HospitalInspections.org

Based on review of facility documentation, medical records (MR), and staff interview (EMP), revealed the facility failed to ensure that each patient's rights were protected and methods used to restrain patients were only utilized after all other alternatives were attempted. (MR5)
Findings include:

Interview with EMP5 on April 1, 2019, revealed the facility purchased tasers in 2015 and trained security staff to carry them while on duty. The facility failed to develop a policy that addressed the use of the taser as a law enforcement action and not a health care intervention. When the taser was used on 3/26/19 due to MR5's physically aggressive behaviors, the facilty failed to ensure that interventions and alternatives were attempted prior to the use of the taser. When law enforcement personnel arrived at the facility after the patient had already been "tased", they indicated that they were unable to assume custody of the patient due to the "summary" offense charges so the patient remained in the facility until transferred to another inpatient health care facility.

These failures placed this patient (MR5) and others in the facility at risk for serious injury and/harm.

Based on review of facility documentation, medical records (MR), and staff interview (EMP), revealed the facility permitted the use of a taser to assist staff in the application of restraints for MR5.

Findings include:

A review of facility policy "Use of Conducted Energy Weapon (Taser)(CEWs), review date 02/18" revealed " Purpose: To authorize the use of a Conducted Energy Weapon (TASER), to defend, disarm, subdue, and control and/or secure a violent person from causing harm to staff, patients and visitors while on UPMC Pinnacle Hanover's premises...Guidelines: A. It shall be the policy of UPMC Pinnacle Hanover's Safety and Security Department, that CEWs will be utilized as a control measure and to stop a person's disorderly, harassing, or other inappropriate criminal action(s) when faced with situations dependent on the actions of the subject(s), or the threat facing the officer, employee, patient, or others and the totality of the circumstances surrounding the incident. In any event, the use of Tasers must be reasonable and necessary...Post Deployment Responsibilities: A. Course of Action When a Taser is Deployed:...5. A taser is considered a law enforcement and security tool and when used, the underlying incident must be reported immediately to the police as a criminal activity. The Security Supervisor/designee will request that the police respond to, and file charges/citation against the person."

A review of MR5 revealed the following nursing documentation: "3/26/2019 Pt asked to wear their boxers during transfer. Pt was advised that the patient would have to wear what the hospital issues. Pt became angry, tore into the locker breaking it open. Pt became more aggressive coming out onto the hall with their fist up calling this RN a .... Pt kicked this RN in the legs and ripped off my name badge. Pt went back into their room and began to bang their head on the sink counter. Pt left quarter sized red mark on their forehead. Pt was stating that the patient wanted someone to kill them and just wanted to die. Pt became aggressive to security and threatened security that they were going to ".... them up" and they wanted security to step into their room. Pt refused to go back into their room and sit down so the patient was tazed in the abdomin (sic). Pt went to floor and was held down by staff. Pt was placed in restraints. Pt was crying screaming "Why don't you just kill me?". Pt received IM meds of 4 mg of Ativan, 2.5 of Zyprexa, and 50mg of benadryl. Pt calmed down after 20 minutes."

A review of the witness statement from all staff involved in the incident indicated that the patient was demanding to leave the hospital and staff explained that the patient was on a 302 and could not leave. The patient attempted to go past/push staff. The patient broke the patient's locker to get to their personal clothing; patient was in paper scrubs due to suicide watch.

An interview conducted on April 2, 2019 with EMP4 revealed that EMP4 was the nurse providing care to the patient. EMP4 stated that the patient demanded to have personal clothing. EMP4 explained that due to the suicide observation level the patient was not allowed their personal clothing but that the clothing would be sent with the patient when transferred. EMP4 stated that the patient then kicked EMP4 on the leg and tore off EMP4's name tag, also ripping EMP4's scrubs. A code green was called and security arrived. "The patient was in our faces (mine and security), the patient was shouting profanities and did make bodily contact with the security as well as EMP4. The patient was a large person over 200 pounds and was not a fat 200 pounds but a muscular 200 pounds. The patient was going to hurt someone that is why the code green was called. The nursing staff and the security staff attempted to talk with the patient and use de-escalating techniques but the patient became more agitated. The police were called but before the police arrived, security deployed the taser. The patient went to the floor and we lifted the patient to the bed and applied restraints. The patient did break the restraints and the bed was bucking as the patient attempted to get out. The provider ordered medication that was given and the patient did then calm down. The patient was very threatening, was swinging at staff with their fists and attempting to kick at us."

An interview conducted on April 2, 2019 with EMP5 revealed that EMP5 was a Security Officer on Duty that afternoon. EMP5 stated that EMP5 and another security officer responded to the code green. The patient was yelling in the door way of their room threatening and challenging staff to fight them. The patient had their fist balled up and was asking if I wanted to fight with them. I attempted to use de-escalating techniques and asked the patient to please go into their room and sit down. The patient made their hand into a fist and advanced towards me. I armed my taser and arch it. The patient backed up but then started to come towards me again. I again armed my taser and arched it. The patient backed up but then quickly advanced towards me with their fists. I tased the patient in the abdomin(sic) and they went to the floor. We quickly subdued the patient and placed the patient in restraints per the providers orders. The police arrived after the patient was tased but due to the preliminary investigation conducted that evening, the patient was charged with a summary offense. Due to the charges, the police were unable to arrest the patient and place the patient in law enforcement custody. The patient remained in the hospital until the patient was removed from the facility and transported to the another inpatient facility.

This incident revealed that a taser was used in the application of a restraint, as a healthcare intervention and not as part of a law enforcement action. The facility failed to demonstrate that "all other use of force means have failed or were not accomplished due expediency."


Cross reference with:
482.13.(e)(4)(i) Patient Right's: Restraints and Seclusion: The use of restraint or seclusion must be-(i) in accordance with a written modification to the patient's plan of care.

482.13(e)(16)(ii) Patient Rights: Restraints or Seclusion [there must be documentation in the patient's medical record of the following:] A description of the patient's behavior and the intervention used.

Based on review of facility policy and procedure and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to use restraints in accordance with a written modification to the patient's plan of care for three of six medical records reviewed (MR3, MR4, and MR5).

Findings include:

A review of facility policy "Medical/Surgical Restraint revised 3/20/2018" revealed " Purpose: To provide guidelines to reduce the use of restraints and to protect the patient's rights, dignity and wellbeing. It also serves as a guideline for the safe, appropriate, and clinically justified use of physical restraints...Documentation: Meditech...Nursing Care Plan-Risk for Injury".

A review of facility policy, " Unit Standard of Care for Medical/Surgical Patient....B. The RN will develop the initial and ongoing plan of care specific to the patient's identified needs...5. The RN will revise the plan of care based on changes in the patient specific needs..."

A review of MR3 revealed the patient was placed in soft wrist restraints on March 15, 2019. Further review of the medical record did not reveal evidence of written modifications to the patient's plan of care.

A review of MR4 revealed the patient was placed in soft wrist restraints on December 18, 2018. Further review of the medical record did not reveal evidence of written modifications to the patient's plan of care.

A review of MR5 revealed the patient was placed in 4 point restraints on April 23, 2019. Further review of the medical record did not reveal evidence of written modifications to the patient's plan of care.

An interview conducted on April 2, 2019 with EMP5 confirmed that the patient were placed in restraints. Further interview confirmed that there was no documented evidence of a written modification to the patients' plan of care.

Cross reference with:
482.13(e) Patient Rights: Use of Restraint or Seclusion

482.13(e)(16)(ii) Patient Rights: Restraints or Seclusion [there must be documentation in the patient's medical record of the following:] A description of the patient's behavior and the intervention used.

Based on review of facility documentation and medical records (MR), as well as employee interviews (EMP), it was determined that the facility failed to ensure that nursing documentation provided a description of the patient's behavior and the interventions used to warrant the use of a taser.

Findings include:

A review of facility policy "Documentation of patient care, edit, and undo reviewed 5/15/2019" revealed "Purpose: To provide guidelines for the collection , documentation and correction of the patient's health data...3. Notes: Nurse's notes shall reflect pertinent changes in the patient's condition, medical and nursing interventions taken place in response to those changes and outcomes of those interventions that cannot be documented otherwise in PCS...10. Misc Interventions: Additional interventions that may be needed will be added to the patient's medical record as appropriate. 11. Care plans will be initiated and individualized in the EMR on admission, every 24 hrs and or prn with condition changes..."
A review of MR5 revealed the following nursing documentation related to the event:
"3/26/2019 Pt asked to wear boxers during transfer. Pt was advised that they would have to wear what the hospital issues. Pt became angry, tore into the locker breaking it open. Pt became more aggressive coming out onto the hall with their fist up calling this RN a .... Pt kicked this RN in the legs and ripped off my name badge. Pt went back into their room and began to bang head on the sink counter. Pt left quarter sized red mark on forehead. Pt was stating that they wanted someone to kill them and they just wanted to die. Pt became aggressive to security and threatened security that they were going to ".... him up" and they wanted security to step into their room. Pt refused to go back into their room and sit down so they were tazed in the abdomin (sic). Pt went to floor and was held down by staff. Pt was placed in restraints. Pt was crying screaming "Why don't you just kill me?". Pt received IM meds of 4 mg of Ativan, 2.5 of Zyprexa, and 50mg of benadryl. Pt calmed down after 20 minutes."

Interview conducted on April 2, 2019, with EMP1 and EMP2 confirmed that the documentation of the events clearly demonstrated that MR5 was becoming abusive to staff however, it failed to include interventions and de-escalating techniques used prior to the patient being tased.

Cross reference with:

482.13(e) Patient Rights: Use of Restraint or Seclusion

482.13.(e)(4)(i) Patient Right's: Restraints and Seclusion: The use of restraint or seclusion must be-(i) in accordance with a written modification to the patient's plan of care.