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Based on document review, video tape review, and interview, it was determined that the Hospital failed to ensure patient care in a safe environment. The cumulative effect of this systemic practice resulted in the Hospital's inability to ensure the patient was cared for in a safe environment. As a result, the Condition of Patient Rights (42 CFR 482.13) was not met. This potentially effected all 170 patients treated in the ED on census on 10/30/14.

Findings include:

1. The Hospital failed to ensure a patient was not injured during restraint intervention. (A-144-A)

2. The Hospital failed to ensure that staff were trained/educated regarding management of aggressive behavior. (A-144-B)

3. The Hospital failed to ensure patient injuries were investigated and an adverse occurrence report was completed, to reduce subsequent potential injury to patients, through review, analysis and corrective action. (A-144-C)

An Immediate Jeopardy (IJ) and serious threat to patient safety and well being was created from the cumulative effect of these systemic practices.

An IJ was identified and announced on 11/6/14 at 12:40 PM, during a meeting with the Chief Executive Officer, Chief Nursing Officer, Chief Medical Officer, Vice President (VP) of Nursing Administration, Manager of Risk Management and Patient Safety, VP of Psychiatric and Behavioral Health, and the Quality Director.

A. Based on document review and interview, it was determined, for 1 of 1 patient (Pt. #1), who attempted elopement from the emergency department, the Hospital failed to ensure the patient was not injured during restraint intervention.

Findings include:

1. On 11/6/14 at 2:05 PM, Hospital policy titled, "Rights and Responsibilities", (revised 9/13), was reviewed, and required, "Patient/legal representatives have the right to the following... to be free from... physical... abuse."

2. On 11/6/14 at 2:25 PM, Hospital policy titled, "Restraint Use - Violent/Self-Destructive Behavior and Nonviolent/Non-Self-Destructive Behavior", (revised March 2013), was reviewed, and required, "Procedure... d. Restraints are applied using only safe techniques..."

3. The clinical record for Pt #1 was reviewed on 11/5/14 at 9:50 AM. Pt. #1 was a 55 year old male, transported by ambulance to the Emergency Department on 10/30/14 at 9:49 AM, for a psychiatric evaluation. Pt. #1 thought the landlord was trying to poison him; he had to "stop the black magic going on at the church," and he was hearing voices. The clinical record indicated initially Pt. #1 was appropriate and cooperative with staff and treatments, including blood draws. Pt. #1 was placed on "security standby" (can not leave the ED), with no other restrictions. Pt. #1 was medically cleared at 12:03 PM and a decision to transfer him to a State Mental Health Center (F1) for psychiatric treatment was made at 1:10 PM.

4. On 11/5/14 at 11:15 AM, an interview was conducted with the ED Registered Nurse (E #2) assigned to Pt. #1 on 10/30/14. E #2 stated Pt. #1 was waiting in the ED hall, in a wheel chair, his clothing removed, wearing 2 patient gowns and hospital socks, under the view of the ED security guard (E #5).

5. Progress notes at 1:39 PM, included Pt. #1 got up from the chair and exited the ED through the ambulance entrance. A security officer (E #5) stopped Pt. #1 just outside the door and a struggle ensued. Other staff came to assist and Pt. #1 was returned to the ED and placed in restraints. However, Pt. #1 sustained abrasions to the face and knees. Pt. #1's ED physician's (MD #1) progress note on 10/30/14 at 2:05 PM, indicated Pt. #1 was examined after the incident, and had lost 2 "canine" teeth. Another progress note at 5:10 PM, indicated Pt. #1 had bilateral elbow pain, X-rays were performed, and included no fracture. Pt. #1 was transferred to State mental Health Center (FI) at 7:38 PM.

6. On 11/5/14 at 10:50 AM, a phone interview was conducted with the ED physician (MD #1) who cared for Pt. #1 on 10/30/14. MD #1 stated Pt. #1 sustained abrasions to his face and knees and Pt. #1 lost a tooth during the elopement attempt.

B. Based on document review and interview, it was determined, for 4 of 4 Emergency Department (ED) staff (E #2, 4, 6, & 8) caring for Pt. #1 on 10/30/14, the Hospital failed to ensure that staff were trained/educated regarding management of aggressive patient behavior.

Findings include:

1. On 11/6/14 at 2:40 PM, Hospital document titled, "Security Personnel on Standby Guidelines"", (revised 8/10), was reviewed, and required, "Hostile or Combative Patients - Should the patient become hostile or combative, the officer will... 5. A minimum of four officers (one per limb) is recommended to restrain an individual... 7. If in the course of the restraint a mask is not available the use of a towel or sheet held above the patient's face is authorized. At no time is the towel to be placed on the face or nose..."

2. The clinical record for Pt #1 was reviewed on 11/5/14 at 9:50 AM. Pt. #1 was a 55 year old male, transported by ambulance to the Emergency Department on 10/30/14 at 9:49 AM, for a psychiatric evaluation. The clinical record indicated initially Pt. #1 was appropriate and cooperative with staff and treatments, including blood draws. Pt. #1 was medically cleared 12:03 PM and a decision to transfer him to a State Mental Health Center (F1) for psychiatric treatment was made at 1:10 PM.

3. On 11/5/14 at 11:15 AM, an interview was conducted with the ED Registered Nurse (E #2) assigned to Pt. #1 on 10/30/14. E #2 stated Pt. #1 was waiting in the ED hall, in a wheel chair, his clothing removed, wearing 2 patient gowns and hospital socks, and being watched by a security guard (E #5). Progress notes at 1:39 PM, included Pt. #1 got up from the chair and exited the ED through the ambulance entrance. A security officer (E #5) stopped Pt. #1 just outside the door and a struggle ensued.

4. A video tape of Pt. #1's struggle and return to the ED was reviewed on 11/5/14 at 11:35 AM. As E #5 (Security Guard) was attempting to get Pt. #1 to lie down, an ED Technician (E #8) and a Registered Nurse (E #6) arrived to assist E #5. Pt. #1 was curled up on his left side. E #6 abruptly placed his knee on Pt. #1's head rapidly forcing Pt. #1's head to the cement.

5. A few minutes later, E #6 was handed a small cloth (wash cloth or small towel) from a paramedic which E #6 placed and held on Pt. #1's mouth. After additional security officers arrived, Pt. #1 was lifted, carried to a cart inside the ED, restrained, and transported back into the ED at 1:47 PM

6. On 11/6/14 at 1:30 PM, the personnel files 4 ED nursing staff (E #2, 4, 6, & 8) present during Pt. #1's restraint intervention on 10/30/14 were reviewed. The 4 nursing staff (E #2, 4, 6, & 8) did not include documentation of training in the management of aggressive/violent patient behavior.

7. On 11/5/14 at 1:00 PM, an interview was conducted with the ED Registered Nurse (E #6) who assisted in restraining Pt. #1 on 10/30/14. E #6 stated that he has worked at the hospital for 5 1/2 years and over 31 years as a Nurse without being trained on safe management of aggressive/violent patients. E #6 stated, "there probably should be training" for events similar to that of Pt. #1.

8. On 11/5/14 at 1:00 PM, an interview was conducted with the ED Technician (E #8) who assisted in restraining Pt. #1 on 10/30/14. E #8 stated that he has worked at the hospital for 1 1/2 years and and has not had training on safe management of aggressive/violent patients.

C. Based on document review and interview, it was determined, for 1 of 1 Patient (Pt. #1), injured during restraint, the Hospital failed to ensure patient injuries were investigated and an adverse occurrence report was completed, as required by policy.

Findings include:

1. On 11/6/14 at 3:45 PM, Hospital policy titled, "Occurrence Reporting", (revised October 2013), was reviewed and required, "Timely reporting of safety events is essential to ensure adequate and thorough evaluation and investigation. Initial reports should be completed by the individual staff member who witnessed the event..."

2. The clinical record for Pt #1 was reviewed on 10/5/14 at 9:50 AM. Pt. #1 was a 55 year old male, transported by ambulance to the Emergency Department on 10/30/14 at 9:49 AM, for a psychiatric evaluation. Progress notes at 1:39 PM, included Pt. #1 got up from the chair and exited the ED through the ambulance entrance. A security officer (E #5) stopped Pt. #1 just outside the door and a struggle ensued. Pt. #1 sustained abrasions to the face, knees and had 2 teeth knocked out . Another progress note at 5:10 PM, indicated Pt. #1 had bilateral elbow pain, X-rays were performed, and included no fracture. Pt. #1 was transferred to a State Mental Health Center (F1) for psychiatric treatment on 10/3014 at 7:38 PM.

3. An interview was conducted with the Director of Quality Management (E #12) on 11/5/14 at approximately 10:00 AM. E #12 stated a Adverse Occurrence Report had not been completed for Pt. #1's injuries.