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Based on observation, interview, and record review, the facility failed to ensure one of two sampled contracted security officers (CSO 3) wore a facility-issued identification (ID) badge. This deficient practice had the potential to compromise patient safety by not being able to identify the security officer as part of the facility.

Findings:

During a concurrent observation and interview, on 7/25/22, at 3:42 P.M., CSO 3 stated he had worked at the facility for over a year and was currently responsible for observing the back of the emergency department (ED). CSO 3 was observed not wearing a ID badge. When asked to produce his ID badge, CSO 3 stated, "I never got a badge."

During an interview with Director of Emergency Department/Intensive Care Unit (DEI), on 7/25/22, at 3:43 P.M., DEI stated that all hospital employees, including contracted employees, are required to wear a ID badge at all times.

A review of the facility's policy & procedure, titled "Identification of Employee, Patient, Physician, Visitor, Contract Worker and Vendor," revised 4/2020, indicated, "[Facility] will establish a safe environment by requiring that all authorized employees, physicians, visitors, patients, contractors and vendors have appropriate identification while on hospital grounds ... Employees, contract employees and physicians are required to wear the hospital-issued photograph identification at all times while on duty."

Based on interview and record review, the facility failed to ensure that the Condition of Participation for Patient Rights was met as evidenced by:

1. The facility failed to ensure that one of 21 sampled patients (Patient 1) was free from abuse or harassment when facility staff did not appropriately de-escalate (reduce the intensity of a conflict or potentially violent situation) a conflict with Patient 1. (Refer to A-0145)

2. The facility failed to ensure two of 21 sampled patients (Patient 1 and Patient 2) received care in a safe setting. (Refer to A-0144)

3. The facility physically restrained one of 21 sampled patients (Patient 1) during an attempt to force psychotropic medication administration. (Refer to A-0161)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Patient Rights.

Based on interview and record review, the facility failed to ensure two of 21 sampled patients (Patient 1 and Patient 2), received care in a safe setting.
This deficient practice resulted in Patient 1 being assaulted and battered by security officers. This deficient practice also had the potential for Patient 2 to be assaulted by security officers.

Findings:

A. During a concurrent interview and record review on July 26, 2022, at 8:01 A.M., with Registered Nurse 1 (RN 1), Patient 1's ED records - Nursing Notes and Medication Administration Record (MAR), dated March 16, 2022, were reviewed. RN 1 stated the following:
1. She (RN 1) was a traveler nurse and worked on the day shift, on March 16, 2022, and was assigned the ED hallway with a 1:1 sitter (1 healthcare provider [Certified Nursing Assistant 1] assigned to observe and monitor 1 patient-Patient 1).
2. She (RN 1) was assigned to care for patients, including Patient 1 with 1:1 sitter- CNA 1.
3. She (RN 1) found Patient 1 agitated and got a physician order for medication to calm Patient 1 down.
4. She (RN 1) was unable to administer the medication to Patient 1 because Patient 1 refused the medication. She (RN 1) couldn't give the medication, until Patient 1 settled down and was placed back in the gurney.
5. A Code Gray ( a standardized hospital emergency code that alerts all staff to potentially or actively combative persons) was called after Patient 1 got agitated with the arrival of two security officers to Patient 1's bedside.
6. Patient 1 got one (CSO 1) of the two security officers (CSO 1 and CSO 2) in a chokehold and CSO 1 got out of the chokehold and fought the Patient 1, during the struggle.

During a concurrent interview and record review on July 27, 2022, at 8:10 A.M., with certified nursing attendant 1 (CNA 1), Patient 1's Suicide Prevention Monitor Observation Flowsheet, dated March 16, 2022, was reviewed. CNA 1 stated the following:
1. Patient 1 was awake and restless, after talking with his (Patient 1's) mother over the telephone - not documented.
2. Patient 1 saw the social worker - not documented.
3. She (CNA 1) left Patient 1 briefly to another 1:1 sitter/CNA, to find the nurse (RN 1) and notify RN 1 that Patient 1 was restless.
4. Security was called at 9:30 A.M. because there was no security stationed at the ED hallway.
5. Patient 1 stood up towards two security officers (CSO 1 and CSO 2) and got one security officer (CSO 1) in a chokehold.
6. CSO 1 fought Patient 1 trying to get free from a chokehold with the patient (Patient 1). CNA 1 stated it looked like CSO 2 was punching Patient 1.
7. She (CNA 1) did not call a Code Gray because there was no telephone in the ED hallway.

During an interview on July 27, 2022, at 10:08 A.M., with security officer 2 (CSO 2), CSO 2 stated the following:
1. Worked at the facility for one year.
2. Worked on March 16, 2022, from 6 A.M. to 2 P.M., as the lead security officer.
3. Got called on the walkie-talkie for assistance in the ED and responded to the ED with another security officer (CSO 1), who was assigned to the ED "back."
4. Upon arrival to the ED with CSO 1, the charge nurse told the security officers that Registered Nurse 1 (RN 1) needed their assistance with Patient 1 (that is to hold the patient so RN 1 can administer medication for Patient 1).
5. CSO 2 was not trained to hold a patient and to help the nurse (RN 1) to give a shot to the patient.
6. CSO 1 was trying to hold Patient 1's arm for the injection.
7. Patient 1 was agitated and, suddenly, got up from the gurney.
8. CSO 2 grabbed Patient 1 from Patient 1's back, and was unable to secure Patient 1's arms.
9. There was a struggle between Patient 1 and CSO 1 and CSO 2. CSO 2 stated that Patient 1 was big and heavy.
10. CSO 2 couldn't see what was going on between Patient 1 and CSO 1, because he (CSO 2) was holding Patient 1 from behind.
11. Patient 1 got tired and appeared to give up fighting with security officers.
12. CSO 2 stated "I don't know if patient got the shot - did not observe this."
13. Director of security later instructed CSO 2 to file an incident report of what happened with the patient (Patient 1). CSO 2 filed a daily activity report (DAR).
14. CSO 2 reported off to next lead security officer on the following shift.

During an interview with Director of Risk (DRM), on July 27, 2022, at 4:58 P.M., DRM stated the facility does not have a policy and procedure for De-escalation (method to prevent potential violence) of assaultive behavior.

Concurrently, the DRM presented surveyors with the policy of the contracted service for security officers on the Use of Force, and stated facility is currently working on a similar policy for the facility.

A review of Patient 1's face sheet, dated March 14, 2022, indicated Patient 1 was admitted to the emergency department (ED) with a chief complaint of drug abuse.

A review of Patient 1's Triage (process of sorting patients at a medical facility to receive medical care based on the urgency or severity of their medical needs) Notes, dated March 15, 2022, indicated Patient 1 was brought in by mother, who stated Patient 1 used unknown drugs, had been hearing voices, and had no suicidal (thoughts of harming one's self) and homicidal ideations (thoughts of harming or causing injury to others).

A review of Patient 1's Nursing Notes, dated March 15, 2022, indicated the following:
1. Patient 1 was anxious, worried, and irritable with inappropriate behavior.
2. Patient 1's modified sad persons total score (suicide risk assessment tool) was 3 - low risk for suicide.
3. Patient 1 had a 1:1 certified nursing attendant (CNA) observer.
4. The charge nurse was notified of Patient 1's behavior.

A review of Patient 1's Nursing Notes, dated March 15, 2022, indicated the following:
1. Patient 1's modified sad persons total scores were six (moderate risk that requires psychiatric consultation) to ten (high risk that requires hospital admission to a psychiatric facility).
2. The charge nurse and house supervisor were notified of Patient 1's behavior.
3. Patient 1 had a 1:2 observations (2 people assigned to monitor 1 patient) by security and 1:1 sitter (CNA).
4. Licensed clinical social worker consultation was requested.

A review of Patient 1's Social Worker note, dated March 15, 2022, indicated the following:
1. Patient 1 was difficult to understand.
2. Patient 1's urine drug test was negative for drugs and alcohol.
3. Patient 1's physician was consulted and was notified patient needed a Psychiatric Emergency Teams (PET - mobile teams operated by psychiatric hospitals and approved by the Department of Mental Health to provide 5150 and 5585 evaluations) evaluation.
4. Patient 1 remained with a sitter in place for safety.
5. PET team evaluated Patient 1 and Patient 1 was placed on a 5150 hold (legal code that allows a person with a mental illness to be involuntarily detained for a 72-hour psychiatric hospitalization).

A review of Patient 1's Social Worker Notes, dated March 16, 2022, indicated the following:
1. Patient 1 was on a 5150 hold and discharge planning, for transfer to a psychiatric facility, was initiated.
2. Patient 1 had a sitter in place for safety.
3. Patient 1 stated they wanted to leave the facility and should not have been on a 5150 hold.
4. The charge nurse was notified of Patient 1's potential for flight risk (patient leaving the facility without knowledge of hospital staff).

A review of Patient 1's Nursing Notes, dated March 16, 2022, indicated the following:
1. Patient 1 was observed agitated and medications were ordered by physician for Patient 1's agitation.
2. Security officers were called to assist with administering Patient 1 with medication.
3. Patient 1 became aggressive towards two security officers (CSO and CSO 2) and put one (CSO 1)of the two security officers in a chokehold (a tight grip around a person's neck, to restrain them by restricting their breathing), while fighting with the security officers.
4. Patient 1 was placed on gurney (a wheeled stretcher used for transporting hospital patients) by the security officers after he (Patient 1) calmed down.
5. Social Worker was at the bedside during incident.

A review of Patient 1's Social Worker's note, dated March 16, 2022, indicated the following:
1. A Code Gray was called because Patient 1 was agitated, with security officers and nursing staff at the bedside.
2. Patient 1 was placed on the gurney and administered medication for safety.
3. Patient 1's mother was outside the facility and not allowed to the bedside to not further agitate Patient 1.
4. Patient 1 had sitter in place for safety.
5. Patient 1's physician notified of incident.
6. Facility will continue to find placement for Patient 1 at a psychiatric facility.

A review of Patient 1's Medication Administration Record (MAR), dated March 16, 2022, indicated Patient 1 received olanzapine (antipsychotic medication to treat mental disorders, including schizophrenia and bipolar disorders) 10 milligrams (mg-a unit of measurement) intramuscular (IM-a method of administering medication into the muscles) once, at 9:40 A.M., to the right deltoid (large, triangular shaped muscle in the shoulder).

A review of lead security officer's (CSO 2) report, dated March 16, 2022, indicated the following:
1. Radio call, from ED hallway, was received for patient assist, at 9:30 A.M.
2. CSO 1 and CSO 2 responded to the radio call.
3. Registered Nurse 1 (RN 1) asked for assistance with holding Patient 1 to administer medication because Patient 1 refused medication.
4. Patient 1 was instructed by CSO 1 and CSO 2 to cooperate with nursing staff.
5. CSO 1 positioned himself to hold Patient 1's arm.
6. Patient 1 suddenly lounged towards sitter (CNA 1).
7. CSO 2 grabbed Patient 1 from the patient's back in a "bear hug" to get Patient 1 to sit back down.
8. There was a struggle between Patient 1 and CSO 1 and CSO 2, for a few minutes.
9. Patient 1 eventually complied with nursing staff and allowed staff to place him (Patient 1)back into gurney.
10. Patient 1 was administered medication.
11. There was an allegation that CSO 1 did wrong with the patient (Patient 1) - not observed by CSO 2, with only view of patient's back during bear hug hold, during the struggle.
12. Security director instructed CSO 2 to file an incident report.

A review of facility's ED daily assignment, dated March 16, 2022, indicated the following:
1. Registered Nurse 1 (RN 1) was assigned to rooms 4, 5, 11, and 12.
2. Certified Nursing Attendants (CNA) 1, 2, and 3 were assigned in the ED as 1:1 sitter.

A review of facility's email communication, dated July 26, 2022, indicated the following:
1. Two security officers (CSO 1 and CSO 3) assigned to the ED on March 16, 2022.
2. The lead security officer was CSO 2.

B. During a concurrent interview and record review on July 26, 2022, at 4:38 P.M., with charge nurse 2 (RN 2), Patient 2's triage notes and ED physician notes, dated July 15, 2022, were reviewed. RN 2 stated the following:
1. Patient 2 was brought into ED by BLS (Basic Lif Support-care process initiated when someone experiences a medical emergency) ambulance with complaint of tripping and falling and having pain in the head.
2. Patient 2 was observed with a sheet over his (Patient 2) head and refused to be assessed by triage nurse.
3. RN 2 stated she received a report from the ambulance staff of blood pressure 116/87, temperature 98.9, heart rate of 98, respirations of 17 and room air oxygen saturation of 99%.
4. ED physician (MD) 2 was notified of Patient's 2 refusal to be assessed by triage nurse (RN 2).
5. ED physician did a visual examination of Patient 2 and instructed Patient 2 to wait in the hospital lobby.
6. Patient 2 became agitated and demanded to be placed in a room.
7. Patient 2 removed belt fastener from the gurney and got up from the gurney screaming at ED staff.
8. Security was called and arrived at the patient's bedside and Patient 2 punched CSO 3.
9. Patient 2 with other security officers, including CSO 3, entered another patient's room in the ED, room 8, and then left room 8.
10. RN 2 checked on patient in room 8, who denied incident with Patient 2.
11. Code Gray was called and announced overhead.
12. Lead security officer (CSO 5) arrived at the ED scene, with other CSO officers already present, and escorted Patient 2 out of the ED.
13. House supervisor was notified of incident with Patient 2.
14. Incident report was filed regarding incident.

During an interview on July 27, 2022, at 4:58 P.M., with Director of Risk (DRM), DRM stated the facility does not have a policy and procedure for De-escalation (method to prevent potential violence) for assaultive behavior.

Concurrently, DRM presented surveyors with the policy of the contracted service for security officers on the Use of Force, and stated facility is currently working on a similar policy for the facility.

A review of Patient 2's face sheet, dated July 15, 2022, indicated Patient 2 was admitted to the facility as an ER (Emergency Room) Patient with a chief complaint of headache.

A review of Patient 2's Triage Notes, dated July 15, 2022, indicated the following:
1. The patient (Patient 2) had a history of tripping and falling.
2. The patient (Patient 2) complained of pain in the head.
3. Patient 2 was uncooperative with emergency department (ED) staff.
4. Patient 2 refused to remove sheet off his (Patient 2) face.
5. ED physician was notified of patient's (Patient 2) behavior and examined Patient 2.
6. Patient 2 demanded a bed and was uncooperative with ED staff.
7. Security officers (CSO) 3 and CSO 4 arrived at Patient 2's bedside and Patient 2 became agitated and combative with CSO 3 and CSO 4.
8. Patient 2 struck CSO 3 in the face.
9. Code Gray was activated.
10. Additional Security Officers arrived, for assistance, including lead CSO 6.
11. Patient 2 was escorted out of the ED by security officers.

A review of Patient 2's ED Physician note, dated July 15, 2022, indicated the following:
1. Patient 2 arrived in the ED with complaint of head pain after a possible fall.
2. Patient 2 was agitated, upon arrival to the ED, and refused to be evaluated by anyone, unless he (Patient 2) was placed in a room.
3. Patient 2 instructed there were no available rooms and physician wanted to do a quick screening of the patient (Patient 2).
4. Patient 2 became more aggravated towards ED physician and refused to be evaluated by the physician.
5. Visual exam was performed, and patient (Patient 2) moved all four extremities, was awake and alert to person and place.
6. Patient 2 was ambulatory without difficulty.
7. Patient 2 refused to answer any questions asked by ED physician and began using profanity towards ED physician and became increasingly agitated.
8. Security was called for assistance.
9. Upon arrival of security officers to the ED, Patient 2 became physically aggressive with security officers.
10. Patient 2 was subdued on the ground by security officers due to potential danger to ED staff.

A review of ED Patient Log, dated July 15, 2022, indicated the following for Patient 2:
1. Patient 2 was brought to ED by ambulance and arrived at 6:12 P.M.
2. Patient 2 was triaged at 6:46 P.M. by Registered Nurse 2 (RN 2).
3. Patient 2 was discharged to law enforcement at 6:54 P.M.
4. Patient 2 was evaluated by ED physician at 6:56 P.M.

A review of ED Daily Assignment, dated July 15, 2022, indicated the following:
1. Registered Nurse 1 (RN 1) was assigned to triage.
2. RN 2 was the charge nurse.

A review of facility's email communication, dated July 26, 2022, indicated the following:
1. Security Officer (CSO 3) was assigned to the back of the ED on July 15, 2022.
2. CSO 4 worked on July 15, 2022.

A review of Security Incident Report, dated July 15, 2022, indicated the following:
1. Code Gray was called overhead from facility operator at the ED back.
2. Lead CSO 6 responded to the Code Gray with CSO 3, CSO 4, CSO 7, and CSO 8, at the ED back, with Patient 2 observed on the floor, being held down, after having punched CSO 3, in the chest and right eye.
3. CSO 3 stated he (CSO 3) wanted to press charges against Patient 2 for assault and battery.
4. CSO 5 handcuffed Patient 2 and instructed Patient 2 he (Patient 2) was being placed under private person's arrest for assault and battery against CSO 3.
5. CSO 5 called local law enforcement and notified Security Director (SD) of Code Gray incident in the ED
6. Local law enforcement agency arrived at the facility and investigated, including taking a picture of CSO 3's injuries to the forehead and left eyebrow.
7. House Supervisor was informed of Code Gray incident in the ED.

A review of facility's Code Gray policy, dated January 26, 2022, indicated the following:
1. There is zero tolerance for workplace violence or crime on hospital grounds.
2. Trained employees from the security department will respond to all acts of violence or aggressive behavior deemed dangerous to others.
3. Code Gray is an emergency involving a person exhibiting violent or aggressive behavior.
4. Security will respond to all Code Gray codes.
5. Employees who completed training on Management of Assaultive Behavior should also respond to the code.
6. Security will remain in the area and be available to assist clinical staff should a physical intervention becomes necessary.
7. All team members who work in the emergency department (ED), including security, will receive Workplace Violence Prevention training, upon hire and annually.

A review of facility's Abuse policy, dated February 27, 2019, indicated employees are trained, through orientation and ongoing sessions, on issues related to abuse prohibition practices, including nonviolent crisis intervention, sexual harassment, safeguarding patient's personal property, identification, and assessment of victims of abuse, reporting process.

A review of facility's contracted service's policy for Use of Force, undated, indicated the following:
1. The security professional's primary responsibility is to observe and report.
2. Use de-escalation and safety techniques to avoid physical contact, whenever possible.
3. Never physically engage, unless to protect self or others, from immediate harm by using minimal force necessary to contain a situation.
4. With imminent risk of harm to patient's self or others, minimal physical force may be necessary, at the direction of the clinical staff.
5. Take immediate action to protect life.
6. Under no circumstance is a security to attempt to detain a voluntary patient, even at the request of the clinical staff.
7. Physical force is never permitted to enforce rules.
8. Terminate staff who does not follow the Use of Force policy.

Based on observation, interview and record review, the facility failed to ensure that one of 21 sampled patients (Patient 1) was free from abuse or harassment when facility staff did not appropriately de-escalate (reduce the intensity of a conflict or potentially violent situation) a conflict with Patient 1.
This failure resulted in Contracted Security Officer (CSO) 1 punching Patient 1 in the abdomen 12 times.

On 7/27/22, at 6:10 p.m., an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the facility's Director of Risk Management (DRM), Manager of Accreditation, Regulatory, and Licensing (ARLM), Chief Information Officer/Vice President of Support Services (CIO), Vice President of Quality/Risk (VPQR), and Chief Nursing Officer (CNO). The survey team notified the hospital leadership about the IJ situation regarding the failure to ensure Patient 1 was free from abuse when Contracted Security Officer (CSO) 1 punched Patient 1 in the abdomen 12 times.

On 7/29/22, at 4:03 p.m., the IJ was removed in the presence of the facility's DRM, ARML, CIO, VPQR, CNO, President/Chief Executive Officer (CEO), Chief Financial Officer (CFO), Vice President of Human Resources (VPHR), and Vice President of Business Development (VPBD) after the survey team validated the hospital's directive action plan (interventions to correct the IJ situation) through observations, interviews, and limited record reviews. The acceptable action plan was as follows:
1. Facility provided draft of a new "De-escalation and Use of Force" policy which includes procedure for de-escalation that guides staff in the appropriate response to aggressive/assaultive/combative patients/visitors and on reporting incidents and de-escalation and use of force training.
2. Facility provided plan for immediate de-escalation training via online learning module, in-person training for all staff, including Emergency Department staff and contracted security officers.
3. Facility provided evidence of a system for tracking and reviewing all use of physical force events to allow for immediate evaluation, remediation, and intervention by on-site leadership that can immediately direct actions and resources to keep the patient and staff population safe while investigation and remedial actions are completed.

Findings:

A review of Patient 1 ' s Emergency Department (ED) Triage Report, dated 3/15/22, at 12:00 a.m., indicated Patient 1 ' s family member brought Patient 1 to the ED for psychiatric evaluation on 3/14/22 at 11:02 p.m. after "using unknown drugs" and sending a "text message with suicidal ideations."

A review of Patient 1 ' s Nursing Note, dated 3/15/22, at 3:19 p.m., indicated Patient 1 was placed on a 5150 hold (an involuntary 72-hour hospitalization legal in the state of California when the patient is evaluated to be a danger to others, a danger to self, or gravely disabled) for suicidal ideation (SI - thinking about or planning to kill yourself) "after an argument with [Patient 1 ' s family member]."

A review of Patient 1 ' s Nursing Note, dated 3/15/22, at 5:07 p.m., indicated, "[Patient 1] insisting to sign AMA (against medical advice - leaving the hospital before the physician recommends it), trying to leave the premises."

A review of Patient 1 ' s Nursing Note, dated 3/16/22, at 8:00 a.m., indicated, "[Patient 1] was placed on a 5150 due to reported wanting to jump off a bridge. [Patient 1] reported [Patient 1] was drunk last [night] and denies having SI/HI (homicidal ideation - thinking about or planning to kill other people) this [morning]."

A review of Patient 1 ' s Social Worker Note, dated 3/16/22, at 8:45 a.m., indicated, "[Patient 1] is asking to leave, [Patient 1] states that it was [Patient 1 ' s family member] ' s fault that [Patient 1] is here, and [Patient 1] shouldn't be on a hold."

A review of Patient 1 ' s Suicide Prevention Monitor (SPM) Observation Flowsheet, dated 3/16/22, indicated the following:
1. At 8:45 a.m., Patient 1 was restless.
2. At 9:00 a.m., Patient 1 was sitting quietly.
3. At 9:15 a.m., Patient 1 was restless.
4. At 9:30 a.m., Patient 1 was awake. Security was called.
5. There was no documentation that Patient 1 was agitated or that Patient 1 ' s primary nurse was notified of any behavioral changes.

A review of Patient 1 ' s Nursing Note, dated 3/16/22, at 9:30 a.m., indicated, "[Patient 1] becoming agitated at present, medications ordered by physician to be given due to agitation, security called to bedside to help give medication currently. [Patient 1] become aggression to security and fighting. [Patient 1] put one of the guard in a choke hold while fighting with security. [Patient 1] placed on gurney by Security Officers, after calming down."

A review of Patient 1 ' s Physician Orders, dated 3/16/22, at 9:35 a.m., indicated that the physician ordered 10 milligrams (mg) of olanzapine (a medication given to treat agitation) to be given intramuscularly (IM - through the muscle, such as the arm muscle) once.

A review of Patient 1 ' s Social Worker Note, dated 3/16/22, at 9:49 a.m., indicated, "A code gray (an emergency in which a person is exhibiting violent or aggressive behavior that is usually communicated over the hospital ' s intercom) was called as [Patient 1] became agitated, security and nursing was at bedside and [Patient 1] was placed on a gurney and medicated for safety."

A review of the facility ' s ED staffing assignment, dated 3/16/22, indicated the following:
1. Registered Nurse (RN) 1 was assigned to rooms 4, 5, 11, and 12.
2. Certified Nursing Attendant (CNA) 1, 2, and 3 were assigned in the ED as 1:1 sitters (one staff member assigned to provide constant supervision to one patient).

A review of CSO 2 ' s incident report, dated 3/16/22, indicated the following:
1. Radio call from ED hallway was received for patient assist at 9:30 a.m.
2. CSO 1 and CSO 2 responded to the radio call.
3. RN 1 asked for assistance with holding Patient 1 to administer medication because Patient 1 refused medication.
4. Patient was instructed by CSO 1 and CSO 2 to cooperate with nursing staff.
5. CSO 1 positioned himself to hold Patient 1 ' s arm.
6. Patient suddenly lunged towards sitter CNA 1.
7. CSO 2 grabbed Patient 1 from behind in a "bear hug" to get Patient 1 to sit back down.
8. There was a struggle between Patient 1, CSO 1, and CSO 2 for a few minutes.
9. Patient 1 eventually complied with nursing staff and allowed staff to place him back into gurney.
10. Patient 1 was administered medication.
11. There was an allegation that CSO 1 did wrong with the patient but was not observed by CSO 2 who only had a view of patient ' s back during the struggle.
12. Security Director instructed CSO 2 to file an incident report.

During an interview with RN 1, on 7/26/22, at 8:03 a.m., RN 1 stated, "[Patient 1] grabbed [Contracted Security Officer (CSO) 1] and put [CSO 1] in a chokehold ... I remember [CSO 1] getting out of the chokehold. I did see [CSO 1] get out of the chokehold. ... I can tell you that after [CSO 1] got out of the chokehold, [CSO 1] was boxing [Patient 1] in the stomach." RN 1 confirmed that CSO 1 punched Patient 1 in the abdomen.

During an interview with Certified Nursing Assistant (CNA) 1, on 7/27/22, at 8:18 a.m., CNA 1 confirmed that CNA 1 was assigned the role of SPM for Patient 1 on 3/16/22. CNA 1 stated, "[Patient 1] was restless and could not sit still. I let [RN 1] know that [Patient 1] is restless and it might escalate. I told [RN 1] when [Patient 1] first started to be restless ... that was at 8:15, but I did not document it."

During an interview with CSO 2, on 7/27/22, at 10:08 a.m., CSO 2 stated that CSO 1 and CSO 2 responded to a call over the security radio requesting assistance. CSO 2 stated, "They were saying that they were going to give [Patient 1] some medication and if we could assist in holding him ... [Patient 1] had told [RN 1] that [Patient 1] was okay and didn't need the [medication]. I was there, I heard it ... I really didn't feel comfortable doing it." CSO 2 confirmed that CSO 2 reviewed the security footage from that day and stated, "You could see myself being real hesitant with what they want me to do."

During a concurrent observation and interview with DRM, ARLM, and CNA 1, on 7/27/22, at 11:55 a.m., the security footage from 3/16/22 was reviewed. The footage showed Patient 1 sitting on a gurney. DRM and ARLM identified CNA 1, RN 1, RN 2, CSO 1, and CSO 2 standing around Patient 1. CNA 1 stated that at that time they were attempting to convince Patient 1 to receive medication. CSO 1 and 2 were observed moving closer to Patient 1. Patient 1 then stood up from the gurney. CSO 2 was observed attempting to hold Patient 1 from behind when Patient 1 grabbed CSO 1. ARLM stated that CSO 1 ' s jacket was observed to be taut which may suggest that Patient 1 placed CSO 1 in a chokehold. CSO 1 was then observed punching Patient 1 in the abdomen 12 times. DRM stated that the security footage was "why we [terminated] the contracted employee for not acceptable behavior."

During an interview with CSO 5, on 7/27/22, at 2:42 p.m., CSO 5 stated that the contracted security agency provides de-escalation training to the security officers. CSO 5 stated, "There are techniques to get out of chokeholds that are taught, but never punching."

During an interview with ARLM, on 7/27/22, at 4:58 p.m., ARLM stated that the facility did not have its own policy on patient de-escalation and used the contracted security company ' s policy instead.

A review of the contracted security agency ' s policy & procedure (P&P), titled "Use of Force - Healthcare Supplement," not dated, indicated, "The Security Professional ' s primary responsibility is to observe and report ... Use de-escalation and safety techniques to avoid physical contact whenever possible ... Physical force is never permitted to enforce rules."

A review of the facility ' s P&P, titled "Abuse, Screening and Education of Staff," last revised 7/19, indicated, "[Facility] will ensure that through its hiring process and employee education to prevent occurrences of abuse."

Based on interview and record review, the facility physically restrained one of 21 sampled patients (Patient 1) during an attempt to force psychotropic medication administration.
This deficient practice resulted in Patient 1 being restrained and battered (Patient 1 being punched) by two security officers (CSO 1 and CSO 2).

Findings:

During a concurrent interview and record review on July 26, 2022, at 8:01 A.M., with Registered Nurse 1 (RN 1), Patient 1's emergency department (ED) records - Nursing Notes and Medication Administration Record (MAR - record of medications), dated March 16, 2022, were reviewed. RN 1 stated the following:
1. She (RN 1) was a traveler nurse and worked on the day shift, on March 16, 2022, and was assigned the ED hallway with 1:1 sitter.
2. She (RN 1) was assigned to care for patients, including Patient 1 with 1:1 sitter (CNA 1).
3. She (RN 1) found Patient 1 agitated and got physician orders for medication administration to calm down Patient 1.
4. She (RN 1) was unable to administer medication to Patient 1 because Patient 1 refused the medication. She (RN 1) couldn't give the medication, until Patient 1 settled down and was placed back in the gurney.
5. A Code Gray (a standardized hospital emergency code that alerts all staff to potentially or actively combative persons) was called after Patient 1 got agitated with the arrival of two security officers to Patient 1's bedside.
6. The patient (Patient 1) got one (CSO 1) of the two security officers (CSO 1 and CSO 2) in a chokehold and CSO 1 got out of the chokehold and fought the patient (Patient 1), during the struggle.

During a concurrent interview and record review on July 27, 2022, at 8:10 A.M., with certified nursing attendant 1 (CNA 1), Patient 1's Suicide Prevention Monitor Observation Flowsheet, dated March 16, 2022, was reviewed. CNA 1 stated the following:
1. Patient 1 was awake and restless, after talking with his (Patient 1) mother over the telephone - not documented.
2. Patient 1 saw the social worker - not documented.
3. She (CNA 1) left the patient (Patient 1) briefly to another 1:1 sitter/CNA, to find the nurse (RN 1) and notify RN 1 that Patient 1 was restless.
4. Security was called at 9:30 A.M. because there was no security stationed at the ED hallway.
5. Patient 1 stood up towards two security officers (CSO 1 and CSO 2) and got one security officer (CSO 1) in a chokehold.
6. CSO 1 fought the patient (Patient 1) trying to get free from a chokehold with the patient (Patient 1). CNA 1 stated it looked like CSO 2 was punching the patient (Patient 1).
7. She (CNA 1) did not call a Code Gray because there was no telephone in the ED hallway.

During an interview on July 27, 2022, at 10:08 A.M., with security officer 2 (CSO 2 ), CSO 2 stated the following:
1. Worked at the facility for one year.
2. Worked on March 16, 2022, from 6 A.M. to 2 P.M., as the lead security officer.
3. Got called on the walkie-talkie for assistance in the emergency department (ED) and responded to the ED with another security officer (CSO 1), who was assigned to the ED "back."
4. Upon arrival to the ED with CSO 1, the ED charge nurse told the security officers that Registered Nurse 1 (RN 1) needed their assistance with Patient 1 - to hold the patient (Patient 1) to administer medication.
5. CSO 2 stated he (CSO 2) was not trained to hold patients and to help the nurses (RN 1) to give a shot to the patients.
6. CSO 1 tried to hold patient's (Patient 1) arm for the injection.
7. Patient 1 was agitated and, suddenly, got up from the gurney (a wheeled stretcher used for transporting hospital patients).
8. CSO 2 grabbed Patient 1 from the patient's back, but was unable to secure Patient 1's arms.
9. There was a struggle between the patient (Patient 1) and CSO 1 and CSO 2. CSO 2 stated the patient was big and heavy.
10. CSO 2 couldn't see what was going on between Patient 1 and CSO 1, because he (CSO 2) was holding the patient (Patient 1) from behind.
11. Patient 1 got tired and appeared to give up fighting with security officers.
12. CSO 2 said "I don't know if patient got the shot" because he (CSO 2) did not observe this (referring if patient 1 received the medication).
13. Director of security later instructed CSO 2 to file an incident report of what happened with the patient (Patient 1), which was filed in a daily activity report (DAR).
14. Reported off to next lead security officer on the following shift.

During an interview on July 27, 2022, at 4:58 P.M., with Director of Risk (DRM), DRM stated the facility does not have a policy and procedure for De-escalation (method to prevent potential violence) for assaultive behavior.

Concurrently, DRM presented surveyors with the policy of the contracted service for security officers on the Use of Force, and stated facility is currently working on a similar policy for the facility.

A review of Patient 1's face sheet, dated March 14, 2022, indicated Patient 1 was admitted to the emergency department (ED) with a chief complaint of drug abuse.

A review of Patient 1's Triage Notes, dated March 15, 2022, indicated Patient 1 was brought in by mother, who stated Patient 1 used unknown drugs, had been hearing voices, but had no suicidal (thoughts of harming one's self) and homicidal ideations (thoughts of causing harm/injury to others).

A review of Patient 1's Nursing Notes, dated March 15, 2022, indicated the following:
1. Patient 1 was anxious, worried, and irritable with inappropriate behavior.
2. Patient 1's modified sad persons total score (suicide risk assessment tool) was 3 - low risk for suicide.
3. Patient had a 1:1 certified nursing attendant (CNA) observer.
4. The charge nurse was notified of Patient 1's behavior.

A review of Patient 1's Nursing Notes, dated March 15, 2022, indicated the following:
1. Patient 1's modified sad persons total scores were six (moderate risk that requires psychiatric consultation) to ten (high risk that requires hospital admission to a psychiatric facility).
2. The charge nurse and house supervisor were notified of Patient 1's behavior.
3. Patient 1 had a 1:2 observations (2 people assigned to observe and monitor patient) by security and 1:1 sitter (CNA).
4. Licensed clinical social worker consultation was requested.

A review of Patient 1's Social Worker note, dated March 15, 2022, indicated the following:
1. Patient 1 was difficult to understand.
2. Patient 1's urine drug test was negative for drugs and alcohol.
3. Patient 1's physician was consulted and was notified patient needed a Psychiatric Emergency Teams (PET - mobile teams operated by psychiatric hospitals and approved by the Department of Mental Health to provide 5150 and 5585 evaluations) evaluation.
4. Patient 1 remained with a sitter in place for safety.
5. PET team evaluated Patient 1 and Patient 1 was placed on a 5150 hold (legal code that allows a person with a mental illness to be involuntarily detained for a 72-hour psychiatric hospitalization).

A review of Patient 1's Social Worker Notes, dated March 16, 2022, indicated the following:
1. Patient 1 was on a 5150 hold and discharge planning, for transfer to a psychiatric facility, was initiated.
2. Patient 1 had a sitter in place for safety.
3. Patient 1 stated wanting to leave the facility and should not have been on a 5150 hold.
4. The charge nurse was notified of Patient 1's potential for flight risk (patient leaving the facility without knowledge of hospital staff).

A review of Patient 1's Nursing Notes, dated March 16, 2022, indicated the following:
1. Patient 1 was observed agitated and medications were ordered by physician for patient's agitation.
2. Security officers were called to assist with administering Patient 1 with medication.
3. Patient 1 became aggressive towards two security officers (CSO 1 and CSO 2) and put one (CSO 1) of the two security officers in a chokehold (a tight grip around a person's neck, to restrain them by restricting their breathing), while fighting with the security officers.
4. Patient 1 was placed back on the gurney by the security officers after calming down.
5. Social Worker was at the bedside during incident.

A review of Patient 1's Social Worker's note, dated March 16, 2022, indicated the following:
1. A Code Gray was called because Patient 1 was agitated, with security officers and nursing staff at the bedside.
2. Patient 1 was placed on the gurney and administered medication for safety.
3. Patient 1's mother was outside the facility and not allowed to the bedside to not further agitate Patient 1.
4. Patient 1 had sitter in place for safety.
5. Patient 1's physician notified of incident.
6. Facility will continue to find placement for patient at a psychiatric facility.

A review of Patient 1's Medication Administration Record (MAR), dated March 16, 2022, indicated Patient 1 received olanzapine (antipsychotic medication to treat mental disorders, including schizophrenia and bipolar disorders) 10 milligrams (mg-a unit of measurement) intramuscular (IM-a method to used to deliver medication deep into the muscles) once, at 9:40 A.M., to the right deltoid.

A review of lead security officer's (CSO 2) report, dated March 16, 2022, indicated the following:
1. Radio call, from ED hallway, was received for patient assist, at 9:30 A.M.
2. CSO 1 and CSO 2 responded to the radio call.
3. Registered Nurse 1 (RN 1) asked for assistance with holding Patient 1 to administer medication because Patient 1 refused medication.
4. Patient 1 was instructed by CSO 1 and CSO 2 to cooperate with nursing staff.
5. CSO 1 positioned himself to hold Patient 1's arm.
6. Patient 1 suddenly lunged towards sitter (CNA1).
7. CSO 2 grabbed Patient 1 from the patient's back in a "bear hug" to get Patient 1 to sit back down.
8. There was a struggle between Patient 1 and CSO 1 and CSO 2, for a few minutes.
9. Patient 1 eventually complied with nursing staff and allowed staff to place him (Patient 1)back into gurney.
10. Patient 1 was administered medication.
11. There was an allegation that CSO 1 did wrong with the patient (Patient 1) - not observed by CSO 2, with only view of patient's (Patient 1) back during bear hug hold, during the struggle.
12. Security director instructed CSO 2 to file an incident report.

A review of facility's ED daily assignment, dated March 16, 2022, indicated the following:
1. Registered Nurse 1 (RN 1) was assigned to rooms 4, 5, 11, and 12.
2. Certified Nursing Attendants (CNA) 1, 2, and 3 were assigned in the ED as 1:1 sitter.

A review of facility's email communication, dated July 26, 2022, indicated the following:
1. Two security officers (CSO 1 and CSO 3) were assigned to the ED on March 16, 2022.
2. The lead security officer was CSO 2.

A review of facility's contracted service's policy for Use of Force, undated, indicated the following:
1. The security professional's primary responsibility is to observe and report.
2. Use de-escalation and safety techniques to avoid physical contact, whenever possible.
3. Never physically engage, unless to protect self or others, from immediate harm by using minimal force necessary to contain a situation.
4. With imminent risk of harm to patient's self or others, minimal physical force may be necessary, at the direction of the clinical staff.
5. Take immediate action to protect life.
6. Under no circumstance is a security to attempt to detain a voluntary patient, even at the request of the clinical staff.
7. Physical force is never permitted to enforce rules.
8. Terminate staff who does not follow the Use of Force policy.

A review of facility's Code Gray policy, dated January 26, 2022, indicated the following:
1. There is zero tolerance for workplace violence or crime on hospital grounds.
2. Trained employees from the security department will respond to all acts of violence or aggressive behavior deemed dangerous to others.
3. Code Gray is an emergency involving a person exhibiting violent or aggressive behavior.
4. Security will respond to all Code Gray codes.
5. Employees who completed training on Management of Assaultive Behavior should also respond to the code.
6. Security will remain in the area and be available to assist clinical staff should a physical intervention becomes necessary.
7. All team members who work in the emergency department (ED), including security, will receive Workplace Violence Prevention training, upon hire and annually.

A review of facility's Restraints - Non-Violent Behavior policy, dated December 1, 2021, indicated the following:
1. Restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely.
2. All patients have the right to be free from any form of abuse and neglect, including the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff.
3. Restraint may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm.
4. If a licensed independent practitioner is not available to issue an order, a registered nurse (RN) may initiate the use of restraints based on an appropriate assessment of the patient.
5. Staff are required to have education, training and demonstrated knowledge based on the specific needs of the patient population that they care for.

Based on interview and record review, the facility failed to update the care plan per facility policy for one of 21 sampled patients (Patient 9).
This deficient practice had the potential for lack of intervention and missed patient goals.

Findings:

A review of Patient 9's History & Physical (H&P), dated 6/15/22, at 5:39 P.M., indicated, that Patient 9 was admitted to the hospital for worsening generalized weakness on 6/15/22.

During a concurrent interview and record review, on 7/28/22, at 9:20 A.M., with Registered Nurse (RN) 5, Patient 9's care plans were reviewed. One of the goals of Patient 9's care plan was to have stable vital signs. The care plan was last evaluated on 7/27/22 at 5:05 P.M. by RN 10. RN 5 stated that care plans are updated once a shift or as needed and confirmed there were two shifts, 7 A.M. to 7 P.M. and 7 P.M. to 7 A.M.

A review of the facility's policy & procedure, titled "Plan of Care Documentation, Interdisciplinary," last revised 4/2019, indicated, "The Interdisciplinary Plan of Care will be updated every shift and as patient condition indicates."