HospitalInspections.org

Based on the nature of deficiencies cited, the hospital failed to comply with the Condition of Participation of Governing Body. The hospital failed to have an effective governing body legally responsible for the conduct of the hospital as an institution. The Governing Body failed to provide effective oversight to ensure facility staff maintained an "effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program (QAPI Condition Tag A263). In addition, the Governing Body failed to "protect and promote each patient's rights" (Patients' Rights Condition Tag A115) with regard to the right to refuse treatment and the use of force, including restraints, handcuffs and tasers.

The facility failed to meet the following standard under the condition of Governing Body:

A083 Contracted Services-Responsibility for Services
The Governing Body failed to be responsible for services furnished in the hospital related to patients' rights and quality assurance/performance improvement activities.

Based on staff interviews, and review of medical records, policies/procedures, personnel/credential files, meeting minutes and other facility documents and reports, the governing body (as the entity ultimately responsible for all services furnished in the hospital) failed to ensure that the hospital "maintained an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program "(QAPI Condition Tag A263). In addition, the governing body failed to "protect and promote each patient's rights" (Patients' Rights Condition Tag A115) with regard to the right to refuse treatment and the use of force, including restraints, handcuffs and tasers. The failures contributed to negative outcomes for patients.

The findings were:

1. Quality Assurance/Performance Improvement (QAPI):

Refer to the QAPI Condition Tag A263 and QAPI Standard Tags 267, 275, 276, 287, 288 and 310, for findings related to the facility's failure to "maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program."

2. Patients' Rights:
Refer to the Patients' Rights Condition Tag A115 and Standard Tags, A131 (right to refuse treatment), A154 (restraint use, including tasers and handcuffs), A162 (involuntary patient confinement), A168 (physician restraint order requirement), and A202 (staff training regarding safe application and use of restraints) for findings.

Based on the number and nature of deficiencies cited, the hospital failed to comply with the Condition of Participation of Patient Rights. The facility failed to ensure patient rights were upheld in all circumstances. This failure created a negative patient outcome. Cross reference A131 Patient Rights: Informed Consent, A154 Use of Restraint or Seclusion, and A162/ A168/ A202 Patient Rights: Restraint or Seclusion.

Based on review of medical records, policy and procedures, and staff interviews, it was determined the facility failed to ensure that patients were placed on mental health holds, DETOX (drug/alcohol) holds, or otherwise prior to preventing them from leaving the facility. In ten (#s 3, 5, 6, 10, 11, 14, 15, 20, 22 & 28) of 28 medical records, there was no clear evidence why patients were held despite their desire to leave. Although the physician's reasoning could be inferred from their documentation, it was not specifically stated and on occasion patients were held against their will prior to being assessed by a physician. In two (#s 13 & 26) of 28 medical records, a medical procedure was performed with evidence that the patient initially refused the procedure and no evidence that the patient later consented. This failure did not ensure patient rights were upheld, that the facility's policies and procedures were consistently followed, and created the potential for a negative patient outcome.

The findings were:

Interviews:

On 5/4/2010 at approximately 10:00 a.m. an interview with the Risk Manager (RM) was conducted. S/he stated, "Our practice here is a medical clearance first and then a mental health evaluation." S/he continued, "Until patients are medically cleared, they are all on a watch and not allowed to leave and the mental health evaluation can not be done." The RM stated that physicians will not place a patient on a M1 (72 hour mental health hold) and will wait for the mental health evaluator and then collaborate. S/he stated that if the patient wants to leave before the mental health evaluation, use of force is implemented.

In an interview on 5/5/2010 at approximately 10:00 a.m. with the Director of Mental Health, s/he stated that the hospital has had the practice for a long time that mental health evaluations and holds are not completed until after the patient is medically cleared. According to the policy and procedure "Suicide and Homicide Risk..." the medical clearance may include the following: comprehensive laboratory panel, thyroid studies, urine toxicology screen, alertness, independently eating, a physician's order, etc. A Licensed Clinical Social Worker (LCSW) at the facility also stated that the mental health evaluation can take up to three hours because it is so thorough. S/he stated that they do not complete the evaluation until the patient's blood alcohol level is below a certain number. In addition, mental health evaluators are hesitant to place patients on M1 holds as they only last 72 hours and they don't want the holds to expire.

On 5/5/2010 at approximately 10:30 a.m. an interview with the Director of Emergency Services was conducted. S/he stated, "Security would not stop a patient from leaving unless a medical person told them that the patient had to stay." When questioned why a medical person would need to keep a patient, including one who voluntarily presented, prior to even evaluating the patient, s/he stated, "We don't have enough info to say whether the patient can leave or not." A "watch" was described as a hold initiated by the physician at the bedside. A security guard would then be assigned to just stand outside the room. S/he stated that if the patient is under the influence (of drugs or alcohol), the patient can't leave because they aren't in the proper state of mind and could walk into traffic. S/he also stated that MDs use their own decision making capacity to keep the patients here.

In an interview on 5/5/2010 at approximately 4:45 p.m. with the Physicians' Medical Director of the facility's north campus, s/he stated, "In my opinion, I can clear patients to a certain point without lab work or anything else." S/he continued that s/he does implement M1 mental health holds and had done several that week. However, it was determined through medical record review that this was not routine practice by physicians. It was found that delay in mental health treatment while waiting for medical clearance (often lab results) was frequently a precursor to aggressive patient behavior and not early identified and addressed as per the facility's policy and procedure "Practice Guidelines for AMA."

Reference Tag A154 for findings related to use of force, including restraint, taser and handcuff use, and delayed mental health evaluations.

Facility Documents:

On 5/10/2010, the facility's policy and procedure titled "Suicide and Homicide Risk - Management of Patients" was reviewed. It stated the following, in pertinent part:

"Standard of Practice for Suicide Precautions:
1. Risk Status:
Patients considered to be a risk for suicide will be considered to have impaired decisions making capacity until cleared by a mental health screen and evaluation. A mental health screen and evaluation cannot be completed until after patient is medically cleared.
2. Patient Want to Leave Hospital Without a Mental Health Evaluation:
Identify patient's understanding of what physicians and other care providers have said regarding treatment and care. Explain the risks to the patient and significant others. Attempt to identify reason why the patient wants to leave and work to resolve the barriers to staying in the hospital. Continue to instruct and encourage the patient to follow recommended treatment and care. Involve the family and support system...
5. Mental Health Evaluation:
...Mental health evaluators may have more than one evaluation at a time and there may be a waiting period until they can get to all patients.
6. Detainment:
The patient will be detained by security staff when necessary until the mental health evaluation is completed and patient is cleared of suicide risk..."

On 5/10/2010, the facility's policy and procedure titled "AMA and Missing Patient - Management of Patients" was reviewed. It stated the following, in pertinent part:

"Practice Guidelines for AMA

...3. Routine AMA Prevention - initial steps
A. Assess for following behaviors
1) Wearing clothes
2) Walking in halls
3) Verbalizing complaints about care
4) Verbalizing plans to leave hospital...

D. Contacts, orders and plans:
1) Notify the physician of patient's concern and review risks associated with patient leaving AMA. Obtain orders from physician for further evaluation and/or treatment as needed and determine extent of detainment to be used to keep patient in hospital.
2) Contact family/friends to assist in convincing patient to remain for completion of care.
3) Expedite completion of plan of care.
4) Notify security of possible AMA risk. Security will be provided with patient information and status. Define a plan regarding the type of security surveillance that is reasonable for patient...

4. AMA Plan of Care when a patient is at medical or psychological risk, has decision-making capacity, and has received education about potential consequences...

4) Patient will not be detained if he/she decides to leave.
5) Security staff role in AMA prevention... Only in cases where the patient is determined to be at risk about absent of decision making capacity, will security physically detain the patient..."

On 5/10/2010, the facility's policy and procedure titled "Patient Rights and Responsibilities" was reviewed. In the "Standard of Practice" section, it stated the following, in pertinent part:

"I. Informed Consent...
The patient should not be subjected to any procedure without his/her voluntary, competent, and understanding consent, or that of his/her legally authorized representative. Where medically significant alternatives for care or treatment exist, the patient shall be so informed of these alternatives and their risks and benefits...

K. Refusal of Treatment...
The patient may refuse any drug, test, procedure or treatment to the extent permitted by law..."

Medical Records and facility reports/documents:

Sample patient #3 was an adult male seen in the ED due to intoxication and status post assault. The patient denied suicidal/homicidal ideations and he was not placed on a mental health hold while in the ED. Per the security Incident Report, three hours after the patient's admission he requested to leave and was informed by the nurse that he was too intoxicated and could not leave until he was sober. While in the ED, the patient was tased and restrained. After a mental health evaluation, the patient was discharged home with a bus pass.

Sample patient #5 was an adult male brought into the ED due to a drug overdose. Per the security incident report, the patient wanted to leave while he was in triage and a family member was physically holding him back and the nurse did not want him to leave. In efforts to control the patient, he was tased three total times, although one was ineffective, and restrained. A mental health evaluation determined that the patient met criteria for a M-1 hold for danger to self and others. However, the chart did not contain evidence that a M-1 hold was ever initiated. Although the physician's documentation stated, in pertinent part, "He was felt to be an extreme flight risk and thought to be agitated enough to be a risk to himself, to be suicidal," it did not contain evidence of a hold or clarification that this patient would be kept against his will until cleared by a mental health evaluator. An addendum to the mental health evaluation stated, in pertinent part: "Pt has been reassessed twice since his first mental health evaluation. He no longer meets criteria for an M-1 Hold ..." The patient was discharged home from the ED approximately two days after initial presentation.

Sample patient #6 was an adult male found slumped behind some bushes and brought into the ED via ambulance. Per the security Incident Report, the patient was verbally and physically aggressive to staff in the ED. The patient repeatedly told the physician that he wanted to leave and did not respond with an answer when the MD asked if the patient had a sober driver. The physician documented that the patient would be restrained and medicated so he did not hurt himself or anyone else, but the record did not contain evidence that the patient was placed on any type of hold. While in the ED, the patient was tased, restrained, and found to be positive for drugs. The patient was eventually discharged home.

Sample patient #9 was an adult male brought to the ED via private vehicle with his sibling, who was also an adult male admitted as a patient (sample patient #10) for multiple trauma wounds. Per the physician's documentation, sample patient #9 was attempting to get #10 to leave. It stated, "The patient (#10) says that he needs to leave and that he is going. I told the patient that he cannot leave and he needs to stay for an evaluation." The documentation inferred that the physician did not want the patient (#10) to leave due to possible trauma injuries he may have received, but the patient was not placed on a hold of any type. The security officer documented that because both had not yet been checked for weapons, the high volume of uncooperative visitors, and the apparent urgency of #10's injuries, the security officer tased patient #9. Then patient #10 began to walk toward the officer with his hands up by his face and he was also tased. Thereafter, #9 was cuffed and transferred to a medical bed where the taser probes were removed/treated and he was later discharged home. Sample patient #10 was cuffed and placed on a medical bed. Shortly thereafter, the handcuffs were removed and medical treatment for his presenting condition ensued. Eventually, #10 was admitted to the hospital and discharged the following day.

Sample patient #11 was an adult male brought to the ED via ambulance due to suicide threats. The report stated, in pertinent part, "Initially he was very calm when he was brought back, and because of all the other psychiatric patients back there becoming violent and escalating, he became violent and required physical restraints." Shortly after the patient's arrival, he attempted to leave the facility. A security officer chased after him and the patient resisted his/her attempts to control him. The patient was eventually tased by another officer, handcuffed, escorted back to a medical bed, and restrained. A mental health evaluator placed the patient on an emergency commitment for patients under the influence of alcohol after the tase incident. Although the ED physician documented that the patient had threatened to hang himself, the patient was not placed on a hold until assessed by the mental health evaluator. He was then transferred to a DETOX facility.

Sample patient #13 was an adult male who presented voluntarily for meth abuse/psychosis and a complaint of possible poisoning. Per the security Incident Report, the patient had urinated but did not provide a urine sample. He did not want a urinary catheter placed to obtain a sample and the nurse explained the need for it. The patient then jumped out of bed and swung his fists at the nurse. A security officer unsuccessfully attempted to control him, the patient ducked underneath his arm and attempted to run away as he entered the hallway, and he was tased twice before complying with security officers. The patient was then handcuffed, placed in bed, and restrained by use of RIPP 4 point restraints. Per nursing documentation, thereafter the patient had a foley catheter placed to obtain a urine specimen while he was restrained. There is no evidence that the patient later consented to the foley catheter. Thereafter, the patient received a mental health evaluation and was placed on an emergency commitment of a person under the influence. The patient's restraints were completely removed approximately 12 hours after initiation. The patient was eventually discharged to a detox facility.

Sample patient #14 was an adult male brought in by ambulance after a call from law enforcement. The patient had called his mother and made suicidal statements. Per the security Incident Report, the patient was threatening to leave if he did not get evaluated timely by a social worker. A security officer then explained that "security would stop him from leaving and restrain him if necessary." While in the ED, the patient was tased and restrained. The ED physician's documentation stated, in pertinent part, "The patient denies any suicidal or homicidal ideation ... He is very irritated about being here. He adamantly denies any suicidal ideation ..." The patient had a mental health evaluation approximately six hours after he presented to the ED (after the tase incident). Eleven hours later, the patient was placed on a M1 72 hour mental health hold and transferred to a mental health facility.

Sample patient #15 was an adult male brought in voluntarily by ambulance due to anger issues. A Nurse Practitioner assessed the patient prior to the physician doing so and s/he stated, in pertinent part, "I recognized that he was here voluntarily but he would definitely benefit from speaking with our medical social worker..." Per the security Incident Report, approximately two hours after the patient presented to the ED he wanted to leave and the security officer explained that since the patient had not been "cleared" he could not leave. At this point, the physician came in and tried to "calm" the patient down and evaluate him. During the interaction with the physician, the patient was tased and then handcuffed. Per the nurse's note, the patient received a mental health evaluation approximately six hours after admission. He was discharged home with outpatient mental health resources approximately eight hours after initial presentation. This patient's case was discussed extensively in the Use of Force Committee Meeting Minutes dated 4/1/2010. It stated, in pertinent part: "doctor indicated patient statement of possibly harming (others)... Visitation was restricted due to potential for a violent outburst ..."

Sample patient #20 was an adult male brought in by police officers due to suicidal remarks and aggressive behavior witnessed by neighbors. Per the security Incident Report, the patient did not want to be at the facility and was verbally abusive and threatening towards security and staff. While in the ED, the patient was tased and restrained. The patient stayed in the ED for two days until mental health facility placement was found and he was transferred. The physician documentation stated that the patient had suicidal statements. However, the chart contained no evidence of a M1 hold, despite documentation by a mental health evaluator which stated the patient's legal status upon discharge was M1 hold.

Sample patient #22 was an adult male that, per the mental health evaluator's report, was sent to the ED from an outlying clinic due to chest pain. Approximately two and an half hours after the patient's admission, the patient attempted to get out of bed and leave. A taser was displayed toward the patient and the patient was then restrained. The physician documented that the patient was homicidal, but the patient was not placed on any type of a hold. After a mental health evaluation, the patient was discharged home with family as he was not a "danger to self or others and not gravely disabled." In regards to this patient discussed in the Use of Force Committee Meeting Minutes dated 10/21/2009 it stated, in pertinent part: "A patient on a watch should not be allowed out of his room as this may put others at risk; acquiescing to a patient's aggressive behavior rewards and encourages the behavior."

Sample patient #26 was an adult male brought into the ED by Colorado Springs Police Department (CSPD) due to a panic attack and hyperventilation after a DUI lab draw. The patient had an extensive psych history. The chart contained no evidence if the patient was under police custody. While in the ED, it was requested that the patient provide a urine sample. Per the security Incident Report, the patient was not able to do so while staff, security, and CSPD were present in the room. At one point, he swore and threw the urinal on the ground. Then a security officer told the patient to get back in bed and he began to swing his fists. The officer pulled out his taser, the patient stopped swinging, and he attempted to urinate again. After a few moments, the patient head-butted the wall and broke one of the dry erase boards and dropped his urinal again. He was then placed in a medical bed and restrained with RIPP (heavy leather/Velcro restraints) as he thrashed and cursed. After he was restrained, an ED tech placed a foley catheter. There is no evidence that the patient later consented to this procedure. Although the physician documented that the patient made several suicidal statements and that staff did a great job trying to protect the patient and themselves, the patient was not placed on any type of a hold prior to the tase incident. After a mental health evaluation, the patient was placed on an emergency commitment for a patient under the influence of ETOH (alcohol) and transferred to another facility for follow-up inpatient treatment.

Sample patient #28 was an adult male who was brought to the ED after found driving erratically by the police. Evaluation and work-up in the ED showed no clear cause for the patient's altered mental status and confusion. Per the security Incident Report, the patient was repeatedly trying to leave and security officers kept placing him back on his bed. The ED physician tried several times to convince the patient to have a CT scan of his head, but he continued to refuse. Two security guards then held down the patients' wrists and feet so the nurse could give him an injection to calm him down. Per security's Incident Report, after the injection "he immediately calmed down and started to cry" and then received a CT of his head. The ED physician documented that the patient had poor short-term memory and the patient stated that he "will be fine and this is normal for him." The patient was admitted because the MD thought he was a danger to himself and others due to falls, forgetfulness, and driving, however the patient was not placed on any type of a hold. The day after admission, a mental health evaluator assessed the patient and determined he was not a candidate for a M1 hold. The patient was admitted as an inpatient to the hospital but he signed himself out against medical advice the following day. According to the inpatient physician discharge summary, in consultation with the patient's friend it was determined the patient was at his mental baseline. The discharge summary stated, in pertinent part, "he is indeed oriented to time, place, and situation ...there were no clear reasons to hold him here ..."

Based on review of medical records, facility documents, policy/procedures, and staff interviews from 5/3/2010 to 5/6/10, it was determined the facility failed to ensure that tasers and handcuffs were not used as a means of restraint for expediency, convenience, and as a form of coercion for intervention with non-compliant and/or aggressive patients in the Emergency Department. In a sample of 28 patients, it was evidenced that a taser was activated on 15 patients (sample #s 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 & 16), displayed on 10 patients (sample #s 4, 18, 19, 20, 22, 23, 24, 25, 26 & 27), and handcuffs were used on 11 patients (sample #s 2, 5, 8, 9, 10, 11, 12, 13, 15, 18 & 20). In addition, multiple patients presented for psych and/or behavioral issues and waited several hours until they were evaluated by a mental health professional. This failure created a negative outcome for all patients that were tased and the potentiality for all other patients.

The findings were:

1. Facility Documents:

On 5/4/2010, the facility's policy and procedure titled "Restraints" was reviewed. Although the definition described tasers, tasers were not listed as a type of restraint. It stated the following, in pertinent part:

"2. Definitions of restraints
A. Physical restraint is 'any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely.' CMS (Centers for Medicare and Medicaid Services), Interpretive Guidelines 4/2008...

4. Type of restraint
Type of restrain will always be the least restrictive possible
A. Bilateral elbow immobilizers
B. Limb holders - soft
C. Enclosure bed
D. Heavy, quick release - example "RIPP" restraints (brand)...

5. Exclusions:
A. Patients for whom medical temporary immobilization is applied for surgical procedures, diagnostic tests, etc...
B. Patients for whom adaptive or postural support is provided.
C. Helmets and untied Mittens...
D. Side rails are...
E. Handcuffs or other device applied by law enforcement officers who are not employed by MHS (Memorial Health System) are not governed by this rule (CMS). Refer to policy "Law enforcement or forensic staff guidelines...

9. Who may apply and discontinue restraint devices
Nursing and Security staff who has documented training in restraint use may apply, monitor and/or discontinue restraints...."

On 5/4/2010, the facility's policy and procedure (P&P) titled "Use of Force" was reviewed. It stated the following, in pertinent part:

"I. PURPOSE:
This Policy establishes guidelines and procedures regarding the use of both non-physical and physical force by security officers in the performance of their duties...
III. POLICY:
It is the policy of the Security Department that officers protect themselves, third parties or individuals incapable of defending themselves from injury by an aggressor. However, officers shall use only that degree of force which is reasonable and necessary, including physical force when justified and legally appropriate...
IV. PROCEDURE...
1. It is crucial in a use-of force situation that witnesses' perceptions of officers' behavior are favorable to the Health system to prevent a legal and necessary use of force incident from being misunderstood..."

The "CONTINIUM OF FORCE" contained levels 1 - 5 and detailed descriptions of those levels. The levels were titled the following: 1 - PRESENCE, 2 - VERBAL, 3 - SOFT EMPTY HANDS, 4 - HARD EMPTY HANDS, 5 - INTERMEDIATE WEAPONS/ELECTRONIC IMMOBILIZING DEVICE.

In the description of LEVEL 3 it stated, in pertinent part: "Also included in Level 3 are handcuffing and the use of RIPP restraints. Both are restraint devices, which only require higher levels of force in response to physical resistance."

The description of LEVEL 5 stated the following: "(E.I.D., O.C., Baton): The use of conducted energy weapons (M-26 and X-26 Advanced Taser), the use of Oleroresin Capsicum (O.C.) Foam and the ASP Expandable Baton 21" or 26" by trained personnel."

The next portion of this P&P contained details and recommended use on "ADVANCED TASER". The section "D. Post - Use Procedures" stated the following, in pertinent part:
"1. Do not attempt probe removal if the subject is combative or if the location of the barb/probe is in the face, ear, breast, groin or deeply imbedded.
2. Barbs superficially in the skin may be removed by an officer who is trained to do so and in the presence of another officer..."

The portion of this P&P titled "WRITTEN REPORTING REQUIREMENTS" stated the following, in pertinent part:
"...E. Anytime a less than lethal weapon is required to be used (not just displayed) on a patient or any other person, the Colorado Springs Police Department will be notified, and the MHS Security Officer that deployed the weapon will initiate criminal charges on the person for whatever criminal behavior necessitated the weapon's use, e.g. assault, menacing. The person's medical condition and the discretion of the Police Department will determine whether the individual is taken into law enforcement custody..."

The potion of this P&P titled "LESS THAN LETHAL WEAPONS" stated the following, in pertinent part:
"...D. The decision to use a less than lethal weapon will be based on the totality of the situation. In most situations, an officer's best defense is weaponless control..."

Review of the "Use of Force" Committee meeting minutes for all of 2009-10 revealed that every case reviewed was determined to be "An appropriate use of force." Review the Security Department's "Taser Tracking Log" for 2009-10 revealed that there were 15 incidents of taser use on patients and 33 additional instances of patients being threatened with taser use after the tasers had been displayed by the security officers. Review of the facility's "Taser History" graph, which included taser display and activation, revealed that taser use began in 2003.

2. Interviews:

On 5/4/2010 at approximately 10:00 a.m. an interview with the Risk Manager was conducted. S/he stated that incidents of taser use, threat of use, and/or use of force complaints were referred to the "Use of Force" Committee. The committee meeting minutes for 2009-10 were provided for review. S/he stated that use of force has evolved over the year. She explained that in use of force "we compare charts to ensure that they both reflect the same story." When asked about particular meeting minutes, s/he stated that the minutes probably aren't reflective of the events and conversations that occur during the meetings because meetings are very extensive. When asked if taser use was monitored as a part of restraint use, the risk manager stated that the facility did not consider taser use as a form of restraint, but rather, a justified use of force to keep patients and staff safe. In regards to a biting or punching patient, s/he said, "I disagree that those situations aren't criminal or life threatening." S/he stated that the numbers of taser use are very low compared to the number of patients seen yearly at the two facilities and that they have decreased the number of taser usage.

On 5/5/2010 at approximately 10:30 a.m. an interview with the Director of Emergency Services was conducted. S/he explained that along with routine skin care by a medical professional after tasing, electrocardiograms are also done as a precaution because the taser hits and freezes the skeletal muscle. S/he also explained that the care unit of the central campus' ED is where psychiatric and intoxicated patients are typically placed, has ten beds, and can be locked. The unit is staffed with two security officers and one nurse unless it has six or more patients and then an additional nurse is staffed. There are currently no mental health techs or specifically trained psych nurses staffed in the unit.

On 5/6/2010 at approximately 8:30 a.m. interviews with the Director of Security (DS) and the Security Operations Officer (SOO) were conducted. Pressure Point Control Tactics (PPCT) training and education that the security officers receive were discussed. The Defensive Training Tactics book that security officers receive contained an entire chapter on handcuffs. The DS stated, "Our officers do carry O.C. foam and they are trained in that... They do carry collapsible batons. It is part of the PPCT..." The DS stated that he did not believe either had been deployed in the past three years, although it was evidenced that tasers and handcuffs had been used. The security officers are also trained in MOAB verbal de-escalation tactics. On 5/5/2010 at approximately 3:00 p.m. the SOO stated, "When I came on, things (security) weren't in place as much. Most security was contract, they got more in-house, and then they started building up these processes..."

3. Medical Record/ Facility Report Review:

Sample patient #1, per the security Incident Report, was an adult male escorted to triage by the CSPD (Colorado Springs Police Department). The patient was never admitted into the ED (Emergency Department). The patient was reportedly intoxicated, verbally disruptive, and smoking outside the entrance. After request by security to leave the property, the patient pushed a security officer. Two separate officers then drew their Tasers and aimed them at the patient. The patient was again told to leave the hospital property and he began to walk towards the two officers with balled fists. The patient was tased twice, but neither tase affected the patient and he turned and ran off the hospital property. The security officers notified CSPD of the incident and were informed that the patient had been brought to the ED for DUI processing and a legal blood draw.

Sample patient #2 was an adult male seen in the ED after a fight at a party and heavy ETOH (ethanol/alcohol) use. Per the security Incident Report, the patient was verbally disruptive, was discharged from the ED, and then escorted out to triage by security to wait for his ride. Nine minutes later, security guards found the patient outside at the smoking hut. He was punching and head butting the glass of the hut and yelling at his girlfriend. He requested to be left alone, but the security officers began to escort him off the property. When the patient was about one hundred feet from East Boulder Street (the edge of the hospital's property) he "made a last effort to get away." Physical techniques were used to get the patient to the ground and, as the patient continued to fight, he was tased with little effect. The patient was then "drive stunned" and thereafter complied with the officers requests. He was handcuffed and escorted back to the ED for medical treatment (per the ED MD report, a second head CT was performed) and to remove the taser probes. The CSPD was called to see if charges could be filed on the patient and the security officer was informed that only a call screen report would be done because the patient did not strike any security officer. Two hours later, the patient was discharged home.

Sample patient #3 was an adult male seen in the ED after transport via ambulance due to intoxication and status post assault. The patient denied suicidal/homicidal ideations and he was not placed on a mental health hold while in the ED. Per the security Incident Report, three hours after the patient's admission he requested to leave and was informed by the nurse that he was too intoxicated and could not leave until he was sober. The patient continued to try to walk towards the door and when he was "assisted onto the bed," he continued to struggle/kick his legs at the officers, and was then tased. He asked the security officer why the tase had gone so long. He continued to resist with restraint application and kicked an officer in the chest and was then tased using the drive stun method. The patient was successfully restrained and taser skin care was completed. The patient had a mental health evaluation 17 hours after he was admitted. The patient was discharged home from the ED with a bus pass.

Sample patient #4 was an adult male seen in the ED for ETOH. He was found by the CSPD sitting on the side of the road with his dog and was brought in by ambulance. The patient was discharged after a medical evaluation and several examinations. Two security guards were escorting the patient off the property, however he was hesitant to leave as he did not know the location of his dog. The patient rolled on his back with clenched fists and attempted to hit and kick the officers. The taser was then applied to the patient, but not activated. Then the patient stopped struggling and was escorted off the property. One of the security officers sought treatment for an injured thumb, but no charges were pressed against the patient.

Sample patient #5 was an adult male brought into the ED by family due to a drug overdose. Per the security incident report, the patient wanted to leave while he was in triage but a family member was physically holding him back and the nurse did not want him to leave. The family member and a nurse attempted to get the patient to sit in a wheelchair while the patient resisted. Eventually, the wheelchair was laid back, the patient remained aggressive and, while attempting to get control, two security guards, the patient, and the nurse all ended up on the ground. The patient was tased three total times, although one was ineffective. The patient attempted to punch a security officer even after the third tase. The patient was handcuffed and RIPP restraints (heavy leather/Velcro) were applied once the patient was transported back to the ED and placed on a bed. The patient was medically treated and then had a mental health evaluation 15 hours after admission. It was determined that the patient met criteria for a M-1 hold for danger to self and others, however the chart did not contain evidence that a M-1 hold was ever initiated. An addendum to the mental health evaluation stated, in pertinent part: "Pt has been reassessed twice since his first mental health evaluation. He no longer meets criteria for an M-1 Hold ..." The patient was discharged home approximately two days after he first presented to the ED.

Sample patient #6 was an adult male found slumped behind some bushes brought into the ED by ambulance after called by CSPD. Per the security Incident Report, the patient was verbally and physically aggressive to staff in the ED. The patient repeatedly told the physician that he wanted to leave and did not respond with an answer when the MD asked if the patient had a sober driver. The patient attempted many times to punch the security officer and was eventually tased by another officer. The patient was then restrained to the bed and taser skin care was performed. The patient was discharged home.

Sample patient #7 was an adult male brought in voluntarily. He reported he had a recent blackout and wanted psychiatric treatment. The patient denied suicidal/homicidal ideations, although he did have a lengthy history of psychiatric problems. The patient was very compliant until he was verbally provoked by another patient that was in the same treatment room. He then began punching the other patient in the head repeatedly and would not stop, despite verbal and physical attempts by security. He was tased but, per the security Incident Report, did not receive any electric discharge but stopped fighting and was compliant thereafter. The other patient requested to press charges, however when a CSPD officer arrived, he refused to make a statement. A mental health evaluation was performed approximately 20 hours after the patient presented to the ED. It stated, in pertinent part: "None of these complaints meet criteria for gravely disabled." The patient was discharged home with resources provided.

Sample patient #8 was an adult male brought to the ED via ambulance per request of a family member and concern that the patient may have taken too many pills. Per the security Incident Report, after multiple threats to leave, the patient attempted to run out of the unit. When security officers attempted to gain control of the patient, he would swing his arms in an aggressive manner. A security officer stated that he deemed it necessary to tase the patient to avoid any of the other nine patients in care unit 4 from trying to elope. The patient was handcuffed, placed in the bed, then restrained with RIPP restraints, and taser skin care was performed. The patient was "de-escalated" by the behavioral health worker approximately six hours after the patient presented to the ED, but there was no evidence of a full assessment. Throughout the patient's admission, he repeatedly denied suicidal/homicidal ideations and was eventually discharged home. In regards to this patient discussed in the Use of Force Committee Meeting Minutes dated 9/4/2009 it stated that, although the use of force was deemed as appropriate, the "reason stated for Tasering, 'to prevent other patients from eloping,' is not satisfactory."

Sample patient #9 was an adult male brought to the ED via private vehicle with his sibling, who was also an adult male admitted as a patient (sample patient #10) for multiple trauma wounds. Both #9 and #10 walked through and alarmed the metal detector at the same time and, due to a large amount of confusion in the waiting room/triage area and the urgency of #10's medical condition, the security officers determined it would be best to address searching the sample patient #9 at a later time. Sample patient #9 would not let go of #10 in order for the patient to be effectively medically evaluated and treated. Per the physician's documentation, the #9 was attempting to get #10 to leave. "I told the patient (#10) that he cannot leave and he needs to stay for an evaluation." The security officer documented that because both had not yet been checked for weapons, the high volume of uncooperative visitors, and the apparent urgency of #10's injuries, the security officer tased #9. Then #10 began to walk toward the officer with his hands up by his face and he was also tased. Thereafter, #9 was cuffed and transferred to a medical bed where the taser probes were removed/treated and he was later discharged home. Sample patient #10 was cuffed and placed on a medical bed. Shortly thereafter, the handcuffs were removed and medical treatment for his presenting condition ensued. The ED went on lockdown that shift due to the high volume of uncooperative visitors and the unknown variables. Eventually, #10 was admitted to the hospital and discharged the following day. A licensed clinical social worker did document a note in the patient's chart, although there was not evidence of a complete assessment.

Sample patient #11 was an adult male brought to the ED via ambulance after reported suicide threats. The report stated, in pertinent part, "Initially he was very calm when he was brought back, and because of all the other psychiatric patients back there becoming violent and escalating, he became violent and required physical restraints." Shortly after the patient's arrival, he attempted to leave the facility. A security officer chased after him and the patient resisted his/her attempts to control him. As the security officer stepped back, s/he was kicked in the stomach by the patient. The patient was then tased by another officer, handcuffed, escorted back to a medical bed, and restrained with RIPP restraints. A mental health evaluator placed the patient on an emergency commitment for patient under the influence of ETOH approximately two and half hours after the patient presented to the ED and after the taser incident. He was then transferred to DETOX facility.

Sample patient #12 was an adult male who came voluntarily to the ED due to bloody emesis. Per the security Incident Report, the patient was not on a "watch" and was free to leave after his IV (intravenous catheter) was removed. The patient was verbally and physically aggressive, but his IV was removed and he was discharged so he could exit the ED. The patient began "posturing and verbally challenging" the security officer, grabbed equipment off the hallway wall, and resisted going in the direction of the exit. After he made a movement as if he were going to strike a security officer, he was tased and fell to the floor. He was then handcuffed, taser skin care was performed, and he was later discharged to home. The ED physician's report stated the following, in pertinent part, " ...that he was welcomed to return to the emergency department at any time with the hopes that he would be more respectful of our environment." In regards to this patient discussed in the Use of Force Committee Meeting Minutes dated 1/14/2010 it stated, in pertinent part: "ED will focus in 2010 on behavioral health and care with higher patient expectations including zero tolerance for verbal violence."

Sample patient #13 was an adult male who presented voluntarily for meth abuse/psychosis and a complaint of possible poisoning. Per the security Incident Report, the patient did not want a urinary catheter placed and the nurse explained the need for it. The patient then jumped out of bed and swung his fists at the nurse. The patient ducked underneath a security officer's arm and attempted to run away as he entered the hallway, and he was tased twice before complying with security officers. The patient was handcuffed, placed in bed, and restrained by use of RIPP 4 point restraints. The patient then had a foley catheter placed to obtain a urine specimen while retrained. Thereafter, the patient received a mental health evaluation and was placed on an emergency commitment of a person under the influence. The patient's restraints were completely removed approximately 12 hours after initiation. During the incident, a nurse and security guard were injured and both declined to press charges, however a CSPD later cited the patient for Disorderly Conduct. The patient was eventually discharged to a detox facility. In regards to this patient discussed in the Use of Force Committee Meeting Minutes, dated 1/14/2010, it stated that the risk manager questioned the appropriateness of Tasing a person in the back while they are fleeing. The meeting minutes stated, in pertinent part: "Although it may be risky to Tase in the back it can be justified under certain circumstances, e.g., to mitigate threat to other persons or property. Difficult to make a hard and fast rule; officers are required to make professional judgment calls."

Sample patient #14 was an adult male brought in by ambulance due to reported suicidal statements. Per the security Incident Report, the patient was threatening to leave if he did not get evaluated timely (within two hours of admission) by a social worker. A security officer then explained that "security would stop him from leaving and restrain him if necessary." There was question as to if the patient had weapons on his person as he repeatedly sent threatening text messages to family/friends. When the security guards took the patient's phone from him, he balled up his fists and raised back his arm towards the security officer. Another officer pointed his taser and, when the patient made no attempt to stop his movement, then he was tased. The patient was then restrained with use of RIPP restraints. The patient had a mental health evaluation approximately six hours after he presented to the ED (after the tase incident). Eleven hours later, the patient was placed on a M1 72 hour mental health hold and transferred to a mental health facility.

Sample patient #15 was an adult male brought in voluntarily via ambulance for treatment of anger issues. Per the security Incident Report, approximately two hours after the patient presented to the ED he became agitated because he wanted to leave and the security officer explained that since the patient had not been "cleared" he could not leave. At this point, the physician came in and tried to "calm" the patient down and evaluate him. Per the physician's report, the patient stood up and approached the MD "physically and verbally confrontational." It stated, in pertinent part, "As he reached for me, I deflected his hand and attempted to set him on the bed behind him. Essentially, a wrestling match ensued ..." The security officer tased the patient, cuffed him, and placed him on a medical bed. Per the security report, the physician's jaw was hit, but charges were not pressed. Per the nurses' note, the patient received a mental health evaluation approximately six hours after admission. He was discharged home with outpatient mental health resources approximately eight hours after initial presentation. This patient's case was discussed extensively in the Use of Force Committee Meeting Minutes dated 4/1/2010. It stated, in pertinent part: "Patient approached doctor in a threatening manner; doctor tried to push patient back; Taser deployed to protect doctor..."
Sample patient #16 was an adult female who presented to the ED with altered mental status. The patient had a history of psychological issues. Per the security Incident Report, the patient was being assessed by an outside mental health evaluator (MHE) and was informed she would be transferred to a facility on a M1 72 hour hold. The patient then became upset and grabbed the MHE's arm. The security officer was able to get the patient away from the MHE, but then the patient grabbed the MHE's pen. She stood on the bed and swung the pen around when the security officer aimed the taser at the patient. The patient then dropped to her knees and began injuring herself with the pen. She was tased, placed in medical bed, and restrained with RIPP restraints. The patient was placed on a M1 hold prior to the incident. Seven hours after the incident, the patient was discharged to a mental health facility.

Sample patient #18 was an adult female who presented to the ED with homicidal and suicidal ideations (HI/SI). The patient had a history of psych issues and was placed on M-1 mental health hold by the outside facility prior to being transferred to the ED. The patient was boarded in the ED for five days due to inability to find a mental health facility placement. She was assessed daily by a mental health evaluator and her M1 was kept current for all five days. At one point during her admission, the patient was trying to take the fire extinguisher out of the cabinet and, although security officers were able to get the patient back to bed, she continued to thrash and remain uncooperative. Although a taser was displayed (removed from holster), the patient was not tased as she had a specific medical condition. She was handcuffed and then restrained with RIPP restraints until calm. Prior to discharge home, the patient denied HI/SI.

Sample patient #19 was an adult male brought in by ambulance due to an assault. Per the security Incident Resort, shortly after admission to the ED the patient became verbally aggressive, refused to return to his room, pulled out his IV, and "squared off" with two security guards. One security guard drew his taser and commanded for the patient to get back on his bed. The patient then threw himself to the ground and spread his arms and feet and stated, in pertinent part, "Alright, I'll do what you want. You'll just beat ...if I don't." The nurse called a "Code Bert (Behavioral Emergency Response Team). The mental health evaluator (MHE) documented the following, in pertinent part, Physician "determined that patient did not have a wound that required sutures. Patient remained hostile and stated he wanted to discharge ..." The patient was then discharged and escorted out of the unit by security.

Sample patient #20 was an adult male brought in by police officers due to suicidal remarks and aggressive behavior witnessed by neighbors. Per the security Incident Report, the patient did not want to be at the facility and was verbally abusive and threatening towards security and staff. The patient continued to escalate as he wanted to leave and, after taking a "fighting stance," he was approached by multiple security guards who were unable to control him and a taser was displayed. The patient then complied with officer's demands, was handcuffed, placed in a medical bed, and then restrained. A mental health evaluation was completed approximately four hours after admission. The patient stayed in the ED for two days until mental health facility placement was found and he was transferred. The chart contained no evidence of a M1 hold, despite documentation by a mental health evaluator which stated the patient's legal status upon discharge was M1 hold.

Sample patient #22 was an adult male that, per the mental health evaluator's report, was sent to the ED from an outlying clinic due to chest pain. The patient's past medical history included psych issues. Approximately two and an half hours after the patient's admission, the patient attempted to get out of bed and leave. The patient was making threatening statements to the staff and had taken a "fighting posture" and, per the security Incident Report, the physician wanted him placed in RIPP restraints. The report stated that due to the minimal amount of staff and the patient's unpredictable state a security officer pulled out the taser prior to attempting restraint placement on the patient. The patient was then compliant, placed in restraints, and the officer's taser was holstered. The patient was intoxicated upon presentation to the ED and therefore the mental health evaluation was not done until approximately 16 hours later. The patient was discharged home with family shortly after the evaluation as he was not a "danger to self or others and not gravely disabled." In regards to this patient discussed in the Use of Force Committee Meeting Minutes dated 10/21/2009 it stated, in pertinent part: "Nurse stepped between patient and Security officer when the patient was displaying aggressive behavior; unnecessary and dangerous for nurse. A patient on a watch should not be allowed out of his room as this may put others at risk; acquiescing to a patient's aggressive behavior rewards and encourages the behavior."

Sample patient #23 was an adult male that came in after he had escaped from DETOX and was found by CSPD. The patient had a lengthy psychiatric history and one of the ED physicians questioned if he had a severe conduct disorder or autism. The day after the patient's admission, he was evaluated by an outside mental health evaluator and placed on a M1 mental health hold. Thereafter, the patient repeatedly attempted to leave and threatened security officers and staff. On one occasion the patient attempted to hit an officer and, once the patient was back on his bed, he repeatedly kicked his feet towards an officer. An officer pulled his taser and placed it on the patient's side with an order to stop kicking. The patient was restrained with RIPP restraints after this incident and many other times during his admission. Per the nursing documentation, psych facility placement was found two days after the patient presented to the ED and he was transferred. In regards to this patient discussed in the Use of Force Committee Meeting Minutes dated 1/14/2010 it stated, in pertinent part: "This patient's response to control techniques varied widely due to developmental issues."

Sample patient #24 was an adult male brought into the ED via ambulance with a complaint of medical symptoms and chest pain after found intoxicated in public. Per the security Incident Report, at one point in the patient's admission he was verbally aggressive and threatening with security and staff. In addition, he repeatedly tried to leave his room and "with closed fists raised in a fighting stance" advanced towards an officer. A taser was drawn and the patient continued to yell and scream, but did not advance further. The patient was restrained in RIPP restraints for "patient and staff safety." One nurse reportedly felt the restraints were not necessary and stated, "If you pointed a taser at me I would try to rush you too." The patient was diagnosed with alcohol withdrawal and discharged home on benzodiazepines.

Sample patient #25 was an adult female that presented to the ED after being involved in a motor vehicle accident and a concern of overdose by bystanders. Per security Incident Report, a nurse directed a security offi

Based on review of medical records, facility internal documents, and staff interviews, it was determined that the facility failed to ensure proper and timely patient and family communication in one (#15) of 28 sample medical records. This failure caused the patient to be involuntarily confined and created a negative patient outcome.

The findings were:

Sample patient #15 was an adult male brought in voluntarily by ambulance after he had called 911. The patient reported anger issues and requested psychiatric treatment. The patient had a history of post-traumatic stress disorder. The Nurse Practitioner assessed the patient prior to the physician doing so and s/he stated, in pertinent part, "I recognized that he was here voluntarily but he would definitely benefit from speaking with our medical social worker..." Per the security Incident Report, approximately two hours after the patient presented to the ED he became agitated. He had requested his clothes and wanted to leave and the security officer explained that since the patient had not been "cleared" he could not leave. At this point, the physician came in and tried to "calm" the patient down and evaluate him. Per the physician's report, the patient stood up and approached the MD "physically and verbally confrontational." It stated, in pertinent part, "As he reached for me, I deflected his hand and attempted to set him on the bed behind him. Essentially, a wrestling match ensued ..." The security officer tased the patient, cuffed him, and placed him on a medical bed. Per the security report, the physician's jaw was hit, but charges were not pressed. The patient's sibling and spouse were required to stay in the waiting room during the patient's ED visit. The security Incident Report stated that an officer later spoke to the patient's sibling and spouse about why they could not go back. He stated that it was due to staff feeling it would be "detrimental to the visit." He also stated that staff were under the understanding that the patient's reason for being there was an argument with his wife. However, the nurse's triage documentation "Chief Complaint Description" stated "Pt arrives via AMR after an outburst of anger while at home... Denies SI or HI." Per the ED nurse's note, the patient received a mental health evaluation approximately six hours after admission. The mental health evaluator's documentation stated, in pertinent part: "LETHALITY: Patient adamantly denies suicidal ideation or any thoughts to harm others... I could not find where the comment originated from that patient made such a statement... Recommendations: ...During evaluation I did not observe any issues described prior to me seeing patient..." The patient was discharged home with outpatient mental health resources approximately eight hours after initial presentation.

On 3/5/2010, the "Use of Force Committee Meeting Minutes" dated 4/1/2010 were reviewed. Sample patient #15 was discussed extensively. The meeting minutes stated, in pertinent part: "Patient approached doctor in a threatening manner; doctor tried to push patient back; Taser deployed to protect doctor ... he had violent episode at home and requested spouse to call 911. Patient claims PTSD but is not substantiated; doctor indicated patient statement of possibly harming (others)... Visitation was restricted due to potential for a violent outburst; family had concerns about not being able to visit, asserting he would "never hurt anyone."

In an interview on 5/5/2010 at approximately 4:45 p.m. with the Physician's Medical Director of the facility's north campus, s/he stated, that family not being allowed back with the patient is "not typically the case." S/he also stated, "typically it is better and safe for family" to be present.

In an interview on 5/5/2010 at approximately 11:30 a.m. with a Patient Representative, s/he stated that upon interviews with the physician and staff involved in this patient's case she learned that the "patient informed the doctor of an argument with his wife. The patient informed triage that he was afraid he'd hurt someone when he gets angered..."

In an interview on 5/5/2010 at approximately 10:45 a.m. with the Director of Emergency Services, s/he stated that the Emergency Department staff does not get specific training on Post Traumatic Stress Disorder (PTSD). S/he also stated, "There are no hard visiting rules at all. It all depends on what the patients need and unless patients' families are contributing to the agitation or patients request not to see them."

In summary, there were concerns in this patient's case that were not thoroughly clarified prior to his mental health assessment. Several factors caused the patient to have anxiety, which ultimately resulted in the patient being tased. Communication clarification and/or an expedited mental health evaluation may have prevented the patient from being secluded from family.

Based on medical record and policy/procedure review on 5/3/2010 and 5/4/10, it was determined that the facility failed to ensure the use of all restraints were done in accordance with the order of a physician and facility policies and procedures in two (#s 20 & 24) of twenty-eight patients. This failure created the potential for a negative patient outcome.

The findings were:

On 5/4/2010, the facility's policy and procedure titled "Restraints" was reviewed. It stated the following, in pertinent part:

"2. Definitions of restraints
A. Physical restraint is 'any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely.' CMS, Interpretive Guidelines 4/2008...

4. Type of restraint
...D. Heavy, quick release - example "RIPP" restraints (brand)...

8. Practice Guidelines:
...B. An order by a physician or LIP will be obtained...
L. Documentation - Date and time, type of restraint, who initiated, behaviors that warranted restraint use, alternative interventions attempted and patient condition are documented...

9. Who may apply and discontinue restraint devices
Nursing and Security staff who has documented training in restraint use may apply, monitor and/or discontinue restraints...."

Electronic medical records review was done on 5/4/2010 with the Quality Specialist Nurse. This review revealed evidence of two patients that were restrained without proper documentation.

Sample patient #20 was an adult male brought in by police officers due to suicidal remarks and aggressive behavior. Per the security Incident Report, the patient escalated as he wanted to leave and after taking a "fighting stance" he was approached by multiple security guards who were unable to control him and a taser was displayed. The patient complied with officers' demands, was handcuffed, placed in a medical bed, and then restrained by use of RIPP and a chest restraint. All restraints were removed entirely after approximately seven hours. The patient stayed in the ED for two days until mental health facility placement was found and he was transferred. The chart contained no evidence of a M1 hold, restraint orders by a LIP, or complete restraint nursing documentation.

Sample patient #24 was an adult male brought into the ED via ambulance with a complaint of medical symptoms and chest pain after found intoxicated in public. Per the security Incident Report, the patient repeatedly tried to leave his room and "with closed fists raised in a fighting stance" advanced towards an officer. A taser was drawn and the patient continued to yell and scream, but did not advance further. The patient was restrained in RIPP restraints for "patient and staff safety." Restraints were removed eighty minutes later. The patient was diagnosed with alcohol withdrawal and discharged home. The chart contained no evidence of restraint orders by a LIP or complete restraint nursing documentation.

Based on review of medical records, policy/procedures, facility's documents, and staff interviews, it was determined that the facility failed to train Emergency Department nurses and techs specific methods for caring for psych and/or intoxicated patients including physical methods of restraint and use of RIPP (heavy leather/Velcro) restraints. As a result, aggressive patients were often controlled primarily by the security officers and with a law enforcement and/or military method. This failure created a negative patient outcome.

The findings were:

Reference Tag A154 for findings related to use of force, including restraint, taser and handcuff use, and negative patient outcomes in those with psych issues or intoxication.

On 5/6/2010 at approximately 8:30 a.m. interviews with the Director of Security (DS), the Security Operations Officer (SOO), and the Risk Manager were conducted. Pressure Point Control Tactics (PPCT) training and education that the security officers received were discussed. These methods were derived from a law enforcement approach. The security officers are also trained in MOAB (Management of Aggressive Behaviors) verbal de-escalation tactics, which does not take psychological diagnoses or issues into consideration. The Risk Manager stated, "No one really had any models around the state, so we kind of developed our own."

On 5/6/2010 at approximately 8:40 a.m., the SOO was questioned if nurses assist the security officers in takedowns. S/he responded, "A long time ago, the older group, they would always help out. But now they all seem to be pulling away." S/he also stated that only the security officers are allowed to initiate the RIPP (heavy leather/Velcro) restraints. It was revealed that, although nurses in the Emergency Department receive MOAB de-escalation training, they do not receive any PPCT or physical tactic training. On 5/5/2010 at approximately 9:35 a.m. the Director of Emergency Services stated that nurses do not receive physical tactic/takedown training or any specific psych/PTSD training, although "psych is important for all ER nurses." On survey, it was identified that a new "Behavioral Health Committee" had been initiated and an Interim Director hired two weeks prior.

On 5/3/2010 at approximately 2:10 p.m. the Security Officer Educator (SOE) was interviewed. S/he stated that last year s/he taught MOAB to all staff (nurses and techs) from both EDs and that s/he annually teaches the security guards. S/he stated that PPCT education includes body escalation, takedowns, and weapon retention. Only the security officers receive this training. S/he also stated that Care Unit 4 (where psych and detox patients are often placed) is where 90% of the security officer work is done. The SOE stated, "Regardless of the situation, we treat everyone the same." When psychiatric patients were brought to attention, s/he then stated, "Every case is on a case by case basis."

On 5/10/2010 the facility's 2010 Restraint CBT Module was reviewed. The Quality Specialist stated that ED nurses complete this module annually. Although the module stated that RIPP restraints were one method of restraint, it did not include education on usage of such restraints. It stated that staff must be trained and competent in "nonphysical intervention skills," but did not address physical interventions. In addition, the annual modules did not address the needs of or methods to treat patients with psych issues.

On 5/11/2010 the Hospital ED Meeting Minutes dated 4/5/2010 were reviewed. In the "New business" portion it stated, in pertinent part:

"...d) Open discussion by (Security Educator) requesting nursing be more supportive of securities role in the dept. Many times they are without a female officer to pat down/search a pt. and would like assist from female medical staff. If staff uncomfortable or not willing security asks pt to be placed in a gown so we can ensure the safety of everyone. This will be included in the education roll out..."

Based on the number and nature of deficiencies cited, the hospital failed to comply with the Condition of Participation of Quality Assurance/Performance Improvement (QAPI). The facility failed to ensure the facility's performance improvement mechanism/activities adequately and consistently reviewed all instances involving use of force (including restraints, tasers, handcuffs and involuntary medication) to manage "aggressive" patient behaviors and instances in which patients were attempting to refuse treatment or requesting to leave the emergency department prior to being discharged by the physician.

In addition, the facility failed to ensure that the quality assurance and performance improvement activities were functioning with appropriate performance data directed to the facility's quality specialist, to ensure incorporation into the quality assurance activities of the facility.

The facility also failed to ensure that the facility-wide quality assurance committee was meeting regularly during the past 18 months, to provide timely oversight of patient care activities.

The facility failed to meet the following standards under the condition of Quality Assurance/Performance Improvement:

A 0267 QAPI Quality Indicators
The facility failed to measure, analyze and track quality indicators, such as circumstances of use and patient injuries, related to the use of force against patients. No data/analysis was reported to the quality assurance specialist for incorporation in the hospital-wide quality assurance and performance improvement activities/committee.

A 0275 QAPI Quality of Care
The facility failed to use the data collected regarding restraint use and use of force against patients to monitor the safety of services and the quality of care, because the data was not directed to the quality assurance specialist for incorporation in the hospital-wide quality assurance and performance improvement activities/committee.

A 0276 QAPI Identify Improvement
The facility failed to use the data collected regarding restraint use and use of force against patients to identify opportunities for improvement and changes that would lead to improvement, because the data was not directed to the quality assurance specialist for incorporation in the hospital-wide quality assurance and performance improvement activities/committee.

A 0287 QAPI Improvement Activities
The facility failed to ensure that the "Use of Force" Committee reviewed incidents, including taser use (or threat of use), timely. In addition, the committee failed to review incidents from the point-of-view of the patient, with the goal of preventing future instances of "use of force." The "Use of Force" Committee had no reporting or interface relationship with the quality assurance/performance improvement committee of the facility.

A 0288 QAPI Feedback and Learning
The facility failed to ensure that the "Use of Force" Committee reviewed incidents with a goal of preventing "use of force" instances by fully evaluating the situations that contributed to the need to use force. The committee failed to generate recommendations for process changes in the emergency department, staff education, and policies/procedure changes to decrease "use of force" events. The "Use of Force" Committee had no reporting or interface relationship with the quality assurance/performance improvement committee of the facility.

A 0310 QAPI/Executive Responsibilities
The chief executive officer (CEO) of the facility failed to ensure that the facility's ongoing program for quality improvement was maintained during an 18 month period of key administrative position turnover (Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer, Chief Financial Officer and Director of Human Resources). The CEO failed to ensure that all departmental QAPI projects reported to the quality assurance and performance improvement committee for review. In addition, the CEO failed to ensure that the quality assurance and performance improvement committee held regular meetings during a 14 month period and that important issues, such as "use of force" against patients, was addressed. Despite the fact that the facility had dedicated resources to develop and implement a new QAPI model for the facility targeted for June 2010, the facility had not maintained a fully functioning, integrated set of QAPI activities to protect the patient care delivery environment during the transition to a new model.

Based on review of facility documents, meeting minutes and staff interviews, the facility failed to ensure that the quality assurance committee/process received and analyzed information regarding use of restraints, tasers and handcuffs to control patient behaviors and/or to prevent patients from refusing treatment. Specifically, reports from the "Use of Force Committee" were not referred to the hospital's quality assurance specialist for review and incorporation into the facility's QAPI (Quality Assurance/Performance Improvement) improvement activities. In addition, the facility failed to ensure that tracking/monitoring data regarding restraint use in the facility, collected by the various department managers, was directed to the hospital's quality assurance specialist for review and incorporation into the facility's QAPI improvement activities. The facility's failure to incorporate clinical information about use of restraints and other types of force with patients in QAPI activities contributed to negative patient outcomes.

The findings were:

1. On 5/4/10 at approximately 10:00 a.m., the risk manager was interviewed and provided the following information:
S/he stated that incidents of taser use, or threat of use, were referred to the "Use of Force" Committee. The committee minutes for 2009-10 were provided for review. The committee composition was reviewed. The committee members included the risk manager, security managers and the educator for security, management representatives of the emergency department, social worker/psychiatric evaluator and patient representative. The meetings were held approximately every 3 months. Review of the meeting minutes revealed that review of individual cases usually occurred 2-3 months after the events. The risk manager stated that s/he and security manager usually reviewed the cases independently soon after the reports were received. S/he stated that action (such as staff training or correction) would be taken, if necessary, prior to the formal review at the "Use of Force" Committee. S/he was unable to supply any documentation of any actions taken to correct problems. Review of the "Use of Force" Committee minutes for all of 2009-10 revealed that every case reviewed was determined to be "An appropriate use of force." Review of a list of taser uses for 2009-10 revealed that there were 15 incidents of taser use on patients and 33 additional instances of patients being threatened with taser use after the tasers had been displayed to the patients by the security officers. Review of additional records of taser use/display-threat revealed that taser use began in 2003. When asked if taser use was monitored as a part of restraint use, the risk manager stated that the facility did not consider taser use as a form of restraint, but rather, a justified use of force to keep patients and staff safe. The "Use of Force" Committee/facility did not maintain any documentation or list of use of handcuffs on patients. In addition, the risk manager stated that no separate list of patient injuries associated with use of force was maintained. S/he stated that that information would have to be recovered from the individual taser security reports/medical records and any patient complaints or grievances related to the taser incidents. S/he stated that "Use of Force" Committee data was not reported to the quality assurance and performance improvement committee or the governing body for review and oversight. S/he stated that the "Use of Force" Committee had recently discussed including the quality assurance specialist on the committee to get the committee into the loop on quality reporting.
S/he stated that some reports were developed for the top executive group that might include taser incidents, some grievances and other use of force incidents. As the risk manager, s/he also stated that s/he was responsible for reviewing deaths for restraint/death reporting requirements to CMS. S/he stated that restraint data was not directed to the quality assurance and performance improvement committee.

2. On 5/5/10 at approximately 3:00 p.m., the quality assurance specialist was interviewed about quality assurance monitoring of use of force incidents and restraint use. S/he stated that the restraint monitoring done by each nursing manager was not directed to him/her or the quality assurance and performance improvement committee. S/he also stated that data related to tasers and other uses of force and the "Use of Force" Committee were not reported to him/her or the quality assurance and performance improvement committee. S/he stated that the "Use of Force" Committee had recently discussed including him/her in the committee to include the quality assurance point of view to the committee. S/he stated s/he had not yet attended a meeting.

3. Reference Tag A154 for findings related to use of force, including restraint, taser and handcuff use, and negative patient outcomes.

Based on staff interviews and review of facility reports, documents and meeting minutes, the facility failed to use the data collected regarding restraint use and use of force against patients to monitor the safety of services and the quality of care, because the data was not directed to the quality assurance specialist for incorporation in the hospital-wide quality assurance and performance improvement activities/committee. The failure contributed to negative patient outcomes.

The findings were:

1. Reference Tag A067 for findings related to failure to provide data to the quality assurance specialist and the quality assurance and performance improvement committee regarding restraint and use of force against patients.

2. Reference Tag A154 for findings related to use of force, including restraint, taser and handcuff use, and negative patient outcomes.

Based on staff interviews and review of facility reports, documents and meeting minutes, the facility failed to use the data collected regarding restraint use and use of force against patients to identify opportunities for improvement and changes that would lead to improvement, because the data was not directed to the quality assurance specialist for incorporation in the hospital-wide quality assurance and performance improvement activities/committee. The failure contributed to negative patient outcomes.

The findings were:

1. Reference Tag A067 for findings related to failure to provide data to the quality assurance specialist and the quality assurance and performance improvement committee regarding restraint and use of force against patients.

2. Reference Tag A154 for findings related to use of force, including restraint, taser and handcuff use, and negative patient outcomes.

Based on staff interviews and review of facility reports, documents and meeting minutes, the facility failed to ensure that the "Use of Force" Committee reviewed incidents, including taser use (or threat of use), timely. In addition, the committee failed to review incidents from the point-of-view of the patient, with the goal of preventing future instances of "use of force." The "Use of Force" Committee had no reporting or interface relationship with the quality assurance/performance improvement committee of the facility. The failures contributed to negative patient outcomes.

The findings were:

1. Reference Tag A067 for findings related to failure to provide data to the quality assurance specialist and the quality assurance and performance improvement committee regarding restraint and use of force against patients.

2. Review of the meeting minutes from the "Use of Force" Committee revealed no evidence of review of the incidents from the point of view of the patient experience. There was no evidence that process changes to improve the patient experience/avoid future incidents requiring the use of force against patients were explored within the committee.

3. Reference Tag A154 for findings related to use of force, including restraint, taser and handcuff use, and negative patient outcomes.

Based on staff interviews and review of facility reports, documents and meeting minutes, the facility failed to ensure that the "Use of Force" Committee reviewed incidents with a goal of preventing "use of force" instances by fully evaluating the situations that contributed to the need to use force. The committee failed to generate recommendations for process changes in the emergency department, staff education, and policies/procedure changes to decrease "use of force" events. The "Use of Force" Committee had no reporting or interface relationship with the quality assurance/performance improvement committee of the facility. The failure contributed to negative patient outcomes.

The findings were:

1. Reference Tag A067 for findings related to failure to provide data to the quality assurance specialist and the quality assurance and performance improvement committee regarding restraint and use of force against patients.

2. Review of the meeting minutes from the "Use of Force" Committee revealed no evidence of review of the incidents from the point of view of the patient experience. There was no evidence that process changes to improve the patient experience/avoid future incidents requiring the use of force against patients were explored within the committee.

3. Reference Tag A154 for findings related to use of force, including restraint, taser and handcuff use, and negative patient outcomes.

Based on staff interviews and review of facility reports, documents and meeting minutes, the chief executive officer (CEO) of the facility failed to ensure that the facility's ongoing program for quality improvement was maintained during an 14 month period of key administrative position turnover (Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer, Chief Financial Officer and Director of Human Resources). The CEO failed to ensure that all departmental QAPI projects reported to the quality assurance and performance improvement committee for review. In addition, the CEO failed to ensure that the quality assurance and performance improvement committed held regular meetings during that 14 month period and that important issues, such as "use of force" against patients, were addressed.

Despite the fact that the facility had dedicated resources to develop and implement a new QAPI model for the facility targeted for June 2010, the facility had not maintained a fully functioning, integrated set of QAPI activities to protect the patient care delivery environment during the transition to a new model. The failures contributed to negative patient outcomes.

The findings were:

1. On 5/6/10 at approximately 10:00 a.m., a group interview with the CNO, the risk manager, the director of the emergency department (ED), the quality assurance specialist and the newly appointed interim director of behavioral health was conducted. During the interview, the chief nursing officer clarified that there had been a change in leadership with most key positions (Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer, Chief Financial Officer and Director of Human Resources)changing due to retirement of long-term managers approximately 14 months ago. S/he stated that the facility had been working with a consultant to develop a new QAPI model, which was targeted for implementation as of June 2010. S/he acknowledged that there had been a gap in quality assurance meetings and that the quality assurance specialist was to get additional resources to enhance the quality assurance and performance improvement activities going forward. S/he acknowledged that some performance improvement projects under nursing were not getting reported into the QAPI system, as would normally be expected in a QAPI system.

2. Review of the requested meeting minutes for the quality assurance and performance improvement committee for the period of 2009-2010, provided by "fax" transmission after the onsite portion of the survey, revealed no evidence of review of restraint or use of force issues in the committee. Further review of the minutes revealed that the minutes appeared to be of a medical staff quality committee. During a phone interview with the quality assurance specialist, s/he stated that the medical staff quality committee had become the only quality committee during the past year. The facility no longer has a separate quality assurance committee. When asked about reporting of nursing unit performance improvement projects and use of force and restraints, s/he stated that information went to another committee (Environment of Care Committee), but that committee did not report to the quality committee.

3. Reference Tag A067 for findings related to failure to provide data to the quality assurance specialist and the quality assurance and performance improvement committee regarding restraint and use of force against patients.

4. Review of the meeting minutes from the "Use of Force" Committee revealed no evidence of review of the incidents from the point of view of the patient experience. There was no evidence that process changes to improve the patient experience/avoid future incidents requiring the use of force against patients were explored within the committee.

5. Reference Tag A154 for findings related to use of force, including restraint, taser and handcuff use, and negative patient outcomes.