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Based on interviews, medical record review, observation and policy review, the facility failed to ensure patients had the right to refuse treatment (A-0131). The facility failed to ensure patients were free from all forms of abuse or harassment (A-0145) and failed to ensure all patients were free from restraint, that restraints were only used to ensure patients physical safety, and that restraints were discontinued at the earliest possible time (A-154). The facility failed to follow manufacturer's instruction for the safe application of a restraint (A-0167). The facility failed to ensure a physician's order for restraints was followed and not used on a PRN (as needed) basis (A-169). The facility failed to monitor a patients in restraints at intervals determined by the facility's policy (A-0175). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the facility protected and promoted each patient's rights. This had the potential to affect all of the facility's 233 active patients and three patients who were in restraints during the time of the survey.

Based on medical record review and facility form review, the facility failed to ensure the patient had the right to refuse treatment for one (Patient #2) of ten medical records reviewed. This had the potential to affect all of the facility's 233 active patients.

Findings include:

The medical record review of Patient #2 revealed the patient was treated at the facility's emergency department from 03/06/16 at 7:40 AM through 03/09/16 at 11:05 AM. The medical record review revealed the facility did not obtain consent from Patient #2 for the emergency department visit from 03/06/16 through 03/09/16. The Patient Consent form from 03/06/16 did not contain Patient #2's signature. The medical record contained an Application for Emergency Admission form from 03/06/16 which did not contain the time the form was completed and did not contain the name of the facility.

An Emergency Department Behavioral Health Flowsheet from 03/07/16 at 7:31 PM, contained documentation stating Patient #2 was talking with the Staff A about leaving. On 03/08/16 at an undocumented time, a social worker documented a Crisis Intervention Reassessment stating Patient #2 still disagrees that he is being legally kept in the emergency department. A Nursing Free Text note from 03/08/16 at 12:24 PM stated Patient #2 was threatening staff with legal action due to being illegally detained according to Patient #2's informant on the other end of the phone.

The facility's Application for Emergency Admission form was reviewed. The form stated the undersigned has reason to believe that Patient #2 is a mentally ill person subject to hospitalization by court order under division B Section 5122.01 of the revised code.

Based on medical record review, policy review and interview, the facility failed to ensure one patient (#2) of ten medical records reviewed, was free from all forms of abuse or harassment. This had the potential to affect all of the facility's 233 active patients.

Findings include:

Patient #2 was treated at the facility's emergency department from 03/06/16 at 7:40 AM through 03/09/16 at 11:05 AM.

Staff E's nursing note from 03/06/16 at 8:45 AM stated Patient #2 walked into the emergency department stating he has been suicidal for the last week and having plans to shoot himself with a gun, patient has access to guns at home. Patient #2 went to a behavioral health facility in attempt to get help and they sent Patient #2 to the facility's emergency department. Patient #2 arrived alone. When Patient #2 was told he needed to get undressed and blood work was needed, Patient #2 became agitated and stated he wanted to leave. The physician was immediately informed and physician "pink slipped" Patient #2.

The police department was called for assistance due to Patient #2's agitation and his threat to leave, his threatening statements and demeanor. Patient #2 was escorted back to Room 22. Patient #2 repeatedly stated "I'm not talking or telling you anything, we're done here. I'm not undressing, I'm leaving, I've changed my mind." Staff E explained to Patient #2 the protocol was to keep him and staff safe and he needs to be undressed for examination by the physician and social worker. Patient #2 refused after multiple attempts.

The police department physically gained control of Patient #2 and placed him on the emergency department cart with the help of security and male technicians. Patient #2 was combative, fighting and resisting, at this time the police department tased Patient #2 to maintain control and prevent anyone from getting injured. Patient #2 was laughing, thinking the situation was funny, being inappropriate and asking for it to be done again. Patient #2 continued to be resistant and the police department tasered Patient #2 again a few more times. During this time, locked restraints were applied to the Patient #2's extremities times four and Ativan and Haldol were administered intramuscular. Patient #2 was cussing and verbally abusive. Patient #2 continued to argue and be noncompliant.

The nurse explained the criteria (calm, cooperative, non threatening behavior) for restraint removal and Patient #2 understands. Patient #2's shirt and sweatshirt were cut off him in the process to maintain safety and for restraint application. Patient #2's pants and boxers were to be removed once he is more calm and sedated. The physician was made aware that Patient #2 was asserted. Patient #2 also has a history of assault on a police officer and served a felony charge in prison for eight years. Patient #2 has multiple stressors in his life.

Staff J's note from 03/06/16 at 9:00 AM stated during triage, Patient #2 reported he was suicidal and had access to weapons at home and that he "would put a pistol in his mouth". Patient #2 completed the triage process and staff was attempting to take Patient #2 to a room when he ripped off his hospital identification band and stated he was leaving. Patient #2 attempted to open door in triage to lobby and due to magnetic locks, he was unable to leave. Patient #2 began yelling at staff to "open the f****** door now!" The staff advised him of the inability due to the significant risk he presents to self and possibly others. Patient #2 walked out of back door of triage to main emergency department hall where he was unable to operate doors properly. Security was called and staff had the physician assist in trying to educate Patient #2 and verbally redirected him peacefully. The "police department was called as he was unwilling to cooperate with staff ". Patient #2 became physically and verbally aggressive with the police department and was physically restrained by the police department and taken to room 22. Once in the room he became more agitated and antagonizing to the police and staff. Patient #2 was to be restrained and medicated by the emergency department physician and staff attempted to restrain him and he became more physically aggressive and the police was forced to use a taser in a dry stun mode multiple times to effectively subdue Patient #2. Patient #2 was restrained to the bed and medicated by staff without injury to anyone involved including himself.

The medical record contained an Application for Emergency Admission form for Patient #2 dated 03/06/16. The form did not contain the time.

On 03/09/16 at 10:30 AM, Staff K documented an emergency department course for Patient #2. Staff K stated Patient #2 reportedly became agitated and required restraints. In discussion with nurse, Patient #2 required police to intervene. Patient #2 was reportedly tasered four times by the police to subdue Patient #2. Patient #2 was found to have rhabdomyolysis during the emergency department stay. "Likely cause of rhabdo were agitation, Cocaine, taser, intramuscular shots".

The facility's Irregular Occurrence Report Narrative, completed by the facility's security staff, was reviewed. The narrative stated the following:
On 03/06/16 at 7:55 AM, a security officer was called to the emergency department for an uncooperative patient. The officer arrived on scene with two additional security officers. A technician was talking to Patient #2. Patient #2 was reporting he wanted to leave and the physician came over and explained to him that he was being pink slipped. At this point, the police arrived on scene. Patient #2 tried to push past the police and security. Patient #2 was then escorted to room 22 by security and police. While in room 22, he became verbally combative, taunting and insulting the police, security and medical staff. The police then went hands on with Patient #2. The police, a nurse, a technician and security officers four-pointed him. During the altercation, Patient #2 was dry stunned (the Taser is held against the target without firing the projectiles, and is intended to cause pain without incapacitating the target. "Drive Stun" is "the process of using the EMD (Electro Muscular Disruption) weapon [Taser] as a pain compliance technique. This is done by activating the Taser and placing it against an individual's body) two to four times.

The facility's Code Violet -Violent Person Response policy was reviewed. The policy stated:
the facility is dedicated to the safety and well-being of its patients, physicians, visitors, and team members. The purpose of this policy is to establish a quick response with the appropriate personnel to control and de-escalate the situation.
Team members who observe violent behavior will take the following actions:
·Contact the Operator and alert them to the situation by dialing 4.4.1.1,
·Where possible the operator will page overhead 3 times (3 x 3) Code Violet and the location to respond to.
·Security at the Medical Centers, with assistance from Plant Operation's staff will curtail any threat to patients ,visitors, or other team members and take direction from ad assist the medical staff taking appropriate action as per crisis intervention training.
·Security at the Medical Centers will also contact Law Enforcement if there is a threat to staff, patients or others that cannot be internally controlled.
·Get assistance, as needed, from your fellow team members.
·Contact your Director/Coordinator and alert them to the situation.
·Keep the individual in sight and attempt to keep them calm through therapeutic communication.
In the event that a Code Violet is called, a Code Violet group will respond consisting of:
·Administrative Coordinator for Nursing
·Plant Operations (Medical Centers and MMC only).
·Crisis Team (Medical Center EDs).
·Other predetermined staff members.

NOTE: Situations that escalate into violence (verbal or physical) require a Patient Safety Report to be filed with Risk Management. The incident will be investigated by Security and reported to the Security Sub-Committee of the Environment of Care Standards Committee for review.

The medical record did not contain evidence of any member of the Clinical Crisis Team assisting with the de-escalation of Patient #2 on 03/06/16.

The facility's Emergency Pages/Stats Blue-Red-Violet-Etc were reviewed. The report revealed there were no code violets called at the facility on 03/06/16.

A security officer, Staff M, was interviewed on 04/06/16 at 11:25 AM. The security officer reported the facility has metal detection wands to be used on patients they suspect may be a risk or have a weapon. Staff M reported the metal detection wand was not used on Patient #2 on 03/06/16.

Staff E was interviewed on 04/06 at 10:26 AM. Staff E reported Patient #2 was suicidal on arrival and didn't want to undress or have bloodwork drawn. Staff E reported trying to talk to Patient #2 for 30 to 45 minutes. A technician called security and Staff E instructed the secretary to call the police. Security was present prior to the police arrival, according to Staff E. Staff E reported Patient #2 was 6' 3" or 6'4" and made Staff E feel uncomfortable. Staff E reported self, a physician and security felt we needed more man power.

Staff E reported needing to make sure Patient #2 was safe. Staff E stated the police arrived and tried to talk Patient #2 down for about 15 minutes unsuccessfully. We were at a "standstill" and Staff E told Patient #2 "I need to know you are not a risk". Patient #2 pulled down his pants to show Staff E there was not a weapon hidden. When Patient #2 went to pull his pants back up, the police and security took Patient #2 to the bed. Staff E reported Patient #2 resisted being moved. Staff E reported the police tased Patient #2 at some point in the lower back without the probes. Staff E reported there were no marks on Patient #2. Staff E reported placing Patient #2 in four point restraints while the men were holding him. Staff E reported not being aware if an incident report was filled out and initially wasn't aware if one was required. Staff E later reported security should have filed an incident report. Staff E reported he/she did not call a code violet.

The facility's Restraint Use: Violent or Destructive Patient Behavior policy was reviewed. The policy stated all patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient benefit and safety. Restraint or seclusion for any other purpose (i.e. coercion, discipline, or convenience) is not permitted. Restraints shall be used only where alternative methods are not sufficient to protect the patients or others from injury, and are not a substitute for less restrictive protective measures. The patient's basic rights of human dignity, respect, and the right to modesty and privacy are protected and observed at all times, in a clean, safe environment. The patient's physical and emotional health and well-being are protected and preserved at all times via frequent assessment, passive exercise, nourishment, and the provision or personal care and hygiene, while in restraints. The decision to apply a restraint will be based on the assessed needs of the patient. Patient indicators which may indicate the need for restraints include:
a. Harm to self or others
b. Agitation/assaultive behavior
c. Combativeness
Device Selection Criteria includes:
a. De-escalation techniques have failed
b. Contracting with the patient is unsuccessful
c. Patient demonstrates poor impulse control

The facility provided a copy of the CPI Nonviolent Crisis Intervention Participant Workbook the facility uses. The workbook stated physical intervention should be avoided at all times unless there is no safer alternative and the risks of not intervening are greater than the risks of physical intervention. Physical intervention should never be used to enforce rules or as a punishment, and should not rely on pain-inducing techniques.

The facility's Patient's Rights and Responsibilities policy was reviewed. The policy stated all patients have the right to considerate (and respectful) care free from abuse or harassment that respects the patient's personal value and belief systems.

The facility's Patients Under Arrest or Police Hold policy was reviewed. The policy stated non-violent crisis intervention techniques shall be utilized by personnel in handling the situation in which a prisoner/patient loses control. Techniques for the de-escalation of the situation should be utilized including:
-non-verbal techniques
-empathetic listening techniques
- Paraverbal techniques
- Safe therapeutic intervention

All law enforcement officers must comply with the facility's policy regarding the status of their weapons while in the facility.

Based on medical record review, policy review, and staff interviews, the facility failed to ensure all patients were free from restraint, that restraints were only used to ensure patients' physical safety, and that restraints were discontinued at the earliest possible time. This affected three of five patients in restraints, Patients' #6, #8, and #10.

Findings include:

1) Facility policy Restraint Use: Medical Management (Non Violent, Non Destructive) Patient (R-61-1) was reviewed. Per policy, "all patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient benefit and safety. Restraint or seclusion for any other purpose is not permitted."

Facility policy Fall Risk Evaluation (F-2-1) was reviewed and revealed under the heading of procedure, bullet #2, "if a patient falls, he/she is re-evaluated after the fall."Appendix A of the policy stated "the fall risk assessment is completed on each new admission, with every shift assessment, and following a fall."

The policy also specified "Restraints shall be used only where alternative methods are not sufficient to protect the patients or others from injury, and are not a substitute for less restrictive protective measures." The restraints "must be ended at the earliest possible time" and "restrain discontinuation may be attempted if the patient demonstrates a reduction in the behaviors that led to his/her being placed in restraint."

2) Review of the medical record for Patient #6 revealed a Restraint Order - Behavioral signed by the physician on 03/30/16 at 5:45 AM. The order was for four (4) point locked restraints.

Review of ED Behavioral Health Flowsheets revealed Patient #6 was in the 4 point restraints at 5:30 AM on 03/30/16. Staff continued to document observations of the patient every 15 minutes. Staff documented Patient #6 was "calm" at 5:45 AM, 5:59 AM, 6:15 AM and 6:31 AM. Patient #6 was noted to be "sleeping" at 6:45 AM, 6:58 AM and 7:15 AM. During those same observations staff also documented "yes" there was a "continued need" for restraints.

Patient #6 was noted to be "calm" again at 7:30 AM, at which time staff documented "pt taken out of L arm and R leg restraint by RN at this time."

Patient #6 remained in restraints from 7:45 AM until 8:32 AM, with staff performing 15 minute checks and noting the patient was "calm" and "sleeping."

Staff A was made aware of these findings related to Patient #6 on 04/07/16 at 1:42 PM. A that time she confirmed the restraints should have been removed prior to two (2) hours

3) Review of the medical record for Patient #8 revealed a Nursing Free Text note collected on 03/30/16 at 1:20 PM. Staff documented "to pts room due to pt sliding slowly under bedside table she was eating at next to bed. Pts visitors assisted pt to floor without injury or complaint. RN and tech in to assist pt back to bed." There was no documented evidence of fall risk assessment following this incident.

At 1:30 PM the physician signed a Restraint Order-Medical Management document. The order was for a "vest."

Ten minutes later, at 1:40 PM, the RN noted in a Nursing Free Text note "posey vest to be placed if appropriate, pt asked to stay in bed and agreeing at this time, family at bedside and tentative to pt and aware that pt need to stay in bed d/t fall risk. pt finishing lunch. posey not placed at this time d/t pt being erectable and reassurance given."

At 2:37 PM in another Nursing Free Text note staff documented "pt restless and got out of bed in presence of family and fell landing on her buttocks from standing position,...pt placed in posey vest." Again there was no documented evidence of a fall risk assessment following this incident.

Staff B confirmed the above findings on 04/06/16 at 2:15 PM during review of the electronic medical record.

Staff A was made aware of and confirmed these findings related to Patient #8 on 04/07/16 at 1:19 PM. Staff A was asked what alternatives were attempted before placing Patient #8 in a posey vest to restrain her and stated it looked like she had a "sitter" per the medical record. Staff A was asked if the "sitter" remained with Patient #8 round the clock and stated no. Staff A explained the "sitter" was likely caring for other patients as well.

4) Review of the medical record for Patient #10 revealed a Nursing Free Text note collected on 04/06/16 at 12:02 AM. Staff documented they spoke with doctor "re: pt fall/slide out of bed. Verbal order for posey for pt safety." The vest was placed on Patient #10 at approximately 12:02 AM. There was no documented evidence of a fall risk assessment following this incident.

Staff M confirmed these findings on 04/06/16 at 10:15 AM during interview. Staff M stated Patient #10 had a posey vest after the patient attempted to "crawl out of bed last night" and fell "even with all the bed rails up." Staff M stated alternatives attempted prior to the posey vest included the use of three (3) and four (4) bed rails, bed alarm, and a nursing student as a sitter during the day.

Observation of Patient #10 following interview with Staff M revealed the patient shared a room with another patient. Patient #10 was unable to be seen from the hallway or nurse's station, as she was in bed farthest from the door and the privacy curtain obstructed any view of the patient until you reached the bed. Staff M stated they were trying to move Patient #10 to another room.

Based on observation and staff interview, the facility failed to follow manufacturer's instruction for the safe application of a restraint. This affected one of one patients observed in a posey criss-cross type vests, Patient #10.

Findings include:

1) Facility policy Facility policy Restraint Use: Medical Management (Non Violent, Non Destructive) Patient (R-61-1) was reviewed. Per page three (3) of said policy, "Restraints will be applied in accordance with manufacturer's recommendations."

2) Review of the Posey Criss-Cross Vests Application Instructions was completed. Per the manufacturer, step #3, "secure straps to the wheelchair or bed frame, out of the patient's reach."

Manufacturer warnings noted "a restraint incorrectly or worn backwards may result in serious injury or death from suffocation, chest compression, or patient escape. Make sure straps cannot slide, tighten, or loosen if the patient pulls on them, or if the bed or chair seat position is adjusted. If the straps loosen, serious injury or death may occur from: patient escape; or from chest compression or suffocation if the patient becomes suspended in the restraint."

3) Observation of Patient #10 was made on 04/06/16 at 10:15 AM with Staff M, unit director, present. Patient #10 was alert, lying in bed, with a posey criss-cross type vest on. Staff M was asked to show where and how the vest was secured and to test the quick release tie on both the left and right sides. Inspection of the right strap revealed it was not secured to the bed frame but rather dangling loose over the right side of the bed.

Staff M confirmed upon own inspection that the right strap was not secured. When interviewed, Staff M confirmed both the right and left straps should be secured by quick release tie to the bed frame. Staff M then proceeded to tie the right strap.

Based on medical record review and staff interviews, the facility failed to ensure physician's order for restraint was followed and not used on a PRN (as needed) basis. This affected one of 10 patients whose medical record was reviewed for restraint orders, Patient #8.

Findings include:

1) Review of the medical record for Patient #8 revealed on 03/30/16 at 1:30 PM the physician signed a Restraint Order-Medical Management document. The order was for a "vest."

Ten minutes later, at 1:40 PM, the RN noted in a Nursing Free Text note "posey vest to be placed if appropriate, patient asked to stay in bed and agreeing at this time, family at bedside and tentative to patient and aware that patient needed to stay in bed due to fall risk. Patient finishing lunch. Posey not placed at this time due to patient being erectable and reassurance given."

At 2:37 PM in another Nursing Free Text note staff documented "pt restless and got out of bed in presence of family and fell landing on buttocks from standing position,...pt placed in posey vest."

Staff B confirmed the above findings on 04/06/16 at 2:15 PM during review of the electronic medical record.

Staff A was made aware of and confirmed these findings related to Patient #8 on 04/07/16 at 1:19 PM. Staff A stated he/she thought the order was good for 24 hours and confirmed there was not another order for the vest (restraint) to be applied.

Based on medical record review, policy review and interview, the facility failed to monitor the condition of two patients (#2 and #8) of 10 medical records reviewed at intervals determined by the facility's policy. This had the potential to affect all of the facility's 233 active patients.

Findings include:

1. The medical record review for Patient #2 revealed the patient was in restraints from 8:30 AM on 03/06/16 through 11:45 AM on 03/06/16. The Emergency Department Restraint Flowsheets listed the restraints were not released and range of motion was documented as "no" from 8:30 am through 10:55 AM on 03/06/16. The medical record did not contain documentation on the Emergency Department Restraint Flowsheets on 03/06/16 from 10:55 AM through 11:45 AM.

The facility's Restraint Use: Violent or Destructive Patient Behavior policy was reviewed. The policy stated attention will be given to such needs as range of motion, hydration, feeding and toileting every two hours.

The findings were shared with Staff C on 04/06/16 at 2:07 PM and confirmed.

2. Review of the medical record for Patient #8 revealed on 03/30/16 at 2:37 PM in a Nursing Free Text note staff documented "pt restless and got out of bed in presence of family and fell landing on her buttocks from standing position,...pt placed in posey vest."

Following the placement of the vest (restraint) at 2:39 PM on 03/30/16 there was no additional documentation related to the restraint. There were no additional documented ED Restraint Flowsheets and no documented evidence of how long Patient #8 remained restrained.

Patient #8 was then admitted to the facility's gero-psych unit from the ED at 5:23 PM. Again there was no documented evidence to reveal when or if the restraint was removed after Patient #8 was admitted.

Staff B was made aware of and confirmed the above findings during review of the electronic medical record on 04/06/16 at 2:52 PM.





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Based on medical record review, policy review and interview, the facility failed to ensure one patient (#2) of ten medical records reviewed, was free from all forms of abuse or harassment. This had the potential to affect all of the facility's 233 active patients.

Findings include:

Patient #2 was treated at the facility's emergency department from 03/06/16 at 7:40 AM through 03/09/16 at 11:05 AM.

Staff E's nursing note from 03/06/16 at 8:45 AM stated Patient #2 walked into the emergency department stating he has been suicidal for the last week and having plans to shoot himself with a gun, patient has access to guns at home. Patient #2 went to a behavioral health facility in attempt to get help and they sent Patient #2 to the facility's emergency department. Patient #2 arrived alone. When Patient #2 was told he needed to get undressed and blood work was needed, Patient #2 became agitated and stated he wanted to leave. The physician was immediately informed and physician "pink slipped" Patient #2.

The police department was called for assistance due to Patient #2's agitation and his threat to leave, his threatening statements and demeanor. Patient #2 was escorted back to Room 22. Patient #2 repeatedly stated "I'm not talking or telling you anything, we're done here. I'm not undressing, I'm leaving, I've changed my mind." Staff E explained to Patient #2 the protocol was to keep him and staff safe and he needs to be undressed for examination by the physician and social worker. Patient #2 refused after multiple attempts.

The police department physically gained control of Patient #2 and placed him on the emergency department cart with the help of security and male technicians. Patient #2 was combative, fighting and resisting, at this time the police department tased Patient #2 to maintain control and prevent anyone from getting injured. Patient #2 was laughing, thinking the situation was funny, being inappropriate and asking for it to be done again. Patient #2 continued to be resistant and the police department tasered Patient #2 again a few more times. During this time, locked restraints were applied to the Patient #2's extremities times four and Ativan and Haldol were administered intramuscular. Patient #2 was cussing and verbally abusive. Patient #2 continued to argue and be noncompliant.

The nurse explained the criteria (calm, cooperative, non threatening behavior) for restraint removal and Patient #2 understands. Patient #2's shirt and sweatshirt were cut off him in the process to maintain safety and for restraint application. Patient #2's pants and boxers were to be removed once he is more calm and sedated. The physician was made aware that Patient #2 was asserted. Patient #2 also has a history of assault on a police officer and served a felony charge in prison for eight years. Patient #2 has multiple stressors in his life.

Staff J's note from 03/06/16 at 9:00 AM stated during triage, Patient #2 reported he was suicidal and had access to weapons at home and that he "would put a pistol in his mouth". Patient #2 completed the triage process and staff was attempting to take Patient #2 to a room when he ripped off his hospital identification band and stated he was leaving. Patient #2 attempted to open door in triage to lobby and due to magnetic locks, he was unable to leave. Patient #2 began yelling at staff to "open the f****** door now!" The staff advised him of the inability due to the significant risk he presents to self and possibly others. Patient #2 walked out of back door of triage to main emergency department hall where he was unable to operate doors properly. Security was called and staff had the physician assist in trying to educate Patient #2 and verbally redirected him peacefully. The "police department was called as he was unwilling to cooperate with staff ". Patient #2 became physically and verbally aggressive with the police department and was physically restrained by the police department and taken to room 22. Once in the room he became more agitated and antagonizing to the police and staff. Patient #2 was to be restrained and medicated by the emergency department physician and staff attempted to restrain him and he became more physically aggressive and the police was forced to use a taser in a dry stun mode multiple times to effectively subdue Patient #2. Patient #2 was restrained to the bed and medicated by staff without injury to anyone involved including himself.

The medical record contained an Application for Emergency Admission form for Patient #2 dated 03/06/16. The form did not contain the time.

On 03/09/16 at 10:30 AM, Staff K documented an emergency department course for Patient #2. Staff K stated Patient #2 reportedly became agitated and required restraints. In discussion with nurse, Patient #2 required police to intervene. Patient #2 was reportedly tasered four times by the police to subdue Patient #2. Patient #2 was found to have rhabdomyolysis during the emergency department stay. "Likely cause of rhabdo were agitation, Cocaine, taser, intramuscular shots".

The facility's Irregular Occurrence Report Narrative, completed by the facility's security staff, was reviewed. The narrative stated the following:
On 03/06/16 at 7:55 AM, a security officer was called to the emergency department for an uncooperative patient. The officer arrived on scene with two additional security officers. A technician was talking to Patient #2. Patient #2 was reporting he wanted to leave and the physician came over and explained to him that he was being pink slipped. At this point, the police arrived on scene. Patient #2 tried to push past the police and security. Patient #2 was then escorted to room 22 by security and police. While in room 22, he became verbally combative, taunting and insulting the police, security and medical staff. The police then went hands on with Patient #2. The police, a nurse, a technician and security officers four-pointed him. During the altercation, Patient #2 was dry stunned (the Taser is held against the target without firing the projectiles, and is intended to cause pain without incapacitating the target. "Drive Stun" is "the process of using the EMD (Electro Muscular Disruption) weapon [Taser] as a pain compliance technique. This is done by activating the Taser and placing it against an individual's body) two to four times.

The facility's Code Violet -Violent Person Response policy was reviewed. The policy stated:
the facility is dedicated to the safety and well-being of its patients, physicians, visitors, and team members. The purpose of this policy is to establish a quick response with the appropriate personnel to control and de-escalate the situation.
Team members who observe violent behavior will take the following actions:
·Contact the Operator and alert them to the situation by dialing 4.4.1.1,
·Where possible the operator will page overhead 3 times (3 x 3) Code Violet and the location to respond to.
·Security at the Medical Centers, with assistance from Plant Operation's staff will curtail any threat to patients ,visitors, or other team members and take direction from ad assist the medical staff taking appropriate action as per crisis intervention training.
·Security at the Medical Centers will also contact Law Enforcement if there is a threat to staff, patients or others that cannot be internally controlled.
·Get assistance, as needed, from your fellow team members.
·Contact your Director/Coordinator and alert them to the situation.
·Keep the individual in sight and attempt to keep them calm through therapeutic communication.
In the event that a Code Violet is called, a Code Violet group will respond consisting of:
·Administrative Coordinator for Nursing
·Plant Operations (Medical Centers and MMC only).
·Crisis Team (Medical Center EDs).
·Other predetermined staff members.

NOTE: Situations that escalate into violence (verbal or physical) require a Patient Safety Report to be filed with Risk Management. The incident will be investigated by Security and reported to the Security Sub-Committee of the Environment of Care Standards Committee for review.

The medical record did

Based on medical record review, policy review and interview, the facility failed to monitor the condition of two patients (#2 and #8) of 10 medical records reviewed at intervals determined by the facility's policy. This had the potential to affect all of the facility's 233 active patients.

Findings include:

1. The medical record review for Patient #2 revealed the patient was in restraints from 8:30 AM on 03/06/16 through 11:45 AM on 03/06/16. The Emergency Department Restraint Flowsheets listed the restraints were not released and range of motion was documented as "no" from 8:30 am through 10:55 AM on 03/06/16. The medical record did not contain documentation on the Emergency Department Restraint Flowsheets on 03/06/16 from 10:55 AM through 11:45 AM.

The facility's Restraint Use: Violent or Destructive Patient Behavior policy was reviewed. The policy stated attention will be given to such needs as range of motion, hydration, feeding and toileting every two hours.

The findings were shared with Staff C on 04/06/16 at 2:07 PM and confirmed.

2. Review of the medical record for Patient #8 revealed on 03/30/16 at 2:37 PM in a Nursing Free Text note staff documented "pt restless and got out of bed in presence of family and fell landing on her buttocks from standing position,...pt placed in posey vest."

Following the placement of the vest (restraint) at 2:39 PM on 03/30/16 there was no additional documentation related to the restraint. There were no additional documented ED Restraint Flowsheets and no documented evidence of how long Patient #8 remained restrained.

Patient #8 was then admitted to the facility's gero-psych unit from the ED at 5:23 PM. Again there was no documented evidence to reveal when or if the restraint was removed after Patient #8 was admitted.

Staff B was made aware of and confirmed the above findings during review of the electronic medical record on 04/06/16 at 2:52 PM.





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