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Based on observation, staff interview, clinical record, administrative document and video recording review, the hospital failed to protect and promote each patient's rights when one of 39 patients' (Patient [Pt] 1) right to be free from all forms of abuse or harassment was violated when Security Guard (SG) 1 in the Behavioral Health Unit (BHU) of the hospital caused the willful infliction of injury on Pt 1. SG 1 used physical force in excess of what was required to control Pt 1's passive behavior. The excessive force used by SG 1 caused Pt 1 to fall, striking his head on the edge of the door frame resulting in an open scalp wound. This resulted in Pt 1 having an unplanned admission to the D Unit of the BHU followed by a transport to the hospital Emergency Department (ED) for treatment of the open scalp wound. The open scalp wound required six staples to close. Pt 1 was transported back to the BHU with subsequent admission. (refer to A0145)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.

Based on observation, staff interview, clinical record, administrative document and video recording review, the hospital failed to protect one of 39 patients' (Patient [Pt] 1) right to be free from all forms of abuse or harassment when Security Guard (SG) 1 in the Behavioral Health Unit (BHU) of the hospital caused the willful infliction of injury on Pt 1. SG 1 used physical force in excess of what was required to control Pt 1's passive behavior. On 2/9/17 Pt 1 exited his assigned room in a calm manner. SG 1 pulled forcefully on Pt 1's left arm and violently shoved him in the upper left shoulder with his right hand. The excessive force of the push caused Pt 1 to fall, striking his head on the edge of the door frame resulting in an open scalp wound.

This failure resulted in Pt 1 having an unplanned admission to the D Unit of the BHU followed by a transport to the hospital Emergency Department (ED) for treatment of the open scalp wound. The open scalp wound required six staples to close. Pt 1 was transported back to the BHU with subsequent admission.

Findings:

The clinical record indicated Pt 1 was brought to the hospital ED on 2/8/17 at 1 p.m. by ambulance under 5150 hold for gravely disabled (as the result of a mental disorder is in danger of serious physical harm resulting from a failure to provide for his or her essential human needs of health or safety). (5150 is a Welfare and Institutions code that places individuals under involuntary hold for 72 hours and is authorized by qualified local law enforcement or clinician for behaviors related to danger to self, danger to others or gravely disabled). Pt 1 was assessed and examined in the ED by a physician and medically cleared of a physical cause of the symptoms prior to being assessed and examined by a qualified mental health provider.

Pt 1 was transferred to the hospital's BHU (located across town from the main hospital) Intake Area (IA) on 2/8/17 at 3:40 p.m. for a psychiatric/mental health evaluation. A clinical Mental Status Examination was conducted by Clinical Social Worker (CSW) 1. The CSW 1 indicated on the Intake Psychiatric Evaluation Form, "...Pt [1] chart: Traumatic Brain Injury. Per his care giver Pt presents w/[with]symptoms: disoriented, severe short term memory problems, fall risk, frequent elopement. Pt is unable to answer any questions. Per consult w/[Medical Doctor (MD) 1] Pt does not meet criteria for inpatient care and should be released to his care giver."

On 3/14/17 at 8 a.m., during a concurrent interview and clinical record review, the Director of Patient Care Services (DPCS) stated after MD 1 discharged Pt 1 on 2/8/17, he remained in Room 107 as staff made several attempts to reach the care giver. DPCS stated Pt 1 did not suffer from mental illness and the diagnosis of traumatic brain injury excluded Pt 1 from admission. DPCS stated staff was unsuccessful in contacting the care giver so they decided to keep him over night and secure a safe discharge in the morning. DPCS stated RN's, CSW and CST's continued to monitor Pt 1, doing every fifteen minute bed checks and providing care. DPCS stated two security guards, both trained to work in BHU were posted in the IA to assist the staff with patients. A Clinical Service Technician (CST) was added to the staffing after 11:30 p.m. to help monitor the patients.

On 3/13/17 at 4:05 p.m. an observation of the BHU IA was conducted. Entry into the IA is through the lobby area to a reception desk for walk-in patients and/or visitors. A locked door restricts access between the lobby and the IA hall; staff must unlock and open the door to enter the IA hall. Once in the 1A hall immediately to the right is a locked work area for the clinical staff. The IA patient area consists of five rooms in the main hall. There is a four bed ward and four single patient interview rooms with beds. A patient bathroom is between two rooms. The single patient interview rooms have large windows in all the doors, the doors are shut, and each room has a single bed, low to the ground against the wall. Room 107 is a single patient private interview room at corner room on the left hand side of the IA main hall. The main hall ends in a 'T'. To the right there are two patient interview rooms and the Security Guard station. The locked ambulance door exit is at the end of the hall. To the left is a locked door. Beyond the door are a medication room and three more patient rooms; a two bed ward and two single patient interview rooms. This area is opened to accommodate four additional patients when census in the main IA hall area reaches capacity.

On 3/14/17 at 9:55 a.m., an interview and concurrent viewing of video footage (continuous recorded monitoring of activity in the hall) of the incident was conducted at the BHU with DPCS, Registered Nurse (RN) 1 and RN 7. The video footage captured actions and behaviors of Pt 1 during the physical interaction with SG 1 and staff on 2/9/17 from 1:29:15 a.m. through 1:46:28 a.m. The video footage was not equipped with sound.

The video footage for 1:29:15 a.m. to 1:30:10 a.m. showed SG 1 and CST 1 in the IA hall where room 107 is located. CST 1 had a clipboard and was walking from room to room looking in windows and writing. DPCS stated CST 1 was doing a 15 minute bed check of the patients and documenting their behaviors. SG 1 was walking in front of room 107, looking in the window. CST 1 moved to the end of the hall past room 107 and continued writing on the clipboard. SG 1 backed up against the wall across from room 107. CST 1 and SG 1 appeared to be talking and SG 1 was pointing to room 107.

The video for 1:30:11 a.m. to 1:30:36 a.m. showed Pt 1 opened the door inward to room 107 and looked into the hall to the right and to the left. Pt 1 stepped out into the hall and looked at CST 1 standing at the end of the hall to his left. SG 1 pointed to the bathroom to the right while standing across the hall from Pt 1. CST 1 stepped into the adjacent hall and disappeared from camera view. At this point the hall was occupied by Pt 1 and SG 1 only. Pt 1 turned to the right and began to walk slowly down the hall both arms down at his sides and his head down. Pt 1 walked past the bathroom. SG 1 moved toward Pt 1 and grabbed his upper left arm by the sleeve, and turned him towards the bathroom door, pointing at it. SG 1 appeared to be talking to Pt 1 when a person with a clipboard entered the hall. DPCS 1 stated the person was a County Social Worker and not an employee of the hospital. The County Social Worker stood against the wall across from room 107 as SG 1 pulled on Pt 1's arm. Pt 1 did not offer resistance, and appeared to be trying to maintain his balance as SG 1 turned him back toward Room 107. At this point using his left hand SG 1 forcefully pulled on Pt 1's left arm while placing his right hand on Pt 1's left shoulder. SG 1 then violently shoved Pt 1 and flung him by his left arm towards the room. Pt 1 fell and struck his head on the door frame approximately 12 inches from the floor. SG 1 grabbed Pt 1 by his arms as he lay on the floor and dragged him into room 107. The County Social Worker was in view during this incident and jumped out of the way of Pt 1's legs as he fell. The County Social Worker continued down the hall towards the work area and out of camera view.

The video footage for 1:30:37 a.m. to 1:32:45 a.m. starts with CST 1 running into camera view around the corner from the adjacent hall and stepping over Pt 1's legs as he was dragged into room 107 by SG 1. CST 1 followed SG 1 and Pt 1 into room 107. SG 2 also ran into camera view from around the corner from the adjacent hall and into room 107. At this point CST 1, Pt 1, SG 1 and 2 were out of camera view. SG 1 exited the room into camera view. CST 1 backed out of the room into camera view, looking into the room. SG 1 walked back and forth in the hall with his hands on his hips in front of room 107 behind CST 1 who was standing in the doorway of room 107. SG 1 appeared to be talking to CST 1. SG 1 balled up his right fist and swung it in a gesture like a punch. SG 1 continued to walk back and forth in front of room 107. SG 1 continued to talk with CST 1. SG 1 pointed to the door frame and bumped the back of his hand against it. CSW 2 entered the hall into camera view and looked into room 107. CSW 2 had a brief conversation with SG 1 who pointed with his right hand back and forth down the hall and appeared to be explaining what happened with Pt 1. CSW 2 continued down the hall to the work area and out of view of the camera. SG 2 exited room 107 and removed his jacket in the hall and dropped it on the floor. CST 1, SG 1 and SG 2 are standing in the hall when Pt 1 appeared in the doorway and stepped out into the hall. Pt 1's arms are down at his sides, his head down, and he appeared passive. CST 1 put his hand on PT 1's left arm to stop him and SG 1 put his right hand on Pt 1's chest and pushed him backwards to stop him from entering the hall. SG 1 pointed back into room 107. CST 1 grabbed Pt 1's left upper arm and SG 1 grabbed Pt 1's right arm as they turned him around into the room. Pt 1 appeared let SG 1 and CST 1 turn him back into the room without attempting to pull free of SG 1 and CST 1's grasp on his arms. SG 2 also went into the room out of camera view. CST 1 and SG 1 and 2 exited room 107 and CST 1 began to hold the door to room 107 shut by the door handle with both hands; the door can be seen being pulled inward. SG 2 started down the hallway towards the work area and stopped half way as RN 3 appeared in the hall. RN 3 saw the door of Room 107 being pulled inward, and CST 1 talked to RN 3 briefly. RN 3 goes back to the work area without doing anything else and out of view of the camera.

The video footage for 1:32:46 a.m. to 1:46:12 a.m. showed SG 2 took over holding the door of room 107 closed with both hands from CST 1. CST 1 walks down the hall and through the locked lobby door, out of camera view. The door to room 107 continues to be pulled inward. RN 3 entered the hall and did not stop to look in room 107 or talk to SG 1 or SG 2; he went around the corner to the left out of camera view. SG 1 and SG 2 continue to stand in the hall, SG 1 pointed to the bathroom and room 107. SG 1 took over holding the door closed to room 107 with both hands from SG 2. A person entered the hall. DPCS stated this was the night shift housekeeper. The housekeeper stopped briefly and looked into room 107 through the window and appeared to talk with SG 1 and SG 2. CST 1 returned to the hall outside room 107 and was joined by RN 4, RN 5 and CST 2 who entered the IA from the ambulance entry. DPCS stated the employees came from the C and D units to help manage Pt 1 after a "Code Gray" (emergency summons utilized in the event of an acute acting out or violent episode) was called. SG 1, SG 2, CST 1, CST 2, RN 4 and 5 stood in the hall outside room 107 and appeared to be talking. SG 2 opened the door and appeared to be talking to Pt 1. There was no more inward pulling on the door. SG 1, SG 2, CST 1, CST 2, RN 4 and 5 put on gloves and when RN 3 entered the hall, SG 1, SG 2, CST 1, CST 2, RN 3, 4 and 5 went into Pt 1's room out of camera view. After 2 minutes and 17 seconds, RN 3 exited, followed by SG 1, SG 2, CST 1, CST 2, RN 4 and 5. CST 1 stood by the doorway and monitored Pt 1. CST 1 pointed to the door and CST 2 stood by the door. SG 1 and 2 were standing in the hall. RN 4, RN 5 and CST 2 entered Pt 1's room and walked back into the hall with Pt 1 between them. Pt 1 was walking slowly, and passively. They exited the camera view through the ambulance entrance.

During the concurrent interview and viewing of video footage, DPCS stated on 2/9/17 about 8 a.m., she was informed by the day shift manager (RN who manages patient flow through the C and D inpatient units) RN 1, that Pt 1 had tried to attack a security guard in the IA and fell, sustaining an injury to his head. DPCS stated she immediately went to see Pt 1 on Unit C to check on his condition and saw the staples in his forehead; then she viewed the video of the incident to see what had occurred. DPCS stated when she saw what actually happened between Pt 1 and SG 1 on the video footage it was obvious the report she received did not match what she had viewed. DPCS stated she called the Hospital Safety Officer (HSO, Security Guard Manager) and told her, "I feel horrible and I have to find out why and how this happened." DPCS requested the HSO remove SG 1 from the BHU immediately because of the manner in which the injury occurred and the inaccuracy of the report SG 1 gave the incident verbally to RN 3 and CST 1. DPCS stated the incident should never have happened and explained her expectation to the HSO. The DPCS stated to prevent patient and staff injuries, it was her expectation that RN's, CST's and SG's use skills learned in CPI (training in nonviolent crisis intervention) to handle situations in which patients are becoming upset. DPCS stated the RN's, CST's and SG's, needed to call upon each other for help, call the shift manager for guidance if there are problems with patients, and/or a "Code Gray" to bring more staff to the IA for physical intervention if a patient has become violent.

During this concurrent interview and viewing of video footage, RN 1 stated he received report on 2/9/17 at 7 a.m. from RN 2, the night shift manager, about issues that occurred during the shift in the BHU. RN 2 told RN 1 Pt 1 had been injured in a fall during an attack on a security guard in the IA. RN 1 stated the video was very disturbing, and did not match the information he was told by RN 2. RN 1 stated RN's, CST's and SG's were taught safer ways of managing patients with CPI training and should not put hands on the patients as SG 1 did by holding Pt 1's arm. RN 1 stated staff needed to have patience to be able to redirect Pt 1 back to his room because of his short term memory loss. RN 1 stated he would have walked beside Pt 1 and tried to talk to him to allow him to focus and be redirected. RN 1 stated if he was unable to redirect Pt 1 or get him to listen he would ask other staff to help him intervene and manage Pt 1 safely. RN 1 stated SG 1 did not handle the situation as expected.

On 3/15/17 at 9 a.m. during an interview, the HSO stated part of her job duties included managing contracted security services for the hospital. HSO stated management of the security guards included compliance with mandatory CPI training in order to safely manage incidents, before they can work in hospital. HSO stated both SG 1 and 2 had completed the training. HSO stated when she came to work on 2/9/17 at 7 a.m. a typed report was in her email notifying her there had been an incident in the BHU during the night involving Pt 1 and SG 1. HSO stated the message read Pt 1 had to be brought over to the ED for treatment and that Pt 1 fell by accident. The HSO stated she was "blown away" that a person was hurt and had to come over to [the ED] for treatment, but when she viewed the video footage it was clear the patient did not just fall, she stated, "I wiped away tears and am devastated by what I saw." HSO stated it was obvious Pt 1 was passive in the video footage and had received the injury to his head from being pushed by SG 1. The HSO stated this was not how security guards had been trained to provide monitoring of patients in the BHU or any part of the hospital. The HSO stated after talking with her Director of Facilities, the Chief Executive Officer, BHU Administrator, DPCS and Quality Manager (QM) about the incident, she called the contracted security company and told them to place SG 1 on administrative leave until a full investigation into the incident could be completed. HSO stated once the review was completed on 2/10/17, both SG 1 and 2 were terminated. SG 1 and SG 2 were unavailable for interview.

On 3/16/17 at 1:57 p.m. during an interview, the QM stated she was aware of the incident involving Pt 1 and SG 1 on 2/9/17. The QM stated she had reviewed the video footage and was aware the SG 1 report did not accurately reflect what happened. The QM stated an interview was conducted with the County Social Worker who confirmed that SG 1 was rough with Pt 1. QM stated the decision was made to terminate the employment of SG 1 and 2 based on a review of the video footage, the inaccurate reporting of the incident by SG 1 and 2, and the interview with the County Social Worker. QM stated SG 1 and SG 2 were not interviewed following the incident.

On 3/16/17 at 7:40 a.m. during an interview, RN 3 stated he started his shift at 7 p.m. on 2/8/17. He stated Pt 1 remained in the IA because staff could not discharge Pt 1 safely without communicating with the care giver. RN 3 stated it was a busy night and he remembered Pt 1 coming out of his room a few times. He stated Pt 1 was easily redirected and he did not remember having any problems with him. RN 3 stated about 1:30 a.m., a security guard came and told him Pt 1 was trying to elope. He stated he went to room 107 to assess the situation and saw Pt 1 pulling on the door, trying to open the door while CST was holding it closed with his hands. When asked if Pt 1 was yelling, RN 3 stated he did not recall and added Pt 1 doesn't talk very much. RN 3 stated he called Pt 1's MD and told her Pt 1 was being aggressive based on his observation of Pt 1 pulling on the door and CST 1's verbal report that Pt 1 was trying to leave. RN 3 stated he did not enter room 107 or talk with Pt 1. RN 3 stated MD 1 gave him orders for medications (Zyprexa [sedative and anti-psychotic] and Benadryl [antihistamine]) to sedate Pt 1, and admission to the BHU D Unit (an area for high risk admissions). RN 3 stated he saw the wound on Pt 1's forehead but did not have time to assess the wound before Pt 1 was walked with staff to the D unit. RN 3 stated, after Pt 1 left the IA, he talked to SG 1 about what had happened in the hall and that SG 1 said Pt 1 got aggressive with him when he tried to stop him from eloping and he fell, hitting his head. When RN 3 viewed the video he stated "Oh my God; that does not agree with what I was told." When asked if a Code Gray was called to manage Pt 1, RN 3 stated he didn't remember.

On 3/16/17 at 9:25 a.m. during an interview, CST 1 stated he conducted 15 minute bed checks on the patients in IA and Pt 1 was mostly lying on his bed in room 107. CST 1 stated he was checking the other patients in IA when he heard noises in the hall and ran around the corner to room 107. He stated SG 1 was moving Pt 1 into his room and Pt 1 was sitting on the floor. CST 1 stated SG 1 told him Pt 1 was walking toward the bathroom when Pt 1 stopped, turned around and threw a punch at SG 1. CST 1 stated SG 1 told him as Pt 1 punched at SG 1 he started to fall and SG 1 was unable to stop him from falling to the floor. CST 1 stated after Pt 1 was back in his room he looked angry and rushed at the door. CST 1 stated he held the door shut until they could get help on the unit to control Pt 1. He stated he noticed blood on the bed and in Pt 1's hair right before he was moved to D Unit, but did not see the wound on his head. CST 1 was offered to view the video and he agreed. After viewing the video CST 1 stated, "It is shocking and heartbreaking that this could happen in our facility." CST 1 stated he did not remember jumping over Pt 1's legs to enter room 107.

On 3/16/17 at 10:08 a.m. during an interview, CSW 2 stated she was interviewing a patient in a room in the adjacent hall. CSW 2 stated SG 2 was standing outside the door while the interview was conducted for her safety, and SG 2 suddenly left his post outside the door. CSW 2 stated she left the interview and entered the hall by room 107. CSW 2 stated she asked SG 1 what happened. CSW 2 stated SG 1 told her Pt 1 fell down and hurt himself on his way to the bathroom. CSW 2 stated she did not see where Pt 1 was hurt. CSW 2 stated after Pt 1 was moved to the D Unit, the County Social Worker told her and RN 3 that he saw SG 1 get rough with Pt 1. CSW 2 was offered to view the video and she agreed. After viewing the video CSW 2 stated, "[RN 3] and I were very puzzled about what happened because no one expects a security guard to do this. It was biased of us to take the side of the security guard and not get the whole story." CSW 2 stated she was very disturbed watching the video and Pt 1 was not aggressive. CSW 2 stated, "I was told the security guard was rough, but seeing the video it is worse than I thought."

The report written by SG 1 and sent to his supervisor following the incident on 2/9/17 indicated, "...At approximately 01:30 [1:30 a.m.] [Pt 1] woke up from his nap and came to the door and proceeded to be extremely verbally abusive and stand in the room in a threatening manner. I then asked him if he needed to use the restroom and he said 'yes'. So I told [Pt 1] that it was open and he is welcomed to use it and at that time [Pt 1] exited room 107 and proceeded to walk past the restroom. I instructed [Pt 1] that he had walked past the restroom to which he replied with telling me 'No' and continued down the hallway. I then gave [Pt 1] two verbal request[s] to return to his room if he did not need to use the restroom he refused to acknowledge my request so I then instructed I would help him return to his room. I proceeded to assist [Pt 1] back to his room at that time [Pt 1] looked at me and said 'No' and raised his closed fist to punch me. I quickly reacted and grabbed [Pt 1] by his other arm and tried to turn him around the other way so I could get him back into his room and out of the hallway. During the process of turning [Pt 1] he lost his footing and went head first into the door frame of [room] 107. [SG 2] heard the commotion and came to assist me, it was then we noticed that [Pt 1] had a deep laceration to the right side of his head and was bleeding ..."

A record review of Pt 1 admission notes to the D Unit written by RN 6 on 2/9/17 at 1:50 a.m. indicated, "Pt [Pt 1] arrived on unit at 0150, escorted by staff and security personnel ...Per security guard, Pt was being escorted back into room, while holding Pt shirt, Pt lost his balance and hit his head on the edge of the door. On the unit, there is a cut on the right side of Pt head/forehead ...On call hospitalist notified at 0200 [2 a.m.] of Pt current status, order to transfer to ER obtained ..."

Review of the ED Physician notes dated 2/9/17 at 4:46 a.m. indicated Pt 1 had a laceration 3 cm in length, linear in shape and the wound required 6 staples to close. Pt 1 was transported to ED at 2:20 a.m. for treatment and returned to BHU Unit C at 7 a.m. for admission.

The Hospital Job Description titled "Healthcare Security Officer" [Security Guard] dated 10/13 indicated, "Description: The primary function of the Healthcare Officer is to protect life...providing public safety to the client...Key Responsibilities:...man post as instructed and serve as a security presence...report all incidents, accidents and medical emergencies...maintain a friendly and professional demeanor..."

The hospital "SECURITY SERVICES AGREEMENT" dated 5/21/15 indicated, "...b. Performance: ...Company agrees that all services shall be provided in accordance with the Hospital's rules and policies."

The Hospital Policy and Procedure titled, "Patient Rights" dated 2/22/17 indicated, "...Hospital respects the rights of the patient, recognizes that each patient is an individual with unique health care needs, and because of the importance of respecting each patient's personal dignity, provides considerate respectful care focused upon the patient's individual needs...PATIENT RIGHTS: You have the right to...13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment...21. Exercise these rights without regard to sex, race, color, religion, national origin, age, disability, medical condition..."

The hospital policy and procedure titled, "Code Gray Policy" dated 6/2013 indicated, "A...emergency summons utilized in the event of an acute acting out or violent episode. A Code Gray is determined as a person having the potential to cause injury to self/others. A Code Gray may be called in any situation which can not be resolved by the staff present, when verbal interventions have not been successful. Calling a Code Gray does not mean that the individual will be physically restrained..."