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Based on document review, video surveillance review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights.

Findings include:

1. The hospital failed to ensure appropriate de-escalation and emergency safety interventions were provided. See deficiency at A-0144.

An Immediate Jeopardy (IJ) was identified on 8/16/2023 at CFR 482.13, Patient Rights, and began on 07/24/2023, due to the hospital's failure to ensure appropriate de-escalation and emergency safety interventions were provided for a patient with violent and destructive behaviors. Subsequently, a taser (electronic defense weapon causing temporary incapacitation) was used on Pt. #1, resulting an abrasion to Pt. #1's right medial thigh.

The IJ was announced on 08/16/2023 at 4:00 PM, during a meeting with the Chief Executive Officer, VP of Operations, Regional Director of Regulatory and Accreditation, Director of Quality, Director of Behavioral Health, Assistant VP of Security, Patient Safety Specialist, Manager of Behavioral Health, Risk Management, VP of Quality and Patient Safety. The IJ was not removed by the survey exit date of 08/16/2023.

Based on document review, video surveillance review, and interview, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed regarding care of a patient with violent and/or destructive behavior, the hospital failed to ensure appropriate de-escalation and emergency safety interventions were provided. Subsequently, a taser (electronic defense weapon causing temporary incapacitation) was used on Pt. #1, resulting an abrasion to Pt. #1's right medial thigh. This could potentially affect all patients admitted to the Hospital.

Finding include:

1. The hospital's policy titled, "Management of Violent/Self Destructive Behavior" (3/2023) included, "Purpose ... Outbursts of violent and aggressive behavior on the part of a patient must be dealt with calmly and effectively ... Procedure ... 3. Staff will intervene as follows when the patient is agitated and have potential for assault ... Utilize ... de-escalation interventions ... Staff will always utilize the least restrictive interventions to maintain safety of all patients and staff ... The clinical staff of the patient's unit will at all times maintain the leadership role in management of the agitated/assaultive patient ... RN/registered nurse directs the team to implement measures necessary to contain assaultive behaviors beginning with the least restrictive means up to and including seclusion and/or restraints ..."

2. The CPI (Crisis Prevention Institute) Non-Violent Crisis Intervention Manual (2020) was reviewed and indicated, " ...CPI Guiding philosophy ... Safety: Protecting rights and minimizing harm. Security: Safe, effective, harmonious, and collaborative relationships ... Module 6: ... Sometimes, a person in distress continues to escalate despite your best efforts and the person places themselves and/or others in a position of imminent or immediate harm ...restrictive interventions in order to maximize the safety and minimize harm ...Module 7 ... Safety Interventions: Holding Skills ... the progressive team responses to physical risk behaviors when a restrictive intervention is necessary for safety ... Principles of Holding in a Standing Position ... Higher-level holding is designed to restrict a person's ability to move away from staff to prevent the person being held from causing significant harm to self or others ..."

3. The hospital's policy titled, "Use of Force" (2/2023) included, " ... D. Health Care Interventions ... II ... When Security Personnel are involved in patient intervention activities (including application of Clinical Restraints/manual, physical or mechanical device used to immobilize a patient or Staff Assist to manage escalating patient behavior), such intervention will be at the direction and supervision of clinical staff and the least restrictive means of Clinical Restraint intervention must be used. Security Personnel supplement, and do not replace, clinical staff members ..."

4. On 8/11/2023, the clinical record for Pt. #1 was reviewed. On 6/29/2023, Pt. #1 was admitted to the hospital for homicidal statement and aggression. The clinical record included:

- On 6/30/2023, MD #1's (Attending Psychiatrist's) notes indicated, " ... Mental Status Examination ... psychomotor agitation ... Mood: Angry, Irritable ... Thought Content: Homicidal ... Assessment ... presenting to the unit for homicidal ideation, suicidal ideation, impulsivity, and aggression. Requires stabilization and individual therapy ... Diagnosis: Suicidal ideation, intermittent explosive. Adjustment disorder with mixed disturbance of emotions and conduct ..."

- On 7/7/2023, the nurse's notes indicated, "(Pt. #1) became triggered during skills group ... (Pt. #1) went to his room and slammed the door. When attempted to process with (Pt. #1), (Pt. #1) came into the hallway and began to punch the ceiling tiles and lights ... (Pt. #1) shattered light fixtures in the hallway. Code security emergency (security officer for extra help) was called ...Minor abrasions to knuckles of the right hand noted ...

- On 7/10/2023, the therapist's notes indicated, " ... observed (Pt. #1), three (mental health counselors), managing supervisor, and two security guards. (Pt. #1) was standing at the end of the hall holding two pieces of metal in (Pt. #1) hand with the aforementioned staff standing around (Pt. #1). This writer was informed that the patient retrieved the metal by smashing through the ceiling. (Pt. #1) was able to break off metal. (Pt. #1) threatened to end (Pt. #1's) life and 'anyone who came near (Pt. #1). (Pt. #1) was unwilling to put the metal down but was somewhat willing to process with staff. More security guards arrived, along with the supervising security guard ..."

- On 7/20/2023, the nurse's notes indicated, " ... (Pt. #1) flipped tables and chairs in dayroom and destroyed plastic bucket ... (Pt. #1) was also verbally threatening (to) staff members in the hallway and broke an overhead light ... Physical hold and restraints were also ordered. Physical hold was initiated at 11:45 (AM). Stretcher was brought from (emergency room) and restraints were applied to bedframe to facilitate process in (Pt. #1) receiving (as needed medication) ... (Pt. #1) was escorted to stretcher and 4-point restraints were applied ... (Pt. #1) currently laying in stretcher in restraints room ..."

- On 7/24/2023, E #1's (Registered Nurse) notes indicated, " ...After group ended at approximately (3:05 PM), (Pt. #1) did not want to leave dayroom ... (Pt. #1) began to escalate and show warning signs of aggressive behaviors as he has done in the past. Security was called and patient began destroying same area of ceiling ... (Pt. #1) broke exit sign ... After increasing staff and security size, (Pt. #1) was standing at the end of the hall - posturing for approximately 10 minutes and broke more of the wiring off. (Pt. #1) was administered 10 mg Haldol (psychotropic medication/intramuscularly) ... at (3:20 PM) but (Pt. #1) returned back to posturing and aggressive behavior at the end of the hall ... Mobile bed arrived (at) the unit and the order to begin to move in to apprehend (Pt. #1) was called. (Pt. #1) sprinted and retreated to the area that was broken, ripped out more metal cord and began to approach back towards staff going to attack with the weapon ... The taser was shot at (3:43 PM by E #3/Security Officer) and discharged into (Pt. #1's) right thigh and chest ... (Pt. #1) fell backwards ..."

- On 7/24/2023, the medical physician's progress note indicated, "Called to bedside to evaluate (Pt. #1) now in restraints ... (Pt. #1) was apparently tased earlier ... Had a small abrasion from the taser on the right medial thigh ..."

5. On 8/11/2023 and 8/15/2023, the video surveillance footage on 7/24/2023 from the 3 South Unit was reviewed. E #1 provided identification of the staff in the video, including Pt. #1's behavior and verbal statements:

- At 3:22 PM, Pt. #1 kicked the emergency exit door. Then, Pt. #1 pushed the exit sign, and ripped the emergency exit signage for fire extinguisher box with both his hands. Pt. #1 then pulled the exit sign from the ceiling and threw the sign on the floor. A metal electrical conduit (tube protecting electrical wiring) was hanging from the ceiling.

- At 3:24 PM, Pt. #1 pulled the metal conduit (approximately 3-4 feet long hanging from the ceiling. Pt. #1 was threatening staff while standing about 10-15 feet away from the staff.

- At 3:31 PM, Pt. #1 threw the metal conduit on the floor and went back to his room.

-At 3:33 PM, Pt. #1 approached the nurse's station and E #4 (Registered Nurse) administered an injection on Pt. #1. Three staff (a registered nurse/E #4 and two mental health counselors) were standing with Pt. #1.

-At 3:39 PM, Pt. #1 was leaning on the wall. According to E #1, Pt. #1's behavior continued to escalate, threatening staff members and refusing to follow redirections. For approximately nine minutes from when Pt. #1 was given intravenous medication, the video did not show that the staff employed another safety intervention (physical hold) to manage Pt. #1's escalating and violent behavior.

- At 3:43 PM, a gurney was brought into the unit and Pt. #1 runs toward Pt. #1's room and pulls the wires hanging from the ceiling and aim wires toward staff.

- At 3:44 PM, E #3 (Security Officer) aimed the taser on Pt. #1's midsection E #2 (Security Officer) placed a handcuff on Pt. #1 and was placed on the gurney by several staff. At 3:46 PM, 4-point restraints were applied on Pt. #1 while on the gurney. At 3:50 PM, Pt. #1 was wheeled to the restraint room.

6. On 8/15/2023 at approximately 9:55 AM, interviews were conducted with E #2 (Security Officer Team Lead) and E #10 (Regional Director of Security). E #2 stated, "(Pt. #1) was in the hallway, visibly upset, did property damage. (Pt. #1) was threatening staff and wanted to kill himself. Nurse Manager (E#9) was saying to get the gurney so the patient can be placed in restraints. When transporting a patient to the restraint room, CPI technique is the option, which includes physical holding. Nobody told us that we needed to do a physical hold. E #10 stated, " I am an instructor for CPI. CPI does not have anything regarding use of gurney in transporting the patient. I would never put anyone in restraint using the gurney. The gurney is not stable. When the gurney was brought in, that triggered the patient's behavior. There should have been a concerted effort to try to verbally deescalate the patient." E #10 confirmed that the video did not show that staff attempted to physically hold Pt. #1 when the patient's behavior was escalating.

7. On 8/15/2023 at approximately 10:49 AM, E #3 (Security Officer) was interviewed. E #3 stated, "When I got there, (Pt. #1) was too riled (irritated/annoyed) up. I was standing by the door, waiting for instructions from (E#9/ Nurse Manager). I was shocked, I had not see (Pt. #1) like that. I heard that we have to wait for the gurney. The clinical staff (registered nurse and nurse manager) did not ask us to talk to the patient. When the patient saw the gurney, (Pt. #1) backed up towards the wall and snatched the wires. The patient was about 5-6 feet when I used the taser. After (Pt. #1) fell, (Pt. #1) was placed in cuffs. If we were instructed to put (Pt. #1) in physical hold after the taser, we would have placed (Pt #1) in physical hold." E #3 stated that Pt. #1 continued to approach the staff with the wire, and was threatening staff, so he had to use the taser for both patient and staff safety.

8. On 8/15/2023 between approximately 11:11 AM and 2:20 PM, interviews were conducted with E #1 and E #4 (Registered Nurses). E #4 stated, "I am not sure what was the plan when (Pt. #1's) behavior was escalating after I gave (Pt. #1) the medication. E #1 stated that he was team lead on how to manage Pt. #1's aggressive behavior. E #1 stated, if a similar situation will happen, I don't necessarily know the best option how to do the physical hold. I know it is in the care plan but putting it in practice is another thing. Engaging in a physical hold is what we are supposed to do clinically. I couldn't give you an answer on how to do it. I am also terrified to implement the care plan myself. I am worried if we do."

9. On 8/15/2023 at approximately 11:45 AM, the CPI Educator/BHA (E #11) was interviewed. E #11 stated that staff are taught to use the CPI techniques to prevent the use of excessive force or taser on patients.

10. On 8/15/2023 at approximately 3:00 PM, an interview was conducted with MD #1 (Attending Psychiatrist). MD #1 stated, " If (Pt. #1) continues to be aggressive and verbal de-escalation is not effective, the next option would be to place (Pt. #1) in restraint or seclusion. Properly following CPI techniques would be the appropriate thing to do. I would expect staff to follow and do what they were trained on how to handle/hold a patient."