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Based on medical record reviews, review of facility documentation, review of facility policy and interviews for two patients who required behavior management (Patient #1, #2), the facility failed to ensure that least restrictive measures were implemented when the patient exhibited acute behavioral dyscontrol to prevent a fracture and/or ensure that appropriate restraint techniques were implemented to prevent a shoulder muscle injury and/or that the patient was free from intimidation and/or coercion.


Cross Reference to A144, A145, 154 and 167.

Based on medical record reviews, review of hospital documentation/ policies, observations and interviews the hospital failed to notify patients of staff observance during patient clothing change and in- room video monitoring in the behavioral health unit (BHU) section of the ED. The findings include:

A tour of the ED BHU was conducted on 6/16/11 at 10:10 am with the Director of the ED (Director #1). Observation on 6/16/11 at 10:30 AM noted that the small changing room door was unlocked by Director #1, a mirror was on the wall and the room could be visualized through this mirror from an adjacent room (one- way mirror). Interviews with the Director and RN #4 on 6/16/11 at 10:30 AM noted that patients are not informed of the one- way mirror or that they would be observed when changing from personal clothing to hospital garments. The behavioral health patient screening policy identified that security would wand the patient prior to entering the changing room in the BHU and a nurse or ED technician would observe the patient undress via the one was mirror. The patient rights policy identified that the patient had the right to be informed and ask questions about hospital policies and practices related to patient care and treatment.

Based on medical record reviews, review of hospital documentation, review of hospital policies and procedures and interviews for two of ten patients who required security assistance for behavior management (Patients #1, #2), the hospital failed to ensure that the patient's behavior was managed safely. The findings include:

1. Patient #1 was admitted to the emergency department (ED) on 4/30/11 at 8:21A.M. with a police emergency evaluation request and chief complaint of anxiety. Nursing documentation dated 4/30/11, 8:38 A.M. identified that the patient presented with severe anxiety, Ativan was ordered and refused by the patient and the patient was referred to the mental health evaluation team at 8:55 AM on 4/30/11. The nursing documentation further noted that the Behavioral Health Unit (BHU) nurse, RN #3 and a Security Officer, (SO #1) came to the patient's ED room to try to persuade the patient to change into hospital garments and take antianxiety/antipsychotic (Ativan/Haldol) intramuscularly (IM)), medications that were ordered by the physician. Nursing narratives and facility documentation dated 4/30/11 identified that the patient had unpredictable behavior, changed his/her mind to cooperate and was manually restrained by SO #1 and nursing staff for IM medication administration at 9:23 AM. The narratives and documentation further noted that the patient agreed then disagreed to change into hospital garments, was manually restrained a second time, and garments were forcibly removed by cutting the patient's clothing. The documentation, nursing narratives and an x-ray dated 4/30/11 at 9:44 AM noted that RN #2 heard a "pop" while the patient was restrained, complained of left shoulder pain and was diagnosed with a comminuted fracture of the left shoulder. Interviews with RNs #2 and #3 on 6/15/11 identified that staff attempted to change the patient into hospital garments before medication effects could be achieved. They further indicated that they suggested moving the patient to the BHU in the ED to undress the patient but that SO #1 informed them that it was against protocol. During interview with RN #2 on 6/16/11 at 1:40 PM, the ED Manager replied it was a "team approach" and the Director of Risk Management/Legal Services identified the nurse as the person in charge during the hands- on security response to the patient's behavior on 4/30/11. Although the ED Manager stated that it was a "team approach", the hospital Code Security policy identified that once security arrives, they will take a lead role in resolving the emergency. The hospital submitted a Corrective Action Plan (CAP) dated 6/1/11 for completion by 8/1/11 that included a review of the event and de-escalation and Manangement Of Aggressive Behaviors (MOAB) refresher for Security Officer #1. Although the hospital complied with the CAP as submitted, the CAP failed to address education/reeducation for the remainder of security staff and nursing staff for situational management involving behaviorally aggressive/non- compliant patients.

2. Patient #2 had a history of multiple sclerosis (wheelchair bound) and was admitted to the ED on 1/3/11 at 7:09 PM for altered mental status. The physician's assessment dated 1/3/11 identified that the patient was oriented and had normal range of motion. Nursing narratives dated 1/4/11, 10:30P.M. noted that the patient became agitated, uncooperative, yelled, screamed and wanted to leave. The narrative further indicated that Ativan 2mg IM was administered as ordered by the physician with good effect and with the assistance of security (Security Officers #2 and #3 responded). Nursing narratives dated 1/5/11 at 2PM identified that the patient complained of left arm/shoulder discomfort indicating that it had been present since admission to the in- patient unit (1/4/11 at 10:58 PM). The left shoulder magnetic resonance imaging dated 1/6/11 identified severe strain of the teres minor muscle and mild strain of the posterior portions of the left deltoid muscle. Interview with the Security Manager on 6/15/11 at 10AM identified that s/he questioned Security Officer (SO) #3 about the 1/3/11 security response for Patient #2. The Security Manager indicated that SO #3 used an escort hold on the patient ' s left arm to assist the nurse with medication administration when the patient was in a wheelchair. The Security Manager reported that SO #3 indicated that the hold technique caused the patient to lean forward, SO #3 heard a "pop" and the patient exhibited pain. Further interview and review of the hospital policy for the management of aggressive behavior (MOAB) with the Security Manager on 6/15/11 identified that the escort hold was used to direct patients from point A to point B or from a standing position to a prone position on the ground (not to restrain an arm). Interviews with the Director of Security on 6/16/11 at 11:40 AM noted that hospital policy for MOAB was not followed by SO #3 in response to the situation for Patient #2 on 1/3/11. The hospital job description for SO identified that an essential function of the SO was to use proper MOAB techniques to protect the safety of self and others at all times.

Based on medical record reviews, review of hospital documentation, review of hospital policies and interviews for one of ten patients who required security assistance for behavior management (Patient #2), the hospital failed to ensure that the patient remained free from intimidation. The findings include:

Patient #2 had a history of multiple sclerosis (wheelchair bound) and was admitted to the ED on 1/3/11 at 7:09 PM for altered mental status. The physician's assessment dated 1/3/11 identified that the patient was oriented and had normal range of motion. Nursing narratives dated 1/4/11, 10:30P.M. noted that the patient became agitated, uncooperative, yelled, screamed and wanted to leave. The narrative further indicated that Ativan 2mg IM was administered as ordered by the physician with good effect and with the assistance of security (Security Officers #2 and #3 responded). Nursing narratives dated 1/5/11 at 2PM identified that the patient complained of left arm/shoulder discomfort indicating that it had been present since admission to the in- patient unit (1/4/11 at 10:58 P.M.). The left shoulder magnetic resonance imaging dated 1/6/11 identified severe strain of the teres minor muscle and mild strain of the posterior portions of the left deltoid muscle. Interview with the Security Manager on 6/15/11 at 10AM identified that s/he questioned Security Officer (SO) #3 about the 1/3/11 security response for Patient #2. The Security Manager indicated that SO #3 used an escort hold on the patient's left arm to assist the nurse with medication administration when the patient was in a wheelchair. The Security Manager reported that SO #3 indicated that the hold technique caused the patient to lean forward, SO #3 heard a "pop" and the patient exhibited pain. The Security Manager identified that the escort hold was used to direct patients from point A to point B or from a standing position to a prone position on the ground (not to restrain an arm). Interviews with SO #2 and RN #1 on 6/15/11 and 6/16/11 noted that they heard SO #3 asked the patient to apologize to the nurse as SO #3 held the patient's left arm. Written documentation from Person #1 dated 2/11/11 noted that the patient informed Person #1 that SO #3 twisted the patient's left arm, asked the patient "That hurt, didn't it? Now apologize". The hospital policy for patient rights identified that the patient should expect considerate and respectful care at all times. The policy further noted that the patient should expect to be free from neglect, exploitation and all forms of abuse and harassment from staff.

Based on medical record reviews, review of hospital documentation, review of hospital policies and interviews for one of ten patients who required security assistance for behavior management (Patient #1), the hospital failed to ensure that the patient was free from coercion. The findings include:

Patient #1 was admitted to the emergency department (ED) on 4/30/11 with a police emergency evaluation request and chief complaint of anxiety. Nursing documentation dated 4/30/11 identified that the patient presented with severe anxiety, Ativan was ordered and refused by the patient and the patient was referred to the mental health evaluation team at 8:55 AM on 4/30/11. The nursing documentation further noted that the behavioral health unit (BHU) nurse, RN #3 and a security officer, (SO #1) came to the patient ' s ED room to try to persuade the patient to change into hospital garments and take antianxiety/antipsychotic (Ativan/Haldol intramuscularly (IM)) medications that were ordered by the physician. Nursing narratives and/or facility documentation dated 4/30/11 identified that the patient had unpredictable behavior, changed his/her mind to cooperate and was manually restrained by SO #1 and nursing staff for IM medication administration at 9:23 AM. The narratives and/or documentation further noted that the patient agreed then disagreed to change into hospital garments, was manually restrained a second time and garments were forcibly removed by cutting the patient ' s clothing. Interview with Manager #2 on 6/16/11 at 1:40 PM noted that if the IM medication that was administered to the patient was effective, it would typically take effect in 30 to 45 minutes. Interviews with RNs #2 and #3 on 6/15/11 identified that staff attempted to change the patient into hospital garments before medication effects could be achieved. Although interview with Manager #2 on 6/16/11 at 1:40 PM indicated that patient clothing required removal to ensure that patients did not have items that could cause injury, measures to maintain the patient's safety while ensuring the patient's rights were not tried to include increased monitoring, wand the patient's clothing and/or waiting for medication effectiveness until the patient became more compliant

Based on medical record reviews, review of hospital documentation, review of hospital policies and interviews for one of ten patients who required security assistance for behavior management (Patient #2), the hospital failed to ensure that the technique used to restrain the patient was in accordance with facility policy. The findings include:

Patient #2 had a history of multiple sclerosis (wheelchair bound) and was admitted to the ED on 1/3/11 at 7:09 PM for altered mental status. The physician ' s assessment dated 1/3/11 identified that the patient was oriented and had normal range of motion. Nursing narratives dated 1/4/11, 10:30 P.M. noted that the patient became agitated, uncooperative, yelled, screamed and wanted to leave. The narrative further indicated that Ativan 2mg IM was administered as ordered by the physician with good effect and with the assistance of security (Security Officers #2 and #3 responded). Nursing narratives dated 1/5/11 at 2PM identified that the patient complained of left arm/shoulder discomfort indicating that it had been present since admission to the in- patient unit (1/4/11 at 22:58 AM). The left shoulder magnetic resonance imaging dated 1/6/11 identified severe strain of the teres minor muscle and mild strain of the posterior portions of the left deltoid muscle. Interview with the Security Manager on 6/15/11 at 10AM identified that s/he questioned Security Officer (SO) #3 about the 1/3/11 security response for Patient #2. The Security Manager indicated that SO #3 used an escort hold on the patient ' s left arm to assist the nurse with medication administration when the patient was in a wheelchair. The Security Manager reported that SO #3 indicated that the hold technique caused the patient to lean forward, SO #3 heard a " pop " and the patient exhibited pain. Further interview and review of the hospital policy for the management of aggressive behavior (MOAB) with the Security Manager on 6/15/11 identified that the escort hold was used to direct patients from point A to point B or from a standing position to a prone position on the ground (not to restrain an arm).

Based on medical record reviews, review of facility documentation, review of facility policies and interviews for one of two patients whose restraint use resulted in injury (Patients #1), the facility failed to fully analyze the event. The findings include:

Patient #1 was admitted to the emergency department (ED) on 4/30/11 with a police emergency evaluation request and chief complaint of anxiety. Nursing documentation dated 4/30/11 identified that the behavioral health unit (BHU) nurse, RN #3 and a security officer, (SO #1) came to the patient ' s ED room to try to persuade the patient to change into hospital garments and take antianxiety/antipsychotic (Ativan/Haldol intramuscularly (IM)) medications that were ordered by the physician. Nursing narratives and facility documentation dated 4/30/11 identified that the patient was manually restrained by SO #1 and nursing staff for IM medication administration at 9:23 AM. The narratives and/or documentation and/or staff interviews conducted from 6/14/11 to 6/16/11 noted that staff manually restrained the patient a second time immediately after the administration of medication and before medication effects could be achieved in an attempt to change the patient's clothing. The facility documentation dated 4/30/11 identified that the patient's garments were forcibly removed by cutting the patient's clothing. The patient complained of left shoulder pain immediately following the incident and was diagnosed with a comminuted fracture of the left shoulder. The hospital submitted a corrective action plan (CAP) dated 6/1/11 which indicated a completion date of 8/1/11 that included a review of the event; found that standards were followed and that the plan included education/reeducation for Security Officer #1. Interviews with the Director of Case Management/Quality and the Director of Security on 6/16/11 noted that although occurrence reports were filed for hands- on security events the event would not be tracked or trended by Quality unless the occurrence was serious and deviated from practice. The Director of Case Management/Quality identified that the event involving Patient #1 would not be tracked/trended.

Based on medical record reviews, review of facility documentation, review of facility policies and interviews for two of two patients who sustained injury following the use of manual restraints (Patients #1, #2), the facility failed to fully implement preventive actions following the occurrences. The findings include:


Patient #1 was admitted to the emergency department (ED) on 4/30/11 with a police emergency evaluation request and chief complaint of anxiety. Nursing narratives and/or facility documentation dated 4/30/11 identified that the patient was manually restrained by SO #1 and nursing staff for IM medication administration at 9:23 AM after verbal persuasion proved unsuccessful. The narratives and/or documentation and/or staff interviews conducted from 6/14/11 to 6/16/11 noted that staff manually restrained the patient a second time immediately after pain medication administration and before medication effects could be achieved in an attempt to change the patient's clothing. The facility documentation dated 4/30/11 identified that the patient's garments were forcibly removed by cutting the patient's clothing. The patient complained of left shoulder pain immediately following the incident and was diagnosed with a comminuted fracture of the left shoulder. Although the hospital submitted a corrective action plan (CAP) dated 6/1/11 that included, in part, education/ reeducation for Security Officer #1, the CAP failed to address education/reeducation for the remainder of security staff and nursing staff for situational management involving behaviorally aggressive/non- compliant patients. In addition, although a two- hour de-escalation class was implemented following the incident, the class exempted all other staff who had already received aggressive behavior management training.

2. Patient #2 had a history of multiple sclerosis (wheelchair bound) and was admitted to the ED on 1/3/11 at 7:09 PM for altered mental status. Nursing narratives dated 1/4/11, 10:30 P.M. identified that the patient became agitated, threatened to leave and Ativan 2mg IM was administered as ordered by the physician with good effect and with the assistance of security (Security Officers #2 and #3 responded). Nursing narratives dated 1/5/11 at 2PM identified that the patient complained of left arm/shoulder discomfort indicating that it had been present since admission to the in- patient unit (1/4/11 at 10:58 P.M.) and was diagnosed with severe and minor strains of the left arm/shoulder muscles. Review of facility policies and/or staff interviews conducted on 6/15/11 and 6/16/11 identified that SO #3 used an inappropriate technique to restrain the patient's left arms and staff heard SO #3 ask the patient to apologize to the nurse as SO #3 restrained the patient's left arm. Further interview with the Security Manager on 6/15/11 at 10:00 A.M. noted that SO #3 was disciplined because s/he failed to file an occurrence report which was a breech of policy. Although interview with the Director of Security on 6/16/11 at 11:40 AM identified that SO #3 failed to follow the policy for Management of Aggressive behavior, reeducation for the remainder of security staff to prevent further occurrence was not implemented.