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Based on facility policy review, medical record review, review of security documentation, review of facility documentation, review of bodycam video footage, and interviews the facility failed to ensure a patient was free from abuse by a security guard and failed to follow facility policy related to Use of Force for 1 patient (Patient #1) of 3 patients reviewed for abuse of 9 patients reviewed.

The findings include:

Patient #1, a nonverbal 17-year-old with diagnoses including Autism and Anxiety presented to the Emergency Department (ED) on 2/10/2023 at 10:07 AM for aggression and agitation. The patient received a medical screening exam at 10:11 AM. Patient #1 was waiting for his discharge placement to be determined because he was unable to return to the domestic violence shelter where his mother and sister were staying due to his aggressive behaviors. Patient #1 had exhibited previous episodes of agitation and self-harm behavior, including slapping his face and head while in the ED. Security had observed the patient exiting his room and kicking a Certified Nursing Assistant (CNA) through video surveillance. On 2/10/2023 at 2:32 PM, two security officers arrived in the ED area where Patient #1 was located. After the arrival of the security officers, Patient #1 exited the room but was redirected back to his room by nursing staff. The patient attempted to exit the room again but was redirected back to his room by a CNA and Security Officer #2. At 2:33 PM, Security Officer #1 (alleged perpetrator-AP: person who carries out a harmful, illegal, or immoral act) rushed toward the patient's room and forcefully took the patient to the ground, told the patient to stay down and that he was not coming out of the room. Security Officer #1 did not offer the patient assistance after the incident. Patient #1 stood up, made a growling noise and had his arms in front of him. Security Officer #2 took the patient's hands and took the patient to the bed and sternly told the patient to sit down. The patient then approached Security Officer #2 with his hands reaching out in front of him. Security Officer #2 was able to verbally deescalate the patient. Patient #1 backed off, looked around and slapped himself 2 times on his left cheek with his left hand. The patient was holding his right hand up next to his face. Security Officer #1 (AP) sprayed Patient #1 in the face with pepper spray, then stood in the doorway of the patient's room, told the patient to sit down and walked away without offering to assist the patient. Patient #1 walked to a back corner of the room. Patient #1's face and eyes were rinsed with water by the nursing staff; medication was administered to the patient to help him calm down; his clothes were changed; and he was moved to a different room. The facility failed to provide alternative measures for de-escalation and failed to follow the Use of Force policy for Patient #1. The facility's failure caused physical harm to Patient #1 and had the potential to cause harm and injury to other patients.

Refer to A-0145

Based on facility policy review, medical record review, review of bodycam video footage, review of security documentation, review of facility documentation, and interviews the facility failed to provide alternative measures for de-escalation and failed to follow the facility's use of force policy for 1 patient (Patient #1) of 3 patients reviewed for abuse of 9 patients reviewed. The facility's failure resulted in abuse to Patient #1.

The findings include:

Review of the facility's policy "Child Abuse and Neglect: Protection and Reporting" dated 10/2/2021 showed "...Child (or Minor): Any person under eighteen (18) years of age. No exception under this policy shall be made for an emancipated Child or mature minor...Child Abuse: Exists when a person under the age of eighteen (18) is suffering from, has sustained, or may be in immediate danger of suffering from or sustaining a wound, injury, disability or physical or mental condition caused by brutality, neglect or other actions or inactions of another person including but not limited to a parent, relative, guardian or Caretaker...Ballad Health is committed to ensuring that all patients shall not be mistreated, neglected, abused, or exploited while in a [named] facility...[named facility] team members are prohibited from verbally, mentally, sexually, or physically abusing, neglecting, or exploiting a patient..."

Review of the facility's policy "Use of Force" last reviewed/revised 7/22/2022 showed "...DEFINITIONS...Force: Any degree of physical action, beyond minimal restraint, exerted upon or against a person or thing to compel or constrain action or movement, usually applied through the use of a person's body, weapon, equipment, and/or other objects...Necessary force: Force that is lawfully utilized to overcome resistance to restraint, to defend oneself or others from harm, or control a situation; such force being minimal and reasonably necessary, but not excessive or abusive, considering the amount of resistance or level of threat encountered...Reasonable belief: Facts or circumstances the officer knows, or should know, that would cause an ordinary and prudent person to act or think in a similar way under similar circumstances...Antagonist: A person who is attempting to do harm to himself/herself and/or others and/or property...POLICY...Officers shall use only the minimum amount of force necessary to control a person or situation, and provide a safe environment for patients, visitors, team members and providers...Once resistance is overcome, the exercise of force shall cease unless required to maintain control...Force is not to be used as 'punishment' or as a coercive tool, once an individual is under control and/or in custody...Force may be used when an antagonist shows intention of resistance by word or action and all lesser measures have proven ineffective or appear to be inappropriate...Force shall not be used when an antagonist offers no resistance and obeys lawful commands...USE OF FORCE CONTINUUM [sequence]...The force continuum is broken down into five (5) broad levels...LEVEL ONE: OFFICER PRESENCE...Defined as the presence of a visible uniformed Security Officer or marked vehicle...Gestures should be non-threatening and professional...LEVEL TWO: VERBAL COMMANDS...Used when the subject fails to comply with Security Officer presence...Verbal commands are administered in a normal speaking voice...The use of de-escalation techniques and interpersonal skills learned during de-escalation class and annual refresher classes to control a given situation are critical at this level...LEVEL THREE: MANUAL HOLD AND RESTRAINTS...LEVEL FOUR: CHEMICAL AGENTS...Chemical agents are a defensive weapon...In most instances all other means should have been exhausted (i.e. [for example] Levels One-Three) before using chemical agents...Extreme caution should be used when using pepper gel near patients, visitors, physicians and team members...Before using pepper gel, the Security Officer will announce in a clear voice, 'PEPPER GEL WILL BE USED IF YOU DO NOT COMPLY'...After the application of pepper gel, the Security Officer will offer the subject assistance with getting decontaminated...The use of pepper gel is a law enforcement function...LEVEL FIVE: LETHAL FORCE..."

Medical record review of an Emergency Department (ED) Care Timeline showed Patient #1 arrived at the facility on 2/10/2023 at 10:07 AM; provider (Physician, Nurse Practitioner, or Physician Assistant) first contact was at 10:11 AM; triage began at 10:21 AM.

Medical record review of an ED Triage Note showed Patient #1 presented to the ED for a mental health evaluation requested by his mother. The patient's mother reported Patient #1 had recent medication changes and had been aggressive toward her and his sister.

Medical record review of an ED provider (Physician Assistant) note dated 2/10/2023 showed Patient #1 had a medical history including Allergic Disorder, Anxiety, Autism Spectrum Disorder (a developmental disability), and Chronic Diarrhea. The patient was accompanied by his mother who reported the patient was experiencing agitation and aggression that was worsening. Patient #1's mother reported the patient had a medication change approximately 1 week prior and they had also moved to a new home around the same time. The patient's physical exam showed the patient was inattentive and his behavior was withdrawn. Medical decision making showed "...Baseline autism, one or two verbal yes answers. Does not offer any detailed history. Distracted, difficult to redirect. Wanders out of room. Pt [patient] was at [named facility] last night, mother states she feels as though pts outburst could be better controlled with inpatient treatment and monitoring with med [medication] adjust. Apparently, while waiting for case management to discuss options with mother, pt had an outburst and security restrained and pepper sprayed pt. My attending ordered some Ativan [anxiety medicine] for pts agitation. Pt sleeping on bed on re-evaluation. Will order xray [x-ray] of right foot as pt had some dried blood noted under great toenail. Case management involved, working on discharge planning/disposition..." Patient #1's diagnoses included Autism and Behavior Disturbance.

Medical record review showed Patient #1 received a telehealth (video) mental health evaluation on 2/10/2023 at 1:51 PM. The patient's mother reported the patient was grabbing her (mother) and was grabbing his sister's hair the morning of 2/10/2023. Patient #1 did not engage with the video assessment "...patient looked at the camera a few times but was continuously walking around, patient smiled at times and appeared to hear...but was unresponsive to prompts..." The patient's nurse reported the patient was "...walking around all over the unit. Patient on floor at times. Patient hostile with mom per RN [Registered Nurse] report, 'Patient raising arms to mom, not rearing back or anything, but mom grabs his wrists and moves his arms away'..." The evaluator documented the patient's disposition as "...Diversion to Outpatient services [outpatient treatment instead of inpatient treatment]..."

Medical record review of an ED Nursing note dated 2/10/2023 at 2:25 PM showed Patient #1 became agitated, came out of his room multiple times but was easily redirected "...Pt began coming out...in a more aggressive manner and began kicking, making contact between the legs of [Certified Nursing Assistant-CNA #1], and pulling off scrub hat. This nurse assisted and we were able to gain control of pt and walk back to room. This continued several more times, but still able to physically walk pt back to room. Two security officers arrived to department. Pt came out of room once again, prompting security to assist. Pt was placed back into room by officers. Upon exiting room pt attempted to leave again. Pt was then slammed to the ground by officer, and officer proceeded to pepper spray the pt. Other officer was also sprayed. Both officers immediately exited the room and went to sink to rinse eyes. Additional security arrive to assist. This nurse immediately made charge nurse and provider aware. Pt sister and mother arrived during this time. Sister allowed into room and attempted to calm pt. Order for medication obtained and administered. Pt clothing removed and pt was moved to another room for safety. Pt sister remained with pt until pt was calm. Mother informed of the incident..."

Review of Security Officer #1's (alleged perpetrator (AP)-identified by the Market Security Manager) bodycam recording for 2/10/2023 showed the following:
2:32 PM 09 seconds: Security Officer #1 (AP) entered the Preassessment Area where Patient #1 was located.

2:32 PM 18 seconds: Security Officer #1 (AP) stopped behind a post while Security Officer #2 continued to approach staff standing outside Patient #1's room. Security Officer #2 continued to approach staff standing outside of Patient #1's room.

2:32 PM 33 seconds: Security Officer #1 (AP) tapped the front of his chest and the bodycam stopped recording.

Review of Security Officer #2's (identified by the Market Security Manager) bodycam recording for 2/10/2023 showed the following:
2:32 PM 14 seconds: Security Officer #2 approached CNA #1 and Licensed Practical Nurse (LPN) #1 (identified by the Market Security Manager) and asked "...What do you want to do? We got meds or anything?..."

2:32 PM 20 seconds: CNA #1 stated "...We have nothing for him..."

2:32 PM 21 seconds: LPN #1 nodding head no "...No, they're sending him home..."

2:32 PM 22 seconds: Security Officer #2 "...They're sending him home..."

2:32 PM 23 seconds: CNA #1 "...They're sending him home..."

2:32 PM 25 seconds: Security Officer #1 "...Okay..."

2:32 PM 25 seconds: Female identified as Patient #1's mother walked up stated "...And I don't understand why for this to happen again, and I mean where is he supposed to go the next time? I mean..."

2:32 PM 32 seconds: Patient #1 exited the room, CNA #1 stated "Joe Joe stay in your room..." The patient was making a grunting/growling sound and appeared to be pushing against CNA #1. CNA #1 and LPN #1 guided/redirected the patient back to his room. CNA #1 "... Come on, come on, turn around, turn around,come on buddy, good boy, good job, thank you..." CNA #1 closed the door to the patient's room. LPN #1 walked away while CNA #1 stood outside of the patient's room observing the patient through the door.

2:32 PM 46 seconds: Patient #1's mother speaking with someone about Patient #1.

2:33 PM 09 seconds: CNA #1 started nodding head no and moving his index finger back and forth. Security Officer #1 (AP) was noted in the background to the left of CNA #1.

2:33 PM 10 seconds: Patient #1 opens the door and attempts to exit the room making growling sounds. The patient's arms were stretched out in front of him. CNA #1 held the patient's hands and was guiding him (backwards) into the room and saying "...back, back, back..." Security Officer #2 was approaching the patient and said "...No..."

2:33 PM 17 seconds: Patient #1 was back in the room. The patient slapp himself on the face and began making growling sound. CNA #1 was in the room with the patient and told the patient to put his socks on. The patient continued to growl and appeared to be reaching for the CNA. CNA #1 kept telling the patient no, to stop, and sit. The patient sat on the bed and immediately stood up again. CNA #1 told the patient to sit and stay. One of the security officers (unclear which officer) told the patient to sit down. The patient began leaning over the bed and moving things around on the bed.

2:33 PM 35 seconds: CNA #1 exited the patient's rooms and stated "...Oh, that one hurt...[explicative]..." Patient #1 remained in the room and could be seen walking around.

2:33 PM 38 seconds: Security Officer #2 "...Did he kick ya?..."

2:33 PM 39 seconds: CNA #1 "...He got me right in the knee..." Security Officer #1 (AP) was standing outside of Patient #1's room and next to the CNA.

2:33 PM 58 seconds: Security Officer #1 (AP) rushed toward the patient's room. It was unclear what Patient #1 was doing. Security Officer #1 (AP) forcefully took the patient to the ground and stated "...Stay down..." CNA #1 could be heard in the background saying "...hey, hey, hey, you don't have to do that..." Security Officer #1 (AP) looked at the patient stated "...You're not coming out of this room..."

2:34 PM 09 seconds: Patient #1 stood up making growling noise and had his arms in front of him. Security Officer #2 took the patient's hands and took the patient to the bed and sternly told the patient to sit down. Security Officer #1 (AP) was heard in the background stating "...You're not coming out of this room..."

2:34 PM 17 seconds: Security Officer #1 (AP) was standing in the doorway of patient's room. Patient #1 approached Security Officer #2 with his hands reaching out in front of him. Security Officer #2 grabbed the patient's right upper arm and left hand and stated "...Joe, I'm telling ya...sit down...you're gonna get hurt brother..." CNA #1 could be heard in the background saying "...come on bud, stop...sit, please...come on..."

2:34 PM 23 seconds: Patient #1 backed off, looked around and slapped himself 2 times on his left cheek with his left hand. The patient was holding his right hand up next to his face.

2:34 PM 30 seconds: Security Officer #1 (AP) sprayed Patient #1 in the face with pepper spray. Security Officer #1 (AP) stood in the door of Patient #1's room and told Patient #1 to "...sit down..." and walked off. Patient #1 was observed walking to a back corner of the room.

2:34 PM 41 seconds: Security Officer #2 exited the patient's room. CNA #1 approached Security Officer #2 and asked if he was alright. CNA #1 stated to Security Officer #1 (AP) "...Hey, you got him..." indicating Security Officer #2 had been pepper sprayed as well.

2:34 PM 44 seconds: LPN #1 to Security Officer #1 (AP) "...Did you pepper spray him..."

2:34 PM 44 seconds: Security Officer #1 (AP) "...I did..."

2:34 PM 46 seconds: LPN #1 "...Why?..." remainder of the LPN's statement was unintelligible.

2:34 PM 54 seconds: Security Officer #1 (AP) stated "...I ain't putting up with him kicking me and punching at me. No sir..." CNA #1 could be heard telling Patient #1 to relax and that he would be in there (in his room) in a second. The remainder of the bodycam footage showed Security Officer #2 rinsing his eyes and face.

Medical record review of an ED Physician Attestation Note dated 2/10/2023 at 2:53 PM showed the physician had face to face time with Patient #1. The patient had been more aggressive at home and presented to the ED for a mental health evaluation. The patient had a history of Autism "...with very limited communication skills..." Patient #1's mother was requesting admission for possible medication adjustment. The patient was deemed medically stable for crisis evaluation.

Medical record review of a medication administration record showed Patient #1 received Ativan 2 mg (milligrams) IM (intramuscular) on 2/10/2023 at 2:55 PM and 7:29 PM. Patient #1 had not received medications prior to 2:55 PM.

Medical record review of a Telepsychiatry Consult note dated 2/13/2023 at 11:07 AM showed Patient #1's presentation was consistent with Autism. Inpatient Psychiatry admission was not recommended "...The patient would benefit from outpatient mgmt. [management]/placement in structured environment..."

Medical record review of an ED Physician attestation note dated 2/13/2023 at 4:25 PM showed Patient #1 was evaluated multiple times by crisis and was not felt to meet criteria for inpatient psychiatric care or committal. Medication adjustments were made "...The issue is that his mother is currently staying in a domestic violence shelter, and they cannot accommodate this patient there because of his autism and behaviors. However, there are no acute medical or psychiatric indications for admission. Social worker will reach out to other family members to see if any of them can safely take the patient home. I have also asked her to make a CPS report and get them involved as well. Hopefully will reach a safe disposition for the patient soon..."

Medical record review showed Patient #1 was discharged from the facility with his family on 2/13/2023 at 4:38 PM. The living arrangement was documented as "...Family members..."

Review of a facility security report dated 2/10/2023 showed the report pertained to a disorderly patient (Patient #1) with a use of force via chemical agent. The report showed a Lieutenant (security supervisor) observed Patient #1 assault an ED team member via a surveillance camera. The Lieutenant asked Security Officer #1 (AP) and Security Officer #2 to respond to the ED to assist at 2:27 PM. Security Officer #2 attempted to verbally deescalate the patient back to the room, where the patient became even more physically aggressive. At approximately 2:33 PM, Security Officer #1 (AP) entered the room using hands on force by taking the patient to the ground in an attempt to gain physical control of the disorderly patient. The patient regained footing and aggressively approached Security Officer #1 (AP) in the doorway. Security Officer #1 (AP) sprayed a 1 second burst of pepper spray to the patient's facial area in an attempt to gain control of the situation.

Review of a facility incident report dated 2/10/2023 showed Patient #1 had become agitated and had been coming out of his room multiple times. The patient was easily redirected. Patient #1 began coming out of his room in a more aggressive manner and began kicking, making contact between the legs of the CNA, and pulling at the CNA's scrub hat. The reporting nurse and CNA were able to gain control of the patient and walk him back to his room. This occurred several more times, but the staff were able to physically walk the patient back to the room. Two security officers (Security Officer #1 (AP) and Security Officer #2) arrived in the ED. Security presence had not been requested. The patient came out of his room once again, prompting security to assist. Patient #1 was placed back into the room by both officers. Upon the officers exiting the room, the patient attempted to leave again. Patient #1 was then "...slammed to the ground..." by Security Officer #1 (AP). Security Officer#1 (AP) proceeded to pepper spray the patient. Additional security arrived in the ED to assist. Patient #1's nurse immediately made the charge nurse and ED physician aware of the excessive force used by Security Officer #1. The patient's eyes were rinsed, and a cloth was provided. Patient #1's clothing was removed, and the patient was moved to another room for safety. An order for medication was obtained and was administered to the patient without difficulty. Patient #1's sister stayed with the patient until he was calm. The degree of injury was documented as "...Circumstances or events that have the capacity to cause harm. The nature of injury was documented as "...aggravation of pre-existing condition...emotional distress...inflammation...pain...rash...Location of Injury on Body ...Pt eyes post pepper spray and left great toe bleeding..." The patient's physician was notified, and x-rays of the patient's left foot were performed.

Review of facility documentation "Attachment 1" showed Security Officer #1 (AP) was involved in a Use of Force incident on 2/10/2023. "...The incident resulted in [Security Officer #1] throwing a seventeen-year-old autistic patient onto the floor. [Security Officer #1] then walked away from the patient offering no assistance or further attempts to control the patient. A few minutes later [Security Officer #1] then sprayed the patient in the face with pepper gel. [Security Officer #1] again walked away from the patient with no attempt to assist or restrain the patient. This deployment of pepper spray also hit another Security Officer who was temporarily incapacitated. It was later determined that prior to the use of force [Security Officer #1] had turned his body camera off. The above-described behavior is in direct violation to [named facility] Use of Force Policy...The list of violations are as follows...[Security Officer #1] turned his body camera off prior to responding...[Security Officer #1] initiated an unnecessary and overly aggressive physical take down of the patient...[Security Officer #1] did not use chemical agent as a defensive weapon...[Security Officer #1] did not issue verbal warning prior to use of a chemical agent...[Security Officer #1] did not use caution when using chemical agent, contaminating [Security Officer #2]...[Security Officer #1] did not assist patient after use of chemical agent..."

Review of education material showed additional abuse education had been provided for security leadership and the entire security team between 2/17/2023 and 2/25/2023. The facility had not provided additional education regarding de-escalation and the Use of Force policy.

During an interview on 5/22/2023 at 12:24 PM, in the conference room, CNA #1 stated Patient #1 was Autistic and was in the ED for behavioral problems. CNA #1 reported the patient came out of his room frequently but was easily redirected. CNA #1 stated Patient #1 had kicked him 2 or 3 times, but not hard. He stated security saw the patient kicking him and came to the ED. CNA #1 stated Patient #1 kicked him several more times. He stated "...I didn't need help..." CNA #1 stated Security Officer #2 came into the patient's room and helped get the patient away from him and helped with keeping the patient in the room. CNA #1 reported Security Officer #1 "...came in and body slammed the kid to the floor for no reason. That didn't deescalate the situation..." CNA #1 stated he stepped back while Security Officer #2 was trying to calm the patient down. He went on to say that Patient #1 tried to come out of the room again and Security Officer #1 pepper sprayed the patient. CNA #1 reported Security Officer #1 was near the preadmit area laughing about what had happened. CNA #1 stated "...It shouldn't have happened..."

During an interview on 5/22/2023 at 12:34 PM, in the conference room, LPN #1 stated Patient #1 was Autistic and was agitated. LPN #1 stated the patient kept coming out of the room which had been his behavior for the day "...It really wasn't a problem..." She reported the patient had become a little more agitated "...he would lunge at you and swing a little..." but she did not feel threatened by the patient. Patient #1 began swinging and slamming the door "...really hard..." LPN #1 stated "...Security must have seen us on the camera. We hadn't called security...We had it under control..." She reported the patient had become "...pretty physical..." with CNA #1. The LPN stated she walked out of the patient's room and heard the patient "...slam to the floor..." LPN #1 reported Security Officer #1 (AP) was laying on top of the patient on the floor. An officer (did not specify which officer) was wrestling with the patient and trying to get him back on the bed "...He [Patient #1] didn't do anything to get pushed back into the room..." LPN #1 reported Security Officer #2 came out of the patient's room rubbing his eyes. She asked Security Officer #1 if he sprayed Patient #1, and he said "yes". LPN #1 stated Security Officer #1 stated the patient was "...kicking around and he wasn't going to put up with it..." LPN #1 stated "...He just sat over there and was laughing and thought it was funny..."

During an interview on 5/22/2023 at 4:20 PM, in the conference room, the Market Security Manager stated Patient #1 was a handful to deal with. The patient would come in and out of his room and he was always reaching for people's heads. He stated the patient was fairly easy to redirect "...Sometimes the redirection would last for 2 seconds, sometimes 2 hours..." The Market Security Manager reported he was in the office and happened to see the patient was coming out of his room "...He just came out and hit [CNA #1]..." He saw the patient come out again. The Market Security Manager stated it appeared one of the officers had been disabled with pepper spray "...I was pretty shocked to be honest, so I went straight there..." Security Officer #1 told him he pepper sprayed the patient. The Market Security Manager stated Security Officer #1 was taken to the security office and was suspended. He reviewed Security Officer #2's bodycam footage "...could see he essentially pepper sprayed that kid...for I don't know why...but for no reason that was acceptable...there was no reason for it..." The Use of Force Committee reviewed the incident. Everyone on the committee agreed the incident with Patient #1 was excessive use of force. The Market Security Manager stated "...Pepper spray is a defensive weapon...the officer was not in a position that needed to defend himself..." When asked if Security Officer #1's use of force was unacceptable he stated "...Absolutely..." The Market Security Manager confirmed Security Officer #1 violated the standards of the Use of Force policy and was terminated on 2/16/2023.

During a telephone interview on 5/22/2023 at 4:45 PM, Security Officer #2 stated Patient #1 was being combative and "...throwing hands at [CNA #1]..." Security Officer #2 stated he went into the patient's room and took him to the bed. He reported the patient went down to the floor with Security Officer #1 at one point "...I think he [Patient #1] was coming back at me...the next thing I know...[Security Officer #1] sprayed the patient..." Security Officer #2 was also sprayed in the eyes "...Once I got sprayed, I couldn't see anything else..." Security Officer #2 stated "...They told me he was Autistic...he charged at me then stopped and then hit himself in the face..." Security Officer #2 confirmed security officers were supposed to announce to the patient that they were going to use pepper spray. Security Officer #2 stated he did not know Security Officer #1 was going to use pepper spray on Patient #1.

During a telephone interview on 5/23/2023 at 1:39 PM, Security Officer #1 (AP) stated Patient #1 was "...going crazy...trying to come out of his room..." and kicked the ED tech and stated "...I went over to address the issue with [Security Officer #2]...He [Patient #1] stuck his arms out like he was going to pull my hair..." Security Officer #1 stated he went to put the patient on the end of the bed, but missed the bed and went in the floor. He reported Security Officer #2 got the patient in the bed "...He [Patient #1] jumped up again and started trying to come after us...He drew his arm back like he was going to hit us. At this point, I did a 1 second burst of [named pepper spray]...I was just trying to get out of there...I was going to have to use pepper spray or get physical..." Security Officer #1 reported the patient was still combative after the pepper spray. Security Officer #1 stated he knew Patient #1 was 17 years old and was special needs but did not know the patient was Autistic. Security Officer #1 admitted he did not announce he was going to use pepper spray on Patient #1. He reported he remained in the ED area for ½ hour or so, and then was dismissed. He was put on administrative leave and terminated. When asked about his bodycam he stated he had a call through facility's communication system and a radio call at the same time and stated "...I went to pause my body cam...I was just going to pause it to not record the nonsense...Double tapped it to pause it...I shouldn't have done that I don't guess...when I double tapped it to resume it was evidently all the way off...I didn't realize it wasn't recording until after everything was all over...I really didn't think anything I done was anything out of the norm..."

During a telephone interview on 5/23/2023 at 2:49 PM, Patient Care Technician (PCT) #1 stated Patient #1 was out of control but could be redirected. She reported the patient would put his hands up on the CNA, but the CNA could redirect him. She also reported the patient "...did kick some..." PCT #1 stated the security officer "...threw..." the patient to the ground and the nurse had said "...that was too far..." PCT #1 stated the security officer pepper sprayed the patient when the patient got back up "...It was very uncalled for...the security officer...he did not care...it could have been handled differently..." PCT #1 stated the security officer had no sympathy for what he had done "...His [Patient #1] eyes were red and swollen...we tried to put wash cloths...finally got him calmed down and moved him to another room. The nurse had given him something to help him calm down after the incident.

During an interview on 5/23/2023 at 3:05 PM, in the conference room, the Market Security Manager, confirmed re-education of Use of Force and de-escalation policy had not been completed for the security officers.

During a telephone interview on 5/24/2023 at 10:05 AM, Physician #1 stated Patient #1 presented to the ED with aggressive behavior. The patient could not talk and was difficult to redirect. Physician #1 assessed the patient after he had been pepper sprayed. The staff were trying to clean the pepper spray from the patient's face and were trying to help him. Patient #1 was pacing back and forth in his room. Physician #1 observed the patient and felt the more staff tried to contain him the more upset he became.