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Based on observation, document review, video surveillance review and interview, it was determined that the Hospital failed to provide care in a safe setting and promote each patient's rights, by failing to ensure that de-escalation techniques and safe interventions were adequate for patients that were in crisis and agitated and by failing to ensure that patients were safe from ligature risks, and failing to follow the process of reporting and investigating an allegation of abuse. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.
Findings include:

1. The Hospital failed to provide care in a safe setting by failing to ensure that the patient were free from ligature risks to prevent potential, serious harm to patients. See deficiency at A-0144.

2. The Hospital failed to ensure that the patients requiring de-escalation and emergency safety interventions, were free from physical abuse. See deficiency at A-0145 A.

3. The Hospital failed to follow the process for reporting and investigating an allegation of an abuse, to ensure the patient was free from abuse or harassment. See deficiency at A-0145 B.

An Immediate Jeopardy (IJ) began on 06/26/2023 due to the Hospital's failure to ensure patients were free from all forms of abuse by failing to ensure the use of de-escalation techniques and ensure safety interventions were adequate for patients that were in crisis and become agitated; and was identified on 7/5/2023 at 42 CFR 482.13, Patient Rights. An additional IJ began on 06/29/2023, due to the Hospital's failure to ensure that patient rooms on 1 of 1 behavioral health units were free from ligature risks; and was identified at 42 CFR 482.13, Patient Rights.

The IJs were announced on 07/05/2023 at 2:45 PM, during a meeting with the Accreditation Manager, Vice President Chief Nursing Executive, Manager of Emergency Department, Inpatient Program Manager, Manager of Patient Care Behavioral Health, and Clinical Practice Specialist for Behavioral Health. The IJs was not removed by the exit date of 07/06/2023.

Based on document review, observation, and interview, it was determined that for 1 of 1 behavioral health unit, the Hospital failed to ensure that care was provided in a safe setting by failing to ensure that the patient rooms were free from ligature risks to prevent potential, serious harm to patients.

Findings include:

1. The Hospital's document titled, "Your Rights and Responsibilities as Our Patient" included, "As our patient, you have the right to: ... Be cared for in an environment that is ...safe."

2. The Hospital's policy titled, "Environmental Tours" (effective 08/14/2020), was reviewed and required, "As part of an ongoing environment of care program... coordinate the environmental tours of the facility, to identify and evaluate information concerning safety..."

3. The Hospital's Risk Assessment Tool, dated 06/09/2023, was reviewed and included, "Risk assessments are proactive evaluations used to decrease the potential of harm to patients... These include anything that you think could potentially cause harm or have a negative effect on patient safety... A hazard is anything that can cause harm or has the potential to cause harm... Consider what particular risks there may be to each of the different groups of people involved (or exposed) to the hazards identified..." This risk assessment did not identify toilet seats or the sink bowl as potential ligature risks. The plan included, "Patient bathrooms have been modified to be ligature resistant ... [Certain rooms] do have built-in shower chairs. Patients at high suicidal risk should not be placed in those rooms ... Chairs and over-the-bed tables are necessary for patient comfort and use. The chairs are behavioral health grade and the tables are without mirrors. If a patient is at high risk for suicide or violence, these items are to be removed from rooms ..." There was no set plan or date to remove these ligature risks.

4. The manufacturer's guidance on the toilet seats, sink bowls, built-in shower chair, over-the-bed tables, and the chairs were reviewed and did not indicate they were designed to be ligature resistant.

5. A tour of the adult behavioral health unit was conducted on 6/29/2023. There were 19 patients on census at the time, of which 17 were on suicide precautions. The unit was divided into two sections: 1 General Adult Area with 13 rooms (#301-313) and 1 High Acuity Area with 7 private (1 bed) rooms (#314-320). Each of the 20 rooms had it's own bathroom.
- Each bathroom had a toilet with a moveable (up and down) U-shaped seat, that could be used as a ligature point. The hinge of the toilet seat was also raised at least 1-centimeter above the base of the toilet bowl which created a gap that could be used as a ligature point.
- Each bathroom had a wall-mounted sink that extended approximately 1-foot from the under-sink enclosure, creating an empty space below the sink bowl to allow for hanging.
- 3 of the bathrooms had built-in shower seats with bars and holes that could be used as ligature points.
- Each room had moveable chairs with open arms and raisable over-the-bed tables with a flat, overhanging top surface that could be used for hanging.
- Patient rooms were open and accessible to anyone on the unit (whether the occupants were in the room or not).
- During the tour, two staff members (E#15 and E#16) were asked if there were any specific ligature risks they were monitoring and stated they would look for contraband and anything that could pose a ligature risk; however, were not able to identify any specific risks currently present in the rooms. The environmental rounding sheets (conducted twice per shift) only included beds and doors; however, lacked specific ligature risks checks for the toilets, sinks, chairs, and tables.

6. An interview was conducted with the Manager of Accreditation (E#1) and the Chief Nursing Executive (E#12) on 7/5/2023, at approximately 1:00 PM. E#12 stated that they did not identify the over-the-bed tables, chairs, sinks, and toilet seats as potential ligature points. E#12 stated that these items were not designed to be ligature resistant; however, for the comfort of the patients and to be ADA [American Disabilities Act] compliant, they had to have a balance. E#12 stated that their plan was to not place any high risk patients in the ADA rooms, if possible, and that all patients are rounded on every 15 minutes. E#12 stated that patients deemed a high risk would be on 1:1 monitoring.

A. Based on document review, video surveillance review, and interview, it was determined that for 3 of 3 (Pt. #20, Pt. #21, and Pt.#22) the Hospital failed to ensure that the patients requiring de-escalation and emergency safety interventions, were free from physical abuse. This could potentially affect all patients admitted to the Hospital.

Findings include:

1. The Hospital's policy titled, "Use of Force & Restraint" (effective 6/1/22) was reviewed and required, "A. ...The use of force and restraint shall be restricted to circumstances authorized by law and only to the degree reasonably necessary... C ... Use of physical force should be avoided if possible ... V. A. 1. Officers shall limit the Use of Force to the minimum force reasonably necessary to accomplish the intended objective ... B. Levels of Force - Dynamics of Use of Force Principles ... 2. The scale of use of force options, in order of increasing severity, is as follows: a. Verbal persuasion or de-escalation. b. non-deadly force ... C. Verbal Persuasion as a Means of Effective Control ... 2. Simple directions ... are by far the most desirable method of dealing with control/restraint situation. Control may be achieved through advice, persuasion ... before resorting to actual physical force ... G. Use of Force During Restraint: 1. All patient restraints are performed at the direction of clinical staff and with the least amount of force necessary. 2. Security will assist clinical staff with physical control and application of restraints as needed."

2. "CPI Nonviolent Crisis Intervention Training" (2nd Edition, 2020) was reviewed and included, "Defensive Behaviors and the Verbal Escalation Continuum ... the individual is verbally and/or nonverbally threatening staff in some manner. Intervention ...Seek assistance. Wait for colleagues to arrive ... Consider safety from the perspective of ... keeping the individual in crisis safe ... Safety interventions must be the last resort and least restrictive ... uphold the person's human rights. You are obligated to reduce use and prevent the misuse of and abuse of safety interventions."

3. The Hospital's policy titled, "Electronic Control Device (ECD)" (effective date 1/18/21) was reviewed and included, "... C... ECDs will only be utilized when no other means of de-escalation or control will prevent physical harm or injury to the individual or others. ECDs cannot be used against a passive individual... 4. Each cycle constitutes a separate use of force... No more than one additional cycle may be used, and it should be avoided whenever possible..."

4. The Hospital's policy titled, "Patient Visitor Searches" (revised 6/10/21) was reviewed and included, "... F. All efforts will be made to conduct the search with the patient's cooperation. If the patient or legal guardian refuses to comply with any step in the search process, a discussion between the patient's nurse, physician and a Security officer should occur to determine next steps..."

5. The Hospital's education to staff titled, "Defensive Tactics in Healthcare" (undated) Levels of Force: Less Lethal Weapons ... pepper spray ... conducted electrical weapon (taser) ... handcuffs ... Weapons are never to be used against patients."

6. Pt. #20 's clinical record was reviewed and included that Pt. #20 presented to the Emergency Department on 06/25/2023, with a chief complaint of suicidal ideation. The clinical record included the following:

-ED Nursing note dated 06/25/2023 at 8:41 PM, "Patient brought by local EMS (emergency medical services) for psychiatric evaluation due to text messages expressing suicidal ideation. Upon RN (Registered Nurse) arrival to room patient is assaulting security officers. Patient subsequently tased and restrained to bed and given IM (intramuscular) medication ..."

-Violent/Self-Destructive Restraint ... Debriefing/Removal Assessment 6/25/23 at 9:15 PM, " ... Trauma resulting from incident? Yes (pain in right shoulder and left cheek) ..."

-ED Nursing note dated 06/26/2023 at 10:45 AM, " ...Pt repeatedly making statements regarding being 'assaulted by security last night' and 'doesn't feel safe here' and wants to go home."

Incident report for Pt. #20 dated 6/25/2023, included, "On 6/25/23 at 2010 (8:10 PM) hours, Charge RN stated that an uncooperative male was en-route to (name of Hospital) for psych (psychiatric) evaluation ... At 8:20 PM, (Pt. #20) was escorted from Ambulance Bay by (Security Officer/E#6). (Pt.#20) remained silent and walked to ER (emergency room) willingly ... (S.O. E#7) explained hospital policy ... belongings would be removed ... (Pt.#20) became aggressive E#6 entered room attempted to de-escalate the patient but was unsuccessful ...(Pt. #20) became combative ... remained combative and attempted to strike ... E#6 then removed the taser (device that electrically stuns and incapacitate a person temporarily) from the holster ..." E #6 tased Pt. #20 twice.

7. A video surveillance review was conducted of ED room #12 on 06/25/2023 from 8:22 PM to 8:33 PM. The following occurred:
-At 8:22 AM, Pt. #20 is walking from the ambulance bay area to the Psychiatric Emergency Services area with a paramedic and Security Officer (E#13).
-At 8:23 AM, Pt. #20 is sitting in the bed with his feet dangling. Two security officers (E #6 and E #7) are in the room, interacting with the patient.
-At 8:24 AM, Pt. #20 had changed into a hospital gown and was sitting on top of his clothing with his legs in the bed and arms crossed. E #6 and E #7 positioned themselves one on each side of the patient by the head of the bed. E #6 and E #7 grab the patient's arm under the shoulder and pull patient back, causing the patients legs to come up towards ceiling. Pt. #20's legs are flailing towards E#6's face and upper body. E#7 is leaning over the patient's chest and head area.
-At 8:25 AM, E #6 tased the patient in the upper body area.
-At 8:29 AM, staff applied bilateral restraints to upper and lower extremities.

8. Pt. #21's clinical record was reviewed and included that Pt. #21 was admitted to the Behavioral Health Unit (BHU) on 06/23/2023 with a diagnosis of schizophrenia (mental condition). The clinical record included the following:

-ED Note dated 6/23/23 at 1:45 AM, included, "(Pt.#21) transferred from the BH (Behavioral Health) unit by wheelchair per security. Per staff patient attempted to elope, ran himself into a wooden door upstairs, falling backwards ... Security responded to BH unit ... patient tased and pepper sprayed per security due to violent behavior. (Pt. #21) presents in handcuffs ..."

Incident report for Pt. #21 dated 6/23/2023, indicated that Pt. #21 had attacked BHU staff and attempted to elope. Upon arrival of the Security Officers E #8, E#9, E#10, and E#6, Pt. #21 to BHU, Pt. 216 was using the bathroom. E #6 requested Pt. #21 to exit the bathroom and to follow security to the quiet room. E #10 stated, ' ... you're (Pt. #21) going to spend the remainder of the night in there.' ... (Pt.#21) panicked and began pulling away ... then became combative and attempted to strike at security ..." E #6 and E #8 deployed their taser on Pt. #21. E #6 used pepper spray (an aerosol spray that causes irritation and used as a disabling weapon) into Pt. #21's eyes and was handcuffed.

9. Pt. #22's clinical record was reviewed. Pt.#22 was admitted to the BHU on 06/21/2023 with a diagnosis of schizophrenia. The clinical record included the following:

-Nursing Note dated 6/25/23 at 10:00 PM, "(Pt.#22) frequently at med (medication) window wanting to engage in social conversation with staff ... endorses anxiety ... thoughts are disorganized has racing thoughts ... from 6:20 PM to 7:30 PM, patient was placed on 4-point restraints due to pointing and gesturing towards security staff personnel." Pt. #22's clinical record did not indicate that the patient was placed in handcuffs.

Incident report for Pt. #22 dated 6/25/23, included, "On 6/25/23 at 1820 (6:20 PM) (Pt. #22) was being verbally aggressive with the nurses through the medication window. E #6 and E #7 were on the unit and attempted to deescalate Pt. #22 but were not successful. Pt. #22 walked toward E #6 and E #7 in an aggressive manner and E #6 took out taser (did not use). E #6 and E #7 assisted Pt. #22 to the ground where Pt. #22 continued to be aggressive and was handcuffed. Pt. #22 complained several times about pain in his left wrist.

10. Interviews were conducted on 06/28/2023 at approximately 11:15 AM, and 06/29/2023 at 2:55 PM, with the Chief Nursing Executive (E#12). E#12 stated that all Security Officers in the ED BHU staff have Nonviolent Crisis Intervention Training (CPI) to use on patients with aggressive behavior. Clinical staff and Security Officers are expected to try verbal de-escalation or re-direction before resorting to more aggressive methods. However, we are seeing an increase in violent patients and when Security staff are called to assist with aggressive patients, it is a possibility that they will have to use the taser or pepper spray.

11. On 06/28/2023 at approximately 12:45 PM, an interview was conducted with the Operations Manager of Security Services (E#11). E#11 stated that all security officers are trained in CPI and are expected to use CPI methods before using their taser or pepper spray when dealing with aggressive patients. E#11 stated that E#11 was aware of the incidents involving (Pt#20, Pt.#21, and Pt.#22) being tased, the use of pepper spray and handcuffs. E #11 stated that he feels that it was appropriate.

12. On 06/28/2023 at 2:15 PM, an interview was conducted with a Resource Coordinator of Security (E#6). E#6 stated that he was told by the RN that EMS reported the patient was en-route and was aggressive. E#6 stated when the patient arrived, he was not being aggressive and was walking to the room willingly, he looked upset and like he did not want to be there. (Pt.#20) took off his clothes and changed into a gown in an angry way but willingly. E#6 stated that he had to use aggressive force on (Pt.#20) because his behavior indicated that he was going to escalate quickly. The patient ignored E#6 when asked to hand over his clothes. E#6 stated that the patient threatened he would start swinging if they took his clothes away. E#6 felt this was a threat and did not want himself or other staff to be injured by the patient, this is when E#6 and E#7 did not want to give the patient the opportunity to swing at me so we took him down on the bed, and the patient began kicking at me, so I took out my taser and applied it to the patient. The RN was right outside of the room when this was going on.

B. Based on document review and interview, it was determined that for 1 of 1 patient (Pt. #20) clinical record reviewed, the Hospital failed to ensure that the patient was free from all forms of abuse, by failing to follow the procedures for prevention of abuse and failure to report an allegation of abuse of a patient in the hospital.

Findings include:

1. On 07/05/2023, the Hospital's policy titled, "Risk Management Incident and Event Reporting" (revised 12/13/21) was reviewed and included, "... B. Abuse of a patient in the hospital... defined as any physical or mental injury... inflicted by hospital employee... 2. Upon receiving a report of suspected abuse of a patient, the hospital shall immediately conduct an internal investigation. This investigation may be done by members of various departments, including ... Risk Management, Patient Relations... local leadership as relevant..."

2. Pt. #20 's clinical record was reviewed and included that Pt. #20 presented to the Emergency Department on 06/25/2023, with a chief complaint of suicidal ideation. The clinical record included the following:

-ED Nursing note dated 06/25/2023 at 8:41 PM, "Patient brought by local EMS (emergency medical services) for psychiatric evaluation due to text messages expressing suicidal ideation. Upon RN (Registered Nurse) arrival to room patient is assaulting security officers. Patient subsequently tased and restrained to bed and given IM (intramuscular) medication ..."

-Violent/Self-Destructive Restraint ... Debriefing/Removal Assessment 6/25/23 at 9:15 PM, " ... Trauma resulting from incident? Yes (pain in right shoulder and left cheek ..."

-ED Nursing note (entered by E#14) dated 06/26/2023 at 10:45 AM, "RN, student RN, 2 Crisis workers and charge RN at bedside ... Pt repeatedly making statements regarding being 'assaulted by security last night' and 'doesn't feel safe here' and wants to go home... RN (E#14) informed pt that his 'assault by security' was in response to his actions... continues to to blame security guards for him not feeling safe..."

3. On 06/29/2023 at approximately 3:00 PM, an interview was conducted with the Chief Nursing Executive (E#12). E#12 stated that all allegations of abuse reported to any hospital employee should be reported to their supervisor and complete an incident report via the hospital reporting system. E#12 stated that there is no report for an allegation of abuse for (Pt.#20). There has not been any investigation conducted for this incident or report from any staff.

4. On 07/05/2023 at 1:50 PM, an interview with an RN (E#14) was conducted. E#14 stated E#14 was made aware through hand off report from the previous nurse that there had been an incident involving the patient and security. E#14 stated that E#14 did not report the allegation from the patient because E#14 assumed it had been taken care of the previous shift.