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Based on medical record review, staff interviews, review of facility documents, and review of video surveillance, it was determined that the facility failed to ensure that a facility approved personal protective equipment is available and utilized as referenced in the "Handle with Care Instructor Manual" to protect staff and patients from bodily fluids (i.e. sputum).

Findings include:

On 1/3/24 at 1:36 PM, time stamped ED hallway video surveillance review for P1, was conducted in the presence of S6, the Security Manager, S5, and S12, the Assistant Vice President of Quality. The video surveillance reviewed did not have any audio recording. The video surveillance began in "Hallway 24" in the ED as confirmed by S6, and it revealed the following:

At 7:16 PM: P1 appeared to spit and verbally communicate in what appeared to be an aggressive manner at facility staff and then began to punch the wall next to the stretcher with the side of his/hers arm. Multiple staff members (RNs and Security officers) were observed to respond and began to lay P1 down onto his/her stretcher in a supine (lying horizontally with face and torso facing up) position in a controlled manner. The staff members were observed to place themselves around the stretcher and physically hold P1, restraining P1 to the stretcher. Staff members were observed physically holding P1's B/L (bilateral) arms and B/L legs.

At 7:17 PM: S10 (Security Officer) was observed to place his/her hand on the top portion of P1's forehead and side of face, however exact hand placement on side of face was difficult to assess due to the angle of the camera. Multiple staff members continued to physically hold P1 restraining him/her to stretcher. S24 (RN) was observed to place a surgical mask on to P1.

On 1/3/24 at 1:40 PM, upon interview with S6, he/she indicated after video surveillance review, he/she "did not see any excessive force and no disciplinary actions were taken." S6 indicated that P1's head was physically secured to the stretcher to prevent P1 from biting or spiting on staff. S6 indicated that this technique was appropriate to keep staff and the patient safe. On 1/3/24 at 1:53 PM, S5 stated, "we do not use spit shields, a surgical mask was used because the patient was spitting and biting." S5 indicated that each situation when a patient becomes agitated is very individualized but verbal de-escalation is always the first step and that the facility provides Handle with Care training yearly that includes de-escalation. S5 indicated that if a patient begins to spit, surgical masks are applied to the patient to prevent staff from being spat on.

On 1/3/24 at 3:00 PM, an interview was conducted with S10. S10 confirmed he/she was present when the event occurred with P1 on 12/2/23. S10 indicated he/she received a call to retrieve P1 belongings for discharge. S10 stated, "[P1] was freaking out." S10 stated that he/she held patients head while on the stretcher because P1 was trying to spit and bite the staff. Once the surgical mask was on the patient, S10 indicated that he/she was holding P1's ear so that P1 he could not remove the mask. S10 indicated that P1 was still attempting to spit and moving head to attempt to remove the mask.

On 1/4/24 at 1:53 PM, upon interview with S12, he/she stated that surgical masks were appropriate for spitting patients and the facility does not use spit shields, though staff have requested spit shields. Upon request, S12 was unable to provide documentation related to the acceptable use of surgical masks for patients that are spitting. The facility provided the Handle with Care training which referenced the use of an appropriate cushion like spitguard in the event of a patient spitting at staff.

Review of the facility document titled, "Handle with Care ...Instruction Manual" it stated, " ...Once oriented, stabilize the head (to prevent head butting, spitting, or biting) ...Watch for spitting. An appropriate cushion like CerviPro SpitGuard can also be used."

Based on medical record review, staff interview, review of facility documents, and review of video surveillance, it was determined that the facility failed to implement the facility's policy to ensure that a documented evidence of a physician order was obtained and documented upon initiation of restraints, for one of 10 patients (#1).

Findings Include:

On 1/3/23 at 10:30 AM, a medical record review of P1 was conducted with Staff 3 (S3), the ED Coordinator of Patient Services, and S5, the ED Manager. P1 arrived at the ED (emergency department) via EMS (Emergency Medical Services) on 12/2/23 at 3:02 PM, with a chief complaint of SI (Suicidal Ideation). An ED Provider Note on 12/2/23 at 7:19 PM stated, "Delayed charting: Patient was seen and evaluated by Behavioral Health and deemed stable for discharge. Diagnosis schizophrenia and autism. Upon being formed [sic] of being discharged, the patient became irate stating [he/she] does not want to go back to [his/her] group home. [He/she] then proceeded to have a agitated outburst where [he/she] threw [his/her] try a [sic] food on the ground and started screaming at staff and having a temper tantrum. ... 2000 [8:00 PM] Delayed charting: After being medicated, patient continued to escalate and become extremely agitated and combative. Security was at bedside helping try to control the patient has [sic] [he/she] was attempting to hit staff as well as harm [him/herself]." A "Nursing Note" on 12/2/23 at 7:21 PM, stated, " ...Patient agitated, Dr. [name] at bedside and orders placed for medication administration." During the medical record review, it was reavealed that on 12/2/23 at 7:18 PM, Haldol 10mg IM (intramuscular) and Ativan 2 mg IM was administered to P1 as ordered.

On 1/3/23 a review of the "Safety/Security Event" report from 12/2/23 revealed, " ... On December 2nd, 2023, at 1915 [7:15 PM] HRS [hours]. Officers received a Strongline Activation to assist ED Clinical Staff of Patient of ED Hall 24. ...Patient was trying to bite [him/herself] and started to hit the wall. Officers then grab Patient by the arms and then started to get Patient onto the stretcher. Clinical Staff then assisted by getting Patient on the Stretcher and started to use Handle with Care until other officers arrived on scene to assist. ED Clinical Staff then got medication as Officer had Patient left Leg. Officer also assisted with holding Patient left leg. Officer [name] had both Patient [P1 name] legs, Officer had Patient right Arm, ED Clinical Staff RN [name] had patient left Arm, Officer had Patient right Knee and leg, and Officer had Patient face. ...ED Clinical Staff gave Patient his medication ..."

On 1/3/24 at 1:36 PM, a review of the time ED hallway video surveillance surrounding the event involving P1 was conducted in the presence of S6, the Security Manager, S5, and S12, the Assistant Vice President of Quality. The video surveillance reviewed did not have any audio recording. The video surveillance began in "Hallway 24" in the ED as confirmed by S6, and it revealed the following:

At 7:16 PM: P1 appeared to spit and verbally communicate in what appeared to be an aggressive manner at facility staff and then began to punch the wall next to the stretcher with the side of his/hers arm. Multiple staff members (RNs and Security officers) were observed to respond and began to lay P1 down onto the stretcher in a supine (lying horizontally with face and torso facing up) position in a controlled manner. The staff members were observed to place themselves around the stretcher, physically hold P1, restraining P1 to the stretcher. Staff members were observed physically holding P1's B/L (bilateral) arms and B/L legs.

At 7:17 PM: S10 (Security Officer) was observed to place his/her hand on the top portion of P1's forehead and side of face, however exact hand placement on side of face was difficult to view due to the angle of the camera. Multiple staff members continued to physically hold P1 restraining him/her to stretcher.

At 7:18 PM: S21 (RN) and S22 (RN) were observed administering IM medications.

At 7:20 PM: P1 was observed to be physically restrained by staff members holding P1's B/L arms, B/L legs and S10 restraining P1's forehead to the stretcher in supine position as he/she was being transported on the stretcher through the ED hallway.

At 7:21 PM: P1 was observed to be transported to Room 9, which S6 and S10 confirmed was the Behavioral Health Room, all medical equipment was removed from this room. Once P1 was transported to Room 9 the visual observation was limited due to no video surveillance in Room 9.

On 1/4/24 at 10:00 AM, a review of P1's medical record review was conducted with S3 and S5, for the ED visit on 11/29/23 and 7/14/23. S5 confirmed that there was no order for restraints for P1 related to the physical hold on 12/2/23.

The facility policy titled, "Restraints and Seclusion" (reviewed 2/23) states, "PURPOSE: ...d. ensure the appropriate ordering of restraint or seclusion. ...B. Definitions of Terms: ...4. Physical Holding: Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint including physically holding a patient in order to administer a medication against his or her wishes. Also known as a "therapeutic hold." ...D. Order Requirement: An order by the licensed provider is required to apply any type of restraint including physical, chemical, seclusion, or physical hold. ...PROCEDURE: ...II. Use of Restraints and Seclusion for Violent or Self Destructive Patients (Behavioral Management) ...C. ...3. A LP [licensed provider] order is issued on initiation of restraints or seclusion 4. Orders are entered into the electronic medical record. ...6. All orders must include the following information: That restraint use is clinically justified. The type of restraint to be used. The time limit for use of restraints according to the age of the patient. ... The date, time and physician or advance practice practitioner signature. ..."