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Based on interview and document review, the hospital failed to ensure patients were free from the use of force when chemical spray and a Taser gun were used by hospital staff to restrain 1 of 5 patients (P1) his behaviors escalated.

As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13.

A condition level deficiency was issued. See A0154.

Based on interview and document review, the hospital failed to ensure patients were free from the use of force when chemical spray and a Taser gun were used by hospital staff to restrain 1 of 5 patients (P1) his behaviors escalated.

Findings include:

P1's medical record indicated P1 presented to the hospital through the emergency department (ED) on 8/1/23 at 3:20 p.m. P1 was admitted voluntarily to the behavioral health unit on 8/1/23 at 9:17 p.m., with diagnoses of depressive disorder, Cluster A personality traits versus disorder (pattern of behavior and personality associated with high achievement and impatience), cannibus use disorder and history of attention deficit hyperactivity disorder (ADHD).

P1's admission history and physical dated 8/2/23 at 4:24 p.m., indicated P1 had a significant history of ADHD and major depression requiring previous hospitalizations. P1 was currently living in adult foster placement. P1 disclosed a suicide attempt on 7/30/23 by taking an overdose of quetiapine (antipsychotic medication) to his guardian and case manager and this was why he was brought to the ED. On admission P1 denied any current plan for suicide. P1's past psychiatric history included reactive attachment disorder, and schizophreniform disorder. P1 denied gender dysphoria (mismatch between biological sex and gender identity) but was recently started on estradiol and spironolacatone (treats high blood pressure and blocks male sex hormone receptions to lower testosterone in the body) to help with his concentration.

A Psychiatric progress note dated 8/3/23 at 4:58 p.m., indicated P1 expressed frustration about his current residence and denied being suicidal at this time. P1 did not want to consider utilizing an anxiolytic medication (used to reduce anxiety) at the time.

A Nursing Assessment completed 8/4/23 at 8:51 a.m., indicated P1 was fidgety, pacing, and guarded with flat affect. P1's thought content included suspicious, paranoid, annoyed and anxious. There were no threats or harm toward others.

A Psychiatric progress note dated 8/4/23 at 3:03 p.m., indicated P1 stated he did not want to stay at the hospital and would rather be in jail. P1 stated he did not want to take any medication, and when he was told he would have to take medication because his guardian wanted him to, P1 stated that it was all a "power trip." P1 began swearing and raising his voice which prompted the end of the conversation. P1 refused to leave the psychiatrist's office. Security was contacted and arrived, and P1 continued to refuse to leave. A Code Green (security alert with team approach) was called, P1 left the office when additional personnel responded, and he walked back to his room. P1 was informed neuroleptic (antipsychotic used to manage symptoms of many psychiatric disorders) medications were ordered. Initially, P1 refused to take the medication orally, but when his hands were placed to remove him from the bathroom in preparation for an intramuscular injection of the medication, he took the medication orally. At 6:35 p.m. an addendum to the note indicated P1's current mental state required the use of emergency involuntary medications to be forced if he would not take them orally.

A Nursing Assessment on 8/4/23 at 5:19 p.m., indicated P1 was anxious and mildly distressed, but was not making threats or harm towards others.

A Nurse Note on 8/4/23 at 9:33 p.m., indicated P1 was told he was unable to refuse medications following supper as they needed to be given on an emergency basis per the provider. P1 had refused oral medications earlier. Intramusclar (IM) Thorazine (antipsychotic medication) 50 milligrams (mg) was prepared. Additional staff were paged to the unit to assist in a manual restraint so P1 could receive the IM injection. P1 became aggressive towards staff involved, and P1 bit the security officer (SO)-A, and another staff member. P1 also kicked SO-A in the groin three times. SO-A then used pepper stay on P1. P1 began rampaging down the hallways, yelling at staff and calling the males who assisted a derogatory term. P1 punched the nurse's station door window, punched the window in his room, and threw his bedside table at the window, which broke it. P1 broke a television, threw the coffee pot and broke it, and pounded walls damaging them. Law enforcement (LE) arrived as P1 was observed in his room putting a nail into his right big toe. LE attempted to handcuff P1, and he was tased for threatening behaviors. P1 was spitting on staff and LE, and a spit hood was applied. P1 was brought into the seclusion room by security officers and police. Four point restraints were initiated.

A Security Report written by SO-A indicated on 8/4/23 at 6:30 p.m., the police department (PD) were contacted to assist with administration of medications which P1 was refusing to take orally. PD declined to come to the hospital, stating they would not help administer medication, and only respond if an assault was in progress. A request was then made for male ED staff to assist. A Code Green was not called due to other patients on the unit that could possibly be triggered. P1 was pacing in his room, and registered nurse (RN)-C asked him to sit on the bed. P1 refused, walked to the bathroom and began to punch the wall. SO-A and two male staff entered the bathroom, and pushed P1 against the wall, grabbing his limbs to prevent further harm to himself. P1 tensed his muscles, lowered his weight to the ground and began screaming calling staff derogatory names. P1 stated, "I will hunt you down, you can't do this to me." P1 struck SO-A three times in the groin, and was told to stop that and not to hit him again. P1 was brought to the bed and bit SO-A on the left forearm (did not break the skin). P1's medication was administered. As staff began to release P1, he was informed he needed to lay on the bed. As soon as staff released him, P1 jumped up off the bed, and called SO-A derogatory names. P1 balled both his hands into fists and began to advance on SO-A making small punching motions towards the ground. P1 was instructed get back, or he was going to get pepper sprayed. P1 continued to advance and Repuls chemical spray was deployed. Staff backed out of the room and P1 followed stating the pepper spray did not affect him. P1 then threatened SO-A. SO-A drew a Taser gun, and repeatedly stated, "Get back, get back. I will tase you. Go back in your room." P1 did not fully comply, but did use the corner of the room to hide from the Taser. Staff and SO-A retreated to the nurse's station. P1 began to scream, walk the hallways, and destroyed property. RN-C attempted to deescalate P1. At approximately 7:11 p.m., SO-A requested assistance from the police department. At 7:22 p.m. LE arrived. RN-C informed the LE and SO-A it was believed P1 had a nail and was cutting himself with it. The two LE officers and SO-A entered P1's room. LE ordered P1 to sit on the bed, but P1 continued to be aggressive. LE and SO-A laid hands on P1. P1 continued to resist, was kicking, hitting and spitting, and was taken to the ground. One of the LE officers stated, "You're going to get dry stunned" and P1 continued to resist, kicking SO-A in the right knee. SO-A asked the officers if they wanted him to use the Taser, and the officer replied it was SO-A's decision. SO-A then used the Taser on P1's left thigh. P1 was not incapacitated, so SO-A tasered P1 a second time. LE placed handcuffs on P1. P1 was taken to the quiet room, his handcuffs were removed and he was placed in restraints. LE told staff they would not arrest P1, and the county jail would not accept him because he was in a mental health facility. so staff agreed P1 would stay at the hospital until a secondary plan could be arranged, or he was accepted in a different facility.

Video of the events from SO-A's body camera indicated on 8/4/23 between 7:11 p.m. and 7:17 p.m., P1 was pacing the hallways, punching walls, spitting, and yelling. RN-C remained with P1 in the hallway. At 7:17 p.m. R1 went into his room. At 7:21 p.m. LE and SO-A went into P1's room, and pulled his arms behind his back. P1 was fighting, kicking, and spitting, and was taken to the ground by LE and SO-A. At 7:23 p.m. the Taser was fired and repeated approximately 20 seconds later. Handcuffs were applied to P1, he was removed from the floor at 7:26 p.m. and walked to the seclusion room.

On 8/23/23 at 12:30 p.m., SO-A stated he was involved in a Code Green for P1 earlier in the day on 8/4/23 so when he was summoned to the unit to assist with medication administration, the police were called for assistance. LE stated they would not assist at that time. SO-A stated two male staff from the ED were requested to assist and they entered P1's room. P1 was held against the bathroom wall, and kicked SO-A in groin three times. P1 was then taken to the bed and bit SO-A's arm. IM Thorazine was administered. SO-A stated staff released P1 and began to exit the room when P1 starting kicking. SO-A stated P1 began shaking balled fists towards staff stating he was going to beat everyone up. P1 looked at SO-A and threatened him. SO-A stated P1 progressed towards him so he grabbed his chemical spray and directed P1 to back up. P1 continued towards SO-A, and SO-A sprayed P1 for 1/4 second. Staff exited the room, P1 continued to move towards staff and SO-A drew his Taser gun. SO-A stated P1 retreated to his room. SO-A stated P1 came out of his room, went into the dining room and threw a coffee pot at the wall, paced the hallways, and taunted SO-A who was now in the nurse's station. P1 broke a coffee pot, punched a door breaking the trim around the Plexiglas, then re-entered his room and ripped the bedside cabinet off the wall and threw it at the window cracking it. SO-A stated when P1 began destroying property, the police department was notified and arrived on the unit. RN-C told them P1 was attempting to harm himself with a nail which had pulled out of the cabinet, so LE and SO-A entered his room. LE directed P1 to get on the ground. P1 refused and stepped towards the LE officers who then pinned P1 to the wall and took him to the ground. P1 continued to kick and spit at the LE officers and SO-A. SO-A stated one of the officers told P1 if he didn't stop, he was going to dry stun him. P1 continued to kick and spit, and SO-A asked the officers what they wanted him to do as they were all being assaulted and nothing had worked. SO-A stated the officers told him it was up to him. SO-A stated, "I felt we needed to Taser him" so the Taser was pulled out, turned on and discharged on P1's outer right thigh. SO-A stated there was no response, and he tasered P1 again. LE handcuffed P1, and after recovery he stood up and was taken to the seclusion room where he was placed in restraints and the handcuffs were removed.

On 8/24/23 at 10:20 a.m., RN-A stated P1 was frustrated he couldn't go home on 8/4/23, but was cooperative and staying to himself until he was told he had to take his medications. RN-A stated P1 refused his oral dose around noon, and as she was preparing IM medication, P1 agreed to take his oral dose. When his second dose of medication was due around supper time, he refused the medication. The psychiatrist was notified and stated P1 could not refuse the medication as it was on an emergency basis. RN-A stated she informed P1 he couldn't refuse his medication, and P1 began pacing and was "ramped" up. RN-A stated another nurse called SO-A and two male RNs to come to the unit. RN-C entered P1's room and attempted to de-escalate him. RN-C stated P1 came out of his room, saw the male staff members in the hallway and went back into his room yelling. RN-C stated it sounded like he was punching the walls. The team of SO-A and the two male RNs entered P1's room, and forced him to the bed. The IM injection was then given. RN-A stated this was when P1 escalated and began yelling obscenities, throwing items, pacing up and down the hallways including to areas where other patients were located. RN-A stated she wasn't in the room when SO-A used chemical spray or when the Taser was deployed.

On 8/24/23 at 8:31 a.m., RN-C stated she went to talk to P1 was he began escalating. RN-C stated P1 became upset and started punching the bathroom walls. RN-C stated at this point, de-escalation techniques were not working and after the "hands on" and medication administration, P1's behavior escalated. RN-C stated SO-A used chemical spray which bounced off P1 and got in her eyes. RN-C stated she stayed with P1 as he "destroyed the unit." RN-C stated P1 went back to his room, and then LE and SO-A entered the room. RN-C stated she entered after them and witnessed the officers take P1 to the ground, but P1 continued to fight. RN-C stated P1 was noncompliant, and was spitting at them so SO-A used a Taser on P1 twice. RN-C stated the psychiatrist requested P1 be arrested for property destruction, but the police officers indicated they couldn't because he was in an acute psychiatric facility.

The hospital policy Security Use of Force policy approved 3/23 directed:

1. SOs are authorized to use force when necessary to maintain the safety of patients, staff and others. This provides SOs with parameters for the use of force while lawfully performing their duties in compliance with all applicable local, state and federal laws and regulations.
2. SOs will first use verbal de-escalation or other de-escalation techniques such as redirection, removing objects that could become improvised weapons, or creating space to make the scene safe whenever it is reasonable under the circumstances.
3. SOs will apply only the amount of force that is reasonable for the circumstances to gain control of an unwilling subject and or control of the situation
4. In determining whether to use force and degree of force that is reasonable under the circumstances, SOs should consider the following: Whether the uncooperative subject person poses an immediate threat to the safety of the officers or others; whether appropriate de-escalation efforts have reasonably been exhausted prior to the use of force; whether the person is resisting direction to establish the safety of the situation or is acting aggressively.
5. The decision to use force shall be made by the individual SO. It may not be dictated by other security employees, medical personnel or other individuals..
The facility recognizes the following measures within it use of force continuum. Officers are not required to follow each step in sequence but will chose the appropriate level of force as the situation dictates.
A. Verbal Directions
B. Soft empty hand techniques
C. Hard empty hand techniques
D. Intermediate Weapons: use of law enforcement tools or improvised weapons in an effort to stop or prevent an immediate threat of physical harm.
E. Deadly Force: when all efforts to stop active violence have failed and great bodily harm or death to the SO or other is imminent, the SO may use force which the officer reasonably believes may cause great bodily harm or death to the person.