HospitalInspections.org

Based on interview and document review, the hospital failed to ensure patient rights were protected when a staff member assaulted a patient.

See A 0144.

An IJ was identified 7/23/20 at 1:00 p.m., related to patients receiving care in a safe setting. The IJ was removed 7/24/20, at 1:00 p.m., but the hospital remained out of compliance at the Condition of Patient Rights.

Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1), when an inadequately trained staff security guard (SG)-E assaulted P1 causing injury. This deficient practice resulted in an immediate jeopardy (IJ).

The IJ began on 7/14/20, when SG-E physically assaulted P1. Upon review, it was determined the staff member and five other staff members had not received required inpatient de-escalation training including implementation of safe physical holds, prior to working independently. Although the SG-E was terminated as a result of the incident, the remaining five staff members who had also not completed the required training, continued to work independently, having patient contact in difficult situations. Because the serious outcome was likely to recur and had the potential to impact all patients at the hospital, the hospital President, Vice President of Patient Care, Vice President of Quality, Director of Quality and Safety, Program Manager for Regulatory Compliance, and Chief Financial Officer were notified of the IJ finding on 7/23/20, at 1:00 p.m.

Findings include:

P1's history and physical dated 7/14/20, indicated P1 was admitted to the hospital on 7/14/20, from jail and under police custody after being found lethargic in his jail cell with several undissolved tablets in his rectum. P1 admitted to ingesting Oxycodone and Xanax. P1's history included polysubstance abuse. Toxicology was consulted and recommended overnight observation for P1. Prior to admission to the floor, P1 became acutely agitated while being checked for weapons by security. P1 was yelling and thrashing, pulling off cardiac monitoring cords, pulling out his IV, and was difficult to redirect. P1 refused the COVID 19 swab.

Review of a document authored by registered nurse (RN)-F dated 7/15/20, and titled S6 Critical incident 7/14/20, revealed on 7/14/20, at 8:35 p.m. P1 was admitted to the inpatient unit for observation related to ingestion of an unknown number of pills. Upon arrival to the unit, P1 was escorted by two law enforcement staff and SG-E. P1 was moved from the transport gurney to the bed, and was shackled to the bed by his right upper extremity and his left lower leg. The patient was cussing at staff and at 9:00 pm he pulled out an IV. The patient was attempting to crawl out of bed, and was swinging at staff and threatening to spit at staff faces. At 9:25 p.m. a behavioral emergency was called due to increased agitation and failed de-escalation attempts. P1 was placed in 4 point restraints, both arms and both legs. During the application of the restraint, RN-F saw SG-E with his arm across the side of P1's neck, and P1 stated "I can't breathe." As RN-F was attempting to remove SG-E from contact with P1, SG-E struck P1 in the face with his elbow. As SG-E was leaving the room, P1 yelled and spat at SG-E, and SG-E "charged" himself at P1 and hit P1 in the face 5 - 6 times with a closed fist. Law enforcement physically removed SG-E from the room.

P1's 7/15/20, discharge summary revealed P1 complained of tenderness to his left cheek, but no bleeding or bruising was observed upon examination. P1 declined imaging studies offered for diagnosis of further injuries.

SG-E's training records reviewed on 7/23/20, revealed he never completed the required training for security guards prior to 7/14/20. The required training SG-E should have received but did not included training related to patient de-escalation, safe use of restraints, and safe patient holds.

During an interview with RN-F on 7/21/20, at 2:00 p.m. he stated he was working with P1 on 7/14/20, when P1 arrived on the inpatient unit. He was aware the patient had ingested unknown substances, was in the custody of law enforcement, and had a history of violent behavior in the emergency department (ED). The patient was unhappy to be there, but allowed RN-F to put on his cardiac monitoring equipment and start an IV. At about 9:00 p.m. the patient pulled off the equipment, and pulled out his IV. At about 9:20 p.m. law enforcement requested help with the patient, and a PERT/behavioral emergency was called. The doctor was called and ordered four point restraints. During the restraint application, RN-F stated he saw SG-E place his forearm over P1's neck, pushing down on his neck. P1 said "I can't breathe." RN-F stated he assisted to pull SG-E off of P1. Then P1 said something to SG-E who then charged at P1 and used a closed fist to hit P1 in the face. SG-E was removed from the room.

During an interview on 7/21/20, at 1:30 p.m., RN-G stated on 7/14/20, P1 was pulling off his cardiac lines and yelling and swearing. RN-G observed SG-E put his forearm across P1's face to hold his face down. The patient spit at SG-E, and SG-E charged at the patient. RN-G stated she could see SG-E swinging his arms, but did not see him make contact with the patient.

During an interview on 7/21/20, at 3:25 p.m. RN-K stated that she was working on 7/14/20, when the incident occurred. She stated after the altercation, the P1's face was bleeding, and P1 was stating that he thought his arm and nose were broken.

During an interview on 7/21/20, at 12:05 p.m. security supervisor (SS)-J stated that he assisted in the investigation into the incident. He stated as part of the investigation he reviewed training records for SG-E. The training related to SG-E's orientation to his role was never documented as completed. SS-J stated that the six most recent security staff hired had not completed their orientation prior to working independently as security staff.

During an interview with SG-H on 7/23/20, at 7:30 a.m. he stated that he never received training in patient de-escalation techniques, safe use of restraints, or safe patient holds. He stated his training was all hands on and he learned de-escalation by watching his peers.

During an interview with SG-I on 7/23/20, at 8:40 a.m. she stated she did not get training related to safe patient holds, safe restraint use or patient de-escalation. She stated she shadowed a supervisor for a week and that was not enough to grasp what to do. She stated she was provided no formal training and was not tested out related to her skills. She stated she has many concerns related to this including:

1. Were the skills she learned elsewhere appropriate for use in the hospital setting?
2. Since her training lacked, she wondered who else lacked appropriate training?
3. She worried if things get bad, do other staff know the defensive tactics needed?
4. She had zero training in restraining violent people, she wished she had field training instead of learning as she went.

A review of security staffing for the most recent 3 weeks revealed the six security staff who had not completed their training/orientation worked 93 shifts independently, without supervision.

The IJ was removed on 7/24/20, at 1:00 p.m. when it could be verified the hospital had submitted and implemented an acceptable removal plan: appropriate education and training of security officers, verification of security officers' competency's in de-escalation, and verification of competency surrounding use of restraints.

The hospital's Restraint (Non-Violent and Violent) and seclusion Policy dated effective 12/16/19, included:

F. Staff Education:

1. All hospital staff involved in use of restraints and seclusion will, at the time of
hire (prior to use of restraints or seclusion), receive the following, as
appropriate to their clinical area:
a. Education to include:
i. Strategies to identify staff and patient behaviors, events, and
environmental factors that may trigger circumstances that require
the use of restraint or seclusion
ii. Use of nonphysical intervention skills
iii. Methods for choosing the least restrictive intervention based on
an assessment of the patient ' s medical or behavioral status or
condition
iv. Safe application and use of all types of restraint or seclusion
used in the hospital, including training in how to recognize and
respond to signs of physical and psychological distress (for
example, positional asphyxia)
v. Clinical identification of specific behavioral changes that indicate
that restraint or seclusion is no longer necessary
vi. Monitoring the physical and psychological well-being of the
patient who is restrained or secluded
b. Return demonstration of competence:
i. Safe application and use of all types of restraint or seclusion
used in the hospital.