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Based on staff interviews and record review the hospital failed to ensure the rights of a patient to be free from the unauthorized use of restraint, in any form, by unauthorized individuals for 1 applicable patient. (Patient #9) Findings include:

On 3/12/13, a contracted security guard initiated an inappropriate and unauthorized "hands on" restraint hold to Patient #9. Per record review, Patient #9, a hearing impaired and developmentally disabled individual, was brought to the Emergency Department (ED) on 3/5/13 for evaluation for assualtive behavioral issues and possible psychiatric hospitalization. During Patient #9's prolonged stay in the ED, contracted security guards were frequently used to provide 1:1 observation of Patient #9. Per interview on 6/6/13 a witness stated while in the ED room with the patient, s/he observed a security guard use unwarranted physical restraint of Patient #9 on 3/12/13 at approximately 11:55 AM. The witness stated Patient #9 was sitting up on the side of an ED hospital stretcher and using his/her hands motioning for the security guard to "leave him/her alone" and running his/her finger across his/her lips addressing the security guard to not talk. Shortly after, the witness stated the security guard lurched toward Patient #9 shoving the patient back onto the stretcher by placing an open hand below the patient's throat, secured the patient's arms and placed his/her right leg on one of Patient #9's legs near the groin area. The witness stated s/he quickly left the room to seek help from ED staff for Patient #9.

Per interview on 6/11/13 at 2:10 PM, ED Physician #1 stated s/he recalled an incident on 3/12/13 involving Patient #9 and a security guard. Subsequent to the witness leaving the room, ED Physician #1 recalls walking by the ED room of Patient #9 and observed what s/he described as the "inappropriate" restraining of Patient #9 by a security guard. "S/he was pushing him/her down and holding him/her down". Physician #1 stated s/he pulled the security guard off of the patient and told the guard to leave the room. Physician #1 further stated s/he failed to report or document the incident because s/he felt the situation was "....over". Physician #1 stated s/he was surprised to see the incident between Patient #9 and the security guard, especially since the contracted security guards are not supposed to put hands on patients. ED Physician #1 also noted there was no indication from what s/he had observed after the incident that warranted the need to place Patient #9 in restraints.

Per interview on 6/12/13 at 8:55 AM, Nurse #1 confirmed s/he worked on 3/12/13 but was not aware of the incident between the security guard and Patient # 9. Nurse #1 confirmed after review of her/his nurse's note for 3/11/13, Patient was noted to be agitated at 12:05 and within 25 minutes s/he was able to calm Patient #9 down, noting s/he had the ability to work with this challenging patient and encouraged the patient to take his/her scheduled medications. When asked about the contracted security guards' role in the ED regarding physical contact with patients, Nurse #1 stated s/he thought the guards were not supposed to "...put hands on".

Per review of the hospital's policy Restraint and Seclusion last reviewed on 3/21/12 states "IV. PROCEDURE: B. Initiation: each episode of restraint shall be initiated; 1. Upon the order of a licensed independent practitioner who is responsible for the patient or 2. By trained registered nurse when he or she determines it is necessary to protect the patient......." it further states "J. Training: Designated hospital staff shall receive focused training as appropriate to perform assigned duties under this policy...". Per interview on the morning of 6/12/13 the Manager of QA/PI confirmed the contracted security officers are not "designated hospital staff" and lack the education, training and authority to implement the use a restraint. In the above mentioned incident, holding Patient #9 in a manner that restricts the patient's movement against the patient's will as observed, is considered a restraint.

Per interview and record review, the hospital failed to assure an assessment by ED staff was conducted to determine if a less restrictive intervention, if any, was required and/or implemented prior to the unauthorized restraint of a patient by a contracted security guard for 1 applicable patient. (Patient #9)
Findings include:

Per record review, Patient #9, a hearing impaired and developementally disabled individual, was brought to the Emergency Department (ED) on 3/5/13 for evaluation for assualtive behavioral issues and possible psychiatric hospitalization. During Patient #9's prolonged stay in the ED, contracted security guards were frequently used to provide 1:1 observation of Patient #9. Per interview on 6/6/13 Witness #1 stated while in the ED room with the patient, s/he observed a security guard use unwarranted physical restraint of Patient #9 on 3/12/13 at approximately 11:55 AM. The witness stated Patient #9 was sitting up on the side of an ED hospital stretcher and using his/her hands motioning for the security guard to "leave him/her alone" and running his/her finger across his/her lips addressing the security guard to not talk. Shortly after, the witness stated the security guard lurched toward Patient #9 shoving the patient back onto the stretcher by placing an open hand below the patient's throat, secured the patient's arms and placed his/her right leg on one of Patient #9's legs near the groin area. The witness stated s/he quickly left the room to seek help from ED staff for Patient #9. The security guard failed to seek assistance from ED staff who would be responsible for the individualized assessment of Patient #9 to determine if any intervention was indicated or necessary or if there was a physical threat of harm to the patient or others.

Per interview on 6/11/13 at 2:10 PM, ED Physician #1 stated s/he recalled an incident on 3/12/13 involving Patient #9 and a contracted security guard. Subsequent to the witness leaving the room, ED Physician #1 recalls walking by the ED room of Patient #9 and observed what s/he described as the "inappropriate" restraining of Patient #9 by a security guard. "S/he was pushing him/her down and holding him/her down". Physician #1 stated s/he pulled the security guard off of the patient and told the guard to leave the room. Physician #1 further stated s/he failed to report or document the incident because s/he felt the situation was "....over". Physician #1 stated s/he was surprised to see the incident between Patient #9 and the security guard, especially since the contracted security guards are not supposed to put hands on patients. ED Physician #1 also noted there was no indication from what s/he had observed after the incident that warranted the need to place Patient #9 in restraints.

Per interview on 6/12/13 at 8:55 AM, Nurse #1 confirmed s/he worked on 3/12/13 but was not aware of the incident between the security guard and Patient # 9. Nurse #1 confirmed after review of her/his nurse's note for 3/11/13, Patient was noted to be agitated at 12:05 and within 25 minutes s/he was able to calm Patient #9 down, noting s/he had the ability to work with this challenging patient and encouraged the patient to take his/her scheduled medications. When asked about the contracted security guards' role in the ED regarding physical contact with patients, Nurse #1 stated s/he thought the guards were not supposed to "...put hands on".

Per review of the hospital's policy Restraint and Seclusion last reviewed on 3/21/12 states "IV. PROCEDURE: B. Initiation: each episode of restraint shall be initiated; 1 Upon the order of a licensed independent practioner who is responsible for the patient or 2. By trained registered nurse when he or she determines it is necessary to protect the patient.......".

Based on interview and record review, the implementation of restraints by both police officers and contracted security guards was not in accordance with hospital policy for 1 applicable patient. (Patient #9) Findings include:

Per record review, Patient #9, a hearing impaired and developmentally disabled individual, was brought to the Emergency Department (ED) on 3/5/13 for evaluation for assaultive behavioral issues and possible psychiatric hospitalization and remained in the ED until 3/14/13. Per Emergency Nursing Record for 3/13/13 at approximately sometime before 0200, Patient #9 became combative and assaultive requiring emergency medications to include Haldol and Ativan. The note states Patient #9 " .....was placed into 4 point restraints Brattleboro police assisted with restraint application....". Per interview on the afternoon of 6/11/13, the ED Nurse Manager stated police are called only if a patient is violent and back up is needed, noting it was for staff safety and not specifically to intervene with patient care.

On 3/12/13 a witness observed a security guard lunged toward Patient #9 shoving the patient back onto a ED stretcher by placing an open hand below the patient's throat, secured the patient's arms and placed his/her right leg on one of Patient #9's legs near the groin area. This observation was confirmed by ED Physician #1 on 6/11/13 at 2:10 PM who had observed the security guard "inappropriately" restraining Patient #1 on 3/12/13.

Per review the hospital's policy Restraint and Seclusion last reviewed on 3/21/12 states "IV. PROCEDURE: B. Initiation: each episode of restraint shall be initiated; J. Training: Designated hospital staff shall receive focused training as appropriate to perform assigned duties under this policy... Such training shall take place prior to staff being asked to implement the provisions of this policy and shall be assessed for competency periodically as indicated in BMH training plan" . This policy did not indicate beside hospital staff other individuals to include the police or contracted security guards can apply or assist with the application of restraints. Per interview on the morning of 6/12/13, the ED Nurse manager confirmed contracted security guards are involved with the application of restraints under the direction/lead of ED staff despite the fact that they are not designated and appropriately trained hospital staff, as per policy.

Based on staff interviews and record review the facility failed to conduct a timely investigation to analyze the cause of an adverse patient event and identify opportunities for improvement; failed to ensure through their Quality Assurance and Performance Improvement (QA/PI) that identified preventable actions and mechanisms were fully implemented to include feedback and learning throughout the hospital. Findings include:

Per record review, Patient #9, a hearing impaired and developmentally disabled individual, was brought to the Emergency Department (ED) on 3/5/13 for evaluation for assaultive behavioral issues and possible psychiatric hospitalization. During Patient #9's prolonged stay in the ED, contracted security guards were frequently used to provide 1:1 observation of Patient #9. Per interview on 6/6/13 Witness #1 stated while in the ED room with the patient, s/he observed a security guard use unwarranted physical restraint of Patient #9 on 3/12/13 at approximately 11:55 AM. The witness stated Patient #9 was sitting up on the side of a ED hospital stretcher and using his/her hands motioning for the security guard to "leave him/her alone" and running his/her finger across his/her lips addressing the security guard to not talk. Shortly after, the witness stated the security guard lunged toward Patient #9 shoving the patient back onto the stretcher by placing an open hand below the patient's throat, secured the patient's arms and placed his/her right leg on one of Patient #9's legs near the groin area. Witness #1 stated s/he quickly left the room to seek help from ED staff for Patient #9. The security guard failed to seek assistance from ED staff who would be responsible for the individualized assessment of Patient #9 to determine if any intervention was indicated or necessary or if there was a physical threat of harm to the patient or others.

Per interview on 6/11/13 at 2:10 PM, ED Physician #1 stated s/he recalled an incident on 3/12/13 involving Patient #9 and a security guard. Subsequent to the witness leaving the room, ED Physician #1 recalls walking by the ED room of Patient #9 and observed what s/he described as the "inappropriate" restraining of Patient #9 by a security guard. "S/he was pushing him/her down and holding him/her down". Physician #1 stated s/he pulled the security guard off of the patient and told the guard to leave the room. Physician #1 further stated s/he failed to report or document the incident because s/he felt the situation was "....over". Physician #1 stated s/he was surprised to see the incident between Patient #9 and the security guard, especially since the contracted security guards are not supposed to put hands on patients. ED Physician #1 also noted there was no indication from what s/he had observed after the incident that warranted the need to place Patient #9 in restraints.

Although administrative staff were not initially appraised of the event of 3/12/13, communication was made via email and phone contact between the owner of the security company and the hospital's Director of Plant Services (who is responsible for the oversight/contract for the security operations for the hospital). Per interview on 6/12/13 at 10:10 AM, the Director of Plant Services was unsure of the specific date of notification regarding the event, however s/he acknowledged awareness of the adverse patient event but had not conducted his/her own internal investigation. Per interview on the morning of 6/12/13 the Manager for QA/PI also confirmed awareness of the adverse event of 3/12/13 but also has not analyzed the cause of the adverse event to determine if preventive actions were required to include implementing clarification of present policies and procedures that would require feedback and learning throughout the hospital. The Manager for QA/PI stated s/he was waiting for the owner of the security company to conduct their internal investigation. As of 6/12/13, the role and responsibilities of contracted security staff had not been reviewed or evaluated to determine if these individuals were performing their duties appropriately and always under the direction of ED staff. In addition, it was further identified ED staff, including nurses and physician, lacked a direct understanding of the role and responsibilities of the contracted security guards.