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Based on interviews with staff, review of policies, procedures, and other documentation inclusive of 13 medical records during an unannounced complaint (MD00137069) survey on 4/17/19, it was determined that the hospital was out of compliance with the Condition of Participation for Patient Rights.

The hospital's policies and procedures surrounding the use of armed officers in interactions with patients, inclusive of training, use of force, and use of forensic weapons was found to have violated the rights of at least one patient reviewed (P1). Security personnel and armed officers were not trained in the safe application of restraints and were found to be using unapproved patient control techniques. The hospital also had no expectation of clinical oversight of, or intervention into, these interactions with patients.

In addition, clinical staff did not release two patients from restraints at the earliest possible time. Another patient (P13) indicated to staff that he/she did not want a surgery to which P13 had previously agreed. No exploration was undertaken to determine if P13, an alert patient, had really changed his/her mind and no capacity evaluation was completed before taking P13 to surgery.

Please see the following Patient Safety Tags.

Based on review of 13 medical records, it was determined that the hospital failed to verify patient #7's documented power of attorney.

Patient #7 (P7) was a 75+ year old patient who presented to the hospital from a group home with blood in their urine. P7 had an intellectual disability and was non-communicative. Per discharge planner note two days into patient's admission, "writer found previous CM (case management) [note] that the POA (power of attorney) is .... The discharge planner called the person, who confirmed they were the POA for the patient. The note further stated, this person "will be the person to notify for pt's care." Review of the patient's chart while on survey revealed there was no legal documentation or attempt to acquire legal documentation that the POA was indeed the healthcare POA. A document was later provided to the surveyor titled "Surrogate Decision Maker Affidavit Form." This form designated a surrogate decision maker but since the hospital referred to this person as the POA a legal document needed to be obtained.

Additionally, review of the nursing admission database assessment, revealed an area titled "legal indicators." This area appeared with simple check boxes next to named legal documents which could impact patient decision-making including "Advance Directive." However, it could not be determined if the hospital was asking for a definitive answer as to whether an Advance Directive existed where only a check box was found. Further, no prompt in the EMR (electronic medical record) to offer Advance Directive information to patients wishing to establish an Advance Directive was found.

In summary, the hospital accepted a designation of POA without actual evidence, and nursing assessment failed to obtain definitive information regarding the existence of patient Advance Directives, and thus to be able to offer information in the absence of an Advance Directive.

Based on a staff interviews, medical record review and review of the hospital job descriptions for security guards and Armed Officers, the hospital Restraint policy, Use of Force (UOF) policy, it was determined that 1) Per job descriptions, Security guards and Armed officers are required to restrain patients, but receive no healthcare restraint training regarding safely manually restraining patients; 2) Handcuffs and other police weaponry were not considered restraints for the purposes of clinical oversight; and 3) Armed officers were authorized to act on situations without clinical direction and oversight.

Review of the hospital job description for Security guards revealed in part, "As directed by appropriate medical staff or their supervisor, assists in restraining ..." In an interview on 4/17/2019 at approximately 1430, the Director of Security stated that security staff do not actually place hands on patients to manually restrain, but rather, use methods which are defensive, for instance, which would push an attacking patient's hand away. This statement did not seem realistic where aggressive or violent patients do require manual restraint at times. Further, a clinical educator stated that neither Security guards nor Armed Officers receive the section of health care restraint training in which manual restraint is taught.

Interview with a security staff on 4/17/2019 at approximately 0930 revealed the general practice by all security staff of using pressure points over nerves and the bending of wrists until enough pain was produced to achieve control of the patient. Neither practice represented approved healthcare restraints, but were a form of police manual restraints. While the hospital did not give attribution to these methods, the interviewed security guard stated these methods were used to bring aggressive patients under control.

Review of restraint records for P1 revealed an account of a security guard-involved restraint which indicated that P1 complained of injury and pain to the left chest following the interaction. Nursing documentation on the first day of P1's presentation stated in part, "Pt became non-redirectable and extremely aggressive. Security called. Pt medicated ...and placed in four point restraints ..." No descriptors were found regarding how security subdued P1. A physician note of 0833 revealed in part, "Now pt. began complaint of CP (chest pain) after being restrained." No security-driven report or any indication of how the patient was treated by security was found.

On P1's second day of presentation regarding the restraint episode that had occurred, a nursing note stated in part, "Patient now awake complaining of non-radiating, aching, left sided chest pain s/p injury during attempt to deescalate situation last night according to patient, and rated 10/10; area appears red and tender to palpation." Another note stated in part, "(P1) is upset and c/o general body pain and CP (chest pain), bruises that (P1) claims (P1) obtained from Security guards here ...Apologized to what happened ..." On day 3 of presentation, a progress note stated in part, " ...complained of pain to the left chest but denies having any chest pain, stated it was due to some occurrences while in the emergency room ..." This documentation indicated that the pain incurred by P1 which P1 stated had occurred due to a security guard-involved restraint episode continued over at least two days.

Documentation on day 3 of P1's stay revealed in part, a physician note of 0905 which stated in part, "Patient this morning became very aggressive, violent threatening the staff and left the room to go home by (P1's) self. Code Green was called ...He was very violent threatening all (P1's) staff, wanting to leave without medical discharge requiring both physical and chemical restraint ..."

Following review of all information, the statement that security guards do not actually place hands on patients to restrain was not found to be accurate. Further, since Security guards do not receive the hospital healthcare restraint training as do clinicians, no clinical oversight as required for safety was given to whatever type of manual restraint was being used by security.

Review of the Armed Officer (AO) job description stated in part under physical requirements, "Assisting with restraining." The Director stated in an interview on the day of survey that if a physician gave direction to the AO to hold a patient, the AO could hold the patient. The answer given to a question regarding restraint training, the Director said that AOs did not receive healthcare restraint training through the hospital, but that AOs received extensive police training at the Sheriff's office. That meant that the hospital had no practice of training AOs in healthcare restraints, but also that no clinical oversight for safety could be given to a restraint process to which clinicians were not also trained.

Review of the hospital "Restraints (Violent and Non-Violent)" (8/15/2018) policy revealed in part under "Definitions: Many appropriate devices and practices that can inhibit a patient's movement do not constitute restraint, including but not limited to ...forensic and correction restrictions used by law enforcement ..." This meant that:

1. There was no expectation in policy for staff to make a determination as to whether a patient was under arrest, detention, or simply brought into the hospital while in handcuffs, for instance on an emergency petition (EP). Absent a clinical determination of the status of a patient, handcuffs could be applied or remain on for as long as the AO deemed necessary. In addition, the hospital Use of Force policy (UOF) (October 2018) failed to address the use of handcuffs.

2. The hospital had no expectation of clinical oversight, orders or documentation if handcuffs were placed on a patient by AO or security. According to policy, Armed officers or security could use handcuffs freely without accountability to a restraint process whether a patient was under arrest or not.

3. Review of the UOF revealed in part, "(The Hospital) does not condone the use of the Taser or expandable baton to be an appropriate healthcare weapon nor should it be used in the application of patient restraint. The baton or Taser should not be used to threaten, intimidate or strike patients. The only exception is when an Armed Officer reasonably believes it is necessary to stop patients from causing serious physical injury or death to themselves or others." In the healthcare setting where any number of individuals might present on a daily basis with aggressive behaviors due to various medical conditions, an Armed Officer had free agency, with singular decision-making and without clinical oversight, or use Taser or a baton on a patient as the officer deemed appropriate.

In summary, the hospital lacked accountability for afe restraint use where:

1. Job descriptions for Security guards and AOs indicate assistance with restraint processes, yet neither are given healthcare restraint training.
2. Handcuffs and other law enforcement restrictions were not considered restraints, and therefore may be freely utilized without accountability.
3. The hospital UOF policy gave free agency to AOs to use a Taser or baton as the Officer deemed appropriate, and failed to address the use of handcuffs.

Therefore, the hospital could not ensure that patients received care in a safe setting.

Based on a review of hospital policy "Restraints (Violent and non-Violent) (8/15/2018) and restraint records for patients #1 (P1) and #2 (P2), it was revealed that P1 and P2 were not released from 4-point restraint at the earliest possible time.

Review of the hospital restraint policy revealed in part, "Restraint will be discontinued at the earliest possible time regardless of the length of time identified in the order."

Patient #1 (P1) was a 49+ year old adult who presented to the emergency department (ED) in April 2019 with a chief complaint of a mental illness condition. P1 presented at 2221 and was triaged at 2241. A nursing note of 2300 revealed in part, "Pt observed in manic episode. Pt became non-redirectable and extremely aggressive. Security called. Pt medicated per MAR and placed in four point restraints ..."

Review of flow documentation for restraints revealed every 15-minute entries regarding in part, patient behaviors and the question of "restraint release." Flow entries for 2300 and 2315 revealed P1 behaviors to be "Aggressive" and the restraint release documented as "No, Release Criteria Not Met."

Following the first two 15-minute documentation intervals, P1 behaviors were noted as "Asleep" through 0200 the following morning, and was then, "Quiet, Redirectable," with one event of "Uncooperative Redirectable" through 0300. Restraint Release related to these behavioral entries revealed "No, Release Criteria Not Met," until 0215 at which time, the RN began releasing specific restraints over the next 45 minutes, ending with release of all restraints at 0300.

Even though P1 had met criteria for release by 2330, P1 was kept in restraints for another 3.5 hours until 0300 for insufficiently documented reasons while P1 was noted to be asleep and quiet. The fact that P1 was kept in restraint to the very end of the 4 -hour restraint order revealed that staff failed to follow policy and regulation for release of P1 "regardless of the length of time identified in the order." Additionally, staff failed to release all P1 restraints at once.
A physician progress note that morning at 0122 revealed in part, "Pt still needs restraint, Pt is hyperactive. Pt is answering questions and said "thank you..." Being hyperactive was not sufficient reason to keep P1 in four-point restraints and P1 was not released at the earliest possible time though all behavioral indicators revealed P1's readiness.

Patient #2 presented via ambulance to the ED after being found lying in the street and unable to give a history of what occurred. Shortly after presentation, P2 was noted to become violent and was placed into 4-point restraint at 2015. Every 15 minute behavioral monitoring to justify ongoing restraint revealed that P2 was "uncooperative." No other objective behavioral descriptors were documented that indicated how being uncooperative represented violent or imminently dangerous behavior. From 2100 through 2130, P2 was noted to be asleep. Even though P2 was asleep and had clearly met criteria for release, P2 was only released gradually over the next half hour.

Based on interviews, a review of the hospital Restraint policy and medical record documentation for P1, it was determined that orders for manual restraints were not required or obtained when security or AO placed hands-on P1 while removing P1 from an elevator, escorting P1 to P1's room against his will, and holding P1 for medication administration.

Review of the hospital "Restraints (Violent and Non-Violent)" (08/15/2018) revealed in part, "Adult Patients that require manual (holding) restraint by personnel must have a physician order confirming an emergent condition." However, if the patient is being manually restrained to apply a restraint device, a separate order is not required." Since P1 had an order for mechanical restraints, although none were applied, no specific documentation or a clinical order was required for the manual hold, even though manual holds are a high risk intervention.

In an interview on 4/17/2019 at approximately 1430, the Director of Security stated that security staff do not actually place hands on patients to manually restrain, but rather, use methods which are defensive, for instance, which would push an attacking patient's hand away. It did not appear a realistic expectation that Security would not at times need to manually restrain patients. For instance P1 was manually removed from an elevator and manually escorted to P1's room and manually held for medication administration without clinician orders.

Since no order for manual restraint was required in the setting of an order for mechanical restraint, there was scant documentation when Security implemented a manual restraint on P1. P1 complained of chest and shoulder pain for three days following this manual intervention.

Based on staff interviews and review of policies and other documentation, it was determined that the hospital failed to train security personnel and Armed Officers in the safe and appropriate use of restraints.

See Tag A-144

Based on interview and review of educational requirements, it was determined that the hospital security staff and Armed Officers who restrain patients are not required to maintain certification in cardiopulmonary resuscitation (CPR).

In an interview on 4/17/2019 at approximately 1430, the Directors of Security and Human Resources confirmed that the hospital had no expectation for security and armed officers to maintain basic certification in CPR as required for personnel involved in restraint and seclusion.

Based on staff interviews, policy review, and review of the hospital's QAPI program, it was determined that the QAPI department failed to monitor all potentially hazardous situations involving security personnel interactions with patients. The hospital failed to require security-patient interactions involving restraint be reported to the QAPI department, leaving QAPI unable to fully track, assess, analyze, and mitigate patient injuries and potential injuries. Therefore, the QAPI department failed in its requirement to use a data-driven approach, focused on problem prone or high risk areas and processes, and involving all hospital departments, to prevent patient injury.

See all Patient Rights tags and tag A-123

Based on interviews, a review the Code Green (behavioral emergencies) policy, a review of the hospital restraint policy, and review of restraint events for patient #1 (P1), and a request for documentation from the Patient Safety Coordinator (PSC) related to P1's restraint, it was determined that the hospital had no expectation for Security guard/Armed Officers (AO) to document restraint events which were not also associated with a Code Green/Workplace Violence Event, meaning that the quality department could not effectively identify, analyze, or track all restraint episodes and injuries.

Review of the Code Green policy revealed in part, "IV. Code Green - A Code Green is called when there is a need for additional support due to violence or a potential for violence that could result in injury to a person(s) ..." The policy contained no clear guidelines for when or when not to call a Code Green, and since the calling of a code green triggered documentation from security, when P1 was restrained without a Code Green, there was no report from security even though they had placed hands on P1.

Review of P1's restraint episodes for which no Code Green was called identified that after one security-involved restraint, P1 reported incurring an injury to the chest that P1 attributed to an interaction with security staff; the pain of which continued over the duration of P1's 3-day admission. A request to the Patient Safety Coordinator for Security documentation of the event revealed no report existed. Since, per policy, no security report was generated or required to be generated, no information went to the Quality department for patient safety monitoring or tracking, and in P1's case, no quality investigation was done related to P1's reported injury. In addition, non-Code Green events were not reported through the hospital's usual clinical incident reporting system.

On further inquiry, the Quality Coordinator stated that only Code Green events are required to have a Security report, meaning that if a Code Green was not called, no accountability for any other restraint process, hands-on events, or injuries were required to be documented by hospital Security. This was also true for Armed Officers (AOs).

Manual holds are a high risk intervention. As noted in tag A-0144, the Director of Security, in an interview on 4/17/2019 at approximately 1430, stated that security staff do not actually place hands on patients to manually restrain. It did not appear a realistic expectation that Security would not at times need to manually restrain patients, but because the hospital did not require a report from security regarding every patient-security restraint episode, there was no accountability for Security implementing a manual restraint, or for implementing a manual restraint by approved healthcare restraint processes (for which Security and AOs were not trained).

Another event for P1 did result in a Code Green. Documentation in part described P1 as "a very, very, irate combative patient." However, documentation of this event was vague related to the actual handling of P1 with such statements as "As security was trying to prevent the patient from leaving ...and Nursing staff assisted security with the patient at that time and medication was administered" ... An order was written for restraint, though P1 was not placed into mechanical restraints. However, based on documentation, it seemed likely that P1 was manually restrained in the process of preventing P1 from leaving and getting P1 back to P1's room, for which no documentation and thus no clinical accountability was noted.

In summary, the restraint process for Security Guards and Armed Officers was not a transparent process, with exceptions to reporting, restraint use and documentation found throughout the restraint process and policies. The lack of documentation regarding security-patient hands-on interactions meant the quality department was unable to fully identify safety concerns, and no quality analysis could move forward absent a clear picture of actual Security guard and AO interactions with patients related to restraint.