HospitalInspections.org

Based on facility policy review, medical record review, video footage review, review of facility documentation, observation and interviews, the facility failed to ensure patient rights were protected for 1 (Patient #25) of 18 patients reviewed for abuse by failing to protect Patient #25 from verbal and physical abuse.

The findings include:

Review of the facility policy "Abuse Reporting" dated 11/2023, revealed "...all patients have the right to be free from all acts of violence that could threaten their physical or mental well-being whether from staff, other patients, or visitors. The hospital will ensure that patients are free from all forms of abuse...if the allegation is against a current caregiver for the patient, the caregiver will be removed from caring for the patient and an alternative caregiver will be assigned...caregiver...will be placed on administrative leave during the investigation..."

Review of the Emergency Department (ED) medical record, dated 10/26/2023 at 7:09 PM, revealed Patient #25 entered the ED with the chief complaint of Suicidal and Alcoholic Intoxication without complication. He was placed in room 36. Review of the "Systems and Physical Exam" revealed "...patient is clinically intoxicated, is answering most questions without difficulty...denies suicidal ideation..." Patient #25 had a blood alcohol [ETOH] level of 399 mg/dl [milligram/deciliter] (high) on 10/26/2023 at 7:51PM. The ED Course & [and] MDM [Medical Decision Making] dated 10/26/2023 at 8:23 PM, revealed "...awaiting sobriety and telepsychiatry evaluation..."

Review of the "Safety Precautions" dated 10/26/2023 at 7:46 PM, for Patient #25, revealed an emergency (involuntary) hold had been placed with emergency detention due to potential danger of harm to self and/or others, suicide and elopement precautions, continuous 1:1 staffing, and placement in a yellow hospital gown. He denied suicidal thoughts, displayed no self-injurious behavior and displayed no harmful actions toward others.

Review of the ED Progress Notes, dated 10/26/2023 at 9:00 PM, revealed Patient #25 was agitated and restless. He was medicated with Haldol (antipsychotic medication) 5 mg. Further review revealed an order for seclusion, dated 10/26/2023 at 9:34 PM, due to behaviors including pushing against staff, threatening harm to others and threatening stance. He was escorted to Room 14, the ED Seclusion Room.

A review of the ED Progress Notes, dated 10/27/2023 at 9:00 AM, showed Patient #25's behavior was charted as calm, cooperative and denied suicidal or homicidal thoughts. He was resting comfortably. Patient #25's emergency hold and detention were discontinued on 10/27/2023 at 9:10 AM and the patient was discharged home on 10/27/2023 at 9:33 AM.

An observation and tour of the ED on 3/4/2024 started at 4:00 PM, with the Director of ED Services and the Director of Risk Management and revealed the ED had a licensed bed capacity for 52 beds with a total bed capacity for 65 patients (including stretchers, vertical recliners, and chairs). Observation of the ED showed multiple staff and patients. Observation of the 1 of 1 Seclusion Room (#14), showed a small, windowless room with a padded, cushioned bed bolted to the floor. There was a small window to view in the door.

A review of the ED video footage, dated 10/26/2023, no audio available, showed the following:
-10:25 at 29 sec: observation of the Seclusion Room (Room 14). A staff member was standing opposite the seclusion room leaning against the wall. The seclusion room's door was open. A security officer walked up to the door and walked out of frame. Patient #25 was observed standing in the door of the room, dressed in a yellow hospital gown with socks. He was observed talking to a sitter and looking up and down the hallway.

-10:25 at 48 sec: Security Officer #1 appeared in the video. Patient Care Technician (PCT) #6 observed standing behind Security Officer #1. Security Officer #1 stepped up to Patient #25 and placed his left hand on the patient's right shoulder. The Security Officer's left hand was open with his palm was on the patient's right shoulder. The patient and the security guard appeared to speak to each other. Patient #25 had his hands to his side. The fists were not clenched. Patient #25 raised his hand to block the security officer. Patient #25 attempted to walk further out of the room. Security Officer #1, with his left-hand, palm opened, pushed Patient #25 back into the room. Security Officer #2 arrived and both officers entered the room and placed the patient on the bed.

-10:26. 8 sec. Security Officer #3 and a Metro Police Officer appeared and entered the Seclusion Room. It was not possible to observe the patient in the room with security and the police blocking the video footage.

-10:26. 39 sec. Security Officer #1 exited the Seclusion Room.

-10:27. Security Officer #2 exited the room. The Metro Police Officer and Security Officer #3 remained in the Seclusion Room.

-10:28. 11 sec. Security Officer #1 re-entered the Seclusion Room. Security Officer #3 remained inside the Seclusion Room. The Metro Police stood in the Seclusion Room doorway.

-10:29. 18 sec. Security exited the Seclusion Room and locked the door.

-10:31. 39 sec. Security Officer #3 opened the Seclusion Door and looked in the room and shut the door. End of video footage.

A review of the facility investigation, dated 10/27/2023, showed Patient #25 was in the Seclusion Room. He had been observed sleeping and the door had been opened. He woke up and walked out of the room. PCT#6 asked him to return to the seclusion room. The patient responded "no." Security Officer #1 jumped in front of the patient and stated "get the f* back into the room" and then "...placed his hands on the patient chest and proceeded to shove him back into the room..." Further review revealed the "push/shove" used by Security Officer #1 was described by the Security Director as a 2-finger redirection, described as a redirectional nudge or push, with the use of 2 fingers to move a person away from you. The redirectional nudge was not a component of verbal de-escalation CIT (Crisis Intervention Training).

During an interview on 2/27/2024 at 11:43 AM, Security Officer #3 stated he received a call for assistance to the Seclusion Room. He said he was unable to remember if he observed Security Officer #1 with his hands on Patient #25. He stated the patient tried to fight security and voiced he wanted to leave the facility.

During an interview on 2/27/2024 at 12:00 PM, and on 2/28/2024 at 4:10 PM, with LSMW (licensed master prepared social worker), Director of the Behavioral Health team, she stated she assessed Patient #25 on 10/27/2023. She stated he did not meet criteria for an involuntary hold and was discharged home with follow-up with substance abuse services. She stated nursing did not have time to verbally de-escalate the situation before security intervened with the patient "...it's all about leading with verbal skills and avoiding physical touch of the patient..." She stated she reviewed the video footage and Security Officer #1 did not use a 2 finger re-directional technique. She confirmed CIT training was based on verbal de-escalation techniques.

During an interview on 2/27/2024 at 4:05 PM, Security Officer #2 stated Patient #25 was yelling and attempted to leave the Seclusion Room. He stated he [Patient #25] balled his fists, grinded his teeth, and was verbally aggressive toward the sitters. He said he was going to the bathroom and leaving the facility. The Officer said the sitters were not allowed to walk to the bathroom with secluded patients...only the medical staff or security walked those patients to the bathroom. He stated he did not see Security Officer #1 place his hand on the patient's shoulder or push him back into the room. He stated he became involved when he heard the patient yelling at security and had to be held in place "...so he wouldn't kick us..." He stated security stayed in the seclusion room and talked to the patient after the incident and explained to him if he cooperated, he would be discharged sooner.

During an interview on 2/28/2024 at 10:50 AM and on 3/4/2024 at 12:55 PM, the Director of Security stated Security Officer #1 was no longer employed at the facility. The Director stated he had observed the video footage. He stated Patient #25 refused to return to the Seclusion Room and the officer ''...turned him by placing a hand on his shoulder..." He stated Security Officer #1 received verbal counseling "...he should have attempted more verbal de-escalation prior to placing his hands on the patient..." He stated facility policy instructed staff to use minimum amount of force necessary on patients. He said Security Officer #1 used a ''...redirectional touch..." When asked to describe the 2-finger technique, the Director of Security stated it was a technique to get a patient to turn in a certain direction "...a nudge..." He confirmed he observed the video footage "...it was more than a 2-finger...it was a palm...palm nudge...". He stated Security Officer #1 received verbal counseling on physical contact with patients "...hands on too quick..." and "...he should have taken more time to de-escalate." He stated Security Officer #1 also received a corrective action plan that included not using profanity, to take time to verbally de-escalate instead of physical re-direction, and to take the CIT (verbal re-directional training for behavioral health patients). He confirmed Security Officer #1 was not suspended or removed from the ED on 10/26/2023. He stated he thought it could be handled with verbal counseling. He confirmed it was the expectation of the facility to provide a safe and secure environment "...cussing at a patient is not in the policy...open palm was not part of our training..."

During a telephone interview on 2/29/2024 at 12:51 PM, ED Physician #1 stated Patient #25 was very intoxicated, violent, and agitated when he entered the ED. He denied suicidal ideation, but was placed on an involuntary hold, with telepsychiatry ordered after he had a chance to sober up overnight.

During a telephone interview on 2/29/2024 at 1:00 PM, PCT #6 stated he was standing across from the Seclusion Room on 10/26/2023 when Patient #25 was in seclusion. Patient #25 stood ''...barely..." outside the opened seclusion door. PCT #6 stated someone asked Security Officer #1 why the patient was outside the seclusion room. PCT #6 said he instructed the patient to return inside the room "...[Security Officer #1] jumped straight in...I didn't ask for assistance..." He said Security Officer told him the patient showed signs of physical aggression because he was clenching his fists. He stated he didn't observe the patient clenching his fists "...I know he shoved him...[Patient #25] was drunk and unsteady on his feet...it could have gone a different way...".

During a telephone interview on 3/4/2024 at 2:10 PM, Registered Nurse (RN) #9 stated at the time of the incident she was caring for a critical patient in another room. She stated, when she observed him in the Seclusion Room, Patient #25 was cooperative and nonviolent. She stated he had no injuries from the incident and he voiced no complaints to her.

During an interview on 3/4/2024 at 3:20 PM, PCT #7 stated the Seclusion Door had been opened because he had been compliant with care, but was very drunk, and required continued observation. She observed Patient #25 in the seclusion doorway. Security Officer #1 approached him and used inappropriate language to the patient. She said the patient made a sudden move and walked out of the room. Security Officer #1 "...put his hand on his chest and pushed him in the room..." She stated Security Officer #1 "...cussed him..."

During an interview on 3/4/2024 at 4:00 PM, the Director of Risk Management stated there was no time to use intervention techniques with Patient #25 because Security Officer #1 intervened too quickly "...it was inappropriate but did not cause physical or mental harm to the patient..."



Refer to TN00065911