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Based on observation, interview and record review, on 9/1/2015- 9/4/2015, the governing body failed to ensure that patient rights were protected, that the roles and responsibilities of contract security officers are defined and ensure an effective nursing assessment and supervision of patient care was provided.


The identified practices resulted in harm to a patient and present the likelihood for substantial harm to all current and potential patients in the Medical Center.


Based on record review and interview, the facility failed to ensure that systems were in place that clearly specify the roles, duties and responsibilities of contracted Police Officers working as security staff at the facility;

The facility failed to provide evidence that contracted police officers responding to calls for security service on patient care units were trained in dealing with confused/disoriented and aggressive patients.

The facility failed to ensure contract police officers were trained in the use of safe, acceptable health care interventions for confused and aggressive patients.

This failed practice resulted in the tasering , shooting and handcuffing of a confused, agressive patient by contract police officers who were working as security officers.


Refer to: 482.12(e)



Based on record review and interview, and the facility failed to protect and promote the rights of a confused patient with history of anxiety disorder to ensure the safe and appropriate use of restraint by qualified medical staff.


This failed practice resulted in facility's security officers using tazer,guns, and handcuffs to subdue a patient with behavioral problems.


Refer to 482.13(e)



This failed practice resulted in the patient becoming aggressive towards the security officers when they entered his room unannounced by nursing staff .The officers tasered, shot and placed the patient in handcuffs causing life threatening injury.



Based on interview and record review, the facility failed to provide adequate supervision and direction to non clinical security officers on their encounter with a confused patient who repeatedly came out of his room naked.


This failed practice resulted in the patient becoming aggressive towards the security officers when they entered his room unannounced by nursing staff .The officers tazed , shot and placed the patient in handcuffs causing life threatening injury.


Refer to 482.23(b) (3), and (4)

Based on record review and interview, the facility failed to ensure that systems were in place that clearly specify the roles, duties and responsibilities of contracted security staff at the facility.

The facility failed to provide evidence that contracted security staff responding to calls for security service on patient care units were trained in dealing with confused/disoriented and aggressive patients.

The facility failed to ensure contract security officers were trained in the use of safe, acceptable health care interventions for confused and aggressive patients.

This failed practice resulted in the tasering , shooting and handcuffing of a confused, agressive patient by contract security officers. Citing security officers L and Z.

Findings:

Patient #2.

Summary: Record review and interview, at the facility revealed a 26 years old, Patient #2, was admitted to the hospital on 8/26/2015 following a motor vehicle collision.

History and physical examination revealed the patient had a past medical history of Manic Depressive Disorder, Anxiety disorder and substance abuse. He was treated in the Emergency Room and moved to an observation unit for overnight monitoring.

Review of documentation dated 8/27/2015, and interviews revealed an anxious, confused patient repeatedly leaving his room naked.

Security was called by the nurse and responded. They went to the patient's room. There was a confrontation which resulted in the security staff tasering, shooting and placing the patient in handcuff.

Review of clinical record for Patient #2 and interviews with facility staff revealed the following information:

On 8/27/2015, at around 10:45 am, Patient #2 came out of his hospital room naked three (3) times. He stepped into the hallway and returned to his room each time when redirected.

He was repeatedly instructed to go back to his room and put clothes on. Patient #2 did not comply with the instructions and his nurse Staff (G) called for hospital security.

During the entrance conference meeting on 9/1/2015, at 9:10 am, with the facility's administrative staff, the Chief Executive Officer stated that off duty police officers work as security officers providing security services in the hospital. He stated they are authorized to carry their weapons on all open units in the hospital.

He stated that the security officers responded to the call for security service and was assaulted by Patient # 2.

He further stated, the minute the patient hit the uniformed police officer it became a criminal offence and the officers went into 'Police Mode' and were justified in the actions they took to protect themselves.

When asked what other interventions could have been used by the security staff the CEO said 'If it should happen today, they would not have done anything different".

During a meeting on 9/4/2015, at 9:50 am, with Administrative staff the facility's attorney, Risk Manager and Director of Quality, they all stated the Police Officers were justified in tazing and shooting Patient #2 because the patient's aggression towards the officers was a criminal offence.

During an interview on 9/1/2015, at 10:40 am, with Staff (G) Registered Nurse assigned to Patient #2, she stated she called security because it was hospital protocol to call security when a patient is confused and not complying with instructions. She stated when the security officers were called, she did not know it would be HPD Officers that would respond.

Review of surveillance record on the unit where patient #2 was located revealed the patient came out of his room naked multiple times and went right back to his room. He did not walk down the hallway nor attempted to go into the nurses station or other patients' room.

Observation on 9/2/2015, at 8:50 am, on unit 8 medical/surgical unit revealed all patient rooms were single patient rooms.

During an interview on 9/1/2015, at 11:50 am, with the Risk Manager when asked if he had interviewed the two police officers, he stated the facility staff were not able to interview the officers because the police department would not allow them to talk to the officers.

During an interview on 9/1/2015, at 12:10 pm, with the Chief Nursing Officer, she stated, the facility had two sets of security officers, armed Police and non-police security who are not armed.

She stated, when a call is made for security officer the category that respond will depend on who is available at the time of the call.

During an interview on 9/4/2015, at 11:20 am, with the facility's Chief Financial Officer(CFO), he stated, when the Police Officers deployed their weapon they were acting as police officers and not as facility staff.

According to the CFO, his general understanding is that when the police officer mode comes into force it was a criminal investigation and the facility now have no jurisdiction. Once that event occurs it trumps hospital policy.

During an interview on 9/3/2015, at 2:10 pm, with the Director of Human Resources(HR), she stated, the Police Officers working security at the facility are classified as Commissioned Security Officers meaning they are armed. The Officers are licensed peace officers.

They receive hospital orientation and some training on line. She stated the facility does not provide Crisis Prevention Intervention( CPI) training for the police officers because she was told they have to do that training to maintain a current license.

She stated, she did not know this for a fact because she had no evidence of that training. The HR Director stated the CPI training is a requirement for facility staff.

Interviews, review of clinical notes from the RN, Social Worker and Case Manager, and review of video surveillance on the unit revealed two uniformed police officers went to the patient's unit, had a brief discussion at the nurses station then went to Patient #2's room and closed the door behind them.

The notes and interview revealed, the officers had a confrontation with the patient and he was tasered, shot and handcuffed by the Police Officers.

Review of the facility's BYLAWS signed and dated November 24, 2914, Section 2 (b) and Section 5 revealed the following information:

"Contractual Relationship: The Governing Body shall review contractual relationships of the Medical Center to ensure that its mission to patients and the community is not harmed by any such relationship.

Section 5 titled 'Adherence to Law' : The Governing Body shall establish mechanisms to ensure that the Medical Center adheres to applicable law and regulations and the requirements of the Joint Commission."

Review of Job Description # FS1160/PL 1975 revised 7/16/13 gave the following information:

JOB summary: Commissioned Security Officer is responsible for the enforcement of city, county, state and federal laws at Hospital Complex. Will serve as liaison between the Hospital and the Houston Police Department (HPD).Performa a wide range of function, the purpose of which the protection of hospital property and personnel.

Review of the facility's Security Officer Service Agreement with Criterion Healthcare Security (CHS) signed and dated 1/19/2015 Section B 3 stated in part:

''CHS shall provide uniforms for all assigned personnel. CHS will provide one (1) Conducted Energy Devise "Taser" and one (1) level 3 holster per officer on duty.
CHS will adopt a policy for the use of Conducted Energy Devices that adheres to our current best practices document that addresses less than lethal force".

The contract further stated:

''The goal of CHS is to substantially reduce the incidence of behavioral patient aggressive behavior and voilence within the facility.

To help acheive this goal Criterion is committed to employing CPI(Crisis Prevention Intervention) practices as the foundation for all de-escelation and restraint efforts."

Review of personnel file for Staff L and Z revealed no CPI training was documented.

Based, interview and record review, the facility failed to ensure there were systems in place that protects patient right to safe and appropriate care:

The facility failed to have systems in place to maintain the safety of confused patients and ensure they receive appropriate healthcare intervention when they exhibit aggressive behavior towards staff.

This failed practices resulted in a confused patient being tasered, shot, and placed in handcuffs by the facility security officers.

Refer to:482.13( c)(3)


Based on record review and interview, the facility failed to protect and promote the rights of a confused patient with history of anxiety disorder to ensure the safe and appropriate use of restraint by qualified medical staff.

This failed practice resulted in facility's security officers using taser, gun, and handcuffs to subdue a patient with behavioral problems.

482.13(e)

Based, interview and record review the facility failed to ensure there were systems in place that protects patients from staff abuse.


The facility failed to have systems in place to maintain the safety of confused patients and ensure they receive appropriate healthcare intervention when they exhibit aggressive behavior towards staff.


This failed practices resulted in a confused patient being tasered, shot, and placed in handcuffs by the facility security officers. Citing Security Officers L and Z.


Findings:

Patient # 2

During an interview on 9/2/2015, at 9:30 am, on the Medical Psychiatric Unit with Patient # 2, he gave the following information:

The patient stated he crashed his car and was hospitalized. While on the unit he developed an anxiety attack. He stated he has had anxiety attacks before but they were not frequent occurrences. When asked what he remembered about the shooting incident he said he remembered he was confused and could not find his clothes.

The patient stated he saw two Police Officers came to his room and threatened his life. He stated he could not recall what occurred he only knew he was shot.

Patient #2 stated, he he forgave the police officers but what he cannot understand is why police officers were in his room when he was an ill patient trying to get well.


During a telephone interview on 9/2/ 2015, at 11:25 am, with Dr. (A), Resident physician assigned to Patient # 2, he gave the following information:

Dr. (A) stated, he was not called when the patient was shot, he heard a code blue page overhead while he was walking upstairs. He realized it was his patient's room and went to the floor.

When he arrived on the floor, he saw not less than twenty (20) uniformed police officers with hand cuffs.

He went to the patient's room and saw him lying on the floor on his back with a drape over him.

The patient was quiet, his eyes were closed. The doctor said he took the drape off the patient and saw he was handcuffed. He had injury on his sternum and Injury to his upper chest. There were multiple tasers in his chest.

Dr. (A) stated, when he asked what happened he was told that the patient was just tasered.

There was a lot of commotion going on and he asked if the patient was shot because of the blood and multiple wounds. Dr (A) stated, the response was that the patient was tasered. At some point while he began to assess the patient someone mention that he was shot.

Dr. (A) stated, Patient# 2 started yelling incoherent when he touched him.

With the assistance of other staff the patient was placed on his hospital bed. The patient was struggling while staff were trying to get his vital signs. He yanked off the pulse ox, throwing punches that were not deliberate but was as a result of his condition.

Dr (A) said, he asked that the handcuff be removed from the patient, tried to get appropriate restraints on but there was none on the unit . He called his Chief of Service who assisted in helping to get the patient medically restrained.


During an interview on 9/1/2015, 11:40 am, at the facility with the Chief Nursing Officer (CNO), she stated, she came on the scene pretty quickly after the incident occurred. She stated the patient was on the ground in his room in handcuffs.

He was combative,when asked what he was doing, the CNO stated the patient was trying to get up and was not staying still so he could be examined.

The CNO stated Dr. (A) arrived and asked that the cuffs be removed from the patient.

Several staff members in the room lifted the patient onto the bed, he was hollering and screaming talking gibberish.

He was subdued with medication and was intubated and examined.


Review of Trauma history and physical notes by Dr. (A)
''Shot by police officer in the hospital while being discharged. Code blue called. On arrival patient found down in his blood with Gunshot wound entered left sternum and exited right chest. Neurological assessment: the patient was confused''.

Past Medical History: Bipolar disorder. Diagnosis: Lung contusion from gunshot wound.

Review of Computed Tomography(CT) scan of chest, abdomen and pelvis dated 8/27/2015, after the patient was shot revealed the following information:

Entry point of a gunshot wound to the chest is located in the left midline at the level of the manubrium.

The exit point appears to be in the right lateral chest.

Scattered metallic bullet fragments are seen in the right lateral thoracic wall and in and around the right pectoral muscle.

Review of the lung shows opacities consistent with hemorrhage. Atelectatic changes are present in both lung bases. The anterior 5th and 6th ribs are fractured.


Review of Social Worker's notes dated 8/27/2015, at 4:37, revealed the following information:

'Attempted to assess patient at approximately 10:45 am, however, patient was exhibiting bizarre behavior (i.e. in hallway naked and speaking incoherently).

Per RN, the patient was already discharged, however, since the patient's behavior was inappropriate and disruptive post discharge, two (2) HPD Officers entered the patient/civilian's room and were significantly assaulted. Civilian was shot and is now in ICU.

Review of Case Manager notes dated 8/27/2015 revealed, she was at the nurses station and saw the patient came out of his room 4-5 times naked.

Patient's nurse asked him to go back to his room, the nurse called security.

Two Officers entered the patient's room and the Case Manager heard scuffles and a gun shot.

Nurses ran to the room to assist patient and officer still in the room.


Policy Review
Review of the facility's Patient Right's policy dated 6/15/2015, revealed the following information:

'The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his/her personal dignity.

This care shall include consideration of psycho social, personal values, beliefs, spiritual and cultural preferences that influence the perception of illness.

The patient has the right to be free from neglect, exploitation and verbal, mental physical and sexual abuse".


Review of the facility's BYLAWS signed and dated November 24, 2914, Section 2 (b) and Section 5 revealed the following information:

"Contractual Relationship: The Governing Body shall review contractual relationships of the Medical Center to ensure that its mission to patients and the community is not harmed by any such relationship.

Section 5 titled 'Adherence to Law' : The Governing Body shall establish mechanisms to ensure that the Medical Center adheres to applicable law and regulations and the requirements of the Joint Commission."


Review of the facility's Security Officer Service Agreement with Criterion Healthcare Security (CHS) signed and dated 1/19/2015, Section B 3 stated in part:

''CHS shall provide uniforms for all assigned personnel. CHS will provide one (1) Conducted Energy Devise "Taser" and one (1) level 3 holster per officer on duty.

CHS will adopt a policy for the use of Conducted Energy Devices that adheres to our current best practices document that addresses less than lethal force".

The contract further stated:

''The goal of CHS is to substantially reduce the incidence of behavioral patient aggressive behavior and violence within the facility.

To help achieve this goal Criterion is committed to employing CPI(Crisis Prevention Intervention) practices as the foundation for all de-escalation and restraint efforts."

Based on record review and interview, the facility failed to protect and promote the rights of a confused patient with history of anxiety disorder to ensure the safe and appropriate use of restraint by qualified medical staff.


This failed practice resulted in facility's security officers using tazer,guns, and handcuffs to subdue a patient with behavioral problems.



Findings:

During a telephone interview on 9/2/ 2015, at 11:25 am, with Dr. (A), Resident physician assigned to Patient # 2, he gave the following information:

Dr. (A) stated, he was not called when the patient was shot, he heard a code blue page overhead while he was walking upstairs. He realized it was his patient's room and went to the floor.

When he arrived on the floor he saw not less than twenty (20) uniformed police officers with hand cuffs.

He went to the patient's room and saw him lying on the floor on his back with a drape over him.

The patient was quiet, his eyes were closed. The doctor said he took the drape off the patient and saw he was handcuffed.

He had injury on his sternum and Injury to his upper chest. There were multiple tasers in his chest.

Dr. (A) stated, when he asked what happened, he was told that the patient was just tasered.

There was a lot of commotion going on and he asked if the patient was shot because of the blood and multiple wounds. Dr (A) stated, the response was that the patient was tased.

At some point while he began to assess the patient someone mentioned that he was shot.

Dr. (A) stated, Patient#2 started yelling incoherent when he touched him.

With the assistance of other staff the patient was placed on his hospital bed. The patient was struggling while staff were trying to get his vital signs. He yanked off the pulse ox, throwing punches that were not deliberate but was as a result of his condition.

Dr (A) said, he asked that the handcuff be removed from the patient, tried to get appropriate restraints on but there was none on the unit . He called his Chief of Service who assisted in helping to get the patient medically restrained.


During an interview on 9/1/2015, at 11:40 am, at the facility with the Chief Nursing Officer (CNO), she stated, she came on the scene pretty quickly after the incident occurred. She stated the patient was on the ground in his room in handcuffs.

The CNO stated, Dr. (A) arrived and asked that the cuffs be removed from the patient.

Several staff members in the room lifted the patient onto the bed, he was hollering and screaming talking gibberish. He was subdued with medication and was intubated and examined.


During an interview on 9/1/2015, at 10:50 am, with Staff G, Registered Nurse assigned to Patient #2, she stated, she called Security for Patient #2 because he repeatedly came out of his room naked and could not be redirected.

Staff (G) stated, the security that came were two (2) HPD officers with their guns and another man in blue.(later told he was a volunteer).

The patient was in his room when the officers came to the unit . The officers asked if the patient had any sharp object and was told no.

The two officers went into the patient's room and the man in blue closed the door behind them.

A few minutes later there was a loud scuffle, raised voices, and a scream was heard then a loud "pop".

Staff (G) said, she could not hear what was said and did not know who screamed, but thinks it could have been the patient. She stated she did not go to the room with the officers.

The patient's door opened and an officer crawled out of the patient's room on his hands.

In the room, the other officer was standing over the patient who was lying on the floor, his shoes was off.

He had a taser on his upper chest. There was blood on the floor and wall.

The patient was conscious, trying to get up stating he was 'Superman' and needs to get up. The patient was handcuffed. He was assessed and had a laceration on his upper abdomen but there was no exit/entry wound found.


Review of Trauma history and physical notes by Dr. (A) revealed:

''Shot by police officer in the hospital while being discharged. Code blue called. On arrival, patient found down in his blood with gunshot wound entered left sternum and exited right chest. Neurological assessment: the patient was confused''.

Past Medical History: Bipolar disorder. Diagnosis: Lung contusion from gunshot wound.

Review of Computed Tomography(CT) scan of chest, abdomen and pelvis dated 8/27/2015, after the patient was shot revealed the following information:

Entry point of a gunshot wound to the chest is located in the left midline at the level of the manubrium.

The exit point appears to be in the right lateral chest.

Scattered metallic bullet fragments are seen in the right lateral thoracic wall and in and around the right pectoral muscle.

Review of the lung shows opacities consistent with hemorrhage. Atelectatic changes are present in both lung bases. The anterior 5th and 6th ribs are fractured.


Review of the facility's Patient Right's policy dated 6/15/2015, revealed the following information:

''The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his/her personal dignity.

This care shall include consideration of psycho social, personal values, beliefs, spiritual and cultural preferences that influence the perception of illness.

The patient has the right to be free from neglect, exploitation and verbal, mental physical and sexual abuse".


Review of the facility's BYLAWS signed and dated November 24, 2914, Section 2 (b) and Section 5 revealed the following information:

"Contractual Relationship: The Governing Body shall review contractual relationships of the Medical Center to ensure that its mission to patients and the community is not harmed by any such relationship.

Section 5 titled 'Adherence to Law' : The Governing Body shall establish mechanisms to ensure that the Medical Center adheres to applicable law and regulations and the requirements of the Joint Commission."


Review of the facility's Security Officer Service Agreement with Criterion Healthcare Security (CHS) signed and dated 1/19/2015 Section B 3 stated in part:

''CHS shall provide uniforms for all assigned personnel. CHS will provide one (1) Conducted Energy Devise "Taser" and one (1) level 3 holster per officer on duty.

CHS will adopt a policy for the use of Conducted Energy Devices that adheres to our current best practices document that addresses less than lethal force".

The contract further stated:

''The goal of CHS is to substantially reduce the incidence of behavioral patient aggressive behavior and violence within the facility.

To help achieve this goal Criterion is committed to employing CPI(Crisis Prevention Intervention) practices as the foundation for all de-escalation and restraint efforts."


Review of the facility's Restraint Policy # RMCO.011 revised 7/2/2015 gave the following information:

''The leadership of the hospital is commited to preventing ,reducing and striving to eleminate the use of restraints. The leaders recognize that the use of restraints has the potential to produce serious consequences, such as physical and psychological harm, loss of dignity, violation of an individual's rights, feelings of isolation, and even death.

Patients will be restrained only when clinically justified to prevent the patient from causing injury to self or others in the therapeutic environment or to enhance medical healing and when alternative methods have proved unsuccesful.

Restraints are never utilized for the purposes of discipline, coercion, conveinance, retaliation of staff or in place of medical or nursing care."

Based on interview and record review, the facility failed to provide supervision to non clinical security officers and direct their encounter with a confused patient who repeatedly came out of his room naked.


This failed practice resulted in the patient becoming aggressive towards the security officers when they entered his room unannounced by nursing staff .The officers tasered , shot and placed the patient in handcuffs causing life threatening injury.


Refer to: 482.23(b)(3)


Based on interview and record review the facility failed to provide supervision to non clinical security officers and direct their encounter with a confused patient who repeatedly came out of his room naked.


This failed practice resulted in the patient becoming aggressive towards the security officers when they entered his room unannounced by nursing staff .The officers tasered , shot and placed the patient in handcuffs causing life threatening injury.


Refer to: 482.23(b)

Based on record review and interview, the facility failed to ensure nursing staff are trained in methods of identifying psychological changes in patients being cared for on Medical/Surgical units and inform appropriate healthcare personnel of the change in patient's condition.

This failed practice resulted in a patient being tasered, shot, and handcuffed by security officers without any medical/nursing intervention. Citing one patient named in a complaint (#2).

Findings:


Review of Medical Record for Patient # 2 revealed the following information:

Emergency Room (ER) record revealed, the twenty six (26) year old patient was seen in the emergency room on 8/26/2015, at 23:40, with history of motor vehicle collision on the street outside the hospital.

The patient was triaged and assigned an acuity level of 2-Emergent. Triage notes documented the patient was not able to give past medical or surgical history because of his altered mental status.

Patient # 2 was examined and had multiple diagnostic studies including:

radiology, blood, and urine studies. Radiology findings were negative. Urine was positive for marijuana use.

His Chief Complaint was documented as Motor Vehicle Collision (MCV).

Diagnosis: Motor Vehicle Accident, Hand Abrasion and Substance Abuse.

A general surgery consult was requested by the ER Physician and the consulting physician documented on 8/27/2015, at 11:56, that the patient had past medical history of Manic Depressive Disorder and social history of Marijuana use.


Review of ER Nursing documentation dated 8/27/2015, at 00:01, revealed the patient was alert and oriented x 4.

He complained of pain in multiple areas of his body including face and limbs.

He was placed on telemetry monitor, had Intravenous (IV) access and Foley catheter placed. His temperature, blood pressure, and pulse were elevated.

Nurses' notes dated 8/27/2015, between the hours of 01:36 and 04:46, revealed the patient started to exhibit signs of anxiety and started pulling at his Foley catheter, telemetry monitors and IV lines.

The Nurses documented six (6) times that the patient was redirected but the patient still continued to pull at the IV lines, the monitor and Foley catheter.

Staff removed his catheter for safety and the patient eventually pulled his IV access out.

Patient # 2 was transferred from the Emergency Room on 8/27/2015, at 05:00, to be cared for as an observation patient on the 8th floor medical/surgical unit.

His differential diagnoses were: Blunt trauma, laceration, closed head injury, abrasion, contusion and substance abuse.

Review of Observation Unit Nurses notes dated 8/27/2015, at 08:00, revealed the following information:

Received patient in bed, no respiratory distress, made comfortable.

Behavior-- restless and agitated, he is forgetful, oriented to person and place.

Heart rate-- tachycardic. Feels depressed dizziness/vertigo, Poor judgement, cooperative, left hand abrasion.

Review of nurses' notes dated 8/27/2015, at 10:20 am, revealed documentation that Patient #2 was in his room, he was anxious and restless.

His family was visiting at that time and requested to speak with the doctor. Dr. (A), Resident physician caring for the patient, arrived but the family had stepped out. When the family returned the doctor had left.

The notes documented that at 10:55 the patient had a shower.

Review of nurses' notes dated 8/27/2015, at 11:00, revealed documentation that the patient was encouraged to put on his gown after he had a shower but refused and started dancing in his room. The patient came out of his room naked 4-5 times. He was redirected while security was called.

There was no documentation that the nurse evaluated the patient's change in condition and informed the patient's physician and Nursing Supervisor.


Review of the case managers (CM) notes dated 8/27/2015, revealed the following information:

Case Manager Staff (F) documented, she saw the patient's parents at around 10:00 am at the nurses station and spoke with the dad. He expressed concern about taking his son going home in the condition he was in.

He told her the son needs psych to see him. He was concerned the son was "going to do the same thing".

The nurse said, they had paged the surgical resident who was scrubbed in and would be tied up for the next three (3) hours.

The Case Manager documented, she told the dad she would talk to the surgical resident and get back to him.

Staff (F) documented, she went into the patient's room and talked to him. When asked where he lived he said he did not know.

He was able to tell her his first name and that he was in the hospital. When asked what year it was he said "1989".

The patient said his hand hurt and began repeatedly slapping his hand.

Further review of the notes revealed documentation that she (CM) was at the nurses' station and saw the patient came out of his room 4-5 times naked.

Patient's nurse asked him to go back to his room, the nurse called security.

Two officers entered the patient's room and the Case Manager heard scuffles and a gun shot.

Nurses ran to the room to assist patient and officer still in the room.


Review of Social Worker's (Staff D) notes dated 8/27/2015, at 4:37, revealed the following information:

Attempted to assess patient at approximately 10:45 am, however, patient was exhibiting bizarre behavior (i.e. in hallway naked and speaking incoherently).



During an interview on 9/1/2015, at 10:45 am, at the hospital with Staff (G), Registered Nurse who cared for Patient #2 on the 8th floor Medical/Surgical Unit, she gave the following information:

She was assigned the care of Patient #2 shortly after 6:30 on 8/27/2015. The patient was in bed, he was cooperative, alert to person and place. He could say who he was and where he was but not why he was there.

Staff (G) stated, she reminded him of his situation by asking him about an abrasion he had on his arm. The patient told her he was in a motor vehicle accident.

Staff (G) stated, at the time of assessment his vital signs were stable except that he was tachycardic.(rapid heart rate).

The patient's parents visited around 10:00 that morning and soon after, the patient became anxious, he started pressing on the call light, when she went to the room he said he did not want anything but as soon as she left he called again.

When she went back to the room the patient told her he was feeling anxious.

Staff (G) stated she gave the patient 10 mg of Flexeril (muscle relaxant) to calm him.

Shortly after he was given the medication, he called again stating his heart was beating fast. The patient's father asked if she could give the patient something else like lorazepam (anxiety medication), she told him the flexeril was just administered and needed time to take effect.

Staff (G) stated, the patient's father again stated the patient needed something like Geodon (psychotropic medication) and lorazepam because he was still anxious.

According to Staff (G), she checked the orders and there was only orders for flexeril. She told the father that was the only order and they could not administer anti psychotropic medication without a psych diagnosis and physician order.

The father requested a psychiatric evaluation (psych eval). She told the father, might need an outpatient psych eval., she would discuss with the doctor and see what the doctor thinks.

Staff (G) stated, the patient's mother told her Patient #2 had a problems with anxiety in 2009 and was exhibiting similar symptoms.

She stated, she attempted to take the patient to out patient psych and he tried to jump out of the car.

Staff (G) stated, she called the Resident physician and told him the family wanted to talk to him; he asked why and she told him they wanted a psych consult. He told her the patient would be discharged.

She told the parents the patient would be discharged but they still insisted they wanted a psych consult.

They were directed to wait in the family room. When the physician arrived the family had left.

She told the patient, she would get towels and a gown. She stated all this time the patient was calm and cooperative.

Sometime later, the patient came out in the hallway naked except he had shoes on. He was told to go back to his room and she would come in to assist him with his gown, she stated she went to the room with another nurse and was trying to help the patient into his gown.

They placed the gown on him and told him to turn around so they could tie the gown.

The patient started to dance and would not comply. All this time the patient was in his room with the gown on unbuttoned.

She stated the patient was acting inappropriate, when asked what he was doing, she stated he would not comply with her orders to turn around so his gown could be buttoned up. She stated, she went to the nursing station and called security.

When asked why she called security, Staff (G) stated, because it was protocol, the patient was dancing and not following orders.

According to Staff (G), in the few minutes it took security to come to the floor. Patient #2 came into the hallway naked with only his shoes on about four times, she re-directed him to his room each time.

When asked what he was doing she stated each time she redirected him he would say "yes mam, righty O, ok mam".

Staff (G) stated, the security that came were two(2) HPD officers with their guns and another man in blue.(later told he was a volunteer).

The patient was in his room. The officers asked if the patient had any sharp object and was told no. The two officers went in the patient ' s room and the man in blue closed the door behind them.

A few minutes later there was a loud scuffle, raised voices and a scream was heard then a loud "pop".

Staff (G) said, she could not hear what was said and did not know who screamed, but thinks it could have been the patient. She stated she did not go to the room with the officers.

She called Code Green and called for backup security. The patient's door opened and an officer crawled out of the patient's room on his hands.

In the room, the other officer was standing over the patient who was lying on the floor, his shoes was off. He had a taser on his upper chest. There was blood on the floor and wall.

The patient was conscious, trying to get up stating he was 'Superman' and needs to get up. The patient was handcuffed. He was assessed and had a laceration on his upper abdomen but there was no exit/entry wound found.


During an interview on 9/3/2015, at 10:56 am, at the facility with Staff (D), Social Worker, he gave the following information:

He was assigned to the unit and Patient #2 was one of his patients. He was approaching the patient's room when the patient came to the door and step out into the hall way naked.

He stated the room door was opened. The patient went back into his room. Staff (D) stated, he asked the nurse what was going on with the patient and she told him ''they were handling it',' and the patient was discharged. He stated at this point he decided not to go to the patient's room.

Staff (D) stated, he was still on the unit around 10:45 am when two HPD Officers came to the Nurses station.

They were talking to the nurses and he only heard the nurses said ''he is waiting for his parents".

The officers went to the patient's room and closed the door behind them. Shortly after, he heard what appeared to be a struggle and then the sound of gun shot.

During a telephone interview on 9/3/2015, at 9:40 am, with Staff (P), Registered Nurse, working on the unit where Patient #2 was a patient she gave the following information:

On 8/27/2015, she was assigned to the 8th floor medical/surgical unit. She was not assigned to Patient #2 however she spoke to him three (3) times when he pressed his call light.

Twice when she answered his call, he told her it was a mistake he called in error. The third time she answered he told her he was having heart palpitations.

According to Staff (P), she told his nurse Staff (G) who said she was aware of it.

Staff (P) stated, some time later she saw the patient came out of his room naked, he did that a couple of times and he was instructed to go back to his room and put his clothes on.

Later, the patient was observed with a wet gown on and she went to his room to assist his nurse in putting on clean dry gown.

During the process of changing his gown the patient grabbed her arm and tried to dance with her. She told him that was inappropriate and she left the room.

A few minutes later, she saw two uniformed police officers and another gentleman came on the unit.

She thought they had missed where they were going.When she enquired, she was told they received a call about the patient in room 834 (Patient # 2).

The staff said, she was not aware the patient's nurse had called security. Security asked her if the patient had any weapon and she told them no. The officers went to the patient's room

Staff (P) stated Patient #2 was not aggressive when she interacted with him prior to the officers coming to the floor, and she did not feel threatened by the patient.


During an interview on 9/2/2015, at 9:30 am, on the Medical Psychiatric Unit with Patient #2 he gave the following information:

The patient stated, he crashed his car and was hospitalized. While on the unit he developed an anxiety attack.

He stated he has had anxiety attack before but they were not frequent occurrences. When asked what he remembered about the shooting incident, he said he remember he was confused and could not find his clothes. According to the patient, he saw police officers came to his room and threatened his life.

He stated, he could not recall what occurred, he only knew he was shot. He said he forgave the police officers but what he cannot understand is why police officers were in his room when he was an ill patient trying to get well.


During a telephone interview on 9/2/2015, at 9:25 am, with Dr. (A), Resident physician assigned to patrient #2, he gave the following information:

He rounded with the medical team that morning around 7:00 am. Patient #2 was not anxious. He answered questions appropriately. His CT and examination showed no injury from his accident.

He was scheduled for discharge. Later that morning, he got a call from the patient's nurse stating the family wanted to speak to him. The doctor said when he went to the unit to see the parents they had left.

He went to the patient's room and spoke to the patient. The patient said he was ok so the discharge paper work was completed.

Dr. (A) stated, he was scrubbing in the OR when he received another call from the nurse that the family was back and wanted to speak to him. He told staff he would not be available for about three hours.

The doctor stated, the nurse never told him the patient was confused or was acting inappropriately.

He was not told that the family was requesting a psychiatric evaluation. If he was told the patient was acting psychotic, he would have asked his superior to see the patient if he could not go himself so that there could be medical or psychological intervention.

Dr. (A) stated, he was not called when the patient was shot; said he heard a code blue page overhead while he was walking upstairs.

He realized it was his patient's room and went to the floor. On his arrival to the patient's room, he saw the patient laying on the floor in his blood. He was shot, tazed and had handcuffs on.

Review of the facility's Nursing Policy titled Assessment of Patients dated 10/1/2013 revealed the following information:

''Identifies and consistently recognizes changes in normal and abnormal parameters in the patient ' s physiological, psychological cultural, development and spiritual needs.

Implements nursing intervention to achieve progress toward expected patient outcomes or to stabilize a patient ' s condition and or prevent complications.

Evaluates and documents patient ' s response to nursing care and modifies or revise treatment plans and /or contacts physicians as circumstances require. Documentation reflects evaluation of patient response to nursing actions. "

There was no evidence nursing staff used proper healthcare intervention when dealing with Patient # 2's confused state.

Based on interview and record review, the facility failed to provide supervision to non clinical security officers and direct their encounter with a confused patient who repeatedly came out of his room naked.


This failed practice resulted in the patient becoming aggressive towards the security officers when they entered his room unannounced by nursing staff .


The officers tasered, shot and placed the patient in handcuffs causing life threatening injury. Citing Staff G.


Findings:


Review of Medical Record for Patient # 2 revealed the following information:

Emergency Room (ER) record revealed, the twenty six (26) year old patient was seen in the emergency room on 8/26/2015, at 23:40, with history of motor vehicle collision on the street outside the hospital.

The patient was triaged and assigned an acuity level of 2-Emergent. Triage notes documented the patient was not able to give past medical or surgical history because of his altered mental status.

Patient #2 was examined and had multiple diagnostic studies including:

radiology, blood, and urine studies. Radiology findings were negative. Urine was positive for marijuana use.

His Chief Complaint was documented as Motor Vehicle Collision (MCV).

Diagnosis: Motor Vehicle Accident, Hand Abrasion and Substance Abuse.

A general surgery consult was requested by the ER Physician and the consulting physician documented on 8/27/2015, at 11:56, that the patient had past medical history of Manic Depressive Disorder and social history of Marijuana use.


Review of ER Nursing documentation dated 8/27/2015, at 00:01, revealed the patient was alert and oriented x 4. He complained of pain in multiple areas of his body including face and limbs. He was placed on telemetry monitor, had Intravenous (IV) access and Foley catheter placed. His temperature, blood pressure, and pulse were elevated.

Nurses' notes dated 8/27/2015, between the hours of 01:36 and 04:46 revealed, the patient started to exhibit signs of anxiety and started pulling at his Foley catheter, telemetry monitors and IV lines.

The Nurses documented six (6) times that the patient was redirected but the patient still continued to pull at the IV lines, the monitor and Foley catheter. Staff removed his catheter for safety and the patient eventually pulled his IV access out.

Patient # 2 was transferred from the Emergency Room on 8/27/2015, at 05:00, to be cared for as an observation patient on the 8th floor medical/surgical unit.

His differential diagnoses were: Blunt trauma, laceration, closed head injury, abrasion, contusion and substance abuse.

Review of Observation Unit Nurses notes dated 8/27/2015 at 08:00: revealed the following information:

Received patient in bed, no respiratory distress, made comfortable.

Behavior-- restless and agitated, he is forgetful, oriented to person and place.

Heart rate-- tachycardic. Feels depressed dizziness/vertigo, Poor judgement, cooperative, left hand abrasion.

Review of nurses ' notes dated 8/27/2015, at 10:20 am, revealed documentation that Patient #2 was in his room, he was anxious and restless.

His family was visiting at that time and requested to speak with the doctor. Dr. (A), Resident physician caring for the patient, arrived but the family had stepped out. When the family returned the doctor had left.

The notes documented that at 10:55 the patient had a shower.

Review of nurses' notes dated 8/27/2015, at 11:00, revealed documentation that the patient was encouraged to put on his gown after he had a shower but refused and started dancing in his room. The patient came out of his room naked 4-5 times. He was redirected while security was called.

Review of the case manager's (CM) notes dated 8/27/2015, revealed the following information:

Case Manager Staff (F) documented she saw the patient's parents at around 10:00 am at the nurses station and spoke with the dad. He expressed concern about taking his son going home in the condition he was in.

He told her the son needs psych to see him. He was concerned the son was "going to do the same thing".

The nurse said, they had paged the surgical resident who was scrubbed in and would be tied up for the next three (3) hours.

The Case Manager documented, she told the dad she would talk to the surgical resident and get back to him.

Staff (F) documented, she went into the patient's room and talked to him. When asked where he lived, he said he did not know. He was able to tell her his first name and that he was in the hospital. When asked what year it was, he said "1989". The patient said, his hand hurt and began repeatedly slapping his hand.

Further review of the notes revealed documentation she (CM) was at the nurses' station and saw the patient came out of his room 4-5 times naked. Patient's nurse asked him to go back to his room, the nurse called security.

Two officers entered the patient's room and the Case Manager heard scuffles and a gun shot. Nurses ran to the room to assist patient and officer still in the room.

Review of Social Worker's (Staff D) notes dated 8/27/2015, revealed the following information:

Attempted to assess patient at approximately 10:45 am, however patient was exhibiting bizarre behavior (i.e. in hallway naked and speaking incoherently).


During an interview on 9/1/2015, at 10:45 am, at the hospital with Staff (G), Registered Nurse, who cared for Patient #2 on the 8th floor Medical/Surgical Unit she gave the following information:

She was assigned the care of Patient #2 shortly after 6:30 on 8/27/2015. The patient was in bed, he was cooperative, alert to person and place. He could say who he was and where he was but not why he was there.

Staff (G) stated, she reminded him of his situation by asking him about an abrasion he had on his arm. The patient told her he was in a motor vehicle accident.

Staff (G) stated, at the time of assessment his vital signs were stable except that he was tachycardic.(rapid heart rate).

The patient's parents visited around 10:00 that morning and soon after, the patient became anxious, he started pressing on the call light, when she went to the room he said he did not want anything but as soon as she left he called again.

When she went back to the room the patient told her he was feeling anxious.

Staff (G) stated, she gave the patient 10 mg of Flexeril (muscle relaxant) to calm him.

Staff (G) stated, the patient's mother told her Patient #2 had a problems with anxiety in 2009 and was exhibiting similar symptoms.

She stated, she attempted to take the patient to out patient psych and he tried to jump out of the car.

Staff (G) stated, she called the Resident physician and told him that the family wanted to talk to him; he asked why and she told him they wanted a psych consult. He told her the patient would be discharged.

Sometime that morning, the patient came out in the hallway naked except he had shoes on. She told him to go back to his room and she would come in to assist him with his gown. She stated she went to the patient's room with another nurse and was trying to help the patient into his gown. They placed the gown on him and told him to turn around so they could tie the gown. The patient started to dance and would not comply. All this time, the patient was in his room with the gown on unbuttoned.

Staff G stated the patient was acting inappropriately. When asked what the patient was doing, she stated he would not comply with her orders to turn around so his gown could be buttoned up. She stated she went to the nursing station and called security When asked why she called security, Staff (G)stated because it was protocol, the patient was dancing and not following orders.

According to Staff (G) in the few minutes it took security to come to the floor. Patient #2 came into the hallway naked with only his shoes on about four times. She stated each time she re-directed the patient to go to his room and put clothes on. When asked how the patient responded, she stated each time she redirected him he would say "yes mam, righty O, ok mam".

Staff (G) stated, the security that came were two (2) HPD officers with their guns and another man in blue.(later told he was a volunteer).

The patient was in his room when the officers came to the unit . The officers asked if the patient had any sharp object and was told no. The two officers went into the patient's room and the man in blue closed the door behind them. A few minutes later there was a loud scuffle, raised voices, and a scream was heard then a loud "pop".

Staff (G) said, she could not hear what was said and did not know who screamed, but thinks it could have been the patient. She stated she did not go to the room with the officers.

The patient s door opened and an officer crawled out of the patient's room on his hands.

In the room, the other officer was standing over the patient who was lying on the floor, his shoes was off. He had a taser on his upper chest. There was blood on the floor and wall. he

Tpatient was conscious, trying to get up stating he was 'Superman' and needs to get up. The patient was handcuffed. He was assessed and had a laceration on his upper abdomen but there was no exit/entry wound found.

During an interview on 9/3/2015, at 10:56 am, at the facility with Staff (D), Social Worker, he gave the following information:

He was assigned to the unit and Patient #2 was one of his patients. He was approaching the patient's room when the patient came to the door and step out into the hall way naked. He stated, the room door was opened. The patient went back into his room.

Staff (D) stated, he asked the nurse what was going on with the patient and she told him ''they were handling it", and the patient was discharged. He stated, at this point he decided not to go to the patient's room. Staff (D) stated, he was still on the unit around 10:45 am when two HPD Officers came to the Nurses station. They were talking to the nurses and he only heard the nurses said ''he is waiting for his parents.''

The officers went to the patient's room and closed the door behind them. Shortly after, he heard what appeared to be a struggle and then the sound of gun shot.

During a telephone interview on 9/3/2015, at 9:40 am, with Staff (P), Registered Nurse working on the unit where Patient #2 was a patient she gave the following information:

On 8/27/2015, she was assigned to the 8th floor medical/surgical unit. She was not assigned to Patient #2, however, she spoke to him three (3) times when he pressed his call light. Twice when she answered his call he told her it was a mistake he called in error. The third time she answered he told her he was having heart palpitations. According to Staff (P) she told his nurse Staff (G) who said she was aware of it.

Staff (P) stated some time later she saw the patient came out of his room naked, he did that a couple of times and he was instructed to go back to his room and put his clothes on. Later, the patient was observed with a wet gown on and she went to his room to assist his nurse in putting on clean dry gown. During the process of changing his gown, the patient grabbed her arm and tried to dance with her. She told him, that was inappropriate and she left the room.

A few minutes later she saw two uniformed police officers and another gentleman came on the unit. She thought they had missed where they were going. When she enquired, she was told they received a call about the patient in room 834(Patient # 2). The staff said, she was not aware the patient's nurse had called security. Security asked her if the patient had any weapon and she told them no. The officers went to the patient's room

Staff (P) stated, Patient #2 was not aggressive when she interacted with him prior to the officers coming to the unit. She said she did not feel threatened by the patient. When asked where the nurses were when the officers went to the patient's room, she stated they were both in the nurses station charting at the computer.

During an interview on 9/2/2015, at 9:30 am, on the Medical Psychiatric Unit with Patient #2 he gave the following information:

The patient stated, he crashed his car and was hospitalized. While on the unit he developed an anxiety attack.

He stated, he has had anxiety attack before but they were not frequent occurrences. When asked what he remembered about the shooting incident, he said he remember he was confused and could not find his clothes. According to the patient, he saw police officers came to his room and threatened his life.

He stated, he could not recall what occurred he only knew he was shot. He said he forgave the police officers but what he cannot understand is why police officers were in his room when he was an ill patient trying to get well.

Review of the facility's Nursing Policy titled Assessment of Patients dated 10/1/2013, revealed the following information:

''Identifies and consistently recognizes changes in normal and abnormal parameters in the patient ' s physiological, psychological cultural, development and spiritual needs.

Implements nursing intervention to achieve progress toward expected patient outcomes or to stabilize a patient ' s condition and or prevent complications.

Evaluates and documents patient ' s response to nursing care and modifies or revise treatment plans and /or contacts physicians as circumstances require. Documentation reflects evaluation of patient response to nursing actions. "