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Based on surveyor observation of recorded video footage, record review and staff interview, it has been determined that the hospital failed to protect the patient's right to be free from all forms of abuse while patients are under the care of the hospital and during the application of restraints.

Findings are as follows

1. The hospital failed to ensure patients are free from abuse for a patient who was forcefully pushed to the ground and handled roughly by a hospital Security Guards as well as another patient, a minor, who was physically assaulted by a Security Guard after being restrained, (Refer to A-0145).

2. The hospital failed to ensure Security Guards completed abuse, neglect, and mistreatment training (Refer to A-0145).

3. The hospital failed to obtain physician orders for the application of violent restraints, (Refer to A-0168)

Based on surveyor observation of recorded video footage, record review and staff interview, it has been determined that the hospital failed to ensure patients are free from abuse for 2 of 3 patients reviewed, Patient ID #s 1 and 2. Patient ID #1 was forcefully pushed to the ground and handled roughly by a hospital Security Guard and Patient ID #2, who was physically assaulted by a Security Guard after being restrained. Additionally, the hospital failed to ensure Security Guards completed abuse, neglect, and mistreatment trainings.

Findings are as follows:

The hospital's policy titled, "Patient/Client/Resident Rights and Responsibilities" effective 10/2022 states in part,

"...It is the responsibility of all employees to recognize, respect and protect the rights of all patients/clients/residents ...

...I. Rights of Patients in a Health Care Facility

1. The patient shall be afforded considerate and respectful care ...

II. Rights under The Joint Commission Standards and CMS Conditions of Participation (COP) ...

...10. The patient/individual has the right to be free from neglect; exploitation; and verbal, mental physical, and sexual abuse ..."

On 5/9/2023, the Rhode Island Department of Health received a report from this hospital which stated that on 5/5/2023, staff expressed their concern about an altercation between a security guard and Patient ID #1, as well as how security personnel handled Patient ID #1.

Record review for Patient ID #1 revealed the patient presented to the Emergency Department in May of 2023 on an emergency certification after making suicidal statements.

Review of an Emergency Department Note for Patient ID #1 dated 5/5/2023 at 9:20 PM written by Employee A, Registered Nurse, revealed that Patient ID #1 was transferred to the Psychiatric Services area of the Emergency Department, known as "D-Pod," at approximately 9:05 PM on 5/5/2023. Employee A states in her note that at approximately 9:15 PM on this day as Patient ID #1 was escorted into D-Pod reluctantly, Employee B, Security Guard, "forcefully" pulled Patient ID #1 onto the unit which caused Patient ID #1 to fall, hit their head on the doorframe which resulted in a 2.5 centimeter abrasion. Employee A further states in her note that Patient ID #1 fell to the floor after hitting their head and was "dragged onto the unit" by security personnel. Additionally, according to Employee A, Patient ID #1 stated, "is this how you treat people? Drag them on the floor like a slave?"

Review of a "Physical Exam" documented by Employee C, Physician Assistant, for Patient ID #1 on 5/5/2023 after the incident stated above, confirmed that Patient ID #1 sustained a "superficial abrasion" to the middle of their forehead.

Review of the hospital's investigation summary dated 5/17/2023 revealed that an interview was conducted with Employee C by the Risk Management Department. During this interview, Employee C revealed that upon questioning Patient ID #1 about bumping their head, Patient ID #1 stated "he pushed me" referring to security personnel.

An incident report created by Employee B and Employee D, Security Guards, on 5/5/2023 at 11:06 PM relative to Patient ID #1 and the incident discussed above, was reviewed. The written report from both Employee B and Employee D states that it was Patient ID #1 who "threw [his/her] weight toward the ground" leading Patient ID #1 to hit their head on the door. Additionally, both Employee B and Employee D state that they "proceeded to move the patient into the unit." Both reports do not correlate with what Patient ID #1 stated to Employee C during their encounter or what Employee A observed during the incident or what the State Surveyors observed on the video footage.

During a surveyor interview on 5/18/2023 at 3:21 PM with Employee D, Security Guard who participated in escorting Patient ID #1 to D-Pod, he indicated that as Patient ID #1 was escorted into D-Pod, Patient ID #1 "began to resist" and Employee B was holding Patient ID #1 as Employee D grabbed Patient ID #1's arm. Employee D stated that Patient ID #1 continued to resist and from Employee D's point of view, Patient ID #1 eventually fell forward to the ground. Employee D indicated that Patient ID #1 "didn't want to get up", "continued to be difficult" and was brought inside the unit. When asked if he saw Employee B use inappropriate technique, Employee D stated "in the moment I did not see anything." When asked by the surveyor if he and Employee B dragged Patient ID #1 into the unit, Employee D stated, "I guess drag would be a fitting term" and later stated "I would not say drag." Employee D indicated that Patient ID #1 was not walking on their own and was not brought a long distance into the unit.

On 5/18/2023 at 12:58 PM, recorded video footage regarding the incident on 5/5/2023 with Patient ID #1 was reviewed by the surveyors. In the recording, Patient ID #1 is observed arriving at the entrance of D-Pod escorted by Employee B on the left and Employee D on the right. As Patient ID #1 arrives at the door with both Employees, Patient ID #1 begins to pull away from Employee B and Employee D at which point Employee B is observed forcefully grabbing and pulling off Patient ID #1's shirt from the bottom eventually exposing Patient ID #1's bare back. Employee B is observed forcefully handling Patient ID #1, pushing Patient ID #1 towards the entryway of the door which had been opened. Patient ID #1 is observed falling over to the ground towards the entryway of the opened door. Throughout the altercation, Employee D is observed holding Patient ID #1's right arm. The video shows both Employee B and D entering the unit doorway with Patient ID #1 who is noted to be on the floor with his/her lower body observed halfway through the entryway, only Patient ID #1's shins and feet are visible from the back of his/her knees to his/her feet. It is then observed in the recorded video Patient ID #1's lower legs moving through the entryway into the D-Pod area as if she/he were dragged on the floor.

Review of email correspondence dated 5/9/2023, the Director of Security Services states that after reviewing video evidence of the event, "...it is evident that officer used his own grip on the patient and pushed the patient forcefully into the doorframe/door of D-Pod causing an abrasion on the patient's head..." The Director of Security Services further sates that Patient ID #1 "...was not assisted to [his/her] feet but dragged by the officers into the unit..."

During a surveyor interview with Employee F, Security Supervisor, he revealed that Employee B was scheduled to work at 4:00 PM on 5/5/2023 until 12:00 AM on 5/6/2023. Employee F revealed that after the incident, Employee B completed his shift which ended at midnight. Employee F revealed that Employees B and D reported to him they went "hands on" with Patient ID #1 on the evening of 5/5/2023 but neither reported how the patient was pushed nor dragged onto the unit as evident on recorded video footage and nursing notes. Additionally, Employee F revealed that nursing staff did not report to him any concerns of abuse against Employee B nor Employee D that evening.

Review of personnel records for Employee B and Employee D revealed that Employee B was hired on 12/20/2021 and Employee D was hired on 11/25/2019. As part of this review, evidence of previous abuse training was requested for both Employees, however, the Director of Security Services stated in email correspondence provided to the surveyors dated 5/19/2023 that there was no active abuse training found for these Employees prior to the incident with Patient ID #1.

During a surveyor interview with the Risk Manager and the Regulatory Readiness Specialist on 5/18/2023 at approximately 3:40 PM, they were made aware that Employee D was unable to recognize that Employee B forcefully pushed Patient ID #1 into the doorframe at the entrance of D-Pod. Additionally, they were informed that Employee D was unable to recognize that Patient ID #1 was handled inappropriately by him and Employee B when both guards dragged the patient into the unit as observed in recorded video footage.

2. On 5/9/2023, the Rhode Island Department of Health received a report from this hospital which stated that on 5/8/2023, after Patient ID #2 was restrained, a Security Guard "struck the patient."

Record review for Patient ID #2 revealed the patient presented to the Children's Hospital Emergency Department in May of 2023 after making suicidal statements.

Review of "ED Provider Notes" dated 5/9/2023 completed by Employee G, Emergency Medicine Pediatrics Resident, states in part that a Code Grey was called for Patient ID #2 who was attempting to elope from the Clinical Decision Unit. Employee G states that Patient ID #2's father and a Security Guard were attempting to stop Patient ID #2 and more security personnel arrived as Patient ID #2 became increasingly aggressive with security and nursing personnel. Employee G states that security personnel were attempting to place Patient ID #2 in a restraint chair and "forcefully" held Patient ID #2's head and neck giving the perception that Patient ID #2 "was being choked." Employee G states that the patient's parents became upset with this, and the father intervened. Employee G states that another Code Grey was called for the parents and Patient ID #2's father "was forcefully thrown onto the bed and restrained." Employee G further states that Patient ID #2 was "actively restrained" by three Security Guards who were holding Patient ID #2's legs and arms down into the restraint chair and a Security Guard "punched the child twice in the left side of [his/her] face over [his/her] temple and kicked [him/her]." Employee G indicates in her note that the patient's parents witnessed this incident, and the Security Guard who hit Patient ID #2 was "made to leave."

Further review of Employee G's note revealed that Tylenol was ordered for Patient ID #2's headache. Additionally, according to Employee G, Patient ID #2 had swelling over the left temple as well as tenderness.

Additionally, review of a "Physical Exam" dated 5/9/2023 documented by Employee G for Patient ID #2 after being assaulted by Employee H, Security Guard, states that Patient ID #2 was "tearful."

An incident report from security personnel dated 5/9/2023 relative to Patient ID #2 and the incident discussed above, was reviewed. The report indicated that after two Security Guards were observed "going hands on" with Patient ID #2 preventing the patient from aggressing toward security and nursing personnel. The report further reveals that more security personnel arrived to assist as the two Security Guards mentioned previously were attempting to restrain Patient ID #2 as well as the patient's Mother and Father who aggressed towards security personnel. The report reveals that Patient ID #2 spat at Employee H, Security Guard, who proceeded to punch Patient ID #2 in the face after the patient "had already been restrained in the chair."

Review of the hospital's investigation summary dated 5/17/2023 for this incident revealed that an interview was conducted with Employee I, Pediatric Behavioral Interventionalist, by the Risk Management Department. During this interview, Employee I revealed she was present during the event and indicated that when Patient ID #2 was restrained to a restraint chair, a Security Guard struck Patient ID #2 twice in the face.

Review of Employee H's personnel record revealed that he was hired on 5/24/2022. As part of this review, evidence of previous abuse training was requested for Employee H, however, the Director of Security Services stated in email correspondence provided to the surveyors dated 5/19/2023 that there was no active abuse training for Employee H prior to the incident with Patient ID #2.

Additional records provided to the surveyors revealed email correspondence from the Director of Security Services dated 5/9/2023 confirming that Employee H, Security Guard, assaulted Patient ID #2 by striking them twice while restrained.


As a result of the above incidents Employees B and H were terminated from employment.

Based on record review and staff interview it has been determined the hospital failed to ensure a physician's order is obtained for the application of violent restraints for 2 of 5 patients reviewed, Patient ID #1 and Patient ID #3.

Findings are as follows:

The hospital's policy titled, "Lifespan Patient Restraint and Seclusion" effective 2/2023 states in part,

" ...Only staff and other providers who have completed required training are authorized to order, initiate, discontinue, monitor and/or care for patients in restraints or seclusion, as follows:

Restraints or seclusion must be ordered by the ordering provider

In urgent situations, the RN [Registered Nurse] may enter the Restraints Violent order appropriate to the age of the patient, order mode initiation of protocol: cosign required while awaiting ordering provider response notification ..."

1. Record review for Patient ID #1 revealed that a 4-point limb restraint was applied to this patient while in the Emergency Department in May of 2023 beginning at 8:00 PM.

Further review of Patient ID #1's record revealed that at 8:45 PM, Patient ID #1 continued to be restrained.

The Record failed to reveal evidence that a physician's order was obtained for Patient ID #1 for the application of a 4-point limb restraint.

During record review for Patient ID #1 with the Regulatory Readiness Specialist on 5/18/2023 at 11:27 AM, she was unable to locate a physician's order for the 4-point limb restraint applied to Patient ID #1.

2. Record review for Patient ID #3 revealed that the patient was placed in a restraint chair on 5/4/2023 at 1:10 PM after security personnel attempted to physically restrain the patient.

Further review of Patient ID #3's record revealed that the patient was restrained until 1:36 PM.

The record failed to reveal evidence that a physician's order was obtained for Patient ID #3 for the application of a chair restraint.

During email correspondence with the Risk Manager on 5/19/2023 at 9:02 AM, she was unable to provide evidence that a physician's order was obtained for the restraint applied to Patient ID #3.