility's policy titled "Restraints/Seclusion, Use of" effective 05-2022 revealed in part:
"... B. Manual Hold
1. A manual hold is initiated when a patient is exhibiting behavior that imminently threatens the safety of the patient or others and it is determined that other least restrictive alternatives are not viable and/or effective. A manual hold is against the patient's will. The hold utilized will be consistent with the requirements outlined by the department of Behavioral Health and Developmental Services.
... Documentation:
Required:
A description of the patient's behavior and the intervention used.
Any alternatives or other less restrictive interventions attempted...."

Patient #13, according to the clinical record, presented to the ED via EMS (Emergency Medical Services) on December 19. 2023 for a Mental Health evaluation from (another community setting) where they had been therapeutically managed for "alcohol abuse". Review of Patient #13's medical record revealed documentation on December 20, 2023 at 4:50 AM, "Patient keeps coming up to the nurses station getting agitated and saying inappropriate words. Patient given B52 (Haldol, Ativan and Benadryl) at this time..." The medical record didn't contain documentation of less restrictive intervention attempts prior to the medication administration or monitoring, nor further description of the patient's behavior warranting the use of the medication combination per facility policy.

Review of Patient #11's medical record titled "ED (Emergency Department) Provider Note" dated December 13, 2023, timed 1356 (1:56 PM) indicated the patient presented to ED voluntarily for increased depression with auditory hallucinations. Clinical Associates note on December 13, 2023, at 7:52 PM contained evidence that Patient #11 was verbally aggressive to staff, hateful, and disrespectful. The patient continued to push the code button "over and over" and the "PD" [the facility's policy department) were at the bedside. Despite Patient #11 having PRN oral medication orders and identified coping skills, neither appeared to be offered and used. Patient #11's medical record didn't contain evidence of less restrictive interventions being used, other than verbal redirecting, prior to Patient #11 being placed in a hold by law enforcement to administer forced intramuscular medications, Haldol 5 mg, Ativan 2 mg IM, and Benadryl 50 mg at 7:58 PM.

During an interview on January 18, 2024 at 9:30 AM, Staff Member #22 stated that they gave Patient #11 a "cocktail" of medication to include intramuscular Haldol. Staff Member #22 stated that they did not often work in the behavioral health portion of the ED and did not often administer Haldol. Staff Member #22 reported Patient #11 was paranoid, cursing at staff, and was threatening staff members and patients. Staff Member #22 reported attempting to verbally de-escalate the patient multiple times, but these interventions "seemed to make things worse." Staff Member #22 stated that the patient did not want the Haldol injection and that two (2) police officers restrained the patient in order for the injection to be administered. Staff Member #22 recalled that after the injection the patient went to sleep.

During an interview January 18, 2024 at 10:30 AM, Staff Member #28 indicated that if law enforcement holds the patient, it is not considered a restraint, but if hospital staff members perform the hold it would be considered a restraint. Staff Member #28 further explained that the emergency room has a standard from their medical director stating if a patient is aggressive to the point of potentially causing physical harm, medication can be administered, and law enforcement can hold the patient down. Staff Member #28 stated this is never considered a chemical restraint. The goal of the medication is therapeutic to relax the patient and not sedate them.


42929

Based on clinical record review, staff interview and review of facility documents, the facility staff failed to obtain orders for a manual hold to administer medications for one (1) patient, (Patient #11).

The findings include:

Review of facility policy titled "Restraints/Seclusion, Use of" effective date 05-2022 revealed in part:
"... III. Policy Statement(s) A. In accordance with the mission of [the facility], restraint or seclusion must only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. B. Manual Hold
1. A manual hold is initiated when a patient is exhibiting behavior that imminently threatens the safety of the patient or others and it is determined that other least restrictive alternatives are not viable and/or effective. A manual hold is against the patient's will. The hold utilized will be consistent with the requirements outlined by the department of Behavioral Health and Developmental Services.
... 3. Orders must be in place prior to application except in emergent initiation of restraint.
... Violent/Self Destructive (Behavioral, Manual Hold or Chemical. Use in a situation of imminent risk to protect patient from injury to self or others when the behavior is dangerous, violent, or aggressive. (Applicable regardless of patient setting). ... Manual Hold: In an emergent situation, a manual hold is initiated with a verbal order from a provider obtained as soon as possible.
... A required progress note will include behavior of patient prior to manual hold, the number of staff required to hold patient, medication administered, and assessment for signs of injury ..."

Review of the facility's policy titled "Patient Rights and Responsibilities" effective 11-2021 evidenced in part:
"... A. Patient Rights: Each patient and/or his or her legally authorized representative, if the patient is not capable to understand, presenting for care has the following rights:
... 13. Receive care in a safe setting free from all forms of harassment or abuse. This includes freedom from restraint or seclusion that is not indicated for safety or medical indications ..."

Review of Patient #11's medical record titled "Clinical Associates note" documented on December 13, 2023, at 7:52 PM contained evidence that Patient #11 was verbally aggressive to staff, hateful, and disrespectful. The patient continued to push the code button "over and over" and the "PD" [the facility's police department) were at the bedside. Patient #11's medical record didn't contain evidence of less restrictive interventions being used, other than verbal redirecting, prior to Patient #11 being placed in a hold by law enforcement (facility staff) to administer forced intramuscular medications, Haldol 5 mg, Ativan 2 mg IM, and Benadryl 50 mg aka "B52" at 7:58 PM.

The surveyor was unable to locate in Patient #11's clinical record an order for a restraint or manual hold. In an interview on February 6, 2024, at 2:50 PM Staff Member #22 recalled, "We tried to talk to (patient) and calm (them)...I let (patient) know I was giving the med and (patient) put up a fuss, so the officers stood on each side of (patient) and each officer placed their one hand on the upper arm and one on forearm below on both of the (patient's) arms and (patient) didn't struggle. (Patient) voiced some derogatory words but (patient) didn't jerk or struggle. (Patient) did say 'you are not going to do that to me', but (patient) didn't struggle when the police officers placed their hands on (patient's arms)."

Patient #11 medical record evidenced that patient received the same "B52" medication combination IM again on December, 14, 2023 at 9:28 AM for "severe agitation". At this time, patient was under ECO. Review of Patient #11's medical record found a "Nursing Note" documented on December 14, 2023, at 0930 (9:30 AM) which evidenced in part, "Pt in hallway speaking to Carilion security...requesting to know when (patient) will be leaving...9:00 a.m. Pt currently on phone agitated..Carilion PD called and are at bedside. Pt currently calling 911 and Carilion PD at bedside. 9:03 a.m. This tech distress badge activated." There was no further documentation in Patient #11's medical record as to what the distress situation was or what interventions facility staff performed other than administering the "B52" medication with assistance from Carilion security officers who restrained the patient.

Review of Patient #11's medical record failed to reveal an order for manual hold while administering medication and assessment of patient after these interventions.

An interview on 2/5/24 at 2:45 PM, Staff Member #29, Carilion Chief of Police explained: "We are both police and security for the facility...in 2015 the General Assembly made a path to privatize eight police departments, Carilion being one of them...we are Carilion Employees and we go through the main orientation and follow the policies that all employees receive. We also have our own specialized departmental orientation...patients have the right to refuse...we do not hold any patients unless we have an order to do so..."

In an interview on January 18, 2024, at 9:30 AM and on February 6, 2024, at 12:50 PM Staff Member #21 recalled the events surrounding medication administration on December 14, 2023, "I administered the IM...(patient) was agitated and violent at that time and assaulted a police officer. (Patient) did need to be physically restrained by PD who responded to the assault; I will say subdued (patient) would be more accurate. I tried to talk (patient) down...I can't really remember but I think (patient) might have agreed to submit, but I don't really know..." Staff Member #21 recalled attempting to verbally de-escalate the patient multiple times, but these interventions "seemed to make things worse." Staff Member #21 stated after the injection the patient went to sleep.

During an interview on January 18, 2023, Staff Member #33, a physician in the ED, stated that physical holds are not used in the ED. The surveyor informed the physician that according to documentation in medical record a patient in the survey sample was held by police to administer medication. The physician stated that holds are only used in extreme circumstances and acknowledged law enforcement at times holds patients to facilitate administration of medication.

The facility presented a document from the Carilion Police dated December 13, 2023, and timed as 7:33 PM start - 8:00 PM end that read in part "...dispatched to annex to stand by while medical gave medication to a disorderly patient...when medication was ready (name of officer) and I tried to talk to (Patient #11) to get (patient) to roll up (their) sleeve and take the medication. After a few minutes (Patient) did not comply and with a nod from (name of officer) I took control of (Patient #11's) left arm...(Patient) did not resist, pull away or tense up. I rolled up (patient) sleeve and medical administered the medication. After that (patient) started crying..."

During an interview January 18, 2024, at 10:30 AM, Staff Member #28, physician stated that law enforcement will physically hold patients to administer medications if the patient is a danger to themselves or others. Staff Member #28 stated that if law enforcement holds the patient, it is not considered a restraint, but if hospital staff members perform the hold it would be considered a restraint. Staff Member #28 explained that the emergency room has a standard from their medical director stating if a patient is aggressive to the point of potentially causing physical harm, medication can be administered, and law enforcement can hold the patient down. Staff Member #28 stated this is never considered a chemical restraint. The goal of the medication is therapeutic to relax the patient and not sedate them.



42929