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Based on observation, interview, record review, policy review and review of security footage, the facility failed to ensure patients were free from abuse by staff. This affected one (Patient #20) of 20 patients reviewed. The census was 639.

See A145

Based on observation, interview, record review, policy review and review of security footage, the facility failed to ensure patients were free from abuse by staff. This affected one (Patient #20) of 20 patients reviewed. The census was 639.

Findings include:

Record review revealed Patient #20 was initially admitted to the emergency department (ED) on 12/07/22 at 5:37 AM after being found unconscious and partially clothed at a public bus stop. Police called emergency medical services unit to transport him to the ED.

Review of the history and physical report dated 12/07/22 revealed Patient #20 had a history of polysubstance abuse, including amphetamines, cocaine and Fentanyl, major depressive disorder, history of tobacco use and altered mental status.

Patient #20 was evaluated with basic lab tests, a drug screen, and was allowed to rest, eat and drink in an observation room of the ED. Review of the lab tests and physician progress notes revealed there was no acute medical condition requiring treatment or further review.

Review of the nursing note dated 12/07/22 at 5:40 AM revealed Patient #20 was assessed as intoxicated, suspected drug overdose, with an altered mental status and was treated with a narcotic reversal agent. Patient #20 regained cognitive awareness and ability after resting in the observational bed, could speak, communicate and ambulate independently by the time he was medically cleared for discharge.

Review of a physician progress note dated 12/07/22 at 7:00 AM revealed Patient #20 was "likely drug-induced psychosis," describing his situation, experience, appearance and behavior while in the ED. Patient #20 was resting in bed at times, lying on his back quietly and at other times moaned out load, restlessly changing position, but offered no complaint of pain or other distress. During Patient #20's stay in the ED behavior observation area he stayed in the room and was given food and drink, rested in bed, and denied suicidal ideation or homicidal ideation when questioned by staff. Patient #20 was medically cleared for discharge and was discharged by nursing staff with instructions at approximately 3:30 PM.

Review of a facility campus police report dated 12/07/22 revealed Patient #20 was in the emergency department lobby area on 12/07/22 at 3:34 PM after exiting the ED observation room. Patient #20 was being supervised by campus safety department police officers for his resistance to and noncompliance with the discharge process. Originally Patient #20 was being supervised by Police Officer (PO) #1, who was standing near him while observing him and was asking him to leave.

Review of the report written by PO #1 revealed Patient #20 was not leaving, not exiting the ED lobby doors, but was standing in an area off to the side of the main lobby doors where wheelchairs were parked.

Review of the police incident report dated 12/07/22 revealed Patient #20 had been issued a discharge from the ED after he was assessed to be medically stable and was not an against medical advice (AMA) departure status. Campus police had provided Patient #20 with socks and shoes and while standing near Patient #20, and Patient #20 began disorderly behavior, yelling and cursing, while the police staff encouraged him to put on the socks and shoes. Patient #20 expressed an interest in finishing eating food, but after becoming disruptive with language the police staff warned Patient #20 that his behavior was not acceptable. The police officers were directing Patient #20 to leave the facility and Patient #20 reacted with verbal confrontation and officers attempted to physically guide him out the exit, but Patient #20 pulled away and ambulated out of the exit onto the parking lot, but dropped his pants to urinate as he was walking.

PO's #1 and #2 followed Patient #20 to place him under arrest, but Patient #20 continued to walk down a ramp exiting the ED. PO #2 tackled Patient #20 from behind and taking Patient #20 to the ground face-forward on a downward slope. Patient #20 experienced a head injury after the PO #2 tackled him.. Review of the documentation with description of the scene revealed after taking Patient #20 down to the ground, Patient #20 was observed by the police with bleeding from his nose and ear, was not responsive, and had an abrasion on his forehead, bleeding from several sites on his face and head, with his pants still down to his mid-thigh. Patient #20 was assisted onto a rolling stretcher by police and medical staff who had responded from the ED, the rolled into the ED by staff for treatment. The facility police wrote charges against Resident #20, including resisting arrest, disorderly conduct, criminal trespass and public indecency.

Review of the video recording of the event on 12/07/22 revealed Patient #20 was non-compliant with staff instruction to leave the facility, standing and sitting in a limited area in the lobby while PO #1 observed. PO #1 implemented de-escalation protocols of listening and re-directing Patient #20. Patient #20 never made physical contact or gestures toward the facility police officers or any of the other staff or visitors.

Review of the video footage from several video camera angles recorded at the facility on 12/07/22 within the ED hallway, into the ED lobby and the ED front desk revealed Patient #20 was ambulatory, alert, standing on his own and walking with a regular gait. Patient #20 left the ED room barefoot, dressed in pants and a short sleeve knit shirt, and walked to the ED lobby area without shoes or socks. Patient #20 was standing in an area near the main ED lobby doors with the PO #1 nearby watching him, standing near to him and while the video had no audio, the two appeared to be having a conversation. Patient #20 was barefoot initially when he was standing in the lobby of the ED near the door while engaged with the PO #1 who had escorted him from the ED treatment area after he had been medically cleared for discharge.

Review of outside camera footage from 12/07/22 revealed Patient #20 leave the ED with his pants partially down. He had a waddling gait. He waddled toward the street outside the hospital, with his pants still partially down. As he went down the ramp toward the sidewalk, hospital police officers were observed running out of the ED doors toward Patient #20. Patient #20 saw the officers and attempted to run, but could not because his pants were still partially down. PO #2 ran up behind Patient #20, grabbing him in a bear hug from behind and taking him to the concrete head first. Several staff then arrive and place Patient #20 on a stretcher. An unidentified person removed Patient #20's socks, and placed them on the head wound that was bleeding. Patient #20 was then taken back into the ED for treatment.

Review of Patient #20's medical record revealed on 12/07/22 at 4:00 PM he was wheeled into the trauma bay in the ED for evaluation of a traumatic head injury. Review of the physician progress note dated 12/07/22 at 4:20 PM revealed Patient #20 had experienced head trauma related to being tackled by a police officer on the hospital property. Review of the physician notes revealed plans for multiple tests including radiological scans of the head, chest, abdomen and pelvis, and neurological assessments were ordered to determine how much damage had been suffered from the injury.

Review of the Injury Summary Plan dated 12/07/22 documented Patient #20 was tackled by the police with significant head and facial injuries. Computed tomography (CT) scan revealed multiple facial fractures, significant intraperitoneal hemorrhage, epidural with possible active extravasation from the middle meningeal artery. Patient #20 was intubated.

Review of the trauma surgeon's note regarding revealed prominent comminuted and displaced calvarias (top part of skull) and facial bone fractures, as described above, consistent with severe trauma. Patient #20 had multicompartmental intracranial hemorrhage (brain bleed) as described above, without significant associated mass effect at this time. This included an extra-axial hematoma measuring five millimeters (mm) in thickness along the anterior wall of the right middle cranial fossa which may be subdural or epidural in origin. Patient#20 had a large right frontal scalp/periorbital laceration with adjacent right periorbital

Review of the physician progress note dated 12/07/22 revealed Patient #20 was intubated and mechanically ventilated due to a decline in consciousness.

During interview on 02/01/23 at 12:54 PM, PO #1 stated she was telling Patient #20 that he was being discharged from the facility and he was required to leave. PO #1 said Patient #20 wanted to leave and stated more than once that he wanted to leave. PO #1 said she summoned two additional officers, PO #2 and PO#3, to the area because once Patient #20 was in the ED lobby near the door he walked back and forth within a limited space, a cubby wall area where wheelchairs were stored, and he stood, not exiting, but engaging verbally with the officer. PO #1 followed Patient #20 to the lobby area because he was identified as acting disruptive by being non-compliant with instruction to leave and cursing at officers, and she was following policy to supervise any patient or visitor who was a potential threat to others. PO #1 said the protocol was listening and observing, allowing Patient #20 to talk, as part of the public safety department's process for de-escalation. PO #1 said Patient #20 was cursing and angry but did not physically strike out at anyone, but his action wandering within the lobby and entrance area and cursing out loud were grounds for a disorderly conduct situation. PO #1 said Patient #20 eventually acquiesced and walked through the ED lobby doors to the area outside and began walking away from the facility but soon after exiting, Patient #20 dropped his pants and began urinating as he was walking away. PO #1 said the officers ordered Patient #20 to cover himself because there were other people, visitors and customers in the vicinity, but Patient #20 kept walking and urinating. PO #1 said at that point Patient #20 was committing a crime, so PO #3 gave orders to arrest Patient #20.

During interview on 02/01/23 at 2:32 PM, PO #4 stated the events involving Patient #20 had been reviewed by the facility's Department of Public Safety, facility leadership and facility legal counsel and they had determined that no wrongdoing had occurred regarding the PO #2's handling of the situation. PO #4 said the "totality of circumstances" of Patient #20's situation in the ED, escalation by his refusal to follow verbal orders to leave the property despite being allowed to talk as part of the de-escalation process, then the erratic behavior he exhibited by exposing himself by urinating outside the facility. PO #4 said the Patient #20 was a potential threat and police staff had to make a split-second decision about their duty to protect public safety and though Patient #20 was moving toward a public street and in a direction leaving the facility property, his public indecency of exposing his genitals and urinating required action. PO #4 said officers had ordered Patient #20 to comply and he was non-compliant, and the use of force was reviewed independently. PO #4 said the review of the event on 12/07/22 revealed PO #2 acted appropriately, in compliance with procedure and state law, and the officer's goal was to ensure safety. PO #4 said Patient #20 was running toward the street where a female staff member was waiting to cross to an employee parking area and was fleeing an officer's lawful order with an unknown and unpredictable intent. PO #4 said the least amount of force possible to make an arrest is recommended and the resulting action by PO #2 Patient #20 and propelling both individuals onto the pavement with significant injury to Patient #20 was not intended and was "unfortunate".

During observation on 02/02/23 at 2:50 PM, Patient #20 was resting in a low bed with mats on the floor for fall risk management. Patient #20 was awake but not making eye contact or interacting with the staff nurse, Staff E, who was in the room at his bedside. Staff #E handed Patient #20 a stuffed animal which he disregarded, shifting his head and gaze from side to side as his left leg inadvertently flopped over the bed rail on the left side of the bed. Patient #20 had tube feeding running. The room was dark with the window shade drawn and the lights off.

During interview at the time of the observation, Staff E said Patient #20 required a reduced stimulus environment with a low volume TV. Patient #20 did not engage meaningfully with staff but was receiving physical and occupational therapy services with a goal to regain some physical ability.

Review of the policy titled "Department of Public Safety Response to Resistance, Aggression and Non-Compliance", effective date 12/10/21, revealed a definition of "non-compliant - when placed under or being informed of their arrest, the subject refuses to cooperate and does not respond to verbal commands but takes no verbal/ physical actions against an officer. De-escalation - tactics and techniques are actions used by officers, when safe ad feasible without compromising law enforcement priorities, that seek to minimize the likelihood of the need to use force during an incident and increase the likelihood of voluntary compliance. De-escalation may take the form of scene management, team tactics, and/or individual engagement. Department of Public Safety Officers are authorized to use reasonable force in response to citizen resistance/ aggression/ non-compliance when necessary to protect life, property and maintain order. The responsible exercise of this authority is among the most critical aspects of law enforcement. Excessive or unjustified force in response to resistance/ aggression/ non-compliance undermines confidence in the department and its officers and will not be tolerated. Ultimately, it may subject the officer, the department, and the hospital to criminal and/or civil liability."

Review of the policy related to staff actions revealed "officers will encounter circumstances which require a response to resistance/ aggression/ non-compliance in the enforcement process. It is the policy of this department that any response to resistance/ aggression/ non-compliance will only be used to overcome resistance or stop aggression, and then only that amount of force which is necessary to overcome that resistance." Review of the policy revealed how officers should act to avoid use of force, "officers will use de-escalation techniques to prevent or reduce the need for force when it is safe and feasible to do so based upon the totality of the circumstances. Officers will continually assess situations and modify the use of force as circumstances change while maintaining consistent officer safety." Review of the Provisions section of the policy revealed "A. Response to Resistance and Non-Compliance - It is the policy of the Department of Public Safety that officers may use only that force which is objectively reasonable to: 1. Defend themselves, 2. Defend others, 3. Effect an arrest or detention on Hospital property, 4. Prevent escape, 5. Overcome resistance."