HospitalInspections.org

Based on observation, interview, record review and document review, the facility failed to ensure: 1) patient had the right to receive care in a safe setting (Tag A0144) and 2) patient had the right to be free of unnecessary restraint (Tag A0154).

The cumulative effect of these systematic practices resulted in the failure of the facility to provide safe care to patients, while protecting their rights and promoting their dignity.

Based on policy review, record review, video observation and interview, the facility failed to ensure care was provided and delivered in a safe setting. Specifically, the facility restrained a patient without orders and for coercion for 1 of 20 patients (Patient 1), misappropriated patients' phones for 3 of 20 patients (Patient 1, 9 and 17), and failed to follow policies and directives regarding security related incidents with patients as demonstrated by security's failure to document patient encounters in an identifiable way for monitoring and oversight.

Findings include:

The facility policy titled Patient Bill of Rights and Patient Responsibility dated November 2020, documented patients had the right for care and the ability to exercise their rights without limitations, bullying, abuse, or harassment.

1) Patient 1 (P1) was admitted to the Emergency Department (ED) on 04/15/2023, with alcohol intoxication as a chief complaint.

On 04/25/2023 in the morning, security surveillance camera footage recorded on 04/15/2023 was reviewed with the Chief Nursing Officer, the Director of ED, the acting Risk Management Director, and the Corporate Market Manager of Security. The video revealed the following:

On 04/25/2023 at 2:23 AM, P1 arrived at the ED on a gurney, accompanied by two ambulance personnel. P1 was admitted to the ED and placed by the ambulance personnel on a gurney located in the ED hallway.

On 04/15/2023 at 4:04 AM, P1 seemed to be using their phone. A security guard (SG1) was walking through the hallway and passed by P1. SG1 turned their attention to P1 and returned. SG1 interacted with P1 without incident and then, left the area.

On 04/15/2023 at 4:06 AM, SG1 and a second security guard (SG2) approached P1. SG2 established a conversation with P1 while the patient laid in a gurney. After approximately one minute of interaction, SG1 and SG2 went to the nurse's desk and talked to the Registered Nurse in Charge (CN).

On 04/15/2023 at 4:08 AM, SG1 and SG2 approached P1 again. SG2 tried to grab P1's phone having physical contact. After approximately 30 seconds of interaction, P1 got up from the gurney and attempted to leave but SG forcibly placed P1 back on the gurney, holding the patient and preventing the patient from leaving the ED.

On 04/15/2023 at 4:09 AM, SG2 called to a staff member that was sitting in the hallway (identified as a Certified Nursing Assistant (CNA)). The CNA assisted in physically restraining P1 while SG2 grabbed P1's left arm. The video revealed P1 was resisting the SG2's forced intervention to obtain P1's phone and appeared to have placed their phone in the bra. In the struggle with SG2, P1's private body areas were exposed, and SG2 covered them with a sheet.

On 04/15/2023 at 4:10 AM, a male ED Technician and the CN arrived and helped SG2 restrain P1. Video review revealed P1's blanket was removed exposing the patient. Immediately afterwards and with the help of the ED Technician, the CN, SG1 and the CNA, SG2 placed P1 on the floor. Four point (both arms, both legs) physical restraint was applied by grabbing P1's outstretched arms and with the patient's legs apart. It was noted P1 fighting back trying to break the restraint. After about four to five minutes, the CN grabbed P1's cell phone and returned to the charge desk. The CN was observed checking P1's phone. SG2 grabbed P1 from the floor and placed back in the gurney.

On 04/15/2023 at 4:15 AM, the ED Technician and two staff members assisted a nurse to remove an intravenous (IV) line from P1's right arm. It was noted that after obtaining P1's phone, staff left the scene and the violent situation deescalated.

On 04/15/2023 at 4:16 AM, SG2 and the ED Technician grabbed P1 by their arms and forcibly dragged P1 through the hallway. At the ED ambulance entrance, P1 was grappling with SG2 and the ED Technician attempting to prevent from being removed from the ED. Several times, SG2 pushed P1 out from the ED ambulance entrance.

On 04/25/2023 at 4:05 PM, the House Supervisor on duty the day the incident occurred, indicated Law enforcement agents requested the ED video surveillance records on 04/16/2023. The Supervisor stated nobody had been notified about the incident occurred in the ED on 04/15/2023 involving P1 and staff members. The Supervisor indicated the police detectives asked why P1 was retained if wanted to leave the facility and had a safe ride and a family member. The Supervisor indicated personal property could not be removed from patients against their will unless the belongings represented a safety issue to the patient or others. Personal property was retained only for safeguard purposes. The Supervisor indicated one valid reason to confiscate a phone was in the event a confused patient start calling 911, but after re-directing, the phone should be returned. The Supervisor did not have details about the incident and did not know why the staff removed the phone from P1. The Supervisor stated the actions taken by the staff to confiscate P1's phone such as the use of force and restraint could not be justified.

On 04/25/2023 at 1:34 PM, the Security Manager indicated there were three possible scenarios that could trigger ED staff to request assistance from the security personnel to restrain a patient; a combative patient placed in legal hold, an agitated intoxicated person, or a person attempting to commit harm to themselves or others. The Security Manager explained if a person was found filming in the facility premises and the recorded video could lead to a potential HIPAA (Health Insurance Portability and Accountability Act) violation, the staff would kindly request the person to stop filming and delete the video. If the person refused to follow the request, that person could be trespassed from the facility. In this case, the staff should contact the house supervisor and law enforcement called depending upon the situation. The Security Manager stated during the incident with P1, the staff did not elevate the concern to the house supervisor or to the Administrator on Call (AOC). The Security Manager acknowledged the use of force to obtain P1's cell phone was out of the established policies and procedures and the staff did not have the authority to perform a search on a person or private property such as a cell phone, only law enforcement following police procedures could have performed these actions with a search warrant.

On 04/26/2023 at 7:40 AM, the CN who oversaw the Emergency Department the day the incident occurred, indicated P1 was placed in a hallway where patients suspected to be under influence were located. P1 had not displayed disruptive behavior at the time of admission. The CN heard about P1 when received a report that P1 had refused blood draw. The CN indicated had heard a female screaming in the hallway and went to verify what was going on. The CN found about five staff members including the security personnel restraining the patient. When asked about the situation, was informed P1 was filming and refused to give the phone to SGs. The CN talked to P1 trying to calm the situation down, but P1 was combative and cursing staff. The CN indicated SG2 took P1's phone and brought the phone to the charge desk. The CN indicated the phone was checked for battery but did not access the phone to delete the video, since it was locked. The CN explained had forgotten to return the phone to P1 when the patient was removed from the ED. The CN did not question the security staff about the procedure to remove the phone because was not familiar with security protocols. The CN stated the House Supervisor was not notified about the incident since had believed was not necessary.




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Restraint and Seclusion policy last revised June 2022, Section IVA. of the Restraint and Seclusion policy provided revealed the patient has a right to be free from restraint or seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff.

-The surveillance video and interviews demonstrated the employees restrained the patient as a means of coercion, punishment, discipline, or retaliation in order to obtain the patient's phone.

Section IVB. of the Restraint and Seclusion policy provided revealed the patient's rights, dignity, privacy, safety, and well-being will be supported and maintained.

-The surveillance video and interviews demonstrated the employees who restrained the patient to obtain the phone violated the patient's rights, dignity, privacy, safety, and well-being.

Section IVF. of the Restraint and Seclusion policy provided revealed the use of restraint must be in accordance with the order of a physician or other authorized licensed practitioner.

-P1's medical record lacked documented evidence of a physician order for restraint(s) of any kind.

Section IVG. of the Restraint and Seclusion policy provided revealed when restraint or seclusion was initiated without an order by a licensed independent practitioner: a registered nurse initiated the restraints based on an assessment that justified the use of restraints. In these emergency application situations, the order must be obtained either during the emergency application of restraints, or when the nurse could safely do so.

-The surveillance video lacked observational evidence a registered nurse conducted a required assessment.

On 04/26/2023 at 10:14 AM, Security Guard 2 (SG2) indicated the Charge Nurse (CN) said to get the patient (P1) out of here; the patient was discharged. The patient wanted the phone and would not leave without the phone. SG2 explained they could not get the patient to leave, so the patient was perceived as trespassing. A medium standing hold was employed with an emergency department technician, and they escorted P1 outside the emergency department. Once outside, the CN wanted to get the pass code to delete the video. P1 gave SG2 the pass code who told the CN who said to delete the video. SG2 verbalized accessing the phone with the pass code, deleting the video, and returning the phone to the patient.

On 04/26/20233, at 7:40 AM to 8:25 AM, the Registered Nurse in Charge (CN) explained, the CN watched department, did assignments, did supervisory duties; anything not able to be handled was escalated to the house supervisor. Received yearly training including abuse/neglect and patient rights. The CN recalled on 04/15/2023, P1 refused blood draw and said we gave bad care. Provider talked to patient to obtain labs and patient was willing to give blood if facility allowed significant other in the back. They had decided against that because of hostility and presence of three other similar patients. Security made rounds. Heard patient yelling and screaming, translated to combativeness to this registered nurse. The CN denied saying security should take phone and let security handle its business. The CN did not make a connection between the patient's behavior and the staff subduing the patient. The CN knew security did not have right to take the phone but said nothing as patient advocate. The CN did not question or know why security did this. The CN did not see security take phones before. The CN did not report this to the house supervisor.

ED staff interviews included two ED Technicians, a Certified Nursing Assistants (CNA) and two Registered Nurses (RNs) on 04/26/2023 in the morning, consistently revealed P1 had been requested to stop videotaping and when P1 refused, security had attempted to retrieve P1's phone. The attempt to retrieve the phone escalated the patient into shouting and combativeness with staff members. The staff members indicated the CN was aware of security taking the phone from the patient and had asked security to remove the patient from the ED and delete the video. An RN explained the CN asked the nurse to hold the patient's arm and directed to take the phone as video needed to be deleted. An ED Technician revealed had observed P1 wrapped up in white hospital sheets and had helped lift the patient from the floor back to the gurney. The ED Technician indicated P1 had kicked a nurse and was screaming and making verbal threats. Once removed from the ED, P1 provided the password to the phone and security deleted the video. P1 did not receive the phone back until local police had arrived.

On 04/26/2023 at 9:53 AM, Security Guard 1 (SG1) explained had seen P1 recording and asked the patient twice to stop recording and patient refused both times. SG1 went to get the lead security officer (SG2). SG2 asked the patient to stop recording several times or the phone would be taken. The patient still refused. SG2 went to the CN. The CN said to confiscate the phone and discharge the patient.

SG2 asked the patient one more time at the gurney for the patient to stop recording but was refused. SG2 used a CPI (certified restraint hold technique) move to neutralize the patient, so the CNA could take the phone. The patient moved around, kicked, and went to the floor (with personnel crowded around). The patient was assisted to the gurney by employees. At some point, the phone was obtained. The phone went to the CN. The CN had asked SG2 if the video could be deleted. The CN was the one who said confiscate the phone, discharge the patient, and escort the patient out. SG1 saw SG2 access the phone and delete the video. The patient would not leave without the phone, and P1 called local police. The police obtained the phone and returned it to the patient.

On 04/26/2023, at 10:14 AM, SG2 described the incident with P1, explaining had seen P1 recording and told the patient to stop recording. SG2 repeated to the patient for 5-6 minutes that the patient could not record or there could be a $9000 fine (for HIPAA laws). The patient used profanity and refused. SG talked to the CN and was directed to follow policy, resulting in confiscating the phone. SG2 tried to tell the patient again to stop recording and delete the video. SG2 saw the phone inside the shoulder strap of a dress and the CNA was asked to witness. SG2 asked the patient again to delete the video refused. P1 tried to prevent security from taking the phone. Employees crowded around the patient on the gurney, and the employees held the patient down on the gurney while the patient kicked and screamed. The CN asked the patient to calm down. The patient wanted to be let go. The patient was taken down on the floor and covered up during the process. The CN said to get the patient out of here and the patient was discharged. The patient refused to leave because of wanting the phone. SG2 indicated this was trespassing because they could not get the patient to leave with verbal commands. A medium standing hold was used by SG2 and another ED technician to escort the patient out. Once outside, the CN wanted to get the patient's password to delete the video, saying we will give the phone back then. Police were called by the patient's spouse. The patient eventually provided the password, SG2 relayed this info to the charge nurse, who then directed to delete the video.

SG2 revealed had been told to take patients' phones before, although most people deleted video when asked. SG2 did not think anything was wrong and was only doing what the charge nurse had directed. SG2 indicated patients recording in the ED was a HIPAA violation, and these violations were reported to risk management. There should be an acknowledgment in the MIDAS system and an incident report.

2) Patient 9 (P9) was admitted to the Emergency Department on 12/02/2021, with abrasion / laceration resulted as passenger in a motor vehicle accident. During the stay, the patient filed a grievance regarding security and nursing staff confiscating a phone.

On 12/15/2021, the Risk Manager apologized for the phone confiscation via grievance letter.

On 04/26/2023 at 1:30 PM, the Marketing Manager of Security (MMS) indicated a final warning letter was issued to the security officer involved, and the officer was later terminated. The MMS verbalized there may have been a verbal counseling, but there was no documented evidence; this was considered an anomalous event.

On 04/26/2023 at 3:00 PM, the Risk Manager at the time of the above incident, indicated it was discussed in a leadership safety huddle and then passed to department safety huddles for dissemination. The Risk Manager recalled the Security Manager was shocked by the phone confiscation at the time.

3) Patient 17 (P17) was admitted to the Emergency Department on 01/30/2023 with alcohol intoxication.

P17's medical record revealed on 01/30/2023 at 2:25 AM, a registered nurse documented, patient attempted to call a named person two times...informed 911 that patient is being held against will...Patient then took out phone and took picture of nurse and started recording. Nurse instructed patient to delete and respect privacy...Patient became agitated and aggressive toward nurse. Nurse obtained phone and handed it to charge nurse. The patient was put in restraints.

On 04/26/2023 at 1:30 PM, the Chief Nursing Officer, MMS and the Security Manager expressed a lack of knowledge about this event.

On 04/25-26/2023, the security department's daily activity reports were reviewed and revealed the following:

- On 03/12/2023 at 4:00 PM, an incident was identified between SG2 and a patient. SG2 documented "call received for a patient who was recording nurse and other staff as they entered room. Security made the patient delete the video."

On 03/12/2023, at 4:00 PM, SG2 documented a Daily Activity Report (DAR) with the entry, "security made a patient delete video after recording a nurse and other staff".

-On 03/17/2023 at 6:20 PM, an incident was identified between SG2, a patient, and a charge nurse (CN). A patient was observed at the main entrance in a wheelchair with an intravenous line. After security arrived, the patient was returned to the room. Security notified the CN that patients cannot leave the unit unless accompanied by nursing staff because of hospital liability. Security then told the CN if the patient continued to violate policy, then visitation would be restricted. Security obtained a verbal understanding from the CN.

On 03/17/2023, at 6:20 PM to 6:45 PM, SG2 documented an entry telling a nurse patients could not leave a unit unless accompanied by nursing staff. If the patient continued to violate policy, then visitation would be restricted. The charge nurse acknowledged it without questioning it.

-On 04/15/2023 at 5:00 AM, a security entry involving SG2 documented a patient was recording medical staff and refused to give phone to security, so security and nursing staff removed the phone from the patient.

The facility was unable to identify the patients in the above reports for review. The 04/15/2023 incident involving P1 was identifiable only due to a complaint investigation, but in each case, there was no auditable mechanism in place to identify the patients involved in encounters with security to review security's handling of the encounters to ensure regulatory compliance with patient rights, facility policies and training. [It was identified shifts lacking reports included day shift on March 19, 2023, night shift on April 7, 21 and 22, 2023]. The facility was unable to identify either patient because there was no mechanism in place to identify all security/patient encounters, only certain encounters.

On 04/26/2023 at 11:30 AM, the Privacy Director explained the Director of Information Management had the dual title of privacy officer. After telling patients to stop recording, department leaders were advised to handle these situations. If the situation could not be resolved the patient would be escorted off the property, but the Privacy Officer would not advise anyone to confiscate the patient's device. The Privacy Officer would escalate this to corporate risk to handle; otherwise, the Privacy Officer was not sure what to do with a patient recording and refusing to stop and delete video.

On 04/28/2023 at 1:10 PM, the Security Manager explained at no time was security to tell staff to restrict visitors; security could not trespass anyone. The Privacy Officer should be notified regarding potential HIPAA incidents. Any contact with patients should require a MRN (medical record number) on a DAR report. Code Greys, pickups and returns of valuables and trespassing were narratives requiring MRNs in DAR. The Security Manager reviewed DARs monthly but did not identify issues with the reports identified as having issues. The Security Manager acknowledged there were shifts missing reports likely due to substitutions made for security coverage.

On 04/28/2023 at 4:20 PM, the Marketing Manager of Security (MMS) explained the onsite security manager's role, who had been in place for about 5 months and was perceived as doing a pretty good job. The security manager took part in patient safety committee and workplace violence committee which met monthly. The security manager was responsible for documenting information for meeting monthly security goals via the security program performance sheet.

On 04/26/2023 at 10:14 AM, SG2 identified as being involved in the three incidents described above and indicated recording with a device or phone was in a policy as a privacy violation of other patients. The House Supervisor and Charge Nurses have previously verbalized to take patient's phones for this reason. SG2 indicated the intent was to document an incident report and MIDAS report upon the next worked shift, but police had arrested SG2 due to the incident with P1, before that could be accomplished.

On 04/26/2023 at 11:15 AM, the Chief Nursing Officer indicated there was no policy which restricted patients to units without nursing staff. There was no policy of justifying the taking of patients' phones. The Chief Nursing Officer understood and verbalized the need to be able to identify patients who had encounters with security. The Chief Nursing Officer indicated the Privacy Officer was not notified of the event with P1 until shortly before the interview on 04/26/2023 at 11:30 AM.

On 04/26/2023 at 11:30 AM, the Privacy Officer verbalized when patients/family/visitors were recording with phones, they would be asked to stop recording; otherwise, family and visitors would be escorted out in the end. If patients did not cooperate, it would be escalated to corporate risk to handle. The Privacy Officer would not advise anyone to confiscate patient phones/devices. The Privacy Officer was not notified of the incident on 04/15/2023 with P1.

The Photographs, Videotapes, and other Recordings policy 13.0 revealed, if the facility became aware of any photograph, videotape or other recording that did not comply with this policy, the Facility Privacy Officer would be notified. The Facility Privacy Officer would take steps to mitigate and prevent further unauthorized uses or disclosures, which may involve confiscating the unauthorized material.

On 04/28/2023 at 1:10 PM, the Security Manager verbalized the facility failed to document an incident worksheet within 24 hours for the 04/15/2023 incident, although the Security Manager indicated interviews had to be conducted and surveillance video reviewed before an incident could be documented. The Security Manager documented the incident at 1:00 PM on 04/20/2023. Patient encounters outlined in daily activity reports involving security should require a medical record number to identify patients and be reported in the facility's MIDAS system, which did not occur. At no time was security to tell patients visitors were restricted. Security did not have the authority to trespass, only police did. The Privacy Officer should have been notified when patients failed to stop recording/delete video.

The Patient Safety Event Reporting policy, last revised February 2023, revealed the purpose of the policy was to describe a mechanism for identifying, responding to, and reporting of patient safety events that occur in the organization. Under section V Procedure: A. Healthcare Facilities, 1. Any healthcare facility employee or staff member who discovers, is directly involved in, or responds to an occurrence is to complete or direct completion of a patient safety event report via MIDAS electronic reporting system. Submission should occur as soon as possible, but no later than 24 hours after discovery. B. Classifying Severity, 1. All event reports received by the facility Risk Manager will be assigned a severity classification level in accordance with established criteria.

Complaint NV00068417

Based on observation, security video surveillance footage review, record review, interview, and document review, the facility failed to ensure staff did not use physical force to prevent a patient from leaving the facility and used physical restraint to forcibly obtain a patient's cell phone against the patient's will for 1 of 20 sampled patients (Patient 1). The failure had the potential to cause physical and emotional harm to the patient.

Findings included:

The facility policy titled Patient Bill of Rights and Patient Responsibility dated November 2020, documented patients had the right for care and the ability to exercise their rights without limitations, bullying, abuse, or harassment.

Patient 1 (P1) was admitted to the Emergency Department (ED) on 04/15/2023, with alcohol intoxication as a chief complaint.

On 04/25/2023 in the morning, security surveillance camera footage recorded on 04/15/2023 was reviewed with the Chief Nursing Officer, the Director of ED, the acting Risk Management Director, and the Corporate Market Manager of Security. The video revealed the following:

On 04/25/2023 at 2:23 AM, P1 arrived at the ED on a gurney accompanied by two ambulance personnel. P1 was admitted to the ED and placed by the ambulance personnel in a gurney located in the ED hallway.

On 04/15/2023 at 4:04 AM, P1 seemed to be using their phone. A security guard (SG1) was walking through the hallway and passed by P1. SG1 turned their attention to P1 and returned. SG1 interacted with P1 without incident and then, left the area.

On 04/15/2023 at 4:06 AM, SG1 and a second security guard (SG2) approached P1. SG2 established a conversation with P1 while the patient laid on a gurney. After approximately one minute of interaction, SG1 and SG2 went to the nurse's desk and talked to the Registered Nurse in Charge (CN).

On 04/15/2023 at 4:08 AM, SG1 and SG2 approached P1 again. SG2 tried to grab P1's phone with physical contact. After approximately 30 seconds of interaction, P1 got up from the gurney and attempted to leave but SG forcibly placed P1 back on the gurney, holding the patient down and preventing the patient from leaving the ED.

On 04/15/2023 at 4:09 AM, SG2 called to a staff member that was sitting in the hallway (identified as a Certified Nursing Assistant (CNA)). The CNA assisted in physically restraining P1 while SG2 grabbed P1's left arm. The video revealed P1 was resisting the SG2's forced intervention to obtain the P1's phone and appeared to have placed their phone in the bra. In the struggle with SG2, P1's private body areas were exposed, and SG2 covered them with a sheet.

On 04/15/2023 at 4:10 AM, a male ED Technician and the Charge Nurse arrived and helped SG2 restrain P1. Video review revealed P1's blanket was removed exposing the patient. Immediately afterwards and with the help of the ED Technician, the Charge Nurse, SG1 and the CNA, SG2 placed P1 on the floor. Four point (both arms, both legs) physical restraint was applied by grabbing P1's outstretched arms and with the patient's legs apart. It was noted P1 fighting back trying to break the restraint. After about four to five minutes, the Charge Nurse grabbed P1's cell phone and returned to the charge desk. The charge nurse was observed checking P1's phone. SG2 grabbed P1 from the floor and placed back the patient back on the gurney.

On 04/15/2023 at 4:15 AM, the ED Technician and two staff members assisted a nurse to remove an intravenous (IV) line from P1's right arm. It was noted that after obtaining P1's phone, staff left the scene and the violent situation deescalated.

On 04/15/2023 at 4:16 AM, SG2 and the ED Technician grabbed P1 by their arms and forcibly dragged P1 through the hallway. At the ED ambulance entrance, P1 was grappling with SG2 and the ED Technician attempting to prevent being removed from the ED. Several times, SG2 pushed P1 out from the ED ambulance entrance.

On 04/25/2023 at 4:05 PM, the House Supervisor on duty the day the incident occurred, indicated Law enforcement agents requested the ED video surveillance records on 04/16/2023. The Supervisor stated nobody had been notified about the incident which occurred in the ED on 04/15/2023 involving P1 and staff members. The Supervisor indicated the police detectives asked why P1 was retained if wanted to leave the facility and had a safe ride and a family member. The Supervisor indicated personal property could not be removed from patients against their will unless the belongings represented a safety issue to the patient or others. Personal property was retained only for safeguard purposes. The Supervisor indicated one valid reason to confiscate a phone was in the event a confused patient start calling 911, but after re-directing, the phone should be returned. The Supervisor did not have details about the incident and did not know why the staff removed the phone from P1. The Supervisor stated the actions taken by the staff to confiscate P1's phone such as the use of force and restraint could not be justified.

On 04/25/2023 at 1:34 PM, the Security Manager indicated there were three possible scenarios that could trigger ED staff to request assistance from the security personnel to restrain a patient; a combative patient placed in legal hold, an agitated intoxicated person, or a person attempting to commit harm to themselves or others. The Security Manager explained if a person was found filming in the facility premises and the recorded video could lead to a potential HIPAA (Health Insurance Portability and Accountability Act) violation, the staff would kindly request the person to stop filming and delete the video. If the person refused to follow the request, that person could be trespassed from the facility. In this case, the staff should contact the house supervisor and law enforcement called depending upon the situation.

The Security Manager stated during the incident with P1, the staff did not elevate the concern to the house supervisor or to the Administrator on Call (AOC). The Security Manager acknowledged the use of force to obtain P1's cell phone was out of the established policies and procedures and the staff did not have the authority to perform a search on a person or private property such as a cell phone, only law enforcement following police procedures could have performed these actions with a search warrant.




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On 04/26/2023 at 10:14 AM, Security Guard 2 (SG2) indicated the Charge Nurse said to get the patient (P1) out of here; the patient was discharged. The patient wanted the phone and would not leave without the phone. SG2 explained they could not get the patient to leave, so the patient was perceived as trespassing. A medium standing hold was employed with assistance of an emergency department technician, and they escorted P1 outside the emergency department. Once outside, the charge nurse wanted to get the pass code to delete the video. P1 gave SG2 the pass code who told the charge nurse who said to delete the video. SG2 verbalized accessing the phone with the pass code, deleting the video, and returning the phone to the patient.

-Restraint and Seclusion policy last revised June 2022, Section IVA. of the Restraint and Seclusion policy provided revealed the patient has a right to be free from restraint or seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff.

The surveillance video and interviews demonstrated the employees restrained the patient as a means of coercion, punishment, discipline, or retaliation in order to obtain the patient's phone.

-Section IVB. of the Restraint and Seclusion policy provided revealed the patient's rights, dignity, privacy, safety, and well-being will be supported and maintained.

The surveillance video and interviews demonstrated the employees who restrained the patient to obtain the phone violated the patient's rights, dignity, privacy, safety, and well-being.

-Section IVF. of the Restraint and Seclusion policy provided revealed the use of restraint must be in accordance with the order of a physician or other authorized licensed practitioner.

The patient's medical record lacked documented evidence of a physician order for restraint(s) of any kind.

-Section IVG. of the Restraint and Seclusion policy provided revealed when restraint or seclusion was initiated without an order by a licensed independent practitioner: a registered nurse initiated the restraints based on an assessment that justified the use of restraints. In these emergency application situations, the order must be obtained either during the emergency application of restraints, or when the nurse could safely do so.

The surveillance video lacked observational evidence a registered nurse conducted a required assessment.

Complaint NV00068417

Based on observation, interview and document review, the facility failed to ensure an auditable mechanism was in place to review security officer encounters with patients.

Findings include:

Patient 9 (P9) was admitted to the emergency department on 12/02/2021 with abrasion / laceration resulted as passenger in a motor vehicle accident. During the stay, the patient filed a grievance regarding security and nursing staff confiscating a phone.

On 12/15/2021, the Risk Manager apologized for the phone confiscation via grievance letter.

On 04/26/2023 at 1:30 PM, the Marketing Manager of Security (MMS) indicated a final warning letter was issued to the security officer involved, and the officer was later terminated. The MMS verbalized there may have been a verbal counseling, but there was no documented evidence; this was considered an anomalous event.

On 04/26/2023 at 3:00 PM, the Risk Manager at the time of the above incident, indicated it was discussed in a leadership safety huddle and then passed to department safety huddles for dissemination. The Risk Manager recalled the Security Manager was shocked by the phone confiscation at the time.

Patient 17 (P17) was admitted to the emergency department on 01/30/2023 with alcohol intoxication.

P17's medical record revealed on 01/30/2023 at 2:25 AM, a registered nurse documented, patient attempted to call a named person two times...informed 911 that patient is being held against will...Patient then took out phone and took picture of nurse and started recording. Nurse instructed patient to delete and respect privacy...Patient became agitated and aggressive toward nurse. Nurse obtained phone and handed it to charge nurse. The patient was put in restraints.

On 04/26/2023 at 1:30 PM, the Chief Nursing Officer, MMS and the Security Manager expressed a lack of knowledge about this event.

On 04/25-26/2023, security department's daily activity reports were reviewed and revealed the following:

-On 03/12/2023 at 4:00 PM, an incident was identified between Security Guard 2 (SG2) and a patient. SG2 documented "call received for a patient who was recording nurse and other staff as they entered room. Security made the patient delete the video."

-On 03/17/2023 at 6:20 PM, an incident was identified between SG2, a patient, and a charge nurse. A patient was observed at the main entrance in a wheelchair with an intravenous line. After security arrived, the patient was returned to the room. Security notified the charge nurse that patients can't leave the unit unless accompanied by nursing staff because of hospital liability. Security then told the charge nurse if the patient continued to violate policy, then visitation would be restricted. Security obtained a verbal understanding from the charge nurse.

-On 04/15/2023 at 5:00 AM, a security entry involving SG2 documented a patient was recording medical staff and refused to give phone to security, ending with security and nursing staff had removed the phone from the patient.

The facility was unable to identify the patients in the above reports for review. The 04/15/2023 incident involving the patient was identifiable only due to a complaint investigation, but in each case, there was no auditable mechanism in place to identify the patients involved in encounters with security to review security's handling of the encounters to ensure regulatory compliance with patient rights, facility policies and training. [It was identified shifts lacking reports included day shift on March 19, 2023, night shift on April 7, 21 and 22, 2023].

The facility was unable to identify the other patients because there was no mechanism in place to identify all security/patient encounters, only certain encounters.

On 04/28/2023 at 1:10 PM, the Security Manager verbalized the facility failed to document an incident worksheet within 24 hours for the 04/15/2023 incident, although the Security Manager indicated interviews had to be conducted and surveillance video reviewed before an incident could be documented. The Security Manager documented the incident at 1:00 PM on 04/20/2023.

The Manager explained, patient encounters outlined in daily activity reports involving security should require a medical record number to identify patients and be reported in the facility's MIDAS system, which did not occur. At no time was security to tell patients visitors were restricted. Security did not have the authority to trespass, only police did. The Privacy Officer should have been notified when patients failed to stop recording/delete video.

The Patient Safety Event Reporting policy, last revised February 2023, revealed the purpose of the policy was to describe a mechanism for identifying, responding to, and porting of patient safety events that occur in the organization. Under section V Procedure: A. Healthcare Facilities, 1. Any healthcare facility employee or staff member who discovers, is directly involved in, or responds to an occurrence is to complete or direct completion of a patient safety event report via MIDAS electronic reporting system. Submission should occur as soon as possible, but no later than 24 hours after discovery. B. Classifying Severity, 1. All event reports received by the facility Risk Manager will be assigned a severity classification level in accordance with established criteria.

Complaint NV00068417