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Based on the nature of deficiency cited, the hospital failed to comply with the Condition of Patient Rights. The facility failed to prevent the utilization of Oleoresin Capsicum (OC) spray by hospital police officers on psychiatric patients with behavioral disturbances.

The facility failed to meet the following standard under the Condition of Patient Rights:

A 0154 Use of Restraint or Seclusion
The facility failed to ensure that weapons (Oleoresin Capsicum (OC) spray) were not used by hospital peace officers as a means of restraint with non-compliant and/or aggressive patients with psychiatric diagnoses in the hospital in three of 33 sample patients. The sample patients represented three patients who were exposed to OC spray by hospital peace officers in the facility in 2010. The failure created negative patient outcomes for all of the patients exposed to OC spray (sample #31, #32, and #33).

Based on review of medical records, facility documents, facility policy & procedures, hospital police policy & procedures, and staff interviews, the facility failed to ensure weapons (Oleoresin Capsicum (OC) spray) were not used by hospital peace officers (employees of the Colorado Mental Health Institute) as a means of restraint with non-compliant and/or aggressive patients with psychiatric diagnoses in the hospital, in three of 33 sample patients. The sample patients represented three patients exposed to OC spray by hospital peace officers in the facility in 2010. The failure created negative patient outcomes for all of the patients exposed to OC spray (samples #31, #32, and #33).
Cross reference to A0115.

The findings were:

1. Review of medical records/facility peace officer reports:

Review of the Hospital Peace Officer Reports and patient medical records revealed the following findings, in pertinent parts:

1. Sample patient #31 was a 35-year-old male patient admitted on 2/21/2010 to a locked psychiatric unit after being placed on a mental health hold. On 3/9/2010 at approximately 10:15 PM, the patient was asked to leave the day hall as it was closed. The patient refused staff redirection and was making verbal threats to the staff indicating he would inflict physical harm to staff and hospital police (if called). PRN (as needed) medications were not ordered for this patient and therefore not given. When hospital peace officers arrived on the unit, the patient "raised his fists to the officers in a threatening stance and stated, 'What you want to get down.'" At this, the officer utilized his OC spray and the patient was handcuffed & restrained for unsafe behaviors to others. After being placed in seclusion and restraints, the nurse called the on-call physician's assistant and received orders for as-needed medication and administered them.

2. Sample patient #32 was a 17-year-old male adolescent admitted on 3/22/2010 to a locked psychiatric unit after being placed on a mental health hold. On 3/24/2010 at approximately 6:15 PM, the patient was being escorted to the restroom by a hospital peace officer. The patient allegedly punched the officer in the nose, causing it to bleed. The patient then ran down the hall towards the exit door and was given verbal warnings by the officer that OC spray would be used. The officer attempted to expose the patient to the OC spray and missed. The patient turned around and took an aggressive stance. The officer then successfully exposed the patient to the OC spray. At this time another officer arrived and was able to aid in escorting the patient to the locked seclusion room where the patient was restrained.

3. Sample patient #33 was a 17-year-old male adolescent admitted on 1/29/2010 to a locked psychiatric unit after being sent there for a legal competency exam. On 3/18/2010 at approximately 12:26 PM, hospital peace officers were called to the unit when the patient refused to go into a locked door seclusion room and had tied the legs of a pair of sweatpants to his/her neck. When officers entered the room, the patient attempted to kick and punch the officers. After officers removed the pants from the patient's neck, the patient then attempted to bite a staff member. When the officer turned the patient's head away from the staff member the patient was attempting to bite, the patient then bit the officer. The patient was told to stop biting the officer and then the patient bit harder. The officer warned the patient that OC spray would be utilized if the patient did not stop biting the officer. The patient was then exposed to the OC spray by the officer being bit. The patient released his bite and was then placed in handcuffs and taken to the seclusion room and placed in restraints.

2. Review of Policies/Procedures:

On 5/5/2010 at approximately 12:20 PM, an interview was conducted with the Director of Quality Support Services. S/he stated that the facility does not have a facility-wide policy on the use of OC spray in the facility, but that the Hospital Peace officers have a policy.

On 5/5/2010 at approximately 12:25 PM, a review of the Department of Public Safety policy titled: Circumstances of Use Policy - Oleoresin Capsicum (O.C.) revealed in pertinent parts:
"The use of OC-10% may be used at the officer's discretion under the following circumstances:
1. When necessary to defend himself/herself or others from imminent harm, and the use of OC is justifiable.
2. To effect an arrest.
3. To prevent the commission of a criminal offense.
4. When lower levels of force are deemed ineffective."

3. Staff interviews:

Based on an interview on 5/5/2010 at approximately 11:45 AM, the Acting Chief of the Peace Officers for the hospital stated that OC spray was used on 3 patients in 2010. S/he stated that the OC spray was utilized by hospital peace officers when the patient does not comply or was threatening and other means of gaining compliance had failed, including verbal judo. S/he also stated that patients are restrained after exposure to the OC spray and then decontaminated with copious amounts of water and paper towels after agreeing to comply. S/he also stated that none of the patients exposed to OC spray were arrested. S/he stated that staff were asked after the deployment of OC spray if the patient should be arrested. The staff stated, in the case of the three patients, that it was not in the best interest of the patients and their treatment to be arrested.

In summary, the facility failed to ensure weapons were not utilized in the application of restraints on hospital patients.

Based on complaint survey a tour of the facility and staff interview was conducted on 5/11 through 5/17/2010 by one surveyor and the following tags were issued. Based on the scope and severity of the cited tags the condition was out of compliance with the Conditions of Participation. See the following K-tags in survey HW6421:

K-11
K-14
K-18
K-56
K-69
K-72
K-74
K-143
K-144