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Based on observation, interview and document review, the hospital failed to ensure all patient rights were protected when a staff member assaulted a patient.

A condition level deficiency was issued. See A0144.

An IJ was identified 11/24/21, related to patients receiving care in a safe setting. The IJ was removed 11/29/21, but the hospital remained out of compliance at the Condition of Patient Rights. See A0144

Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) reviewed when a staff security guard (SG)-A physically and verbally assaulted P1. This deficient practice resulted in an immediate jeopardy (IJ) for P1.

The IJ began on 11/16/21, at approximately 3:29 p.m. when patient (P)1 required manual hold for medication administration related to behaviors. Security Guard (SG)-A placed his hand in the front of P1's neck and throat, and slammed P1 down onto the bed. In addition, SG-A told P1 to "Show some f*ing respect." The Chief Executive Officer (CEO), Regulatory and Quality Improvement RN (RQI), Senior Director of Quality (DQ), Chief Nursing Officer (CNO), Vice President of Operations (VPO), Vice President of Nursing Practice and Clinical Education (VPNP), Supervisor of Behavioral Health (BHS), and Administrative Assistant (AA) were notified of the IJ finding on 11/24//21, at 11:16 p.m.

Findings include:

On 11/19/21, at 8:54 a.m. a facility report to the State Agency (SA) indicated it was reported a Code Green was called for a manual hold for P1. The nurse called for hands off, and staff complied and was leaving the room. P1 sat up from her bed, and called SG-A a, "Wanna be cop." SG-A placed his left hand on P1's lower neck, and told her to stop it. SG-A then took P1 by the lower neck, and slammed her into the bed, and told her to, "Have some f*ing respect."

P1's History and Physical dated 11/15/21, indicated P1 was admitted to the hospital on 11/15/21, under police custody after having periods of psychosis, mania, agitation and medication non-adherence. P1 was placed on a 72-hour, medically cleared in the emergency department (ED) and admitted to the hospital's behavioral health unit (BHU).

On 11/16/21, a progress note authored by registered nurse (RN)-A titled, Violent/Self-Destructive Seclusion or Restraint Initiation Note, revealed on 11/16/21, at 3:29 p.m. P1 was yelling in the lounge area, slamming the phone, and intimidating other patients. P1 was noted to lunge towards another patient while yelling and screaming. P1 then went to her room, and RN-A had initiated a Code Green, a manual hold for medications. The order for a manual hold was received by nurse practitioner (NP)-A.

On 11/18/21, a note by medical doctor (MD)-A titled, Fairview Range Psychiatric Progress Note, revealed on 11/16/21, P1 had been assessed by MD-A for possible harm following a Code Green on 11/16/21. MD-A evaluated P1 on the evening of 11/17/21, after staff had made him aware of the incident which occurred on 11/16/21. MD-A noted P1 sustained no negative physical findings. Imaging performed on 11/18/21, also indicated P1 had sustained no apparent injury. MD-A attempted to evaluate P1 for potential psychological harm; however, P1 refused further assessments.

On 11/22/21, at 12:55 p.m. P1 was interviewed. P1 stated she had no recollection of the altercation involving SG-A, and had not received any injuries.

On 11/23/21, at 9:38 a.m. RN-A was interviewed. RN-A stated on 11/16/21, she had initiated a manual restraint hold to administer as needed (PRN) medication to P1. RN-A stated multiple staff members arrived to assist with the hold, including three security officers. RN-A stated two social workers (SW)-A and SW-B also arrived. RN-A stated after administering the medication to P1, she instructed all staff "hands-off" of P1. RN-A stated as she was exiting the room, she saw SG-A "pounce" on P1 out of the corner of her eye.

On 11/23/21, at 10:33 a.m. SW-A was interviewed and stated he was part of the response team that assisted with the manual hold for P1. SW-A stated RN-A had instructed all staff hands-off. SW-A stated P1 continued to swear, and she called SG-A, "Wanna be cop" and, "Fake cop." SW-A stated P1 sat up, and he witnessed SG-A place his hand in the front of P1's neck and throat, and SG-A pushed P1 down onto the bed. SW-A stated SG-A told P1 to, "Show some f*ing respect."

On 11/23/21, at 11:02 a.m. the VPO was interviewed and stated SG-A had been suspended; however, to his knowledge no additional training had been completed with any hospital employees, including security staff, related to use of force and restraints. VPO stated after hearing of the incident on 11/17/21, he urged the human resources (HR) team for safety of the patients to get this retraining completed. VPO stated the facility had not yet completed its investigation into the incident.

On 11/23/21, at 12:27 a.m. SW-B was interviewed. SW-B stated she was part of the response assisting with the manual hold. SW-B stated RN-A had instructed all staff hands-off. SW-A stated P1 was swearing and called SG-A a, "Wanna be cop" and, "Fake cop." SW-A stated P1 sat up and SG-A placed his hand in the front of P1's neck and throat, and he slammed P1 down onto the bed. SW-A stated SG-A told P1 to, "Show some f*ing respect." SW-B stated she yelled out, "Hey" to SG-A in an attempt to get him to stop after witnessing the incident.

On 11/23/21, at 12:55 p.m. RN-B was interviewed and stated SG-A had been suspended pending a complete interval investigation on 11/17/21. RN-B stated P1 had also been assessed for physical and or psychological harm which resulted in no harm.

On 11/23/21, at 11:28 a.m. the Director of Emergency and Behavioral Health Services, RN-C, and Manager of Quality, RN-D were interviewed. RN-C stated the facility had not provided additional training or education any staff after this incident had been reported.

On 11/23/21, at 12:01 p.m. SG-A was interviewed. SG-A stated he was part of the Code Green called involving P1 on 11/16/21. SG-A stated he was suspended on 11/17/21, but he had no idea why he had been suspended. SG-A stated P1 had swung at him, and hit him in the left elbow region. SG-A stated he then took hold of both of P1's arms at her wrist and elbows. SG-A stated he used an authoritative voice, and told P1, "You will not hit, that is not okay." SG-A denied using profanity towards P1.

The hospital's Management of Escalating or Aggressive Patient Behaviors Policy revision date 1/20/20, directed the purpose of calling behavioral response team members to a rapid response or a behavioral emergency response is to protect the escalating/aggressive patient, other patients, and staff from harm. Verbal de-escalation is the priority tactic. Physical interventions are a last resort option, in order to maintain safety.

The hospital's Restraint or Seclusion Policy dated 6/17/19, directed Fairview Health Services recognizes the unique needs associated with the care of the patient whose actions pose a safety risk to self or others. The use of restraint or seclusion poses an inherent risk to the physical safety and psychological well-being of the patient and staff.

The IJ was removed on 11/29/21, at 2:53 p.m. when it could be verified the hospital had submitted and implemented an acceptable removal plan which included appropriate education and training of all employees, including security officers, verification of security officers' competencies in de-escalation, and verification of competency surrounding use of restraints. This was verified through observation, interview and policy review.