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Based on document review and interview, the hospital failed to ensure restraint/seclusion was applied or assisted in a safe manner by trained and competent individuals (tag 144), failed to ensure the use of restraint or seclusion was in accordance with the physician's orders for 4 of 10 patients (P1, P2, P5 and P10) (see tag 168), failed to ensure that 4 of 10 patients (P1, P2, P3 and P7) were seen face-to face within 1 hour after the initiation of restraint intervention for the management of violent or self-destructive behavior (see tag 178), and failed to ensure 5 of 5 contracted security staff (O1, O2, O3, O4 and O5) had education and training with demonstrated knowledge for the safe application and use of all types of restraint or seclusion used in the hospital (see tag 202).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Patients Rights were promoted.

Based on document review and interview, the hospital failed to ensure patients received care in a safe setting by failing to ensure restraint/seclusion was applied or assisted in a safe manner by trained and competent individuals on 4 occasions in 1 facility.

Findings include:

1. Review of policies and procedures.
A. Review of the policy titled "Restraint and Seclusion Guidance", Last Revised 04/2018, indicated the following:
Purpose: To provide guidelines for use of least restrictive interventions to avoid restraint or seclusion use.
Appendix D: Definitions. The definitions of restraint use types are applicable in any setting in the facility and are not driven by diagnosis.
Physical restraint: Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body to include immobilization or reduction of the ability of a patient to move his or her arms, legs, body, or head freely is considered a physical restraint.
Weapons: CMS (Centers for Medicare and Medicaid Services) regulations specifically state that the use of weapons (pepper spray, mace, nightsticks, Tazers, stun guns, etc.) used in the application of restraint is not considered to be safe appropriate health care intervention.
Exceptions to the Definition of Restraints:
Use of Handcuffs: The use of handcuffs and other restrictive devices used by law enforcement who are not employed or contracted by the facility for custody, detention or other public safety reasons, and not for the provision of healthcare, is not governed by these standards. However the use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients.

B. Review of the policy titled "Code Security", Last Revised 08/2018, indicated the following:
Policy: Designated, trained staff will respond...
Procedure: Designated, trained staff will respond immediately. Designated staff may include: The Security Manager, Security Officers, EVS (Environmental Services) Director, the Director or Manager of the unit..., the charge nurse..., the Hospital Supervisor, and available Behavioral Health Unit personnel.
The Code Security team leader is responsible for, assessing the crisis, developing a plan of action, directing the team and carrying out the plan of action, assures debriefing occurs with the code security team at the conclusion of each event.
The team will utilize the least restrictive means possible to help the individual regain control...The individual's dignity will be preserved at all times.
Security will only restrain an individual under emergency detention, immediate detention, court order or in the act of affecting arrest.

C. Review of the policy titled "Patient Rights and Responsibilities", Reviewed 11/2017, indicated the following:
Policy: (The Hospital) maintains that individuals hold basic rights for independence of expression and decision as well as action and concern for personal dignity and human relationships.
Procedure: Respect and Consideration: The patient has the right to considerate, compassionate, respectful care at all times and under all circumstances, with recognition for his/her personal dignity and value...
Personal Safety: In order to preserve personal safety, the patient has the right to expect reasonable safety where hospital practices and environment are concerned. The patient has the right to be free from all forms of abuse and harassment.
Restraints: The patient has the right to be free from restraint or seclusion used in the provision of acute medical-surgical care unless clinically indicated and utilized for the prevention of harm to self or others. The patient has the right to be free of restraint or seclusion used for management of behavior unless clinically justified. It is the policy of (The Hospital) to use the least restrictive methods of restraint...to ensure restraint or seclusion is never used as a means of coercion, discipline, convenience or retaliation by staff.

2. Medical record review:
A. The MR for patient P1 indicated the patient was admitted to the Emergency Department (ED) on 4/3/19 on an Immediate Detention (ID). Emergency Department Notes dated 4/3/19 indicated that contracted staff officer O1 tazed the patient multiple times when he/she would not return to bed. MDM (Medical Decision Making Notes dated 4/3/19, time not noted, indicated the following: Patient has been cooperative with staff, and not threatened staff...Patient has not threatened to hurt staff, but is agitated and restless. Geodan and Benadryl ordered...it is reported patient attempted to leave department, and was subsequently tazed. He/she had not received Geodan or Benadryl as ordered. Review of physician MDM (Medical Decision Making) "Additional Text" on 4/3/19 at 2139 hours indicated the following: 2130 (hours) Patient was seen and evaluated by me post taser....He/she received a few shocks before he/she finally submitted....Tachycardic...Few abrasions during the struggle on his/her upper back. He/she has puncture wounds from the taser electrodes on his/her chest. The MR lacked documentation of the taser (and handcuffs, as noted in an incident report dated 4/3/19), having been used by a non-employed or non-contracted law enforcement person for the purpose of obtaining custody or detention of the patient or for other public safety reasons.

B. The MR for patient P3 indicated the patient was admitted 5/24/19 and discharged 5/31/19. Nurse Notes indicated the following: On 5/26/19 at 1911 hours, Witnessed by myself and (another registered nurse) on the monitor that security, O2 (Director of Security), (was) holding a pillow over patient face. I went in and asked him/her to remove the pillow and he stated I'm not covering his/her nose and mouth, but he/she is spitting. I offered face shields for security and refused.

3. Facility document review:
A. Review of facility incident reports indicated 3 separate incidents were documented on 4/3/19, related to the incident with patient P1. The reports indicated the following:
i. An altercation between patient and security staff took place. According to staff...officer O1 "tased" the patient...I observed patient on the floor, on his/her stomach with officer O1 holding him/her down.
ii. Patient was cursing into his/her cell phone...after a few minutes...called security on patient.
iii. Patient was being aggressive and refusing to get back in bed. [Security Office (sic) O1 was called earlier due to patient breaking his/her phone and throwing it)]. After no corporation (sic)...O1 tazed patient. I heard the sound and when I looked up...patient had tazer prongs in his/her chest. Patient was lowered to the ground and "handcuffed".

B. Review of the document titled Intensive Analysis regarding patient P1 indicated the following: Location of Event: ED. Time of Event: Arrived to Ed at 1723. (The time of the event was not noted). Brief Summary: Patient was tased in the ED by security.
Report Notes (from O1) indicated the officer tased the patient 3 times as follows: Once in the chest/upper abdomen. O1 indicated he/she then noted the "spread of the probes was not very wide and the taser was not giving me the desired affect (sic)", so "I closed my distance"..."and pressed my taser onto his/her leg"... "taser was effective and P1's muscles locked up." "I then took P1 to the ground and ordered him/her to put his/her hands behind his/her back." "P1 did not comply until I pressed my taser against his/her back and gave him/her another shock." "I then placed P1 in handcuffs behind his/her back."...

C. Review of security report logs, date range 5/1/19 to 7/7/19, lacked documentation of patient identification. The log included, but was not limited to, the following security events:
On 5/1/19 at approximately 9:08 a.m....called to BHU in reference to a patient that was agitated and out of control...After several minutes the BHU staff advised that I could leave...At approximately 9:49 a.m., I was paged again...The BHU staff advised us that (the patient) would have to go to the exclusion room to be restrained. After several minutes of trying to get (the patient) to go in the room... (the patient) turned his/her back to me and I shot down and performed a double leg take down on (the patient). Once (the patient) was on the ground he/she was lying on his/her back and I got (the patient) in the mounted position, secured his/her left arm/hand in a twist lock and rolled him/her over to his/her stomach. Once on his/her stomach I placed him/her in handcuffs.
On 5/26/19, by reporting person "Security officer", O5: Contacted (time not noted) via pager that security was needed...When I arrived civilian security officer, C1, had already arrived and was assisting nursing staff...After the patient in room 519 was returned to his/her room he/she was still attempting to lash out and had to be physically stopped from striking a nurse...C1 and I held the patient down until medications were administered.

4. Review of personnel files for security staff members O1, O2, O3, O4 and O5 lacked documentation of restraint/seclusion training, and lacked documentation of demonstrated competency in the safe application of restraint and seclusion.

5. Interview(s):
A. On 7/8/19 between approximately 12:15 p.m. and 2:15 p.m., O2, Director of Security verified that security log did not document who were the patients involved in the reports. O2 verified that he/she was the officer in room 519 on 5/26/19. O2 indicated that he/she used a pillow only to block the patient's spit. O2 indicated that security staff are trained in their "own restraint" and indicated this was not the same restraint/seclusion training of the hospital. He/she also indicated that they have a "Use of Force" policy to follow. O2 indicated that use of a taser was not considered a restraint. O2 indicated that the patient who was tazed was under an emergency detention, struck an officer 2 times and therefore tasing the patient was a police action.

B. On 7/8/19 between approximately 12:15 p.m. and 2:15 p.m., A1, Vice President of Quality, indicated that the patient involved in the spitting on the security report for 5/26/19 was patient P3.

C. On 7/8/19, between approximately 1:45 p.m. and 2:45 p.m., A4, Director of Advanced Clinicals, verified MR documentation of patient P1 having been tased, by hospital staff security officer, to return to bed and physician documentation of physical injury related to the tazing.

D. On 7/8/19, between approximately 4:00 p.m. and 5:00 p.m., A7, Human Resources Business Partner, verified that O1, O3, O4 and O5 were contracted staff of the hospital and that O2 was directly employed as the Director of Security. A7 verified that their files lacked documentation of restraint/seclusion training and demonstrated competency in the safe application of restraint and seclusion.

Based on document review and interview, the hospital failed to ensure the use of restraint or seclusion was in accordance with the physician's orders for 4 of 10 patients (P1, P2, P5 and P10).

Findings include:

1. Policy and Procedure review.
Review of the policy titled Restraint and Seclusion Guidance, Last Revised 04/2018, indicated the following:
Purpose: To provide guidelines for use of least restrictive interventions to avoid restraint or seclusion use.
Procedure:
Order for Restraint or Seclusion.
An order for restraint or seclusion must be obtained from a licensed independent practitioner (LIP)/physician who is responsible for the care of the patient prior to the application of restraint.
If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required.
Order for Restraint with Non-Violent of Non-Self Destructive Behavior.
To continue restraint or seclusion beyond the initial order duration, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint is necessary.
If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/physician.
Order for Restraint with Violent of Self Destructive Behavior.
Physician orders for restraint or seclusion must be time limited...
To continue restraint or seclusion beyond the initial order duration, the RN (Registered Nurse) determines that the patient is not ready for release and call the ordering physician to obtain a renewal order.
Discontinuation of Restraint/Seclusion
Once restraints or seclusion are discontinued, a new order for restraint or seclusion is required to reapply or reinitiate.

2. Review of medical records (MR) lacked documentation of restraint and/or seclusion in accordance with physician's orders as follows:
A. The MR for patient P1 indicated the patient was admitted to the Emergency Department (ED) on 4/3/19. Emergency Department Notes dated 4/3/19 indicated that at 2131 (hours) officer, O1, tazed patient as a means of restraint in attempt to get the patient to comply and return to his/her bed. The MR lacked documentation of an order for restraint/use of taser.

B. The MR for patient P2 indicated the patient was admitted to the ED on 2/15/19. Physician orders dated 2/24/19 at 1751 hours indicated that restraint/seclusion was ordered as follows: Violent restraint device: Seclusion/restraint. Violent Restraint Time Limit: 4 hours. The restraint order date and time was 2/24/19 at 1750 hours. Restraint expiration date and time was 2/24/19 at 2150 hours. Restraint log documentation titled "Restraint Monitor for Violent or Self Destructive Behavior" indicated the following: Beginning on 2/24/19 at 1750 hours, 4 Point Restraint(s) were applied. The log indicated that restraints remained in place through 2/25/19 at 0715 hours. The MR lacked documentation of an order to continue the restraints beyond 4 hours.

C. The MR for patient P5 indicated the patient was admitted 5/22/19. Physician orders dated 5/22/19 at 2135 hours indicated Soft BUE (Bilateral Upper Extremity) restraints were to be applied for Non-violent purposes. The order expiration date and time was 5/23/19 at 2135 hours. Physician orders dated 5/24/19 at 0111 hours indicated Soft BUE (Bilateral Upper Extremity) restraints were to be applied for Non-violent purposes. The order expiration date and time was 5/25/19 at 2359 hours. Non-violent Restraint Time Limit 1 calendar day. Restraint log documentation indicated restraints were initiated on 5/22/19 at 2135 hours and remained in place through 5/25/19 at 0600 hours. The MR lacked documentation of an order for restraints between 5/23/19 at 2135 hours and 5/24/19 at 0010 hours and lacked documentation of discontinuation or restraints between that time.

D. The MR for patient P10 indicated the patient was admitted 5/14/19. Physician orders dated 5/14/19 at 0855 hours indicated Soft BUE restraints were to be applied for Non-violent purposes. The order expiration date and time was 5/15/19 at 0855 hours. Non-violent Restraint Time Limit 24 hours. Restraint documentation indicated that restraints were initiated on 5/14/19 at 0856 hours and continued through 5/16/19 at 1838 hours. The MR lacked documentation of an order to continue use of the restraints between 5/15/19 at 0855 hours and 5/16/19 at 1838 hours.

3. On 7/8/19, between approximately 1:45 p.m. and 2:45 p.m., A4, Director of Advanced Clinicals, verified lack of orders for restraints as noted above for patients P1 and P2. Between approximately 4:30 p.m. and 5:00 p.m., A4 verified lack of orders for restraints as noted for patients P5 and P10

Based on document review and interview, the hospital failed to ensure that 4 of 10 patients (P1, P2, P3 and P7) were seen face-to face within 1 hour after the initiation of restraint intervention for the management of violent or self-destructive behavior.

Findings include:

1. Review of the policy titled Restraint and Seclusion Guidance, Last Revised 04/2018, indicated the following:
Purpose: To provide guidelines for use of least restrictive interventions to avoid restraint or seclusion use.
Procedure: Face-to-face assessment by a Physician or LIP (Licensed Independent Practitioner), RN (Registered Nurse) or physician assistant with demonstrated competence, must be done within one (1) hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

2. Medical record (MR) review:
The MR for patient P1 indicated the patient was ordered to be and placed in restraints on 4/3/19 at 2226 hours for violent/self-destructive behavior. The MR lacked documentation of a 1 hour face-to-face assessment following initiation of the restraints.
The MR for patient P2 indicated the patient was ordered to be and placed in restraints on 2/24/19 at 1750 hours for violent/self-destructive behavior. The MR lacked documentation of a 1 hour face-to-face assessment following initiation of the restraints.
The MR for patient P3 indicated the patient was ordered to be and placed in restraints on 5/26/19 at 1931 hours for violent/self-destructive behavior. The MR lacked documentation of a 1 hour face-to-face assessment following initiation of the restraints.
The MR for patient P7 indicated the patient was ordered to be and placed in restraints on 3/2/19 at 0900 hours for violent/self-destructive behavior. The MR lacked documentation of a 1 hour face-to-face assessment following initiation of the restraints.

3. On 7/8/19, between approximately 1:45 p.m. and 2:45 p.m., A4, Director of Advanced Clinicals, verified lack of face-to-face assessments for restrained patients P1, P2 and P3. Between approximately 4:30 p.m. and 5:00 p.m., A4 verified lack verified lack of face-to-face assessments for restrained patient P7.

Based on document review and interview, the hospital failed to ensure 5 of 5 contracted security staff (O1, O2, O3, O4 and O5) had education and training with demonstrated knowledge for the safe application and use of all types of restraint or seclusion used in the hospital.

Findings include:

1. Policy and Procedure review:
Review of the policy titled Restraint and Seclusion Guidance, Last Revised 04/2018, indicated the following:
Purpose: To provide guidelines for use of least restrictive interventions to avoid restraint or seclusion use.
Appendix A: Training Requirements.
Direct Care Staff: Staff will demonstrate competency in the application of restraints, implementation of seclusion...Training will be provided to all staff designated as having direct patient care responsibilities, including contract or agency personnel. In addition, if hospital security guards or other non-healthcare staff assist direct care staff, when requested in the application of restraint or seclusion, the security guards, or other non-healthcare staff are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion. Training will occur: 1. Before performing restraint application... 2. As part of orientation, and 3. On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients. 4. The results of skills and knowledge assessment, new equipment, or QAPI (Quality Assurance Performance Improvement) data may indicate a need for targeted training or more frequent or revised training.

Review of the policy titled Code Security, Last Revised 08/2018, indicated the following:
Policy: A "Code Security" signals that an assistance is requested regarding a person who is exhibiting potentially dangerous behavior. Upon hearing the...announcement, designated, trained staff is to respond immediately...
Procedure: Designated, trained staff will respond immediately. Designated staff may include: The Security Manager, Security Officers, EVS (Environmental Services) Director, the Director or Manager of the unit..., the charge nurse..., the Hospital Supervisor, and available Behavioral Health Unit personnel.
The Code Security team leader is responsible for, assessing the crisis, developing a plan of action, directing the team and carrying out the plan of action, assures debriefing occurs with the code security team at the conclusion of each event.
The team will utilize the least restrictive means possible to help the individual regain control...The individual's dignity will be preserved at all times.
Security will only restrain an individual under emergency detention, immediate detention, court order or in the act of affecting arrest.

2. Medical record (MR) review:
A. The MR for patient P1 indicated that on 4/3/19, security staff (contracted staff O1) tazed the patient multiple times.
B. The MR for patient P2 indicated that on 4/24/19, a "Hospital Police" officer on duty and a "hospital guard" assisted in placing patient in restraints. (Note: the officers were not named in the notes.)...

3. Facility document review:
A. Review of facility incident reports indicated that on 4/3/19, officer O1 tazed patient P1 times 3, and was observed holding him/her down on his/her stomach and handcuffed the patient.
B. Review of security report logs indicated that on 5/1/19, an officer performed a double leg take down on a patient, held the patient down on the ground in a mounted position, secured the patient's arm/hand in a twist lock and then placed him/her in handcuffs.

4. Review of personnel files indicated the following:
A. O1 was a contracted security officer hired on 6/7/10. The file lacked documentation of restraint/seclusion training, and lacked documentation of demonstrated competency in the safe application of restraint and seclusion.
B. O2, Director of Security, was hired to his/her position on 6/10/13. The file lacked documentation of restraint/seclusion training, and lacked documentation of demonstrated competency in the safe application of restraint and seclusion.
C. O3 was a contracted security officer hired on 6/27/16. The file lacked documentation of restraint/seclusion training, and lacked documentation of demonstrated competency in the safe application of restraint and seclusion.
D. O4 was a contracted fire watch officer hired on 11/19/18. The file lacked documentation of demonstrated competency in fulfilling the duties of their job. Unable to determine required duties, due to the file lacked documentation of a job description.
E. O5 was a contracted security officer hired on 11/12/15. The file lacked documentation of restraint/seclusion training, and lacked documentation of demonstrated competency in the safe application of restraint and seclusion.

5. On 7/8/19, between approximately 4:00 p.m. and 5:00 p.m., A7, Human Resources Business Partner, verified that O1, O3, O4 and O5 were contracted staff of the hospital and that O2 was directly employed as the Director of Security. A7 verified that O1, O2, O3 and O5 were officers who could perform restraint and that their files lacked documentation of restraint/seclusion training and demonstrated competency in the safe application of restraint and seclusion. A7 further indicated that he she was uncertain of the role for O4 (the file lacked a job description), but believed he/she could assist with restraint and/or seclusion if needed.