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Based on staff interviews, record reviews, observations, review of the facility policies and procedures, facility security video's, and police officer body camera footage on the Behavioral Health Unit (BHU); the facility: 1) failed to protect the patients right to receive care in a safe setting by failing to maintain a safe environment for patients identified as being at risk to cause harm to other patients and staff; 2) failed to ensure nursing staff were maintaining a safe, calm therapeutic environment for the care of psychiatric patients by utilizing techniques to de-escalate patients, implementing safety plans, providing medications, utilizing seclusion and/or restraints to ensure the patients were safe from self harm or harm to other patients or staff; and 3) failed to provide nursing supervision of patient care for 1 of 10 sampled patients (Patient 2). These failures resulted in 1 patient (Patient 2) to continue to have escalating behaviors for 2 hours including masturbating, posturing, verbally and physically threatening and attempted to enter the nurses station over the counter. The failure to provide supervision and maintain a safe environment had the potential for other patients or staff on the Behavioral Health Unit to sustain an injury/death. These findings result in the determination, after consultation with the Centers for Medicare and Medicaid Services, that the Condition of Participation for Patient Rights was not met. The total sample was 10. The facility census was 94 and 6 patients on BHU.

Refer to A144

Based on staff interviews, record reviews, observations, review of the facility policies and procedures, facility security video and police officer body camera footage on the Behavioral Health Unit (BHU); the facility 1) failed to follow their policy and procedure to appropriately restrain/seclude an acutely psychotic patient (Pt 2) and provide medication for care of a psychotic patient; 2) failed to protect the patients right to receive care in a safe setting by failing to maintain a safe environment for patients identified as being at risk to cause harm to other patients and staff; The total sample was 10. The facility census was 94 and 6 patients on BHU.

Findings are:

A. A review of Patient 2's medical record revealed that the patient was admitted under an EPC (Emergency Protective Custody) by local law enforcement to the BHU on 1/22/21 at 15:47 (3:47 PM) for increasing psychosis and bizarre behaviors after receiving medical clearance in the Emergency Department (ED) (12:44-3:47 PM). The ED physician did contact the patient's family with the patient's permission and was informed that the patient has been crying for the last 5 days and went into a really bad depression after seeing some things about his child and ex-girlfriend on social media. Per the Hospitalist Consultation Notes on 1/22/20 the provider described the patient as agitated, aggressive nature, naked from waist down, alert and oriented to self, place, delusional, loud pressured speech (speech that is accelerated) with verbal outburst and vulgar profanities, normal gait, gesticulating wildly and paranoid. On admission the patient was in a highly excited state, exhibiting anger, irritability, posturing (exaggerated movements and flexing of body in an angry manner), frequent masturbation and digital stimuli (fingers inserted into rectum) of rectum. The patient was discharged on 1/22/21 to the care of Scottsbluff Police Department (SPD) at 17:47 (5:47 PM) for protective custody after an assault of a security guard with an open hand slap.

Review of the progress Notes from the BHU by Registered Nurse (RN A) on 1/22/21 at 1747 (5:47 PM): "Pt admitted to unit at 1543, accompanied by security and law enforcement. Pt agitated, unable to redirect, pt yelling vulgarities, threatening to kill people, masturbating, and sticking fingers inside anus, unable to redirect, pt threatens violence with any attempt to administer offered medications, pt attempted to jump over counter and struck security staff in the face. Police notified, physician notified, pt taken by law enforcement off unit at 1724 (5:24 PM).

Review of the facility security video (no audio) from 1/22/21 showed Pt 2 locked in the back pod day room by himself. The video revealed:
-3:57 PM-4:17 PM; The patient was seen masturbating (penis flaccid) while pacing, he would walk up to the desk/locked half door area and posture with gestures and by his expression could tell he was "yelling".
-4:18 PM-4:19 PM; The patient was hitting the half door and "yelling", then tried to jump over the door and on way down took a swing at the security officers with an open hand. The patient did graze the left jaw of one of the Security Officers (Sec Off B).
-4:20 PM-4:26 PM; The patient continued wandering around the day room, masturbating, placed fingers into his rectum then continued to masturbate, and continual "yelling" obscenities towards staff. He again attempted to jump over the locked half door.
-4:26 PM; Scottsbluff Police Department (SPD) arrived to the floor.
-4:27 PM-5:05 PM; The video showed the patient continue to gesture, masturbate, posture, pace and you could tell that he continued to "yell" at the staff the entire time from 3:57 PM until the patient left the day room independently and went to his room to shower at 5:10 PM.
-5:27 PM; The patient was seen exiting the BHU area in handcuffs accompanied by Scottsbluff Police Department and facility Security Officers.

Review of the visual/audio footage from the Scottsbluff Police Department Body Camera on 1/22/21 revealed, the footage shows only the time in which the Scottsbluff Police Department (SPD) arrived and the footage starts at 00:00:00. The 3 SPD officers were escorted to the BHU; upon arrival to the BHU the Director of Security met with them directly outside the BHU locked doors to inform them of what was happening. (Per staff interview, and facility security video they arrived to the floor at 4:26 PM) The body cam footage identifies the SPD arrived outside the BHU doors 3:24 (3 minutes and 24 seconds after arrival to the facility and camera initiated). Upon arrival to the outer entrance of the BHU between the secure doors the Director of Security meets with the officers the footage revealed:
-The SPD officer asked the Director of Security, "You have a taser, why are we here?" The Security Director responded, "I have different rules than you do." All parties heard laughing and video shows a yellow handled object on the Director of Security's right hip. The Director of Security explained to the SPD officers that "this guy (Pt 2) is masturbating, sticking his fingers in his butt, so be careful of body fluids, and exposing himself to every lady up there." SPD officer asks "what do you want done?" The Director of Security responds, "He's going to jail, he can't be here." The officer replies, "From 5th floor?" Security Director replied, "yeah he can't be here." At 4 minutes & 16 seconds the RN comes to the area where the Director of Security and SPD are meeting and reports, "He just hit Security Officer B (Sec Off B)". The Director of Security states, "Now he has hit a healthcare worker." At 4 minutes & 37 seconds the SPD officers with guns secured in their belt entered the unit. Upon entering the unit the footage records Pt 2 yelling obscenities, vulgar sexual statements, threatening verbiage and calling staff names continually. SPD officer puts a call into his Sergeant to come to the area. At 11 minutes & 22 seconds the SPD officer asks staff "Can you give him a shot to calm him down?" The Staff replied, "We have one ordered but we haven't gone over there yet." Pt 2 replied to the question, 11 minutes:43 seconds "Because their scared of me, why are you so scared of me?" SPD responded "We aren't". Pt continued to verbally yell obscenities, gesturing, dancing, exposing self, masturbating and calling names. SPD asked, "He was fine in ER?" Staff replied, "yes, he was having some outbursts." At 17 minutes & 05 seconds the video showed the RN A in the medication room mixing the injection for Pt 2. At 18 minutes & 48 seconds the SPD Sergeant arrives on the BHU. The SPD officer tells the Sergeant, "I don't know that we have any charges yet, but they don't want to keep him." The Director of Security tells the Sergeant, "We can't have him here, he was masturbating, exposing himself." The Sergeant replied, "Is that it, that all we got? He isn't going to jail." Director of Security responded, "Well he's not staying here, he's a danger to others." The Sergeant stated, "Our road block is, is he competent to know what he is doing? He is on a mental health ward. If a Doctor wants to say that, then its on him." The Director of Security replied, "oh he knows what he's doing." The Sergeant replied, "That will be for a doctor to say." The Director of Security replied, "Well we will get a doctor on the phone." At 36: minutes & 35 seconds, SPD calls and talks with the County Sheriff that brought him to the hospital on an the EPC to see if any charges were pending, "no". The SPD officier spoke to Sec Off B that was stuck by the pt. Sec Off B told them the patient did not hurt him, SPD then called the County Attorney. SPD reported, "That the County Attorney doesn't have anything to arrest him on, and we can not help the staff hold the patient down for medication. The Director of Security verified with RN A that, "The psychiatrist (Dr S) cleared him to go to jail." The SPD again calls the County Attorney related to the patient being cleared to go to jail by the Psychiatrist. At 47 minutes & 54 seconds, the Sergeant tells the Security Director that they will take him for "attempted assault on a health care worker." At 55 minutes & 17 seconds the patient was in the shower. The SPD goes to the patient room and gets him out of the shower, has the pt dry off, puts clothes on and they handcuff patient, the patient is heard making squealing sound and then talking to himself quietly. Sec Off B assists the patient with putting socks on. The Pt is cooperative and offers no resistance and leaves the unit with SPD, Sec Off B and Sec Off C. Accompanied to the ER to get final medical clearance. Left the facility at 5:47 PM.

An interview on 2/24/21 at 1:15 PM with the Registered Nurse (RN A) that was on duty 1/22/21 revealed, "That day when (Pt 2) arrived, I was the charge nurse. We had 6 patients on the BHU, 4 were adolescents and 2 were adults. The adolescents were on the opposite back locked pod, and the 2 other adults were in another locked pod. We took the adolescents to the back day room and the 2 adults stayed in their rooms while Pt 2 was there." Pt 2 was in the intake room initially with the psychiatric tech and (Sec Off B), about 20 minutes into the intake interview the patient left the intake room and was gesturing and making loud noises. RN A then unlocked the doors to the back pod and accompanied (Pt 2) down to the patients room. Before the patient entered his room, he stopped and "froze his position for a few seconds" then started screaming vulgarities and profanity. RN A offered the patient something to eat or drink, a oral medication to help him settle down and the patient refused and continued to escalate and get louder and more vulgar. There was a Hispanic security officer (Sec Off C) that Pt 2 seemed to be targeting. The patient be-rated (Sec Off C) and was saying racial slurs, threatening rhetoric and vulgar profane verbiage to him for at least 20 minutes. "I have never heard anyone curse like that. I was a little scared, he was very loud." "I even tried to get between Sec Off C and (Pt 2) line of sight. I had hoped the security officers (Sec Off B, Sec Off C and the Director of Security) could calm him down but it didn't help, they couldn't redirect him either, I called (Dr S-the psychiatrist) for an order for an antipsychotic medication. Dr S ordered Geodon (a medication to treat symptoms of psychosis) and I obtained it from pharmacy and was preparing it. "By the time I had the injection ready the Police arrested him and he was in handcuffs and it was not given." Earlier when the Director of Security arrived, he said he felt that (Pt 2's) masturbating, exposing himself, possibly spreading bodily fluids was assault, I was asked if I wanted the Director of Security to call the police. I said "yes. It was ultimately my decision." His behaviors were escalating even after giving him space and hoped he would tire out but he did not. I talked with Dr S and described the patients demeanor, behavior and look in his eyes scared me. The level of vulgarity, the kill/rape/sexual verbal tirade was of an extreme degree. Just as the Police arrived at 4:26 PM, the Security Director was talking with them. It was about that time that Pt 2 jumped like he was going to come over the half door and he grazed (Sec Off B) jaw. I went to the area when the Police and the Security Director were and informed them. They (SPD) were hesitant about taking (Pt 2), not sure if they had the authority to take the patient to jail. There were several phone calls between the officers and their Sergeant and the County Attorney. They said since the patient hit the security guard and if the physician would clear the patient, they would take the patient to jail (arrested at 5:27 PM). Prior to the patient being arrested I and the Social Worker prepared the restraint bed in case the police didn't take him. When RN A was asked if there was Personal Protective Equipment (PPE) available on BHU to protect them from potential bodily fluid. RN A answered "Yes", when asked RN A if he was aware if Pt 2 ejaculated, RN A answered, "No, not that I am aware of." When asked RN A if security helps to restrain a patient or get them into the seclusion room, RN A answered "Yes, but I didn't feel we could restrain him without a ninja fight and he may masturbate on us". When asked if the staff had training and if there were enough trained staff to assist with getting the patient to the quiet room, into restraints if needed and medicated? RN A answered "Yes, If the police wouldn't have taken him we would have taken him to seclusion, we had enough trained staff to do so. I feel the patient was trying to be in control of the situation and he was." When asked if RN A called a BHU Rapid Response Team overhead, RN A said, "No, all of security was here. I don't know where the house supervisor was but I think she was tied up with other patients." RN A stated, "I have had another patient that was less aggressive, but was verbally threatening and saying he was going to kill the staff. Police came they couldn't take him, we would put him in seclusion and medicated him."

An interview on 2/23/21 at 2:15 PM with the Director of Security (in this position for 6 months) that was on duty 1/22/21 revealed, "I recall the patient (Pt 2), I met the patient after he was medically cleared in the ED and ready to go upstairs (to BHU). The sheriff deputies were here with (Pt 2) for an EPC. The 2 sheriff deputies and myself and the other 2 security officers (Sec Off B and Sec Off C) accompanied the patient to the BHU. The patient was posturing, but showed no aggression towards us while accompanying him to floor. Upon entering the BHU, the Psych Tech took the patient into the intake room and (Sec Off B) accompanied them, I went back down the ED." "I was again called to the BHU overhead, so I returned to the floor." When the Director of Security arrived to the floor the "Pt was yelling, screaming, masturbating and had escalating agitation." It was observed the patient was locked in the back pod, the half door locked, the nurses and staff where in the nurses station and my security officers were positioned between the half door and the staff in the nurses station. The nurse (RN A) wanted to get the patient to seclusion room and then that was off the table. The nurse (RN A) called the doctor (psychiatrist), "I spoke to Dr S and told the doctor that this was not the right place for (Pt 2), and then the nurse again talked to the doctor." When asked the Director of Security what the role of security on the BHU is, "Our job is to keep patients and staff safe. We do not use handcuffs or place anyone in restraints, we assist with restraint procedures if asked to help. We are all trained and prepared to physically intervene as per our training. We have been called to BHU with similar patients and assisted." "I made the decision to call the police. We had female staff, juveniles on the unit and I felt he needed more help than we could give him, police could hold him in jail. A big concern for me was the potential bodily fluids on unit and the pt threw his mask." When asked if the staff had PPE available, the staff answered "Yes". "This patient is strong and on a level of 1-10 was a 10 on escalation. I think the police were called before the patient tried to strike security. In the moment, I felt the police call kept the patient and staff safe and a win." "I had encountered this person (Pt 2) in my previous job in law enforcement and aware he can be violent. Once the police arrive they are in charge."

An interview with Security Officer B (Sec Off B) (worked in this position 16 years) on 2/24/21 at 11:20 AM revealed, "I was working on 1/22/21, it was mid afternoon about 3 PM when we brought (Pt 2) to the BHU. The patient was acting bizarre, he had been answering questions with the Psych Tech initially then got upset and walked out of the room. (Pt 2) was directed to the back pod and secured behind the locked doors. The patient started to get very verbally abusive, angry, masturbating, taking clothes off. At one time he acted like he was trying to come over the 1/2 door to the nurses station, we (Security officers) got behind the half door to prevent entry to nurses station. The pt swung and struck my jaw with an open hand, more like a grazing slap then a punch because I just backed away." The slap didn't occur until the patient was in the locked pod for about 30 minutes. "The Director of Security called the police. We deal with psych patients all the time, it was not a big deal he struck me, no injury to me." After the police came there was some discussion regarding (Pt 2) behaviors and if the Police could take him into custody. "We have had patients violent like him before, he was not worse than the others I have seen on the unit. He wasn't violent except the one slap." "The police asked me how the patient struck me, I explained to them he just grazed my jaw with an open hand. I did not press charges for assault then or ever. I felt we could handle the situation if needed to."

An interview with the Psychiatric Tech on 2/24/21 at 3:20 PM revealed, "I was working on 1/22/21 when (Pt 2) came to the unit. I took the patient into the intake/exam room and Sec Off B came in with us. We were talking and the patient just "switched" He got up and walked out, I felt like he was agitated. We got him into the locked back pod alone. He was screaming, shouting vulgar things, masturbating and being bizarre. I had no further interaction with him, we were trying to give him his space. I know the RN called the doctor for an injection and spoke with Dr S, we just were planning to wait and see if the patient would self calm." We have TEAM (Techniques for Effective Aggression Management) training for working on BHU. I feel the training gave me the confidence in my ability to restrain a violent patient." Our approach was to give him space to prevent harm.

Review of the "BHU Admission Criteria" Policy 702.0.01 dated 7/2019 revealed:
-The individual demonstrates a clear and reasonable inference of imminent serious harm to others. This is evidenced by having any one of the following: 1) a current plan or intent to harm others with an available 7 lethal means, or 2) Assaultive behavior threatening others within 72 hours prior to admission. A recent lethal attempt to harm others with continued imminent risk as demonstrated by poor impulse control, command hallucinations directing them to harm others or an ability to plan reliably for safety, or 3) Violent unpredictable or uncontrolled behavior that represents an imminent risk of serious harm to the body or property of others, or 4) Other similarly clear and reasonable evidence of imminent serious harm to others.
-The individual's condition requires an acute psychiatric assessment technique or intervention that unless managed in an inpatient setting, would have a high probability to lead to serious, imminent and dangerous deterioration of the individual's general medical or mental health. 1) Chronic & continuing self-destructive behavior (bulimic behaviors, substance abuse) that poses a significant and/or immediate threat to life, limb or bodily function. 2) Psychiatric symptoms (hallucinations, delusions, panic reaction, anxiety, agitation, depression) severe enough to cause disordered, bizarre behavior (catatonia, mania, incoherence, autism) or psychomotor retardation resulting in significant interference with activities of daily living. 3) cognitive impairment (disorientation or memory impairment) disorder that endangers the welfare of patients or others. 4) For patients with a dementing disorder for evaluation or treatment of a psychiatric co morbidity (risk of suicide, violence, severe depression) warranting inpatient admission.

Review of the "Care of Assaultive Patient" Policy 702.0.29 dated 5/3/18 revealed:
-These guidelines will help the patient regain self-control, protect the patient, protect other patients and staff from injury. The physically assaultive patient requires calm, rapid, skillful nursing intervention in order to protect the patient and staff and to control the patient in a manner, which is not harmful to their therapeutic treatment. Prevention of combative situations is always the priority. it is recognized, however, that this is not always possible. non-violent crisis intervention is utilized by hospital staff to train for dealing with the assaultive patient.
PREVENTION:
a)When loss of control has occurred, & the patient is acutely disturbed and is assaultive: i) Remove all other patients and moveable equipment from the he area. ii) Attempt to start or continue conversion. iii)Get necessary help before attempting to physically control the patient.
b) The 1st person on the scene at the time of the incident assumes the responsibility in evaluating & planning the care of the aggressive patient until someone with higher level of therapeutic level of authority is available for giving directions to all other staff. This person may give control to someone else who may have a better rapport with the pt or may be better trained to handle the situation.
c) Obtain needed extra help. Any person witness to a violent incident or a situation that poses a threat to the safety of staff, patient, or employees may initiate a response by calling the Transfer Center & stating to call a code-TEAM response (the personnel to respond is security; house supervisor; charge nurse; facilities management staff and all TEAM trained staff on the affected unit) with location. TEAM trained employees from other areas in the hospital will come to the unit and help safely restrain the patient. Security staff will call 911 as a last resort if they assess this is needed.
PHYSICAL INTERVENTION:
a) Be sure the seclusion area is ready, restraints are on the bed if needed, and that any medication to be administered is prepared prior to the actual physical intervention.
b) Whenever possible , the pt will be presented with "a show of force" by TEAM trained staff members. When the pt is faced by the physical presence of all the staff necessary to control him/her, they may be able to regain self-control. If the pt cannot regain control, the the Team will ensure rapid, safe control.
c) Once the decision has been made to seclude &/or restrain, avoid further attempts to reason with the pt. This usually results in arguing/bargaining, and causes an increase in anxiety in both the pt and staff.
d) Prior to the signal to proceed, the person in charge will give brief step-by-step directions regarding the intervention plan. This will include specific assignments regarding who will retain each limb. The person in charge will give the signal to proceed & will continue to give specific, concrete directions to other staff members throughout the entire procedure. The staff having initial contact or good report with the pt will assume the role of team leader. No other staff will attempt communication with the pt. Verbal abuse by the pt at this time may be excessive. Do not respond to it.
e) Staff will move in quickly one the signal has been given. The goal is physical restraint is quick, sequential control of the extremities as well as the best care, welfare, safety and security of the patient and staff.
f) Action towards the pt will be defensive, not offensive. Defensive action attempts control with as little discomfort as possible & no injury.
g) If limbs must be grasped, they will be held above & below the major joint to reduce leverage to prevent a possible fracture. Pt will be transported in a safe manner. if staff member begins to lose grasp of the pt, the team will communicate how to reestablish the hold.
h) If the patient has a weapon of any kind, a shield, pillow or mattress should be used. Extreme caution & extra help is also necessary.
i) The need for medication, seclusion & mechanical restraints depends upon the situation. The RN will make the decision, obtain the physician orders, and give the instructions. (refer to utilization of restraints/seclusion Policy)
j)Nursing staff not directly involved with the combative situation will be with the other pts as the situation may increase their fear/anxieties.
SECLUSION/RESTRAINTS:
a) Seclusion & or physical, chemical & mechanical restraints shall be used as a last resort when all other means of intervention have been exhausted or deemed ineffective given staff assessment of the situation.

Review of "Utilization of Restraints/Seclusion" Policy 500.5.09 dated 7/6/94 revealed:
-(This Hospital) uses restraint/seclusion only to protect the immediate physical safety of the patient, staff or others.
DEFINITIONS:
a) Seclusion-The involuntary confinement of a pt alone in a room, from which the patient is physical prevented from leaving, used to manage violent or self=destructive behavior. Seclusion is only utilized on the BHU.
b) Restraint- Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the pt to move his or her arms, legs, body or head freely. The restraint definition applies to all uses of restraint in all hospital settings. 1)Violent or Self-Destructive Behavior- Attempts to cause physical harm to others such as, but not limited to, hitting, kicking, biting, throwing objects at others, or attempts to harm self such as, but not limited to, cutting self, hitting walls or objects with enough force to injure self or others; behavior that cause bodily harm. 2) Drug/Chemical Restraint- Medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
SECLUSION/RESTRAINT/DRUG RESTRAINT FOR VIOLENT, SELF-DESTRUCTIVE BEHAVIOR:
-Indications- Attempts to cause physical harm to others such as, but not limited to hitting, kicking, biting, throwing objects at others, or attempts to harm self such as, but not limited to, cutting self, hitting walls or objects with enough force to injure self, or other behaviors that cause bodily harm.
TRAINING:
-Hospital and medical staff members receive training in the following subjects as it relates to duties performed under this policy. (The hospital) trains staff on the use of restraints and seclusion, & assess their competence at orientation, before participating in the use of restraint & seclusion and on a periodic basis thereafter.

Review of the job descriptions and personnel files for the BHU and Security staff revealed that all the staff are required to take TEAM Essential training, the personnel files reviewed contained the certificates of completion. TEAM Essential training is curriculum that is designed exclusively for the healthcare environment. TEAM is a comprehensive violence intervention program designed to defuse disruptive behavior before an incident escalates into a violent crisis. Health facilities use TEAM for de-escalation techniques to professionally manage aggressive behavior. TEAM provides healthcare employees with the skills, techniques, and confidence they need to intervene, diffuse disruptive behavior, and feel safe at work. TEAM Advanced training is required for the BHU staff which focuses on the techniques, defense, escapes, spit avoidance, ground defense and escorts. It also discusses documentation and debriefing.

Based on staff interviews, record reviews, observations, review of the facility policies and procedures, facility security video and police officer body camera footage on the Behavioral Health Unit (BHU); the facility failed to provide Registered Nurse Supervision in 1 of 10 sampled patients (Patient 2) to ensure the staff followed their policy and procedure to appropriately restrain/seclude and provide ordered medication in the care of an acutely psychotic patient (Pt 2); and failed to protect the patients right to receive care in a safe setting by failing to maintain a safe environment for patients identified as being at risk to cause harm to other patients and staff. These findings result in the determination, after consultation with the Centers for Medicare and Medicaid Services, that the Condition of Participation for Nursing Service was not met. The total sample was 10. The facility census was 94 and 6 patients on BHU.

Refer to A395

Based on staff interviews, record reviews, observations, review of the facility policies and procedures, facility security video and police officer body camera footage on the Behavioral Health Unit (BHU); the facility failed to provide Registered Nurse Supervision in 1 of 10 sampled patients (Patient 2) to ensure the staff followed their policy and procedure to appropriately restrain/seclude and provide ordered medication in the care of an acutely psychotic patient (Pt 2); and failed to protect the patients right to receive care in a safe setting by failing to maintain a safe environment for patients identified as being at risk to cause harm to other patients and staff; The total sample was 10. The facility census was 94 and 6 patients on BHU.

Findings are:

A. A review of Patient 2's medical record revealed that the patient was admitted under an EPC (Emergency Protective Custody) by local law enforcement to the BHU on 1/22/21 at 15:47 (3:47 PM) for increasing psychosis and bizarre behaviors after receiving medical clearance in the Emergency Department (ED) (12:44-3:47 PM). The ED physician did contact the patient's family with the patient's permission and was informed that the patient has been crying for the last 5 days and went into a really bad depression after seeing some things about his child and ex girlfriend on social media. Per the Hospitalist Consultation Notes on 1/22/20 the provider described the patient as agitated, aggressive nature, naked from waist down, alert and oriented to self, place, delusional, loud pressured speech (speech that is accelerated) with verbal outburst and vulgar profanities, normal gait, gesticulating wildly and paranoid. On admission the patient was in a highly excited state, `exhibiting anger, irritability, posturing (exaggerated movements and flexing of body in an angry manner), frequent masturbation and digital stimuli (fingers inserted into rectum) of rectum. The patient was discharged on 1/22/21 to the care of Scottsbluff Police Department (SPD) at 17:47 (5:47 PM) for protective custody after an assault of a security guard with an open hand slap.

Review of the progress notes from the BHU by Registered Nurse (RN A) on 1/22/21 at 1747 (5:47 PM): "Pt admitted to unit at 1543 (3:43 PM), accompanied by security and law enforcement. Pt agitated, unable to redirect, pt yelling vulgarities, threatening to kill people, masturbating, and sticking fingers inside anus, unable to redirect, pt threatens violence with any attempt to administer offered medications, pt attempted to jump over counter and struck security staff in the face. Police notified, physician notified, pt taken by law enforcement off unit at 1724 (5:24 PM)."

An interview on 2/24/21 at 1:15 PM with the Registered Nurse (RN A) that was on duty 1/22/21 revealed, "That day when (Pt 2) arrived, I was the charge nurse. We had 6 patients on the BHU, 4 were adolescents and 2 were adults. The adolescents were on the opposite back locked pod, and the 2 other adults were in another locked pod. We took the adolescents to the back day room and the 2 adults stayed in their rooms while Pt 2 was there." Pt 2 was in the intake room initially with the psychiatric tech and (Sec Off B), about 20 minutes into the intake interview the patient left the intake room and was gesturing and making loud noises. RN A then unlocked the doors to the back pod and accompanied (Pt 2) down to the patients room. Before the patient entered his room, he stopped and "froze his position for a few seconds" then started screaming vulgarities and profanity. RN A offered the patient something to eat or drink, a oral medication to help him settle down and the patient refused and continued to escalate and get louder and more vulgar. There was a Hispanic security officer (Sec Off C) that Pt 2 seemed to be targeting. The patient be-rated (Sec Off C) and was saying racial slurs, threatening rhetoric and vulgar profane verbiage to him for at least 20 minutes. "I have never heard anyone curse like that. I was a little scared, he was very loud." "I even tried to get between Sec Off C and (Pt 2) line of sight. I had hoped the security officers (Sec Off B, Sec Off C and the Director of Security) could calm him down but it didn't help, they couldn't redirect him either, I called (Dr S-the psychiatrist) for an order for an antipsychotic medication. Dr S ordered Geodon (a medication to treat symptoms of psychosis) and I obtained it from pharmacy and was preparing it. "By the time I had the injection ready the Police arrested him and he was in handcuffs and it was not given." Earlier when the Director of Security arrived, he said he felt that (Pt 2's) masturbating, exposing himself, possibly spreading bodily fluids was assault, I was asked if I wanted the Director of Security to call the police. I said "yes. It was ultimately my decision." His behaviors were escalating even after giving him space and hoped he would tire out but he did not. I talked with Dr S and described the patients demeanor, behavior and look in his eyes scared me. The level of vulgarity, the kill/rape/sexual verbal tirade was of an extreme degree. Just as the Police arrived at 4:26 PM, the Security Director was talking with them Pt 2 jumped like he was going to come over the half door and he grazed (Sec Off B) jaw. I went to the area when the Police and the Security Director were and informed them. They (SPD) were hesitant about taking (Pt 2), not sure if they had the authority to take the patient to jail. There were several phone calls between the officers and their Sergeant and the County Attorney. They said since the patient hit the security guard and if the physician would clear the patient, they would take the patient to jail (arrested at 5:27 PM). Prior to the patient being arrested I and the Social Worker prepared the restraint bed in case the police didn't take him. When RN A was asked if there was Personal Protective Equipment (PPE) available on BHU to protect them from potential bodily fluid. RN A answered "Yes", when asked RN A if he was aware if Pt 2 ejaculated, RN A answered, "No, not that I am aware of." When asked RN A if security helps to restrain a patient or get them into the seclusion room, RN A answered "Yes, but I didn't feel we could restrain him without a ninja fight and he may masturbate on us". When asked if the staff had training and if there were enough trained staff to assist with getting the patient to the quiet room, into restraints if needed and medicated? RN A answered "Yes, If the police wouldn't have taken him we would have taken him to seclusion, we had enough trained staff to do so. I feel the patient was trying to be in control of the situation and he was." When asked if RN A called a BHU Rapid Response Team overhead, RN A said, "No, all of security was here. I don't know where the house supervisor was but I think she was tied up with other patients." RN A stated, "I have had another patient that was less aggressive, but was verbally threatening and saying he was going to kill the staff. Police came then, they couldn't take him we would put him in seclusion and medicated him."

An interview with the Psychiatric Tech on 2/24/21 at 3:20 PM revealed, "I was working on 1/22/21 when (Pt 2) came to the unit. I took the patient into the intake/exam room and Sec Off B came in with us. We were talking and the patient just "switched" He got up and walked out, I felt like he was agitated. We got him into the locked back pod alone. He was screaming, shouting vulgar things, masturbating and being bizarre. I had no further interaction with him, we were trying to give him his space. I know the RN called the doctor for an injection and spoke with Dr S, we just were planning to wait and see if the patient would self calm." We have TEAM (Techniques for Effective Aggression Management) training for working on BHU. I feel the training gave me the confidence in my ability to restrain a violent patient." Our approach was to give him space to prevent harm.

An interview with Security Officer B (Sec Off B) (worked in this position 16 years) on 2/24/21 at 11:20 AM revealed, "I was working on 1/22/21, it was mid afternoon about 3 PM when we brought (Pt 2) to the BHU. The patient was acting bizarre, he had been answering questions with the Psych Tech initially then got upset and walked out of the room. (Pt 2) was directed to the back pod and secured behind the locked doors. The patient started to get very verbally abusive, angry, masturbating, taking clothes off. At one time he acted like he was trying to come over the 1/2 door to the nurses station, we (Security officers) got behind the half door to prevent entry to nurses station. The pt swung and struck my jaw with an open hand, more like a grazing slap then a punch because I just backed away." The slap didn't occur until the patient was in the locked pod for about 30 minutes. "The Director of Security called the police. We deal with psych patients all the time, it was not a big deal he struck me, no injury to me." After the police came there was some discussion regarding (Pt 2) behaviors and if the Police could take him into custody. "We have had patients violent like him before, he was not worse than the others I have seen on the unit. He wasn't violent except the one slap." "The police asked me how the patient struck me, I explained to them he just grazed my jaw with an open hand. I did not press charges for assault then or ever. I felt we could handle the situation if needed to."

An interview on 2/23/21 at 2:15 PM with the Director of Security (in this position for 6 months) that was on duty 1/22/21 revealed, "I recall the patient (Pt 2), I met the patient after he was medically cleared in the ED and ready to go upstairs (to BHU). The sheriff deputies were here with (Pt 2) for an EPC. The 2 sheriff deputies and myself and the other 2 security officers (Sec Off B and Sec Off C) accompanied the patient to the BHU. The patient was posturing, but showed no aggression towards us while accompanying him to floor. Upon entering the BHU, the Psych Tech took the patient into the intake room and (Sec Off B) accompanied them, I went back down the ED." "I was again called to the BHU overhead, so I returned to the floor." When the Director of Security arrived to the floor the "Pt was yelling, screaming, masturbating and had escalating agitation." It was observed the patient was locked in the back pod, the half door locked, the nurses and staff where in the nurses station and my security officers were positioned between the half door and the staff in the nurses station. The nurse (RN A) wanted to get the patient to the seclusion room and then that was off the table. The nurse (RN A) called the doctor (psychiatrist), "I spoke to Dr S and told the doctor that this was not the right place for (Pt 2), and then the nurse again talked to the doctor." When asked the Director of Security what the role of security on the BHU is, "Our job is to keep patients and staff safe. We do not use handcuffs or place anyone in restraints, we assist with restraint procedures if asked to help. We are all trained and prepared to physically intervene as per our training. We have been called to BHU with similar patients and assisted." "I made the decision to call the police. We had female staff, juveniles on the unit and I felt he needed more help than we could give him, police could hold him in jail. A big concern for me was the potential bodily fluids on unit and the pt threw his mask." When asked if the staff had PPE available, the staff answered "Yes". "This patient is strong and on a level of 1-10 was a 10 on escalation. I think the police were called before the patient tried to strike security. In the moment, I felt the police call kept the patient and staff safe and a win." "I had encountered this person (Pt 2) in my previous job in law enforcement and aware he can be violent. Once the police arrive they are in charge."

Review of the "Care of Assaultive Patient" Policy 702.0.29 dated 5/3/18 revealed:
-These guidelines will help the patient regain self-control, protect the patient, protect other patients and staff from injury. The physically assaultive patient requires calm, rapid, skillful nursing intervention in order to protect the patient and staff and to control the patient in a manner, which is not harmful to their therapeutic treatment. Prevention of combative situations is always the priority. it is recognized, however, that this is not always possible. non-violent crisis intervention is utilized by hospital staff to train for dealing with the assaultive patient.
PREVENTION:
a)When loss of control has occurred, & the patient is acutely disturbed and is assaultive: i) Remove all other patients and moveable equipment from the he area. ii) Attempt to start or continue conversion. iii)Get necessary help before attempting to physically control the patient.
b) The 1st person on the scene at the time of the incident assumes the responsibility in evaluating & planning the care of the aggressive patient until someone with higher level of therapeutic level of authority is available for giving directions to all other staff. This person may give control to someone else who may have a better rapport with the pt or may be better trained to handle the situation.
c) Obtain needed extra help. Any person witness to a violent incident or a situation that poses a threat to the safety of staff, patient, or employees may initiate a response by calling the Transfer Center & stating to call a code-TEAM response (the personnel to respond is security; house supervisor; charge nurse; facilities management staff and all TEAM trained staff on the affected unit) with location. TEAM trained employees from other areas in the hospital will come to the unit and help safely restrain the patient. Security staff will call 911 as a last resort if they assess this is needed.
PHYSICAL INTERVENTION:
a) Be sure the seclusion area is ready, restraints are on the bed if needed, and that any medication to be administered is prepared prior to the actual physical intervention.
b) Whenever possible , the pt will be presented with "a show of force" by TEAM trained staff members. When the pt is faced by the physical presence of all the staff necessary to control him/her, they may be able to regain self-control. If the pt cannot regain control, the the Team will ensure rapid, safe control.
c) Once the decision has been made to seclude &/or restrain, avoid further attempts to reason with the pt. This usually results in arguing/bargaining, and causes an increase in anxiety in both the pt and staff.
d) Prior to the signal to proceed, the person in charge will give brief step-by-step directions regarding the intervention plan. This will include specific assignments regarding who will retain each limb. The person in charge will give the signal to proceed & will continue to give specific, concrete directions to other staff members throughout the entire procedure. The staff having initial contact or good report with the pt will assume the role of team leader. No other staff will attempt communication with the pt. Verbal abuse by the pt at this time may be excessive. Do not respond to it.
e) Staff will move in quickly one the signal has been given. The goal is physical restraint is quick, sequential control of the extremities as well as the best care, welfare, safety and security of the patient and staff.
f) Action towards the pt will be defensive, not offensive. Defensive action attempts control with as little discomfort as possible & no injury.
g) If limbs must be grasped, they will be held above & below the major joint to reduce leverage to prevent a possible fracture. Pt will be transported in a safe manner. if staff member begins to lose grasp of the pt, the team will communicate how to reestablish the hold.
h) If the patient has a weapon of any kind, a shield, pillow or mattress should be used. Extreme caution & extra help is also necessary.
i) The need for medication, seclusion & mechanical restraints depends upon the situation. The RN will make the decision, obtain the physician orders, and give the instructions. (refer to utilization of restraints/seclusion Policy)
j)Nursing staff not directly involved with the combative situation will be with the other pts as the situation may increase their fear/anxieties.
SECLUSION/RESTRAINTS:
a) Seclusion & or physical, chemical & mechanical restraints shall be used as a last resort when all other means of intervention have been exhausted or deemed ineffective given staff assessment of the situation.

Review of "Utilization of Restraints/Seclusion" Policy 500.5.09 dated 7/6/94 revealed:
-(This Hospital) uses restraint/seclusion only to protect the immediate physical safety of the patient, staff or others.
DEFINITIONS:
a) Seclusion-The involuntary confinement of a pt alone in a room, from which the patient is physical prevented from leaving, used to manage violent or self=destructive behavior. Seclusion is only utilized on the BHU.
b) Restraint- Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the pt to move his or her arms, legs, body or head freely. The restraint definition applies to all uses of restraint in all hospital settings. 1)Violent or Self-Destructive Behavior- Attempts to cause physical harm to others such as, but not limited to, hitting, kicking, biting, throwing objects at others, or attempts to harm self such as, but not limited to, cutting self, hitting walls or objects with enough force to injure self or others; behavior that cause bodily harm. 2) Drug/Chemical Restraint- Medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
SECLUSION/RESTRAINT/DRUG RESTRAINT FOR VIOLENT, SELF-DESTRUCTIVE BEHAVIOR:
-Indications- Attempts to cause physical harm to others such as, but not limited to hitting, kicking, biting, throwing objects at others, or attempts to harm self such as, but not limited to, cutting self, hitting walls or objects with enough force to injure self, or other behaviors that cause bodily harm.
TRAINING:
-Hospital and medical staff members receive training in the following subjects as it relates to duties performed under this policy. (The hospital) trains staff on the use of restraints and seclusion, & assess their competence at orientation, before participating in the use of restraint & seclusion and on a periodic basis thereafter.

Review of the job descriptions and personnel files for the BHU and Security staff revealed that all the staff are required to take TEAM Essential training, the personnel files reviewed contained the certificates of completion. TEAM Essential training is curriculum that is designed exclusively for the healthcare environment. TEAM is a comprehensive violence intervention program designed to defuse disruptive behavior before an incident escalates into a violent crisis. Health facilities use TEAM for de-escalation techniques to professionally manage aggressive behavior. TEAM provides healthcare employees with the skills, techniques, and confidence they need to intervene, diffuse disruptive behavior, and feel safe at work. TEAM Advanced training is required for the BHU staff which focuses on the techniques, defense, escapes, spit avoidance, ground defense and escorts. It also discusses documentation and debriefing.

Review of the facility security video (no audio) from 1/22/21 showed Pt 2 locked in the back pod day room by himself. The video revealed:
-3:57 PM-4:17 PM; The patient was seen masturbating (penis flaccid) while pacing, he would walk up to the desk/locked half door area and posture with gestures and by his expression could tell he was "yelling".
-4:18 PM-4:19 PM; The patient was hitting the half door and "yelling", then tried to jump over the door and on way down took a swing at the security officers with an open hand. The patient did graze the left jaw of one of the Security Officers (Sec Off B).
-4:20 PM-4:26 PM; The patient continued wandering around the day room, masturbating, placed fingers into his rectum then continued to masturbate, and continual "yelling" obscenities towards staff. He again attempted to jump over the locked half door.
-4:26 PM; Scottsbluff Police Department (SPD) arrived to the floor.
-4:27 PM-5:05 PM; The video showed the patient continue to gesture, masturbate, posture, pace and you could tell that he continued to "yell" at the staff the entire time from 3:57 PM until the patient left the day room independently and went to his room to shower at 5:10 PM.
-5:27 PM; The patient was seen exiting the BHU area in handcuffs accompanied by Scottsbluff Police Department and facility Security Officers.