HospitalInspections.org

Based on observation, interview, record review, policy review and digital video recording review, the hospital failed to:
- Provide a safe setting for patients when two staff members (Staff CC, Security Police Officer [SPO]/Chief Executive Officer of Contracted Security Services [CEO-Security] and Staff GG, Security Deputy Sheriff [SDS]) were not immediately removed from patient care areas after patient abuse incidents, and contracted Security Police Officers (SPOs) were not properly trained in Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement) as specified in their contractual agreement (A-0144).
- Recognize and prevent staff to patient abuse for two patients (#6 and #7) of two patients reviewed for abuse (A-0145).
- Follow their internal policy and protect one patient (#7) of one patient reviewed, when Staff GG taser (electrical weapon, used to stun a person through the delivery of electrical current) drive-stunned (when a taser is held against the body and is intended to cause pain without incapacitating) the patient prior to being placed in a restraint chair on the locked Behavioral Health Unit (BHU) (A-0154).

These deficient practices resulted in the hospital's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The hospital census was 47.

These failures created an unsafe environment and had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ).

As of 10/14/22, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- Two contract security officers (Staff CC and Staff GG) were terminated for failure to use CPI techniques for patient de-escalation and inappropriate use of force.
- The contracted security firm was provided with a 30-day notice of termination of services, on 10/14/22.
- House wide education began to all staff, on 10/14/22 and continued until all employees were educated and prior to their next scheduled shift.
- Education related to the Escalation of Force policy, Code Strong policy, Abuse and Neglect policy, with CPI hands on scenario training with the emphasis on nursing leadership of de-escalation.

Based on observation, interview, record review, policy review, and digital video recording review, the hospital failed to provide a safe setting for patients when two staff members (Staff CC, Security Police Officer [SPO]/Chief Executive Officer of Contracted Security Services [CEO-Security] and Staff GG, Security Deputy Sheriff [SDS]) were not immediately removed from patient care areas after patient abuse incidents, and contracted Security Police Officers (SPOs) were not properly trained in Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement) as specified in their contractual agreement. This had the potential to lead to an unsafe environment and/or abuse, and could impact all patients. The hospital census was 47.

Findings included:

1. Review of an agreement between the hospital and the contracted security officer group, dated 06/01/22, showed that the contracted service would provide active patrol with an "unarmed" guard throughout the hospital.

Review of the hospital's policy titled, "Abuse and Neglect," dated 09/2022, showed that:
- Abuse is the willful or reckless infliction of injury, unreasonable confinement, intimidation, coercion or punishment that results in physical harm, pain, fear or mental anguish.
- Upon the observation that a patient has been, or will be, subjected to abuse, neglect or harassment the care providers will first address and ensure the safety and well-being of the involved patient and reasonably remove all immediate threats to life and safety.
- For the protection of patients and involved personnel, patient care providers involved in matters of patient abuse, neglect and/or harassment must be relieved of patient care responsibilities and excused from patient care areas of the hospital, pending an investigation.

Review of the hospital's document titled, "Abuse and Neglect Investigation Standard Work Sheet," dated 06/2022, directed that when a case of abuse and/or neglect was suspected, involved staff would be immediately removed from duty and instructed to clock out.

Review of Patient #6's medical record showed he was a 55-year-old disabled male that arrived for treatment to the Emergency Department (ED) on 10/03/22, to have his behavior evaluated after exhibiting anger issues when he slapped a fellow resident at his nursing home. He was to be admitted to behavior health, on assault precautions (AP, measures to alert staff of a patient's potential to become violent with others). After 22 hours in the ED, he became aggressive, and was struck in the head twice by Staff CC.

Review of the hospital's digital video recording in the ED dated 10/02/22 at 2:03 PM through 2:50 PM, showed Patient #6 standing in the hallway twirling a cane. Staff CC approached and grabbed the cane, Patient #6 held on, then wrapped the cane behind Staff CC's back. When Patient #6 refused to release the cane, he was punched twice in the left side of the head by Staff CC, SPO, then taken to the floor. Patient #6 was observed face up on the floor with his head turned to the right, Staff CC on his knees beside him with a closed fist to his neck and an open hand on his jaw, pressing his head into the floor. Staff CC was not immediately removed, he remained within the ED patient care area, and continued to work. He continued to interact with staff and observe patient's coming and going for more than 47 minutes after he abused Patient #6. He was not relieved by any other security officers and completed his shift.

Review of Patient #7's medical record showed that he was a 33-year-old disabled male that had been admitted on 10/01/22, with depression (extreme sadness that doesn't go away), paranoia (excessive suspiciousness without adequate cause), suicidal ideations (SI, thoughts of causing one's own death) and auditory hallucinations (AH, hearing things which are not there). On 10/02/22 at 1:10 AM, he refused to perform a Covid-19 (highly contagious, and sometimes fatal, virus) swab test. He was observed posturing (positioning of body in an aggressive manor) with his fist directed toward staff, slamming the door of his room and switching the lights on and off. A Code Strong (a response from all available staff to respond to an escalating patient in attempt to de-escalate the situation without using force and using the least restrictive intervention) was initiated, and during the Code Strong, the patient was tased (electrical weapon, used to stun a person through the delivery of electrical current) by Staff GG, medicated, and placed in a restraint chair.

Review of the hospital's digital video recording of the third floor Behavioral Health Unit (BHU) hallway, dated 10/02/22 at 1:36 AM, showed a total of nine staff members and Patient #7 in the hallway. Patient #7 could be seen gesturing at times, no aggressive behavior noted. Staff members arrived with the restraint chair. A few minutes into the video, Patient #7 ran down the hallway and out of camera view. Multiple staff members followed, including Staff GG. Staff GG removed the taser from her belt, held it with her left hand, and concealed it behind her back for 30 seconds. The taser then appeared in her right hand, aimed at Patient #7, who was out of camera view. During the interaction, Staff GG appeared to direct the nursing staff to move toward Patient #7, and the restraint chair was brought down the hall to their location. The taser remained in Staff GG's hand. Multiple staff members, including Staff GG, moved out of camera range toward Patient #7. The use of the taser was not directly observed on the video as the parties involved were out of direct camera view; however, several staff members remained in camera view and one could reasonably conclude by their visible reactions that Patient #7 had been tased.

Review of the undated written statement by Staff GG, showed the following:
- She was called to the third floor to assist with a combative patient, Patient #7.
- Patient #7 threatened staff and walked up to a nurse in an aggressive manner.
- She stepped in front of the nurse with her hands out toward the patient and told him not to walk up on the nurse and to calm down.
- Patient #7 proceeded to walk up on the nurse a few more times and staff called a Code Strong.
- Patient #7 continued to make threats and stated that he was going to leave.
- She pulled her taser, with no intent to use it, but hoped that it would help Patient #7 to cooperate by just seeing it.
- Staff grabbed a hold of the patient, but he started to break loose from them.
- She drive-stunned Patient #7 for one to two seconds.
- She started to reach out and drive-stun him again, but she noticed he had calmed down so the second time it didn't connect.
- Use of the taser calmed the patient down "a lot," so staff were able to give him the shot, put him in the restraint chair, and strapped him down.

Review of the undated written statement by Staff II, Registered Nurse (RN), showed that Staff GG was asked to not use the taser on the patient, before Staff GG held the taser to the patient and discharged twice.

Review of the undated written statement by Staff JJ, RN, showed that she observed Staff GG, with a taser in her hand and asked her not to use the taser on the patient, then she observed Staff GG approach the patient and she placed the taser on his torso area twice.

During an interview on 10/13/22 at 4:05 PM, Staff QQ, House Supervisor, stated that she did not send Staff GG home immediately, but believed that Staff GG had gone to the security office, away from patients.

Review of the hospital's digital video recording in the ED dated 10/02/22 from 2:45 AM through 5:40 AM, showed that Staff GG was not immediately removed from patient care areas, and remained within the ED patient care area.

These failures allowed Staff CC and Staff GG to continue to work in patient care areas after they were alleged to have abused patients, and placed all patients at risk for abuse.

2. Review of an agreement between the hospital and the contracted security officer group, dated 06/01/22, showed that all armed or unarmed security officers assigned to work on the premises would have received CPI training prior to working any shifts.

Although requested, the hospital was unable to provide documentation that showed Staff GG, the contracted SDS who abused Patient #7, had completed CPI training as part of the agreement between the contracted security office group and the hospital.

Review of an undated document, (list of security CPI training dates), supplied by the hospital on 10/12/22 at 11:00 AM, showed Staff SPOs K, V, X, Y, Z, AA, BB, CC, DD, and EE had not completed their CPI training.

Review of the hospital's document titled, "October 2022 Security Schedules," showed that Staff K, V, Y, Z, AA, BB, CC and DD were scheduled to work in the hospital during the month of October.

Observation on 10/11/22 at 2:50 PM, showed Staff X, SPO, was on duty and working.

During an interview on 10/11/22 at 3:30 PM, Staff K, SPO, stated that she was not CPI trained, and she was authorized to use any weapon she carried (baton, taser [electrical weapon, used to stun a person through the delivery of electrical current] or gun). Staff K was not authorized to use any weapon per policy, this was her perception.

During an interview on 10/13/22 at 12:25 PM, Staff A, Chief Nursing Officer (CNO), stated that she was not aware that contracted SOs had not completed CPI training.

During an interview on 10/13/22 at 12:55 PM, Staff SS, Chief Executive Officer (CEO), stated that the owner of the contracted security firm reported to her. She was not aware that the SPOs providing service to the hospital did not have CPI training, or that the contract specified that this should be completed prior to staffing any shifts.

Based on observation, interview, record review, policy review and digital video recording review, the hospital failed to recognize and prevent staff to patient abuse for two patients (#6 and #7) of two patients reviewed for abuse. These failures placed all patients in the hospital at risk for abuse and neglect by staff. The hospital census was 47.

Findings included:

1. Review of the hospital's policy titled, "Abuse and Neglect," revised 09/2022, showed the following:
- Patients have the right and expectation to receive health care services, care and treatment in a safe setting, and remain free at all times from abuse.
- The hospital will take all reasonable steps to ensure that patients are free from all forms of abuse and follow prescribed processes that safeguard patients when abuse is suspected, reported, or witnessed.
- Abuse is the willful or reckless infliction of injury, unreasonable confinement, intimidation, coercion, financial exploitation, or punishment, with resulting physical harm, pain, fear, or mental anguish.

Review of the hospital's policy titled, "Escalation of Force," dated 07/2022, showed the following:
- When faced with an incident that may require an escalation of force, a security officer will be responsible for assessing the situation, collaborating with clinical staff when appropriate, and utilizing the proper use of force as defined in the escalation of force continuum.
- Security officers are expected to use the lowest level of force in the continuum necessary to de-escalate a potentially violent or unsafe situation and ensure a safe and successful outcome.
- Level One Force: Officer Presence; establish force with the officer's presence and symbol of authority such as officer's uniform, physical positioning, attitude and stance.
- Level Two Force: Verbal; establish force with spoken direction and control. Non-violent crisis intervention techniques are ideal. Verbal direction and control are the most desirable force options for security officers. Officers will complete a de-escalation course with annual recertification.
- Level Three Force: Physical Control; establish control with physical contact or the display of an intermediate weapon (a tool not fundamentally designed to cause deadly force with conventional use). Use of empty hand techniques such as physical contact methods taught in de-escalation courses. Assisting in the restraint of a patient under clinical supervision does not constitute the use of level three force.

Review of an agreement between the hospital and the contracted security officer group, dated 06/01/22, showed that the contracted service would provide active patrol with an "unarmed" guard throughout the hospital, and that all armed or unarmed security officers assigned to work on the premises would have received Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement) training prior to working any shifts.

Review of Patient #6's medical record showed the following:
- He was a 55-year-old disabled male that arrived via ambulance for treatment to the Emergency Department (ED) on 10/03/22 via ambulance to have his behavior evaluated after exhibiting anger issues when he slapped a fellow resident at his nursing home.
- On 10/03/22, he was to be admitted to behavior health with a diagnosis of depression (extreme sadness that doesn't go away) and to be placed on assault precautions (AP, measures to alert staff of a patient's potential to become violent with others).
- After 22 hours in the ED, he became agitated because of the long wait, when he exited his ED room and paced in the ED hallway and verbally threatened several staff members. Staff CC, Security Police Officer (SPO) and Chief Executive Officer of the contracted security services approached the patient, the patient placed his cane around the officer's back which confined the officer. When the officer was unable to free himself from the patient's hold, the officer struck the patient in the head twice. He was sedated, experienced difficulty breathing and low oxygen levels, and required bag mask ventilation (the circulation and exchange of gases in the lungs, the process of breathing).
- On 10/04/22, he was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) while he awaited transfer to Hospital B (local acute care hospital with necessary specialty equipment) for evaluation of possible bleeding in the brain and a possible neck fracture.
- No negative outcome, patient was discharged from Hospital B.
- No police reports were completed.

Review of the hospital's digital video recording in the ED dated 10/02/22 at 2:03 PM through 2:50 PM, showed Patient #6 standing in the hallway twirling a cane. Staff CC approached and grabbed the cane, Patient #6 held on, then wrapped the cane behind Staff CC's back. When Patient #6 refused to release the cane, he was punched twice in the left side of the head by Staff CC, then taken to the floor. Patient #6 was observed face up on the floor with his head turned to the right, Staff CC on his knees beside him with a closed fist to his neck and an open hand on his jaw, pressing his head into the floor. Staff CC was not immediately removed, he remained within the ED patient care area, and continued to work. He continued to interact with staff and observe patient's coming and going for more than 47 minutes after he abused Patient #6. He was not relieved by any other security officers and completed his shift.

During an interview obtained by the hospital on 10/04/22, Staff CC, stated that Patient #6 was able to put a cane behind the SPO's back and tightly squeezed his chest in a bear hug. When staff were unable to get Patient #6 to release Staff CC, he struck the patient on the left side of his head with his fist.

Review of the hospital's undated self-report document related to Patient #6 showed that the hospital identified that Staff CC had not utilized CPI techniques, and had inappropriately applied the use of force. Staff CC started work on or around 06/01/22 when the security contract was put in place.

Review of a undated document (list of security CPI training list) supplied by the hospital on 10/12/22 at 11:00 AM, showed Staff CC had not completed CPI training.

During an interview on 10/13/22 at 3:00 PM, Staff TT, Chief Medical Officer (CMO), stated that he had reviewed a video recording of Staff CC punching Patient #6, and felt that the incident in the ED could have been prevented. Staff TT stated that it would be considered excessive for a patient to be punched or tased, and believed that Staff CC was
overly aggressive when he held the patient with a fist to his neck, after he struck him.

During an interview on 10/13/22 at 12:25 PM, Staff A, Chief Nursing Officer (CNO), stated that punching a patient in the head was patient abuse.

During an interview on 10/13/22 at 12:55 PM, Staff SS, Chief Executive Officer (CEO), stated that Staff CC reported directly to her, and although she had not reviewed the video, she felt that Staff CC had acted appropriately when he punched Patient #6 in the head. "He had no other choice."

Review of Patient #7's medical record showed the following:
- He was a 33-year-old disabled male that had been admitted on 10/01/22, with depression (extreme sadness that doesn't go away), paranoia (excessive suspiciousness without adequate cause), suicidal ideations (SI, thoughts of causing one's own death) and auditory hallucinations (AH, hearing things which are not there).
- On 10/02/22 at 1:10 AM, he refused to perform a Covid-19 (highly contagious, and sometimes fatal, virus) swab test.
- He was observed posturing (positioning of body in an aggressive manor) with his fist directed toward staff, slamming the door of his room and switching the lights on and off.
- When he refused to follow redirection, a Code Strong (a response from all available staff to respond to an escalating patient in attempt to de-escalate the situation without using force and using the least restrictive intervention) was initiated.
- During the Code Strong, he was tased (electrical weapon, used to stun a person through the delivery of electrical current) by Staff GG, Security Deputy Sheriff (SDS), medicated, and placed in a restraint chair.

Review of the hospital's digital video recording of the third floor Behavioral Health Unit hallway, dated 10/02/22 at 1:36 AM, showed a total of nine staff members and Patient #7 in the hallway. Patient #7 could be seen gesturing at times, no aggressive behavior noted. Staff members arrived with the restraint chair. A few minutes into the video, Patient #7 ran down the hallway and out of camera view. Multiple staff members followed, including Staff GG. Staff GG removed the taser from her belt, held it with her left hand, and concealed it behind her back for 30 seconds. The taser then appeared in her right hand, aimed at Patient #7, who was out of camera view. During the interaction, Staff GG, appeared to be directing the nursing staff to move toward Patient #7, and the restraint chair was brought down the hall to their location. The taser remained in Staff GG's hand. Multiple staff members, including Staff GG, moved out of camera range toward Patient #7. The use of the taser was not directly observed.

During an interview obtained by the hospital on 10/06/22, Staff GG, SDS, stated that Patient #7 had been aggressive, threatened staff and walked towards the nurse aggressively. Patient #7 had run down the hall. She pulled her taser out in an attempt to get him to cooperate. Staff grabbed a hold of him, and when he attempted to get away, she drive tased (placing the taser against the skin of a person, squeezing the trigger, to cause pain without incapacitating them) him for two seconds. She started to tase him a second time, but stopped because he had calmed down from the first tase. The staff were then able to medicate him and strap him in the restraint chair.

Review of the undated written statement by Staff II, Registered Nurse (RN), showed that Staff GG was asked to not use the taser on the patient, before Staff GG held the taser to the patient and discharged twice.

Review of the undated written statement by Staff JJ, RN, showed that she observed Staff GG, with a taser in her hand and asked her not to use the taser on the patient, then observed Staff GG approach the patient and she placed the taser on his torso area twice.

Review of the hospital's undated self-report document related to Patient #7 showed that the hospital identified that Staff GG, had not utilized CPI training and had inappropriately applied the use of force.

During an interview on 10/13/22 at 3:00 PM, Staff TT, CMO, stated that he was made aware of the event that involved Staff GG tasing Patient #7, the day after it occurred.

Although requested, the hospital was unable to provide documentation that showed Staff GG had completed CPI training.

During an interview on 10/13/22 at 12:25 PM, Staff A, Chief Nursing Officer (CNO), stated that the use of tasers on a patient was abuse, and that the hospital Chief Executive Officer (CEO) was responsible for the oversight of the security services contract and compliance.

During an interview on 10/13/22 at 12:55 PM, Staff SS, CEO, stated the following:
- A weapon should not have been on the BHU.
- Security staff should only serve as back-up for the clinical staff.
- She was not aware that security staff were supposed to be CPI trained prior to their first shift worked in the hospital, as required in their contractual agreement.

The hospital failed to recognize and prevent the abuse of Patient #6 and Patient #7. On 10/02/22, Staff GG tased Patient #7 two times, after the patient had refused a COVID-19 test, and began to escalate. The hospital's self-report showed that the hospital identified Staff GG had not utilized appropriate CPI techniques. During the survey, when requested, the hospital was unable to provide documentation that Staff GG had completed CPI training as part of the contractual agreement with the hospital. On 10/03/22, Staff CC punched Patient #6 in the head twice, and the patient required medical evaluation at another hospital for possible injuries sustained during the abuse. During the survey, Staff CC still had not been trained in CPI, a week after he failed to follow appropriate CPI techniques. The CEO failed to review the videos of the abuse, believed Staff CC had acted appropriately, and was unaware that the contracted security officers actively staffing the hospital were not trained in CPI, or that it was a requirement of their contractual agreement with the hospital.






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Based on observation, interview, record review, policy review and digital video recording review, the hospital failed to follow their internal policy and protect one patient (#7) of one patient reviewed, when Staff GG, Security Deputy Sheriff (SDS), taser (electrical weapon, used to stun a person through the delivery of electrical current) drive-stunned (when a taser is held against the body and is intended to cause pain without incapacitating) the patient prior to being placed in a restraint chair on the locked Behavioral Health Unit (BHU). This failure placed all patients at risk for their safety. The hospital census was 47.

Findings included:

1. Although requested, a policy that specifically addressed weapons was not provided; however, hospital administration referred the survey team to the policy titled, "Escalation of Force," for further reference.

Review of the hospital's policy titled, "Escalation of Force," dated 07/2022, showed the following directive for staff:
- When faced with an incident that may require an escalation of force, a security officer will be responsible for assessing the situation, collaborating with clinical staff when appropriate, and utilizing the proper use of force as defined in the escalation of force continuum.
- Security officers are expected to use the lowest level of force in the continuum necessary to de-escalate a potentially violent or unsafe situation and ensure a safe and successful outcome.
- Level One Force: Officer Presence; establish force with the officer's presence and symbol of authority such as officer's uniform, physical positioning, attitude and stance.
- Level Two Force: Verbal; establish force with spoken direction and control. Non-violent crisis intervention techniques are ideal. Verbal direction and control are the most desirable force options for security officers. Officers will complete a de-escalation course with annual recertification.
- Level Three Force: Physical Control; establish control with physical contact or the display of an intermediate weapon (a tool not fundamentally designed to cause deadly force with conventional use). Use of empty hand techniques such as physical contact methods taught in de-escalation courses. Assisting in the restraint of a patient under clinical supervision does not constitute the use of level three force.

Review of the hospital's policy titled, "Restraints or Seclusion," reviewed 02/2021, showed the following directive for staff:
- Patients have the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff.
- When necessary to protect a patient, staff members or others from harm, restraints or seclusion may be employed, but the least restrictive intervention that will be effective is utilized.
- Restraint or seclusion is not allowed for punishment or convenience.
- Restraint or seclusion can only be used to ensure the immediate physical safety of the patient, a staff member or others and when it was the least restrictive intervention that will be effective to protect the patient, a staff member or others from harm.
- Crisis Prevention Intervention (CPI, a type of training where staff learn safe physical hold to restrict a person's movement) has been identified as the standard training for verbal de-escalation and physical intervention.

Review of the hospital's policy titled, "Code Strong (a response from all available staff to respond to an escalating patient in attempt to de-escalate the situation without using force and using the least restrictive intervention)," revised 08/2021, showed the following directive for staff:
- The primary focus of the Code Strong team is to de-escalate the situation without using force and using the least restrictive intervention to maintain the safety of patients, visitors and staff members.
- When a patient is displaying escalating and/or violent behaviors, staff will communicate with the patient using verbal de-escalation techniques.
- The primary nurse or designee will direct team assignments for the Code Strong.
- If physical intervention is required to ensure safety of the patient(s) or staff, CPI interventions will be utilized.

Review of an agreement between the hospital and the contracted security officer group dated 06/01/22, showed that the contracted service would provide active patrol with an "unarmed" guard throughout the hospital, and that all guards assigned to work on the premises had CPI training prior to working any shifts.

Review of Patient #7's medical record showed the following:
- He was a 33-year-old disabled male that had been admitted on 10/01/22, with depression (extreme sadness that doesn't go away), paranoia (excessive suspiciousness without adequate cause), suicidal ideations (SI, thoughts of causing one's own death) and auditory hallucinations (AH, hearing things which are not there).
- On 10/02/22 at 1:10 AM, he refused to perform a Covid-19 (highly contagious, and sometimes fatal, virus) swab test.
- He was observed posturing (positioning of body in an aggressive manor) with his fist directed toward staff, slamming the door of his room and switching the lights on and off.
- When he refused to follow redirection, a Code Strong (a response from all available staff to respond to an escalating patient in attempt to de-escalate the situation without using force and using the least restrictive intervention) was initiated.
- During the Code Strong, he was tased (electrical weapon, used to stun a person through the delivery of electrical current) by Staff GG, medicated, and placed in a restraint chair.

Review of the hospital's digital video recording of the third floor BHU hallway, dated 10/02/22 at 1:36 AM, showed a total of nine staff members and Patient #7 in the hallway. Patient #7 could be seen gesturing at times, no aggressive behavior noted. Staff members arrived with the restraint chair. A few minutes into the video, Patient #7 ran down the hallway and out of camera view. Multiple staff members followed, including Staff GG, SDS. Staff GG removed the taser from her belt, held it with her left hand, and concealed it behind her back for 30 seconds. The taser then appeared in her right hand, aimed at Patient #7, who was out of camera view. During the interaction, Staff GG appeared to direct the nursing staff to move toward Patient #7, and the restraint chair was brought down the hall to their location. The taser remained in Staff GG's hand. Multiple staff members, including Staff GG, moved out of camera range toward Patient #7. The use of the taser was not directly observed on the video as the parties involved were out of direct camera view; however, several staff members remained in camera view and one could reasonably conclude by their visible reactions that Patient #7 had been tased.

Review of the undated written statement by Staff GG, SDS, showed the following:
- She was called to the third floor to assist with a combative patient, Patient #7.
- Patient #7 threatened staff and walked up to a nurse in an aggressive manner.
- She stepped in front of the nurse with her hands out toward the patient and told him not to walk up on the nurse and to calm down.
- Patient #7 proceeded to walk up on the nurse a few more times and staff called a Code Strong.
- Patient #7 continued to make threats and stated that he was going to leave.
- She pulled her taser, with no intent to use it, but hoped that it would help Patient #7 to cooperate by just seeing it.
- Staff grabbed a hold of the patient, but he started to break loose from them.
- She drive-stunned Patient #7 for one to two seconds.
- She started to reach out and drive-stun him again, but she noticed he had calmed down so the second time it didn't connect.
- Use of the taser calmed the patient down "a lot," so staff were able to give him the shot, put him in the restraint chair, and strapped him down.

Review of the undated written statement by Staff II, Registered Nurse (RN), showed the following:
- A CPI Code Strong was initiated.
- Staff GG, SDS, brought out a taser and continued to ask the patient to comply.
- The staff nurse asked Staff GG to not use the taser.
- A CPI hold was initiated due to the patient's combativeness to receive a medication injection.
- Staff GG then held the taser to the patient and discharged twice.

Review of the undated written statement by Staff JJ, RN, showed the following:
- A Code Strong was initiated as the patient continued to escalate.
- She observed Staff GG, SDS, with a taser in her hand and asked her not to use the taser on the patient.
- The taser remained in Staff GG's hand, and a few moments later, she observed Staff GG approach the patient and she placed the taser on his torso area twice.

Review of the hospital's undated self-report document related to Patient #7 showed that the hospital identified that staff had not utilized CPI training and had inappropriately applied the use of force.

Although requested, the hospital was unable to produce documentation to show that Staff GG had been trained in CPI techniques.

During an interview on 10/11/22 at 3:30 PM, Staff K, SPO, stated that she was not CPI trained, and she was authorized to use any weapon she carried (baton, taser or gun).

During an interview on 10/13/22 at 12:25 PM, Staff A, Chief Nursing Officer (CNO), stated that there was a safe on 3-West for weapons to be secured prior to entry of the locked BHU, and that the use of tasers by security staff would be considered police tactics.

During an interview on 10/13/22 at 12:55 PM, Staff SS, Chief Executive Officer (CEO), stated that a weapon should not have been on the BHU, and that security staff should only be there to serve as back-up for the clinical staff.




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