HospitalInspections.org

Based on observation, interview, record review, and policy review, the facility failed to ensure patients were provided a safe environment when the facility failed:
-To eliminate ligature/hanging hazards by allowing patients access to phone cords approximately 18 inches long,
-To prevent patient access to looping/hanging hazards on six of 43 psychiatric beds, which had rectangular restraint openings on the wooden part of the head, foot and sides of the beds in behavioral health units which housed suicidal patients
- To eliminate contraband from two patients (#20 and #45), which could have caused a potential hanging (shoestrings) and/or a fire/burn (lighter);
-To ensure tables and chairs were anchored so they could not be used as weapons (Patient #38) and
-The facility allowed 15 of 15 patient bathrooms to have vinyl shower curtains, which could be a suffocation hazard .
-To utilize the least restrictive, most appropriate restraint by using handcuffs on 19 patients and subdued one patient (#44) with a Taser and a law enforcement baton as forms of restraint in the Behavioral Health Unit and in the Emergency Department (ED) over a nine month period (01/01/11 through 09/20/11.)
-To protect five patients from injury during restraint episodes when security staff restrained the patients with handcuffs;
-To obtain a physician's order for restraints for twenty two patients restrained; and failed
-To perform the one hour face-to-face assessment following behavioral restraint episodes for nineteen patients restrained.

The severity and cumulative effect of not utilizing the least restrictive, most appropriate restraint by using handcuffs and subduing a patient with a Taser and a law enforcement baton as forms of restraint resulted in the facility being out of compliance with 42 CFR 482.13 - Condition of Participation: Patient's Rights. Subsequently the situation constituted a condition of immediate jeopardy (IJ). The hospital administration was notified of the IJ on 09/19/11 and an immediate plan of correction was received, accepted, and implemented prior to exit, therefore, the IJ was abated. On 09/16/11 the facility began education to the Behavioral Health and security staff, and began revising facility policies regarding restraints. The facility started the education and policy revisions prior to being informed an immediate jeopardy situation existed. On 09/20/11 the facility stopped the use of handcuffs. The facility census was 114.

Please refer to tags A0144, A0165, A0167, and A0168.

Based on clinical record review and interview the facility failed to have documented evidence patients were informed of patient's rights in five patients (#4, #5, #17, #38) of five patient records reviewed for patient's rights, and failed to provide patient rights to two patients (#2 and #5) of three patients interviewed regarding provision of patient rights. The facility census was 114.

Findings included:

1. Record review of Patient #5's Kardex (a document staff use to show current patient's condition and needs) showed the patient was admitted on 09/06/11 with a diagnosis of schizophrenia.

During an interview on 09/13/11 at 1:34 PM, Patient #5 stated the facility failed to notify him/her of his/her rights when admitted. Patient #5 stated he/she did not know, at this time, what the patient's rights were. Patient #5 stated he/she did not received a brochure containing the patient rights and did not sign anything confirming he/she did receive patient rights.

2. Record review of Patient #2's History and Physical dated 09/10/11, showed the patient was admitted on 09/09/11 with a diagnosis of psychosis.

During an interview (the facility identified the patient as alert, oriented and reliable for interview) on 09/13/11 at 1:44 PM, Patient #2 stated the facility failed to notify him/her of his/her rights when admitted. Patient #2 stated he/she did not received a brochure containing the patient rights and did not sign anything confirming he/she did receive patient rights.

3, During a review of clinical records the facility failed to have documented evidence that patients were informed of their patient rights when the patient rights section on the Conditions of Admission form failed to be completed by the patient or the staff for Patient #4, Patient
#5, Patient #17 and Patient #38.

4. During an interview on 09/15/11 at 10:16 AM, with Staff K, Associate Administrator, stated that the patient rights section at the bottom of the Condition of Admission form is where the patient would initial that he/she had been informed of patient rights. A section is also present for the staff to document the patient had been given his/her rights. Staff K confirmed the facility failed to document Patients #4, #5, #17 and #38 had been informed of their rights.

Based on interview, record review and policy review, the facility failed to provide a written response to two patients (#19 and #22) of four reviewed that filed a grievance. The facility census was 114.

Findings Included:

1. Record review of a facility policy titled, "Grievance Resolution," revised 09/01/09, showed the following:
-A grievance is a formal or informal, written or verbal complaint that cannot be solved promptly by staff;
-A grievance is resolved when the patient is satisfied with the actions taken by the hospital;
-All grievances are resolved as soon as possible;
-In most cases, a thorough investigation and resolution will be achieved within seven business days, and the grievance will receive a written response;
-If the grievance cannot be resolved within this timeframe, the hospital informs the grievance in the written response that the hospital is still working to resolve;
-All written responses are reviewed by the Guest Services Department, Associate Administrator or Division Leader.

2. Record review of a Comment/Grievance Case Detail Report dated 05/10/11, showed Patient #19 filed a written complaint on 04/30/11. The written complaint showed a concern regarding an incident on 04/25/11 with a security guard whereby the patient felt the security guard was too rough while handling him/her. The patient alleged the security guard pushed him/her into a chair, hard, three times, put a hand around his/her throat, and bent his/her thumb back causing residual pain. The report showed it was resolved on 08/22/11; however, staff failed to provide documentation of a thorough investigation and follow-up letter notifying the patient of the resolution.

3. Record review of a Comment/Grievance Case Detail Report dated 08/03/11, showed Patient #22 filed a phone/verbal complaint on that date. The complainant showed a concern regarding an incident with a security guard whereby the patient felt the security guard was too rough while handling him/her. The patient alleged the security guard applied so much pressure to a recently sutured incision that it caused pain and re-opening of the incision and bleeding. The report showed it was resolved on 08/03/11 even though staff failed to provide documentation of a thorough investigation and follow-up letter notifying the patient of the resolution.

4. During an interview on 09/14/11 at 12:25 PM, Staff M, Compliance Officer, stated that at the time of the above complaints/grievances, pertinent staffing had changed, causing no letter to be sent. Staff M confirmed no letters had been sent to the above complainants.

Based on observation, interview and record review the facility failed to ensure patients were provided a safe environment. The facility failed:
-To include physician ordered precaution level(s) and/or observation level(s) on the "Behavior Observation Records" sheets as required by policy for ten patients (#3, #6, #12, #18, #38, #48, #50, #51, #52 and #53);
-To eliminate ligature/hanging hazards by allowing patients access to phone cords approximately 18 inches long;
-To protect patients from suffocation hazards in 15 of 15 patient bathrooms that had vinyl shower curtains (2C-77, 2C-79, 2C-54/2C-57, 2C-45, 2C-41/2C-44, 2C-37/2C-40, 2C-86/2C-89, 2C-90/2C-93, 2C-94/2C-97, 2D-4/2D-1, 2D-5/2D-8, 2D-9/2D-12, 2D-50, 2D-52/2D-55, 2D-56/2D-59);
- To eliminate contraband from two patients (#20 and #45) which could have caused a potential hanging (shoestrings) and/or a fire/burn (lighter); and
-To prevent patients access to looping/hanging hazards on six of 43 psychiatric beds (2D-50, 2D-36, 2C-73, 2C-75, 2C-61 and 2C-51) which had rectangular restraint openings (on the wooden part of the head, foot and sides of the beds) when restraint slots failed to be covered when not in use in behavioral health units which housed suicidal patients, and had the potential to affect all patients.

The facility census was 114.

Findings included:

1. Record Review of the policy titled "Rounds-Behavior Observation Record," Approval Date: June 13, 2011, showed the following in the policy section: Truman Medical Center Behavioral Health provides a safe and therapeutic milieu for all clients and clients who are being evaluated in the Behavioral Health Emergency Department. All clients are monitored according to physician orders and at minimum of four (4) times per hour with intervals occurring every 10-20 minutes between rounds.

The Procedure Section, Item G, showed: The charge nurse is responsible for ensuring that the form is initiated on all clients and completed accurately to include observation level and precaution status.

2. Record Review of the policy titled "Precautions ", Approval Date: 06/13/11, showed the following in the policy section: Precautions are staff intervention for safety. The purpose section stated: The purpose of these specialized interventions is to provide a more intense level of observation and safety for clients who present a heightened level of danger to themselves or others. The assignment to a precaution requires an order by the psychiatrist caring for the client.

Precautions:
Accompanied Status: Clients placed on Accompanied Status are to be specially observed and their specific activities monitored and documented by the assigned nursing staff. Clients on accompanied status may attend therapeutic activities off the unit while accompanied by assigned staff. Clients on accompanied status may go to the gym with staff or the vending machine with staff.
Close Observation: These clients are to be located within the immediate visual area and may have unit and court yard privileges.

Precautionary:
Assault Precaution: Client's who have been assessed to have a history of assaultive behavior or who may be on the violent offender's list or who have displayed assaultive behavior on the unit.
Elopement Precaution: Clients on 1:1 (one staff member for one patient) observation or close observation may also be put on elopement precautions if there is an assessed risk of leaving the facility without permission. A client on elopement precautions may not be on accompanied status.
Fall Precautions: Treatment of clients on fall precautions will comply with the corporate policy on Fall Prevention and Management Program.
Seizure Precautions: Treatment of clients on seizure precautions will comply with the corporate Nursing Department Policy entitled Policies with Procedural Skills.
Sexual Acting Out Precaution: Clients with a history of sexual acting out behavior (i.e. inappropriate or unwanted sexual advances toward another person in a community, inpatient or residential treatment facility) or who have documented legal charges as a sexual perpetrator.
Suicide/Self Harm Precautions: Clients on suicide precaution have indicated that they have thoughts of self harm. They may have a plan and may have demonstrated behaviors that indicate the desire to self harm. Risk has been assessed and the client will be placed on the appropriate observation status. Clients who have demonstrated self harm behaviors may have thoughts to hurt themselves but not assessed to be actively suicidal.

3. Record review of physician orders and the "Behavior Observation Records" (documentation of rounding on all patients four (4) times per hour used to indicate the location, behaviors and activity of the patients to ensure their safety) sheets dated 09/14/11, 7:00 AM - 7:30 PM, showed:

-Patient #3: The physician ordered Close Observation on 09/08/11 and ordered Elopement Precautions on 09/08/11.
Patient #3's sheet failed to include Close Observation or Elopement Precautions.

-Patient #6: The physician ordered Observation for Sexual Acting Out and Close Observation on 09/03/11.
Patient #6's sheet failed to include Observation for Sexual Acting Out and Close Observation.

-Patient #12: The physician ordered Close Observation on 08/29/11.
Patient #12's sheet failed to include Close Observation.

-Patient #18: The physician ordered Close Observation and Assault Precautions on 07/29/11.
Patient #18's sheet failed to include Close Observation or Assault Precaution.

-Patient #38: The physician ordered Close Observation on 06/30/11.
Patient #38's sheet failed to include Close Observation.

-Patient #48: The physician order Close Observation on 07/26/11; Elopement Precautions on 07/26/11; and ordered Accompanied Status while off the unit on 09/02/11.
Patient #48's sheet failed to include an Observation Level, Elopement Precaution or Accompanied Status

-Patient #50: Physician order on 09/12/11 for patient to be on Close Observation and on 09/14/11 an order for patient to be on Accompanied Status.
Pt #50's sheet did not have a precaution level indicated and the observation section had Close observation indicated rather than the change to Accompanied status.

-Patient #51: Physician order on 09/13/11 for patient to be on Close Observation.
Pt #51's sheet did not have a precaution level.

-Patient #52: Physician order on 09/08/11 for patient to be on Close Observation.
Pt #52's sheet did not have a precaution level.

-Patient #53: Physician order on 09/11/11 for patient to be on Close Observation.
Pt #53's sheet did not have a precaution level.

During an interview on 09/13/11 at 2:38 PM, Staff J, MHT (Mental Health Tech), stated that the purpose of the precaution levels and observation levels being on the Behavior Observation Records is so the MHT will know what behaviors to observe for during the shift. He/she stated the previous shift prepared the day shift's Behavior Observation Records and they should have included the precaution levels and observation levels on the Behavior Observation Record and confirms it failed to be done.

During an interview on 09/15/11 at 9:53 AM, Staff W, MHT stated that the purpose of the precaution levels and observation levels indicated on the Behavior Observation Records was so that MHT would know what behaviors they should observe patients for during the shift. He/she stated that nurses and MHT discuss each patient's observation status at the beginning of each shift daily. He/she stated that if staff failed to indicate an observation status on the Behavior Observation Record Sheets, they noted the patient's status in the meeting; also, he/she stated that he/she would look on the bulletin board in the nursing staff lounge to find the patients' observation statuses.

4. Observations on 09/12/11 at between 3:00 PM and 4::00 PM of the 2C Unit hallways showed the following:
-Two wall phones (one on the north hallway wall and the other one on the south hallway wall) hung in the areas of the patients' bedrooms. The phones measured approximately three and one-half (3.5) feet from the floor and they each had a metal corrugated-type cord that measured approximately 18-inches in length. The patients used the phones and they could not be viewed from the Nurses' station and/or desk area outside of the Nurses' stations. The cords posed a ligature risk to suicidal patients.

According to physician's orders the 2C unit housed six patients on Close observation precautions (have thoughts of suicide, according to the facility).

Observations on 09/13/11 from 9:45 through 10:10 AM, on the 2D unit, showed the following:
-One phone hung on the north hallway wall, approximately 3.5 feet up from the floor and had a metal corrugated-type cord that was approximately 18-inches in length. This cord poses a ligature risk to suicidal patients.

According to the precautions dry-erase board, the 2D unit housed two patients that required self-harm precautions, and one patient on Close observation precautions (have thoughts of suicide, according to the facility).

During an interview on 09/14/11 at 3:00 PM, Staff FF, Registered Nurse (RN) stated that patients used the phones and agreed that the phones could not be viewed from the Nurses' stations nor the desk outside of the Nurses' stations.

5. The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with the Joint Commission patient safety goals as well as the current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, JAMA, 2005, v 294, 2064 -2074).

The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is a United States-based not-for-profit organization. The Joint Commission accredits over 19,000 health care organizations and programs in the United States.

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA, TJC and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to prospectively identify and eliminate environmental risks for inpatient suicide and suicide attempts.

The MHEOCC recommended shower curtains be made out of breathable material and not plastic or vinyl to reduce suicidal attempts by suffocation.

6. During an observation on 09/13/11 from 9:39 AM to 10:20 AM, on D Unit showed six of six patient bathrooms had plastic/vinyl shower curtains to both the entrance into the bathroom and entrance to the shower:
-Shared bathroom for patient rooms 2D-4 and 2D-1;
-Shared bathroom for patient rooms 2D-5 and 2D-8;
-Shared bathroom for patient rooms 2D-9 and 2-12;
-Private bathroom for room 2D-50;
-Shared bathroom for patient rooms 2D-52 and 2D-55; and
-Shared bathroom for patient rooms 2D-56 and 2D-59.

According to the precautions dry-erase board, the 2D unit housed two patients that required self-harm precautions, and one patient on Close observation precautions (have thoughts of suicide, according to the facility). These shower curtains were accessible to patients at all times.

7. Observation on 09/14/11 from 2:00 PM to 3:00 PM, on C Unit showed nine of nine patient bathrooms had plastic/vinyl shower curtains to both the entrance into the bathroom and entrance to the shower:
-Private bathroom for room 2C-77;
-Private bathroom for room 2C-79;
-Shared bathroom for rooms 2C-54 and 2C-57;
-Private bathroom for room 2C-45
-Shared bathroom for rooms 2C-41 and 2C-44;
-Shared bathroom for rooms 2C-37 and 2C-40;
-Shared bathroom for rooms 2C-86 and 2C-89;
-Shared bathroom for rooms 2C-90 and 2C-93; and
-Shared bathroom for rooms 2C-94 and 2C-97.

According to physician's orders the 2C unit housed six patients on Close observation precautions (have thoughts of suicide, according to the facility).

8. Review of a facility policy titled, "Contraband on the Mental Health Unit," revised 06/20/11, showed shoestrings, lighters and matches were not allowed.

Review of the precautions list on the 2D unit on 09/13/11 at 11:11 AM, showed two patients on self-harm precautions, and three on assault precautions.

Observations on 09/13/11 at 9:55 AM, and at 2:08 PM, showed a pair of black tennis shoes with shoestrings, accessible to all patients inside the open cabinet of Patient #20.

Review of patient #20's H & P dated 09/13/11, showed the patient was admitted to the 2D unit on 09/12/11 with a diagnosis of a recent suicide attempt.

Review of Patient #20's admission inventory list showed a pair of black tennis shoes. Staff failed to identify the shoestrings on the list. Staff also failed to identify these shoestrings while doing contraband rounds at 11:00 AM.

During an interview on 09/12/11 at 2:35 PM, Staff C, stated shoestrings were not allowed on the inpatient units.

During an interview on 09/13/11 at 2:15 PM, Staff G, and Staff E, Mental Health Technicians (MHTs) stated that contraband rounds were completed twice daily at 11:00 AM and 6:00 PM. Staff E stated that Patient #20 was admitted the night prior. Staff G stated the patient should not have shoestrings as patients can put them around their necks (demonstrated hanging by shoestring).

During an interview on 09/14/11 at 3:28 PM, Staff AA, MHT who admitted Patient #20, stated that he/she remembered the patient's black tennis shoes and admitted he/she did not take the shoestrings out of the shoes, but should have. Staff AA stated that the nurse did the patient's assessment and over time, forgot to remove the shoestrings.

9. Review of an Event Report dated 01/22/11, showed Patient #45 was found smoking on the 2D unit. When searched by staff, the patient had a lighter and half-smoked cigarette inside clothing. The lighter could have been used to start a fire, causing injury to Patient #45 and/or other patients and staff.

10. Observations 09/14/11 from 3:14 PM to 3:55 PM on Behavioral Health Unit 2D showed the following looping and hanging hazards when restraint slots failed to be covered when not in use:

-Patient's bed in room 2D-50 had eight open restraint slots approximately 1.5 inches in height, approximately 5 inches wide and approximately 13-14 inches off the floor (one at the center of head of the bed; one at the center of the foot of the bed and three along each of the long sides of the bed).
-Patient's bed in room 2D-36 had two open restraint slots approximately one and one halve inches in height, approximately five inches wide and approximately 13-14 inches off the floor at the middle of each long side of the bed which is used for a waist restraint.

During an interview on 09/14/11, at 4:10 PM, Staff K, Associate Administrator, stated that the restraint slots should not be open and they should be covered with a plate when not in use to prevent patients from using the slots for looping and hanging. Staff K then put in a work order for the restraint slots on the psychiatric beds to be covered for rooms 2D-50 and 2D-36.

According to the precautions dry-erase board, the 2D unit housed two patients that required self-harm precautions, and one patient on Close observation precautions (have thoughts of suicide). These beds were accessible to all patients at all times.

11. Observations on 09/16/11 between 2:00 PM and 3:00 PM on Behavioral Health Unit 2C showed the following looping and hanging hazards when restraint slots failed to be covered when not in use:

-Patient's beds in rooms 2C-73, 2C-75, 2C-61, 2C-51, had eight open restraint slots approximately 1.5 inches in height, approximately 5 inches wide and approximately 13-14 inches off the floor (one at the center of head of the bed; one at the center of the foot of the bed and three along each of the long sides of the bed).

During an interview on 09/16/11 at 2:30 PM Staff FF confirmed the beds had opened restraint slots and stated that they should be covered with a plate when not in use to prevent patients from using the slots for looping and hanging.

According to physician's orders the 2C unit housed six patients on Close observation precautions (have thoughts of suicide, according to the facility).


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Based on record review, interview and policy review, the facility failed to utilize the least restrictive, most appropriate restraint by using handcuffs on 19 patients (#11, #23, #26,#27 #28, #29, #30, #32, #33, #34, #36, #37, #39, #40, #41, #42, #43, #44 and #49) and subdued one patient (#44) with a Taser and a law enforcement baton as forms of restraint in the Behavioral Health Unit and in the Emergency Department (ED) over a nine month period (01/01/11 through 09/20/11). Twenty four restraint records were reviewed. The use of handcuffs are considered law enforcement restraint devices and are not considered safe or appropriate restraint interventions by hospital staff. Tasers and batons are considered weapons and if a weapon is used by security in a facility the situation should be handled as a criminal activity and the perpetrator should be placed in the custody of local law enforcement. The facility census was 114.

Findings included:

1. Review of the facility's policy titled, "Patient Rights and Responsibilities," revised 02/02/09, showed the following:
-Every employee shall be knowledgeable and supportive of all patient rights and shall take responsibility ensuring compliance with them;
-The patient shall be free from restraints of any form that are not medically necessary;

Review of the facility's policy titled, "Management of Restraints, Behavioral," revised 01/13/10, showed the following:
-Restraint use is implemented when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm;
- In accordance with safe and appropriate restraint techniques as determined by hospital policy in accordance with state law;
-Prior to restraint the Registered Nurse (RN) and other team members have identified possible alternatives;
-Restraints used in the hospital are soft extremity, mittens that are tied down or mittens that are not tied down and are used in combination with other devices, mechanical extremity, manual/physical hold and waist restraint.

The policy did not list handcuffs, batons or Tasers as restraints used in the hospital.

Record review of the security facility policy titled, "Use of Force", revised 12/26/08, showed the the policy used the terminology, "an officer" [versus security officer]
-An officer is justified in physical control methods to stop potentially dangerous and unlawful behavior [law enforcement officers employed by the government ensure obedience to the law-not a security officer per definition on uslegal.com/law enforcement]
-To protect from injury or death
-To protect patients from injuring self and
-When in the process of effecting a lawful arrest or detention;

The policy contains a chart showing de-escalation techniques and law enforcement techniques. The chart depicts levels of resistance, levels of control and examples of control that an officer may have to employ in order to control a situation. The chart depicts when the level of resistance is one of active aggression law enforcement techniques are used. The level of control is intermediate weapons/Taser and an example of control is listed as impact weapons, batons and handcuffs.

2. Review of discharged Patient #40's discharge summary showed the patient entered the facility 08/31/11 following a suicide attempt by overdosing on Phenobarbital (anxiety medication) and Dilantin (seizure medication). The physician placed the patient on a 96 hour involuntary admission.

Record review of an incident report showed security used a baton on the patient and handcuffed Patient #40 on 08/31/11. Review of the incident report showed the following:
- Two security officers responded to inpatient room 443 to escort Patient #40 to the Behavioral Health Unit.
- While exiting the lobby of the hospital into parking lot E the patient attempted to run and tried to escape.
- One security officer grabbed the patient's left arm and the officer and the patient fell to the ground. A second security officer grabbed the patient's right arm and placed his/her body on top of the patient to restrict the patient's movement.
- One security officer placed a handcuff on the patient's left wrist. Three additional security officers arrived and one officer used his/her baton to apply a strong side arm lock (a procedure in which a baton is placed between the upper arm and torso of a subject, the baton is twisted along with the subject's arm in order to bend the subjects arm behind his back) to the patient's right arm to assist getting it behind his/her back. The handcuffs were then placed on both wrists. The security officer did not strike the patient with the baton.

Prior to handcuffing the patient, the patient was subdued by five security officers. The facility failed to attempt a less restrictive method of restraint such as leather restraints before handcuffing the patient.

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #40.

3. Review of discharged Patient #44's ED progress notes dated 09/04/11 at 9:31 AM showed the patient entered the ED on 09/04/11 at 6:36 AM. The patient came to the facility by ambulance. The patient was found in the street confused and agitated.

Record review of a security report dated 09/04/11 at 11:58 PM showed security used a Taser device (an electroshock weapon which fires projectiles that administer an electrical current to disrupt voluntary control of muscles; a patient struck by a Taser experiences strong involuntary muscle contractions) four times on the patient, struck the patient three times with a baton and then handcuffed Patient #44 on 09/04/11 at 11:24 AM. Review of the security report showed the following:
- Two security officers responded to a request for assistance in the ED to help with a physically aggressive patient.
- Upon arrival the security officers observed the patient attempting to pull out his/her IV (intravenous therapy is the giving of substances directly into a vein.)
- The patient succeeded in pulling his/her IV out and also broke the saline bag of fluid.
- Two security officers attempted to hold the patient down but the patient broke away and attempted to leave the ED exam room. Four additional security officers arrived to assist with the patient.
- Security officers attempted to take the patient to the ground but were unsuccessful.
- One security officer then struck the patient's upper thigh with a baton three times.
- The patient continued to struggle with the security officers and one security officer attempted to put the patient in a wrist lock.
- The security report documents security was unable to restrain the patient due to blood and IV fluid on the floor. One security officer in fear of his/her life created space from the struggle and deployed a Taser into the patient's right front side of the stomach and right upper thigh. The report showed the officer was concerned that the other officers would be harmed while attempting to control the patient due to the large amount of blood and saline making the floor slippery.
- The patient removed the Taser prong that was inserted in his/her thigh.
- The same security officer again deployed a second cycle from the Taser to the patient but it was unsuccessful.
- The patient continued to be combative with the responding officers.
- One security officer then "drive stunned" the patient on his/her back right shoulder. ( The Taser is held against the patient without firing the projectiles, and is intended to cause pain without incapacitating the patient. "Drive Stun" is "the process of using the Taser as a pain compliance technique.)
- The security officers then gained control of the patient and applied handcuffs.

A wrist lock and " Drive stunned" are pain control restraint techniques.

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #44.

Review of the physician's ED progress notes showed the physician admitted the patient to a general internal medicine unit for detoxification from a Phencyclidine (PCP) overdose (PCP is a hallucinogen drug which distorts perceptions of sight and sound. Users can experience unpleasant psychological effects, with symptoms mimicking schizophrenia (delusions, hallucinations, disordered thinking, extreme anxiety). .

4. Review of discharged Patient #28's ED nursing notes showed the patient presented at the ED on 07/14/11 for being combative and confused. The patient has a history of schizophrenia.

Record review of a security report dated 07/14/11 at 8:33 PM showed security handcuffed Patient #28 on 07/14/11 at 1:45 PM. Review of the security report showed the following:
- Four security officers responded to a call from the emergency department that a visitor was in the bathroom kicking the toilet and punching the walls.
- On arriving in the ED security documented Patient #28 was not responding to verbal directions from security staff.
- Security attempted to take the person out of the bathroom by taking control of his/her arms. - The patient became physically combative and security attempted to place patient #28 in handcuffs, but were unsuccessful.
- Security officers requested additional support and three additional officers responded.
- Security then placed Patient #28 in handcuffs.
- Security then transported the patient to an exam room and placed the patient in four point restraints.
- Security documented the patient received an injury during the incident to the right arm.

Prior to handcuffing the patient, the patient was subdued by seven security officers. The facility failed to attempt a less restrictive method of restraint such as leather restraints before handcuffing the patient.

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #28.

Review of a radiology report dated 07/14/11 at 4:04 PM showed soft tissue swelling of the wrist (which wrist is not indicated on the report) with no acute fracture or misalignment.

5. Record review of discharged Patient #23's History and Physical (H & P) dated 02/24/11, showed the patient was admitted to behavioral health on that date with a diagnosis of schizophrenia (a mental illness where people may hear voices other people don't hear and/or believe other people are reading their minds, controlling their thoughts, or plotting to harm them).

Record review of an Event Report dated 03/07/11 showed the following:
-Patient #23 was admitted to the behavioral health unit 2C on 02/24/11.
-On 03/07/11 at 10:08 AM Patient #23 became agitated and physically aggressive. The patient began picking up chairs and tables, throwing them. Security placed the patient in a manual hold, along with one mental health technician (MHT) but the patient's behavior became more combative so the patient was placed in handcuffs (a restraint) by security staff.

Record review of a Nurses' note dated 03/07/11, timed 10:05 AM, showed a (one) MHT attempted to utilize ProAct (a de-escalation technique intended to be performed by multiple staff) without success, so the patient's arms/hands were restrained behind him/her by security.

After multiple requests, and review of the patient's electronic medical record, staff failed to provide documentation a less restrictive restraint was utilized prior to using handcuffs on this patient.

During an interview on 09/16/11 at 1:30 PM, Staff Q, MHT, stated it was the facility policy to intervene, by a hold, with two or more people. Staff Q agreed more staff could have manually restrained Patient #23 and transported to the restraint room rather than have security handcuff the patient. Staff Q stated security staff made the decision to handcuff the patient, not the nurse in charge.

6. Record review of discharged Patient #27's H & P dated 08/28/11, showed the patient was admitted to behavioral health on that date with a diagnosis of bipolar disorder.

Record review of an Event Report, dated 08/28/11, showed the following:
-On 08/28/11 at around 2:18 PM, Patient #27 became agitated on the behavioral health unit 2D;
-A responding security officer attempted to calm the patient via verbal techniques, then called for additional officers when this did not occur;
-Before the additional officers arrived, the first security officer took the patient to the ground and handcuffed the patient.

Record review of a Nurses' note dated 08/28/11, timed 8:11 PM, showed the patient was manually held by security related to an additional episode of agitation.

After multiple requests, and review of the patient's electronic medical record, staff failed to provide documentation a less restrictive restraint was utilized prior to using handcuffs on this patient.

Facility staff failed to attempt a less restrictive method of restraint.




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7. Record review of current Patient #49's H & P dated 08/31/11, showed the patient was admitted to behavioral health with a diagnosis of mood disorder, alcohol dependence and anxiety.

Review of a security report dated 08/24/11 showed security handcuffed Patient #49.
On 08/24/11 at 8:25 AM two security officers responded to a Code 13 Distress Alarm (call to security for assistance) from Behavioral Health Unit 2C. The report showed:
- The clinical staff informed the security officers that Patient #49 had barricaded him/herself in his/her room.
- The officers entered the patient room and the patient moved toward them. The officers grabbed the patient and assisted him/her to the floor.
-The patient hit one of the security officers and the officers then handcuffed the patient.

Once the patient was secured on the floor by security, facility staff failed to attempt a less restrictive method of restraint. With the patient completely controlled on the floor, additional staff could have been called to secure the patient's limbs to apply mechanical restraints

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #49.

8. Review of a security report dated 01/01/11 at 9:04 PM showed discharged Patient #37 sought treatment in the behavioral health Emergency Department (ED) due to inappropriate behavior. Record review showed security handcuffed Patient #37 on 01/01/11.
Review of the security report showed the following:
- One security responded to Behavioral Health ED for medication standby for Patient #37 at 1:25 PM.
- Patient #37 kicked the front door of the ED and a security officer told the patient to stop.
- Patient #37 then turned around and attempted to choke the security officer.
- Security then restrained Patient #37 in an arm lock and then took the patient to the floor and placed handcuffs on the patient.

Review of a Behavioral Health ED evaluation dated 01/01/11 at 3:00 PM showed the patient was intoxicated and uncooperative. When the handcuffs were removed staff placed the patient in four point mechanical restraints (all four limbs restrained.)

Once the patient was secured on the floor by security, facility staff failed to attempt a less restrictive method of restraint. With the patient completely controlled on the floor, additional staff could have been called to secure the patient's limbs to apply mechanical restraints

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #37.

9. Review of discharged Patient #41's ED nursing notes showed the patient presented at the ED 01/04/11 with delusions and bizarre behavior. The patient's mother brought the patient to the hospital and the physician placed the patient on a 96 hour involuntary hold (involuntary treatment under certain conditions with appropriate due process.)

Record review of a security report dated 01/04/11 at 6:09 PM showed security handcuffed Patient #41 on 01/04/11 at 10:42 AM. Review of the security report showed the following:
- Four security officers responded to a call from the ED that Patient #41 was disruptive and not cooperating with staff.
- Security informed patient he/she would need to remove his/her belt and the patient was upset and tried to kick open the entrance door to the ED.
- Security radioed for backup and two additional officers responded.
- Patient #41 attempted to go through the door when the two additional officers arrived.
- The six security officers used physical force to prevent the patient from leaving the ED by taking him/her down to the ground and handcuffing the patient.

Once the patient was secured on the floor by six security officers, the facility failed to attempt a less restrictive method of restraint. With the patient completely controlled on the floor, staff did not attempt to secure the patient's limbs to apply mechanical restraints, instead used handcuffs on the patient.

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #41.

10. Review of discharged Patient #43's progress notes dated 01/13/11 at 4:07 PM showed the patient entered the facility 01/12/11 on a 30 day court order. Prior to admission the patient attempted to hang him/herself with a bed sheet.

Record review of a security report dated 01/26/11 at 4:19 AM showed security handcuffed Patient #43 on 01/25/11 at 9:30 PM. Review of the security report showed the following:
- Four security officers responded to a Code 13 Distress Alarm from Behavioral Health Unit 2C.
- Upon arrival security officers observed 2C staff holding Patient #43 to the floor.
- The responding officers placed the patient in handcuffs.

Record review of a security report dated 01/27/11 at 4:18 AM showed security handcuffed Patient #43 on 01/26/11 at 8:42 PM. Review of the security report showed the following:
- Two security officers responded to a Code 13 Distress Alarm from Behavioral Health Unit 2C.
- Upon arrival security officers observed Patient #43 arguing with staff and the patient refused to return to his/her room. Patient #43 became aggressive and attempted to push one security officer.
- Two security officers gained control of the patient and escorted him/her to the ground and placed the patient in handcuffs.

In both restraint episodes, once the patient was secured on the floor by security officers, the facility failed to attempt a less restrictive method of restraint. With the patient completely controlled on the floor, additional staff could have been called to secure the patient's limbs to apply mechanical restraints, instead security used handcuffs on the patient.

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #43.

11. Review of discharged Patient #36's discharge summary showed the patient entered the facility 01/19/11 for treatment of bipolar disorder (mood swings between abnormally elevated or irritable moods and depression.)

Record review of a security report dated 01/29/11 at 5:15 AM showed security handcuffed Patient #36 on 01/28/11. Review of the security report showed the following:
- Three security officers responded to a Code 13 Distress Alarm from Behavioral Health Unit 2D.
- On arriving on the unit security found four behavioral health staff manually restraining the patient on the floor.
- Security officers placed Patient #36 in handcuffs on 01/28/11 at 10:26 PM.

Review of the nursing documentation dated 01/28/11 at 11:19 PM showed security staff handcuffed the patient for less than five minutes. No exact times are documented.

Once the patient was secured on the floor by four behavioral health staff, the facility failed to attempt a less restrictive method of restraint. With the patient controlled on the floor and with the assistance of three security officers, staff did not attempt to secure the patient's limbs to apply mechanical restraints, instead security restrained the patient with handcuffs.

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #36.

12. Review of discharged Patient #42's discharge summary showed the patient entered the facility 01/21/11 due to bizarre behavior. Initially the physician placed the patient on a 96 hour hold and then committed the patient for a 21 day involuntary admission.

Record review of a security report dated 01/25/11 at 11:21 PM showed security handcuffed Patient #42 on 01/25/11 at 3:56 PM. Review of the security report showed the following:
- Three security officers responded to the Behavioral Health unit 2D which requested help with Patient #42 who would not take medication.
- A security officer asked the patient to take the medication and Patient #42 became more irritated and more aggressive.
- One security officer grabbed the patient and redirected his/her body position to the ground.
- A second security officer applied handcuffs to the patient.

Record review of a security report dated 01/29/11 at 2:13 PM showed security handcuffed Patient #42 on 01/28/11 at 1:13 PM. Review of the security report showed the following:
- Three security officers responded to the Behavioral Health unit 2D which requested help with Patient #42 who was being loud and out of control.
- The patient refused to take medication and attempted to walk away from the security officers.
- Security physically restrained and placed handcuffs on the patient so nursing staff could administer medication.

Record review of a security report dated 02/21/11 at 5:44 AM showed security handcuffed Patient #42 on 02/10/11 at 10:30 PM. Review of the security report showed the following:
- Two security officers responded to the Behavioral Health unit 2D which requested help with Patient #42 who was being disruptive.
- The patient lunged at the security officers and the officers took the patient down to the floor.
- The security officers placed the patient in handcuffs.

In all three restraint episodes, the facility staff failed to attempt a less restrictive method of restraint once the patient was secured on the floor by security. Additional staff could have been called to secure the patient's limbs to apply mechanical restraints

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #42.

13. Review of discharged Patient #11's discharge summary showed the patient entered the facility 04/13/11 for evaluation of homicidal threats and paranoid schizophrenia.

Record review of a security report dated 05/13/11 at 5:22 AM showed security handcuffed Patient #11 on two occasions on 05/12/11. Review of the security report showed the following:
- On 05/12/11 security responded to a Code 13 Distress Alarm from Behavioral Health Unit 2D.
- Security officer saw a staff member holding Patient #11 on the floor, preventing the patient from getting up off the floor.
- Security officer placed Patient #11 in handcuffs at 10:02 PM.
- Security officer and one staff member escorted Patient #11 to his/her room and removed the handcuffs.
- Patient #11 went to the unit day room and started throwing furniture.
- Security officer took the patient to the floor and again placed handcuffs on the patient (time not documented.)
- Security escorted the patient to the restraint room, removed handcuffs and placed Patient
#11 in four point (both arms and legs) restraints.

Review of nursing documentation showed no assessment of the need for any less restrictive restraint prior to security handcuffing the patient during either restraint episode.

In both restraint episodes, the facility staff failed to attempt a less restrictive method of restraint once the patient was secured on the floor. Additional staff could have been called to secure the patient's limbs to apply mechanical restraints

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #11.

14. Review of discharged Patient #26's discharge summary showed the patient entered the facility 04/21/11 due to inappropriate behavior.

Record review of a security report dated 09/03/11 at 11:18 PM showed security handcuffed Patient #26 on 09/03/11. Review of the security report showed the following:
- Two security officers responded to a Code 13 Distress Alarm from Behavioral Health Unit 2D.
- Behavioral health staff informed security Patient #26 hit another patient (#49.)
- One security officer placed Patient #26 in handcuffs.
- Security removed handcuffs and placed patient in four point restraints.
- Security contacted local law enforcement who took a statement from the patient struck (Patient #49) and informed security officers because Patient #26 isn't discharged it would do no good to arrest the patient because the patient would be returned right back to the unit. Local law enforcement officers on the unit at 12:45 PM.

Review of the nursing documentation showed Patient #26 in handcuffs from
12:10 PM until 12:45 PM. When staff removed the handcuffs they restrained the patient in four point restraints from 12:45 PM until 3:20 PM.

Review of nursing documentation dated 09/03/11 at 8:11 PM showed staff consulted with the director of nursing, the assistant patient care manager and the physician for a decision if charges would be filed against Patient #26. At 3:20 PM staff removed the restraints from the patient and the physician discharged the patient to the custody of local law enforcement.

During a telephone interview on 09/16/11 at 1:15 PM, Staff S, Security Officer, stated that he/she placed the handcuffs on Patient #26 on 09/03/11. Staff S stated, "He/she was not making any move to hit or assault anyone. I felt it was better to handcuff him/her due to his/her history of being physically aggressive on the unit." Staff S stated that handcuffs and restraints are two different things. If a patient is up and moving, we use handcuffs. If a guy is big, we use handcuffs.

At the time security handcuffed Patient #26, the patient was not being aggressive.

15. Review of discharged Patient #30's discharge summary showed the patient entered the facility 05/05/11 with a history of schizophrenia and for treatment of threatening behavior.

Record review of a security report dated 07/01/11 at 3:48 AM showed security handcuffed Patient #30 on 06/30/11 at 9:56 PM. Review of the security report showed the following:
- Security responded to a Code 13 Distress Alarm from Behavioral Health Unit 2C. Staff reported Patient #30 was hitting his/her head against the wall.
- On arriving on the unit security documented patient #30 was striking him/herself on the head.
- Security officer told the patient to place his/her hands upon a wall. The patient complied.
- Security then handcuffed the patient and escorted the patient to the restraint room.
- The patient calmed down and security released the patient from the handcuffs.

Review of the nursing documentation dated 06/30/11 at 11:35 PM showed staff placed the patient in a manual hold from 9:40 PM until 9:45 PM. [The] Patient again started to hit him/herself in the head and security was called for assistance and a manual hold was again initiated from 9:56 PM to 10:01 PM. There is no documentation in the nursing documentation that security placed the patient in handcuffs.

During an interview on 09/15/11 at 2:52 PM, Staff FF, Registered Nurse stated that he/she cannot find a restraint order for restraining Patient #30. Staff FF stated on 09/16/11 at 9:30 AM that the restraint was considered a manual hold and he/she did not tell security to put the patient in handcuffs.

Facility staff failed to attempt a less restrictive method of restraint once the patient was secured in a manual hold. Additional staff could have been called to secure the patient's limbs to apply mechanical restraints.

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #30.

16. Review of discharged Patient #34's H & P dated 05/19/11 showed the patient presented at the ED on 05/18/11. The patient's case worker brought the patient to the ED due to confusion and agitation.

Record review of a security report dated 05/18/11 at 11:48 PM showed security handcuffed Patient #34 on 05/18/11 in the ED. Review of the security report showed the following:
- Two security officers responded to a call from the ED to escort Patient #34 to his/her room.
- When in the hallway Patient #34 attempted to pull away from security and stated he/she wanted to go home.
- Security restrained the patient with handcuffs and then escorted the patient to his/her room. At that point the patient stated that he/she would remain calm and security removed the handcuffs.

Facility staff failed to attempt a less restrictive method of restraint.

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #34.

17. Review of discharged Patient #39's discharge summary showed the patient entered the facility 05/26/11 with a history of schizophrenia and for treatment of threatening behavior.

Record review of a security report dated 05/30/11 at 2:57 AM showed security handcuffed Patient #39 on 05/29/11. Review of the security report showed the following:
- Security responded to a Code 13 Distress Alarm from Behavioral Health Unit 2D.
- On arriving on the unit security documented Patient #39 was making verbal threats to staff and observed the patient hit a staff member.
- A behavioral health technician and two security officers manually restrained both arms and legs of the patient.
- Security placed Patient #39 in handcuffs and took the patient to the restraint room.
- Staff then placed the patient in five point restraints.

Review of the nursing documentation dated 05/29/11 at 9:05 PM showed staff placed the patient in five point restraints (all four limbs restrained plus a restraint around the waist.) No time of the restraint episode is documented.

Facility staff failed to attempt a less restrictive method of restraint once the patient was secured on the floor and all four limbs were manually restrained.

Review of the security report showed no documentation that security notified law enforcement personnel of the incident or that the security officers were in the process of effecting a lawful arrest or detention of the patient when they applied the handcuffs to restrain Patient #39.

18. Review of discharged Patient #29's ED nursing notes showed the patient presented at the ED 06/17/11 at 10:10 PM being combative and confused. The police brought the patient to the hospital on a 96 hour involuntary hold.

Record review of a security report dated 06/18/11 at 4:40 AM showed security handcuffed Patient #29 on 06/17/11 at 10:16 P

Based on record review and policy review, the facility failed to protect five patients (#28,
#23, #19, #27, and #22) from injury during restraint episodes when security staff restrained the patients with handcuffs. Twenty-four restraint records were reviewed. The facility census was 114.

Findings included:

1. Record review of the facility's policy titled, "Abuse, Neglect or Exploitation at Truman Medical Center," revised 07/06/11, showed the following:
-Individuals shall not be subjected to abuse by anyone;
-Physical abuse includes controlling behavior through corporal punishment;
-All events such as suspicious bruising, occurrences, patterns and trends will be identified to determine the direction of a thorough investigation;
-A Patient Safety Net (PSN) report is generated with all injuries, a preliminary review of the incident will be completed by the Patient Care Manager (PCM)/Director of Shift Operations (DSO), and physician. If additional investigation is needed the Chief Nursing Officer (CNO) or designee will investigate.

2. Record review of the facility's policy titled, "Patient Rights and Responsibilities," revised 02/02/09, showed the following:
-Every employee shall be knowledgeable and supportive of all patient rights and shall take responsibility ensuring compliance with them;
-The patient shall expect care in a safe environment;
-The patient shall be free from restraints of any form that are not medically necessary;
-The patient shall be protected from all forms of abuse, neglect, harassment or indiscretion.

3. Record review of the security facility policy titled, "Use of Force", revised 12/26/08, showed the the policy used the terminology, "an officer" [versus security officer]
-An officer is justified in physical control methods to stop potentially dangerous and unlawful behavior [law enforcement officers employed by the government ensure obedience to the law-not a security officer per definition on uslegal.com/law enforcement]
-To protect from injury or death
-To protect patients from injuring self and
-When in the process of effecting a lawful arrest or detention;

The policy contains a chart showing de-escalation techniques and law enforcement techniques. The chart depicts levels of resistance, levels of control and examples of control that an officer may have to employ in order to control a situation. The chart depicts when the level of resistance is one of active aggression law enforcement techniques are used. The level of control is intermediate weapons/Taser and an example of control is listed as impact weapons, batons and handcuffs.

4. Review of discharged Patient #28's emergency department (ED) nursing notes showed the patient presented at the ED on 07/14/11 for being combative and confused. The patient has a history of schizophrenia (a mental illness where people may hear voices other people don't hear and/or believe other people are reading their minds, controlling their thoughts, or plotting to harm them).

Record review of a security report dated 07/14/11 at 8:33 PM showed security handcuffed Patient #28 on 07/14/11 at 1:45 PM. Review of the security report showed the following:
- Four security officers responded to a call from the emergency department that a visitor was in the bathroom kicking the toilet and punching the walls.
- On arriving in the ED security documented Patient #28 was not responding to verbal directions from security staff.
- Security attempted to take the person out of the bathroom by taking control of his/her arms.
- The patient became physically combative and security attempted to place Patient #28 in handcuffs, but were unsuccessful.
- Security officers requested additional support and three additional officers responded.
- Security then placed Patient #28 in handcuffs.
- Security then transported the patient to an exam room and placed the patient in four point restraints.

Prior to handcuffing the patient, the patient was physically subdued by seven security officers.

Security documented the patient received an injury to his/her right arm during the restraint incident.

Review of a radiology report dated 07/14/11 at 4:04 PM showed soft tissue swelling of the wrist (which wrist is not indicated on the report) with no acute fracture or misalignment.

Staff failed to provide an investigation regarding the above incident. Without investigating the restraint injury, the facility did not determine if this was a case of excessive force or abuse by security.




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5. Record review of Patient #23's History and Physical (H & P) dated 02/24/11, showed the patient was admitted to behavioral health on that date with a diagnosis of schizophrenia.

Record review of an Event Report dated 03/07/11 showed the following:
-Patient #23 was admitted to the behavioral health unit 2C on 02/24/11.
-On 03/07/11 at 10:08 AM Patient #23 became agitated and physically aggressive. The patient began picking up chairs and tables, throwing them. Security placed the patient in a manual hold, along with one mental health technician (MHT) but the patient's behavior became more combative so the patient was placed in handcuffs by security. Security was on either side of the patient and the MHT was behind the patient. The MHT reported he/she fell on top of the patient. The patient reported pain in the left shoulder and an X-ray showed left humeral neck fracture. According to facility staff, the security video supported that the MHT fell on the patient; therefore, no further investigation was conducted. The patient was not charged for treatment to the fractured shoulder.

Record review of a Nurses' note dated 03/07/11, timed 10:05 AM, showed a MHT attempted to utilize ProAct (a de-escalation technique intended to be performed by multiple staff) without success, so the patient's arms were restrained behind him/her by security. The patient insisted, "My arm is broken!".

Record review of the psychiatric physician's note dated 03/07/11, timed 12:01 PM, showed the patient complained of shoulder pain and appeared to be in significant pain when manipulated.

Record review of an X-ray report dated 03/07/11 showed the patient had a comminuted (numerous fractures causing fragments) fracture of the left humeral head (shoulder joint) involving the surgical neck with minimal displacement (bone out of alignment).

After multiple requests, staff failed to provide a more thorough investigation regarding the above incident.

During an interview on 09/16/11 at 9:58 AM, Staff N, Corporate Medical Director, stated there was no documentation of an investigation or interviews regarding the above incident. Staff N said staff failed to document appropriately per prior described policy and procedure.

Observation of the security video, by three surveyors, showed no conclusive evidence the MHT fell on the patient. The patient was surrounded by security and one MHT, they took hold of him/her and took the patient down to the floor, handcuffing after on the floor. It was not exactly clear how this injury occurred. At one point, there were six security officers present around the patient.

During an interview on 09/16/11 at 1:30 PM, Staff Q, MHT, stated security showed up, he/she got caught in the middle and they all tumbled. Staff Q stated it was the facility policy to intervene by a hold with two or more people. Staff Q agreed more staff could have manually restrained the patient and transported to the restraint room rather than have security handcuff the patient. Staff Q stated security staff made the decision to handcuff the patient, not the nurse in charge. Staff Q stated he/she did not recall anyone questioning him for investigation of this event.

Facility staff failed to document a thorough investigation to include interviews and/or a resolution to this event. Facility staff failed to identify if this was a case of excessive force or abuse by security.

6. Record review of Patient #19's H & P dated 04/24/11, showed the patient was admitted to the Behavioral Health Unit on that date with a diagnosis of bipolar disorder (mood swings between abnormally elevated or irritable moods and depression).

Record review of a Comment/Grievance Case Detail Report, dated 05/10/11, showed the following:
-On 04/25/11 at around 9:00 PM, Patient #19 was brought to the Behavioral Health Emergency Department (BHED). Patient #19 and another patient in the BHED had a confrontation. A security guard put his finger in Patient #19's chest and pushed him/her, hard, into a chair three times. Then, the security guard put his hand around Patient #19's throat causing difficulty breathing. During the scuffle with security the patient's thumb was bent back causing residual pain. Five point rubber restraints were applied;
-Restraint documentation identified an injury (red mark);
-Facility staff failed to document any X-ray or treatment (other than range of motion) to the injury;
-On 08/20/11 the patient said his/her thumb still hurt.

Facility staff failed to attempt a less restrictive method of restraint and/or document a thorough investigation to include interviews and/or a resolution to this event. Facility staff failed to identify if this was a case of excessive force or abuse by security.

7. Record review of Patient #27's H & P dated 08/28/11, showed the patient was admitted to behavioral health on that date with a diagnosis of bipolar disorder. The patient stated he/she was suicidal and had several superficial, self-inflicted, cut marks on the left wrist.

Record review of an Event Report, dated 08/28/11, showed the following:
-On 08/28/11 at around 2:18 PM, Patient #27 became agitated on the behavioral health unit 2D;
-A responding security officer attempted to calm the patient via verbal techniques, then called for additional officers when this did not occur;
-Before the additional officers arrived, the first security officer took the patient to the ground and handcuffed the patient.

Record review of a Nurses' note dated 08/28/11, timed 8:11 PM, showed the patient was manually held by security related to an additional episode of agitation. The cut marks to the left wrist were broken open and oozing blood during the manual hold.

Record review of a medication administration record (MAR), dated 08/28-30/11, showed treatment to the above cuts did not begin until 08/30/11 until 8:38 AM.

Staff failed to provide an investigation of the above event(s), even though requested.

During an interview on 09/19/11 at 4:14 PM, Staff M stated there was no safety investigation regarding injuries to Patient #27. Staff M stated the facility had no system to interface or require staff to include information regarding injuries in event reports.

Facility staff failed to document a thorough investigation to include interviews and/or a resolution to this event. Facility staff failed to identify if this was a case of excessive force or abuse by security.

8. Record review of Patient #22's H & P dated 07/30/11, showed the patient was admitted to the behavioral health unit on that date with diagnoses of a mood disorder, swelling and laceration to the right hand (had sutures in recent past).

Record review of an Event report dated 08/05/11 showed the following:
-On 08/03/11 at about 2:07 PM Patient #22 refused to take medication and was yelling;
-Three security officers (requested by nursing) held the patient down while staff administered an injection;
-The patient's right hand laceration was broken open, bleeding, and required bandaging.

Even though requested, staff failed to provide an investigation of the above incident.

Facility staff failed to document a thorough investigation to include interviews and/or a resolution to this event. Facility staff failed to identify if this was a case of excessive force or abuse by security.

Based on record review and policy review, the facility failed to obtain a physician's order for restraints for twenty two patients (#19, #23, #27, #22, #14, #49, #37, #41, #43, #36, #42, #11, #30, #34, #39, #29, #33, #32, #28, #40, #26 and #44) of 24 patients reviewed with restraints. The facility census was 114.

Findings included:

1. Record review of the facility's policy titled "Management of Restraints, Behavioral" revised 01/13/10, showed the following:
- The administration, medical, and nursing staffs believe that patients have the right to be free from both physical and chemical restraint usage. Restraints will never be used for the purposes of coercion, discipline, retaliation or convenience.
- A physician, clinical psychologist, or other authorized licensed independent practitioner primarily responsible for the patient's ongoing care orders the use of restraint.

2. Record review of Patient #23's History and Physical (H & P) dated 02/24/11, showed the patient was admitted to Behavioral Health on that date with a diagnosis of schizophrenia (a mental illness where people may hear voices other people don't hear and/or believe other people are reading their minds, controlling their thoughts, or plotting to harm them).

Record review of an Event Report dated 03/07/11 showed the following:
-Patient #23 was admitted to the Behavioral Health Unit (BHU) 2C on 02/24/11;
-On 03/07/11 at 10:08 AM Patient #23 became agitated and physically aggressive. The patient began picking up chairs and tables, throwing them. Security placed the patient in a manual hold, along with one mental health technician (MHT) but the patient's behavior became more combative so the patient was placed in handcuffs by security.

Review of physician's orders for the date of 03/07/11, for this patient, showed staff failed to obtain an order for both this episode of manual hold and handcuffs.

3. Record review of Patient #19's H & P dated 04/24/11, showed the patient was admitted to the BHU on that date with a diagnosis of bipolar disorder (mood swings between abnormally elevated or irritable moods and depression).

Record review of a Comment/Grievance Case Detail Report, dated 05/10/11, showed the following:
-On 04/25/11 at around 9:00 PM, Patient #19 was brought to the BHED. Patient #19 and another patient in the BHED had a confrontation. Mechanical restraints were applied to Patient #19 by security.

Review of physician's orders for the date of 04/25/11, for this patient, showed staff failed to obtain an order for this episode of mechanical restraint.

4. Record review of Patient #27's H & P dated 08/28/11, showed the patient was admitted to BHU on that date with a diagnosis of bipolar disorder.

Record review of an Event Report, dated 08/28/11, showed the following:
-On 08/28/11 at around 2:18 PM, Patient #27 became agitated on the BHU 2D;
-A responding security officer attempted to calm the patient via verbal techniques, then called for additional officers when this did not occur;
-Before the additional officers arrived, the first security officer took the patient to the ground and handcuffed the patient.

Review of physician's orders for the date of 08/28/11, for this patient, showed staff failed to obtain an order for this episode of mechanical restraint.

5. Record review of Patient #22's H & P dated 07/30/11, showed the patient was admitted to the BHU on that date with a diagnosis of a mood disorder.

Record review of an Event report dated 08/05/11 showed the following:
-On 08/03/11 at about 2:07 PM Patient #22 refused to take medication and was yelling;
-Three security officers (requested by nursing) held the patient down while staff administered an injection.

Review of physician's orders for the date of 08/03/11, for this patient, showed staff failed to obtain an order for this episode of manual restraint.

6. Record review of Patient #14's H & P dated 09/10/11, showed the patient was admitted to the BHU on 09/09/11 with a diagnosis of Psychosis (loss of contact with reality, usually including false beliefs about what is taking place or who one is and seeing or hearing things that aren't there).
Review of a Nurses' noted dated 09/09/11, timed 7:39 PM, showed the patient became agitated, banging his/her fist on the Nurses' station desk. Security assisted with a manual hold on the patient so an injection could be administered.

Review of physician's orders for the date of 09/09/11, showed staff failed to obtain an order for this episode of manual restraint.


19957

7. Record review of current Patient #49's H & P dated 08/31/11, showed the patient was admitted to BHU with a diagnosis of mood disorder, alcohol dependence and anxiety.

On 08/24/11 at 8:25 AM two security officers responded to a Code 13 Distress Alarm (call to security for assistance) from BHU 2C. The report showed:
- Review of a security report dated 08/24/11 showed security handcuffed Patient #49.
- The clinical staff informed the security officers that Patient #49 had barricaded him/herself in his/her room.
- The officers entered the patient room and the patient moved toward them. The officers grabbed the patient and assisted him/her to the floor.
-The patient hit one of the security officers and the officers then handcuffed the patient.

Review of physician's orders for 08/24/11, for this patient, showed staff failed to obtain an order for a manual hold and handcuffs.

8. Review of a security report dated 01/01/11 at 9:04 PM showed discharged Patient #37 sought treatment in the BHED due to inappropriate behavior. Record review showed security handcuffed Patient #37 on 01/01/11.

Review of the security report showed the following:
- One security officer responded to BHED for medication standby for Patient #37 at 1:25 PM.
- Patient #37 kicked the front door of the ED and a security officer told the patient to stop.
- Patient #37 then turned around and attempted to choke the security officer.
- Security then restrained Patient #37 in an arm lock and then took the patient to the floor and placed handcuffs on the patient.
Review of a BHED evaluation dated 01/01/11 at 3:00 PM showed when the handcuffs were removed staff placed the patient in four point mechanical restraints (all four limbs restrained.)

Review of physician's orders for 01/01/11, for this patient, showed staff failed to obtain an order for a manual hold, handcuffs and the four point mechanical restraints.

9. Review of discharged Patient #41's ED nursing notes showed the patient presented at the ED 01/04/11 with delusions and bizarre behavior. The patient's mother brought the patient to the hospital and the physician placed the patient on a 96 hour involuntary hold (involuntary treatment under certain conditions with appropriate due process.)

Record review of a security report dated 01/04/11 at 6:09 PM showed security handcuffed Patient #41 on 01/04/11 at 10:42 AM. Review of the security report showed the following:
- Four security officers responded to a call from the ED that Patient #41 was disruptive and not cooperating with staff.
- Security informed patient he/she would need to remove his/her belt and the patient was upset and tried to kick open the entrance door to the ED.
- Security radioed for backup and two additional officers responded.
- Patient #41 attempted to go through the door when the two additional officers arrived.
- The six security officers used physical force to prevent the patient from leaving the ED by taking him/her down to the ground and handcuffing the patient.

Review of physician's orders for 01/04/11, for this patient, showed staff failed to obtain an order for a manual hold and handcuffs.

10. Review of discharged Patient #43's progress notes dated 01/13/11 at 4:07 PM showed the patient entered the facility 01/12/11 on a 30 day court order. Prior to admission the patient attempted to hang him/herself with a bed sheet.

Record review of a security report dated 01/26/11 at 4:19 AM showed security handcuffed Patient #43 on 01/25/11 at 9:30 PM. Review of the security report showed the following:
Four security officers responded to a Code 13 Distress Alarm from BHU 2C.
Upon arrival security officers observed 2C staff holding Patient #43 to the floor.
The responding officers placed the patient in handcuffs.

Review of physician's orders for 01/25/11, for this patient, showed an order for a manual hold, but no order for handcuffs.

Record review of a security report dated 01/27/11 at 4:18 AM showed security handcuffed Patient #43 on 01/26/11 at 8:42 PM. Review of the security report showed the following:
- Two security officers responded to a Code 13 Distress Alarm from BHU 2C.
- Upon arrival security officers observed Patient #43 arguing with staff and the patient refused to return to his/her room. Patient #43 became aggressive and attempted to push one security officer.
- Two security officers gained control of the patient and escorted him/her to the ground and placed the patient in handcuffs.

Review of physician's orders for 01/26/11, for this patient, showed staff failed to obtain an order for a manual hold and handcuffs.

11. Review of discharged Patient #36's discharge summary showed the patient entered the facility 01/19/11 for treatment of bipolar disorder.

Record review of a security report dated 01/29/11 at 5:15 AM showed security handcuffed Patient #36 on 01/28/11. Review of the security report showed the following:
- Three security officers responded to a Code 13 Distress Alarm from BHU 2D.
- On arriving on the unit security found four behavioral health staff manually restraining the patient on the floor.
- Security officers placed Patient #36 in handcuffs on 01/28/11 at 10:26 PM.

Review of physician's orders for 01/29/11 at 1:47 AM, for this patient, showed an order for a manual hold, but no order for handcuffs.

12. Review of discharged Patient #42's discharge summary showed the patient entered the facility 01/21/11 due to bizarre behavior. Initially the physician placed the patient on a 96 hour hold and then committed the patient for a 21 day involuntary admission.

Record review of a security report dated 01/25/11 at 11:21 PM showed security handcuffed Patient #42 on 01/25/11 at 3:56 PM. Review of the security report showed the following:
- Three security officers responded to the BHU 2D which requested help with Patient #42 who would not take medication.
- A security officer asked the patient to take the medication and Patient #42 became more irritated and more aggressive.
- One security officer grabbed the patient and redirected his/her body position to the ground.
- A second security officer applied handcuffs to the patient.

Review of physician's orders for 01/25/11, for this patient, showed an order for a manual hold, but no order for handcuffs.

Record review of a security report dated 01/29/11 at 2:13 PM showed security handcuffed Patient #42 on 01/28/11 at 1:13 PM. Review of the security report showed the following:
- Three security officers responded to the BHU 2D which requested help with Patient #42 who was being loud and out of control.
- The patient refused to take medication and attempted to walk away from the security officers.
- Security physically restrained and placed handcuffs on the patient so nursing staff could administer medication.

Review of physician's orders for 01/28/11, for this patient, showed no orders for a manual hold and handcuffs.

Record review of a security report dated 02/11/11 at 5:44 AM showed security handcuffed Patient #42 on 02/10/11 at 10:30 PM. Review of the security report showed the following:
- Two security officers responded to the BHU 2D which requested help with Patient #42 who was being disruptive.
- The patient lunged at the security officers and the officers took the patient down to the floor.
- The security officers placed the patient in handcuffs.

Review of physician's orders for 02/10/11, for this patient, showed no orders for a manual hold and handcuffs.

13. Review of discharged Patient #11's discharge summary showed the patient entered the facility 04/13/11 for evaluation of homicidal threats and paranoid schizophrenia.

Record review of a security report dated 05/13/11 at 5:22 AM showed security handcuffed Patient #11 on two occasions on 05/12/11. Review of the security report showed the following:
- On 05/12/11 security responded to a Code 13 Distress Alarm from BHU 2D.
- Security officer saw a staff member holding Patient #11 on the floor, preventing the patient from getting up off the floor.
- Security officer placed Patient #11 in handcuffs at 10:02 PM.
- Security officer and one staff member escorted Patient #11 to his/her room and removed the handcuffs.
- Patient #11 went to the unit day room and started throwing furniture.
- Security officer took the patient to the floor and again placed handcuffs on the patient (time not documented.)
- Security escorted the patient to the restraint room, removed handcuffs and placed Patient
#11 in four point (both arms and legs) restraints.

Review of physician's orders for 05/12/11, for this patient, showed no orders for a manual hold, handcuffs or four point restraints.

14. Review of discharged Patient #30's discharge summary showed the patient entered the facility 05/05/11 with a history of schizophrenia and for treatment of threatening behavior.

Record review of a security report dated 07/01/11 at 3:48 AM showed security handcuffed Patient #30 on 06/30/11 at 9:56 PM. Review of the security report showed the following:
- Security responded to a Code 13 Distress Alarm from BHU 2C. Staff reported Patient #30 was hitting his/her head against the wall.
- On arriving on the unit security documented Patient #30 was striking him/herself on the head.
- Security officer told the patient to place his/her hands upon a wall. The patient complied.
- Security then handcuffed the patient and escorted the patient to the restraint room.
- The patient calmed down and security released the patient from the handcuffs.

Review of the nursing documentation dated 06/30/11 at 11:35 PM showed staff placed the patient in a manual hold from 9:40 PM until 9:45 PM. Patient again started to hit him/herself in the head and security was called for assistance and a manual hold was again initiated from 9:56 PM to 10:01 PM. There is no documentation in the nursing documentation that security placed the patient in handcuffs.

During an interview on 09/15/11 at 2:52 PM, Staff FF, Registered Nurse (RN) stated that he/she cannot find a restraint order for restraining Patient #30.

15 Review of discharged Patient #34's H & P dated 05/19/11 showed the patient presented at the ED on 05/18/11. The patient's case worker brought the patient to the ED due to confusing and agitation.

Record review of a security report dated 05/18/11 at 11:48 PM showed security handcuffed Patient #34 on 05/18/11 in the ED. Review of the security report showed the following:
- Two security officers responded to a call from the ED to escort Patient #34 to his/her room.
- When in the hallway Patient #34 attempted to pull away from security and stated he/she wanted to go home.
- Security restrained the patient with handcuffs and then escorted the patient to his/her room. At that point the patient stated that he/she would remain calm and security removed the handcuffs.

Review of physician's orders for 05/18/11, for this patient, showed no orders for handcuffs.

16. Review of discharged Patient #39's discharge summary showed the patient entered the facility 05/26/11 with a history of schizophrenia and for treatment of threatening behavior.

Record review of a security report dated 05/30/11 at 2:57 AM showed security handcuffed Patient #39 on 05/29/11. Review of the security report showed the following:
- Security responded to a Code 13 Distress Alarm from BHU 2D.
- On arriving on the unit security documented Patient #39 was making verbal threats to staff and observed the patient hit a staff member.
- A behavioral health technician and two security officers manually restrained both arms and legs of the patient.
- Security placed Patient #39 in handcuffs and took the patient to the restraint room.
- Staff then placed the patient in five point restraints.

Review of the nursing documentation dated 05/29/11 at 9:05 PM showed staff placed the patient in five point restraints (all four limbs restrained plus a restraint around the waist.) No time of the restraint episode is documented.

Review of physician's orders for 05/29/11, for this patient, showed an order for a manual hold and five point restraints but no order for handcuffs.

17. Review of discharged Patient #29's ED nursing notes showed the patient presented at the ED 06/17/11 at 10:10 PM being combative and confused. The police brought the patient to the hospital on a 96 hour involuntary hold.

Record review of a security report dated 06/18/11 at 4:40 AM showed security handcuffed Patient #29 on 06/17/11 at 10:16 PM. Review of the security report showed the following:
- Security responded to a call from the ED that the patient attempted to leave and ED staff needed help to stop him/her.
- One security officer grabbed the patient and attempted to place the patient in a wrist lock (a wrist lock is typically applied by grabbing the hand, and bending and/or twisting it. Wrist locks are also widely used as pain compliance hold.) The patient continued to resist and two security officers and a physician restrained the patient manually to the ground.
- While on the ground two security officers placed each of Patient #29's hands in a wrist lock.
- Security assisted the patient to his/her feet and the patient continued to resist.
- Four additional security officers arrived and took Patient #29 to the ground and then handcuffed the patient.
- Security escorted the patient to a room and security and two ED staff placed the patient in four point restraints.

Review of physician's orders for 06/17/11 at 10:28 PM, for this patient, showed an order for a physical hold and four point mechanical restraints. There is no order for handcuffs.

18. Review of discharged Patient #33's H & P dated 06/19/11 showed the patient presented at the ED 06/19/11. The police brought the patient to the hospital because he/she was standing in traffic taking picture of cars and their license plates and was unresponsive to law enforcement.

Record review of a security report dated 06/18/11 at 8:07 PM showed security handcuffed Patient #33 on 06/18/11 at 12:21 PM in the ED. Review of the security report showed the following:
- One security officer responded to a call from the ED that the patient was being disruptive.
- Security attempted to calm the patient down but the patient continued making threats.
- Security called for an additional officer to assist.
- The patient started hitting the exit door and told security he/she could take all of them on and choke them. Both security officers drew their batons (a club of less than arm's length made of wood, plastic, or metal, used to strike, jab, block, bludgeon or aid in the application of arm locks and sometimes, they also are employed as weapons.)
- The two security officers grabbed the patient's arms and took the patient down to the floor.
- Four ED staff members assisted the two security officers in gaining control of the patient and got the patient into a room.
- Security handcuffed the patient.
- The physician then ordered five point restraints.

Review of physician's orders for 06/18/11 at 12:35 PM, for this patient, showed an order for five point mechanical restraints. There is no order for a physical hold or handcuffs.

19. Review of discharged Patient #32's H & P dated 06/21/11 showed the patient presented at the ED on 06/20/11 following a suicide attempt. The police brought the patient to the hospital.

Record review of a security report dated 06/20/11 at 11:07 PM showed security handcuffed Patient #32 on 06/20/11 at 4:00 PM. Review of the security report showed the following:
- One security officer responded to a call from the ED that the patient attempted to harm him/herself by using his/her shirt to choke him/herself.
- Security grabbed the patient's arm and was able to release the patient's grip from the shirt.
- The patient continued to resist and three additional security officers responded and placed the patient on the ground and placed handcuffs on the patient.

Review of physician's orders for 06/20/11 at 4:17 PM, for this patient, showed an order for four point mechanical restraints and a physical hold. There is no order for handcuffs.

20. Review of discharged Patient #28's ED nursing notes showed the patient presented at the ED on 07/14/11 for being combative and confused. The patient has a history of schizophrenia.

Record review of a security report dated 07/14/11 at 8:33 PM showed security handcuffed Patient #28 on 07/14/11 at 1:45 PM. Review of the security report showed the following:
- Four security officers responded to a call from the emergency department that a visitor was in the bathroom kicking the toilet and punching the walls.
- On arriving in the ED security documented Patient #28 was not responding to verbal directions from security staff.
- Security attempted to take the person out of the bathroom by taking control of his/her arms. - The patient became physically combative and security attempted to place Patient #28 in handcuffs, but were unsuccessful.
- Security officers requested additional support and three additional officers responded.
- Security then placed Patient #28 in handcuffs.
- Security then transported the patient to an exam room and placed the patient in four point restraints.
- Security documented the patient received an injury during the incident to the right arm.

Review of physician's orders for 07/14/11 for this patient, showed no orders for a physical hold, handcuffs or four point restraints.

21. Review of discharged Patient #40's discharge summary showed the patient entered the facility 08/31/11 following a suicide attempt by overdosing on Phenobarbital (anxiety medication) and Dilantin (seizure medication). The physician placed the patient on a 96 hour involuntary admission.

Record review of an incident report showed security used a baton on the patient and handcuffed Patient #40 on 08/31/11. Review of the incident report showed the following:
- Two security officers responded to inpatient room 443 to escort Patient #40 to the BHU.
- While exiting the lobby of the hospital into parking lot E the patient attempted to run and tried to escape.
- One security officer grabbed the patient's left arm and the officer and the patient fell to the ground. A second security officer grabbed the patient's right arm and placed his/her body on top of the patient to restrict the patient's movement.
- One security officer placed a handcuff on the patient's left wrist. Three additional security officers arrived and one officer used his/her baton and then applied a strong side arm lock to the patient's right arm to assist getting it behind his/her back. The handcuffs were then placed on both wrists.

Review of physician's orders for 08/31/11 for this patient, showed no orders for a physical hold or handcuffs.

22. Record review of the H & P dated 04/21/11 showed Patient #26 entered the facility through the ED on 04/21/11 due to bizarre and paranoid behavior in the group home where he/she lived.

Record review of a security report dated 09/03/11 at 11:18 PM showed security handcuffed Patient #26 on 09/03/11. Review of the security report showed the following:
- Two security officers responded to a Code 13 Distress Alarm from BHU 2D.
- Behavioral health staff informed security Patient #26 hit another patient (#49.)
- One security officer placed Patient #26 in handcuffs.
- Security removed handcuffs and placed patient in four point restraints.
Review of the nursing documentation showed Patient #26 placed in handcuffs from 12:10 PM until 12:45 PM. When staff removed the handcuffs they restrained the patient in four point restraints from 12:45 PM until 3:20 PM.

Review of physician's orders for 09/03/11, for this patient, showed no orders for a manual hold, handcuffs or four point restraints.

23. Review of discharged Patient #44's ED progress notes dated 09/04/11 at 9:31 AM showed the patient entered the ED on 09/04/11 at 6:36 AM. The patient came to the facility by ambulance. The patient was found in the street confused and agitated.

Record review of a security report dated 09/04/11 at 11:58 PM showed security used a Taser device (an electroshock weapon which fires projectiles that administer an electrical current to disrupt voluntary control of muscles; a patient struck by a Taser experiences strong involuntary muscle contractions) four times on the patient, struck the patient three times with a baton and then handcuffed Patient #44 on 09/04/11 at 11:24 AM. Review of the security report showed the following:
- Two security officers responded to a request for assistance in the ED to help with a physically aggressive patient.
- Upon arrival the security officers observed the patient attempting to pull out his/her IV (intravenous therapy is the giving of substances directly into a vein.)
- The patient succeeded in pulling his/her IV out and also broke the saline bag of fluid.
- Two security officers attempted to hold the patient down but the patient broke away and attempted to leave the ED exam room. Four additional security officers arrived to assist with the patient.
- Security officers attempted to take the patient to the ground but were unsuccessful.
- One security office then struck the patient's upper thigh with a baton three times.
- The patient continued to struggle with the security officers and one security officer attempted to put the patient in a wrist lock.
- The security report documents security was unable to restrain the patient due to blood and IV fluid on the floor. One security officer in fear of his/her life created space from the struggle and deployed a Taser into the patient's right front side of the stomach and right upper thigh. The report showed the officer was concerned that the other officers would be harmed while attempting to control the patient due to the large amount of blood and saline making the floor slippery.
- The patient removed the Taser prong that was inserted in his/her thigh.
- The same security officer again deployed a second cycle from the Taser to the patient but it was unsuccessful.
- The patient continued to be combative with the responding officers.
- One security officer then "drive stunned" the patient on his/her back right shoulder. (The Taser is held against the patient without firing the projectiles, and is intended to cause pain without incapacitating the patient. "Drive Stun" is "the process of using the Taser as a pain compliance technique.)
- The security officers then gained control of the patient and applied handcuffs.

Review of physician's orders dated 09/04/11 at 6:43 AM for this patient, showed an order for four point restraints but no order for a physical hold, a Taser, a baton or handcuffs.

Based on record review, policy review and interview, the facility failed to perform the one hour face-to-face assessment following behavioral restraint episodes for nineteen patients restrained (#19, #23, #27, #22, #14, #49, #37, #41, #43, #42, #30, #34, #39, #33, #32, #28, #40, #26 and #44) of 24 patients reviewed with restraints. The facility census was 114.

Findings included:

1. Record review of the facility's policy titled, "Management of Restraints, Behavioral," revised 01/13/10, showed the following:
-Restraints used in the hospital are soft extremity, mittens that are tied down or mittens that are not tied down and are used in combination with other devices, mechanical extremity, manual/physical hold and waist restraint.
- A physician, licensed independent practitioner or trained Registered Nurse (RN) must complete a face-to-face evaluation within one hour from initiation of behavioral restraints to determine the ongoing need for restraints.

2. Record review of Patient #23's History and Physical (H & P) dated 02/24/11, showed the patient was admitted to Behavioral Health on that date with a diagnosis of schizophrenia (a mental illness where people may hear voices other people don't hear and/or believe other people are reading their minds, controlling their thoughts, or plotting to harm them).

Record review of an Event Report dated 03/07/11 showed the following:

-Patient #23 was admitted to the Behavioral Health Unit (BHU) 2C on 02/24/11;
-On 03/07/11 at 10:08 AM Patient #23 became agitated and physically aggressive. The patient began picking up chairs and tables, throwing them. Security placed the patient in a manual hold, along with one mental health technician (MHT) but the patient's behavior became more combative so the patient was placed in handcuffs by security.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 03/07/11, for this patient, showed staff failed to perform the one-hour face-to-face assessment for both this episode of manual hold and handcuffs.

3. Record review of Patient #19's H & P dated 04/24/11, showed the patient was admitted to the BHU on that date with a diagnosis of bipolar disorder (mood swings between abnormally elevated or irritable moods and depression).

Record review of a Comment/Grievance Case Detail Report, dated 05/10/11, showed the following:

-On 04/25/11 at around 9:00 PM, Patient #19 was brought to the Behavioral Health Emergency Department (BHED). Patient #19 and another patient in the BHED had a confrontation. Mechanical restraints were applied to Patient #19 by security.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 04/25/11, for this patient, showed staff failed to perform the one-hour face-to-face assessment for this episode of mechanical restraint.

4. Record review of Patient #27's H & P dated 08/28/11, showed the patient was admitted to the BHU on that date with a diagnosis of bipolar disorder.

Record review of an Event Report, dated 08/28/11, showed the following:

-On 08/28/11 at around 2:18 PM, Patient #27 became agitated on the BHU 2D;
-A responding security officer attempted to calm the patient via verbal techniques, then called for additional officers when this did not occur;
-Before the additional officers arrived, the first security officer took the patient to the ground and handcuffed the patient.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 08/28/11, for this patient, showed staff failed to perform the one-hour face-to-face assessment for this episode of mechanical restraint.

5. Record review of Patient #22's H & P dated 07/30/11, showed the patient was admitted to the BHU on that date with a diagnosis of a mood disorder.

Record review of an Event report dated 08/05/11 showed the following:

-On 08/03/11 at about 2:07 PM Patient #22 refused to take medication and was yelling;
-Three security officers (requested by nursing) held the patient down while staff administered an injection.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 08/03/11, for this patient, showed staff failed to perform the one-hour face-to-face assessment for this episode of manual restraint.

6. Record review of Patient #14's H & P dated 09/10/11, showed the patient was admitted to the BHU on 09/09/11 with a diagnosis of Psychosis (loss of contact with reality, usually including false beliefs about what is taking place or who one is and seeing or hearing things that aren't there).

Review of a Nurses' noted dated 09/09/11, timed 7:39 PM, showed the patient became agitated, banging his/her fist on the Nurses' station desk. Security assisted with a manual hold on the patient so an injection could be administered.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 09/09/11, for this patient, showed staff failed to perform the one-hour face-to-face assessment for this episode of manual restraint.


19957

7. Record review of current Patient #49's H & P dated 08/31/11, showed the patient was admitted to the BHU with a diagnosis of mood disorder, alcohol dependence and anxiety.

On 08/24/11 at 8:25 AM two security officers responded to a Code 13 Distress Alarm (call to security for assistance) from BHU 2C. The report showed:
- Review of a security report dated 08/24/11 showed security handcuffed Patient #49.
- The clinical staff informed the security officers that Patient #49 had barricaded him/herself in his/her room.
- The officers entered the patient room and the patient moved toward them. The officers grabbed the patient and assisted him/her to the floor.
-The patient hit one of the security officers and the officers then handcuffed the patient.

Review of physician's orders for 08/24/11, for this patient, showed staff failed to obtain an order for a manual hold and handcuffs.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 08/24/11, for Patient #49, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

8. Review of a security report dated 01/01/11 at 9:04 PM showed discharged Patient #37 sought treatment in the BHED due to inappropriate behavior. Record review showed security handcuffed Patient #37 on 01/01/11.

Review of the security report showed the following:
- One security officer responded to BHED for medication standby for Patient #37 at 1:25 PM.
- Patient #37 kicked the front door of the ED and a security officer told the patient to stop.
- Patient #37 then turned around and attempted to choke the security officer.
- Security then restrained Patient #37 in an arm lock and then took the patient to the floor and placed handcuffs on the patient.
Review of a BHED evaluation dated 01/01/11 at 3:00 PM showed when the handcuffs were removed staff placed the patient in four point mechanical restraints (all four limbs restrained.)

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 01/01/11, for Patient #37, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

9. Review of discharged Patient #41's ED nursing notes showed the patient presented at the ED 01/04/11 with delusions and bizarre behavior. The patient's mother brought the patient to the hospital and the physician placed the patient on a 96 hour involuntary hold (involuntary treatment under certain conditions with appropriate due process.)

Record review of a security report dated 01/04/11 at 6:09 PM showed security handcuffed Patient #41 on 01/04/11 at 10:42 AM. Review of the security report showed the following:
- Four security officers responded to a call from the ED that Patient #41 was disruptive and not cooperating with staff.
- Security informed patient he/she would need to remove his/her belt and the patient was upset and tried to kick open the entrance door to the ED.
- Security radioed for backup and two additional officers responded.
- Patient #41 attempted to go through the door when the two additional officers arrived.
- The six security officers used physical force to prevent the patient from leaving the ED by taking him/her down to the ground and handcuffing the patient.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 01/04/11, for Patient #41, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

10. Review of discharged Patient #43's progress notes dated 01/13/11 at 4:07 PM showed the patient entered the facility 01/12/11 on a 30 day court order. Prior to admission the patient attempted to hang him/herself with a bed sheet.

Record review of a security report dated 01/27/11 at 4:18 AM showed security handcuffed Patient #43 on 01/26/11 at 8:42 PM. Review of the security report showed the following:
- Two security officers responded to a Code 13 Distress Alarm from BHU 2C.
- Upon arrival security officers observed Patient #43 arguing with staff and the patient refused to return to his/her room. Patient #43 became aggressive and attempted to push one security officer.
- Two security officers gained control of the patient and escorted him/her to the ground and placed the patient in handcuffs.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 01/26/11, for Patient #43, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

11. Review of discharged Patient #42's discharge summary showed the patient entered the facility 01/21/11 due to bizarre behavior. Initially the physician placed the patient on a 96 hour hold and then committed the patient for a 21 day involuntary admission.

Record review of a security report dated 01/25/11 at 11:21 PM showed security handcuffed Patient #42 on 01/25/11 at 3:56 PM. Review of the security report showed the following:
- Three security officers responded to the BHU 2D which requested help with Patient #42 who would not take medication.
- A security officer asked the patient to take the medication and Patient #42 became more irritated and more aggressive.
- One security officer grabbed the patient and redirected his/her body position to the ground.
- A second security officer applied handcuffs to the patient.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 01/25/11, for Patient #42, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

Record review of a security report dated 01/29/11 at 2:13 PM showed security handcuffed Patient #42 on 01/28/11 at 1:13 PM. Review of the security report showed the following:
- Three security officers responded to the BHU 2D which requested help with Patient #42 who was being loud and out of control.
- The patient refused to take medication and attempted to walk away from the security officers.
- Security physically restrained and placed handcuffs on the patient so nursing staff could administer medication.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 01/28/11, for Patient #42, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

Record review of a security report dated 02/11/11 at 5:44 AM showed security handcuffed Patient #42 on 02/10/11 at 10:30 PM. Review of the security report showed the following:
- Two security officers responded to the BHU 2D which requested help with Patient #42 who was being disruptive.
- The patient lunged at the security officers and the officers took the patient down to the floor.
- The security officers placed the patient in handcuffs.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 02/10/11, for Patient #42, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

12. Review of discharged Patient #30's discharge summary showed the patient entered the facility 05/05/11 with a history of schizophrenia and for treatment of threatening behavior.

Record review of a security report dated 07/01/11 at 3:48 AM showed security handcuffed Patient #30 on 06/30/11 at 9:56 PM. Review of the security report showed the following:
- Security responded to a Code 13 Distress Alarm from BHU 2C. Staff reported Patient #30 was hitting his/her head against the wall.
- On arriving on the unit security documented Patient #30 was striking him/herself on the head.
- Security officer told the patient to place his/her hands upon a wall. The patient complied.
- Security then handcuffed the patient and escorted the patient to the restraint room.
- The patient calmed down and security released the patient from the handcuffs.

Review of the nursing documentation dated 06/30/11 at 11:35 PM showed staff placed the patient in a manual hold from 9:40 PM until 9:45 PM. [The] Patient again started to hit him/herself in the head and security was called for assistance and a manual hold was again initiated from 9:56 PM to 10:01 PM. There is no documentation in the nursing documentation that security placed the patient in handcuffs.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 06/30/11, for Patient #30, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

13. Review of discharged Patient #34's H & P dated 05/19/11 showed the patient presented at the ED on 05/18/11. The patient's case worker brought the patient to the ED due to confusing and agitation.

Record review of a security report dated 05/18/11 at 11:48 PM showed security handcuffed Patient #34 on 05/18/11 in the ED. Review of the security report showed the following:
- Two security officers responded to a call from the ED to escort Patient #34 to his/her room.
- When in the hallway Patient #34 attempted to pull away from security and stated he/she wanted to go home.
- Security restrained the patient with handcuffs and then escorted the patient to his/her room. At that point the patient stated that he/she would remain calm and security removed the handcuffs.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 05/18/11, for Patient #34, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

14. Review of discharged Patient #39's discharge summary showed the patient entered the facility 05/26/11 with a history of schizophrenia and for treatment of threatening behavior.

Record review of a security report dated 05/30/11 at 2:57 AM showed security handcuffed Patient #39 on 05/29/11. Review of the security report showed the following:
- Security responded to a Code 13 Distress Alarm from BHU 2D.
- On arriving on the unit security documented Patient #39 was making verbal threats to staff and observed the patient hit a staff member.
- A behavioral health technician and two security officers manually restrained both arms and legs of the patient.
- Security placed Patient #39 in handcuffs and took the patient to the restraint room.
- Staff then placed the patient in five point restraints.

Review of the nursing documentation dated 05/29/11 at 9:05 PM showed staff placed the patient in five point restraints (all four limbs restrained plus a restraint around the waist.) No time of the restraint episode is documented.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 05/29/11, for Patient #39, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

15. Review of discharged Patient #33's H & P dated 06/19/11 showed the patient presented at the ED 06/19/11. The police brought the patient to the hospital because he/she was standing in traffic taking picture of cars and their license plates and was unresponsive to law enforcement.

Record review of a security report dated 06/18/11 at 8:07 PM showed security handcuffed Patient #33 on 06/18/11 at 12:21 PM in the ED. Review of the security report showed the following:
- One security officer responded to a call from the ED that the patient was being disruptive.
- Security attempted to calm the patient down but the patient continued making threats.
- Security called for an additional officer to assist.
- The patient started hitting the exit door and told security he/she could take all of them on and choke them. Both security officers drew their batons (a club of less than arm's length made of wood, plastic, or metal, used to strike, jab, block, bludgeon or aid in the application of arm locks and sometimes, they also are employed as weapons.)
- The two security officers grabbed the patient's arms and took the patient down to the floor.
- Four ED staff members assisted the two security officers in gaining control of the patient and got the patient into a room.
- Security handcuffed the patient.
- The physician then ordered five point restraints.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 06/18/11, for Patient #33, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

16. Review of discharged Patient #32's H & P dated 06/21/11 showed the patient presented at the ED on 06/20/11 following a suicide attempt. The police brought the patient to the hospital.

Record review of a security report dated 06/20/11 at 11:07 PM showed security handcuffed Patient #32 on 06/20/11 at 4:00 PM. Review of the security report showed the following:
- One security officer responded to a call from the ED that the patient attempted to harm him/herself by using his/her shirt to choke him/herself.
- Security grabbed the patient's arm and was able to release the patient's grip from the shirt.
- The patient continued to resist and three additional security officers responded and placed the patient on the ground and placed handcuffs on the patient.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 06/20/11, for Patient #32, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

17. Review of discharged Patient #28's ED nursing notes showed the patient presented at the ED on 07/14/11 for being combative and confused. The patient has a history of schizophrenia.

Record review of a security report dated 07/14/11 at 8:33 PM showed security handcuffed Patient #28 on 07/14/11 at 1:45 PM. Review of the security report showed the following:
- Four security officers responded to a call from the emergency department that a visitor was in the bathroom kicking the toilet and punching the walls.
- On arriving in the ED security documented Patient #28 was not responding to verbal directions from security staff.
- Security attempted to take the person out of the bathroom by taking control of his/her arms. - The patient became physically combative and security attempted to place Patient #28 in handcuffs, but were unsuccessful.
- Security officers requested additional support and three additional officers responded.
- Security then placed Patient #28 in handcuffs.
- Security then transported the patient to an exam room and placed the patient in four point restraints.
- Security documented the patient received an injury during the incident to the right arm.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 07/14/11, for Patient #28, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

18. Review of discharged Patient #40's discharge summary showed the patient entered the facility 08/31/11 following a suicide attempt by overdosing on Phenobarbital (anxiety medication) and Dilantin (seizure medication). The physician placed the patient on a 96 hour involuntary admission.

Record review of an incident report showed security used a baton on the patient and handcuffed Patient #40 on 08/31/11. Review of the incident report showed the following:
- Two security officers responded to inpatient room 443 to escort Patient #40 to the BHU.
- While exiting the lobby of the hospital into parking lot E the patient attempted to run and tried to escape.
- One security officer grabbed the patient's left arm and the officer and the patient fell to the ground. A second security officer grabbed the patient's right arm and placed his/her body on top of the patient to restrict the patient's movement.
- One security officer placed a handcuff on the patient's left wrist. Three additional security officers arrived and one officer used his/her baton and then applied a strong side arm lock to the patient's right arm to assist getting it behind his/her back. The handcuffs were then placed on both wrists.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 08/31/11, for Patient #40, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

19. Record review of the H & P dated 04/21/11 showed Patient #26 entered the facility through the ED on 04/21/11 due to bizarre and paranoid behavior in the group home where he/she lived.

Record review of a security report dated 09/03/11 at 11:18 PM showed security handcuffed Patient #26 on 09/03/11. Review of the security report showed the following:
- Two security officers responded to a Code 13 Distress Alarm from BHU 2D.
- Behavioral health staff informed security Patient #26 hit another patient (#49.)
- One security officer placed Patient #26 in handcuffs.
- Security removed handcuffs and placed patient in four point restraints.
Review of the nursing documentation showed Patient #26 placed in handcuffs from 12:10 PM until 12:45 PM. When staff removed the handcuffs they restrained the patient in four point restraints from 12:45 PM until 3:20 PM.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 09/03/11, for Patient #26, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

20. Review of discharged Patient #44's ED progress notes dated 09/04/11 at 9:31 AM showed the patient entered the ED on 09/04/11 at 6:36 AM. The patient came to the facility by ambulance. The patient was found in the street confused and agitated.

Record review of a security report dated 09/04/11 at 11:58 PM showed security used a Taser device (an electroshock weapon which fires projectiles that administer an electrical current to disrupt voluntary control of muscles; a patient struck by a Taser experiences strong involuntary muscle contractions) four times on the patient, struck the patient three times with a baton and then handcuffed Patient #44 on 09/04/11 at 11:24 AM. Review of the security report showed the following:
- Two security officers responded to a request for assistance in the ED to help with a physically aggressive patient.
- Upon arrival the security officers observed the patient attempting to pull out his/her IV (intravenous therapy is the giving of substances directly into a vein.)
- The patient succeeded in pulling his/her IV out and also broke the saline bag of fluid.
- Two security officers attempted to hold the patient down but the patient broke away and attempted to leave the ED exam room. Four additional security officers arrived to assist with the patient.
- Security officers attempted to take the patient to the ground but were unsuccessful.
- One security office then struck the patient's upper thigh with a baton three times.
- The patient continued to struggle with the security officers and one security officer attempted to put the patient in a wrist lock.
- The security report documents security was unable to restrain the patient due to blood and IV fluid on the floor. One security officer in fear of his/her life created space from the struggle and deployed a Taser into the patient's right front side of the stomach and right upper thigh. The report showed the officer was concerned that the other officers would be harmed while attempting to control the patient due to the large amount of blood and saline making the floor slippery.
- The patient removed the Taser prong that was inserted in his/her thigh.
- The same security officer again deployed a second cycle from the Taser to the patient but it was unsuccessful.
- The patient continued to be combative with the responding officers.
- One security officer then "drive stunned" the patient on his/her back right shoulder. (The Taser is held against the patient without firing the projectiles, and is intended to cause pain without incapacitating the patient. "Drive Stun" is "the process of using the Taser as a pain compliance technique.)
- The security officers then gained control of the patient and applied handcuffs.

Review of physician's progress notes, and search throughout the electronic medical record (by facility staff) for documentation entered on 09/04/11, for Patient #44, showed staff failed to perform the one-hour face-to-face assessment following the restraint episode.

Review of physician's orders dated 09/04/11 at 6:43 AM for this patient, showed an order for four point restraints but no order for a physical hold, a Taser, a baton or handcuffs.

21. During an interview on 09/14/11 at 10:30 AM, Staff R, Medical Director of Behavioral Health, stated that he/she had developed a form for the physicians to use when conducting the face-to-face evaluation on a patient who had been in a restraint. Staff R stated that he/she had not fully implemented the form and needed to do physician education to fully implement the use of the form. Staff R stated that he/she expected all physicians to complete a face-to-face evaluation on all patients who have been in a restraint.

22. During an interview on 09/15/11 at 1:40 PM, Staff U, Psychiatrist, stated that he/she did not conduct face-to-face assessments when a patient is restrained in a manual hold. Staff U stated that he/she did not know it was required when a patient is physically held by staff.