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Based on observation, interview, and document review, the hospital failed to protect and promote patient rights for 1 of 10 patients (P1) reviwed for behavior disturbances. A security guard restrained P1 using a taser and handcuffs that are law enforcement tools. This resulted in the potential for serious harm, injuries or death for P1.

As a result of these failures, the deficient practices resulted in an immediate jeopardy (IJ). The hospital was found out of compliance with Condition of Participation Patient Rights at 42 CFR 482.13

The IJ began on 5/11/24 when facility security officer used a taser and handcuffs on P1. The Hospital Accreditation and Certification Program Specialist, 2 Safety and Quality Advisors, Patient Care Director, Security Director, System Accreditation Specialist, Vice President (VP) of Nursing Services, VP of Medical Affairs, VP of Security, VP of Safety, Quality and Experience and Director of Risk Management were notified of the IJ findings on 5/22/24 at 5:30 p.m. The IJ was removed on 5/24/24 at 2:00 p.m. after verification of an acceptable removal plan, but a condition level deficiency was issued.

The IJ was removed on 5/24/24 at 2:00 p.m. after the following actions were completed: Facility policies Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior and Use of Security Interventions were reviewed, and revisions approved. Facility policy Restraints: Non-Violent Behavior was reviewed with no changes. Hospital-wide procedure: Restraint/Seclusion for Violent and/or Self-Destructive Behavior was discontinued. Process change was implemented on the mental health unit. Code Green response team roles were reinforced, and role of clinical staff clarified in facility policy Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior. P1's care plan was updated. Audits were completed for utilization of agitation protocol on all patients on the mental health unit. Education was provided to all relevant staff prior to start of shift. Violent Restraint/Seclusion document audit was completed for all patients with active restraint use. This was verified through staff interview and document review.

Findings include:

See A-0154
Based on observation, interview and document review, the hospital failed to ensure a patient's rights to be free from restraint when a security officer used a taser and handcuffs that are law enforcement tool, for 1 of 10 patients (P1) reviewed for behavorial incidents.

Based on observation, interview and document review, the hospital failed to ensure a patient's rights to be free from restraint when a security officer used a taser and handcuffs that are law enforcement tool, for 1 of 10 patients (P1) reviewed for behavioral incidents. P1 was tased and placed in handcuffs during a behavioral health event with security officers.

Findings include:

P1's electronic medical record (EMR) indicated P1 was transferred to Mercy Hospital - Unity campus on 5/9/24. P1's diagnoses included schizoaffective disorder, bipolar type and methamphetamine use disorder.

P1's care plan 5/9/24 indicated risk for violence towards others with the following interventions: assist with self-control of anger, utilize verbal de-escalation preferences, initiate patient identified de-escalation preferences, manage inappropriate sexual behavior, manage aggressive behavior, safe application of restraints, seclusion, administer medications, and monitor effectiveness of medication.

Facility case report dated 5/11/24 indicated a taser was deployed with darts hitting P1 in the chest and sternum. P1 was then handcuffed and escorted into the seclusion room. The local police department arrived at the hospital but did not assume custody of P1.

On 5/11/23 at 12:28 p.m., video recording indicated P1 was in his room with the door closed. At 12:33:00, P1 entered the hallway and knelt on the floor with both hands placed on his head. Three security officers (SOs) were in the hallway approximately 6-8 feet from P1. P1 jumped to his feet, elbows at 90-degree angle with fists closed. He bounced around on his feet from side to side and backwards. The SOs were facing P1. P1's hands drop to his side, and he took a step towards the SOs. At 12:33:12, Two SOs drew their taser's and state "Don't do it" loudly several times. At 12:33:16, SO-A deployed his taser on P1. P1 fell to the floor and the SO and nursing staff attended to the patient. P1 was assisted to his feet with handcuffs around his wrists and was escorted to the seclusion room. The handcuffs were removed and P1 was placed in 4-point locked restraints. The taser darts were removed and 3 puncture areas were visible on P1's chest.

P1's EMR lacked documentation of interventions attempted prior to 12:28 p.m. video recording for event de-escalation.

On 5/21/2024 at 2:34 p.m., security manager stated the deployment of a taser is a law enforcement action. P1 was placed in handcuffs and the local police department were notified. When the police department arrived P1 was not placed into police custody.

On 5/22/2024 at 9:45 a.m., RN-A stated assessment of a patient after taser deployment was not part of any education he has received.

On 5/22/2024 at 10:58 a.m., SO-A stated the use of a taser is indicated when a patient is committing an assault on a nurse, security officer, or a visitor fears a patient will cause substantial or great bodily harm. SO-A stated the call started as a show of support (security presence in support of nursing staff) request. P1 was in his room yelling and doing push-ups and squats with his shirt off. SO-A felt very scared and fearful because elevated heart rate and pumped-up muscles are pre-attack indicators. SO-A stated he knew from report, P1's capability for violence was high due to P1's background. P1 came out of his room and knelt on the floor with his fingers interlaced on his head. When the Code Green (a code called by a staff member who identified unsafe or threatening behavior on the part of a patient, to summon additional personnel to continue de-escalation or to intervene) was paged overhead, P1 jumped to his feet and took several bladed stances (one foot in front of the other and the body is at an angle to the person in front that provides power for attacking, used in boxing). P1 made threatening comments. Then took one or two steps backwards and put his hands down then he took one step forward. As soon as P1 took that step forward SO-A thought he was about to get punched in the face so SO-A deployed his Taser. SO-A further stated one of the first darts missed P1, so SO-A deployed the second cartridge because two connections are required to get neuromuscular incapacitation (disruption of muscle function to stop an attacker). P1 was then handcuffed.

On 5/20/2024 at 4:20 p.m., RN-B stated when a patient's behavior is beginning to escalate, least restrictive interventions should be tried first like talking with the patient, music, decreased stimulation, food, beverage, and/or as needed medication. If the patient's behavior continues to escalate, the nurse could request a show of support from security officers. If that does not resolve the situation, a Code Green can be called. Verbal de-escalation should be continued during the entire process. RN-B stated she has not been trained to use a taser or handcuffs or to assess a patient following taser or handcuff use. RN-B stated the patient's nurse is responsible to lead a Code Green.

On 5/22/2024 at 1:38 p.m., Security manager (SM) stated security officers receive the same Code Green training as the nursing staff that includes the use of least restrictive interventions with the addition of security based training that is scenario based. A Code Green can be called by any staff member, but a nurse is always in charge of leading the code. Security is part of the team, but cannot make any clinical decisions like restraint application. Security staff are trained to utilize a TASER with specific training that is supplied by TASER and instructed by a TASER certified trainer. SM stated security staff are trained to use a TASER when an officer perceives an imminent risk of substantial (bite, kick, punch) or great (broken bone, death) bodily harm. SM stated they reviewed the event after it occurred. Based on the review P1 other measures that were least restrictive should have been implemented creating more space between SO-A and P1. SO-A seemed to have been leading to the Code Green. The Code Green process includes a registered nurse as the director of a Code Green.

On 5/22/2024 at 2:47 p.m., MD-A stated staff should utilize de-escalation techniques like talking, coping skills, a quieter environment, relaxation skills, or as needed medications when a patient is getting agitated. MD-A stated use of a taser could be a traumatic experience.

On 5/22/2024 at 3:34 p.m., MD-B stated the use of a taser could cause a life-threatening irregular heartbeat or a heart attack in a person with heart disease. MD-B would worry about taser use in the hospital because staff do not always know all of a patient's health conditions.

On 5/21/2024 at 2:39 p.m., accreditation program manager stated de-escalation techniques should be attempted first during a Code Green before a clinical decision is made for restraint use. A nurse or provider make clinical decisions during a code green. A TASER and handcuffs are not clinical restraints and should not be used as such.

The TASER Handheld Energy Weapon Warnings, Instructions, and Information: Law enforcement manufacturer document dated 9/20/22 indicated use of a taser could cause death or serious injuries including hernia rupture, dislocation, tear, or other injury to soft tissue, organ, muscle, tendon, ligament, cartilage, disk, nerve, bone or joint. Injuries may be more serious and more likely to occur in people with pre-existing injuries, orthopedic hardware, and other conditions or special susceptibilities including pregnancy, low bone density, spinal injury, or previous muscle, disk, ligament, joint, bone or tendon damage or surgery. Energy weapon use, anticipation of use, or response to use can cause startle, panic, fear, anger, rage, temporary discomfort, pain, or stress.

The TASER - Conducted Electrical Weapon policy dated 11/2022 instructed the TASER will not be used as a health care intervention to restrain patients, to place patients in seclusion, to punish, or to gain compliance of a resistant, nonviolent individual.

The Use of Security Interventions policy dated 1/23/24 instructed law enforcement tools must not be used as a clinical intervention or any part of patient care, including to gain patient compliance or subdue a patient to place the patient in restraint or seclusion. Law enforcement restraint devices may be used only to hold a person in custody when effecting an arrest and delivering them to the custody of law enforcement.