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34824

Based on document review and interview, it was determined the Hospital failed to protect patients from the use of abusive forms of restraints- weapons (pepper spray and handcuffs). Therefore, the Condition of Participation, 42 CFR 482.13, Patient Rights, was NOT met, as evidenced by:

Findings Include:

1. The Hospital failed to protect patients from the use of abusive forms of restraints- weapons (pepper spray and handcuffs). The practice of utilizing law enforcement restraint devices by hospital staff including hospital security is not a safe or appropriate health care restraint intervention. These failures put the patients at risk for abuse. See A-0154.

An immediate jeopardy (IJ) investigation was conducted on 05/20/2021 through 05/24/2021 for Complaint #IL 00133989/211469. An immediate jeopardy was identified, due to the Hospital's failure to protect patients from the use of abusive forms of restraints- weapons (pepper spray and handcuffs). The practice of utilizing law enforcement restraint devices by hospital staff including hospital security is not a safe or appropriate health care restraint intervention. These failures put the patient, other patients, and staff at risk for harm. Subsequently, Pt #1 was restrained with pepper spray and Pt #8 was restrained with pepper spray and handcuffs. The IJ event was identified on 04/22/2021, at 42 CFR 482.13, Patient Rights, and was announced on 05/24/2021 at *****M, during a meeting with the Director of Quality and Patient Safety Eastern Regions Officer (E #1), (E #1) and (E #6). The IJ was not removed by the survey exit date of 05/24/2021.*****

Based on document review and interview, it was determined for 2 of 2 (Pt #1 and Pt #8) restrained patients, the Hospital failed to protect patients from the use of abusive forms of restraints- weapons (pepper spray and handcuffs). The practice of utilizing law enforcement restraint devices by hospital staff including hospital security is not a safe or appropriate health care restraint intervention. These failures put the patients at risk for abuse. This has the potential to affect all inpatients and outpatients who require the use of restraints.

Findings include:

1. During an interview with the Director of Quality and Patient Safety -Eastern Region (E#1) on 5/20/21 at approximately 2:00 PM. E#1 stated, "Pepper foam (SABRE Red H20/ Oleoresin Capsicum) and handcuffs are used at this facility." E #1 stated, "Security filed an incident report on these 2 events." The Chief Medical Officer (MD#1), the Chief Nursing Officer (E#2), the Risk Manager (E#11), the Manager of Quality and Safety (E#12), the Quality Safety Coordinator (E#14) and I reviewed the details of the events." When asked if the facility had notified the State of the abuse, E #1 stated, "No, we did not identify this as abuse and did no further investigation."

2. The "MIDAS (computer program) Security report" was reviewed on 05/21/21 at approximately 8:00 AM. Two events were listed regarding the use of pepper foam (Pt #1 and Pt #8).
- The event dated 05/14/21 stated "On above date and time (Pt #1) was getting transferred from 8 East room #834 to 5 East room #516 ... Patient was sprayed (Pepper Foam (Oleorsin Capsicum) .... "
- The event dated 04/22/21 stated "Security Officer (E #5) escorted EMTs (emergency medical technicians) to 5 East for a direct admit of (Pt #8). Upon (Pt #8) being informed (Pt #8) will be staying for multiple days (Pt #8) became agitated and began to walk around the room (508) crying and yelling. At which time (E #5) radio'd for Officer (E #4) to come to 5 east in the event of (Pt #8) becoming combative or uncompliant with staff .... A Control Alert (an alert that Security and help is needed for a combative person) was then issued ... Security along with other staff managed to get a hold of (Pt #8) and assist him to the ground where a small dose of pepper spray (Pepper Foam (Oleorsin Capsicum) was deployed..."

3. The clinical record for Pt #1 was reviewed on 05/20/21 at approximately 12:30 PM and included that the patient arrived to the Emergency Department (ED) by EMS (emergency medical services) with police on 05/12/21 at 11:20 PM with a chief complaint of Behavioral Problem and Acute Psychosis. Pt #1 was admitted to room 834 (Medical Floor) on 05/13/21 at 8:11 AM with a diagnosis of Rhabdomyolysis, Acute Kidney Injury and Toxic Encephalopathy. Pt #1 was then transferred to the Behavioral Health Unit (5 East) room 516A on 05/14/21 at 1:43 PM. A "BH (Behavioral Health) Admission Note" on 05/14/21 stated, "(Pt #1) had a control code called due to refusing to transfer to 5 E. (Pt #1) was medicated with Zyprexa (antipsychotic) 10 mg (milligrams) and Ativan (antianxiety) 2 mg IM (intramuscular). (Pt #1) settled down and we were ready to transfer (Pt#1) by wheelchair, when (Pt #1) got upset and started throwing things in (Pt#1's) room and had to be maced. After this, (Pt #1) was taken per wheelchair to 5 E and into (Pt#1's) room where (Pt#1) settled down and was helped by staff to clean the mace off (Pt #1). (Pt #1) quickly laid down and went to sleep."

4. The clinical record of Pt #8 was reviewed on 05/21/21 at approximately 9:00 AM and included that the patient was a direct admit to the Behavioral Health Unit on 04/22/21 with a diagnosis of Bipolar Disorder. A
"Restraint for Violent/Self-Destructive Behavior 18 yrs (years) and Up" order dated 04/22/21 at 5:18 PM stated "Type of Restraint Physical Hold; Comment: Patient placed in handcuffs by security from 4:45 PM - 4:50 PM ..." The record lacked any documentation of the use of pepper foam (spray) as noted in the MIDAS security report).

5. During an interview with RN (E #7) on 05/21/21 at approximately 12:00 PM, E #7 stated that Pt #8 "Had shouldered (Pt #8's) way through the doors. It took 5-6 of us to take (Pt #8) down softly. As we got (Pt #8) to the ground, we all started coughing and someone asked if pepper spray had been used. Then security placed (Pt #8) in handcuffs. (Pt #8) calmed down and was removed from the restraints in about 5-10 minutes."