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Based on observations, interviews, and record reviews, it was determined that the Condition of Participation for Patient Rights 42 CFR 482.13, was not met. The investigation revealed that the facility failed to ensure patient's rights were protected and promoted for one (1) patient (Patient #1), in the selected sample of three (3) patients.

Refer to: A145

Based on observations from video tape review, interviews with facility staff and law enforcement officers, and review of Patient #1's Emergency Department (ED) record, incident report, policies and procedures, uniform citation form, and written witness statements, it was determined that the facility failed to ensure that patients had the right to be free from all forms of abuse and harassment for one (1) patient (Patient #1), in the selected sample of three (3) patients.

A review Patient #1's ED medical record revealed the patient presented to the ED on 03/19/11 at 2:37 PM. Patient #1 was accompanied by the law enforcement officers (from jail). The officers had a "Uniform Citation" that was presented to the facility which charged Patient #1 with "Arrest, person is mentally ill and a danger to self and others." Patient #1 was taken from the jail to the facility by order of the County Attorney. Review of the "Focused Nursing Assessment" revealed Patient #1 was agitated and cursing loudly. The patient's face was red from pepper spray and Patient #1 stated his/her skin was burning from the pepper spray. Further review of the history of Patient #1's visits to the facility's ED and admissions to the facility, revealed Patient #1 was admitted to the facility's psychiatric unit on 03/23/09 through 04/01/09 with the diagnosis of "Psychosis." Patient #1 experienced auditory hallucinations (hearing voices).

A video of Patient #1 was taken by the facility on 03/19/11, while the patient was in the Behavioral Health Room in the ED. The facility provided the video upon surveyors' request to review the video. Review of the video revealed it contained no audio. The video encompassed the entire time Patient #1 was in the ED on 03/19/11. Observations of the video, in conjunction with the review of Patient #1's ED record, incident report, uniform citation form, and the written statements from witnesses present during the incident on 03/19/11, revealed Patient #1 was transferred from jail to the hospital's ED in handcuffs and shackles by two law enforcement officers on 03/19/11. Patient #1 was transferred to the hospital's ED for evaluation by "order of County Attorney" due to "person mentally ill and a danger to self/others." Patient #1 presented to the ED on 03/19/11 at 2:37 PM. Patient #1 was in jail for contempt of court and had a history of mental illness and psychiatric hospitalizations. Patient #1 was agitated, yelling, and cursing upon entry to the ED. Patient #1's assigned ED Physician was ED Physician #2. ED Physician #2 ordered Geodon 20 mg intramuscularly (IM) and Ativan 2 mg IM for agitation. Two ED nurses (RN #1 and RN #2) administered the IM injections to a cooperative but loud patient at 2:50 PM on 03/19/11. The ED nurse documented that Patient #1 was "fond of the F word." Patient #1 complained to ED staff that he/she had not taken any medications in a while before going to jail, because the patient ran was out of medications. The ED nurses (RN #1 and RN #2) verified that Patient #1 was receptive and cooperative to receiving the two IM medications for agitation. Approximately one and a half (1 1/2) minutes after Patient #1 received the IM injections, ED Physician #1 was observed rushing into the patient's room, while raising his arm and pointing his finger at Patient #1, he yelled "Shut Up there's old people and children and they don't need to hear all that yelling and cursing". ED Physician #1 started to leave the room when Patient #1 yelled "F--- You." ED Physician #1 abruptly turned around and went back towards Patient #1, he placed his left hand on Patient #1's neck and upper chest area and he pushed Patient #1 down on to the stretcher. ED Physician #1 proceeded to use a non hospital approved "carotid pressure point maneuver" to "calm" and "quiet" the patient. The patient informed the physician that he was "choking" him/her. ED Physician #1 informed the patient that he was not choking him/her, because if he was, he/she wouldn't be able to talk. Patient #1's ED record contained no documentation of the non hospital approved "carotid pressure point maneuver" which was utilized by ED Physician #1 on Patient #1 (within 1 1/2 minutes after Patient #1 received two IM injections for agitation). ED Physician #1 left Patient #1's ED room and did not return while Patient #1 was in the ED. Patient #1 had good results from the medications and was able to calm self and consumed his/her meal tray without any further incidents. Patient #1 was observed calmly walking out of the ED accompanied by the Deputy Jailor.

An allegation of abuse by ED Physician #1 towards Patient #1 on 03/19/11, was reported to the facility's House Supervisor on 03/19/11. ED Physician #1 was not removed from patient care after the abuse allegation was made by staff. ED Physician #1 continued working in the facility's ED and has received no type of disciplinary action for his behavior and actions taken towards Patient #1 on 03/19/11. Review of the facility's policy "Protecting Patients From Abuse While In Our Care" revealed that "If the abuse or suspected abuse is by a member of the medical staff or allied health professional, they will be immediately removed from patient care." Additionally, The facility's policy defined abuse as "The willfully infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This includes: Verbal abuse: Any use of oral, written or gestured language that includes disparaging and derogatory terms to patient or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Physical Abuse: Includes, but is not limited to, hitting, slapping, pinching or kicking. It also includes controlling behavior through corporal punishment. Mental Abuse: Includes, but is not limited to humiliation, harassment, threats of punishment or deprivation." Observations of video, interviews with staff, and record reviews revealed that the actions taken by ED Physician #1 towards Patient #1 on 03/19/11, met the facility's definition of abuse, although the facility's physicians reviewing the incident did not come to that conclusion. The facility failed to immediately put corrective measures in place in order to prevent reoccurrence and to ensure that patient's rights were protected and promoted.

Interviews with the Chief Medical Officer, Chief of Staff, Chief of Staff of ED, President of the contracted group of ED Physicians, ED Physician #1 and ED Physician #2 revealed all four (4) physician's felt that the actions taken by ED Physician #1, to include yelling and telling the patient to shut up, and the carotid pressure point technique, were appropriate and necessary. Additionally interviews with the Chief Medical Officer and Chief of Staff revealed after review of the 03/19/11 incident, it was determined that the interventions utilized by ED Physician #1 were acceptable and no further actions were needed.

Review of the facility's policy "Security Measures for Psychiatric Emergencies" revealed that "Physicians" were listed as "Responsible Persons" related to following the policy. The policy revealed "All ED Staff shall be trained in Crisis Prevention Intervention (CPI) and complete an annual review." The policy revealed that "Staff shall attempt verbal de-escalate and redirection initially. Restraints shall be used only as a last resort. Security shall be contacted for additional safety measures." The investigation verified that ED Physician #1 failed to follow the hospital's policy and procedures when interacting with Patient #1. ED Physician #1 did not "approach" Patient #1 and "introduce self, explain all procedures, recognize and treat the patient as a person, not a clinical entity, use techniques to diffuse, not escalate crisis (reassurance, personal warmth)." The physician failed to attempt to "verbally de-escalate" the patient and approach the patient in a "calm" and "confident manner to reduce anxiety." ED Physician #1 failed to "treat" the patient" gently but firmly, "listen to the patient" and "assure patient's dignity and privacy." Additionally, ED Physician #1 did not "monitor" his "reactions and comments" to Patient #1. Observations of the video and interviews with staff, revealed ED Physician #1 did not introduce himself to Patient #1, he just rushed into Patient #1's room and yelled "Shut Up there's old people and children and they don't need to hear all that yelling and cursing". The physician started to leave the room when Patient #1 yelled "F--- You." ED Physician #1 abruptly turned around and went back towards Patient #1, he placed his left hand on Patient #1's neck and upper chest area and pushed Patient #1 down on the stretcher. He proceeded to place Patient #1 in a non hospital approved technique of a "carotid pressure point maneuver."

The personnel records, training records, and credentialing files were reviewed. The record reviews revealed that ED Physician #1 and ED Physician #2 were not trained in Crisis Prevention Intervention (CPI), as per the hospital's policy and procedures. Additionally, physicians do not receive any type of classroom and/or instructional training on the policies and procedures for "Protecting Patients From Abuse While In Our Care" or "Security Measures for Psychiatric Emergencies." Physicians are given a copy of the facility's policies and procedures to read on their own. The physicians sign a document every two years, at the time for their reappointment, which indicates that they have read the policies and procedures.

An interview was conducted with ED Doctor #1 at the facility on 03/29/11 at 2:00 PM, revealed that patient #1 was loud, yelling, cursing, and disruptive to the entire milieu of the ED. He revealed that he entered Patient #1's room and told the patient "Shut Up." He revealed that as he turned to exit the room the patient yelled something back at him so he placed the patient in a "carotid pressure point maneuver" to "calm" and "quiet" the patient. He revealed that he placed one finger on the carotid bulb, which is a pressure point, which lowers the patient's blood pressure and calms the patient. He stated that he has never received CPI training from the hospital. He revealed that he learned the "carotid pressure point maneuver" from a "Medic in Special Forces" and he has rarely had to utilize the maneuver.

A review of the facility's investigation into the 03/19/11 (Saturday) incident, revealed that the abuse allegation was reported by staff on 03/19/11 to the House Supervisor approximately an hour after the incident occurred. An investigation was immediately initiated by the House Supervisor. All appropriate administrative staff were notified of the incident with the exception of the Case Manager, as per the facility's policy and procedures. The Chief Medical Officer arrived at the facility to review the video and question Physician #1 and staff. It was the decision of the Chief Medical Officer on-site, to have ED Physician #1 take a urine drug screen and to let the physician continue working in the ED, and to further discuss the incident with the staff on Monday, 03/21/11. There were no recommendations and/or actions taken against ED Physician #1, as per decision by the medical staff committee on 03/21/11. The incident was reported by the Case Manager to the Department of Community Based Services (DCBS) and the Office of Inspector General (OIG) and to the Office of Attorney General (OAG) on 03/25/11. Although the facility began in-servicing staff (House Supervisors) on 03/28/11, regarding immediately removing staff, to include physicians, from patient care if an allegation of abuse was made against them, the facility has not begun to train all ED physicians in CPI, "Security Measures for Psychiatric Emergencies," and "Protecting Patients From Abuse While In Our Care." The investigation further revealed that the medical staff failed to identify and/or address the verbal, mental, and or physical abuse (as defined by the facility's policy, "Protecting Patients From Abuse While In Our Care.") with ED Physician #1.

The facility failed to follow their "Protecting Patients From Abuse While In Our Care" policy and procedure by not removing the alleged perpetrator (ED Physician #1) from patient care after an allegation of abuse was made against him. The facility failed to follow their policy "Security Measures for Psychiatric Emergencies" related to all ED staff not being trained in CPI and not utilizing the techniques detailed in the policy regarding how to approach a person with behavioral or emotional disorders. The facility failed to ensure patient's rights were protected and promoted for Patient #1.

Based on observations from video tape review, interviews with facility staff and law enforcement officers, and review of Patient #1's Emergency Department (ED) record, incident report, policies and procedures, uniform citation form, and written witness statements, it was determined that the facility failed to ensure that patients had the right to be free from all forms of abuse and harassment for one (1) patient (Patient #1), in the selected sample of three (3) patients.

A review Patient #1's ED medical record revealed the patient presented to the ED on 03/19/11 at 2:37 PM. Patient #1 was accompanied by the law enforcement officers (from jail). The officers had a "Uniform Citation" that was presented to the facility which charged Patient #1 with "Arrest, person is mentally ill and a danger to self and others." Patient #1 was taken from the jail to the facility by order of the County Attorney. Review of the "Focused Nursing Assessment" revealed Patient #1 was agitated and cursing loudly. The patient's face was red from pepper spray and Patient #1 stated his/her skin was burning from the pepper spray. Further review of the history of Patient #1's visits to the facility's ED and admissions to the facility, revealed Patient #1 was admitted to the facility's psychiatric unit on 03/23/09 through 04/01/09 with the diagnosis of "Psychosis." Patient #1 experienced auditory hallucinations (hearing voices).

A video of Patient #1 was taken by the facility on 03/19/11, while the patient was in the Behavioral Health Room in the ED. The facility provided the video upon surveyors' request to review the video. Review of the video revealed it contained no audio. The video encompassed the entire time Patient #1 was in the ED on 03/19/11. Observations of the video, in conjunction with the review of Patient #1's ED record, incident report, uniform citation form, and the written statements from witnesses present during the incident on 03/19/11, revealed Patient #1 was transferred from jail to the hospital's ED in handcuffs and shackles by two law enforcement officers on 03/19/11. Patient #1 was transferred to the hospital's ED for evaluation by "order of County Attorney" due to "person mentally ill and a danger to self/others." Patient #1 presented to the ED on 03/19/11 at 2:37 PM. Patient #1 was in jail for contempt of court and had a history of mental illness and psychiatric hospitalizations. Patient #1 was agitated, yelling, and cursing upon entry to the ED. Patient #1's assigned ED Physician was ED Physician #2. ED Physician #2 ordered Geodon 20 mg intramuscularly (IM) and Ativan 2 mg IM for agitation. Two ED nurses (RN #1 and RN #2) administered the IM injections to a cooperative but loud patient at 2:50 PM on 03/19/11. The ED nurse documented that Patient #1 was "fond of the F word." Patient #1 complained to ED staff that he/she had not taken any medications in a while before going to jail, because the patient ran was out of medications. The ED nurses (RN #1 and RN #2) verified that Patient #1 was receptive and cooperative to receiving the two IM medications for agitation. Approximately one and a half (1 1/2) minutes after Patient #1 received the IM injections, ED Physician #1 was observed rushing into the patient's room, while raising his arm and pointing his finger at Patient #1, he yelled "Shut Up there's old people and children and they don't need to hear all that yelling and cursing". ED Physician #1 started to leave the room when Patient #1 yelled "F--- You." ED Physician #1 abruptly turned around and went back towards Patient #1, he placed his left hand on Patient #1's neck and upper chest area and he pushed Patient #1 down on to the stretcher. ED Physician #1 proceeded to use a non hospital approved "carotid pressure point maneuver" to "calm" and "quiet" the patient. The patient informed the physician that he was "choking" him/her. ED Physician #1 informed the patient that he was not choking him/her, because if he was, he/she wouldn't be able to talk. Patient #1's ED record contained no documentation of the non hospital approved "carotid pressure point maneuver" which was utilized by ED Physician #1 on Patient #1 (within 1 1/2 minutes after Patient #1 received two IM injections for agitation). ED Physician #1 left Patient #1's ED room and did not return while Patient #1 was in the ED. Patient #1 had good results from the medications and was able to calm self and consumed his/her meal tray without any further incidents. Patient #1 was observed calmly walking out of the ED accompanied by the Deputy Jailor.

An allegation of abuse by ED Physician #1 towards Patient #1 on 03/19/11, was reported to the facility's House Supervisor on 03/19/11. ED Physician #1 was not removed from patient care after the abuse allegation was made by staff. ED Physician #1 continued working in the facility's ED and has received no type of disciplinary action for his behavior and actions taken towards Patient #1 on 03/19/11. Review of the facility's policy "Protecting Patients From Abuse While In Our Care" revealed that "If the abuse or suspected abuse is by a member of the medical staff or allied health professional, they will be immediately removed from patient care." Additionally, The facility's policy defined abuse as "The willfully infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This includes: Verbal abuse: Any use of oral, written or gestured language that includes disparaging and derogatory terms to patient or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Physical Abuse: Includes, but is not limited to, hitting, slapping, pinching or kicking. It also includes controlling behavior through corporal punishment. Mental Abuse: Includes, but is not limited to humiliation, harassment, threats of punishment or deprivation." Observations of video, interviews with staff, and record reviews revealed that the actions taken by ED Physician #1 towards Patient #1 on 03/19/11, met the facility's definition of abuse, although the facility's physicians reviewing the incident did not come to that conclusion. The facility failed to immediately put corrective measures in place in order to prevent reoccurrence and to ensure that patient's rights were protected and promoted.

Interviews with the Chief Medical Officer, Chief of Staff, Chief of Staff of ED, President of the contracted group of ED Physicians, ED Physician #1 and ED Physician #2 revealed all four (4) physician's felt that the actions taken by ED Physician #1, to include yelling and telling the patient to shut up, and the carotid pressure point technique, were appropriate and necessary. Additionally interviews with the Chief Medical Officer and Chief of Staff revealed after review of the 03/19/11 incident, it was determined that the interventions utilized by ED Physician #1 were acceptable and no further actions were needed.

Review of the facility's policy "Security Measures for Psychiatric Emergencies" revealed that "Physicians" were listed as "Responsible Persons" related to following the policy. The policy revealed "All ED Staff shall be trained in Crisis Prevention Intervention (CPI) and complete an annual review." The policy revealed that "Staff shall attempt verbal de-escalate and redirection initially. Restraints shall be used only as a last resort. Security shall be contacted for additional safety measures." The investigation verified that ED Physician #1 failed to follow the hospital's policy and procedures when interacting with Patient #1. ED Physician #1 did not "approach" Patient #1 and "introduce self, explain all procedures, recognize and treat the patient as a person, not a clinical entity, use techniques to diffuse, not escalate crisis (reassurance, personal warmth)." The physician failed to attempt to "verbally de-escalate" the patient and approach the patient in a "calm" and "confident manner to reduce anxiety." ED Physician #1 failed to "treat" the patient" gently but firmly, "listen to th