HospitalInspections.org

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Based on observation, interview and and record review it was determined the hospital failed to ensure that 1 of 5 sampled patients (Patient 5) was not secluded for the convenience of staff, and was free from physical restraint (Tased) as a means of coercion. Findings include:


1. During the survey it was revealed that on 7/2/2011 at 18:50 (6:50 pm) Patient 5 had been brought to the hospital emergency department (ED) by law enforcement personnel for a mental evaluation related to suicidal ideation. Because of prior incidents and admissions, Patient 5 was well-known to both law enforcement and hospital personnel. Upon arrival to the ED Patient 5 was placed in Room 14, the ED's "secure hold room," until he could be evaluated.

The hospital had a variety specific policies that described the procedures to be used in the utilization of the secure hold room, the use of restraint and/or seclusion and the use of force. Those procedures are described in policies entitled "Patient Rights," "Psychiatric Patient on Hospital Hold," "Hospital Hold Evaluation," "Restraint and Seclusion" and "Use of Force." During the survey it was determined the procedures described in those policies were not implemented in providing care to Patient 5 on 7/2/11.

Hospital policy "Restraint and Seclusion" defines seclusion as "The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving." Hospital policy "Psychiatric Patient on Hospital Hold," indicates that "Adult patients will be confined within the holding area with the doors to their individual rooms left open. A sitter will be provided for the patient."

On 7/2/11 these policies were not implemented in the provision of care to Patient 5. According to hospital records Employee 3, a hospital security guard, was present when Patient 5 arrived. Reportedly, Employee 3 was to remain on stand-by in the area of Room 14.

A written report from Employee 3 (Report for Case #2011-02493) indicated that "While on this standby, I had to leave for a Code Green to ICU. I told Patient (5) that I had another emergency to go to, I had to leave and lock the door, but someone would be down to be with him as soon as possible."

A 7/3/11 written "ED report" from Physician 9 stated that "I recommended that the patient be placed on a hold....The only sitter was a young woman and I told them I was going to have to close the door and lock it until security came back."

The hospital staff failed to implement hospital policy "Restraint and Seclusion" and "Psychiatric Patient on Hospital Hold." Patient 5 was involuntary confined alone in a room from which he was physically prevented from leaving due to the lack of an available security guard and/or sitter. Patient 5 was placed in seclusion for the convenience of the hospital.

2. The survey investigation further revealed that on 7/2/11 at approximately 21:18 (9:18 pm) physical force and a restraint (Taser) was used on Patient 5 by Employee 3. Observation, interview and record review determined hospital policies and procedures were not followed in the use of such force.

Hospital policy "Use of Force," states that "The X26 Tazer will not be used on any patients. The only exception would be during an obvious imminent life-threatening act that cannot be controlled with-in the scope of Management of Assaultive Behavior training methods."

Hospital records from Employee 3 reflect that "at 19:20 hours a Panic Button ER Psych Room 14 came over the radio." "Upon arrival...Patient (5) was pounding on the locked door. I deactivated the magnetic door lock and opened the door."

Records from both Employee 3 and Physician 9 indicate that Patient 5's behavior continued to escalate. In those written reports Patient 5's behaviors are described as "agitated" and "verbally and physically threatening."

Written reports from both Employee 3 and Physician 9 indicate that soon after the arrival of a mental health specialist (Witness C) at 21:18 Patient 5 became increasingly agitated. Those reports reflect that Patient 5 became increasingly upset, and threatened to leave the hospital.

The written report from Employee 3 stated that he felt Patient 5 was "going to attempt escape and physically fight security and hurt anyone that got in his way." Employee 3 reported that when Patient 5 was "within 4 feet of me I pulled my Taser... and aimed the red dot at his chest. I told Patient (5) to get back in the room three times. I warned him that if he did not cooperate and get back in the room I was going to be forced to Taser him. At this time Patient (5) started to lean forward. I felt he was coming after me so I activated the Taser..." There is no indication or evidence that Employee 3 used other "Management of Assaultive Behavior" methods prior to the use of the Taser.

A written 7/3/11 "Emergency Department Report" from Physician 9 stated that "(Patient 5) started edging out into the hall. The security guard told him to go back in the room and that he was going to be Tased if he came out into the hall. He continued to come out into the hall. Security guard raised his weapon and again told him he was going to Taser him, and he Tased the patient."

On 8/31/11 a video record of this incident was reviewed. The video had been recorded from a camera within the room. The video record reflected only those events visible within the room, and not in the adjoining hallway. Patient 5's behavior was visible on the video, but Employees 3, Physician 9 and Witness C were not observed.

The review of the video revealed that Patient 5 never fully left the secure room. The video revealed that although Patient 5 leaned forward, he was Tased while still partially in Room 14. Although Patient 5 appeared to be very agitated and threatening, there was no evidence that he was armed with any weapon or initiated any "obvious imminent life-threatening act."

Employee 3 indicated in a written report that when Patient 5 was "within 4 feet of me I pulled my Taser... and aimed the red dot at his chest. There is no evidence that Employee 3 used other "Management of Assaultive Behavior" methods prior to the use of the Taser, as required by policy. The hospital failed to ensure that Patient 5 was free from the use of force (Taser) as a means of coercion and restraint to remain in the secure hold room.

In interview on 8/31/11 Employee 1 acknowledged that the hospital had failed to ensure that hospital policies and procedures regarding restraint/seclusion and the use of force were implemented in the provision of care to Patient 5.

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Based on interview and record review it was determined the hospital failed to ensure that the restraint and seclusion of Patient 5 was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined in hospital policy. Findings include:

During the survey it was revealed that on 7/2/2011 at 18:50 (6:50 pm) Patient 5 had been brought to the hospital emergency department (ED) by law enforcement personnel. Patient 5 was placed in Room 14, the ED's "secure hold room," until he could be evaluated.

The hospital had a variety of specific policies that described the procedures to be used in the utilization of the secure hold room, the use of restraint and/or seclusion and the use of force. Those procedures are described in policies entitled "Patient Rights," "Psychiatric Patient on Hospital Hold," "Hospital Hold Evaluation," "Restraint and Seclusion" and "Use of Force."

During the survey it was determined the procedures described in those policies were not implemented in providing care to Patient 5 on 7/2/11.
Refer to Tag A 154 elsewhere in this report.

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Based on interview and record review it was determined the hospital failed to document the training and demonstration of competency related to restraint and seclusion techniques in the personnel records 3 of 3 sampled security staff (Employees 2, 3 and 4). Findings include:

During the survey it was revealed that the facility security officers are routinely expected to respond to incidents of restraint and/or seclusion. According to hospital records Employees 2 and 4 had specifically responded to a 7/2/11 restraint/seclusion incident involving Patient 5.

The training requirements to maintain qualifications as a security officer and respond to incidents of restraint/seclusion are listed in detail on the facility job description "Security Officer", and in hospital policy "Restraint and Seclusion" and "Use of Force."

The job description indicated that security staff would possess "DPSST Certification; successful completion of annual competency for proper use of handcuffs, cap stun, and restraints; successful completion of IAHSS Basic Security Officer training; successful completion of PART (crisis intervention training); and successful completion of Asante Security Officer Training Program."

During the survey a sample of personnel records of security staff who respond to incidents of restraint and/or seclusion was selected for review. That review revealed that Employees 2, 3 and 4 had not completed and/or maintained the training requirements outlined on the job description.

Although all three officers had maintained DPSST Certification, there was no evidence they had completed the other required training's including the annual competency for proper use of handcuffs, cap stun, and restraints; the successful completion of IAHSS Basic Security Officer training; the successful completion of PART (crisis intervention training); and the successful completion of Asante Security Officer Training Program."

In interview on 8/31/11 at 2:35 pm Employee 7 acknowledged that Employees 2, 3 and 4 had not completed the training requirements for a security guard as described in hospital policy.

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