HospitalInspections.org

Based on policy review, document review, medical record review, video review and interview, the hospital failed to ensure patients' rights were promoted to receive care in a safe setting and free from physical abuse for 1 of 1 (Patient #1) sampled patients who was physically abused by a hospital security guard.

The findings include:

1. Review of the satellite children's hospital's abuse policy titled, Adult/Elder Abuse, Neglect and Exploitation with a revised date of 11/2020 revealed this was a policy was for the hospital's adult and elders and did not address abuse, neglect and exploitation of the hospital's pediatric patient population.

2. Medical record review for Patient #1 revealed the 17 year old patient was admitted to the satellite children's hospital on 10/20/2021 with a diagnoses of Acute Agitation, Psychosis and Altered Mental Status.

Review of the psychiatry inpatient consultation note on 10/21/2021 revealed Patient #1 had a history of unspecified mood disorder and complaints of aggression and psychosis following the death of his father last week. Patient #1 was waiting to be transferred to an inpatient psychiatric hospital.

Review of the physician progress notes on 10/24/2021 revealed Patient #1 had eloped to the hospital lobby and then outside of the hospital. Patient #1 returned to his room after physicians talked with him. Ativan was administered to the patient for agitation. Patient #1 began exhibiting paranoia behaviors, and repeatedly asked to go home, stating individuals at the hospital were trying to harm him. Patient #1 continued to pace around the 12th floor of the hospital with a sitter and security guard following him. Patient #1 refused to re-enter his room for fear of "being trapped" in his room. On 10/24/2021 at 4:12 PM Patient #1 eloped again to the hospital lobby and went outside the front doors of the hospital. Patient #1 was persuaded to come back inside the hospital and the patient to sat on the couches in the hospital lobby with security guards watching him for a short time until he was persuaded to go back to the 12th and was agreeable to medications for calming.

Review of the physician progress notes on 10/25/2021 revealed Patient #1 attempted to leave the hospital again but was redirected back to the hospital. Patient #1 attempted a second time to leave hospital, and security was able return Patient #1 back to his room. Patient #1 was pacing the hallways before going towards the elevators, and security was called to assist with watching the patient. Security guards were able to stop Patient #1 from getting on the elevator. The Sitter and multiple security guards were assisting and talking with the patient to convince the patient to return to his room. Security Guard #1 and Patient #1 had a verbal altercation which led to Security Guard #1 attacking and assaulting the 17 year old patient. Patient #1 received a superficial laceration/scrape on left lower eyelid.

Witness statements were collected along with the hospital's video footage which confirmed the attack/assault by Security Guard #1. The security guard was terminated. The hospital failed to implement immediate action plans to ensure the protection of other patients at the satellite children's hospital.

Refer to A145.

Based on policy review, document review, hospital's investigation report, medical record review, video review and interview, the hospital failed to protect a patients from physical abuse for 1 of 1 (Patient #1) sampled patients who was physically assaulted by a hospital security guard.

The findings include:

1. Review of the pediatric/children's satellite hospital's policy titled Adult/Elder Abuse, Neglect and Exploitation with a revised date of 11/2020 revealed this was a policy was for the hospital's adult and elders and did not address abuse, neglect and exploitation of the hospital's pediatric patient population.

Review of the hospital's policy titled Use of Security Personnel to De-escalate and Resolve Threats to Safety with a revised date of 4/2021 revealed, "...Security Officers should respond promptly to request for assistance to de-escalate physical threats...or situations in which the safety of patients, staff, or others potentially an issue, in accordance with [Methodist Hospitals of Memphis] Security Officer training, the procedures outlined in [Methodist Hospitals of Memphis] policies...In the interest of maintaining the safest environment of care possible, officers should strive to de-escalate volatile situations absent of physical force. However, when circumstances warrant the use of force, officers should use the minimum, reasonable amount of force necessary to preserve the safety and tranquility of the healthcare environment...Security Personnel, when faced with situations that compromise the safety, order, or serenity of the healthcare environment, shall utilize the minimum level of force necessary to gain control of the situation ranging from officer presence to physical techniques, based upon the articulate and objective facts and circumstances presented during the event...When faced with a situation that may require the use of force, the involved officers should evaluate the totality of circumstances and determine which of the following approaches could be used to gain control of the situation, with minimal risk of injury to all involved parties. The approaches to be considered are as follows: Officer Presence : Officer Presence is a psychological tool that is established by the uniformed security officer's presence in the area. The decreased response time and general show of authority in the area has the potential to decrease the volatility of a situation, or wholly prevent an incident from occurring. Verbal Interaction: Verbal Interaction is the use of verbal commands or instructions in an effort to gain control of an unpredictable situation prior to escalation to a physical event. This includes the utilization of de-escalation techniques and empathic listening in an effort to calm the emotional state of the subject. Verbal Interaction and de-escalation efforts are the most desirable approach to gaining control of situations. Non Assertive Techniques: Non Assertive Techniques involves the use of physical control techniques performed by the officers that present a low risk to injury to subjects when applied correctly , and are accomplished without the use of implements of force. This includes, but is not limited to, certain escorts, defenses, restraint techniques, and escapes from holds...Impact Weapons: Impact Weapons involves the use of a baton or other item, despite its manufactured purpose, to impede a violent or potentially violent subject's movements and protect the officer or a third party from assault, injury, or serious injury...When determining whether or not to apply a level of force, and evaluating whether or not an officer has used reasonable force, the totality of circumstances surrounding the incident should be considered...While various force options are at the officers' disposal, each officer is obligated to use the only option which is reasonable, provided the circumstances ... Use of Force Against Patients...Force can be used against patients once all other reasonable solutions or resources have been exhausted, and it is reasonably believed to be necessary in an effort to prevent or mitigate physical harm or injury at the hands of the patient....Use of Force to Prevent Patient Elopement...Security may be called to assist clinical staff in preventing patient elopement. State law does not allow clinical or security staff to detain an individual attempting flight from a facility, unless the patient is held under court order or involuntary commitment. should a patient successfully elope, law enforcement authorities should be notified..."

Review of the hospital's policy titled No Hit Zone Policy with a revised date of 8/2020 revealed, "...The purpose of this policy is to support a "No Hit Zone" environments for patients, families and staff working...All facilities are designated "No Hit Zones..."

2. Medical record review revealed Patient #1 was admitted on 10/20/2021 with an diagnoses of Acute Agitation, Psychosis and Altered Mental Status. The patient was waiting to be transferred to an inpatient psychiatric hospital.

Review of the hospital's psychiatry consult note dated 10/21/2021 revealed, "...Patient #1 is a 17 year old African American male with history of unspecified mood disorder who was brought to the ED [Emergency Department] by the [local Police Department] on 10/20 with family's complaints of aggression and psychosis following the death of his father last week. Patient #1 admitted to [the hospital's 12th floor] for altered mental status. ..Psychiatry consulted for acute psychosis. Patient still psychotic and disorganized at this time as well as intermittently agitated. He will need further stabilization in a psychiatric setting once medically cleared...Continue 1:1 sitter and all safety precautions...Transfer to inpatient psych once medically cleared..."

Review of the physician progress notes dated 10/24/2021 revealed, "Notified by nursing at 3:35 PM that [Patient #1] had eloped to the lobby and outside. [Physician Resident #1] and [Physician #2] walked to the lobby and found [Patient #1] back in lobby. [Physician #2] de-escalated the situation, encouraged [Patient #1] to return to his room. PO [by mouth] Ativan provided to patient, who willingly swallowed pill. [Patient #1] repeated requesting to go home, stating individuals here were trying to harm him. Multiple attempts to contact his mother by both [Patient #1] and [Physician #2]. Mother en-route and unable to answer phone. [Patient #1] arrived back to the 12th floor around 3:5PM. Patient #1 continued to walk around the 12th floor with sitter and security, refusing to re-enter room for fear of "being Trapped" in his room. Risk management contacted, psychiatry contacted and will be arriving to the hospital to evaluate. Psychiatry OK-ed starting patient on Seroquel [medication used to improve thinking and behavior] 25 mg [milligrams]. Social work contacted; still no beds available to transfer patient..Notified by nursing at 4:12 PM that patient had eloped to lobby again and out the front doors. This [Resident Physician #1] and[Physician #2] walked to lobby. Arrived to see patient outside the front doors, with multiple security agents and sitter walking with him. Repeatedly shouting he wants to go home and multiple paranoid statements. "She's on the phone with the police" "I don't trust none of ya'll...I got elevated levels by people putting something in my food"... Risk management contacted, stated if patient is currently having a psychiatric episode that he is NOT free to leave the hospital and can escalate management to keep patient in house. [Physician #2] attempted to call mother, unable to [Physician #2] attempted to de-escalate with chips, calming statements...Was able to direct [Patient #1] back inside to sit on the lobby couches, with security standing nearby if needed. This [Resident Physician #1] contacted Mobile Crisis, who will send a unit to assess if there is a temporary holding facility that [Patient #1] can be sent to. [Patient #1] able to be convinced to return to 12th floor, agreeable to medications for calming "as long as they don't put me to sleep". IM [Intramuscular Injection] Haldol 5 mg [medication used to calm patient] ordered verbally as PO Ativan has not taken effect...Patient #1 arrived back to 12th floor at 4:45PM, went immediately to dedicated window overlook...Refusing to return to room. This [Resident Physician #1] and [Physician #2] and RN [registered nurse]#1 sat with patient and discussed risk/benefit of Haldol. Stated that Haldol will NOT put him to sleep with the prescribed dosage and that it will help him with agitation and anxiety. Patient continued to wring hands, sweating, stating he wants to go home. Psychiatry fellow arrived at patient side shortly thereafter. After significant discussion agreeable to Haldol. Delivered by nursing RN #1 without agitation at 5:00PM. Patient escorted back to room, at which time mother had arrived at bedside...will attempt to obtain a video game for [Patient #1] for distraction as well as awaiting placement and safety plan. Psychiatry attending arrived shortly thereafter and currently talking with mother about options for care..."

Review of the physician progress notes dated 10/25/2021 revealed, "...Working on inpatient psych transfer 10/24 afternoon. [Patient #1] attempted to leave the hospital but was redirected and came back. 10/25 AM [Patient #1] again tried to leave hospital, and security was able to guide pt [Patient #1] back to his room. Security office remained outside the door with concerns over pt [Patient #1] leaving the hospital...This AM at bedside [Patient #1] was calm and conversing talking about how he has to get back to school. [Patient #1] then got fixated on wanting to go to school, and decided to leave. [Patient #1] was pacing the hall before going towards the elevators, and security was called. Security guard was able to stop him from getting on the elevator. Sitter and multiple security guard were helping pt return to his room. Upon return [Patient #1] had a superficial laceration/scrape on left lower eyelid which was not bleeding. [Patient #1] repeatedly said he was not violent during interaction with security. Psych was called and recommended giving one dose of Haldol 5 mg. [Patient #1] agreed to medication..."

3. Review of the hospital's incident investigation dated 10/25/2021 of what had occurred that led to the laceration above the eye of Patient #1 revealed a statement from Security Guard #1 which read, "[Security Guard #1] am writing this statement for an incident that occurred on 10/25/2021. [Security Guard #1" am the in-house officer for the shift. At or around 8:15 [AM] I received a call from dispatch stating that the patient in room 1202 [Patient #1] was trying to leave the hospital. I responded to the call. I got up to the 12th floor and notified dispatch. I proceeded to room 1202 and the staff informed me that the patient was headed towards the public elevators. I went around to the elevator where the patient, his sitter and another staff member were present. The patient was trying to get on the elevator. I got in front of him and told him that he could not leave. The patient then began to get aggressive verbally and made lunging movement toward me. I then wrapped both my arms around him and took him down to the floor. I then go on my radio and let dispatch know what had just transpired. I held him down on the ground until manager [Security Guard #2] arrived. After approved by [Security Guard #2] I let the patient up off the floor. The patient then started using vulgar language saying that he would beat my ass and he began to walk towards me again trying to physically harm me.
At this point I pulled out my baton and told him not to take another step towards me due to his violent state of mind and body language. [Security Guard #2] then told me to put my baton away and I did. Then patient continued cussing and took off running all the way around the 12th floor. The patient got back around to where my manager [Security Guard #2] and I was and once again tried to fight me. [Patient #1] took a swing at me and I defended myself as trained in MOAB [a contracted company named Management of Aggressive Behavior]. I had to grab him in a head lock because he was swinging wildly striking me several times. Then other officers on scene grabbed him and the situation was over. I cleared scene and reported to Director of Security..."

Review of an handwritten statement dated 10/25/2021 from the patient's sitter revealed, "...[Patient #1] was going to the elevator, we asked for security to come and asked the patient not to leave. [Patient #1] then balled his fist up and asked security not to touch him. [Security Guard #1] got [Patient #1] down on the ground and called for backup. After back up arrived, [Security Guards #1 and #2] got [Patient #1] up, [Patient #1]was calm, then asked to fight security. [Patient #1] then ran around the floor, found security, broke loose and ran up to security with his fist balled up and [Security Guard #1 and Patient #1] both began swinging..."

Review of an handwritten statement dated 10/25/2021 by nursing assistant #2 revealed, "...I witnessed [Patient #1], who was accompanied by the sitter and [ Physician #1], trying to get on the elevator with his gown and socks on. I called security and when security arrived, [Security Guard #1] had to grab the patient and hold him down on the floor. I then called security for more help, because the patient was being combative and very disrespectful to authority. The patient was then released, and began running on the unit..."

Review of an handwritten statement dated 10/25/2021 by RN #1, "...Patient #1 was agitated and walking the 12th floor halls with [Physician #1] and the sitter. I was in another patient's room, and could see them through the open doorway. I just saw the patient in the hall near the 12th floor family room. He was in an agitated state and Security Guard #1 was holding [Patient #1], arms wrapped around him from behind. [Security Guard #1] and the other Security Officers brought him down the hall. I went to speak with the doctors. I saw [Patient #1] sitting on the couch, in his room, in discussion with Security..."

Review of an typed statement by Security Guard #2 dated 10/25/2021 revealed, "...Around 8:00 AM, I got off the elevator to collect information on an incident the previous day. Once I got off the elevator, I saw [Security Guard #1] lying on top of [Patient #1]. I got [Security Guard #1's] radio from an associate and called for backup. I started talking to [Patient #1] and had told [Security Guard #1] get off him to escort him back to his room. As I was walking with [Patient #1], he was extremely angry with [Security Guard #1]. [Security Guard #1] and [Patient #1] went back and forth with words. The patient escalated more when [Security Guard #1] pulled out his baton out of its holster. I had to tell [Security Guard #1] several times to put his baton up. I had my arms wrapped around [Patient #1] escorting him back to his room. [Patient #1] broke away and ran around the floor to the other side. I followed him. Once I got to the nursing station, the staff said [Patient #1] went the other way. I directed [Security Guard #1] and [Security Guard #3] to go around the other hallway to catch the patient. [Patient #1] came towards me and I again engaged him to escort him back to his room...I turned [Patient #1] to go back up the hallway to prevent him and [Security Guard #1] from getting at each other. [Security Guard #1] swung and hit [Patient #1] several times. The patient was also swinging and hitting . I had other Security Officers remove [Security Guard #1], and by that time, more security staff was arriving to assist. Security Officers escorted the patient back to his room..."

Review of an typed statement dated 10/25/2021 by Security Guard #3 revealed, "...At approximately 8:07 AM, I arrived on the 12th floor to assist [Security Guard #2] and [Security Guard #1] with a combative patient [Patient #1]. Once on the floor, the patient began to walk toward us, talking to [Security Guard #1] saying, "where is your stick [the security guards baton] now, pull it now Old Bitch Ass [derogatory word]". [Security Guard #2] grabbed [Patient #1] in a bear-hug position, holding his arms. The patient began to say, "get off me, I'm finna beat his ass". With [Security Guard #2] still holding the patient in a bear-hug position, [Patient #1] and [Security Guard #1] begin to walk towards each other and [Security Guard #1] strikes the patient first, and they begin striking each other, with [Security Guard #2] still holding the patient in a bear-hug position while the patient and [Security Guard #1] are striking each other. [Security Guard #2] began telling [Security Guard #1] to stop, but [Security Guard #1] continued to strike the patient. [Security Guard #2] then asked me and [Security Guard #4] to pull [Security Guard #1] off the patient. [Security Guard #1] pulled away and once apart, I walked over to [Security Guard #1] and told him that [Security Guard #2] said for him to clear [leave] - [Security Guard #1] exited the stairwell on the 12th floor..."

Review of an e-mail statement dated 10/25/2021 by Security Guard #4 revealed, "... At about 8:15 AM, I made scene to a 'code strong' [disruptive patient behavior] for room 1202. [Patient #1] left his room and was trying to leave the hospital. [Security Guard #1] made scene first. [Security Guard #2] and [Security Guard #5] made scene right before myself and [Security Guard #3]. We all made a circle of the 12th floor to catch up with [Patient #1]. [Security Guard #2] and [Security Guard #1] had gotten to him first. Once I came around the corner, I saw [Security Guard #2] walking behind [Patient #1] trying to get him back to his room. [Patient #1] was aggressive and was saying to [Security Guard #1] "whatsup whatsup" [Security Guard #1] then hit the young man [Patient #1] many times. [Security Guard #2 grabbed [Patient #1] and I attempted to grab [Security Guard #1] - [Security Guard #1] snatched away from me and continued to walk toward [Patient #1]...[Security Guard #2] said for [Security Guard #1] to leave the scene...".

Review of a typed statement dated 10/25/2021 by the hospital's Director of Security (DOS) revealed, "...At 8:10 AM, I was contacted by [Security Guard #2] who advised that there was a physical altercation between [Security Guard #1 and the Patient #1]...[Security Guard #2] stated that [Security Guard #1] had punched [Patient #1]. I contacted Security Dispatch and directed [Security Guard #1] to immediately report to my office. Upon his arrival, [Security Guard #1] provided a statement that [Patient #1] hit him resulting in [Security Guard #1] striking the patient in return. [Security Guard #1] was directed to provide a written statement and was then placed on suspension with pay, pending the investigation. Witness statements were collected and video footage from the CCTV [Closed Circuit Television] system was secured. The physical altercation occurred at 0808 [8:08 AM]. Video footage shows [Security Guard #1] strike [Patient #1] several times. Witness statements correspond with video footage with the exception of [Security Guard #1's] statement. After a review of all available information, it was determined that [Security Guard #1] provided false statements regarding the timing of the patient striking him. Additionally, it was determined that [Security Guard #1] violated Methodist Hospital of Memphis Use of Force Policy. Due to these factors [Security Guard #1] employment with Methodist Hospitals of Memphis was terminated..."

The hospital's incident investigation documented, "...A review of the statements of the witnesses, and a review of the video show that the patient did not strike the security officer first. The Security officer struck the patient first..."

Review of the Termination Report revealed Security Guard #1's date of termination was 10/25/2021, and the reason was for gross misconduct.

As a result of the hospital's investigation, the hospital developed the following:
Security Guard #1 was terminated.
Security Guards will complete training with 90% compliance.
Incident and shift reports will be "monitored" for 90 days.
Compliance results will be reported to facility Quality and Safety Oversight and to the system Quality Oversight Council as directed.
The hospital will update annual MOAB training for officers to better emphasize both the wrong use of force and the correct use of force. To be completed by all officers upon next annual retraining...".
There was no documentation of immediate re-training of the hospital's Security Guards or other immediate interventions developed and implemented to ensure the hospital Security Guards followed the hospital's policies and procedures and the pediatric/children patients were protected and free from abuse.

4. Review of the video recording dated 10/25/2021 starting at 8:08 AM revealed Patient #1 coming around the corner of a hallway dressed in a hospital gown and yellow socks.
At 21 - 24 seconds into the video Security Guard #2 puts a cross arm bear hug on Patient #1.
At 45 seconds into the video Patient #1 breaks away from Security Guard #2 and starts back up the hallway towards the elevators.
At 47 seconds Security Guard #1 lunged towards Patient #1 and backed the patient up against the wall and started hitting Patient #1's face with his fists.
At 50-59 seconds into the video other Security Guards are observed separating Patient #1 and Security Guard #1.

5. Multiple attempts by the surveyor to contact Security Guard #1 by telephone have been unsuccessful.

6. During an interview on 11/2/2021 beginning at 2:40 PM with the hospital's Director of Risk Management (DRM), the DRM stated, "...All security [guards]receive their training when they are hired and then annually. [Security Guard #1's] initial training was in 2020 and his annual was in February 2021. In this training he received MOAB [Management of Aggressive Behavior - this training is conducted by a contract entity] this is the name of the company and also the name of the program. As part of the correction plan we [the hospital] are working on the MOAB training to provide more of the the wrong use of force and the correct use of force hoping to provide this with some videos...".
The DRM was asked for an policy on preventing and reporting of abuse and the DRM stated, "we do not have an abuse policy..." When asked for clarification that the hospital didn't have an abuse policy, this surveyor was told by members of the Risk Department that the hospital did have an abuse policy and provided the surveyor with a policy titled, Adult/Elder Abuse, Neglect and Exploitation with a revised date of 11/2020. Review of the policy revealed no documentation related to pediatric abuse, neglect or expostulation.

During an interview on 11/2/2021 at 2:58 PM with the Security Guard #2, the Security Guard #2 stated, "...This incident with [Security Guard #1] happened around 8:00 AM, I was coming up to the 12th floor to get some information on this particular kid [Patient #1] from the weekend because he had tried to leave over the weekend. As I get off the elevator I see [Security Guard #1] laying on top of the kid I get an radio and called for backup...I get this kid [Patient #1] up off the floor...the kid and [Security Guard #1] were mad at each other and they were going back and forth verbally with each other...[Security Guard #1] pulled his baton out and I had to tell him three or four times to put the baton up...the kid was hot and he ran off and around the end of the hall. [Security Guard #3 and Security Guard #4] were on the floor by this time and they when to the other side look for the kid and they meet us coming down the hall and [Security Guard #1] is yelling I got the kid ... [Security Guard #1] punches the kid and then the kid starts fighting back...the other officers help me break them up and and I walked the kid back to his room..."

During an interview on 11/2/2021 beginning at 3:17 PM, the DOS stated, "...I told [Security Guard #1] this is not acceptable this was not how you did de-escalation...he had MOAB training and had been here awhile...when he left the floor he [Security Guard #1] came to the security administration where we got a statement from him and a voice recording and we suspended him with pay while we were investigating the incident at this point this was the only conversation I had with HR [Human Resources] and I also told him I needed his badge. We called him in the next day and terminated him.
The DOS was asked about the verbal and written warnings in the personnel file of Security Guard #1 and the DOS stated, "...[Security Guard #1] got into a verbal altercation with one of the other officers and used inappropriate language in a public space and we issue him his first verbal warning. The second was a written warning for his attendance on 9/26/2021. The 3rd one was a final written warning for damage to a department radio.
The DOS was asked if Security Guard #1 had ever displayed any aggressive behavior before such as what had occurred with Patient #1 and the DOS stated, "...No...actually [Security Guard #1] did not start out in the security department he was hired as a Logistics Specialist Part Time and transferred to security..."

On 11/4/2021 beginning at 2:17 PM, this surveyor received a call from the hospital's DRM who stated, "...You asked me if we had an abuse policy, I have searched and I could not find one...we have a no hit policy...which I will send you this policy was written to stop parents from hitting their children in the Pediatric hospital...we sometimes have a problem with how the parents go about discipline their children...".

On 11/16/2021 at 10:01 AM during a telephone interview to determine what the MOAB training consisted of with the System Director of Security, Safety and Emergency Management and the Safety Security Program Manager (SSPM), the SSPM stated, "... The [MOAB] training material consists of a power point and a book that is provided to the security officers...This is a two day training which includes class time, and 3 or 4 hours more intense physical skills...they receive a written test for the classroom portion...there is a demonstration of the physical part of the training...The written test is sent to MOAB office..."
The SSPM was asked if the MOAB training included how to deal with patients with a mental diagnosis and the SSPM stated, "...It does not cover mental situations... it covers the physical and verbal de-escalation...it does cover how to handle a smaller adult or a child and there are some specific holds that we teach them...we teach the same class to our nursing staff and clinical staff and the security staff will receive more of the physical training".
The SSPM was asked what type of training did they receive in order to teach the MOAB class and the SSPM stated, "...We have a 2 or 3 day course that we go off site for that is taught by the company MOAB, in which we receive training on how to teach the techniques...class room version and the physical version, and we also take the written test and then we receive a certification to teach the class...When we have an incident..we look to see if we have any video evidence and check that to see if the report matches. The first thing we try with de-escalation we try to talk to the person and talk them down, we only put out hands on them...For a behavior 72 hour hold under 18 years of age it is not appropriate to stop them put them on the floor and be lying on top of them...I did not see this but, from what I was told this is not a good use...it is a bad use by the way the security officers are taught...this is not the way we teach them..."
The SSPM was asked was it appropriate to put pediatric patients in the bear hug and the SSPM stated, "...yes this was a grab from the back and it was good use... this is what they are taught...".

In an e-mail correspondence on 11/17/2021 at 10:40 AM between this surveyor and the hospital's DRM, the DRM verified an outside vendor would check the background checks for new hires as well as would check the TN Abuse registry.

In an e-mail correspondence on 11/17/2021 2:13 PM between this surveyor and the hospital's Director of Human Resources (DHR), this surveyor notified the DHR that while reviewing the personnel file of Security Guard #1 this surveyor had noticed that Security Guard #1 had been found guilty of an assault charge on 3/26/2001, had been found guilty of a violation of probation on 2/14/2002, had been found guilty five (5) times for driving while license was suspended/revoked/canceled and had been found guilty of disorderly conduct on 8/16/2006. This surveyor asked the DHR was it the hospital policy to hire someone in the Security Department who had been found guilty of all these offenses and the DHR replied, "...the background check process is outsourced. The background check would have been reviewed by a system committee and they would have reviewed for length of time since the offense, type of offense, type of role and history since the offense. They try their best to balance protection of our patients and staff with the likelihood of the person doing something wrong again...They decide if the person may need a second chance...[Named Company] is our third party vendor for our background checks and each Associate is thoroughly reviewed before hire. The vendor searches thru the National Federal Criminal records search which includes the Tennessee Abuse registry for each potential hire. This Associate was checked through this vendor prior to hiring and cleared that process for hire..."

During a telephone interview on 11/17/2021 at 3:56 PM with the Background Screening Processor, this surveyor asked for the abuse registry check for Security Guard #1 and the Background Screening Processor stated, "There was not Tennessee Abuse Registry check done on [Security Guard #1]..."
The Background Screening Processor was asked where would I see the abuse registry check documented if one had been completed and the Background Screening Processor stated, "...It will be listed separately under Overall Results Review..." There was no documentation of an Abuse registry check for Security Guard #1.

During an interview on 11/18/2021 beginning at 1:36 PM when asked for an Abuse registry check policy the Senior Director of Accreditation stated, "...Yes we do have an Abuse and Neglect policy it is part of orientation training and is included in the annual safety training..."

Based on policy review, document review, medical record review, video review and interview, the hospital failed to have an organized nursing service which ensured interventions were developed and implemented to prevent a mentally altered patient with paranoia symptoms from attempting to elope from the hospital which ended up in a physical altercation with a hospital Security Guard for 1 of 1 (Patient #1) sampled patients who was attacked and assaulted by a hospital Security Guard..

The findings include:

1. Medical record review for Patient #1 revealed the 17 year old was admitted to the satellite children's hospital on 10/20/2021 with diagnoses including altered mental status and Psychosis. Patient #1 was being hospitalized while waiting on transfer to an inpatient psychiatric hospital.

Review of physician's notes and nurses notes revealed during the patient's hospitalization, Patient #1 was exhibiting paranoia behaviors, and exit seeking behaviors and required frequent redirection and mood calming medications to be administered to treat these behaviors. Patient #`1 told staff he felt the staff at the hospital were trying to harm him.

There was no documentation the patient's plan of care had been revised with interventions for the patient's paranoia and exit seeking behaviors.

2. Review of the hospital video recording dated 10/25/2021 revealed Patient #1 was attempting to elope from the hospital, and had an altercation with a hospital security guard in which the security guard physically assaulted Patient #1 and caused a laceration above the patient's left lower eyelid. The security guard was terminated and the patient was discharged to a psychiatric hospital the next day.

The hospital failed to develop and implement safety interventions to protect the patient from exit seeking and paranoia behaviors which resulted in a hospital Security Guard attempting to redirect the patient from eloping and using physical force and abuse to restrain the patient from exiting the hospital.

Refer to A 396 and A 145.

Based on policy review, document review and medical record review, video observations and interviews, the hospital failed to ensure the each patients' nursing care plan was developed with appropriate nursing interventions in response to identified nursing care needs, was kept current by ongoing assessments of the patients' status, and updated and/or revised with new interventions to protect the patients for 1 of 1 (Patient #1) sampled patients who was exchibiting paranoria and exit seeking behaviors.

The findings include:

1. Medical record review revealed Patient #3 was admitted to the satellite children's hospital on 10/20/2021 with an diagnoses of Acute Agitation, Psychosis and Altered Mental Status.

Review of Nursing Addendum Note on 10/21/2021 at 5:41 PM revealed, "...Observation: Pt [Patient #1] waiting to leave...Intervention: Called MD [Doctor of Medicine], security, family called back to room, and medication administered..Response: pt [Patient #1]...Rn [registered nurse (RN #2)] was walking down the hall and several RNs were outside the room due to the pt stating he was going to leave. MD was called to assess...talked to the pt [Patient #1]. Haldol was also ordered. Brother and mom came to beside and calmed pt [Patient #1] down. RN went in room and spoke with pt [Patient #1] to calm him down, and returned to give medication. Security was outside the room if needed..." There was no documentation the patient's plan of care had been updated with interventions for the patient's agitation and interventions to protect the patient from exit seeking behaviors and paranoria.

Review of Nursing Addendum Note on 10/23/2021 at 5:46 PM revealed, "...Observation: @ [at] 2330 [11:30 PM] the pt [Patient #1] was found outside his room, running down the hallway. [RN #3] immediately began to follow the patient and encouraged him to stop. Security...were called by the charge nurse. Pt. [Patient #1] repeatedly stated "Leave me alone, I don't trust non of y'all!" He was disoriented and was unaware that he was in the hospital. [RN #3] was able to get in between him and the door and continue to redirect him to his room. When [Patient #1] entered his room he went to the window and repeated that he needed to go home and that he wasn't safe. He believed someone was trying to get to him. He then went to the corner of the room and wrapped himself in the curtain stating we were trying to get him. He then went to the other wall and stood in the corner stating he was paranoid, and someone had tried to drug him when they gave him the "lean". [Patient #1] was able to redirected to his bed after approximately 15 mins [minutes] of attempting to reorient him and encouraging him to sit down and watch a movie.
Paranoia ideations included; someone drugged him, he can't trust anyone, someone is trying to hurt his family...Delusions stated: His father is reincarnated in him, He was shot in the head and in the leg before he came here-asked [RN #3] if she could see the hole in his leg...Hallucinations: stated "my daddy is talked to me right now! I can hear him!" noted to have a change in his voice to a deep harsh tone when detailing what his father was saying to him. Intervention: Ativan 2mg [miligrams] was ordered and administered...Response: [Patient #1] remained tense for an additional 30-45 minutes, eyes darting around, repeating that he wanted to leave, but was able to sleep for a few hours after the dose of Ativan..." There was no documentation the patient's plan of care had been updated with interventions for the patient's paranoria.

Review of the Nursing Addendum Note on 10/25/2021 at 10:58 AM revealed, "...[Patient #1] boarded the elevator and eloped to lobby at 3:00 with his sitter following him. At 3:35 PM, [Patient #1] left though the front door...2 security officers and [RN #1] followed him attempting to convince him to return to the floor. He walked through the [name of street] parking lot, to the sidewalk on [name of street], and down toward [name of another hospital]...security officer on foot and an officer in a van assisted. When the patient left the hospital grounds with security following I returned to the floor and notified the DRM [Director of Risk Management]...[Patient #1] and the security officers returned to the lobby and DRM notified me that the patient was back in the building....[Physician #2] was able to get [Patient #1] to take a 2 mg Tablet of Ativan...". There was no documentation the patient's plan of care had been revised with safety interventions or measures to assist the patient with agitation, paranoria and exit seeking behaiors.

2. Review of the hospital's incident investigation dated 10/25/2021 revealed Patient #1 was exhibiting exit seeking behaviors and was wandering up and down the hospital hallways. Security Guard approached Patient #1 and a verbal altercation ensued. Security Guard #1 attacked Patient #1 and took the patient down to the floor and remained on top of the patient until Security Guard #2 ordered Security Guard #1 to get off the patient. At one point during the confrontation, Security Guard #1 removed his baton weapon from his holster and waved it towards Patient
#1. As the altercation continued to escalate, Security Guard #1 attackd Patient #1 and punched Patient #1 in the face with his fist.

3. The hospital failed to develop and implement safety interventions to protect the patient from exit seeking and paranoia behaviors which resulted in a hospital Security Guard attempting to redirect the patient from eloping and using physical force and abuse to restrain the patient from exiting the hospital.



























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