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Based on observation, interview, and document review, the hospital failed to ensure patients were free from excessive use of force and law enforcement tools for 1 of 11 patients (P1) reviewed for patient rights. P1 was thrown to the ground and was handcuffed when a security officer restrained her during an aggressive episode and P1 sustained multiple facial fractures

As a result of these failures, this deficient practices resulted in an immediate jeopardy (IJ) for P1. The hospital was found out of compliance with Condition of Participation Patient Rights at 42 CFR 482.13.

Findings include:

See A-0154:
The hospital failed to ensure patients were free from excessive use of force and law enforcement tools for 1 of 11 patients (P1) reviewed for patient rights. P1 was thrown to the ground and was handcuffed when a security officer restrained her during an aggressive episode and P1 sustained multiple facial fractures

Based on observation, interview and document review, the hospital failed to ensure patients were free from excessive use of force and law enforcement tools for 1 of 11 patients (P1) reviewed for patient rights. P1 was thrown to the ground and was handcuffed when a security officer restrained her during an aggressive episode and P1 sustained multiple facial fractures. The deficient practice resulted in an immediate jeopardy (IJ).

The IJ began on 9/18/23 at approximately 11:49 a.m., when P1 was brought to the ground by security staff, sustained multiple facial fractures, and was handcuffed. On 10/9/23 at 4:47 p.m., the hospital president, VP of Safety and Quality, Safety and Quality manager, Quality and Accreditation Supervisor and Manager, Director of Corporate Security, and risk manager were notified of the IJ. The IJ was removed on 10/11/23 at 6:30 p.m., when an acceptable removal plan was verified it had been implemented; however, the hospital remained out of compliance with the COP of Patient's Rights at 42 CFR 483.13.

Findings include:

P1's Diagnosis List indicated diagnoses of unspecified psychosis and sleep disturbance.

P1's emergency department (ED) admission paperwork indicated P1 was admitted to the hospital ED on 9/16/23 at 10:29 p.m. with a primary diagnosis of agitation.

On 9/17/23 at 3:29 p.m. Physician Orders indicated P1 was placed on an emergency 72 hour hold.

On 9/18/23 a nursing note indicated P1 was in seclusion, and operating her medical bed in a dangerous and inappropriate way. The note indicated staff attempted to educate P1 about safe bed height and P1 refused to listen to their safety concerns. The note indicated staff entered P1's room to remove the bed with security present. The note indicated P1 verbally threatened staff and lunged towards registered nurse (RN)-A, physically grabbing her and pushing her into the hallway. The note indicated a security officer intercepted P1, pushing P1 against the wall and then bringing P1 down to the ground. The note indicated P1 was secured and then escorted back to her room and placed in restraints.

A Hospital Security Incident Report dated 9/18/23 at 11:51 a.m., indicated security officer (SO)-A witnessed P1 lunge at RN-A and make physical contact. The report indicated SO-A then attempted to gain control over P1 by securing both her arms, pinning her against the wall, and then bringing her to the ground. The report indicated SO-A was able to gain control over P1 once on the ground, and he then applied handcuffs due to the assault on RN-A. The incident report indicated local law enforcement was contacted in relation to the incident on 9/18/23 at 12:00 p.m. The report indicated both P1 and RN-A suffered a minor injury from the event. The report indicated law enforcement did not obtain custody of P1 after the event.

On 9/18/23 at 1:11 p.m. a pain assessment was completed on P1. The pain assessment indicated P1 had acute head pain, which she rated as an 8 out of 10 (severe pain).

On 9/18/23 at 1:18 p.m. Physician Orders indicated P1 was to have CT imaging of her facial bones without contrast performed immediately. Interpretation of P1's facial bones CT at 2:41 p.m., indicated P1 had suffered fractures of the anterior, posterior lateral and medial maxillary sinus, and left inferior orbital floor involving the lateral aspect of the infraorbital neural foramen in relation to a traumatic event. The interpretation indicated the fracture also involved the left infraorbital nerve foramen.

On 9/20/23 a medical progress note indicated P1 suffered a facial fracture from an in-hospital fall on 9/18/23.

On 9/22/23 at 11:29 a.m., a skin assessment indicated P1 had a bruise on her left anterior lateral shoulder.

On 10/5/23 at 12:01 p.m., P1 was interviewed. P1 stated she did not remember how she sustained her facial fractures. P1 stated she did not remember what happened to her in the ED. P1 stated the left side of her face was numb.

On 10/5/23 at 2:40 p.m., the video from 9/18/23 at 11:48 a.m. was reviewed with the security director, risk management, hospital accreditation specialist and the program manager. In the video, registered nurse (RN)-A, mental health coordinator (MHC)-A and security officer (SO)-A approached P1's room. P1 spoke with them through the door and allowed RN-A and SO-A to enter the room. RN-A attempted to leave the room and P1 lunged at her. RN-A and P1's hands locked in a physical struggle. SO-A intervened and used a manual hold to push P1 against the wall. P1 continued to struggle, and SO-A threw P1 to the floor. P1 landed on the left side of her face. SO-A positioned himself on top of P1, secured her hands behind her back, and applied handcuffs. SO-B entered the room, and SO-A and SO-B assisted P1 to her feet and into to her room. P1's face was bleeding, and blood was noted on the floor.

On 10/5/23 at 2:40 p.m., the director of security (DS)-A stated SO-A was no longer employed at the hospital, and was not dismissed in relation to his use of force or law enforcement tools. DS-A stated all security officers carried handcuffs, chemical spray, and tasers. DS-A stated all security staff are trained in soft hand techniques prior to working with patients. DS-A stated when SO-A sat on top of P1's hips, it was called a rear mount position and was commonly used when applying handcuffs.

On 10/5/23 at 4:10 p.m., MHC-A stated P1 had assaulted RN-A, and SO-A intervened and tried to secure P1 against the wall. MHC-A stated P1 was still struggling while against the wall, so SO-A brought P1 to the ground and landed on top of her. MHC-A stated when SO-A brought P1 to the floor, P1 stopped resisting. MHC-A stated SO-A positioned himself on top of P1 and applied handcuffs immediately.

On 10/9/23 at 8:26 a.m., P1's family member (FM)-A stated when she visited P1 on 9/19/23, P1 had multiple bruises she did not have the previous day. FM-A stated the entire left side of P1's face was swollen, and she had a black eye. FM-A stated P1 had bruises on her arms, and a large bruise on her left shoulder. FM-A stated she felt P1 was unsafe while being treated at the hospital due to the potential abuse she may be suffering at the hands of staff.

On 10/9/23 at 1:49 p.m., SO-B stated when he arrived on-scene, P1 was already in handcuffs and secured by SO-A. SO-B stated if security staff had control of a patient, the security staff needed to wait for more support to arrive before moving on. SO-B stated security officers do not need to advance in the use of force continuum if a patient is secured. SO-B stated SO-A applied handcuffs because P1 had been in the process of assaulting a nurse. SO-B stated other security personnel contacted the local police department about P1 assaulting the nurse. SO-B stated P1 could not be taken into custody in relation to her crime as she currently had an emergency 72-hour hold due to her psychiatric instability.

On 10/9/23 at 2:16 p.m., RN-A stated P1 had locked hands with her and had threatened to kill her. RN-A stated SO-A intervened and brought P1 to the wall where they continued to struggle. RN-A stated SO-A brought P1 to the ground, and P1 stopped resisting. RN-A stated P1 was crying and wailing on the ground. RN-A stated she did not know how to assess someone after the use of handcuffs, as handcuffs were not a healthcare restraint.

On 10/10/23 at 4:31 p.m., SO-A stated he pushed P1 against the wall, was unable to maintain control of her and then brought her to the ground. SO-A stated P1 stopped resisting as soon as she hit the ground. SO-A stated he did not need to escalate beyond soft hand techniques or use any law enforcement tools to gain compliance from P1. SO-A stated he then got on top of P1 in a rear mount position and applied handcuffs. SO-A stated P1 was bleeding from her nose. SO-A stated he waited until SO-B arrived to assist P1 to stand, and they escorted P1 back to her room. SO-A stated they sat P1 on the edge of her bed and removed the handcuffs. SO-A stated staff then placed her in four-point restraints. SO-A stated he applied the handcuffs because he witnessed P1 assault RN-A. SO-A stated 9/18/23 was his final shift at the hospital and was allowed to complete the remainder of his shift. SO-A stated he had received multiple in-service trainings from the hospital in 2023 on how to safely maintain control of patients.

The facility policy Security Use of Force dated May 2023 directed "Security officers will apply only the amount of force that is reasonable for the circumstances to gain control of an unwilling subject and/or control of the situation."

The facility policy Security Use of Force dated 10/6/23 directed "Handcuffs are considered a law enforcement restraint device and are not considered an appropriate health care restraint intervention. Handcuffs may only be used for the purpose of detention while waiting for law enforcement to take custody of the person."

The IJ was removed on 10/11/23 at 6:30 p.m. when the hospital had submitted and implemented an acceptable removal plan. This included review of policies, providing face-to-face training to all security staff of proper patient de-escalation techniques and appropriate use of handcuffs, re-education security staff to focus on appropriate use of force, using the least restrictive measures and most appropriate techniques, and policy review, education to ED and mental health staff to focus on restraints and use of tools by security, and the Use of Force reviews were changed to lessen the amount of time to review all incidents involving security officers. This was verified through interview and document review.