HospitalInspections.org

Based on policy and procedure review, medical record review, and staff and physician interviews, the governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights for a safe environment; an organized and effective quality assessment and performance improvement program for patient safety; and failed to have an effective emergency services to meet behavioral health patient care needs.

The findings include:

1. The hospital failed to provide care in a safe setting by using OC (Oleoresin Capsicum) foam and/or Conducted Electrical Weapons (tasers) on 2 of 4 ED behavioral health patients reviewed (Pts #4, #13).

~cross refer to 482.13 Patient Rights' Standard: Tag 0144

2. The hospital staff failed to recognize and obtain an order for seclusion of a pediatric behavioral health patient for 1 of 3 pediatric/ adolescent behavioral health sampled patients. (Pt #4)

~cross refer to 482.13 Patient Rights' Standard: Tag 0154

3. The hospital failed to provide an effective quality assessment and performance improvement program for patient safety by failing to immediately analyze use and actions to prevent use of OC foam and Tasers on behavioral health patients in the emergency department.

~cross refer to 482.21 Quality Assessment and Performance Improvement Standard: Tag 0286

4. The hospital failed to ensure an organized and effective emergency services that met the needs of behavioral Health patients by failing to ensure behavioral health patients in the emergency department were provided emergency medications and other therapeutic measures to deescalate behaviors and prevent the deployment of OC foam and/or Tasers for 2 of 4 behavioral health patients (Pts #4, #13).

~cross refer to 482.55 Emergency Department Services Standard: Tag 1101

Based on policy review, medical record reviews and interviews, the hospital failed to protect and promote patient's rights by failing to provide a safe environment for behavioral health patient care.

The findings include:

1. The hospital failed to provide care in a safe setting by using OC (Oleoresin Capsicum) foam and/or Conducted Electrical Weapons (tasers) on 2 of 4 emergency department behavioral health patients reviewed (Pts #4, #13).

~cross refer to 482.13 Patient Rights' Standard: Tag 0144

2. The hospital staff failed to recognize and obtain an order for seclusion of a pediatric behavioral health patient for 1 of 3 pediatric/ adolescent behavioral health sampled patients. (Pt #4)

~cross refer to 482.13 Patient Rights' Standard: Tag 0154

Based on hospital policies review, medical record reviews, and interviews, the hospital staff failed to provide care in a safe setting by using OC (Oleoresin Capsicum) foam and/or Conducted Electrical Weapons (tasers) on 2 of 4 ED behavioral health patients reviewed. (Pts #4, #13).

Findings included:

Review of the hospital policy titled "Oleoresin Capsieum (O.C. Foam)" approved 07/27/2022 revealed "... 3. Absent exigent (pressing; demanding) circumstances, the O.C. Foam should not knowingly be used on the following people: ... d. Children ..."

Review of the hospital policy titled "Use of Force" approved 07/08/2022 revealed "... F. All Security personnel must exhaust every reasonable means of defense before resorting to the use of O.C. Foam or CEW (conducted electrical weapons). O.C. Foam or CEW is considered a defense of last resort to protect our Security personnel or someone else, and will only be used when the Security personnel reasonably believes the Security personnel or someone else is in imminent danger of death or serious bodily harm ..."

Review of the Contract Security Service policy titled "Legal --- Use of Force and Reporting Policy" revised 08/22/2021 revealed "... The Use of Force Continuum shall be the standard model for the use of force ... The continuum is broken down into six broad levels ... Level One Officer Presence ... Level Two Verbal Communication ... Level Three Use of Open Hands, Control Holds, & (and) Restraints ... Level Four Less Lethal Defensive Spray (O.C.) ... Before a Security Professional may moving (sic) to level four, it is assumed that he or she exercised other less physical measures or deemed them inappropriate ..."

1. Review on 03/21/2023 of the closed medical record for Patient #4 revealed a 9-year-old female arrived to the Emergency department (ED) on 11/11/2022 at 1155 with a chief complaint of "Behavioral Issues". Review of the triage note at 1204 revealed "Chief Complaint: Patient presents via ems (emergency medical service) for psych (psychiatric) consult. Ems (sic) states she gave her foster mother a black eye and bit her. Pt (Patient) is aggressive with ER (emergency room) staff upon arrival. Pt struck cna (certified nursing assistant) twice and stated 'shut the expletive up bitch'." Review of the Provider Note at 1201 revealed "The patient is a 9-year-old ... female sent to the emergency department by Respite (a short period of rest or relief from something difficult or unpleasant) mom who had recently brought the child to her home. The child has been fighting her and biting her and she states that she can no longer care for the child. She reported this ... who is responsibility for the child and they recommended that she be brought to the emergency room with involuntary commitment for placement. Child is completely uncooperative and is attempting to fight the staff ..." Review of the medical record revealed Patient #4 had multiple therapeutic holds, chemical restraints, and restraint episodes between 11/11/2022 and 02/2023. Review of the Provider Note electronically signed on 03/03/2023 at 08:30 PM revealed "Patient received OC for to (sic) her face due to hitting the sitter and security multiple times and also spitting on them multiple times. Called to bedside to evaluate and make sure okay."

Review of the Nurse Note dated 03/03/2023 at 1905 revealed "Pt states to sitter at 1905, 'I am going to act out.' when sitter asked, 'why?', pt replies, 'So they will spray me.' The follow (sic) describes the list of behaviors from 1905 to 2112.
1906- Attempting to close door. Told that the door is not to be shut. Pt states, "I can do whatever the expletive I want."
1908-Climbed on and lying on sitters bedside table. Pt told numerous times to get off of bedside table. Pt refused.
1912- Pt lying on table, told sitter she was going to slap her across the face. Security arrival to room to try and deescalate situation.
1915- Spit gum on sitter
1918- Spit again on sitter
1919- Hit sitter in face. Kicked sitter 2 times in chest and 1 time in stomach.-(Provider name) notified. Per (Provider name) pt is to be sprayed indirectly if she were to continue to spit and assault staff. Ptcontinues to pit (sic) and assault security and sitter.
1920-Door closed. Pt indirectly sprayed with OC spray.
1923-Pt stripped off clothes
1924-Pt urinated on floor.
1926-Pt taken to decon shower escorted by sitter and 2 security guards ...
1940-Pt redressed and taken back to room.
1953-Pt verbalizes that she intends to hurt herself. Scratching face.
2008- Pt destroying room. striped side of fall (sic) and started to punch hole in wall of room. Pt asked to quit hitting wall and pt refuses and states, "this is your mouth".- ED DON (Emergency department director of nursing) arrival to room and nurse supervisor at bedside with security to assist with situation.
2020-Pt verbally threatening to supervisor, ED DON, and security.
2024-(Provider name) at bedside to assess pt. PRN IM (as needed intramuscular) medications given per MAR (medication administration record) for continued behavior of assaulting and threatening staff.
2035-Pt pushing code blue button in room refusing to stop when asked to stop.
2036- Pt continues to try and punch staff. Door closed. Pt isolated. Pt repeatedly punching door and tv in room.
2037-Pt spitting on window and making sexually explicit comments towards security guard.
2044-Pt tearing wall apart.
2055- More medication given. See MAR. Door closed, pt remains isolated with staff outside in view of pt for staff protection.
2100- Pt attempting to cut wrists with material from wall. Material taken from pt and pt held by security on mattress.
2108-Pt deescalated by (Name), DON. Pt taken out of hold and became cooperative. Given water and something to eat.
2109- Pt calm and sitting on mattress, 1:1 sitter remains at bedside."

Review of the medical record and the eMAR (electronic medical administration report) revealed Patient #4 received her regular scheduled medication of Methylphenidate (Ritalin-treats attention deficit hyperactivity disorder) 10 mg (milligram), Clonidine (decreases anxiety) 0.1 mg, Fluoxetine (for mental health disorders) 20 mg and Risperidone (can treat mental health disorders) 1 mg on 03/03/2023. Review revealed no administration of ordered PRN medications which included Chlorpromazine 40 mg and Ativan 1 mg both ordered IM (intramuscular) for agitation to Patient #4 prior to her being sprayed with O.C. Foam. Continued review of the medical record revealed Patient #4 was transferred to (Name of Facility) on 03/09/2023 at 1725.

Interview on 03/21/2023 at 1611 with Security #1 revealed "at the moment (Patient #4) was attacking nurse, security went in to get in between and felt it was safest for child, nurse, and staff safety. Did not have time to get a bed for restraints." Interview revealed "could not have done a therapeutic hold at that moment." Interview revealed "indirect" means "not sprayed in her eyes".

Interview on 03/22/2023 at 0821 with RN #2 revealed he was the Nurse assigned to psych area in the ED on 03/03/2023. Interview revealed it was normal for Patient #4 to state she was going to act up and then do it. Interview revealed a sitter was positioned in the doorway outside the door of Patient #4's room with a bedside table between her and Patient #4. Interview revealed when Patient #4 said she was going to act out, RN #2 would try to talk her down, get her a snack, and tried to refocus Patient #4. Interview revealed Patient #4 had seen another patient get sprayed with the OC spray and wanted to act out to get sprayed. Interview revealed Patient #4 stated "I want to get sprayed." Interview revealed RN #2 spoke with Provider #6 who stated to "Go ahead do the spray". Interview revealed RN #2 relayed this information to Security #4 and Security #5 via telephone. Interview revealed the medication was not working, the PRN medications were not working, and the holds were not working. Interview revealed Patient #4 was sprayed with the OC Foam and then taken to the shower for decontamination. Interview revealed Patient #4 received Benadryl after Provider #6 assessed her for the redness, warmth and irritation on Patient #4's cheek from the spray. Interview revealed Patient #4 screamed when she was sprayed with the OC Foam.

Interview on 03/22/2023 at 1004 with CNA #3 revealed she remembered Patient #4. Interview revealed CNA #3 started her shift at 1900 and Patient #4 said she was going to act out. Interview revealed Patient #4 wanted to get sprayed. Interview revealed CNA #3 told Patient #4 being sprayed was not something that she wanted. Interview revealed Patient #4 laid on the table, CNA #3 told her to get off the table and removed the table. Patient #4 got the table and laid on it again. Interview revealed CNA #3 removed the table further away this time and Patient #4 called CNA #3 a (expletive). Interview revealed RN #2 came to the room to see Patient #4. Interview revealed Patient #4 spit on CNA #3, kicked her in her chest and stomach and slapped her face. Interview revealed Security went into the room and Patient #4 tried to hit the Security Officers. Interview revealed Patient #4 was sprayed with the OC Foam on her left cheek. Interview revealed Patient #4 stripped out of her clothes and walked to the shower for decontamination. Interview revealed when Patient #4 first arrived to the facility, she was too small for the restraints and would always get out of them. Interview revealed Patient #4 had to be put in therapeutic holds and given medication. Interview revealed the IVC (involuntary commitment) Safety beds does not have the capability to restrain patients. Interview revealed "for this patient -more of a risk to put a metal stretcher in the room."

Interview on 03/22/2023 at 1052 with Security #4 revealed he was in the ED making his rounds when he noticed the patient (Patient #4) get agitated. Interview revealed there were two patients in rooms side by side and they "were going at it." Interview revealed RN #2 went in to talk with Patient #4. Interview revealed Patient #4 got more agitated and hit and spit on the CNA. Interview revealed Security #4 and Security #5 put on gloves, attempted to go in the room where Patient #4 was attempting to block the door with her mattress. Interview revealed Security #4 had pulled his OC pepper spray out of his belt at this time. Interview revealed the Security Officers went in Patient #4's room, tried to speak to her, and she tried to hit and spit on Security #4. Interview revealed Security #4 warned Patient #4 if she spit again or hit again she would be sprayed. Interview revealed Patient #4 tried to hit and spit again. Interview revealed Security #4 deployed his OC pepper spray foam after Patient #4 hit him on the arm. Interview revealed after deploying the OC pepper spray foam in the room, the Security Officers went out of the room and closed the door allowing Patient #4 time to deescalate. Interview revealed Security #4 was unsure of how long Patient #4 was in the room alone with the door closed after being sprayed. Interview revealed Patient #4 wiped her face with her arm/hand. Interview revealed Patient #4 "stripped naked" and the Security Officers escorted her to the shower for decontamination. Interview revealed the CNA tried to cover Patient #4 with a blanket. Interview revealed Patient #4 cried after being sprayed because it was burning.

Interview on 03/22/2023 at 1052 with Security #1 revealed the security officers are trained to use the OC Foam and the taser. Interview revealed the Security Officers are not sworn officers. Interview revealed the OC Foam has been deployed in the ED on two patients and two patients have been tased that Security #1 was aware of. Interview revealed Security #1 does not review every time OC Spray or a taser is deployed. Interview revealed there is a debriefing performed.





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2. Review of a hospital policy titled "Conducted Electrical Weapons....TASER...", approved 07/14/2022, revealed "...Policy 1. CEW's will not be used if the Security Personnel has reason to believe: ....d. It is possible the person(s) have been exposed to a potentially flammable type of oeaoresin capsicum spray (O.C. Foam). ..."

Medical record review on 03/22/2023 revealed Patient #13, a 35-year-old male arrived to the ED on 02/15/2023 for a psychiatric evaluation. Review of the Provider Note, dated/timed 02/15/2023 at 2127, revealed "...started back to day program at (program name) after being off since dec. (December). Caregiver states he destroyed property/computers at site, hit staff and has threatened to kill self and caregiver family.... CG (caregiver) states that patient went to his one-on-one worker today....after 3 hours she was being called as the patient had destroyed the office.... He was not listening, violent to staff there....She states that he does have a history of violence and threatening behavior but never with her. She states however that she is concerned because she has noticed things that are outside his normal ....She states that today he also states that he wanted to kill her and himself. She states that this has never happened in the past ....I have reviewed the patients previous available records. Finding as follows: Patient last seen the ED (sic) on 2 December 2022 after physical assault. He had negative imaging. States has a history of bipolar disorder (chronic mental health disorder characterized by extreme mood swings), intellectual disability, lives in a group home ....poor impulse control, schizoaffective disorder (serious chronic mental health disorder)....Medical Decision Making: Medically cleared for telepsychiatry evaluation. Assessment/Plan 1. Involuntary Commitment. ..." Review of a "BH (Behavioral Health) ED Telepsych Consultation" dated 02/17/2023 at 1045 revealed "...Reason for Consultation: out of control behavior and physical aggression ....Psychiatry Problems Intellectual Disability Schizoaffective disorder....Remain in the ED and Begin Bed Search for Inpatient Tx (treatment). ..."

Review of a Nursing Note, signed 02/22/2023 at 1304, revealed at 1256 "Pt return to room talking loudly & (and) walked up to nurses station. Encouraged pt to return to room and (Name), security standing at nurses station & noted pt reached out to strike at security. Pt turned around & walked back into room & (Name) security follow pt to room. Encouraged pt to calm down. Provided pt drink. Safety sitter 1:1 in full view of pt sitting at doorway for pt safety." A Nursing Notes, signed at 1320, revealed at 1305, "Pt continues to yell loudly at (Name) security and verbally treating (sic) to kill him .... Encouraged pt to calm down. Provided sprite drink. Pt sitting Indian style on end of bed. Safety sitter 1:1 in full view of pt for pt safety. Security ....on unit for safety." Another Nursing Note, signed at 1732, revealed at 1330, "Discussed increase agitation & (and) requested medication with Dr. (Physician Last Name). V.O. (verbal order) feed pt.... No medication orders at this time ..." A note, signed at 1804, indicated that at 1802 Patient #13 was "...yelling, slamming door, and charging at security staff. Notified Dr. (Physician Last Name) of the pt being verbally and physically aggressive, asked for medications to help calm pt down. Dr. (Name) stated 'this has been going on all day and isn't an emergency at this time'..... Notified Nursing supervisor at this time." Review revealed at 1825 "...Pt yelling, trying to hit security & spitting on staff member. Discussed with Dr. (Name) pt had to be pepper sprayed by security." Nursing Note review, signed at 1850 revealed at 1840 "...Nurse in with pt. Discussed medication with pt. Pt lay on bed & cooperative & let nurse adm (administer) medication. ..." A Nurses Note, signed at 2258, revealed at 1900 "Pt continues to scream, curse and threaten to kill staff and others. Pt hitting and kicking walls. Pt continues to hit window in door with his fist Pt spitting as well. Law enforcement and security standing at doorway with door closed. Pt in full view of security, law enforcement and safety attendant at all times. Pt refusing all attempts at redirection. ..." The next Nurses Note, signed at 2300, revealed that at 2020 "Security and law enforcement in room at this tie. Pt continues to attempt to fight. Security officer using Taser on patient at this time as pt attacking security and law enforcement. Pt attempting to close security officers wrist/arm in doorway. Pt with no adverse affects (sic) from this at this time ....Pt continues to shout and curse at staff, security and law enforcement. ..." Review of restraint orders and a flowsheet for restraint documentation revealed 4 point velcro restraints were ordered and initiated at 2048. A Nursing Note, signed at 2307, revealed at 2048 "Pt placed in 4 point Velcro restraints at this time due to continued aggression, violence and threats. ..." Review revealed the restraint was discontinued at 2218. Review of a "Patient Behavior Observation" sheet (for sitter observation notes) from 02/22/2023 revealed notations on the sheet at 1745 which included behavior codes noted as "E" for "Screaming out/crying/talking loudly" and "I" for "Change in Behavior". At 1749 code "B" was noted as "Threatening to harm others" along with code "E" and a written note "Cursing/Spitting". Further notes revealed at 1751,"Slamming door", at 1755 "Talking to RN", at 1800 "Cursing" and at 1820 "pt pooped on the floor". The observation sheet documented at 1826 "pepper sprayed", at 1840 "meds given", at 1945 "shots given". Observation continued at least every 15 minutes with the code E documented for "Screaming out/crying/talking loudly. At 2030 a handwritten note indicated "tazed patient", at 2045 "patient restrained" and at 2218 "restraints removed." ED Record review did not reveal emergency medications administration, therapeutic holds or physical restraints prior to the OC foam being deployed at 1825 and did not reveal a restraint order or attempts at therapeutic holds or physical restraints prior to the taser being used at 2020.

Interview with MD #8, on 03/23/2023 at 1330, revealed Patient #13 was on a medication regimen, both routine and prn (as needed). Interview revealed the patient got very loud every day and talked non-stop all day long. Interview revealed at the time the nurse requested an emergency medication for Patient #13, there was nothing different or emergent occurring. In response to the escalation and need for OC foam shortly thereafter MD #8 stated he was sorry that occurred, but at the time the patient was no different than usual. Interview revealed Patient #13 received additional medications after the OC spray.

Interview with RN #9, on 03/23/2023 at 1312, revealed RN #9 was present when Patient #13 started getting out of control, yelling, cursing. Interview revealed another RN was helping her and the second RN asked the physician for medication but he said it was not an emergency. Interview revealed that after they did not get medication, they closed the patient's door and used telemonitoring so he could calm down. Interview revealed shortly after that the patient had to get "pepper sprayed" (OC foam). RN #9 stated she was "of course" concerned that the physician did not order any medications for the patient when requested. Interview revealed Patient #13 was spitting, threatening and charged out of the room towards security. RN #9 stated he was manic and when he got so "hyped up" it was hard for him to come back down. Interview revealed after the patient was sprayed with the OC foam, she recalled going in Patient #13's room to give medication, around 1850, and recalled her eyes burning from the spray. Interview revealed the medication did not settle the patient down much but she thought he was still lying in bed when she left for the night. Interview revealed they must have tased the patient after she left.

Interview with RN #10, a nurse supervisor, on 03/22/2024, revealed RN #10 was on duty when the 02/22/2023 incident involving Patient #13 occurred. Interview revealed a nurse notified her that medication had been requested on the patient but nothing was ordered and nursing was concerned. Interview revealed RN #10 went immediately to the ED and Patient #13 was quiet right then so she told the staff to contact her if anything changed. Interview revealed RN #10 was then notified after the OC foam and taser and she in turn notified the Administrator on Call and the ED Director. Interview revealed it was the first time RN #10 had known of OC foam use.

Interview on 03/24/2023 at 1430 with Security #1, the head of facility security, revealed two security officers had been injured by this patient. Interview revealed the determination on the use of OC foam and/or tasers was how big of a threat the person believed it to be. Interview revealed "our training is to use the least amount of force possible" and indicated it should be a last resort. Interview revealed the patient "really ramped up" and that local police were present as well, stating that security had the assistance of police during this time.

Based on hospital policy and procedures, medical record review, and staff interviews, hospital staff failed to recognize and obtain an order for seclusion of a pediatric behavioral health patient for 1 of 3 pediatric/adolescent behavioral health sampled patients. (Pt #4)

The findings include:

Review of the hospital policy titled "Restraint Interventions" approved 07/25/2023 revealed "... Restraint is utilized only when necessary to ensure the immediate physical safety of the patient, a staff member, or others ... Seclusion, the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving, is not a restrictive intervention utilized by (Initials of Hospital) ... D. Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving ..."

Review on 03/21/2023 of the closed medical record for Patient #4 revealed a 9-year-old female arrived to the Emergency department (ED) on 11/11/2022 at 1155 with a chief complaint of "Behavioral Issues". Review of the triage note at 1204 revealed "Chief Complaint: Patient presents via ems (emergency medical service) for psych (psychiatric) consult. Ems (sic) states she gave her foster mother a black eye and bit her. Pt (Patient) is aggressive with ER (emergency room) staff upon arrival. Pt struck cna (certified nursing assistant) twice and stated 'shut the expletive up bitch'." Review of the Provider Note at 1201 revealed "The patient is a 9-year-old ... female sent to the emergency department by Respite (a short period of rest or relief from something difficult or unpleasant) mom who had recently brought the child to her home. The child has been fighting her and biting her and she states that she can no longer care for the child. She reported this ... who is responsibility for the child and they recommended that she be brought to the emergency room with involuntary commitment for placement. Child is completely uncooperative and is attempting to fight the staff ..." Review of the medical record revealed Patient #4 had multiple therapeutic holds, chemical restraints, and restraint episodes between 11/11/2022 and 02/2023. Review of the Nurse Note dated 11/14/2022 at 0701 revealed "... pt became verbally aggressive and physically violent. Pt cussing and threatening staff. Staff with multiple attempts at redirection and distraction without success ...Two security officers present during all of this event ...Pt's behaviors got to a point where it was determined that pt needed to be separated from staff to allow self calming and de-escalation for her safety and risk of elopement, as well as staff's safety. (LPN #12 and CNA #3's names) pulled and held pt's door closed. This RN remained in area to observe situation From 0500-0520, pt's door remained closed, lights on ...For the first 5 minutes, pt continued to cussed and threaten staff through window, putting face up to window and spitting, and giving staff the middle finger. Staff remained calm, encouraged pt to calm down, discussed re-establishing trust between staff and patient. Pt calmed, sat on bed. Staff continued to talk with her. Once pt showed that she was calm, staff cracked door ..."Review of the Nurse Note dated 02/09/2023 at 2020 revealed "Pt sitter alerted this nurse that pt was showing signs of a episode of anger about to begin. This nurse went to bedside and began trying to divert pts attention to other activities and began to ask questions regarding why she could not just walk out of ER (emergency room). Pt was then educated on IVC policy and what would happen if she left. Pt began stating that she was going to walk out and run away. Pt then stood up and started walking to room door. This nurse blocked door while trying to reason with pt ..." Review of the Nurse Note dated 02/16/2023 at 2128 revealed "... pt continues to sware (sic) and yell vulgarities out to anyone near the door. door held shut to cease the yelling that has disrupted the entire ED. (Patient #4) banging so hard on the window that writer is afraid it will break." Review of the Nurse Note dated 03/02/2023 at 2045 revealed "pt getting verbally aggressive and offensive to sitter. writer sat with pt for a bit and she reached for glasses to break them, then grabbed writers arm with intent to harm. security called and medication given. pt continues to be verbally offensive and aggressive. trying to tear up room. staff outside room with door shut to keep her confined. pt laughing wildly." Review of the Nurse Note dated 03/03/2023 at 1905 revealed "Pt states to sitter at 1905, 'I am going to act out.' when sitter asked , 'why?', pt replies, 'So they will spray me.' The follow (sic) describes the list of behaviors from 1905 to 2112.
1906- Attempting to close door. Told that the door is not to be shut. Pt states, "I can do whatever the expletive I want."
1908-Climbed on and lying on sitters bedside table. Pt told numerous times to get off of bedside table. Pt refused.
1912- Pt lying on table, told sitter she was going to slap her across the face. Security arrival to room to try and deescalate
situation.
1915- Spit gum on sitter
1918- Spit again on sitter
1919- Hit sitter in face. Kicked sitter 2 times in chest and 1 time in stomach.
-(Provider name) notified. Per (Provider name) pt is to be sprayed indirectly if she were to continue to spit and assault staff. Pt
continues to pit (sic) and assault security and sitter.
1920-Door closed. Pt indirectly sprayed with OC (Oleoresin Capsicum) spray.
1923-Pt stripped off clothes
1924-Pt urinated on floor.
1926-Pt taken to decon shower escorted by sitter and 2 security guards ...
1940-Pt redressed and taken back to room.
1953-Pt verbalizes that she intends to hurt herself. Scratching face.
2008- Pt destroying room. striped side of fall (sic) and started to punch hole in wall of room. Pt asked to quit hitting wall and pt
refuses and states, "this is your mouth".
- ED DON (Emergency department director of nursing) arrival to room and nurse supervisor at bedside with security to assist with situation.
2020-Pt verbally threatening to supervisor, ED DON, and security.
2024-(Provider name) at bedside to assess pt. PRN IM (as needed intramuscular) medications given per MAR (medication administration record) for continued behavior of assaulting and threatening staff.
2035-Pt pushing code blue button in room refusing to stop when asked to stop.
2036- Pt continues to try and punch staff. Door closed. Pt isolated. Pt repeatedly punching door and tv in room.
2037-Pt spitting on window and making sexually explicit comments towards security guard.
2044-Pt tearing wall apart.
2055- More medication given. See MAR. Door closed, pt remains isolated with staff outside in view of pt for staff protection.
2100- Pt attempting to cut wrists with material from wall. Material taken from pt and pt held by security on mattress.
2108-Pt deescalated by (Name), DON. Pt taken out of hold and became cooperative. Given water and something to eat.
2109- Pt calm and sitting on mattress, 1:1 sitter remains at bedside.
Review of the Nurse Note dated 03/06/2023 at 2004 revealed "no reaction to med (medication) injections. continues to rip paper/hard plastic off wall. making attempts to cut self with it no injury noted. . (sic) banging on the door window, wall disrupting the entire hallway. security at door, holding it shut. able to watch (Patient #4 name) on Avasure (video monitoring system) when not at door. Review of the Provider Orders revealed there were no orders for seclusion for Patient #4 for her hospital stay 11/11/2022 through 03/09/2023. Continued review of the medical record revealed Patient #4 was transferred to (Name of Facility) on 03/09/2023 at 1725.

Interview on 03/22/2023 at 1510 with Administrator #13 revealed the hospital does not have a seclusion policy and does not use seclusion.

Interview on 03/23/2023 at 0822 with LPN #12 revealed she remembered Patient #4 and the episode on 11/14/2022. Interview revealed Patient #4 was attention seeking when she was acting out and the staff didn't have time to get medication. Interview revealed to try to de-escalate Patient #4, LPN #12 pulled the door closed and held it. Interview revealed LPN #12 did not recall how long the door was held closed. Interview revealed LPN #12's definition of seclusion was when the door was locked.

Interview on 03/23/2023 at 1306 with RN #14 revealed she remembered the episode involving Patient #4 on 11/14/2022. Interview revealed RN #14 could not remember how long the door was held shut, thought it was a couple of minutes. Interview revealed RN #14's definition of seclusion was "basically where a pt is violent they go in a room and cannot get of it."

Based on policy review, internal document review and staff interviews the hospital failed to maintain an effective, ongoing, data-driven quality assessment and performance improvement program for patient safety.

1. The hospital failed to provide an effective quality assessment and performance improvement program for patient safety by failing to immediately analyze use and actions to prevent use of OC foam and Tasers on behavioral health patients in the emergency department.

~cross refer to 482.21 Quality Assessment and Performance Improvement Standard: Tag 0286

Based on policy review, quality assessment and performance improvement data and staff interview, the hospital failed to provide an effective quality assessment and performance improvement program for patient safety by failing to immediately analyze use and actions to prevent use of OC foam and Tasers on behavioral health patients in the emergency department.

The Findings include:

Review of the hospital policy titled "Oleoresin Capsicum (O.C. Foam)" approved 07/27/2022 revealed "8. ... Security personnel shall report all uses of O.C. Foam (to include the drawing of the O.C. Foam even if not used), in a thorough factual and objective manner to supervisors for evaluation and review ... 9. All reported use of force related to O. C. Foam shall be reviewed and a compact cause analysis conducted as soon as a review panel can be convened. The panel may include: a. Security Account Manager b. Manager of Environment of Care/Safety c. Risk Manager d. Director Quality or their designee e. Accreditation Coordinator f. Supervisor for the department where the use of O.C. Foam spray occurred g. Allied Universal Director of Operations or other Corporate Representation ..."

Review of the hospital policy titled "Use of Force" approved 07/08/2022 revealed "... J. All reported uses of force shall be reviewed promptly and evaluated by a supervisor to determine whether the particular use of force was within ... Security's policy and reasonable and necessary. To the extent possible, the review of use of force incidents and use of force reports shall include an examination of the security tactics and precipitating events that led to the use of force so that ... Security can evaluate whether any revisions to training or practices are necessary. K. All reported use of force related to O.C. Foam or CEW (conducted energy weapon) shall be reviewed and a compact cause analysis conducted as soon as a review panel can be convened. The panel may include: a. Security Account Manager b. Manager of Environment of Care/Safety c. Risk Manager d. Director of Quality or their designee e. Accreditation Coordinator f. Supervisor for the department the where the use O.C. Foam or CEW occurred g. Allied Universal Director of Operations or other Corporate Representation ..."

Review of the hospital Quality Assurance and Performance Improvement data revealed there was no data related to use of O.C. Foam nor Tasers.

Interview on 03/22/2023 at 1052 with Security #1 revealed the OC Foam has been deployed in the ED on two patients and two patients have been tased that Security #1 was aware of. Interview revealed Security #1 does not review every time OC Spray or a taser is deployed. Interview revealed there is a debriefing performed.

Interview on 03/23/2023 at 1042 with Administrator #7, Interim CNE (Chief Nurse Executive) and Director of Quality/Accreditation and Compliance Officer revealed she was not aware of the O.C. Foam nor taser use on Patient #13 on 02/22/2023. Interview revealed Administration #7 was made aware of the 02/22/2023 incident after the 03/03/2023 incident of O.C. Foam use on Patient #4. Interview revealed an RCA (root cause analysis) was initiated after the 03/03/2023 incident but is not completed. Interview revealed during a previous scheduled tour of another facility on 03/08/2023, Administrator #7 was made aware of another incident of the use of a taser on a patient in the ED. Interview revealed the three incidents were grouped into this one RCA. Interview revealed each individual incident had not been tracked and reviewed individually immediately after the incident.

Based on policy and procedure review, medical record review and staff and physician interviews the hospital failed to have effective emergency services to meet the needs of behavioral health child and adult patients in the Emergency Department.

The findings include:

The hospital failed to ensure an organized and effective emergency services that met the needs of behavioral Health patients by failing to ensure behavioral health patients in the emergency department were provided emergency medications and other therapeutic measures to deescalate behaviors and prevent the deployment of OC foam and/or Tasers for 2 of 4 behavioral health patients (Pts #4, #13).

~cross refer to 482.55 Emergency Department Services Standard: Tag 1101

Based on policy reviews, medical record reviews and staff and physician interviews, the hospital failed to ensure an organized and effective emergency services that met the needs of behavioral Health patients by failing to ensure behavioral health patients in the emergency department were provided emergency medications and other therapeutic measures to deescalate behaviors and prevent the deployment of OC foam and/or Tasers for 2 of 4 behavioral health patients (Patients #4, #13).

The findings include:

Review of the hospital policy titled "Oleoresin Capsieum (O.C. Foam)" approved 07/27/2022 revealed "... 3. Absent exigent (pressing; demanding) circumstances, the O.C. Foam should not knowingly be used on the following people: ... d. Children ..."

Review of the hospital policy titled "Use of Force" approved 07/08/2022 revealed "... F. All Security personnel must exhaust every reasonable means of defense before resorting to the use of O.C. Foam or CEW (conducted electrical weapons). O.C. Foam or CEW is considered a defense of last resort to protect our Security personnel or someone else, and will only be used when the Security personnel reasonably believes the Security personnel or someone else is in imminent danger of death or serious bodily harm ..."

Review of the Contract Security Service policy titled "Legal --- Use of Force and Reporting Policy" revised 08/22/2021 revealed "... The Use of Force Continuum shall be the standard model for the use of force ... The continuum is broken down into six broad levels ... Level One Officer Presence ... Level Two Verbal Communication ... Level Three Use of Open Hands, Control Holds, & (and) Restraints ... Level Four Less Lethal Defensive Spray (O.C.) ... Before a Security Professional may moving (sic) to level four, it is assumed that he or she exercised other less physical measures or deemed them inappropriate ..."

1. Review on 03/21/2023 of the closed medical record for Patient #4 revealed a 9-year-old female arrived to the Emergency department (ED) on 11/11/2022 at 1155 with a chief complaint of "Behavioral Issues". Review of the triage note at 1204 revealed "Chief Complaint: Patient presents via ems (emergency medical service) for psych (psychiatric) consult. Ems (sic) states she gave her foster mother a black eye and bit her. Pt (Patient) is aggressive with ER (emergency room) staff upon arrival. Pt struck cna (certified nursing assistant) twice and stated 'shut the expletive up bitch'." Review of the Provider Note at 1201 revealed "The patient is a 9-year-old ... female sent to the emergency department by Respite (a short period of rest or relief from something difficult or unpleasant) mom who had recently brought the child to her home. The child has been fighting her and biting her and she states that she can no longer care for the child. She reported this ... who is responsibility for the child and they recommended that she be brought to the emergency room with involuntary commitment for placement. Child is completely uncooperative and is attempting to fight the staff ..." Review of the medical record revealed Patient #4 had multiple therapeutic holds, chemical restraints, and restraint episodes between 11/11/2022 and 02/2023. Review of the Provider Note electronically signed on 03/03/2023 at 08:30 PM revealed "Patient received OC for to (sic) her face due to hitting the sitter and security multiple times and also spitting on them multiple times. Called to bedside to evaluate and make sure okay." Review of the Nurse Note dated 03/03/2023 at 1905 revealed "Pt states to sitter at 1905, 'I am going to act out.' when sitter asked , 'why?', pt replies, 'So they will spray me.' The follow (sic) describes the list of behaviors from 1905 to 2112.
1906- Attempting to close door. Told that the door is not to be shut. Pt states, "I can do whatever the (expletive) I want."
1908-Climbed on and lying on sitters bedside table. Pt told numerous times to get off of bedside table. Pt refused.
1912- Pt lying on table, told sitter she was going to slap her across the face. Security arrival to room to try and deescalate
situation.
1915- Spit gum on sitter
1918- Spit again on sitter
1919- Hit sitter in face. Kicked sitter 2 times in chest and 1 time in stomach.
-(Provider name) notified. Per (Provider name) pt is to be sprayed indirectly if she were to continue to spit and assault staff. Pt continues to pit (sic) and assault security and sitter.
1920-Door closed. Pt indirectly sprayed with OC spray.
1923-Pt stripped off clothes
1924-Pt urinated on floor.
1926-Pt taken to decon shower escorted by sitter and 2 security guards ...
1940-Pt redressed and taken back to room. ...
2024-(Provider name) at bedside to assess pt. PRN IM (as needed intramuscular) medications given per MAR (medication administration record) for continued behavior of assaulting and threatening staff. ...
2055- More medication given. See MAR. Door closed, pt remains isolated with staff outside in view of pt for staff protection. ...
2109- Pt calm and sitting on mattress, 1:1 sitter remains at bedside."
Review of the medical record and the eMAR (electronic medical administration report) revealed Patient #4 received her regular scheduled medication on 03/03/2023. Review revealed no administration of PRN medication to Patient #4 prior to her being sprayed with O.C. Foam. Continued review of the medical record revealed Patient #4 was transferred to (Name of Facility) on 03/09/2023 at 1725.

Interview on 03/22/2023 at 0821 with RN #2 revealed he was the Nurse assigned to psych area in the ED on 03/03/2023. Interview revealed it was normal for Patient #4 to state she was going to act up and then do it. Interview revealed a sitter was positioned in the doorway outside the door of Patient #4's room with a bedside table between her and Patient #4. Interview revealed when Patient #4 said she was going to act out, RN #2 would try to talk her down, get her a snack, and tried to refocus Patient #4. Interview revealed Patient #4 had seen another patient get sprayed with the OC spray and wanted to act out to get sprayed. Interview revealed Patient #4 stated "I want to get sprayed." Interview revealed RN #2 spoke with Provider #6 who stated to "Go ahead do the spray". Interview revealed RN #2 relayed this information to Security #4 and Security #5 via telephone. Interview revealed the medication was not working, the PRN medications were not working, and the holds were not working. Interview revealed Patient #4 was sprayed with the OC Foam and then taken to the shower for decontamination. Interview revealed Patient #4 received Benadryl after Provider #6 assessed her for the redness, warmth and irritation on Patient #4's cheek from the spray. Interview revealed Patient #4 screamed when she was sprayed with the OC Foam.

Telephone interview on 03/23/2023 at 0735 with Provider #6 revealed he "can not authorize or direct the use" of the OC Spray. Interview revealed Provider #6 had a meeting with hospital leadership to discuss staff getting injured in the Emergency department (ED) by behavioral health patients. Interview revealed during the meeting Provider #6 was notified there would be an increase in security presence in the ED and the use of OC Spray. Interview revealed Provider #6 was not aware O.C. Spray Foam was used on Patient #4 until after it had been used. Interview revealed Provider #6 did say "if situation met criteria then should use it if spray and situation warranted." Interview revealed there are no side effects of using the O.C. Spray Foam on a nine-year-old, there are no permanent damage or injury.
"It is going to burn and be an irritant." Interview revealed the staff always try to de-escalate, try to give regular medications if that does not work do have prn medications. Have to be careful with the medications as Patient #4 would get ramped up and would be given the medications then she would sleep all day." Interview revealed when Patient #4 arrived to the ED she was "just too small" for the restraints. Interview revealed the restraints would cause skin abrasions or cuts to Patient #4. Interview revealed the ED had adult size restraints that did not fit well. Interview revealed "when suggesting hold to what extent" and "for how long" and give medication. Have to look at each situation individually. Interview revealed revealed Provider #6 did not communicate with psychiatry. Interview revealed communicating with psychiatry "would have been the pediatricians responsibility to do."

Telephone interview on 03/23/2023 with Provider #15 revealed he was covering the ED when Patient #4 arrived. Interview revealed Provider #15 would not have been the one to communicate with psychiatry as he was consulted.

Interview on 03/22/2023 at 1052 with Security #1 revealed the security officers are trained to use the OC Foam and the taser. Interview revealed the Security Officers are not sworn officers. Interview revealed the OC Foam has been deployed in the ED on two patients and two patients have been tased that Security #1 was aware of. Interview revealed Security #1 does not review every time OC Spray or a taser is deployed. Interview revealed there is a debriefing performed.

NC00199630, NC00199648, NC00199623, NC00199496


33790

2. Review of a hospital policy titled "Conducted Electrical Weapons....TASER...", approved 07/14/2022, revealed "...Policy 1. CEW's will not be used if the Security Personnel has reason to believe: ....d. It is possible the person(s) have been exposed to a potentially flammable type of oeaoresin capsicum spray (O.C. Foam). ..."

Medical record review on 03/22/2023 revealed Patient #13, a 35-year-old male arrived to the ED on 02/15/2023 for a psychiatric evaluation. Review of the Provider Note, dated/timed 02/15/2023 at 2127, revealed "...started back to day program at (program name) after being off since dec. (December). Caregiver states he destroyed property/computers at site, hit staff and has threatened to kill self and caregiver family.... He was not listening, violent to staff there....She states that he does have a history of violence and threatening behavior but never with her. She states however that she is concerned because she has noticed things that are outside his normal ....She states that today he also states that he wanted to kill her and himself....I have reviewed the patients previous available records. Finding as follows: Patient last seen the ED (sic) on 2 December 2022 after physical assault...States has a history of bipolar disorder (chronic mental health disorder characterized by extreme mood swings), intellectual disability, lives in a group home ....poor impulse control, schizoaffective disorder (serious chronic mental health disorder)....Medical Decision Making: Medically cleared for telepsychiatry evaluation. Assessment/Plan 1. Involuntary Commitment. ..." Review of a "BH (Behavioral Health) ED Telepsych Consultation" dated 02/17/2023 at 1045 revealed "...Reason for Consultation: out of control behavior and physical aggression ....Psychiatry Problems Intellectual Disability Schizoaffective disorder....Remain in the ED and Begin Bed Search for Inpatient Tx (treatment). ..."

Review of a Nursing Note, signed 02/22/2023 at 1304, revealed at 1256 "Pt return to room talking loudly & (and) walked up to nurses station. Encouraged pt to return to room and (Name), security standing at nurses station & noted pt reached out to strike at security. Pt turned around & walked back into room & (Name) security follow pt to room. Encouraged pt to calm down. Provided pt drink. Safety sitter 1:1 in full view of pt sitting at doorway for pt safety." A Nursing Note, signed at 1320, revealed at 1305, "Pt continues to yell loudly at (Name) security and verbally treating (sic) to kill him .... Encouraged pt to calm down. Provided sprite drink. Pt sitting Indian style on end of bed. Safety sitter 1:1 in full view of pt for pt safety. Security ....on unit for safety." Another Nursing Note, signed at 1732, revealed at 1330, "Discussed increase agitation & (and) requested medication with Dr. (Physician Last Name). V.O. (verbal order) feed pt.... No medication orders at this time ..." A note, signed at 1804, indicated that at 1802 Patient #13 was "...yelling, slamming door, and charging at security staff. Notified Dr. (Physician Last Name) of the pt being verbally and physically aggressive, asked for medications to help calm pt down. Dr. (Name) stated 'this has been going on all day and isn't an emergency at this time'..... Notified Nursing supervisor at this time." Review revealed at 1825 "...Pt yelling, trying to hit security & spitting on staff member. Discussed with Dr. (Name) pt had to be pepper sprayed by security." Nursing Note review, signed at 1850 revealed at 1840 "...Nurse in with pt. Discussed medication with pt. Pt lay on bed & cooperative & let nurse adm (administer) medication. ..." A Nurses Note, signed at 2258, revealed at 1900 "Pt continues to scream, curse and threaten to kill staff and others. Pt hitting and kicking walls. Pt continues to hit window in door with his fist Pt spitting as well. Law enforcement and security standing at doorway with door closed. Pt in full view of security, law enforcement and safety attendant at all times. Pt refusing all attempts at redirection. ..." The next Nurses Note, signed at 2300, revealed that at 2020 "Security and law enforcement in room at this tie. Pt continues to attempt to fight. Security officer using Taser on patient at this time as pt attacking security and law enforcement. Pt attempting to close security officers wrist/arm in doorway. Pt with no adverse affects (sic) from this at this time ....Pt continues to shout and curse at staff, security and law enforcement. ..." Review of restraint orders and a flowsheet for restraint documentation revealed 4 point velcro restraints were ordered and initiated at 2048. A Nursing Note, signed at 2307, revealed at 2048 "Pt placed in 4 point Velcro restraints at this time due to continued aggression, violence and threats. ..." Review revealed the restraint was discontinued at 2218. Review of a "Patient Behavior Observation" sheet (for sitter observation notes) from 02/22/2023 revealed notations on the sheet at 1745 which included behavior codes noted as "E" for "Screaming out/crying/talking loudly" and "I" for "Change in Behavior". At 1749 code "B" was noted as "Threatening to harm others" along with code "E" and a written note "Cursing/Spitting". Further notes revealed at 1751,"Slamming door", at 1755 "Talking to RN", at 1800 "Cursing" and at 1820 "pt pooped on the floor". The observation sheet documented at 1826 "pepper sprayed", at 1840 "meds given", at 1945 "shots given". Observation continued at least every 15 minutes with the code E documented for "Screaming out/crying/talking loudly. At 2030 a handwritten note indicated "tazed patient", at 2045 "patient restrained" and at 2218 "restraints removed." ED Record review did not reveal emergency medications administration, therapeutic holds or physical restraints prior to the OC foam being deployed at 1825 and did not reveal a restraint order or attempts at therapeutic holds or physical restraints prior to the taser being used at 2020.

Telephone interview with Provider #6, ED Medical Director, on 03/23/2023 at 0735, revealed he could not authorize or direct the use of OC foam. Provider #6 stated "I can't direct Security to do their job." Interview revealed there had been problems where staff were being injured and in the past responses were passive and reactive not proactive. In relation to Pt #13 Provider #6 stated the use of OC form and taser did not occur while he was on duty. Interview revealed in relation to the patient, the facility was not getting responses quickly enough from (name of a MCO -managed care organization) to adjust the patient's meds and stated they struggled for a long time to control the patient's behavior. Interview revealed the routine for Telepsych had been every 5 days and it took several calls and "lots of pleading" to get agreement for every two days for this patient. Interview revealed the patient could be directed when he was not manic, but when manic the patient was "off the chain."

Interview with MD #8, on 03/23/2023 at 1330, revealed Patient #13 was on a medication regimen, both routine and prn (as needed). Interview revealed the patient got very loud every day and talked non-stop all day long. Interview revealed at the time the nurse requested an emergency medication for Patient #13, there was nothing different or emergent occurring. In response to the escalation and need for OC foam shortly thereafter MD #8 stated he was sorry that occurred, but at the time the patient was no different than usual. Interview revealed Patient #13 received additional medications after the OC spray.

Interview with RN #9, on 03/23/2023 at 1312, revealed RN #9 was present when Patient #13 started getting out of control, yelling, cursing. Interview revealed another RN was helping her and the second RN asked the physician for medication but he said it was not an emergency. Interview revealed that after they did not get medication, they closed the patient's door and used telemonitoring so he could calm down. Interview revealed shortly after that the patient had to get "pepper sprayed" (OC foam). RN #9 stated she was "of course" concerned that the physician did not order any medications for the patient when requested. Interview revealed Patient #13 was spitting, threatening and charged out of the room towards security. RN #9 stated he was manic and when he got so "hyped up" it was hard for him to come back down. Interview revealed after the patient was sprayed with the OC foam, she recalled going in Patient #13's room to give medication, around 1850, and recalled her eyes burning from the spray. Interview revealed the medication did not settle the patient down much but she thought he was still lying in bed when she left for the night. Interview revealed they must have tased the patient after she left.

Interview with RN #10, a nurse supervisor, on 03/22/2024, revealed RN #10 was on duty when the 02/22/2023 incident involving Patient #13 occurred. Interview revealed a nurse notified her that medication had been requested on the patient but nothing was ordered and stated nursing was concerned. Interview revealed RN #10 went immediately to the ED and Patient #13 was quiet right then so she told the staff to contact her if anything changed. Interview revealed RN #10 was then notified after the OC foam and taser and she in turn notified the Administrator on Call and the ED Director. Interview revealed it was the first time RN #10 had known of OC foam use.

NC00199630, NC00199648, NC00199623, NC00199496