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Based on record review and interview the hospital failed to meet the Condition for Participation for Governing Body by:

1. failing to ensure that appropriate health care interventions were used by security officers in the Emergency Department as evidenced by security officers using a weapon (Stun Device) to restrain the behaviors of patients #3 and #9 when these patients became uncontrollable and exhibited threatening behaviors while seeking medical care in the Emergency Department. (See findings cited at A0154)

2) failing to ensure that weapons were only used in the hospital for law enforcement purposes and not used as a health care intervention for 2 of 2 patients reviewed where a Stun Device was used to control the patient prior to the application of restraints (#3, #9). (See findings cited a A0154).

3. failing to ensure that hospital administration, physicians, and appropriate supervisory staff were aware of hospital policies and procedures which allowed for the use of Stun Devices on patients as a means to control aggressive behaviors of patients prior to the application of restraints on patients seeking medical attention in the Emergency Department. (See findings at A1104).

4. failing to ensure that the hospital maintained a true and accurate description of the patient's treatment as evidenced by patient #9's medical record not reflecting the use of a Stun Device to control the patient's behavior prior to the application of restraints when the patient was seeking medical treatment in the Emergency Department. (See findings cited at A0438).

5. failing to ensure appropriate safety measures were in place as evidenced by the failure to have all Security Officers trained in Crisis Prevention Intervention as required by hospital policy for 10 of 19 Security Officers employed by the hospital (Officers S4, S6, S46, S47, S48, S49, S50, S51, S52, S53) and that the hospital was staffed on all shifts with Security Officers who were current with CPI training for 4 of 16 days reviewed (6/27/2010, 7/03/2010, 7/10/2010, and 7/11/2010). (See findings cited at A0144).

Based on record review and interview, the hospital failed to meet the Condition of Participation for Patient Rights by:

1) Failing to ensure that appropriate health care interventions were used by security officers in the Emergency Department as evidenced by the use of a weapon (Stun Device) to control patients' behaviors prior to the application of restraints for patients #3 and #9 when these patients became uncontrollable and exhibited threatening behaviors while seeking medical care in the emergency department (See findings cited at A0154).

2) failing to ensure that weapons were only used in the hospital for law enforcement purposes and not used as a health care intervention for 2 of 2 patients reviewed where a Stun Device was used to control the patient's behavior prior to the application of restraints (#3, #9). (See findings cited at A0154)

3) failing to ensure measures were in place that all Security Officers were trained in Crisis Prevention Intervention as required by hospital policy for 10 of 19 Security Officers employed by the hospital (Officers S4, S6, S46, S47, S48, S49, S50, S51, S52, S53). This practice could affect all patients where security officers were deployed to intervene with aggressive patients and/or patients in need of restraint application. (See findings cited at A0144).

4) failing to ensure measures were in place so that the hospital was staffed on all shifts with Security Officers who were current with CPI training for 4 of 16 days reviewed (6/27/2010, 7/03/2010, 7/10/2010, and 7/11/2010). This practice could affect all patients where security officers were deployed to intervene with aggressive patients and/or patients in need of restraint application. (See findings cited at A0144).

Based on record review and interview the hospital failed to ensure measures were in place to ensure patients received care in a safe setting by:

1) failing to ensure all Security Officers were trained in Crisis Prevention Intervention (CPI) as required by hospital policy for 10 of 19 Security Officers employed by the hospital (Officers S4, S6, S46, S47, S48, S49, S50, S51, S52, S53). Security officers have used a taser weapon to control aggressive behaviors prior to restraining 2 patients (#3, #9) who exhibited uncontrolled behavior in the emergency department rather than using non violent crisis intervention techniques (CPI). (See findings cited at A0154).
2) failing to ensure the hospital was staffed on all shifts with Security Officers who were current with CPI training for 4 of 16 days reviewed (6/27/2010, 7/03/2010, 7/10/2010, and 7/11/2010).
3) failing to ensure 1:1 staffing was implemented for a suicidal patient in the Emergency Department as per policy for 1 of 7 patients reviewed for staff monitoring (Patient #3) out of a total sample of 9.
4) failing to ensure a suicidal patient was checked for contraband and/or items that could be used to harm self or others upon arrival to the Emergency Department for 1 of 4 patients reviewed for contraband searches (Patient #3) out of a total sample of 9.

Findings:


1) failing to ensure all Security Officers were trained in Crisis Prevention Intervention as required by hospital policy for 10 of 19 Security Officers employed by the hospital (Officers S4, S6, S46, S47, S48, S49, S50, S51, S52, S53).

Review of a document titled, "Safety/Security Staff Years of Service" presented by the hospital as current information revealed there were 19 Security Officers on staff at the hospital. Further review revealed 10 of the 19 had no documented training in CPI (Crisis Prevention Intervention) to include Officers S4, S6, S46, S47, S48, S49, S50, S51, S52, S53.

During a face to face interview on 7/13/2010 at 5:15 p.m., Security Director S4, indicated not all Security Officers were current in CPI (Crisis Prevention Intervention) as they should be according to hospital policy. S4 presented a list of 19 officers employed by the hospital with their current CPI status. 9 of the 19 employees were documented as being current with CPI training and 10 were listed as having no current CPI training. The ten officers listed with no current CPI training included Officers S4, S6, S46, S47, S48, S49, S50, S51, S52, S53. S4 indicated all employees were required to be current in CPI per hospital policy. S4 further indicated all employees had been trained in Restraint Application and Use of Stun Devices. S4 indicated patients should be handled with Non-violent Crisis Intervention Techniques and Techniques for Proper Application of Restraints when restraints were the least restrictive manner in which to keep a patient safe. S4 indicated the use of a Stun Device was a last resort effort when an individual was violent and unable to be contained by other methods which included CPI.

Review of the hospital policy titled, "Restraint and Seclusion, last revised 3/16/2010" presented by the hospital as their current policy revealed in part, "Training of Staff: Hospital staff members who assess patients for restraint or who apply restraints must attend Nonviolent Physical Crisis Intervention (CPI) training class. Participants must attend the entire 8 hour course every 2 years."

2) failing to ensure the hospital was staffed on all shifts with Security Officers who were current with CPI training for 4 of 16 days reviewed (6/27/2010, 7/03/2010, 7/10/2010, and 7/11/2010).

Review of a document titled, "Work Schedule Assignments- Staff- With CPI" presented by the hospital as current information revealed the following shifts had no security officer on duty with current CPI training :
6/27/2010, 7 a.m. - 3 p.m. shift staffed with 2 officers with no current CPI training (S47, S48)
7/03/2010, 11 p.m. - 7 a.m. shift staffed with 3 officers with no current CPI training (S51, S52, S53),
7/10/2010, 7 a.m. - 3 p.m. shift staffed with 2 officers with no current CPI training (S47, S48), and
7/11/2010, 7 a.m. - 3 p.m. shift staffed with 2 officers with no current CPI training (S47, S48).

This finding was confirmed by Security Director S4 on 7/13/2010 at 5:15 p.m.

3) failing to ensure 1:1 staffing was implemented for a suicidal patient in the Emergency Department as per policy for 1 of 7 patients reviewed for staff monitoring (Patient #3) out of a total sample of 9.

Review of Patient #3's medical record revealed the patient was admitted to the hospital through the Emergency Department on 7/08/2010 at 0822 (8:22 a.m.) with diagnoses that included " Overdose, bleach ingestion, and Major Depression with Suicidal Ideation" . Review of Patient #3 ' s medical record revealed a PEC (Physician's Emergency Certificate) was completed at 11:30 a.m. indicating the reason for admission was due to "drank bleach in attempt to hurt himself. Also OD (overdose). . . " Review of Physician's orders for Patient #3 dated 7/08/2010 at 11:30 a.m. revealed in part, " Diagnoses Suicidal, bleach ingestion, overdose. Suicide Precautions ". Review of the patient #3's medical record revealed the patient was transferred from the Trauma Unit located in the Main Emergency Room to the Mental Health Extension Unit at 1408 (2:08 p.m.).

During a face to face interview on 7/14/2010 at 2:15 p.m., Registered Nurse (RN) S23 indicated she was one of the two nurses assigned to the Trauma Unit (a 6 bed unit) on 7/08/2010. S23 indicated she was the nurse that was assigned as the primary care nurse for Patient #3; however, she was sharing the responsibility for his care with RN S31. S23 indicated Patient #3 was on constant visual. S23 indicated the arrangement of beds in the trauma area were such that patients beds were separated by curtains; however, there were no separating walls. S23 indicated Patient #3 was on a monitor and had a vital sign machine connected to his arm. S23 indicated the machine cycled every 15 minutes and if it had become disconnected an alarm would have sounded. S23 indicated she remembered two occasions when she found Patient #3 ' s bed to be empty. S23 indicated it had not been possible to keep her eyes on Patient #3 at all times because other patients occasionally had needs that required privacy during their care and the curtains would have been pulled between the patients. S23 indicated she had also been caring for a cardiac patient awaiting a cardiac catheterization at the same times she was assigned to watch Patient #3 as a 1:1. S23 indicated there was no tech available to do 1:1 with a suicidal patient. S23 indicated she had instructed patient #3 that a urine sample would be needed; however, the first time she noticed that he was missing, someone had walked him back indicating he had been in the bathroom. S23 indicated Patient #3 left the room on another occasion upon which he had taken off his gown and placed his shirt back on. S23 confirmed that she failed to document in the patient's medical record any of Patient #3 ' s elopement attempts. Review of the patient's medical record also confirmed that the elopements from the Emergency Department were not entered into the patient's medical record by S23. S23 indicated that she notified her Charge Nurse after the second successful attempt by Patient #3 to leave the Trauma area and Patient #3 was then transferred to the locked Mental Health Extension Unit. S23 confirmed that she had not requested any staffing assistance from the charge nurse prior to requesting the patient be transferred to the Extension Unit. S23 indicated Patient #3 had been placed in the Trauma unit due to the need for medical observation - post overdose. S23 indicated Patient #3 had been awaiting bed availability in the hospital ' s CCU (Cardiac Care Unit).

During a telephone interview on 7/15/2010 at 4:00 p.m., Registered Nurse (RN) S31 indicated she assisted RN S23 in the care of Patient #3 while located in the Trauma Unit on 7/08/2010. S31 indicated Patient #3 was a big guy and she was not going to stop him from doing anything he wanted to do which included leaving the Trauma Room and going to the bathroom. S31 indicated she informed Security Officer S15 that Patient #3 was PEC ' d and could not leave the Emergency Department. S31 did not recall the time of this notification. S31 further indicated Patient #3 had disappeared from the Trauma Unit several times. S31 indicated she told Patient #3 that she (S31) was a mother that needed to support her children and if he continued to leave the Trauma Room he could jeopardize her job and affect her ability to provide for her children. S31 indicted Patient #3 told her he did not care and that he was not liable for her. S31 indicated she and RN S23 would not have been able to watch Patient #3 at all times when the Trauma Unit became busy. S31 indicated she notified the Charge Nurse and Patient #3 was transferred to the Mental Health Extension Unit. S31 indicated that was the only time she communicated with the Charge Nurse to request assistance in providing 1:1 care for Patient #3. S31 indicated there were either 3 or 4 patients in the Trauma Unit when Patient #3 was transferred: assigned to her (S31) and S23 (as a team).

During a face to face interview on 7/15/2010 at 11:50 a.m., Director of Emergency Department S30 indicated S23 and S31 had not followed hospital protocol. . S30 indicated she had reviewed staffing and patient admissions for the date of 7/08/2010 and found that the two nurses assigned to the Trauma Unit on 7/08/2010 for the 7:00 a.m. - 7:00 p.m. shift only had 5 patients (2 nurses for 5 patients) for their entire 12 hour shift. S30 further indicated one of these 5 patients was Patient #3, one patient was a simple Cardiac Admission, two patients were medical patients that were discharged home, and the one patient that needed a cardiac catheterization had not arrived at the hospital until after Patient #3 had already been transferred to the Mental Health Extension Unit. S30 provided computer printouts of Admissions to the Trauma Unit for 7/08/2010 to confirm her statement (as reviewed below). S30 indicated any time there was a need for additional assistance in the Trauma Unit, the charge nurse was to be notified and she would make sure re-assignments were made and help was provided. S30 indicated the Nursing Assistant on duty could always be pulled to sit with 1:1 psychiatric patients if needed. S30 indicated she could find no evidence that the Trauma Unit was too busy for RN S23 and S31 to have provided 1:1 care for Patient #3. S30 further indicated she was on duty that day and could have sat with the patient herself; however, at no time did RN S23 or S31 ask for extra assistance. S30 indicated since two nurses were assigned to the Trauma Unit and shared responsibility for the patients located in the area (prior to transfer to the Emergency Department ' s Mental Health Extension Unit at 2:08 p.m.), there was no reason one of the two could not be in constant visual contact with Patient #3. S30 indicated Patient #3 presented with a suicide attempt and should have been placed on 1:1 from the point of entrance into the Emergency Department.

Review of electronic documentation of a form titled, " Staff Events Groups by Staff " for the date of 7/08/2010 presented by Director of Emergency Department S30 revealed a list of 5 patients assigned to Registered Nurse S23 on the date of 7/08/2010. Record review revealed three of the 5 patients which included Patient #3 were triaged as " Orange (High Risk situation, < 15 minutes/less than 15 minutes) " and 2 patients were triaged as " Yellow(1-2 hours) " . A handwritten notation at the top of the form indicated " Only patient (RN S23) cared for alone was a med/surg. Admit (a line was drawn from this hand written notation with an arrow pointing towards the patient that arrived at 4:38 p.m.). " Review of the time sequence for patients under the care of RN S23 revealed one Level Orange patient (#3) was admitted to her care at 8:22 a.m. The next arrival was admitted to her care at 10:13 a.m. (Level Yellow), followed by the next patient (Level Yellow) at 12:06 p.m. (Patient #3 was transferred to the Emergency Department ' s Mental Health Extension Unit at 2:08 p.m.) The remainder of the two patients assigned to the care of RN S23 for the 12 hours shift she was assigned in the Trauma Unit for 7/08/2010 arrived at 2:29 p.m. and 4:38 p.m. Both were triaged as Level Orange.

4) failing to ensure a suicidal patient was checked for contraband and/or items that could be used to harm self or others upon arrival to the Emergency Department for 1 of 4 patients reviewed for contraband searches (Patient #3) out of a total sample of 9.

Review of Patient #3's medical record revealed the patient was admitted to the hospital through the Emergency Department on 7/08/2010 at 0822 (8:22 a.m.) with diagnoses that included " Overdose, bleach ingestion, and Major Depression with Suicidal Ideation " . Review of Patient #3 ' s medical record revealed a PEC (Physician ' s Emergency Certificate) was completed at 11:30 a.m. indicating the reason for admission was due to " drank bleach in attempt to hurt himself. Also OD (overdose). . . " Review of Physician ' s orders for Patient #3 dated 7/08/2010 at 11:30 a.m. revealed in part, " Diagnoses Suicidal, bleach ingestion, overdose. Suicide Precautions " . Record review also revealed no documented evidence that Patient #3 had been cleared for contraband and placed in a hospital gown while located in the Main Emergency Department. Further review revealed patient #3 was transferred from the Trauma Unit located in the Main Emergency Room to the Mental Health Extension Unit at 1408 (2:08 p.m.).


During a face to face interview on 7/14/2010 at 2:15 p.m., Registered Nurse (RN) S23 indicated she was one of the two nurses assigned to the Trauma Unit (a 6 bed unit) on 7/08/2010. S23 indicated she was the nurse that was assigned as the primary care nurse for Patient #3; however, she was sharing the responsibility for his care with RN S31. S23 indicated she had never removed his pants or checked his pants for objects that might be a danger to himself or others. S23 indicated the patient denied suicidal ideations and she felt that he was credible (Record review revealed S23 triaged Patient #3 at 8:22 a.m. as Code Orange and documented in part, " anxious, depressed. . . ingested unknown qty. (quantity) of xanax, bleach, and anti-hypertensive " . Further record review revealed Patient #3 was placed under a PEC (Physician ' s Emergency Certificate) on 7/08/2010 at 11:00 a.m.).

During a telephone interview on 7/15/2010 at 4:00 p.m., Registered Nurse (RN) S31 indicated she assisted RN S23 in the care of Patient #3 while located in the Trauma Unit on 7/08/2010. S31 confirmed that she was the person that undressed Patient #3 upon arrival to the Emergency Department. S31 indicated she removed his shirt and left his pants on. S31 indicated staff were supposed to remove suicidal patient ' s pants and check for sharps (anything the patient could use to harm themselves or others). S31 indicated Patient #3 was a big guy and she was not going to stop him from doing anything he wanted to do which included leaving the Trauma Room and going to the bathroom. S31 indicated she told Patient #3 that she (S31) was a mother that needed to support her children and if he continued to leave the Trauma Room he could jeopardize her job and affect her ability to provide for her children. S31 indicted Patient #3 told her he did not care and that he was not liable for her. S31 confirmed that Patient #3 had been left with his street clothes on during the entire stay in the Main Emergency Department with no assessment to ensure he did not have contraband and/or dangerous items on his person (8:22 a.m. until 2:08 p.m.)

During a face to face interview on 7/15/2010 at 11:50 a.m., Director of Emergency Department S30 indicated all Emergency Department nurses were oriented to the need for checking psychiatric patients for sharps. S30 indicated these patients were to be placed in hospital gowns and their belongings were to be stored in a locked bin. S30 indicated S23 and S31 had not followed hospital protocol. S30 indicated Patient #3 should have been checked for sharps and should have been placed in a hospital gown at the time of his arrival to the hospital for the protection of himself and others.

Review of the hospital policy titled, " Emergency Department Suicide Precautions (last revised 12/11/2009) presented by the hospital as their current policy revealed in part, " Suicide Precautions include, but are not limited to: a) constant visual contact b) Continually observation and monitoring with visitors c) Repeated assessment of suicidal ideation d) Patient dressed in gown. e) Belongings searched for contraband and secured in compliance with policy " Patient Belongings " after patient has been PEC'd f) Hospital security should be notified of PEC ' d patients and request to sit with patient. If security is unavailable, this should be documented. The ED Clinical Director or Nursing Supervisor (Supervisor) should be notified and a sitter requested. If sitter is unavailable, nurse will observe patient. 7. A staff member must always be with patient when the patient goes out of the Emergency Department for any reason. . . . Procedure . . . 2. Nursing staff implements " Suicide Precautions " based on: a) Patient behavior or statements b) Physician Order c) PEC, CEC, or OPC . . . There are multiple ways for patients to inflict self harm or make a suicide attempt while in the Emergency Department. Therefore, it is important to monitor patients as closely as possible and secure patient belongings. "

Based on record review and interview the hospital failed to ensure hospital staff enforce Patient's Rights by:
1) failing to ensure psychiatric patients were restrained with appropriate techniques as evidenced by the use of a weapon (Stun Device) to control patient's behaviors prior to the application of restraints for patients #3 and #9 (2 of 4 patients reviewed for restraint application out of a total sampled of 9) when these patients became uncontrolled and exhibited threatening behaviors while seeking medical care in the emergency department.
2) failing to ensure that weapons were only used in the hospital for law enforcement purposes and not used as a health care intervention for 2 of 2 patients reviewed where a Stun Device was used to control the patient prior to the application of restraints (#3, #9).

Findings:

1) failing to ensure psychiatric patients were restrained with appropriate techniques as evidenced by the use of a weapon (Stun Device) to control patient's behaviors prior to the application of restraints for patients #3 and #9 (2 of 4 patients reviewed for restraint application out of a total sampled of 9) when these patients became uncontrolled and exhibited threatening behaviors while seeking medical care in the emergency department.

Patient #3:
Review of Patient #3's medical record revealed the patient was admitted to the hospital through the Emergency Department on 7/08/2010 at 8:22 a.m. with diagnoses that included Overdose, Bleach Ingestion, and Major Depression with Suicidal Ideation ". Patient #3 was transported to the hospital's Emergency Department by local Emergency Medical Services (ambulance) and triaged at 8:22 a.m. as an Acuity Orange (High Risk Situation: a patient you would give your last bed). Triage documentation revealed in part,"Presenting complaint: Patient states: anxiety. EMS (Emergency Medical Services) states: EMS states ingested unknown qty (quantity) of Xanax, bleach and anti-hypertensive about an hour and a half ago. Vomited prior to arrival. . . . General: appears in no apparent distress, comfortable, Behavior is cooperative, pleasant." 0831 (8:31 a.m.) assessment (documented by RN S23) "General: appears in no apparent distress, comfortable, behavior is cooperative, pleasant . . . states that one of the medicine bottles was empty and one had 3 - 5 pills - mother verifies this. Also pt (patient) drank unknown qty (quantity) of bleach and has vomited several times PTA (prior to arrival) per EMS (Emergency Medical Services) - no pill fragments observed. . . . " Further review revealed Physician S24 ordered that Patient #3 be admitted to the hospital's Cardiac Care Unit on 7/08/2010 at 9:51 a.m. Review of Patient #3's medical record revealed a PEC (Physician s Emergency Certificate) was completed at 11:30 a.m. indicating the reason for admission was due to "drank bleach in attempt to hurt himself. Also OD (overdose). . . " Medical Record review revealed Patient #3 was transferred from the Trauma Room to MH-(Mental Health Extension) at 1408 (2:08 p.m.) while continuing to await bed placement in CCU (Cardiac Care Unit).

Review of Patient #3's medical record as documented while located in the Mental Health Extension Unit of the Emergency Department revealed in part, 1435 (2:35 p.m./as documented by Registered Nurse S11) "General: appears angry, aggressive, yelling, becoming combative. Behavior is agitated, anxious, uncooperative, SVC (Strict Visual Contact) monitoring for needs and safety continues. 1439 (2:39 p.m.) Patient is uncooperative, defensive, guarded, hostile, irritable, speech is loud, pressured, affect is blunted. Subjective: patient's mood is angry, irritable, delusions are denied, hallucinations are denied. . . Patient will be an involuntary commitment via PEC (Physician's Emergency Commitment). 14:40 Geodon 20 mg (milligrams): route: IM (intramuscular); site: right gluteus. 1500 (3:00 p.m.) General: appears combative, fighting, yelling, scratching, Code White called. Seizure started, IV 20 gauge started left hand. Placed in cloth restraints, 4 point, tonic clinic seizure lasted for one minute. Pt. bite (bit) his tongue during seizure. . . Discontinued IV during code white. Found IV catheter intact on floor. Pressure held to site and covered with gauze and taped. Inserted peripheral IV: 20 gauge in left hand. . 1505 (3:05 p.m.): Restraints Implementation: The following alternative methods were tried: calming interaction with one on one intervention, decreased stimuli, administered meds to decrease agitation, Geodon 20 mg (milligrams) IM (intramuscular) rt (right) buttock. Restraints without trying less restrictive methods because pt. was self destructive, disoriented and harmful to self. Yelling, screaming, threatening, punching, very aggressive. Physician assessed patient at 1505 (3:05 p.m.). The patient was given an explanation of the restraint protocol, their patient rights, Restraints applied at 1505. Patient was restrained with soft limb restraints to right arm, left arm, rt (right) leg and rt leg (as documented). Restraints were applied because patient is a danger to self, danger to others, danger to staff. . . . " Further review of nursing documentation in the Mental Health Extension Unit revealed no documented evidence of the use of a Stun Gun on Patient #3.

Review of Patient #3's History and Physical as dictated by Hospitalist, Physician S14 on 7/08/2010 at 1543 (3:43 p.m.) revealed in part, "We had a calm conversation in the Emergency Room. However, when the staff members tried to get him to put on a gown and told him that he was going to have to stay in the hospital, the patient became belligerent. Several Security guards had to be called and situation became quite combative with multiple Security guards having to restrain the patient. He was tasered. He was put in bed by the officers and restrained in four-point restraints. At that time he had a generalized tonic clonic seizure and bit his tongue. This lasted maybe a minute to two minutes. He came around fairly quickly. At this point he is fairly calm although he is complaining of aches and pains and discomfort in various places. . . General: Calm black male looking down at the floor, answering questions slowly when I saw him but then became belligerent, argumentative, and defensive when we asked him to get in the bed. He had to be restrained physically and received a shot of Geodon. Generally, he is fairly calm again but he is in four point restraints. Impression: Possible Suicide attempt/depression: I feel the patient has had several emotional or physical traumas in his life and apparently this has become overwhelming to him to the point where this morning he sent a text to his sister saying "I love you and good bye". Since there was no one in the bathroom with him, I have to assume he drank the bleach and took the medications. Currently, he is hemodynamically stable. He will need a GI (Gastro Intestinal) evaluation for the swallowing of the bleach. There seems to be no acute adverse effects from the Xanax or the indapamide he may have taken. He is currently PEC'd and Psychiatry will be seeing him to determine if any additional treatment counseling as (is) needed. Ingestion of toxic substances. Epilepsy and acute seizure: Speaking to (Physician S34) over the phone he says the patient's compliance has not been good. He was last seen in the office in March and his Trileptal level was very low. He seriously doubts compliance. His sister feels the seizure was brought on by the tasering but it could have also been brought on by the agitation and combativeness as well. . . "

Review of a hospital event report regarding the use of a Stun Device on Patient #3 revealed, " WJnet {West Jefferson Event report}
EVENT REPORT # 25440 (Open) Reported by (S22) on 7/8/2010 @ 4:55pm
Details-Follow-up
Identification-Person Involved
Event Information,
Description: Security staff were called to POD 5 at approximately 1430 (2:30pm) to stand by for assistance with a patient (#3) was refusing to cooperate with nurses requests and threatening to elope. (Patient #3) was PEC'ed by ER doctors. A code white was called by security when (Patient #3) refused to take medication, stood up next to bed, took an aggressive stance with both fist clinched at his side. He stated he would not take medication and to "Bring It On" . S/O (Security Officer) S22 approached him and asked him to lay down and take his medication. He (Patient #3) refused again and S/O S22 backed away and nurse attempted to calm him to no avail. At this time, S/O S21 advised security that it was time to restraint patient as all attempts to get his cooperation failed. Security staff approached (#3) and patient backed into corner and began swinging his arms. As security attempted to restrain patient, he (#3) became aggressive and began pushing officers away. Officers were able to get patient on floor, but he continued to struggle and swing at officers. At this time, S/O S22 deployed his stun device and applied a 1-2 second activation on patient ' s back to stop him. Patient stopped resisting and was given medication by nurse. Security lifted patient onto bed and while positioning him to be restrained, patient kicked S/O S22 in the groin area and began to struggle with officers who were attempting to restrain him in bed with help of EMS (Emergency Medical Services) and unit staff. When restraints were completely applied, patient calmed down and unit staff took over. This was about 1530 (3:30 p.m.).
It should be noted that during struggle security called (local police department) to assist and several officers were struck by patient without any serious injury. Security cleared scene and met with (local police department) outside unit and advised them that they were no longer needed."

During a face to face interview on 7/15/2010 at 9:40 a.m., Counselor S28 indicated she was assigned to the Emergency Department on 7/15/2010. S28 indicated her job duties include counseling families of patients that are critically ill or dying, assisting in obtaining beds for psychiatric patients when no beds are available in their facility, and evaluating patients when requested by the physician. S28 indicated she had not been involved with Patient #3 other than walking him from the Trauma Room to the Mental Health Extension Unit (2:08 p.m.). S28 indicated Patient #3 had a loud tone to his voice and was rambling about not wanting to be there. S28 indicated Patient #3 entered the unit, sat on the bed, and began rocking back and forth. S28 indicated Patient #3 was not at all happy about being there and kept talking about leaving. S28 indicated she informed security because the patient seemed to be at risk of elopement and he was under a Physician's Emergency Commitment. S28 indicated after the first officer responded (S38), she felt the patient was still at risk and she asked (S21) to come to the Unit as well. S28 indicated she then left the unit and did not return for at least 30 minutes. S28 indicated when she returned Patient #3 was in restraints with his sister at his bedside visiting. S28 indicated Patient #3 was yelling loud enough for everyone in the area to hear him that he had been hit, his hair had been pulled, and he had been Tased. S28 indicated Patient #3's sister was very upset seeing her brother fighting to get out of restraints. S28 indicated one of his (#3) arms was loose and he was trying to undo the restraints with it (One of Patient #3's arms had been released in order to turn the patient on his side during a seizure). S28 indicated she walked Patient #3's sister off the unit and explained medical admissions, PEC's (Physician's Emergency Commitments), and restraints to her. S28 indicated she notified the Director of the Emergency Department (S30) of the sister's concerns about her brother being "Tased" .

During a face to face interview on 7/13/2010 at 11:40, Registered Nurse S5 indicated she was the preceptor for a nurse, in orientation, that was assigned to the care of Patient #3 on the date of 7/08/2010 while located in the Mental Health Emergency Extension Unit. S5 indicated there had been 3 Registered Nurses and 1 Mental Health Technician located on the Unit that day. S5 indicated Patient #3 arrived on the unit with his clothing on. S5 indicated she had explained to the patient that he would need to remove his clothing and be placed in a gown as part of the safety requirements of the unit. S5 indicated Patient #3 refused. S5 indicated Counselor (S28) also spoke with Patient #3 regarding the need to be placed in a hospital gown while located on the unit. S5 indicated other staff also took a shot at encouraging the patient (#3) to change into a gown although she could not recall who the other staff had been. S5 indicated Patient #3 was determined to remain in his clothing. S5 indicated a Security Officer showed up to speak with the patient and he continued to refuse to be placed in a gown for safety purposes (Sharps Policy). S5 indicated Hospitalist S14 arrived to perform Patient #3's History and Physical. S5 indicated Patient #3 was sitting on the side of the bed at that time and remained there while S14 completed his History and Physical which took about 15 minutes. States patient was approached after the History and Physical was completed in regards to putting on a gown and he became agitated again. States Security spoke with patient after she tried to persuade him but he continued to become agitated and his behavior and mood escalated. States Patient #3 backed into the corner of the room and by this time approximately 4 security guards had arrived on the scene. S5 indicated Patient #3 had his fist balled. S5 indicated RN S11 came to the bedside to administer medication to Patient #3 (Geodon intramuscularly) explaining to the patient she was going to give him some medication to help calm him; however, Patient #3 would not cooperate. S5 indicated at that time Patient #3 backed up further into the corner of the room and took the TV that was attached to an extendable arm and threw it at the security officers two times. S5 indicated Patient #3 then started fighting with the security officers using his fist. S5 indicated Security was able to get #3 to the ground with him fighting them the entire time. S5 indicated RN S11 was able to give Patient #3 the medication (Geodon) at that time. S5 indicated, at the same time, Emergency Room staff were placing restraints on the bed in preparation for placing the patient in them. S5 indicated Patient #3 was then placed into restraints on the bed. S5 indicated she never saw anyone use a stun device on Patient #3; however, she did hear a noise that she had never heard before and afterwards the patient was on the ground. S5 indicated some time later (not sure when) she heard from security that a stun device had been used. S5 indicated she heard RN S11 instruct Security to place Patient #3 in the bed when she was needing to administer a shot but never heard S11 instruct security to use a stun gun. S5 indicated she saw no one with their hands on Patient #3 other than security. S5 indicated she believed the stun gun helped security to control the situation. S5 indicated she had been afraid of Patient #3.

During a face to face interview on 7/13/2010 at 3:10 p.m., Registered Nurse S13 indicated she worked in the Mental Health Extension Unit on 7/08/2010 when Patient #3 was located in the Unit. S13 indicated she had not been assigned to his care but did remember the patient. S13 indicated Patient #3 arrived on the unit with his street clothes on and staff approached him requesting that he remove his clothing and put on a gown. S13 indicated Patient #3 was a large man and that he refused to change into a gown. S13 indicated several staff members attempted to persuade him to change and explained the practice was to ensure safety on the unit. S13 indicated after multiple unsuccessful attempts, a security guard showed up and tried to encourage the patient to change into a gown. S13 indicated Patient #3 was agitated and his voice had been loud and was becoming louder. S13 indicated Hospitalist S14 came to the unit and performed a medical exam. S13 indicated after her exam, staff attempted to pursue changing Patient #3 into a gown and checking for sharps. S13 indicated she could not see everything that occurred; however, she recalled the patient escalating and becoming louder, more security guards showing up, S11 preparing an injection to calm the patient as ordered by the Emergency Department Physician S24, heard S11 encourage Patient #3 to allow her to medicate him, heard Patient #3 refuse, heard Patient #3 becoming more worked up and saw him backing into the corner with his fist balled in the fighting position, heard security encourage patient to cooperate with the injection, saw bodies move to the floor, heard loud voices, yelling, heard a crackly noise that she had never heard before, and then saw Patient #3 being moved onto the bed into restraints. S13 indicated she had been standing near the panic button but had never pressed it. S13 indicated she could not see well from where she was standing. S13 indicated a Code White was called for a patient in the Mental Health Extension Unit when someone had escalated out of control and was moving towards violence. S13 indicated when a Code White was called, the situation was turned over to security when they arrived because they were trained in handling violent situations which included stun devices. S13 indicated she was unsure who had called the Code White for Patient #3. S13 indicated she had no knowledge that a stun device had been used on Patient #3 and would not know if it had been indicated or not. S13 indicated Stun devices had not been presented in any of her training on violent patients, CPI (Crisis Prevention Intervention/ Non Violent Crisis Intervention), or Restraints. S13 indicated Patient #3 reportedly had a seizure when he had been moved to the bed for restraints; however, she had not witnessed it. S13 indicated she did hear Patient #3 complain that he had been punched in the face by a security guard and that his tooth was loose. S13 indicated she looked in his mouth and saw some blood. S13 indicated she had not reported the allegation of being struck by a security guard to anyone; however, the house supervisor had been in the room in response to the calling of a "Code White." S13 indicated she had never seen anyone punch Patient #3. S13 further indicated she did see Patient #3 holding some pieces of hair after the event was over, when the patient sat up in bed.

During a face to face interview on 7/13/2010 at 3:50 p.m., Senior Mental Health Specialist S10 indicated she had been returning from lunch when Patient #3 had been transferred from the Emergency Department's Trauma Unit to the Mental Health Extension Unit. S10 indicated when she entered the Unit, she bumped into a security guard that was on the unit. S10 indicated at the time of her arrival, Patient #3 had been putting up a fuss about changing from his street clothes into a hospital gown. S10 indicated the patient was yelling that he did not need to be there. S10 indicated she approached Patient #3 and the security guard backed off. S10 indicated Patient #3 allowed her to remove his socks as she explained to him the purpose was for his safety as well as the safety of others. S10 indicated all went well until she attempted to remove other pieces of clothing and based on the patient ' s movements she thought he was uncomfortable with her removing his clothing and might prefer a male assist him. S10 indicated she then stepped back and allowed a security guard to approach the patient. S10 stated Patient #3 then began to yell loudly that he did not belong there. He refused to be searched for sharps. S10 indicated Patient #3 moved toward the corner wall and the RN unclamped his IV (Intravenous Fluid). S10 indicated the RN gave the patient an injection of Geodon and he started clenching his hands into fists and moved against the wall. S10 indicated Patient #3 took the Television that was mounted to an extension arm on the wall and threw it towards the security officers in the room. S10 indicated Patient #3 began to wrestle with security and she saw them slide him down the wall to the floor. S10 indicated Patient #3 was still combative. S10 indicated there were four security officers in the room and Patient #3 was wearing them all out. S10 indicated at some point during the event she heard a popping noise. S10 indicated Patient #3 continued to fight after she heard the noise. S10 indicated Patient #3 was kicking, biting, and punching the security officers. S10 indicated she never saw security officers punch Patient #10, that all she saw was them holding the patient. S10 indicated she assisted by holding the patient ' s legs. S10 indicated restraints had been placed on the patient's bed by nursing staff while security contained him and the patient was placed in four point restraints. S10 indicated Patient #3 had a seizure while he was being placed in the restraints and later awoke asking "what's happening?" S10 indicated vital signs were obtained and were normal. Patient #3's bed became open in CCU and report was given by the nurse. S10 indicated there were pieces of hair on the floor after the event and she collected them and placed them in a bag for the patient. S10 indicated she was unsure but thought the pieces of hair were extensions. S10 indicated the patient's hair was very fragile and came out easily. S10 indicated she had not known Stun Devices were used in the hospital prior to the incident with Patient #3. S10 indicated there had never been any mention of Stun Devices in education classes such as CPI, Restraints, or Code Whites. S10 indicated she did believe a Stun Device was needed with Patient #3 because he had been fighting, kicking, biting, throwing the Television, and punching.

During a face to face interview on 7/13/2010 at 4:15 p.m., Registered Nurse S11 indicated she was the nurse assigned to the care of Patient #3 on 7/08/2010 while located in the Mental Health Extension Unit of the Emergency Department. S11 indicated she had been a Registered Nurse since 1976 (34 years) with psychiatric in-patient experience since 1997 (13 years). S11 indicated she was still in orientation at West Jefferson Medical Center with a start date of 4/26/2010. S11 indicated when psychiatric patients present to the unit; they were undressed and placed in a gown. S11 indicated most patients cooperate; however, if they were resistant, staff spent extra time explaining the safety reasons for having all patients placed in gowns and searching their belongings for dangerous items. S11 indicated staff would continue to try and work with the patient by other means such as administering medications for anxiety; however, if the patient became agitated and escalated to physical aggression, the security department would be called by initiating a "Code White". S11 indicated there were two methods of calling a "Code White" on the Unit; one was to use the phone and the other was to press the panic button. RN S11 indicated on the 7/08/2010 a "Code White" was called for Patient #3. S11 indicated she documented the "Code White" in Patient #3's medical record; however, she had not called the "Code White". S11 indicated Counselor S28 had walked Patient #3 over to the unit from the Main Trauma Unit. S11 indicated Patient #3 was able to tell her why people thought he needed to be there. S11 indicated security showed up while she was speaking to the patient and the patient ' s speech became faster when they were present. S11 indicated she asked security to step back and they did. S11 indicated the patient continued to talk with her and Physician S14 arrived to perform a medical exam on Patient #3. S11 indicated Patient #3 spoke with the physician for approximately 10 - 15 minutes and was still dressed in street clothes at the time. S11 indicated after the physician completed her exam security asked again for the patient to remove his clothing. S11 indicated Patient #3 was getting more and more angry and his voice was becoming louder as he refused to remove his clothing and allow his belongings to be searched for items that might be dangerous. S11 indicated she had called the Main Emergency Department to get an order for a prn (as needed) medication to help calm the patient. S11 indicated that while she was preparing to draw up the medication (Geodon) that someone came to her and informed her that Senior Mental Health Specialist S10 was getting the patient to remove his clothing and the shot might not be needed. S11 indicated when she re-entered the patient care area, that Patient #3 was pushing S10 and saying that he wouldn't put it on (gown). S11 indicated Patient #3 was standing up near the TV holding a PowerAde in his hand and talking back and forth with security staff. S11 indicated she returned to the medication room and drew up the Geodon as ordered. S11 indicated when she exited the medication room the patient was continuing to argue with security. S11 indicated she asked Patient #3 to give her the PowerAde and he did. S11 indicated a security guard asked Patient #3 to get into the bed for his medication and the patient said "Man, do what you have to do!" S11 indicted Patient #3 stood in the corner of the room and forcefully pushed the TV attached to an extendable arm towards a security officer like a weapon. S11 described Patient #3 as a tall stout man and indicated he began kicking hard and trying to fight the four security officers in the room at that time. S11 indicated Patient #3 was kicking, swinging, yelling and it was difficult for the officers to get the patient to the floor for her to administer his injection. S11 indicated after she administered the patient's injection, he continued to yell and kick but was picked up and placed on a bed with restraints. S11 indicated the patient was facing the wrong direction and had to be turned to fit the restraints properly (head was at foot). S11 indicated she never saw the use of a Stun Device on Patient #3 during the incident but heard during a debriefing later with security that one had been used. S11 indicated she could not recall informing anyone upstairs (CCU in report) that a Stun Device had been used on Patient #3. S11 indicated Patient #3's sister was allowed to visit him after the incident and she heard Patient #3 yell to his sister "(Sister's name) look what they did. They punched me in the mouth, tased me, and pulled out my hair. I have a law suit now." S11 indicated Patient #3 had a seizure after he was placed in restraints and before his sister came to visit him. S11 indicated she loosened the patient's left hand and placed him on his side during the seizure. S11 indicated after the seizure she noticed the patient's lip was swollen- appearing as if he had bitten it during the seizure. S11 indicated there were pieces of hair lying on the floor after Patient #3 scuffled with security. S11 confirmed that she had not documented any assessment of Patient #3 post restraints or post seizure. S11 indicated Patient #3 had a swollen lip, blood in his mouth, and some hair missing. S11 indicated she did not do an event report on the incident nor did she report the patient's allegations of mistreatment by security to her supervisor. S11 indicated she did not think to do so.

During a face to face interview on 7/13/2010 at 4:55 p.m., Legal Counsel S12 indicated the video recording device located in the hospital's Emergency Department Mental Health Extension Unit had not been working on the date of 7/08/2010. S12 indicated real time viewing of the video device had been working; however, the recording device had not been working.

Review of Agency A's documentation on letterhead dated 7/15/2010 revealed in part, "As of July 9,2010 (Agency A) began performing an internal review of the issues that lead to the recording gap that occurred on July 8,2010. This document is considered a preliminary report and a final report with findings from (Agency A) and the equipment manufacturer shall be forwarded when all testing and review is completed. Summary: On July 8, 2010 at 06:09:20 GMT (Greenich Mean Time) - 6 the DVR (Digital Video Recorder) in question, a sixteen channel unit connected to some Emergency Room, POD4, and other camera locations, stopped recording and did not resume until July 8, 2010 at 15:19:18 GMT-6 when manually reinitiated due to a service call to (Agency A). Subsequently, the Administration Log of the unit were pulled and submitted to internal (Agency A), West Jefferson Medical Center and the manufacturer. The log was reviewed showing multiple abnormal reboots. The administrative logs record all active and passive events which include, but are not limited to Log in, DVR setting changes, DVR state changes, Hard Drive installation, Hard drive formatting along with other highend states. These logs cannot be altered on the units, but can be cleared. The logs in this case are holistic dating from the building of system at the manufacturers' facility to current. Per the manufacturer, the term Abnormal Reboot, with no other specificity, encompasses power loss or power spike/surge. The DVR in question was installed in a controlled/ keyed enclosure with a surge protection unit fed by West Jefferson medical Center emergency power circuit that feeds a total of four DVRs. Agency A metered the power circuit supplied by West Jefferson Medical Center and found the power to be correct voltage at time of installation. Prior to installation and post incident, Agency A tested the surge protection unit and it was found to be in good working order. Agency A then pulled the logs of the remaining three DVRs sharing the same circuit finding almost exact duplication in time and event of abnormal reboots. Upon review and discussion with the manufacturer it was determined that power conditions were the cause of these reboots and alerted West Jefferson Medical Center of said findings."

During a face to face interview on 7/13/2010 at 11:10 a.m., Registered Nurse S3 indicated she was the nurse that admitted Patient #3 to CCU (Critical Care Unit) on 7/08/2010 and also provided care to the patient on the 7:00 a.m. - 7:00 p.m. shift on 7/09/2010. S3 indicated Patient #3 was quiet and withdrawn upon arrival to CCU. S3 indicated the patient had a non-definitive cut to his upper lip that she described as being reddened from the outer corner of the lip to the middle of the lip. S3 indicated the lip was swollen with no bleeding and no drainage. S3 indicated she had received information in report from the Emergency Department (Mental Health Extension Unit) that Patient #3 had bitten his lip during a seizure. S3 indicated she received no information regarding the use of a stun device on Patient #3 during report. S3 indicated Patient #3's mother came to the unit to visit the patient and asked if a stun gun had been used on her son. S3 indicated that was the first time she had heard anything about a stun device being used on Patient #3. S3 indicated she informed the house supervisor of Patient #3's mother's concern and questions. S3 indicated the house supervisor did speak with the patient's mother. S3 indicated Patient #3 consistently stated that he believed he had been punched in the mouth and Tazed by Security Officers in the Emergency Department. S3 indicated Patient #3 had been discharged on 7/09/2010 after being cleared for injury to his esophagus by Gastroenterologist and being cleared for suicidal ideation by psychiatry.

During a face to face interview on 7/15/2010 at 11:00 a.m., House Supervisor S29 indicated he was on duty when Patient #3 was seen in the Emergency Department on 7/08/2010. S29 further indicated he had been in the Main Emergency Room when he heard a call for a Code White. S29 indicated he responded to the Code and when he got there Patient #3 was on the floor. S29 indicated he helped to secure one of the lower extremities and elevate the patient into the bed for placement into restraints. S29 indicated Patient #3 stated that someone had hit him in the mouth. S29 indicated Patient #3 made the statement about being hit in the mouth moments before he had what appeared to be a seizure. S29 indicated it did not appear to be a typical grand mal seizure

Based on record review and interview the hospital failed to ensure ongoing quality improvement was maintained by:
1) failing to ensure event reports were completed and analyzed with tracking and trending for all "Code Whites" in the hospital as per hospital policy.
2) failing to ensure event reports were completed and analyzed with tracking and trending for all uses of Stun Devices in the hospital as per hospital policy for 1 of 2 patients in which a stun device was used (#9).

Findings:

1) failing to ensure event reports were completed and analyzed with tracking and trending for all "Code Whites" in the hospital as per hospital policy.

Review of the hospital's Code White Log revealed Code Whites had been called on 5/28/2010, 6/07/2010, 6/17/2010 (x2 separate events), 6/20/2010, 6/26/2010, 7/08/2010, and 7/11/2010. Review of "WJMC Hospital Security Daily Reports" and hospital "Event Reports" revealed no documented evidence that event reports had been completed for the events that occurred on 5/28/2010, 6/17/2010 (x1), 6/20/2010, and 6/26/2010. This finding was confirmed by S1 (Chief Regulatory), S2 (Chief Nursing Officer), S12 (Attorney), S17 (Senior Director of Quality), S27 (Chief Administrative Officer), S32 (Senior Director of Nursing), and S33 (Director of Quality and Education) in a face to face group interview on 7/15/2010 at 4:20 a.m. who further indicated the Code White Log had never been compared to the Event reports to ensure all Code Whites were reported. They further indicated the Event Reports were used for problem identification and track/trending purposes and without complete data the analysis of Code Whites would be inaccurate.

Review of the hospital policy titled, " VIOLENT SITUATION (CODE WHITE/ DR. HOOVER)-Nursing Services Departmental-Revised: 6/15/2010 " revealed in part, " 6. An on line Event Report is completed."

2) failing to ensure event reports were completed and analyzed with tracking and trending for all uses of Stun Devices in the hospital as per hospital policy for 1 of 2 patients in which a stun device was used (#9).

Patient #9:
Review of Patient #9's medical record revealed the patient was admitted to the hospital through the Emergency Department on 4/12/2010 at 1440 (2:40 p.m.) with diagnoses that included Paranoid Schizophrenia. Patient #9 was transported to the hospital's Emergency Department by local police officers and triaged at 1438 (2:38 p.m.) as an Acuity Orange (High Risk Situation: a patient you would give your last bed). Triage documentation revealed in part, "Presenting complaint: Presenting complaint: brought in by (local police). Pt. (Patient) Schizophrenic and off meds. Wants to kill self. Knife taken from pt (patient) by (local police)". Nursing documentation revealed "1455 (2:55 p.m.) Patient is uncooperative, aggressive, belligerent, challenging, combative, hostile, irritable, suspicious, speech is loud, pressured, threatening. Affect is blunted. Security at bedside. Noise minimized. Visitors limited. Lights dimmed. Verbal reassurance given. . . Patient was restrained with leather restraints to right hand, right foot, left foot, and left hand. . . Patient's behavior is more agitated, more hostile. Patient is unable to follow directions." Further review revealed Patient #9 received the following medications as ordered by physician in the Emergency Department: Geodon 20 milligrams intramuscularly and Ativan 2 milligrams intramuscularly at 1500 (3:00 p.m.). Physician's notes dated 4/12/2010 at 1608 (4:08 p.m.) revealed in part, "Patient is violent and very uncooperative." Further review revealed Patient #9 remained in restraints until released at 1845 (6:45 p.m./ 2 hours and 37 minutes). Review of the entire medical record revealed no documented evidence of a Stun Device being used on Patient #9.

Review of documentation (no title) presented by Director of Security, Officer #S4 revealed in part, "On Monday 4/12/10, I responded with several security staff to (Mental Health Extension Unit) for a patient that was out of control and threatening staff and a police officer who had brought patient into hospital. while assisting the officer and other security staff member in attempting to control this patient, I used our stun device to stop his resistance at the time he appeared to be breaking free of our attempt to control him. When finished, I did a quick draft of a report to enter in our report system; as I usually do and then completed an event report to the best of my memory. Yesterday (7/13/2010), I looked for this report and was unable to locate it in my office or in our event report file. Others tried to locate it also with no results. I can only conclude that I did not enter it properly and it was not recorded in the system for some reason. The following are the details of that event that should have been recorded: On Monday, 4/12/2010, at about 2:35 p.m., Security Director (S4) responded to an assistance call in (Mental Health Extension Unit) for a patient that was resisting a (police officer) who had brought this patient into the hospital. (S4), along with security officers (S6, S15, S21, S38) attempted to assist the officer in controlling the patient (#9) who was swinging his fists and kicking at officers. Officers attempted to get patient off his feet and onto a bed as staff advised they were going to restraint (restrain) him. The patient struggled with officers for several moments and at this point, the patient began to free himself from officer's grasp and stand up. At this time, the (local police officer) removed his taser to use on the patient. At this same time, (S4) obtained a stun device from one of the officers so that the police officer would not have to use his taser. (S4) used the device on the upper back of the patient for about 1-2 seconds to get patient to stop resisting. Immediately after (S4) used the divide, the patient stopped resisting and laid back on the bed where department staff applied restraints with security assistance. When patient was medicated and under control, the (police officer) and security staff left area. There were no signs of injury to patient or staff."

During a face to face interview on 7/14/2010 at 5:15 p.m., Director of Security, Officer S4 indicated he remembered the incident with Patient #9 where he used a Stun Gun. S4 indicated Security was notified prior to the arrival of Patient #9 because local police officers had alerted them that Patient #9 was extremely violent. S4 indicated Patient #9 was released from handcuffs by local police officers shortly after arriving at the hospital. S4 indicated Patient #9 immediately became violent and he used a Stun Device on Patient #9 to gain control of the situation. S4 indicated Patient #9 was then placed in restraints. S4 indicated he recalled entering an event report into the electronic reporting system; however, no one was able to locate it; therefore he believed he must not have entered it correctly.

During a face to face interview on 7/14/2010 at 11:30 a.m., the hospital's Medical Director S18 indicated he took the position as Medical Director in January. S18 indicated he knew there was a policy for "Use of Force" approved for adoption by the former Governing Body/Medical Staff. S18 indicated he also knew that security had been trained on the use of the Stun Device. S18 indicated he only knew of one use of the Stun Device since he took the position as Medical Director in. S18 indicated he had no idea the Stun Device had been used on a patient in April (Patient #9). S18 indicated he reviewed all event reports as part of his assigned responsibilities as Medical Director. S18 confirmed that there should have been an event report generated regarding the use of a Stun Device on Patient #9 which would have been analyzed for appropriateness upon receipt for Quality Assurance Purposes.

Based on record review and interview the hospital failed to maintain a true and accurate description of the patient's treatment as evidenced by patient #9's medical record not reflecting the use of a Stun Device to control the patient's behavior prior to the application of restraints when the patient was in the Emergency Department seeking medical treatment (for 1 of 2 patients reviewed where a Stun Device was used to control behavior in the Emergency Department).

Findings:

Patient #9:
Review of Patient #9's medical record revealed the patient was admitted to the hospital through the Emergency Department on 4/12/2010 at 1440 (2:40 p.m.) with diagnoses that included Paranoid Schizophrenia. Patient #9 was transported to the hospital's Emergency Department by local police officers and triaged at 1438 (2:38 p.m.) as an Acuity Orange (High Risk Situation: a patient you would give your last bed). Triage documentation revealed in part, "Presenting complaint: Presenting complaint: brought in by (local police). Pt. (Patient) Schizophrenic and off meds. Wants to kill self. Knife taken from pt (patient) by (local police)". Nursing documentation revealed "1455 (2:55 p.m.) Patient is uncooperative, aggressive, belligerent, challenging, combative, hostile, irritable, suspicious, speech is loud, pressured, threatening. Affect is blunted. Security at bedside. Noise minimized. Visitors limited. Lights dimmed. Verbal reassurance given. . . Patient was restrained with leather restraints to right hand, right foot, left foot, and left hand. . . Patient's behavior is more agitated, more hostile. Patient is unable to follow directions." Further review revealed Patient #9 received the following medications as ordered by physician in the Emergency Department: Geodon 20 milligrams intramuscularly and Ativan 2 milligrams intramuscularly at 1500 (3:00 p.m.). Physician's notes dated 4/12/2010 at 1608 (4:08 p.m.) revealed in part, "Patient is violent and very uncooperative." Further review revealed Patient #9 remained in restraints until released at 1845 (6:45 p.m./ 2 hours and 37 minutes). Review of the entire medical record revealed no documented evidence of a Stun Device being used on Patient #9.

Review of documentation (no title) presented by Director of Security, Officer #S4 revealed in part, "On Monday 4/12/10, I responded with several security staff to (Mental Health Extension Unit) for a patient that was out of control and threatening staff and a police officer who had brought patient into hospital. while assisting the officer and other security staff member in attempting to control this patient, I used our stun device to stop his resistance at the time he appeared to be breaking free of our attempt to control him. When finished, I did a quick draft of a report to enter in our report system; as I usually do and then completed an event report to the best of my memory. Yesterday (7/13/2010), I looked for this report and was unable to locate it in my office or in our event report file. Others tried to locate it also with no results. I can only conclude that I did not enter it properly and it was not recorded in the system for some reason. The following are the details of that event that should have been recorded: On Monday, 4/12/2010, at about 2:35 p.m., Security Director (S4) responded to an assistance call in (Mental Health Extension Unit) for a patient that was resisting a (police officer) who had brought this patient into the hospital. (S4), along with security officers (S6, S15, S21, S38) attempted to assist the officer in controlling the patient (#9) who was swinging his fists and kicking at officers. Officers attempted to get patient off his feet and onto a bed as staff advised they were going to restrain him. The patient struggled with officers for several moments and at this point, the patient began to free himself from officer's grasp and stand up. At this time, the (local police officer) removed his taser to use on the patient. At this same time, (S4) obtained a stun device from one of the officers so that the police officer would not have to use his taser. (S4) used the device on the upper back of the patient for about 1-2 seconds to get patient to stop resisting. Immediately after (S4) used the device, the patient stopped resisting and laid back on the bed where department staff applied restraints with security assistance. When patient was medicated and under control, the (police officer) and security staff left area. There were no signs of injury to patient or staff."

Face to face interviews were conducted on 7/14/2010 at 3:20 p.m. with nursing staff that provided care to Patient #9 during his admission to the hospital on 4/12/2010 as follows: Registered Nurse (RN) S42 (Mental Health Extension Unit), RN S43 (Behavioral Health Unit), RN S44 (Mental Health Extension Unit), RN S45 (Mental Health Extension and Behavioral Health Unit), RN S46 (Main Emergency Department). All interviewed (S42, S43, S44, S45, S46) indicated they had no knowledge of a Stun Device being used on Patient #9. All interviewed indicated they had received no report from Security and/or other nursing staff to alert them that a Stun Device had been used on Patient #9.

During a face to face interview on 7/14/2010 at 11:30 a.m., the hospital's Medical Director S18 indicated the medical record for Patient #9 should have held documentation regarding the use of a Stun Device on the patient.

Hospital Security Officers were interviewed as follows: Officer S4 on 7/13/2010, Officer S15 on 7/14/2010 at 10:30 a.m., Officer S21 on 7/14/2010 at 1:00 p.m., and Officer S22 on 7/14/2010 at 1:40 p.m. All interviewed indicated they had been aware that Stun Devices had been used on violent psychiatric patients in the hospital's Emergency Department. S4, S15 and S21 confirmed that a Stun Device had been used on Patient #9 for containment of aggressive behavior (on 4/12/2010).

Review of the hospital policy titled, "Alternative (Non Lethal) Weapons, last revised 6/22/2010" presented by the hospital as their current policy revealed in part,"The stun device is designed to stop an assault. . . If an officer must use device on a patient, the attending nurse must be notified for reporting purposes."

Based on record review and interview the hospital failed to ensure the services of the Security Department and Inpatient units were integrated with the Emergency Department by failing to ensure communication occurred between security officers and nursing staff after the use of Stun Devices on patients in the Emergency Department for 2 of 2 patients that were restrained with the use of a Stun Device while in the Emergency Department (#3, #9).

Findings:

Hospital Security Officers were interviewed as follows: Officer S4 on 7/13/2010, Officer S15 on 7/14/2010 at 10:30 a.m., Officer S21 on 7/14/2010 at 1:00 p.m., and Officer S22 on 7/14/2010 at 1:40 p.m. All interviewed indicated they had been aware that Stun Devices had been used on violent psychiatric patients in the hospital. S4 confirmed the use of a Stun Device on Patient #3 on 7/08/2010 and Patient #9 on 4/12/2010. S15, S21, and S22 also confirmed that a Stun Device had been used on Patient #3 for containment of aggressive behavior (on 7/08/2010). S15 and S21 confirmed that a Stun Device had been used on Patient #9 for containment of aggressive behavior (on 4/12/2010).

During a face to face interview on 7/13/2010 at 11:10 a.m., Registered Nurse (RN) S3 indicated she had not been aware of the use of a Stun Device on Patient #3 who had been admitted to her care in the CCU (Coronary Care Unit) of the hospital on 7/08/2010 until the Patient's mother questioned her regarding the use of a Taser on her son. S3 indicated when the patient had been transferred from the Mental Health Extension Unit, she had received report from the nurse (S11) who had been caring for the patient but there had been no mention of the use of a Stun Gun on the patient.

During a face to face interview on 7/13/2010 at 4:15 p.m., RN S11 indicated she had provided care to Patient #3 while located in the Emergency Department's Mental Health Extension Unit on 7/08/2010. S11 indicated Patient #3 became agitated and began fighting staff resulting in the need to be restrained. S11 indicated she never saw the use of a Stun Device on Patient #3 during the incident but heard during a debriefing later with security that one had been used. S11 indicated she could not recall informing anyone upstairs (CCU in report) that a Stun Device had been used on Patient #3.

Face to face interviews were conducted on 7/14/2010 at 3:20 p.m. with nursing staff that provided care to Patient #9 during his admission to the hospital on 4/12/2010 as follows: Registered Nurse (RN) S42 (Mental Health Extension Unit), RN S43 (Behavioral Health Unit), RN S44 (Mental Health Extension Unit), RN S45 (Mental Health Extension and Behavioral Health Unit), RN S46 (Main Emergency Department). All interviewed (S42, S43, S44, S45, S46) indicated they had no knowledge of a Stun Device being used on Patient #9. All interviewed indicated they had received no report from Security and/or other nursing staff to alert them that a Stun Device had been used on Patient #9.

During a face to face interview on 7/14/2010 at 8:30 a.m., Psychiatrist S8 indicated that he had been in practice for many years and had never had to use a Stun Device to restrain a patient. Psychiatrist S8 indicated he had worked with numerous violent patients and had never had to use a stun device to contain the situation. Psychiatrist S8 indicated no one in Administration had consulted him about the use of Stun Devices on his psychiatric patients. S8 indicated he did not understand how Stun Devices could be beneficial in a therapeutic environment and he had many clinical concerns about their use. S8 indicated he was very disappointed that he had not been included in the decision to use Stun Devices in the hospital on Psychiatric patients. S8 also indicated he had never been informed by staff that a Stun Device had been used on Patient #9 (4/12/2010) who was a long term chronically mentally ill patient that never should have been Stunned. S8 indicated Patient #9 had a long history of becoming psychotic, getting loaded, and engaging in violent behavior such as throwing carts; however, he shouldn't have been shocked with a Stun Device. S8 indicated he had never been told that Patient #9 had been shocked with a Stun Device and staff should have immediately informed him, as the attending physician, that his patient had been shocked with a Stun Device.

Review of the hospital policy titled, "Alternative (Non Lethal) Weapons, last revised 6/22/2010" presented by the hospital as their current policy revealed in part, "The stun device is designed to stop an assault. . . If an officer must use device on a patient, the attending nurse must be notified for reporting purposes."