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Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined that the governing body of the hospital failed to ensure that P&Ps and processes were fully developed and implemented that ensured the provision of safe and appropriate care to patients in the hospital and compliance with the Conditions of Participation.

The hospital's failures included:
* The hospital failed to prevent non-law enforcement hospital SOs from applying handcuffs to patients, using excessive force during handcuff application, and detaining patients in a security area hold room until law enforcement arrived. These failures contributed to injuries of at least one patient, Patient 6, and created the likelihood of harm to other patients. The failures related to Patient 6 included: The patient presented to the ED on 03/29/2025 by EMS in four-point restraints with suicidal thoughts, aggressive behavior, and acute agitation. The patient was discharged the next day. Prior to leaving the ED, the patient was banging on walls and spit at an RN. Multiple SOs escorted the patient out of the ED. The patient was described as "verbally inappropriate" toward a SO as they were walking away from the hospital. Security Officers failed to attempt de-escalation techniques and instead escalated the situation by telling the patient to "get your shit and go, dude, bye." The patient turned to face the SO and spit or motioned to spit at the SO, then continued leaving at which point SOs took the patient to the ground on a wet, cement staircase. While holding the patient down one or more SOs punched the patient's torso area at least twice and held the patient's head directly onto a cement stair, first with an open hand, then a knee, and then by stepping on the patient' head. The patient was crying out and stated, "please stop." The patient's neck was near or on the edge of the stair during these activities which lasted approximately 90 seconds. Security Officers told the patient they were "under arrest" and applied metal handcuffs to the patient while still in this position. The patient's head was visibly bleeding after these activities. An ED nurse came out of the ED and briefly assessed the patient's head. The patient was then taken to a security area "hold room" for three hours with handcuffs still in place and held by SOs without monitoring their head injury and other potential injuries until law enforcement arrived. The hospital subsequently determined the use of force was "outside policy."
* The hospital failed to prevent non-law enforcement hospital SOs from deploying tasers on patients for non-criminal activities and applying handcuffs after tasing. The hospital's failures created the risk of harm to at least one patient, Patient 8, and created the risk of harm to other patients. The failures related to Patient 8 included: The patient presented to the ED with complaints that included auditory hallucinations, delusions, and paranoia. The patient was brought in from a mental health program facility by a "caregiver" of that facility. The employee slipped a note to the triage RN stating the patient was being checked in for SI/HI, and for paranoia and hallucinations. At no time during the triage process were SOs alerted to this patient and their associated risks. The patient went through metal detector screening upon entering the ED and an RN took the patient to a room without SO knowledge or presence. The patient was not on a physician hold and when they saw the room, they ran out the ED entrance. At least three SOs followed the patient. Approximately 10 seconds after leaving the ED, the patient stopped in a parking area and turned towards one of the SOs. The patient's right hand was observed behind their back, their left hand was holding a red sack, and the SO was observed to have a taser pointed toward the patient. The patient moved both hands to the front of their body and up toward their chest and head in a flinching, defensive posture. Approximately one second later the patient put both hands behind their back, dropped the red sack and appeared to pull up their pants. The SO was not observed or heard to attempt de-escalating the patient at any time and yelled, "Back the fuck up now or you're going to get tased. Don't reach for anything." Approximately two seconds later, the patient was observed falling toward the ground after the SO released the taser prongs. The patient stated, "I was pulling my pants up." Three SOs pinned the patient face down on the asphalt ground, applied metal handcuffs, put the patient in a wheelchair with the handcuffs still intact, and returned the patient to the ED. The patient did not have a weapon. The patient did not commit a criminal activity, and the incident was not handled as a criminal activity as the patient was not placed in law enforcement custody.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care. On 06/26/2025 at 1350 the hospital was notified that two IJ situations had been determined to exist.

Refer to Tag A-144 for the details of the identification of two IJ situations, IJ notifications, IJ Removal Plan approvals, and IJ Removal Plan Verification Visit. An IJ Removal Plan Verification Visit was conducted on 07/23/2025 and the two IJ situations were determined to be removed.

Findings include:

1. Refer to Tag A-115, CFR 482.13 - CoP: Patient's Rights. The hospital failed to ensure the provision of care in a safe setting (Tag A-144). The hospital failed to ensure patients' rights to be free from all forms of abuse and harassment (Tag A-145).

2. Refer to Tag A-263, CFR 482.21 - CoP: Quality Assessment and Performance Improvement Program. The hospital failed to thoroughly investigate, analyze, trend and develop corrective actions of adverse patient events (Tag A-286). Events included:
* Non-law enforcement hospital SOs handcuffing patients, using excessive force during handcuffing, and detaining injured patients in a security area hold room without appropriate exam and monitoring.
* Non-law enforcement hospital SOs tasing patients who had not committed a criminal activity.

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Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined the hospital failed to ensure that P&Ps and processes were fully developed and implemented that ensured patients received care in a safe setting.
* The hospital's failures caused injuries to Patient 6 who was leaving the ED when SOs applied handcuffs to the patient and used excessive force including stepping on the patient's head and punching the patient's torso area during handcuff application; and detained the patient while still handcuffed in a security area hold room for approximately three hours without appropriate examination and monitoring of the patient's injuries.
* The hospital's failures created the likelihood of serious harm to Patient 8 who was leaving the ED when SOs tased and handcuffed the patient. The patient was not engaging in criminal activity when this occurred.
* The hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur.
* The governing body failed to ensure, through the Quality Assessment and Performance Improvment Program (QAPI), the prevention and reduction of adverse events that included complete and thorough investigations, analyzing findings, and implementing actions to prevent recurrence of those.

This Condition is determined to be out of compliance based on findings that hospital staff failed to attempt de-escalation techniques for Patient 6 who had been discharged and was leaving hospital property. The patient was "verbally inappropriate" and instead of attempting de-escalation, SOs verbally provoked the patient leading to increased behaviors. In response to these behaviors, SOs applied handcuffs, and used excessive force including holding the patient's head and neck on or near a cement stair ledge by stepping on their head. The patient sustained head injuries and was then detained in a security hold room for three hours without appropriate examination, treatment and monitoring of their injuries. Regarding Patient 8, the hospital failed to ensure an ED nurse notified SOs of the patient's behavioral health risks and attempt de-escalation techniques before tasing and handcuffing the patient. The patient had gone through a metal detector in the ED, did not have a weapon, and was not on a physician hold. The patient left the ED and SOs went after the patient. Although the patient had not committed a criminal act, an SO tased and handcuffed the patient and then returned them to the ED.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

On 06/26/2025 at 1350 the hospital was notified that two IJ situations had been determined to exist. Refer to Tag A-144 for the details of the IJ identification, IJ notification, and submission of unsuccessful IJ Removal Plans prior to the exit conference.

Findings include:

1. Refer to the findings cited under this CoP, CFR 482.13(c)(2) - Standard: Privacy and Safety. Those findings reflect that provisions for appropriate management and response of patients with behavioral health symptoms, including but not limited to failure to attempt de-escalation, application of handcuffs by non-law enforcement SOs and tasing patients were not fully developed and implemented and resulted in injury and harm to Patient 6 and likelihood of serious injury and harm to Patient 8 and other patients experiencing similar symptoms (Tag A-144).

2. Refer to the findings cited under this CoP, CFR 482.13(c)(3) - Standard: Privacy and Safety. Those findings reflect that hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur. (Tag A-145).

3. Refer to the findings cited under CoP, CFR 482.21 - QAPI. Those findings reflect that the governing body failed to ensure, through the QAPI program, the prevention and reduction of adverse events that included complete and thorough investigations, analyzing findings, and implementing actions to prevent recurrence of those (Tag A-263).

Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined that the governing body failed to ensure, through the QAPI program, the prevention and reduction of adverse events, complete and thorough investigations, analyzing findings, and formulating and implementing actions to prevent recurrence of those.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under this Condition at Tag A-286 under CFR 482.21(a), (c)(2), (e)(3) - Standard: Patient Safety, that reflects the QAPI program failed to ensure that incidents and adverse patient events were clearly investigated and analyzed, and that corrective actions were subsequently planned and implemented to prevent recurrence of those, to promote learning, and to establish clear expectations for patient safety. Those failures reflect the incidents involving Patients 6 and 8 had not been thoroughly investigated and analyzed to determine corrective actions and corrective actions planned and implemented to address gaps. Patient 6 was injured when handcuffed by non-law enforcement hospital SOs, and Patient 8 was at high likelihood of serious harm when tased and handcuffed by non law-enforcement hospital SOs.

2. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient's Rights, that reflects the QAPI program failed to ensure each patient's rights were protected and promoted, including the right to receive care in a safe setting. Those failures created an unsafe environment that caused patient harm for Patient 6 and created the likelihood of harm to Patient 8 and other patients. Patient 6 was injured when handcuffed by non-law enforcement hospital SOs, and Patient 8 was at high risk for injuries and harm when tased and handcuffed by non law-enforcement hospital SOs (Tag A-144). The hospital further failed to conduct clear and complete investigations of adverse events that addressed all potential gaps and deficient practices, and failed to subsequently develop and implement corrective actions to prevent recurrence for Patient 6, Patient 8, and other patients (Tag A-145).

Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined the hospital failed to ensure that P&Ps and processes were fully developed and implemented that ensured patients received care in a safe setting as follows:
* Regarding Patient 6: The hospital's failures caused injuries to the patient who was leaving the ED when SOs applied handcuffs to the patient and used excessive force including stepping on the patient's head and punching the patient's torso area during handcuff application; and detained the patient while still handcuffed in a security area hold room for approximately three hours without appropriate examination and monitoring of the patient's injuries.
The failures related to the injuries of Patient 6 who was handcuffed on 03/30/2025 included:
- The patient presented to the ED on 03/29/2025 by EMS in four-point restraints with suicidal thoughts, aggressive behavior, and acute agitation. The patient was discharged from the ED the next day.
- Prior to discharge, the patient was banging on walls and spit at an RN.
- Multiple SOs escorted the patient out of the ED.
- The patient was described as "verbally inappropriate" toward an SO as they were walking away from the hospital. Security Officers failed to attempt de-escalation techniques and instead escalated the situation by telling the patient to "get your shit and go, dude, bye."
- The patient turned to face the SO and motioned to spit or spat at the SO, then continued leaving at which point SOs took the patient to the ground on a wet, cement staircase. While holding the patient down one or more SOs punched the patient's torso area at least twice and held the patient's head directly onto a cement stair, first with an open hand, then a knee, and then by stepping on their head. The patient was crying out and stated, "please stop." The patient's neck was near or on the edge of the stair during these activities which lasted approximately 90 seconds. Security Officers told the patient they were "under arrest" and applied metal handcuffs to the patient in this position.
- The patient's head was visibly bleeding after these activities.
- An ED nurse came out of the ED and briefly assessed the patient's head.
- The patient was then taken to a security area "hold room" for three hours with handcuffs still in place and held by SOs without monitoring of their head injury and other possible injuries until law enforcement arrived.
- The hospital subsequently determined SOs' use of force was "outside policy."

* Regarding Patient 8: The hospital's failures created the likelihood of serious harm to the patient who had left the ED when SOs tased and handcuffed them.
The failures related to Patient 8 who was tased and handcuffed on 04/06/2025 included:
- The patient presented to the ED with complaints that included auditory hallucinations, delusions, and paranoia.
- The patient went through metal detector screening upon entering the ED.
- The patient was brought in from a mental health facility by an employee of that facility. The employee slipped a note to the ED triage RN stating the patient was being checked in for SI/HI, paranoia and hallucinations. At no time during the triage process were SOs alerted to this patient and their associated risks.
- An RN took the patient to an ED room without SO presence or knowledge.
- The patient was not on a physician hold.
- When the patient saw the ED room, they ran out the ED entrance, and at least three SOs followed the patient.
- Approximately 10 seconds after leaving the ED, the patient stopped in a parking area and turned towards one of the SOs. The patient's right hand was observed behind their back, their left hand was holding a red sack, and the SO was observed to have a taser pointing toward the patient. The patient moved both hands to the front of their body and up toward their chest and head in a flinching, defensive posture.
- Approximately one second later the patient put both hands behind their back, dropped the red sack and appeared to pull up their pants. The SO yelled, "Back the fuck up now or you're going to get tased. Don't reach for anything."
- Approximately two seconds later, the patient was observed falling toward the ground after the SO released the taser prongs. The patient stated, "I was pulling my pants up."
- Three SOs pinned the patient face down on the asphalt ground, applied metal handcuffs, put the patient in a wheelchair with the handcuffs still intact, and returned the patient to the ED.
- The patient did not have a weapon.
- The patient did not commit a criminal act, and the incident was not handled as criminal activity as the patient was not placed in law enforcement custody.
- No attempts to de-escalate the patient's behaviors prior to tasing and applying handcuffs were observed or heard.
* The hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur.

As described above in this tag and at findings 1.a. through 4.a. below in this tag it was determined that two IJ situations existed, one involving Patient 6 and one involving Patient 8. On 06/24/2025 at ~ 1305 the SA survey team met with the SA Survey Manager to review survey findings for potential IJ. On 06/26/2025 at 1430, hospital leadership staff were presented with two IJ templates. Two IJ Removal Plans submitted on 06/30/2025 (with an "amendment" submitted for one of those on 07/01/2025) and 07/03/2025 were not approved. An exit conference for the full survey was conducted on 07/11/2025 at 1000 before an acceptable IJ Removal Plan was received by the hospital. IJ Removal Plans submitted on 07/11/2025 at 1554, and 07/16/2025 were not acceptable and were not approved. The fifth IJ Removal Plans submitted on 07/17/2025 were determined to be acceptable and were approved. The details of the approved IJ Removal Plans with implementation dates of 07/22/2025 at 1200 included:
The IJ Removal Plan regarding Patient 6 included but was not limited to:
* "Handcuffs will not be used by staff on the hospital campus/property. Handcuffs will no longer be carried by any security officers."
* "Patients with behavioral health symptoms in the hospital with an already identified electronic medical record Risk for Violence (RFV) alert, or those that have a newly identified need for this RFV alert to be placed, will trigger an immediate notification by the direct care RN (DCN) to the charge RN, who will initiate a huddle with the supervising security officer and the hospital nursing supervisor or nurse leader ... to develop a proactive patient safety plan (to include triggers, de-escalation tips, team approach, and patient specific interventions to maintain safety, etc.). This interprofessional team (DCN, charge RN, security supervisor, hospital nursing supervisor or nursing leadership) will utilize the Pre-Code Gray process to develop a proactive patient safety plan ..."
* "The proactive patient safety plan will utilize a paper checklist that will be shared with security, patient access services/registration, and involved nursing teams ..."
* "Education regarding this IJ Removal Plan will be provided and attested to by security, hospital nursing supervisors, nurses, patient access services/registration staff, ED providers, hospitalists, and psychiatrists at the start of their next respective shifts ..."
* "Security officer education will include ... De-escalation techniques with emphasis of the importance of their use ... Prioritizing retreat and/or back away and the importance of de-escalation tactics ..."
* "Education will be provided to nurses, hospital nursing supervisors, nurse leaders (nurse managers, assistant nurse managers, and nursing directors) specific to identifying patients presenting with behavioral health symptoms and who have been determined to be at risk for violence and the process of notifying the hospital nursing supervisor or nurse leader and supervising security officer ..."
* "Education for the patient access/registration team ..."
* "An overview of the proactive patient safety plan process and the cessation of handcuff use will be provided to ED providers, hospitalists, and psychiatrists as part of the IJ Removal Plan provider education."
* "The hospital implemented an executive and security huddle. This executive and security huddle started on April 23, 2025, occurs daily ... and includes at least one of: the chief executive officer, chief nursing officer (or designee), chief medical officer, or chief operating officer, plus the quality director (or designee) and security manager (or designee). At least one member of the huddle team will be a RN. The review will additionally now include a review of security reports and confirmation that responses were in alignment with the IJ removal plan ..."

The IJ Removal Plan regarding Patient 8 included but was not limited to:
* "Tasers will only be used when an individual is threatening with a weapon or actively physically assaulting in a manner that is a threat to life (such as choking another individual in a way that presents an imminent risk of serious bodily injury or death, brandishing a lethal weapon or actively stabbing another individual) and that cannot be managed using the standard de-escalation methods ... Tasers will not be used to manage spitting, hitting, yelling, agitation, or elopement. Following taser deployment, the individual will be taken to the Emergency Department and offered a medical screening exam, to comply with EMTALA requirements. Law enforcement will be immediately notified, as will security leadership and the hospital nursing supervisor."
* "In the Emergency Department, patients that present to the ED with behavioral health symptoms, such as a risk of harm to self or others, will trigger an immediate notification by the ED RN to the ED charge RN, who will partner with the security team to develop a proactive plan to safely transition the patient to an appropriate treatment space ..."
* "If the ED RN has concerns that the patient may elope prior to arriving to the room, this would be included in the ED RN and security team communication and documentation, a plan will be put into place prior to transitioning the patient to their room, and escalation to an ED provider for immediate assessment will occur. The security officer involved will radio communication to other security officers in the ED, alerting to the presence and location of an elopement risk patient. The ED RN and security team communication will be documented on a paper checklist and kept with the security officer located at the ED security triage desk ... Security will convey this checklist information with their team during handover and shift reports ..."
* "Handcuffs will not be used by staff on the hospital campus/property. Handcuffs will no longer be carried by any security officers."
* "These expectations will be outlined in a document that will be reviewed and attested to by security, ED nurses, hospital nursing supervisors, ED leadership, patient access services/registration staff, and ED providers during their respective shifts."
* "The hospital implemented an executive and security huddle. This executive and security huddle started on April 23, 2025, occurs daily ... and includes at least one of: the chief executive officer, chief nursing officer (or designee), chief medical officer, or chief operating officer, plus the quality director (or designee) and security manager (or designee). At least one member of the huddle team will be a RN. The review will additionally now include a review of security reports and confirmation that responses were in alignment with the IJ removal plan ..."

An onsite IJ Removal Verification Visit was conducted on 07/23/2025 and the SA determined that the two IJ Removal Plans had been implemented.

Findings include:

1.a. Patient 6's medical record was reviewed and reflected the patient presented to the ED on 03/29/2025 at 1654 by ambulance with chief complaints that included suicidal thoughts and aggressive behavior.
* An RN note dated 03/29/2025 at 1658 reflected "Thoughts of Violence Towards Others Any Threats or Attempts to Harm Others this Shift?: Yes ... ([patient] has demonstrated behaviors that [patient] will be a risk for violence towards staff. [Patient] unwilling to agree to be safe at this time.) ... Attention Span: Distracted Mood: Angry; Agitated; Irritable; Labile Affect: Hostile Thought Process: Rambling; Impaired judgement; Irrelevant Thought Content: Preoccupied Behavior: Agitated; Aggressive."
* An RN note dated 03/29/2025 at 1706 reflected "[Patient] agrees to be medicated but refuses zyprexa. When RN offers the zyprexa, the [patient] purposefully knocked medication out of RNs hands."
* An RN note dated 03/29/2025 at 1707 reflected "Medication Not Given ... [patient] knocked it out of RNs [sic] hand and refused to take it. Security with RN at this time."
* A Social Worker note dated 03/29/2025 1717 reflected the patient "... appears to be responding to internal stimuli as evidenced by [them] talking and gesturing to [themselves] ... [They are] oriented to self and place but cannot give any additional orienting information. [They struggle] with relaying history, [are] internally preoccupied and [appear] increasingly agitated and aggressive as the interview progresses. I attempt to obtain a lay caregiver, [they tell] me 'call Cascadia,' [they then spit] and [hit their] pillow on the bed ... Mental Status Exam ... Dress/Grooming/Appearance: disheveled, older than stated, and unkempt Behavior: psychomotor agitation, hyperactive, agitated, restless and fidgety, and grimacing Attitude and Participation: guarded, hostile, and aggressive Mood: irritable and agitated Affect: increased in intensity, inappropriate laughter, and heightened Orientation: self/place Speech: rambling, mumbled, and Impoverished Thought Processes: disorganized and Impoverished Thought Content: delusional and suicidal Insight and Judgement: suspect impairment due to substance use and actions demonstrate poor judgement."
* An RN note dated 03/29/2025 at 1730 reflected "[Patient] is escalated banging on the door with [their] fists and yelling out nonsensical words. [Patient] unable to be redirected. [Patient] posturing and spitting at the RN while continuously yelling ..."
* An RN note dated 03/29/2025 at 1924 reflected "Safety/[Behavioral Health] Potential for violence during this ED visit? ... Yes Per report of previous RN, [patient] slapped med out of hands and was spitting at staff ... Standby Staff: Security".
* An RN note dated 03/29/2025 at 2033 reflected "Violence Risk Mitigation Note for use with Risk for Violence (RFV) FYI Alert ... Lengthy history of arrests for domestic violence, assault, public indecency ... history of violence and inappropriate sexual behaviors in medical settings towards peers and staff as well as in the community. [Patient] has a diagnosis of schizoaffective disorder vs. Bipolar with psychosis and substance abuse."
* An RN note dated 03/30/2025 at 0800 reflected "... [patient] out of room, agitated, demanding coffee, asking to go to the restroom. [Patient] went to bathroom and declined to provide a urine specimen. [Patient] more agitated and screaming expletives at staff. MD aware of this and medications to be ordered. [Patient] noted to come out of room and posture at staff, [sic] [Patient] secluded in room and sitter at bedside ..."
* An RN "Violent Restraint or Seclusions Face to Face Assessment" note dated 03/30/2025 at 0831 reflected "Patient displayed the following behaviors verbal threats; physical threats ... Patient will remain in restraints until they meet criteria for discontinuation including no displays of harm to self or others."
* A Social Worker note dated 03/30/2025 at 1205 reflected the patient "... is now presenting as cooperative, and denies SI, HI, AH/VH, and paranoid ideation. Substances seem to have metabolized ... The patient does not meet criteria for [physician hold] and will be discharged home ... [Patient] was discharged to return to the Salvation Army shelter via public transportation."
* An RN note dated 03/30/2025 at 1751 reflected "Patient discharged ... verbalizes understanding of instructions ... Denies [homicidal ideation and suicidal ideation]. Refused to clean feet when offered, wanted to take shower, when informed that the shower was out of order [they were] noted to call this writer a "[expletive] with green blood." Security on standby to escort patient out of ambulance bay ..."
* The record reflected the patient discharged on 03/30/2025.
Although the medical record reflected the patient had a known history of challenging behaviors and violence, and exhibited behaviors throughout their ED encounter, including spitting at staff, aggression, knocking medications out of a nurse's hands, posturing, yelling, banging on a door, and verbally inappropriate comments, there was no documentation of plans or communication between ED staff and SO staff to manage and de-escalate those behaviors during SO escort from the ED.

1.b. Review of SO body camera footage on 06/16/2025 beginning at ~ 1500 with hospital staff that included the CMO, DON, DAR, QD and SDS confirmed that on 03/30/2025:
* Patient 6 was escorted out of the ED by SOs and was leaving the hospital property.
* The patient approached a wet, cement staircase outside.
* The patient made a verbal comment to an SO. The SO responded, "Get your shit and go, dude ..."
* The patient turned to face the SO and spit or motioned to spit at the SO, then continued leaving.
* Multiple SOs took the patient to the ground on the cement staircase. While holding the patient down, one or more SOs punched the patient at least twice in the torso area. The patient was crying out and stated, "Please stop" as SOs were holding the side of the patient's head directly onto a cement stair with their hand and then their knee; and then stepping on the patient's head with the left side of the patient's head directly on the cement stair. The patient's neck was near or on the edge of the stair during these activities which lasted approximately 90 seconds. An SO stated, "You're under arrest." No efforts to de-escalate the patient's behaviors were observed at any time during these activities.
* SOs applied metal handcuffs to the patient and then assisted them to a standing position and into a wheelchair with the handcuffs still in place. The left side of the patient's head was visibly bleeding.
* An ED nurse came out of the ED and appeared to assess the patient's head.
* The patient was not observed to be taken back inside the ED at any time.

1.c. Incident documentation for Patient 6 was reviewed and reflected that on 03/30/2025 at 1730 "Patient was discharged from ED, being escorted out by security officers. Patient was verbally inappropriate toward officers and was leaving property. Security Officers [name] made a comment to the patient in a derogatory manner which prompted the patient to stop. Patient turned, spat at officer [name], then turned again and began leaving. Officers [two names] initiated arrest, taking patient to the ground, landing on staircase at edge of property leading from Ambulance Bay to Glisan street. Patient sustained injury to [their] face, and was arrested. Patient sustained two punches to the side, by officer [name], and [their] head was stepped on by officer [name]. Patient was seen for facial injury briefly by ED staff, then taken to be held until Police arrival." The "Manager Review" section reflected "A use of force review was completed for this event ... The use of force was deemed outside policy."

1.d. "Use of Force Review" documentation regarding Patient 6 included:
* "Review Summary ... Officers affected an arrest on a discharged patient who spit at an officer. Upon investigation of the event, it was found that possibly inappropriate force was used during the arrest, and that the arrest was the cause of prior interaction from security officers."
* Documentation of an interview with an SO who was involved in the incident reflected:
- "What was your impression of the other involved officers' response to the event? 'I tried to pull [SO name] off [Patient 6]. [SO name] appeared to be hitting [Patient 6] in the back and ribs out of frustration. I was shocked ..."
- "Did you witness any unnecessary use of force in your opinion? 'Yes. [SO name] was violent.' '[SO name] said in the office when we were talking about it that [they] punched [Patient 6] in the kidney.' [In regard to [SO name] foot being on the subject's head] 'You could tell pressure was being placed, you could see the skin on [Patient 6's] face moved and it was white.'"

1.e. During interview on 06/16/2025 at 1515 the QD provided the following information regarding Patient 6:
* The SOs involved in the handcuff incident were non-law enforcement hospital SOs.
* After the handcuff incident, staff never took the patient inside the ED and the patient was never evaluated by a physician or other LIP following the incident.
* Security Officers took the patient to a security area hold room where they were "held" until police arrived and removed the patient from the hospital campus.
* The QA had no information about the patient's outcome after being taken to the security hold room, including consideration of the head injury and "two punches to the side" the patient incurred during the incident.

1.f. Email documentation from the QD dated 07/09/2025 at 1255 reflected that Patient 6 was in the security area hold room for three hours before law enforcement arrived.

1.g. Email documentation from the QD dated 07/10/2025 at 0737 reflected:
* In response to the question, "Were any staff assigned to monitor the patient while they were in the security hold room? If so, what was their title and what sort of monitoring occurred ..." the QD wrote "Yes, there was a Senior Security Officer (SSO) assigned to monitor the individual that was in the hold room the entire time. One SSO was relieved by another SSO during shift change but [Patient 6] was being monitored the entire time so constant visual monitoring. The SSO checked for capillary refill to ensure the handcuffs were not too tight and double checked to ensure the handcuffs were double locked which ensures the handcuffs can't tighten. Capillary refill was in good range which is 1-3 seconds." There was no documentation that reflected hospital staff monitored the patient's head injury or other potential injuries incurred during the handcuff incident including but not limited to being punched by a SO in the torso area, nor monitoring related to having handcuffs applied for at least three hours, such as impaired skin integrity.
* In response to the question, "Did the patient remain handcuffed while in the security hold room?" the QD wrote, "Yes, the practice is that handcuffs remain on the individual until law enforcement arrives."
* In response to the question, "Does the hospital have a [P&P] for how patients are managed and monitored while in the security hold room? If so, please provide. If not, please confirm" the QD wrote "No policy that specifically addresses the PPMC security hold room. The arrests by Security Officers policy ... outlines post arrest protocols."

2.a. Patient 8's medical record was reviewed and reflected the patient presented to the ED on 04/06/2025 at 2017 with a caregiver and chief complaint of anxiety.
* An RN triage note 04/06/2025 at 2018 reflected "Denies any SI or HI. Per caregiver, [patient] is AH, delusions and paranoia. Stated difficulty getting [patient] to come to ER ... Providence has a no weapons policy, Do you currently have any weapons, of any type, in your possession: no ... Has the patient had metal detection screening via metal detector or wand?: yes."
* An RN note dated 04/06/2025 at 2035 reflected "RN brought [patient] back to the room, [patient] calm and cooperative [sic], when [patient] saw the room [they] said "oh fuck no" and turned around and proceeded to walk towards the exit and when RN stated '... you cannot leave you need to be seen by a doctor,' [patient] said 'this is where they [tortured] my son,' [patient] saw security at metal [detector] and started running, due to safety concerns of this incident and escalating behavior of the [patient], RN informed security [patient] could not leave without being assessed by MD code grey called. Per security, [patient] appeared to reach behind towards the back of [their] waist band, security then tazed [patient] transferred to wheel chair and brought to room to be medically cleared."
* A Social Worker note dated 04/06/2025 at 2224 reflected "Presenting Problem: Patient ... with a primary mental health history of meth induced psychosis, Bipolar Disorder, and Meth Use Disorder who was brought in by case manager with a chief complaint of increasing anxiety, difficulty urinating ... and abdominal pain ... Patient then began discussing how security tased [them] and how mad [they were]. Patient exclaimed [they have] a heart problems [sic] and [security guard] knows that patient struggles with a heart condition ... patient tried to elope from ED tonight and fled to the parking lot where an altercation ensued and patient was tased. Access to weapons: Patient denied having access to a weapon."
* A Social Worker note dated 04/07/2025 at 0946 reflected "... [Patient] reports belief that the security officer who tazed [them] did it on purpose right at [their] heart with knowledge that [they have] heart problems. The [patient] said that [they are] going to sue the hospital for [their] being tazed and forced to stay against [their] will ... I consulted with Dr. [name] who evaluated the [patient] and agrees that the [patient] does not meet criteria for continued hold in the hospital against [their] will ... The patient does not meet criteria for [physician hold] and will be discharged home ..."
* An RN note dated 04/07/2025 at 0956 reflected "Patient discharged safely to Home ... [Patient] ambulates out of [ED] with a steady gait."

2.b. Review of SO body camera footage regarding Patient 8 on 06/16/2025 beginning at ~ 1520 with hospital staff that included the CMO, DON, DAR, QD and SDS confirmed that on 04/06/2025:
* The patient ran out of the ED entrance and at least three SOs went after the patient.
* Approximately 10 seconds after leaving the ED, the patient stopped and turned towards one of the SOs. The patient's right hand was observed behind their back, their left hand was holding a red sack, and an SO was observed to have their taser pointing toward the patient.
* The patient moved both hands to the front of their body and up toward their chest and head in a flinching, defensive posture.
* Approximately one second later, the patient put both hands behind their back, dropped the red sack and appeared to pull up their pants.
* The SO was not observed or heard to attempt de-escalating the patient and yelled, "Back the fuck up now or you're going to get tased. Don't reach for anything." Approximately two seconds later, the patient was observed falling towards the ground after the SO released the taser prongs.
* The patient stated, "I was pulling my pants up."
* Three SOs pinned the patient face down on the asphalt ground, applied metal handcuffs and put the patient in a wheelchair with the handcuffs still intact.
* The patient was not observed committing a criminal activity prior to being tased or at any time.

2.c. Incident documentation for Patient 8 was reviewed and reflected that on 04/06/2025 "... [patient] checked into ED with caregiver from outpatient bridge program. Per EPIC triage note: '[Brought in by] caregiver. [Complaints of] increasing anxiety. No relief [with] meds. Denies any SI or HI. Per caregiver, [patient] is AH, delusions and paranoia. Stated difficulty getting [patient] to come to ER.' The patient denies any weapons in their possession and did go through the metal detector. The patient was triaged with [chief complaint] of Hallucinations, Paranoid [and] Anxiety. ESI Level 2. Denied HI/SI to triage RN. Per the notes it appears that the patient was walked to Room [number] where [they] decided that [they] did not want to stay and turned to leave. The patient was able to walk out of ED, past the metal detector, with ED staff following. The security officers in the breezeway were told the patient couldn't leave and they ran after the patient to get [them] to return. The patient was tased in the parking lot and returned to the ED."
* The "...extent of harm at time of event" section reflected "Temporary or minor/moderate injury."
* The "Which category best describes the type of event or unsafe condition" section reflected "Patient Security."
* The "Manager Review" section reflected "QM review initiated after report at safety huddle. Event remains under review. A thorough use of force review is currently underway for the taser deployment. Security was not informed of this patient after arrival to ED, or about this patient being checked in for suicidal/homicidal ideation. Security was first alerted to this patient as [the patient was] walking out the ED front entry, [followed] by a nurse advising [the patient that they] could not leave. The nurse then told 2 security officers that were at the metal [detector] that [Patient 8] was not safe to leave. When the patient heard this, [the patient] proceeded to run ... two security officers perused [sic] on foot after the patient in attempt to detain and bring back to the ED. The patient then stopped running, turned towards Security, stated, 'What's up motherfucker,' and began walking towards the two security officers. At the same time, the patient began reaching behind [their] back towards [their] waistline area. One officer drew [their] taser, fearing the patient may produce a weapon and have intent to cause physical harm. Security commanded to patient to stop ... Due to perceived threat, the patient was tased ... security officers responded and assisted with placing the patient into handcuffs for their safety. A wheelchair was retrieved, and the patient was brought back inside the ED ... Security notified the House Supervisor, as well as Portland Police to alert them of the taser deployment. Police took the info but did not respond. After being brought back to the ED, it was then learned by Security this patient was brought in from a mental health facility by an employee of that facility. That employee slipped a note to the triage RN stating the patient was being checked in for SI/HI, and for paranoia and hallucinations. At no time during the triage process was Security alerted to this patient and [their] associated risks. Nursing staff escorted the patient to room [number] without Security knowledge or presence, the patient saw room [number] and refused to go in and then eloped towards the ED entry. I feel this is a gap in communication between nursing and security. The initial use of force review has been completed and the use of taser force has been deemed justified."

2.d. During an interview on 06/23/2025 at 0905 with SDS, QD and MOS, the following information was provided regarding Patient 8:
* MOS stated the caregiver who brought the patient to the ED "slipped a note" to the triage nurse about the patient's symptoms. Typically security is alerted when this happens for general awareness, to monitor the patient, and to walk with the nurse and patient to an ED room. The MOS acknowledged this did not happen. Refer to finding 2.c. above in this tag that reflects there was a gap in communication between nursing and SO staff because SO staff were not notified of the patient's SI/HI and other risks.
* The QD stated the process of ED staff alerting SOs of patients at risk of leaving the ED is described in the AMA policy. Refer to finding 3.d. in this tag regarding the AMA policy.
* MOS stated the patient was handcuffed after being tased because they were "verbally adamant" and the SOs perceived this as a threat. The MOS s

40575


Based on interviews, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital Security Officers (SOs) (Patients 4, 6, 8, 9, 11, 12 and 13), review of P&Ps, and review of other documentation, it was determined that the hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur.

Findings included:

1. The P&P titled "Event Reporting and Response Policy and Procedure" dated last revised "01/2024" was reviewed. It reflected:
* "Each of us play a critical role in ensuring patient, caregiver, and organizational safety. All Providence Workforce Members are expected to follow our High Reliability behavior of Speaking Up for Safety. In doing so, together we can move towards reliability and zero harm for all."
* "This policy describes the expectations and procedures for identifying and responding to Safety Concerns including reporting, analyzing, tracking, trending, resolving, and following up on events with established committees, boards, and state/federal agencies. The intent of this policy is to reinforce consistent processes and practices with the goal of reducing risks and improving safety for all."
* "Event Reports are investigated, and actions are taken to reduce risk and increase safety. Specific actions may include (but are not limited to) corrective and/or preventative actions and action plans, cause analysis RCA or ACA), performance improvement and/or tracking and trending."
* "The department's core leader or their designee is responsible for reviewing every Event Report generated within their department to ensure thorough understanding and response to each. Additional reviewers may be assigned to contribute to the investigation and follow-up for events as needed."
* "Workforce Members should report any Safety Concerns including any occurrence or condition that is a deviation from generally accepted performance standards and/or inconsistent with safe operations of the health care system or the safe care of a particular patient."
* "All events are investigated at the department level by the department core leader or their designee. Events that meet state or regulatory criteria are escalated for investigation by the Quality Team. Unit/department core leaders will request consultation from the Quality Team if additional support is necessary or the investigation uncovers complexities that need further attention and expertise."
* "After the electronic Event Report has been entered, it is assigned to the designated core leader(s) of the unit(s)/department(s) involved for review, investigation, and appropriate follow-up. The department where the incident or near miss occurs will document the investigation and any follow-up actions in the ERS. If the ministry/facility allows core leaders to lock (close) an event, those core leaders would utilize the Safety Event Classification scale to classify event and complete additional fields prior to locking the event."

2. The P&P titled "PHSOR Workplace Violence Prevention" dated last revised "05/2024" was reviewed. It reflected:
* "PHSOR is committed to preventing workplace violence (WPV) and to maintaining a safe work environment. As such, PHSOR has adopted the following policy regarding violent behaviors, identifying our expectation for responding to, mitigating, and reporting violence in the workplace."
* "In keeping with our mission and values, PHSOR is committed to providing a safe and secure workplace and an environment free from violence. PHSOR does not tolerate violence. Violent incidents are taken seriously and thoroughly investigated."
* "Security: Security will be responsible for conducting an immediate post event team debrief following every Code Gray event. Security will also conduct a threat assessment when a potential risk is proactively identified, as needed."

3. The P&P titled "Use of Defensive Tools" dated last revised "09/2024" was reviewed. It reflected:
* "Purpose: While on duty a Providence security officer may be called upon to use force to resolve a threatening situation. Providence security officers are issued specific defensive tools and given specific training so that this force and these defensive tools will be applied in a legally recognized manner. This policy provides oversight for Providence security officers utilizing authorized defensive tools."
* "Threat means any person, animal, or object controlled by a person that is presenting a danger to themselves or others, or; any person resisting arrest or being lawfully controlled ..."
* "Restraints are specific equipment designed for restraint to include chained or hinged metal handcuffs as well as medical restraints or Posey devices."
* "If a defensive tool is used to protect people or property from harm, the situation should be handled as criminal activity and law enforcement should be notified. No defensive tool shall be applied to any person without legal justification."
* "Notification and Reporting: In the event that a defensive tool is used or presented for use, as soon as practical, the security officer will notify Security Leadership. Security Leadership will notify law enforcement ... A Security Incident Report will be completed prior to the end of the reporting officer's shift ... This report will document the conditions and rational for the use ... Security Leadership will conduct a formal review of these events in timely manner."

4.a. Workplace Violence Incident documentation for Patient 4 was reviewed and reflected on 03/03/2025 "Patient was disruptive in the ED and bypassing access control into the department. After staff verbally enforced expectations and policy, [they] threw [their] blanket at and shoved security. [Patient 4] was then placed under arrest, during which [they] hit and kicked [SO] until handcuffs were secured."
* The "General Type of Injury" section reflected "Workplace Violence."
* The "Workplace Violence Event Category" section reflected "Physical Attack without weapon."
* The "Physical Attack without weapon" section reflected "Kicking, Punching/Slapping."
* The "Manager Review" section reflected "[Manager name] found no gaps is [sic] procedures in my investigation of this event. This patient was upset at the long wait time in the ED."

4.b. "Use of Force Review" for Patient 4 was reviewed and reflected:
* The "Review Summary" section reflected "A patient in the emergency department triage lobby assaulted a security officer and was arrested."
* Three SO's Interview Summaries.
* The "Witness Interview Summary" section reflected "None."
* The "Review Findings:" section reflected "... the entire Security team present at the event, acted within ... Providence Policy - Yes, Providence Mission and Core Values - Yes."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&Ps. For example:
* The documentation was unclear whether the patient had an EMC.
* There was no documentation that reflected if there was harm to the patient.
* The "Use of Force Review" did not reflect that body camera footage was reviewed and did not have any witness listed.
* The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs.
* There was no investigation that reflected whether abuse and neglect were ruled out.
* There was no documentation of further follow up actions.

5.a. Refer to finding 1.b. under Tag A-144 that reflect:
* Patient 6 was escorted out of the ED by SOs and was leaving the hospital property.
* The patient approached a wet, cement staircase outside.
* The patient made a verbal comment to an SO. The SO responded, "Get your shit and go, dude ..."
* The patient turned to face the SO and spit or motioned to spit at the SO, then continued leaving.
* Multiple SOs took the patient to the ground on the cement staircase. While holding the patient down, an SO punched the patient at least twice in the torso area. The patient was crying out and stated, "Please stop" as SOs were holding the side of the patient's head directly onto a cement stair with their hand and then their knee; and then stepping on the patient's head with the left side of the patient's head directly on the cement stair. The patient's neck was near or on the edge of the stair during these activities which lasted approximately 90 seconds. An SO stated, "You're under arrest." No efforts to de-escalate the patient's behaviors were observed at any time during these activities.
* SOs applied metal handcuffs to the patient and then assisted them to a standing position and into a wheelchair with the handcuffs still in place. The left side of the patient's head was visibly bleeding.
* An ED nurse came out of the ED and appeared to assess the patient's head.
* The patient was not observed to be taken back inside the ED at any time following these activities.

5.b. Incident documentation for Patient 6 was reviewed and reflected that on 03/30/2025 at 1730 "Patient was discharged from ED, being escorted out by security officers. Patient was verbally inappropriate toward officers and was leaving property. Security Officers [name] made a comment to the patient in a derogatory manner which prompted the patient to stop. Patient turned, spat at officer [name], then turned again and began leaving. Officers [name and name] initiated arrest, taking patient to the ground, landing on staircase at edge of property leading from Ambulance Bay to Glisan street. Patient sustained injury to [their] face, and was arrested. Patient sustained two punches to the side, by officer [name], and [their] head was stepped on by officer [name]. Patient was seen for facial injury briefly by ED staff, then taken to be held until Police arrival."

* The "... extent of harm at time of event" section reflected "Temporary or minor/moderate injury."
* The "Which category best describes the type of event or unsafe condition" section reflected "Patient Behavior."
* The "Manager Review" section reflected "A use of force review was completed for this event ... The use of force was deemed outside policy."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&Ps. For example:
* The documentation was unclear whether the patient involved in the incident was examined and the specific type of injury or injuries.
* The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs.
* There was no investigation that reflected whether abuse or neglect were ruled out.
* There was no documentation of further follow up actions.

6.a. Incident documentation for Patient 8 was reviewed and reflected that on 04/06/2025 "35yo [sex] pt checked into ED with caregiver from outpatient bridge program. Per EPIC triage note: 'BIB caregiver. C/o increasing anxiety. No relief c [sic] meds. Denies any SI or HI. Per caregiver, pt is AH, delusions and paranoia. Stated difficulty getting pt to come to ER.' The patient denies any weapons in their possession and did go through the metal detector. The patient was triaged with CC of Hallucinations, Paranoid & Anxiety. ESI Level 2. Denied HI/SI to triage RN. Per the notes it appears that the patient was walked to Room #14 where [they] decided that [they] did not want to stay and turned to leave. The patient was able to walk out of ED, past the metal detector, with ED staff following. The security officers in the breezeway were told the patient couldn't leave and they ran after the patient to get [them] to return. The patient was tased in the parking lot and returned to the ED."

* The "...extent of harm at time of event" section reflected "Temporary or minor/moderate injury."
* The "Which category best describes the type of event or unsafe condition" section reflected "Patient Security."
* The "Manager Review" section reflected "QM review initiated after report at safety huddle. Event remains under review. A thorough use of force review is currently underway for the taser deployment. Security was not informed of this patient after arrival to ED, or about this patient being checked in for suicidal/homicidal ideation. Security was first alerted to this patient as [they were] walking out the ED front entry, following by a nurse advising [them they] could not leave. The nurse then told 2 security officers that were at the metal detection that [Patient 8] was not safe to leave. When the patient heard this, [they] proceeded to run ... two security officers perused [sic] on foot after the patient in attempt to detain and bring back to the ED. The patient then stopped running, turned towards Security, stated, "What's up motherfucker and began reaching behind [their] back towards [their] waistline area. One officer drew [their] taser, fearing the patient may produce a weapon and have intent to cause physical harm. Security commanded the patient to stop ... Due to perceived threat, the patient was tased ... security officers responded and assisted with placing the patient into handcuffs for their safety. A wheelchair was retrieved, and the patient was brought back inside the ED ... gap in communication between nursing and security. The initial use of force review has been completed and the use of taser force has been deemed justified."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&Ps. For example:
* There was no investigation that reflected Security Officers were interviewed.
* The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs.
* There was no investigation that reflected whether abuse and neglect were ruled out.

6.b. Refer to finding 2.b. cited under Tag A-144 that reflects:
Review of SO body camera footage regarding Patient 8 on 06/16/2025 beginning at ~ 1520 with hospital staff that included the CMO, DON, RD, QD and SDS confirmed that on 04/06/2025:
* The patient ran out of the ED entrance and at least three SOs went after the patient.
* Approximately 10 seconds after leaving the ED, the patient stopped and turned towards one of the SOs. The patient's right hand was observed behind their back, their left hand was holding a red sack, and an SO was observed to have their taser pointing toward the patient.
* The patient moved both hands to the front of their body and up toward their chest and head in a flinching, defensive posture.
* Approximately one second later, the patient put both hands behind their back, dropped the red sack and appeared to pull up their pants.
* The SO was not observed or heard to attempt de-escalating the patient and yelled, "Back the fuck up now or you're going to get tased. Don't reach for anything." Approximately two seconds later, the patient was observed falling towards the ground after the SO released the taser prongs.
* The patient stated, "I was pulling my pants up."
* Three SOs pinned the patient face down on the asphalt ground, applied metal handcuffs and put the patient in a wheelchair with the handcuffs still intact.
* The patient was not observed committing a criminal activity prior to being tased or at any time.

7.a. Incident documentation for Patient 9 was reviewed and reflected that on 04/22/2025 "Workplace violence event filed due to visitor trespass event. In debrief of event it was noted that the visitor was taken to the ED due to question about mental health concerns. Security report has significant detail on patient behavior and verbal threats yet ED documentation does not reflect this, nor state that the patient refused/did not want evaluation. Dispo was marked LWBS yet the note states pt was arrested by security, nothing about patient offered/declined treatment."
* The ...extent of harm at time of event" section reflected "No evident harm."
* The "Manager Review" section reflected "Reached out to Triage RN [Manager name] have nothing to add here. A separate WPV report was filed, and [Manager name] included my review in that report."

7.b. "Use of Force Review" for Patient 9 was reviewed and reflected:
* The "Review Summary" section reflected "... was asked to leave the property after the patient [they were] visiting became uncomfortable with [their] presence. [Patient 9] refused to participate in conversations about how caregivers can best serve [them]."
* Three SO's Interview Summaries.
* The "Witness Interview Summary" section reflected "None."
* The "Manager's Review" dated 04/24/2025 section reflected "... confirm that security officers utilized patience and exercised core values in their attempts to assist this individual to check in to PPMC's ED. It was not until the person made threatening comments and gestures of physical violence that the arrest was affected."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&Ps. For example:
* The documentation was unclear whether the patient involved in the incident had an EMC that needed to be ruled out.
* There was no documentation that reflected whether there was harm to the patient.
* The documentation was not clear regarding the results of reaching out to Triage RN. Was the Triage RN interviewed and what information was received?
* The "Use of Force Review" did not reflect that body camera footage was reviewed and did not have any witnesses listed.
* The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs.
* There was no investigation that reflected whether abuse and neglect were ruled out.

8. "Use of Force Review" for Patient 11 was reviewed and reflected:
* The "Review Summary" section reflected "An individual came through the Main Entrance metal detector. Drug paraphernalia was shown in [their] backpack by x-ray detection. Officers informed [them they] can't come into the hospital with it ... cursed at officers and grabbed [their] backpack and walked briskly toward the Cancer Center. [They were] uncooperative with Security's request to remove the item from the building. The individual made several attempts to push past the officers and them attempted to physically shove the Lead Officer. [They were] subsequently arrested."
* Narratives of the security report authored by Lead Security Officer for the section "Officer Involved Interview Summary."
* The "Witness Interview Summary" section reflected "All statements were removed from the narrative of the report authored by Security Officer [SO name]." It continued "The [patient] began to walk towards integrated medicine for an appointment ... the [patient] would not stop and talk ... repeated multiple times the [patient] needed to leave the property ... the [patient] stepped towards my direction ... continued and pushed into [SO name]. [SO name] pushed back ... the [patient] then grabbed [SO name] right arm. [SO name] removed the [patient's] hand from [their] right arm ... the [patient] continued to escalate. The [patient] responded with an explosive push ... At which point [SO name], and I assisted the [patient] to the ground ... advised the [patient they were] under arrest ... [SO name] yelled call a code and radioed the code grey. [SO name] arrived and contained the [patient's] legs. [SO name] began to apply the handcuffs ... House Supervisor [name] arrived at the hold room and asked the [patient] if he needed any medical attention. The [patient] advised [they] needed a full work up in the emergency department ED [sic]. Injuries to report [patient] contusion to the forehead and [their] right knee."
* The "Coaching Opportunity" section reflected "Although these actions are deemed to be justified by policy ... we don't always need to act on an individual's refusal to cooperate with Providence SOPs, given that the paraphernalia brought in was not considered to be dangerous and could have been overlooked."
* The "Manager's Review" dated 04/30/2025 section reflected "I, [manager name], agree with the finding above. I will add that I have also coached both Officers [SO name and SO name] that in these types of situations it is best practice to notify the House Supervisor and the Security Supervisor and ask them to respond to help form a plan of appropriate next steps. Both officers were receptive to this coaching and direction."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&Ps. For example:
* There was no incident/event report documentation per the hospital's P&P.
* The "Use of Force Review" did not reflect that body camera footage was reviewed.
* The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs.
* There was no investigation that reflected whether abuse and neglect were ruled out.
* There was no documentation of further follow up actions.

9.a. The security report was reviewed for Patient 12 and reflected that "On April 28th, 2025, at 0240, I, [SO name] responded to a radio call to ED21 with [SO name]. Upon arrival the Patient [name] was yelling at nurse [name] and nurse [name]. Pt stated [they] did not want to leave. [They] then kicked the nurse on [their] right side between [their] ribs and hip at which point SO [SO name] and I took control of the limbs so that [they] could not kick anymore. Pt sated multiple times [they] would kill someone if let out ... Pt stated [they] would rather go to jail then be let out on to the street ... Pt was placed in handcuffs ..."

9.b. Workplace Incident Violence documentation for Patient 12 was reviewed and reflected that on 04/28/2025 "... a patient arrived via ambulance after reportedly falling at a convenience store. Upon arrival, the patient complained of hip pain and was unable to ambulate ... the patient is typically ambulatory without issue ... The patient underwent a full medical workup, including a CT scan, and was administered Tylenol. Discharge was planned at 0237 hrs. Upon being informed of discharge by Primary RN, [RN name] ...the patient became agitated and began demanding methadone and Dilaudid. Staff explained that these medications were not indicated and that discharge instructions had been provided. The patient then refused to leave, requesting to speak with a social worker. Staff informed the patient that social work services were not available ... the patient became physically aggressive and kicked the nurse, causing [them] to strike the wall of the room. Security personnel, already stationed near ED Room 21, responded immediately and Code Grey was called. Security intervened physically to restrain the patient ... The patient was detained in a hospital holding area ..."
* The "Workplace Violence Event Category" section reflected "Physical Attack without weapon."
* The "Physical Attack without weapon" section reflected "Kicking."
* The "Were there any current injuries or an event that may require future medical treatment" section reflected "No."

9.c. "Use of Force Review" for Patient 12 was reviewed and reflected:
* The "Review Summary" section reflected "Security affected an arrest on a discharged patient after they kicked a nurse and spit on security staff."
* The "Officer Interview Summary" reflected a summary of an interview of the lead officer for the shift during which the arrest occurred.
* The "Witness Interview Summary" section reflected "Please see the attached reports from SO's [names of five SO's involved]."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&Ps. For example:
* The "Use of Force Review" did not reflect that body camera footage was reviewed.
* The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs.
* There was no investigation that reflected whether abuse and neglect were ruled out.
* There was no documentation of further follow up actions.

10.a. Workplace Violence Incident documentation for Patient 13 was reviewed and reflected on 05/17/2025 "Patient was being walked out with security towards the ambulance bay. Patient pulled the fire alarm disturbing the entire emergency department and hospital. Patient was then arrested for [sic] by security staff. Then shortly after was taken into custody by Portland police."
* The "General Type of Injury" section reflected "Workplace Violence."
* The "Workplace Violence Event Category" section reflected "Verbal Intimidation/Harassment/Bullying."
* The "Verbal Intimidation/Harassment" section reflected "Threat of Property Damage."
* The "Manager Review" section reflected "Patient was arrested by Portland Police. No harm to caregivers."

10.b. The "Use of Force Review" for Patient 13 was reviewed and reflected:
* The "Review Summary" section reflected "Discharged patient being escorted out of the ED by Security, chose to pull the fire alarm on the way out of the ambulance bay ... [they were] arrested."
* Four SO's Interviews from excerpts from narratives of officer reports.
* The "Review Findings:" section reflected "After reviewing all of the pertinent reports, as well as viewing body-warn camera video of the arrest ,,, this arrest, the subsequent use of physical control and hand-cuff application were justified and well within guidelines ..."

The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital's P&Ps. For example:
* There was no documentation that reflected if there was harm to the patient.
* The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs.
* There was no investigation that reflected whether abuse and neglect were ruled out.
* There was no documentation of further follow up actions.

Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients.

Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined that the hospital failed to ensure that incidents and adverse patient events were thoroughly investigated and analyzed, and that corrective action plans were developed to prevent recurrence and to establish clear expectations for patient safety including compliance with CMS.

Findings include:

1. Refer to the findings for Patients 4, 6, 8, 9, 11, 12, and 13 cited at Tag A-145, CFR 482.13(c)(3) - Standard: Freedom from Abuse, that reflects the investigations of patients handcuffed and/or tased on hospital property were unclear and incomplete. All potential gaps or concerns related to those incidents had not been thoroughly investigated and analyzed to determine potential trends, whether corrective actions were indicated, and whether CMS regulatory requirements were met.

2. Refer to the findings for Patients 6 and 8 cited at Tag A-144, CFR 482.13(c)(2) - Standard: Privacy and Safety, that reflects Patient 6 was harmed when handcuffed by non-law enforcement hospital SOs, and Patient 8 was at high likelihood of harm when tased and handcuffed by non law-enforcement hospital SOs.

3. The P&P titled "PSJH-CLIN-1212 Event Reporting and Response Policy and Procedure" dated effective "01/2024" reflected:
* "Adverse Events: One of several types of Safety Concerns reported through the Event Reporting System. Defined as an event in which care resulted in an undesirable clinical outcome - an outcome not caused by underlying disease - that prolonged the patient stay, required life-saving intervention, caused permanent patient harm, or contributed to death ..."
* "Event Reporting System (ERS): ...electronic tool used by all Providence Workforce Members to report any Safety Concern that is thought to be a deviation from generally accepted performance standards and/or inconsistent with safe operations of the health care system or the safe care of a particular patient. The tool provides the framework for reporting, analyzing, tracking, trending, resolving, and following up on events with established committees, boards, and state/federal agencies to ensure appropriate actions are taken to prevent future harm."
* "GAPS: Generally Accepted Performance Standards (GAPS) are determined by comparing actual performance to expected performance ..."
* "Patient Safety Plan: The Patient Safety Plan is an integral component of the quality assessment and performance improvement structure for each ministry and encourages non-punitive reporting of patient safety concerns and opportunities, and the use of evaluative processes that support learning from incidents and system failures to assess for, anticipate, and prevent future events. The plan should be reviewed annually and updated based on themes or trends related to quality and safety."
* "Quality Program: An ongoing, long-term, proactive set of focused activities designed to monitor, analyze, and improve the quality of processes to achieve better healthcare outcomes in an organization. By gathering and analyzing data in key areas, a ministry/facility can effectively improve outcomes for patients ..."
* "The data gathered through the ERS are reported to the designated review committee(s) of each ministry/facility ... Each ministry/facility utilizes Event Report data to proactively identify opportunities for performance improvement and to track and trend processes that have been the subject of improvement activities such as Root Cause Analysis (RCA), and Failure Mode and Effects Analysis (FMEA). Such discussions are recorded in the minutes of respective review committees of each Quality Program. The outcome of safety events, safety trends, corrective and preventative action plans are shared with respective boards at a reliable cadence".
* "Event investigation is completed on behalf of the Quality and Safety Improvement Committee, (QSIC) or equivalent of each ministry/facility's Quality Program ... All events are investigated at the department level by the department core leader ... Events that meet state or regulatory criteria are escalated for investigation by the Quality Team. Unit/department core leaders will request consultation from the Quality Team if additional support is necessary or the investigation uncovers complexities that need further attention and expertise."
All aspects of the P&P were not carried out as the QAPI program failed to ensure that incidents and adverse patient events involving patients who were handcuffed and tased by non-law enforcement hospital SOs were thoroughly investigated and analyzed, and that corrective action plans were developed to prevent recurrence and to establish clear expectations for patient safety including compliance with CMS.








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