HospitalInspections.org

Based on interview, record review, policy review, video surveillance recording and security body camera and audio recording review the hospital failed to:
- Protect one discharged, voluntary patient's (#8), of one discharged patient reviewed, rights when she was physically and chemically restrained for the collection of a COVID-19 (highly contagious, sometimes fatal, virus) test in the Emergency Department (ED). (A-0145)
- Ensure one discharged, voluntary patient (#8), of one discharged patient reviewed, had the right to refuse treatment or services in the Emergency Department (ED) when she was physically and chemically restrained (administration, generally involuntarily, of medications to control a patient's dangerous behavior) during a COVID-19 test that she had refused. (A-0161)
- Ensure five staff (E, G, O, BB and II) of five staff personnel records reviewed were trained in first aid related to restraints. (A-0206)
These failed practices resulted in the overall noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights and placed all patients who received care at risk for their health and safety. The hospital census was 110.

Based on interview, record review, policy review and security body camera and audio recording review the hospital failed to follow their policy to protect one discharged, voluntary patient (#8), of one discharged patient reviewed, rights when she was physically restrained for the collection of a COVID-19 (highly contagious, sometimes fatal, virus) test in the Emergency Department (ED). This failure had the potential to affect all patients and their rights, placing them at risk for their health and safety. The hospital census was 110.

Findings included:

1. Review of the hospital policy titled, "Patient Rights, Patient Bill of Rights," reviewed 12/13/21 showed that patients would be treated with respect and dignity, be cared for in a safe environment that preserved dignity and contributed to a positive self-image. Patients would be protected against all forms of abuse, discrimination and harassment while a patient at the hospital and be free from restraints of any form that were not medically necessary.

Review of the undated, hospital brochure given to patients titled, "Patient Rights," showed that patients have the right to be protected from all forms of abuse, discrimination or harassment and be free from restraints that were not medically necessary.

Review of the undated, hospital policy titled, "Asymptomatic [without symptoms] Testing of Inpatient Psychiatric Admissions," showed that the following guidelines/special instructions would be implemented to assist in preventing the transmission of COVID-19 within the facility and community. The process showed once the decision to admit to inpatient psychiatric was made in the ED, the COVID-19 test was to be completed.

Review of Patient #8's medical record showed she was a 56 year old female who presented to the ED on 09/27/22 at 12:34 PM. The triage (process of determining the priority of a patient's treatment based on the severity of their condition) note timed at 12:39 PM, showed documentation by Staff BB, ED Registered Nurse (RN), that the patient was brought in by law enforcement after she had cut her wrist due to "feeling bad" and these feelings had persisted since the beginning of the COVID-19 pandemic (a sudden increase in the number of cases of a disease above what is normally expected and has spread over several countries or continents, usually affecting large number of people). Staff BB documented that the patient denied suicidal (SI, thoughts of causing one's own death) and reported that the pain of hurting herself was better than the mental pain. ED Physician Notes showed that Staff CC, ED Physician saw the patient at 12:36 PM and documented that the patient had a history of anxiety and depression and that the patient denied SI but wanted to get help, and the only way she knew she could get help was to cut her wrist. Staff CC documented that the patient had small, superficial, hesitation cuts to her left wrist, none that required stiches. Staff CC documented that the patient did not want to go with the ambulance so she was brought in by law enforcement for a voluntary psychiatric evaluation. Staff CC documented in his medical decision making note that he was concerned with her behavior that she may be high risk for suicide attempt. He ordered a medically necessary hold for the patient at 1:00 PM with the reason listed as harm to self. He documented he would medically clear her and have psychiatry evaluate her. Staff CC documented that the patient became quite agitated when they tried to do a COVID-19 test and she required ketamine (short acting anesthetic) to sedate her for the "acute testing required, and also to calm her down" since she tried to leave the hospital. Staff CC documented that the psychiatric nurse had evaluated the patient and felt she was safe for discharge. He documented "this was an unfortunate turn of events which escalated rapidly." Staff CC documented that the patient denied SI and had a safety plan in place and would be discharged home with a safety plan and psychiatry to follow up.

Review of Patient #8's pre-admission intake (PI) dated 09/27/22 at 5:55 PM, completed by Staff I, RN, Psychiatric Intervention Team (PIT) nurse showed documentation the patient had presented to the ED after she had cut her left wrist then called 911 for help. While in the ED the patient had been uncooperative with a COVID-19 test and had received a ketamine injection. Staff I documented that the patient was very tearful when she spoke about past abuse and triggers. The patient repeatedly denied SI or intent of killing herself or harming others. The patient reported that she had a lot of anger related to past abuse and issues related to COVID-19. The patient reported that she had stress related to the recent placement of her mother (who had abused her as a child), in a nursing home and her frustration with the inability to get her the COVID-19 vaccine. The patient reported that today she was triggered when she prepared to go to a dental appointment related to staff who wore masks (the person that had raped her in the past had worn a mask) and stated that when she was unable to reach her "safety lines" (support/coping skills) that her anxiety increased and she cut herself. The patient reported that she had been forced to have a COVID-19 test today in the ED and it was a trigger related to the past rape. The patient denied the need for inpatient and verbalized multiple coping skills, support of church and friends and that her husband would not be working out of town for the next two weeks. She reported that she was pushing through in her outpatient therapy and that it was difficult but knew she had to continue working in therapy. The patient contracted for safety and would be discharged to home.

Review of sheriff's report dated 09/27/22 showed that the 911 call was received from Patient #8 at 11:38 AM with arrival time to scene at 11:50 AM. The responding deputy documented that upon arrival he met with Patient #8 who was on her kitchen floor crying. Patient #8 had cut her left wrist with a knife and felt that no one cared for her. Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived on scene and bandaged her wrist. Patient #8 refused to go to the hospital with EMS, so the sheriff's deputy transported her to the ED so "they could do a 96 hour (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) evaluation."

Review of Patient #8's medical record showed no affidavits (a written statement confirmed by oath, for use as evidenc in court) for a 96 hour hold.

Review of the hospital video surveillance recording titled, "Mid Nurse Station -2022-9-27-13h48min00s000ms," showed the following:
- At 1:48:10 PM, Patient #8 walked out of her room past Staff BB, RN and turned right into the hallway as Staff BB walked beside her.
- At 1:48:22 PM, Patient #8 turned right down another hallway which was out of camera view.
- At 1:48:37 PM, (15 seconds after she walked out of camera view) Patient #8 walked back into camera view and walked toward the nurse's station and stopped in the hallway outside of her room where she appeared to have talked with staff.
- At 1:49:10 PM, Patient #8 walked back into her ED room without incidence.

Review of the hospital document titled "Incident File Full Report," dated 09/27/22 at 1:48 PM, Staff GG, Security Officer, documented that hospital security received a call from the ED for assistance with a medical hold patient who refused a COVID-19 test and had attempted to leave. Staff GG documented that on arrival, the patient was in her room, had refused a COVID-19 test and she stated that she would fight. The report showed that they had attempted "multiple" times to de-escalate (reduction of the intensity of a conflict or potentially violent situation) her without success. Staff GG documented that he explained to Patient #8 that it was policy to have the COVID-19 test completed and that nursing staff also informed the patient that for placement to a mental health facility she had to have a COVID-19 test completed. Staff GG documented that Patient #8 responded that she would, "fight all of us, she would not lay down and she would not take any medications or receive medical care." Staff GG documented that security, along with nursing staff, "took control" of Patient #8 and nursing staff provided "medical care" as ordered.

Review of Staff GG's body camera visual and audio recording showed the following:
- At 1:50:08 PM Staff FF and Staff HH, Security Officers were in camera view inside Patient #8's ED room.
- At 1:50:34 PM, Staff BB, RN, verbalized, "Do I have orders for meds?" and, "Well we are getting a COVID swab."
- At 1:50:40 PM, Staff GG, Security Officer, entered the room and talked to Patient #8, who was seated on the bed. Patient #8 calmly verbalized why she was refusing the COVID-19 test and stated "I just don't understand, I'm not sick."
- At 1:53:59 PM, Staff GG, stated to Patient #8, "Nobody here wants to have to fight you, but it is going to happen, and you know it."
- At 1:54:13 PM, Staff GG, Security Officer stated to Staff BB, RN, "Medical Hold, ready to go" to which Staff BB replied, "Med hold, but I am trying to give her some "Ket" to calm her down before doing the swab. That is what I am waiting on."
- At 1:54:25 PM, Staff Z, Emergency Medical Care Technician (EMCT), asked Staff GG, Security Officer "Wrangle her?" to which Staff GG stated, "Yea, it's going to happen, I mean to swab her, we are going to end up fighting her for a swab."
- At 1:58:35 PM, Staff BB, RN entered the room with a medication syringe in her hand, and stated to Patient #8, "I have some medication to try and help calm you down before we are doing the swab." Patient #8, who was seated on the bed, calmly stated that she did not want the medication either. Staff BB responded, "Well okay, but we are going to do both" and exited the room. Patient #8, looked at Staff HH, Security Officer, and asked, "Are you sure you guys want to do this?"
- At 1:59:31 PM, Staff BB, RN re-entered the room and asked Patient #8 if she would lay down on the bed. Patient #8 shook her head in a negative response.
- At 2:00:45 PM, Staff FF, Staff GG, and Staff HH, Security Officers held the patient down while Staff AA, RN performed the COVID-19 test and Staff BB, RN administered Ketamine IM.
- At 2:05:10 PM, the three security officers released the physical hold on Patient #8.
- At 2:09:06 PM, Patient #8 appeared to have had trouble breathing and was moved to another ED examination room. Oxygen was placed on Patient #8 by mask.
- At 2:21:27 PM Staff GG's body camera was turned off.

Review of Staff FF, Security Officer's body cam visual and audio recording showed the following:
- At 1:50:10 PM, showed Patient #8 calmly seated on the bed in her ED room with Staff GG and Staff HH, Security Officers, in the room.
- At 1:52:49 PM, Staff FF, Security Officer, can be heard saying, "You are going to have to take the COVID swab."
- At 1:54:22 PM, Patient #8, still seated on the bed stated, "If I were sick, I would be more than happy to do it."
- At 1:59:42 PM, Patient #8 stated to Staff FF, GG and HH, Security Officers and ED Staff II, RN, ED Charge Nurse, Staff BB and AA who had entered the room, "You know it's wrong." Staff BB, RN replied, "We have to get you placement in a facility and they won't accept you without the COVID swab."
-At 2:00:45 PM, Staff GG, Staff HH, Staff FF and Staff Z, placed the patient in a physical hold. Patient #8 screamed and fought back in response to the hold.
- At 2:00:57 PM, showed Staff GG, Security Officer held the patient with his right knee placed over her rib cage and his left arm over the patient's head (which was turned toward the left) with his hand on her chin and elbow at her ear. It appeared that her head was off the mattress and her head was bent backwards. The patient continued to fight.
- At 2:01:08 PM, Staff AA, performed the COVID-19 test while Patient #8 screamed.
- At 2:01:23 PM, Staff GG had his left arm on the patient's head, which was off the bed. Patient #8 was heard coughing and gasped for breath. Staff GG stated, "Let's put her down on the bed," and the patient was placed further down in the bed on her back.
- At 2:02:01 PM, Patient #8 stated, "You are hurting my head" which Staff GG replied "Then don't bite" to which the patient replied, "I won't bite."
- At 2:02:17 PM, Patient #8 stated, "I can't believe you guys did that. I feel like I have been raped again. You guys did it, you guys did it."
- At 2:05:10 PM, the patient was released from the physical hold while it appeared that the sedation medication had taken effect as the patient appeared to have relaxed with eyes closed.


During an interview on 12/07/22 at 8:46 AM, Staff HH, Security Officer, stated that she remembered on her arrival to Patient #8's ED room that the patient was standing in the back of the room and verbalized that she was not going to take any meds and that she would fight them if they tried. She stated that the patient screamed to stop, that she didn't want to do this. Staff HH stated that the patient sat down on the ED bed by herself and that Staff GG, Security Officer asked the patient to lie down on the bed and explained to the patient that they would have to hold her down. Staff HH stated that the patient was held down for "some shots."

During an interview on 12/07/22 at 9:30 AM, Staff FF, Security Officer, stated that he was called to the ED to assist with a patient that was on a medically necessary hold and that she had refused medical treatment that was ordered by the physician. He stated that he attempted de-escalation as the patient had verbally threatened multiple times to fight. He stated that security took control for everyone's safety. He stated that Patient #8 was very adamant that she was not going to receive medical treatment as it had been ordered. Staff FF stated that Patient #8 had only verbally yelled prior to when she was physically held down and that she only became combative when they placed their hands on her to hold her down. He stated that the patient fought as hard as she could and tried to bite him and Officer GG when they tried to hold her down for medical treatment.

During an interview on 12/07/22 at 10:05 AM, Staff GG, Security Officer, stated that prior to the physical hold with Patient #8 the patient was agitated. He stated that her body language was not threatening in the beginning but he heard the frustration in her voice. He stated that he noted her body language changed when the conversation changed and it was clear that the medical procedure was going to happen. He stated that the patient verbalized that she would fight and cause physical harm. He stated that he was under the impression that the security officers were called to hold her down for a COVID-19 test.

During an interview on 12/07/22 at 9:51 AM, Staff AA, RN, ED, stated that she was the RN that obtained the COVID-19 test from Patient #8. She stated that since the patient was self-harming she was pretty certain that the patient would be admitted. She stated that the physician had ordered the ketamine to calm the patient down related to her physical aggression. Staff AA stated that the PIT nurse won't come and evaluate a patient unless they had all of their testing done first and those tests included the COVID-19 test. She stated that Staff BB administered the ketamine injection "pretty close" to the time she performed the COVID-19 test.

During a telephone interview on 12/07/22 at 1:02 PM, Staff CC, ED Physician stated that a medically necessary hold was placed on patients with SI or SI gestures so that the patient cannot leave until medical and psychiatric evaluations were completed. He stated that patients needed the mental capacity to make medical decisions. He stated that Patient #8 was there for SI and because she had injured herself, she lacked the mental capacity to make her own decisions. Staff CC stated that it was policy to have the COVID-19 test prior to admission. He stated that he talked with the patient briefly but doesn't remember what was discussed. He stated that he ordered ketamine related to her agitation and that if her behavior escalated then it would be given. He stated that the patient tried to leave the ED and was fighting with staff so the ketamine was given and "while she was down and had calmed down" the COVID-19 test was obtained because it was needed. He stated that he thought that the patient would be admitted but at the time of the COVID-19 test the patient's disposition had not yet been determined.

During a telephone interview on 12/07/22 at 1:30 PM, Staff DD, Physician, Emergency Medicine Chairman, stated that he didn't feel it was necessary to sedate a patient to obtain a COVID-19 test and that they could have delayed the COVID-19 until after the PIT nurse had evaluated the patient. Staff DD stated that he felt it was in anticipation of care and that the feeling was that the patient was going to be admitted.

During an interview and concurrent body camera and audio recording review on 12/07/22 at 9:15 AM, Staff Y, Physician, ED Medical Director, stated that the ketamine did not have a chance to work on Patient #8 before the COVID-19 test was performed and that, per video review, the patient was not aggressive before the staff went "hands on.

During an interview on 12/07/22 at 1:55 PM, Staff II, RN, ED Charge Nurse, stated that she wasn't there during Patient #8's initial admission but she heard her screaming and that she had attempted to exit through the ambulance doors. She stated that staff talked with her and that she was sedated because of her aggressive behavior towards staff but she didn't recall any specifics. She stated that in order for ED staff to have a patient be evaluated by PIT the patient had to be medically cleared first and that included a COVID-19 test.

During a telephone interview on 12/07/22 at 3:26 PM, Staff BB, RN, ED, stated that she was Patient #8's primary care nurse on 09/27/22. She stated that she "vaguely" knew of the patient's abusive history but that it involved previous trauma and a bad experience with masks. She stated that Staff CC, ED Physician came in during the middle of the triage process and assessed the patient. She stated that she did have a conversation with Staff CC regarding the patients past history with mask issues, bad experience and trauma with masks but unable to recall at what time during the patient's visit this occurred. She stated that prior to administering the sedation medication she had asked if she had an order and informed Staff CC, ED Physician that the patient was refusing the COVID-19 test. She stated that Staff CC informed the patient that it was required, per the PIT policy, and that she would need it for placement. Staff BB stated at this time, Staff CC walked up to the nursing station and stated to her that he would put an order in. She stated that Patient #8 then walked out of her room and went down the hallway to the ambulance bay doors and pulled at the doors in an attempt to open them. She stated that there weren't any specific instructions regarding the order in which the sedation and the COVID-19 test were completed and that the medication was given for the patients' agitation and not to obtain the COVID-19 test. Staff BB stated that the patient wasn't able to refuse the COVID-19 test based on the PIT policy to obtain a viral test and that every psychiatric patient was to have a COVID-19 test before the intervention team consult. Staff BB stated that after the sedation was given that she was at the patients' beside for a while and that she noted some areas of redness on the patient's ankles and on her arms where she had pushed up against staff while being held. She stated there were no obvious injuries, bruising or deformities noted.

During an interview on 12/05/22 at 2:20 PM, Staff I, PIT RN, stated that patients in the ED weren't required to have the COVID-19 test prior to the PIT assessment. She stated that she remembered Patient #8 and that she had Post Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock) related to anyone with masks and that she had a dental appointment prior to her coming to the ED and that it had triggered her PTSD related to a past rape by someone with a mask. She stated that the patient had refused the COVID-19 test and that the ED had forced her to take the test prior to her PIT assessment and that it wasn't necessary. Staff I stated that she remembered the patient had reported to her that her mother had locked her in a closet when she was a child and that she had cared for her mother prior to her nursing home placement and was unable to get her mother the COVID-19 vaccine. She stated that the patient reported that her husband had a lot of stress related to COVID-19 with his job and the day of the ED visit all of the past stressors came out. She stated that the patient had reported she was a paramedic (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) and had refused the COVID-19 test in the ED but that they gave her ketamine and obtained the test. Staff I stated that the ED nurse had reported to her that the patient had received ketamine due to trauma and potential for injury with the COVID-19 test because she had refused it. She stated that the patient reported to her she had refused because she had no symptoms of COVID-19 and that she had told the staff that she would fight if they did the test and that she hadn't even been evaluated yet so, at that time, she didn't even know if she would be admitted or not. Staff I stated that she spoke to the patient's husband after she had completed the assessment and informed him that the patient was upset regarding the COVID-19 test. Staff I stated that she felt the COVID-19 test could have waited and been obtained once the patient was determined to have needed inpatient admission that the patient's history with her mother, COVID-19 with her husband's job, the rapist, then the ED staff mandating that she have a COVID-19 test and being held down to obtain it all equaled up to a trigger. Staff I stated that the patient did not meet inpatient criteria and was discharged home with a safety plan.

Review of Patient #8's discharge instructions showed that she was discharged to home at 6:25 PM.

During an interview on 12/06/22 at 2:14 PM, Staff B, Vice President of Nursing, stated that Patient #8 refused the COVID-19 test but it had to be done because the patient would have been placed in a communal environment with the other psychiatric patients. She stated that on 09/27/22 the process was to do the medical screening exam and with psychiatric patients that included the COVID-19 test.

During a telephone interview on 12/06/22 at 3:34 PM, Staff LL, PIT Manager, stated that a COVID-19 test was not required until the decision had been made to admit the patient.

Record review from an outside urgent care facility dated 09/28/22 at 4:00 PM, showed Patient #8 presented for care with chief complaint of right leg soreness and generalized bruising after she had been "tackled" by ED nurses the night before. Documentation of the physical assessment showed a left upper arm bruise and right outer thigh bruise. The patient was diagnosed with muscle spasm (painful contraction of a muscle caused by trauma, tension, or disease), abrasion of the upper arm, and bruises of the leg and arm. The patient was prescribed a muscle relaxer.

During a telephone interview on 12/08/22 at 2:30 PM, Patient #8's husband stated that he first learned of what had occurred in the ED with his wife when the ED Charge Nurse called him and asked about the patient's history and what had happened to her in the past. He stated that he told the ED Charge Nurse not to try and hold his wife's arms down or try and restrain her and she replied that they had issues with her with a test and had to sedate her to "do the test." He stated that he replied that he "figured that didn't go well" and that the charge nurse replied that it had not. He stated that he asked the ED Charge Nurse when his wife would be ready to be discharged and she informed him that since she had to be sedated, she had not had her mental health evaluation yet. He stated that when he asked why a COVID-19 test had to be done he was informed that it was needed for psychiatric admission. He stated that he then asked if she (charge nurse) was sure his wife would be admitted and the charge nurse replied that she wasn't sure if his wife would be admitted or not. He stated that shortly after he received a call from his wife and she told him what had happened then Staff I, PIT RN called approximately one hour after that. Patient #8's husband stated that Staff I explained to him that she had completed her mental health evaluation and that his wife was not a candidate for a 96 hour hold or inpatient admission. He stated that he mentioned to her that he was aware they had sedated his wife and he asked if she had been violent. He stated that Staff I informed him that his wife had not been violent but she had refused a COVID-19 test and when the ED staff, informed her it was needed and she refused the test they sedated her. He stated that when he picked up his wife from the ED she was visibly upset and tearful and that the next few days "were hell." He stated that his wife was very sore, and unable to sleep that night due to muscle soreness in her arms, legs, jaw and neck with a visible knot on her leg which he felt was from the injection. He stated that when bruising started to become visible with continued soreness they sought care at a local urgent care. He stated that she was evaluated at the urgent care and was given muscle relaxers for deep tissue bruising.

During a telephone interview on 12/08/22 at 2:43 PM, Patient #8 stated that she had a dental appointment scheduled for 09/27/22. She stated that she had put it off for over a year because of anxiety related to the fact they wore masks but her teeth had been hurting so she knew she needed to go to the appointment. She stated that she had a lot of past history with people wearing masks and that her pastor was going to call the dentist and see if they could wear a clear face shield when working with her, but she hadn't heard back from him. She stated that as it got closer to the time of her appointment her anxiety increased and she couldn't wait so she called her pastor again with no answer and then she called her husband with no answer. She stated that when she couldn't reach either of them her anxiety continued to increase and she went to the kitchen and felt if she hurt herself then it would get someone to come and help her and that the physical pain would be better than the emotional pain she felt. She stated that she had never cut herself before as this was the first time and after she cut herself she called 911 hoping that since she was a paramedic and knew a lot of the EMS staff that someone that she knew would respond. She stated that she was not handcuffed or arrested and that the deputy transported her to the ED and upon arrival the sheriff's deputy walked inside with her and she was taken into an empty ED room. She stated that the ED staff immediately took her cell phone, removed bobby pins from her hair and had her remove her clothes and put on paper scrubs. She stated that the ED physician came in and told her that some tests needed to be done and that she needed to go to the psychiatric unit. She stated that she questioned the physician if a mental health assessment needed to be done first and that the physician replied that blood tests, urine test and a COVID-19 test needed to be done. She stated that she informed him she would comply with the blood and urine tests but that she wasn't sick and did not want the COVID-19 test until she was evaluated by the mental health team. She stated that the physician told her that the tests had to be done first because she would be going to the psychiatric unit. She stated at this point the ED physician had not even talked with her regarding why she was there nor had he done any physical exam and she hadn't even been triaged by a nurse yet. She stated after this she was seated on the edge of the bed, crying and had given the urine test and had her blood taken for testing without any problems. She stated at this time the staff restated to her that a COVID-19 test needed to be done and she stated that she again refused that she didn't want or need it. She stated that when the staff continued to tell her it was needed she got up and began to pace in the room as her anxiety was increasing and she walked to the door of her ED room, turned right and walked out of the room and down the hallway towards the ambulance bay entrance and tried to open the ambulance bay doors to leave. She stated when she wasn't able to pry the doors open she turned around and walked back down the hallway and back into the exam room. She stated that she was talking to herself and told herself she could get through this when security showed up to the room. She stated that the security officers stayed in her room a long time and talked to her as they explained that they needed her to do the test and she stated that she told them she didn't want to do it and explained her past history with COVID-19 related issues, mask and a rape and that was why she didn't want it done and if the mental health evaluation said she needed to be admitted then she would comply with the COVID-19 test at that time, or if she had symptoms of COVID-19 she would get the COVID-19 test but she did not. She stated that one of the male security officers had tears in his eyes like he knew it was wrong to make her do this against her will. She stated that no one told her she would be given a shot for sedation and that she remembered she was sitting on the bed when multiple staff walked in and security and other staff held her down and she stated that she remembered yelling no, don't do this to me, and that someone held her head to the side with their thumb on her jaw and they told her to quit moving her head then someone did the COVID-19 test and she stated she had no memory after that. She stated the next thing she remembered was she woke up in a different ED room with a nurse seated next to the bed then the psychiatric nurse came and at some point the psychiatric nurse gave her cell phone back. She stated that she remembered the physician came in and talked to her, but doesn't remember the conversation. Patient #8 stated that the day was messed up with the inability to contact any of her "life lines," support people and the anxiety was more than she was able to handle. She stated that she never wanted to hurt herself her life lines just didn't work that day. She stated that over the next few days she was unable to walk normally as her right thigh was swollen. She stated that her arms, jaw, teeth and neck hurt. She stated that her husband encouraged her to go get checked out at urgent care just to make sure it was soreness from being held down. Patient #8 stated that the whole thing was a "nightmare." She stated that she never postured or try to "come at" any of the staff and that the only thing she did was she did try to leave through the ambulance doors. Patient #8 stated that the only time she "fought" staff was when they came towards her to hold her down and she told them she would fight if they tried to hold her down.

Patient #8 was tearful throughout the telephone interview and had to stop multiple times during the conversation.

Patient #8 came to the ED voluntarily after she had self-harmed in response to increased anxiety related to a scheduled dental appointment, where staff wore masks, which triggered her PTSD related to her past history of being raped by a man in a mask. When she was unable to reach her support system her anxiety increased and she felt the physical pain would be better than the emotional pain she felt, she cut herself and then called 911 hoping someone she knew would come to help her. Patient #8 willingly consented to blood and urine testing and had the right to refuse a COVID-19 test and, per hospital policy, the COVID-19 test was only required if it was decided that the patient would be admitted to the psychiatric unit. Patient #8 refused the COVID-19 test, was held down against

Based on interview, record review, policy review, video surveillance recording and security body camera and audio recording review the hospital failed to follow their policy and procedure to ensure one discharged, voluntary patient (#8) had the right to refuse treatment or services in the Emergency Department (ED) when she was physically and chemically restrained (administration, generally involuntarily, of medications to control a patient's dangerous behavior) during a COVID-19 (highly contagious, and sometimes fatal, virus) test that she had refused. This failure had the potential to affect all patients and their right to refuse treatment. The hospital census was 110.

Findings included:

1. Review of the hospital policy titled, "Patient Rights, Patient Refusal of Services," review date 04/01/20 showed that all patients have the right to refuse services to the extent permitted by law and regulation.

Review of hospital policy titled, "Patient Rights, Patient bill of Rights," review date 12/31/21 showed that the purpose of the policy was to inform patients and their family members of their rights, and responsibilities. Patients have the right to participate in the development and implementation of their plan of care that included requesting or refusing treatment. Each patient will receive a copy of their rights and responsibilities.

Review of the undated, hospital brochure given to patients titled, "Patient Rights," showed that patients have the right to request or refuse treatment or services.

Review of the hospital policy titled, "Patient Rights, Medically Necessary Hold," reviewed 09/23/22 showed that the purpose of the policy was for management of patients who came to the hospital in need of medical and/or mental health intervention for their safety, who were unable to make decisions for themselves due to a temporary or permanent impairment and who weren't allowed to leave the hospital against medical advice due to the likelihood of serious physical harm. The patient's dignity, worth, and rights shall always be held in the highest consideration. When a patient exhibits a moderate to high risk of harm to themselves or others due to a temporary or permanent incapacity, the physician may place a medically necessary hold order to prevent the patient from leaving the non-psychiatric facility.

Review of the undated, hospital policy titled, "Asymptomatic [without symptoms] Testing of Inpatient Psychiatric Admissions," showed that the following guidelines/special instructions would be implemented to assist in preventing the transmission of COVID-19 within the facility and community. The process showed once the decision to admit to inpatient psychiatric was made in the ED, the COVID-19 test (highly contagious, sometimes fatal, virus) was to be completed.

Review of Patient #8's medical record showed she was a 56 year old female who presented to the ED on 09/27/22 at 12:34 PM. The triage (process of determining the priority of a patient's treatment based on the severity of their condition) note timed 12:39 PM, showed documentation by Staff BB, ED Registered Nurse (RN), that the patient was brought in by law enforcement after she had cut her wrist due to "feeling bad" and these feelings had persisted since the beginning of the COVID-19 pandemic (a sudden increase in the number of cases of a disease above what is normally expected and has spread over several countries or continents, usually affecting large number of people). Staff BB documented that the patient denied suicidal (SI, thoughts of causing one's own death) and reported that the pain of hurting herself was better than the mental pain. ED Physician Notes showed that Staff CC, ED Physician saw the patient at 12:36 PM and documented that the patient had a history of anxiety and depression and the patient denied SI but wanted to get help, and the only way she knew she could get help was to cut her wrist. Staff CC documented that the patient had small, superficial, hesitation cuts to her left wrist, none that required stiches. Staff CC documented that the patient was brought in by law enforcement for a voluntary psychiatric evaluation. Staff CC documented in his medical decision making note, that he ordered a medically necessary hold for the patient at 1:00 PM with the reason listed as harm to self. He documented he would medically clear her and have psychiatry evaluate her. Staff CC documented that the patient became quite agitated when they tried to do a COVID-19 swab and required ketamine (short acting anesthetic) to sedate her for the "acute testing required, and also to calm her down." Staff CC documented that the psychiatric nurse had evaluated the patient and felt she was safe for discharge. He documented "this was an unfortunate turn of events which escalated rapidly." Staff CC documented that the patient denied SI, had a safety plan in place and would be discharged home.

Patient #8 willingly consented to blood and urine testing prior to her mental health evaluation but refused the COVID-19 test.

Review of Patient #8's pre-admission intake (PI) dated 09/27/22 at 5:55 PM, completed by Staff I, RN, Psychiatric Intervention Team (PIT) nurse showed documentation the patient had presented to the ED after she had cut her left wrist then called 911 for help. While in the ED the patient had been uncooperative with a COVID-19 test and had received a ketamine injection. Staff I documented that the patient was very tearful when she spoke about past abuse and triggers. The patient repeatedly denied SI or intent of killing herself or harming others. The patient reported that she had a lot of anger related to past abuse and issues related to COVID-19. The patient reported that today her anxiety was triggered when she prepared to go to a dental appointment related to staff who wore masks (the person that had raped her in the past had worn a mask) and stated that when she was unable to reach her "safety lines" (support/coping skills) that her anxiety increased and she cut herself. The patient reported that she had been forced to have a COVID-19 test today in the ED and it was a trigger related to the past rape. The patient denied the need for inpatient hospitalization and verbalized multiple coping skills, support of church and friends and that her husband would not be working out of town for the next two weeks. The patient contracted for safety and would be discharged to home.

Review of sheriff's report dated 09/27/22 showed that the 911 call was received from Patient #8 at 11:38 AM with arrival time to scene at 11:50 AM. The responding deputy documented that upon arrival he met with Patient #8 who was on her kitchen floor crying. Patient #8 had cut her left wrist with a knife and felt that no one cared for her. The sheriff's deputy transported her to the ED so "they could do a 96 hour [court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others] evaluation."

Review of Patient #8's medical record showed no affidavits (a written statement confirmed by oath, for use as evidenc in court) for a 96 hour hold.

Review of the hospital document titled "Incident File Full Report," dated 09/27/22 at 1:48 PM, Staff GG, Security Officer, documented that hospital security received a call from the ED for assistance with a medical hold patient who refused a COVID-19 test and had attempted to leave. Staff GG documented that on arrival, the patient was in her room, had refused a COVID-19 test and she stated that she would fight. The report showed that they had attempted "multiple" times to de-escalate (reduction of the intensity of a conflict or potentially violent situation) her without success. Staff GG documented that he explained to Patient #8 that it was policy to have the COVID-19 test completed and that nursing staff also informed the patient that for placement to a mental health facility she had to have a COVID-19 test completed.

Review of Staff FF, Security Officer's body cam visual and audio recording showed the following:
- At 1:50:10 PM, showed Patient #8 calmly seated on the bed in her ED room with Staff GG and Staff HH, Security Officers, in the room.
- At 1:52:49 PM, Staff FF, Security Officer, can be heard saying, "You are going to have to take the COVID swab."
- At 1:54:22 PM, Patient #8, still seated on the bed stated, "If I were sick, I would be more than happy to do it."
- At 1:59:42 PM, Patient #8 stated to Staff FF, GG and HH, Security Officers and ED Staff II, RN, ED Charge Nurse, Staff BB and AA who had entered the room, "You know it's wrong." Staff BB, RN replied, "We have to get you placement in a facility and they won't accept you without the COVID swab."
-At 2:00:45 PM, Staff GG, Staff HH, Staff FF and Staff Z, placed the patient in a physical hold. Patient #8 screamed and fought back in response to the hold.
- At 2:01:08 PM, Staff AA, performed the COVID-19 test while Patient #8 screamed.
- At 2:02:17 PM, Patient #8 stated, "I can't believe you guys did that. I feel like I have been raped again. You guys did it, you guys did it."
- At 2:05:10 PM, the patient was released from the physical hold.

During an interview on 12/07/22 at 9:30 AM, Staff FF, Security Officer, stated that he was called to the ED to assist with a patient that was on a medically necessary hold and that she had refused medical treatment that was ordered by the physician.

During an interview on 12/07/22 at 9:51 AM, Staff AA, RN, ED, stated that she was the RN that obtained the COVID-19 test from Patient #8. Staff AA stated that the PIT nurse won't come and evaluate a patient unless they have had all of their testing done first and those tests included the COVID-19 test. She stated that if a patient was on a medically necessary hold that it didn't always mean that they were involuntary, and if a patient was voluntary then they had the right to refuse a COVID-19 test.

During a telephone interview on 12/07/22 at 1:02 PM, Staff CC, ED Physician stated that a medically necessary hold was placed on patients with SI or SI gestures so that the patient cannot leave until medical and psychiatric evaluations were completed. He stated that patients needed the mental capacity to make medical decisions. He stated that Patient #8 was there for SI and because she had injured herself that she lacked the mental capacity to make her own decisions. Staff CC stated that it was policy to have the COVID-19 test prior to admission. He stated that the patient tried to leave the ED and was fighting with staff so the ketamine was given and "while she was down and had calmed down" the COVID-19 test was obtained because it was needed. He stated that he thought that the patient would be admitted, but at the time of the COVID-19 test, the patient disposition had not yet been determined.

During a telephone interview on 12/07/22 at 1:30 PM, Staff DD, Physician, Emergency Medicine Chairman, stated that a medically necessary hold policy and procedure was to protect someone who had self-harmed and lacked capacity to make decisions from making decisions for themselves. He stated that just because a patient was on a medically necessary hold didn't mean they did not have any rights. He stated that he didn't feel it was necessary to sedate a patient to obtain a COVID-19 swab and that they could have delayed the COVID-19 test until after the PIT nurse had evaluated the patient.

During an interview and concurrent body camera and audio recording review on 12/07/22 at 9:15 AM, Staff Y, Physician, ED Medical Director, stated that a patient with a medically necessary hold had the right to refuse treatment. He stated that if a psychiatric patient refused treatment he would not push treatment unless the psychiatric physician insisted.

During an interview on 12/07/22 at 1:55 PM, Staff II, RN, ED Charge Nurse, stated that medically necessary hold patients were able to refuse "to an extent", and that in order for ED staff to have a patient evaluated by the PIT the patient had to be medically cleared first and that included a COVID-19 test.

During a telephone interview on 12/07/22 at 3:26 PM, Staff BB, RN, ED, stated that she was Patient #8's primary care nurse on 09/27/22. She stated that prior to administering the sedation medication she had asked if she had an order and informed Staff CC, ED Physician that the patient was refusing the COVID-19 test. She stated that Staff CC informed the patient that it was per the psychiatric team policy and that she would need it for placement. She stated that there weren't any specific instructions regarding the order in which the sedation and the COVID-19 test were to be completed and that the medication was given for the patients' agitation and not to obtain the COVID-19 test. Staff BB stated that the patient wasn't able to refuse the COVID-19 test based on the PIT policy to obtain a viral test and that every psychiatric patient was to have a COVID-19 test before the intervention team consult.

During an interview on 12/05/22 at 2:20 PM, Staff I, PIT RN, stated that patients in the ED weren't required to have the COVID-19 test prior to the PIT assessment. She stated that the patient had refused the COVID-19 test and that the ED had forced her to take the test prior to her PIT assessment and that it wasn't necessary. She stated that the patient had reported she had refused the COVID-19 test in the ED but they gave her ketamine and obtained the test. Staff I stated that she felt the COVID-19 test could have waited and been obtained once the patient was determined to have needed inpatient admission. Staff I stated that the patient did not meet inpatient criteria and was discharged home with a safety plan.

During an interview on 12/06/22 at 2:14 PM, Staff B, Vice President of Nursing, stated that Patient #8 refused the COVID-19 test but it had to be done because the patient would have been placed in a communal environment with the other psychiatric patients. She stated that on 09/27/22 the process was to do the medical screening exam and with psychiatric patients that included the COVID-19 test.

During a telephone interview on 12/06/22 at 3:34 PM, Staff LL, PIT Manager, stated that a COVID-19 test was not required until the decision had been made to admit the patient.

During a telephone interview on 12/08/22 at 2:43 PM, Patient #8 stated that she had a dental appointment scheduled for 09/27/22. She stated that she had put it off for over a year because of anxiety related to the fact they wore masks. She stated that she had a lot of past history with people wearing masks. She stated that the ED physician came in and told her that some tests needed to be done and that she needed to go to the psychiatric unit. She stated that she questioned the physician if a mental health assessment needed to be done first and that the physician replied that blood tests, urine test and a COVID-19 test needed to be done. She stated that she informed him she would comply with the blood and urine tests but that she wasn't sick and did not want the COVID-19 test until she was evaluated by the mental health team. She stated that the physician told her that the tests had to be done first because she would be going to the psychiatric unit. She stated at this time, the staff restated to her that a COVID-19 test needed to be done and she stated that she again refused, that she didn't want or need it. She stated that when the staff continued to tell her it was needed she got up and began to pace in the room as her anxiety was increasing. She stated that the security officers stayed in her room a long time and talked to her as they explained that they needed her to do the test. She stated that she had told them she didn't want to do it, and explained her past history with COVID-19 related issues, masks and a rape that she did not want it done, but, if the mental health evaluation said she needed to be admitted then she would comply with the COVID-19 test at that time. She stated that one of the male security officers had tears in his eyes like he knew it was wrong to make her do this against her will. She stated that no one told her she would be given a shot for sedation, and that she remembered she was seated on the bed when multiple staff walked in, and security and other staff held her down. She stated that she remembered yelling "no, don't do this to me", and that someone held her head to the side with their thumb on her jaw and they told her to quit moving her head then someone did the COVID-19 test and she stated she had no memory after that
Patient #8 was tearful throughout the telephone interview and had to stop multiple times during the conversation.

Patient #8 came to the ED voluntarily after she had self-harmed in response to increased anxiety related to a scheduled dental appointment where staff wore masks, which triggered her PTSD related to her past history of being raped by a man in a mask. Patient #8 had the right to refuse a COVID-19 test and, per hospital policy, the COVID-19 test was only required if it was decided that the patient would be admitted to the psychiatric unit. Patient #8 refused the COVID-19 test, was held down against her will, sedated with a COVID-19 test performed, prior to her mental health evaluation. The COVID-19 test was not necessary as Patient #8 did not meet inpatient criteria and was later discharged home.


45698

Based on interview and record review, the hospital failed to ensure that staff were trained in first aid (the first and immediate assistance given to any person suffering from either a minor or serious illness or injury) related to restraints (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient), for five staff (E, G, O, BB and II) personnel files of five staff personnel files reviewed. This failure had the potential to result in serious injury or death to patients to who required restraints in the hospital. The hospital census was 110.

Findings included:

1. Review of the hospital's restraint log showed a total of 63 patients required restraints for the previous six months.

Review of five staff personnel records for Staff E, Registered Nurse (RN), Staff O, RN, Staff G, RN, Nurse Manager, Staff BB, RN and Staff II, RN, showed no restraint first aid training.

During an interview on 12/07/22 at 11:20 AM, Staff X, RN, Staff Educator stated that he trained staff for restraint training. He stated that he did not specifically train staff on first aid in relation to restraints.