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Based on documentation and interviews and review of patient #1's emergency room medical record, it was determined that the hospital failed to promote and protect the rights of patient #1 when a staff person restrained patient #1 in an unapproved, unreasonable and punitive manner and spoke to patient #1 in a harassing, disrespectful and derogatory manner.

Findings include:

The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13.


Based on documentation and interviews, the hospital failed to protect all patients from abuse and harassment when one staff used a non-therapeutic and unauthorized physical restraint and verbally threatened one of twenty-one child/patient (patient #1).

Based on documentation and interviews, the hospital failed to ensure that one of twenty-one child/patients (patient #1) was free from unnecessary restraints.

Based on documentation and interviews, the hospital failed to protect all patients from abuse and harassment when one staff used a non-therapeutic and unauthorized physical restraint and verbally threatened one of twenty-one child/patient (patient #1) reviewed.

Findings include:

Documentation in patient #1's 8/9/15 Emergency Department (ED) record revealed the paramedics and the police brought the adolescent patient to the ED on a hold order and in two point restraints at 6:23 p.m. The patient was admitted to the ED for suicidal thoughts and behavior problems. The patient has a history of behavior problems related to diagnoses of attention deficit hyperactive disorder and autism. Prior to the patient's arrival at the ED, the patient became very aggressive with family members. The patient became calm and cooperative following his arrival at the ED, and the two point restraints were removed. The record indicated that on one occasion patient #1 attempted to leave the ED safe room, and CSA-H who was providing 1:1 monitoring of patient #1, grabbed the patient and held him to prevent him from leaving the room. The patient complained of pain on the anterior portion of his neck after CSA-H grabbed him but examination of the area did not reveal any trauma to the area. The police conducted an investigation of the incident. The patient was discharged from the ED and admitted as an inpatient to the hospital while waiting for a adolescent inpatient psychiatric bed to become available. On 8/10/15, the patient was transferred to an inpatient psychiatric unit at another hospital.

The hospital's 8/9/15 security reports pertaining to patient #1 (room 3 in the ED) were reviewed. The reports stated the following: 1) 6:21 p.m.- ED staff called and asked for assistance with a patient who had been in restraints and had just arrived to room #3 (admission). Restraints were removed from the patient. The patient is autistic and very agitated. Security officers stood by and spoke with the patient until he was calm. 2) 7:30 p.m.-patient is agitated and told staff that he wanted to leave. Staff was able to coax him back to his bed, but would like security to stand by with the patient until he calms down. 3) 10:12 p.m.-panic alarm was activated at ED nurses' station, and security staff arrived. The patient's parents told security officer (K) that prior to the officers arrival following the panic alarm, CSA-H, who was monitoring the patient, "grabbed the patient by the throat" when the patient tried to leave the room. Security officer (K) reported this information to the nursing supervisor and told the supervisor that the parents had called the police about the incident. Security officer (K) spoke with patient #1 following the incident, and patient #1 told (K) that he tried to leave the room because he did not want to be in the hospital. The patient told security officer (K) that CSA-H "choked" him when he walked into the hallway, pushed patient #1 back into his room and onto the bed and whispered in his ear "don't f--k with me." The patient stated he was not injured and said the marks on his neck were from an altercation that occurred prior to his admission to the ED. The security report indicated CSA-H was sent home, the police arrived, and staff interviews were conducted by security and the police.

The police report pertaining to the 8/9/15 incident was reviewed. The police interviewed RN-E and RN-F in person on 8/9/15 and interviewed CSA-H in person on 8/9/15 and 8/19/15. RN-F said she saw patient #1 walk out of his room and saw CSA-H wrap his arm around the patient's upper chest and turn the patient around and push the patient back into his room with his arm around the patient's upper chest. RN-E said she saw the same thing but went into the room and saw CSA-H pushing the patient onto the bed. RN-E stated patient #1 then stood up and said "are you going to let him choke me?" RN-E said "no" and CSA-H left the room.

During the 8/9/15 police interview with CSA-H he said the patient did not want to be in the room and wanted to leave the hospital. Patient #1 then got out of bed and walked toward the door of the room. CSA-H said he put his foot straight out and attempted to keep patient #1 from leaving the room. Patient #1 stepped over his foot and started walking through the doorway. CSA-H stated he then got up and placed his right arm all the way around the patient's neck, but did not put any pressure on his neck. CSA-H said he was frustrated and mumbled under his breath, "Don't f--k with me." CSA-H stated he walked the patient back into his room and let go of him when he was next to his bed. He stated patient #1 yelled "he tried choking me." During the 8/19/15 police interview with CSA-H he repeated similar details and said he did not use much pressure with the patient. He stated "I was firm, but I did not choke him."

RN-E was interviewed by the investigator on 10/1/15, and she stated she was working in the ED on 8/9/15 when the incident occurred. She stated she saw patient #1 come out of his room and into the hall and observed CSA-H come out into the hall and put his right arm around patient #1's neck tightly and forcefully. The patient's back was resting on CSA-H's chest. CSA-H then placed his left hand on the patient's lower back and pushed the patient into his room. RN-E stated she entered the room and observed CSA-H pushing the patient onto his bed. RN-E stated she said "We're done here" and CSA-H took his hands off of the patient and stood there. The patient said, "Are you going to let him choke me?"

RN-F was interviewed by the investigator on 10/1/15, and she stated she was working on the evening of 8/9/15. She stated she heard RN-E say security was needed in room #3 (patient #1's room). She walked down the hall and observed patient #1 and CSA-H in the hall. CSA-H was standing behind patient #1 and his arm was around the patient's neck and his elbow was at the level of the patient's chin. CSA-H was also pushing the patient's back with his left hand and directing the patient into his room. When RN-F arrived at the room, she observed that patient #1 was sitting on his bed and that he appeared to be upset. RN-F told CSA-H to go to the nurses' station and wait for the supervisor to meet with him. RN-F assigned another CSA to patient #1. RN-F stated the incident she observed appeared to be very inappropriate. CSA-H should have pushed the emergency button in the patient's room and called a Code Green alert when the patient left the room.

Family member (G) was interviewed by phone on 10/2/15, and she stated she was present in the ED on 8/9/15 when patient #1 was admitted and was present in the family waiting room (located next to the patient's room) when the incident with CSA-H occurred. Patient #1 did not know family member (G) was in the waiting room. Patient #1 received care at the hospital on several occasions prior to the 8/9/15 ED visit. Patient #1 has been having flashbacks about the the 8/9/15 incident and has brought it up many times. Family member (G) stated patient #1 has been very fearful about the incident and possibly having to return to the hospital for care in the future. She stated she will not be taking patient #1 back to the hospital for any further care.

CSA-H was interviewed by the investigator on 10/2/15, and he stated he was frustrated and angry when the incident occurred on 8/9/15. He stated he should have thought before he acted. He denied choking the patient and denied throwing the patient on his bed. He said he used profane language when the incident occurred. CSA-H said the statement that he provided to the police is accurate.

The hospital's Workplace Violence and Abuse Policy, dated 3/2/13, and Appropriate Work Behavior/Harassment Policy, dated 11/13/13 were reviewed as they pertain to the ED and the 8/9/15 incident. Each policy indicates the hospital will take all reasonable actions to strive for a safe environment for all persons who are employed at the hospital or use the hospital's services.

The hospital's restraint policy, dated 2/21/14, was reviewed. The policy stated the hospital is committed to reducing the use of restraints and promoting nonphysical interventions as preferred interventions. Care planning and treatment focuses on preventing and decreasing frequency of situations that have the potential to lead to the use of restraint. Restraints are not used as a means of coercion, discipline, convenience, staff retaliation, or in a manner that causes undue physical discomfort, harm or pain to the patient.

The hospital's internal investigation of the 8/9/15 incident revealed CSA-H was a long term employee who received appropriate training related to his duties. CSA-H was immediately placed on administrative leave pending the results of the investigation. CSA-H and other staff were interviewed related to the incident.

As a result of the hospital's investigation, (Clinical Support Associate) CSA-H was terminated on 8/20/15. The termination notice stated the following: 1. Specific Performance/Behavior Noted (Violation of Hospital Policy 1084.00 Workplace Violence and Abuse, Policy 1054 Positive Environment/Appropriate Work Behavior/Harassment Prevention and Service Standards: On August 9, 2015 you used physical means to restrain a non-aggressive patient by placing your arm around the patient's neck, your hand on the small of his back moving him back into the patient room and placing the patient on the bed face down. You stated to the patient, "Don't f--k with me." Your actions were unnecessary and excessive; your comments were inappropriate, intimidating and offensive.

Based on documentation and interviews, the hospital failed to ensure that one of twenty-one child/patients (patient #1) was free from unnecessary restraints. Findings include:

The hospital's 8/9/15 security reports pertaining to patient #1(room 3 in the ED) were reviewed. The
reports stated the following: 1) 6:21 p.m.- ED staff called and asked for assistance with a patient who had been in restraints and had just arrived to room #3 (admission). Restraints were removed from the patient. The patient is autistic and very agitated. Security officers stood by and spoke with the patient until he was calm. 2) 7:30 p.m.-patient is agitated and told staff that he wanted to leave. Staff was able to coax him back to his bed, but would like security to stand by with the patient until he calms down. 3) 10:12 p.m.-panic alarm was activated at ED nurses' station, and security staff arrived. The patient's parents told security officer (K) that prior to the officers arrival following the panic alarm, CSA-H, who was monitoring the patient, "grabbed the patient by the throat" when the patient tried to leave the room. Security officer (K) reported this information to the nursing supervisor and told the supervisor that the parents had called the police about the incident. Security officer (K) spoke with patient #1 following the incident, and patient #1 told (K) that he tried to leave the room because he did not want to be in the hospital. The patient told security officer (K) that CSA-H "choked" him when he walked into the hallway, pushed patient #1 back into his room and onto the bed and whispered in his ear "don't f--k with me." The patient stated he was not injured and said the marks on his neck were from an altercation that occurred prior to his admission to the ED. The security report indicated CSA-H was sent home, the police arrived, and staff interviews were conducted by security and the police.

The police report pertaining to the 8/9/15 incident was reviewed. The police interviewed RN-E and RN-F in person on 8/9/15 and interviewed CSA-H in person on 8/9/15 and 8/19/15. RN-F said she saw patient #1 walk out of his room and saw CSA-H wrap his arm around the patient's upper chest and turn the patient around and push the patient back into his room with his arm around the patient's upper chest. RN-E said she saw the same thing but went into the room and saw CSA-H pushing the patient onto the bed. RN-E stated patient #1 then stood up and said "are you going to let him choke me?" RN-E said "no" and CSA-H left the room.

During the 8/9/15 police interview with CSA-H he said the patient did not want to be in the room and wanted to leave the hospital. Patient #1 then got out of bed and walked toward the door of the room. CSA-H said he put his foot straight out and attempted to keep patient #1 from leaving the room. Patient #1 stepped over his foot and started walking through the doorway. CSA-H stated he then got up and placed his right arm all the way around the patient's neck, but did not put any pressure on his neck. CSA-H said he was frustrated and mumbled under his breath, "Don't f--k with me." CSA-H stated he walked the patient back into his room and let go of him when he was next to his bed. He stated patient #1 yelled "he tried choking me." During the 8/19/15 police interview with CSA-H he repeated similar details and said he did not use much pressure with the patient. He stated "I was firm, but I did not choke him."

RN-E was interviewed by the investigator on 10/1/15, and she stated she was working in the ED on 8/9/15 when the incident occurred. She stated she saw patient #1 come out of his room and into the hall and observed CSA-H come out into the hall and put his right arm around patient #1's neck tightly and forcefully. The patient's back was resting on CSA-H's chest. CSA-H then placed his left hand on the patient's lower back and pushed the patient into his room. RN-E stated she entered the room and observed CSA-H pushing the patient onto his bed. RN-E stated she said "We're done here" and CSA-H took his hands off of the patient and stood there. The patient said, "Are you going to let him choke me?"

RN-F was interviewed by the investigator on 10/1/15, and she stated she was working on the evening of 8/9/15. She stated she heard RN-E say security was needed in room #3 (patient #1's room). She walked down the hall and observed patient #1 and CSA-H in the hall. CSA-H was standing behind patient #1 and his arm was around the patient's neck and his elbow was at the level of the patient's chin. CSA-H was also pushing the patient's back with his left hand and directing the patient into his room. When RN-F arrived at the room, she observed that patient #1 was sitting on his bed and that he appeared to be upset. RN-F told CSA-H to go to the nurses' station and wait for the supervisor to meet with him. RN-F assigned another CSA to patient #1. RN-F stated the incident she observed appeared to be very inappropriate. CSA-H should have pushed the emergency button in the patient's room and called a Code Green alert when the patient left the room.

Family member (G) was interviewed by phone on 10/2/15, and she stated she was present in the ED on 8/9/15 when patient #1 was admitted and was present in the family waiting room (located next to the patient's room) when the incident with CSA-H occurred. Patient #1 did not know family member (G) was in the waiting room. Patient #1 received care at the hospital on several occasions prior to the 8/9/15 ED visit. Patient #1 has been having flashbacks about the the 8/9/15 incident and has brought it up many times. Family member (G) stated patient #1 has been very fearful about the incident and possibly having to return to the hospital for care in the future. She stated she will not be taking patient #1 back to the hospital for any further care.

CSA-H was interviewed by the investigator on 10/2/15, and he stated he was frustrated and angry when the incident occurred on 8/9/15. He stated he should have thought before he acted. He denied choking the patient and denied throwing the patient on his bed. He said he used profane language when the incident occurred. CSA-H said the statement that he provided to the police is accurate.

The hospital's Workplace Violence and Abuse Policy, dated 3/2/13, and Appropriate Work Behavior/Harassment Policy, dated 11/13/13 were reviewed as they pertain to the ED and the 8/9/15 incident. Each policy indicates the hospital will take all reasonable actions to strive for a safe environment for all persons who are employed at the hospital or use the hospital's services.

The hospital's restraint policy, dated 2/21/14, was reviewed. The policy stated the hospital is committed to reducing the use of restraints and promoting nonphysical interventions as preferred interventions. Care planning and treatment focuses on preventing and decreasing frequency of situations that have the potential to lead to the use of restraint. Restraints are not used as a means of coercion, discipline, convenience, staff retaliation, or in a manner that causes undue physical discomfort, harm or pain to the patient.

The hospital's internal investigation of the 8/9/15 incident revealed CSA-H was a long term employee who received appropriate training related to his duties. CSA-H was immediately placed on administrative leave pending the results of the investigation. CSA-H and other staff were interviewed related to the incident.

As a result of the hospital's investigation, (Clinical Support Associate) CSA-H was terminated on 8/20/15. The termination notice stated the following: 1. Specific Performance/Behavior Noted (Violation of Hospital Policy 1084.00 Workplace Violence and Abuse, Policy 1054 Positive Environment/Appropriate Work Behavior/Harassment Prevention and Service Standards: On August 9, 2015 you used physical means to restrain a non-aggressive patient by placing your arm around the patient's neck, your hand on the small of his back moving him back into the patient room and placing the patient on the bed face down. You stated to the patient, "Don't f--k with me." Your actions were unnecessary and excessive; your comments were inappropriate, intimidating and offensive.