HospitalInspections.org

Based on interview, record review, policy review and digital video recording review, the facility failed to:
- Remove one staff (DD) from patient care after he abused one patient (#21) of one patient reviewed for abuse; (A-0144).
- Adequately investigate allegations of staff to patient abuse, and identify staff to patient abuse for one patient (#21) of one patient reviewed for abuse; (A-0145).
- Follow their internal policy and protect one patient (#21) of one patient reviewed, when security Taser (electrical weapon, used to stun a person through the delivery of electrical current) drive stunned (when a Taser is held against the body and is intended to cause pain without incapacitating) the patient while he was held down by staff.
These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The facility census was 104.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 01/08/19, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 01/09/19, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Decision was made to remove Tasers and handcuffs from service;
- Staff J and Staff DD, Security Officers were both placed on administrative leave until Human Resource (HR) and safety event investigations are complete;
- Recognition of intimidation behaviors and alternative interventions for de-escalation education started with the Emergency Department (ED), Critical Care, and Security night staff on 01/08/19 and continued to all staff organization wide prior to their next scheduled shift until all staff have been educated;
- All staff were assigned the annual education module titled "Abuse and Neglect" with 80% completion by 01/12/19 and 100% completion by all staff by 01/16/19;
- Mock drills began on 01/08/19 during night shift to ED and Critical Care staff. These drills will continue randomly on each shift throughout the clinical service areas for two weeks and once 100% compliance was reached the drills will continue three times per week on alternate shifts until revisit; and
- Immediate education was provided to ED physicians regarding appropriate medical management of the acute behavioral health patients prior to the next shift worked.

Based on interview, record review, policy review and video review, the facility failed to remove one staff member (DD) from patient care, after he abused one patient (#21) of one patient reviewed for abuse. These failures had the potential to place all patients in the facility at risk for their safety. The facility census was 104.

Findings included:

1. Review of the facility's policy titled, "Response to Allegation of Abuse or Neglect on Hospital Premises," revised 09/15/17, showed the following:
- All patients have a right to be free from all forms of abuse or neglect, and protected if abuse or neglect is alleged or suspected to have occurred on hospital premises.
- Abuse includes mental, physical and sexual.
- Mental abuse is humiliation, harassment, shaming and threats of punishment.
- Physical abuse is hitting, slapping, punching, or kicking also includes controlling behaviors through corporal punishment.
- All staff are required to report immediately any observed behavior that is suspected abuse or neglect or any received report of alleged abuse to their immediate supervisor. Notify House Supervisor after business hours.
- After receiving an allegation of abuse or neglect occurring on hospital premises, an internal investigation is initiated by Quality Management in collaboration with other departments as deemed necessary, and completed as quickly as possible.
- Any person alleged of abuse will be removed from patient care until an investigation is completed.

Review of the facility's policy titled, "Tasers (electrical weapon, used to stun a person through the delivery of electrical current)," reviewed 04/12/17, showed the directive for Security staff to do the following:
- To deploy and use the Taser only as a last resort to protect the safety of hospital staff, other patients, and visitors.
- The Taser shall not be used as a tool of coercion to intimidate an individual into compliance with simple requests or directions by an officer, or for means of subduing a patient in order to place them in restraints or seclusion, or to prevent elopement of a patient who does not present the threat of harm to himself/herself or others.
- Authorized personnel may use a Taser when circumstances known and perceived to the individual officer at the time indicate that the application of the Taser is reasonable to subdue or control a violent or physically aggressive subject who poses a credible threat to officers or others.
- The Taser may also be used in a drive-stun (the Taser is held against the individual's body and is intended to cause pain without incapacitating the individual) capacity with a fired cartridge in the device or when the Taser is not loaded with a cartridge.

Review of Patient #21's Medical Record dated 12/27/18, showed the following:
- He was a 51 year old male brought to the Emergency Department (ED) by his daughter at 3:30 PM.
- He was seen by Staff HH, Physician at 3:37 PM and diagnosed with psychosis (a mental disorder characterized by a disconnection from reality), bizarre delusional disorder (a serious mental illness in which a person cannot tell what was real from what was imagined) and the patient occasionally responded to internal stimuli (hears/responds to voices in his head). The patient had a history of schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and did not take his psychiatric medications.

Review of the facility's video recording titled, "Security Incident Report (SIR) Taser Deployment," showed the following:
- The video was not dated, timed and did not include audio.
- Staff Z, Registered Nurse (RN) walked behind Patient #21 as he opened the door to the ED nurses' station (referred to as center court).
- As the patient opened the door, Staff DD, Security Officer, tried to forcefully push him back out the door into the hallway, Staff AA, RN grabbed Patient #21's left shoulder.
- The patient was pulled back into the hallway, while his feet drug on the floor.
- The patient was brought to the floor and laid on the floor, and Staff AA knelt next to the patient and positioned his left elbow in the patient's lower chest and abdomen.
- Staff DD removed his Taser from the holster (holds an object when worn on the body) and shook it in Patient #21's face.
- Staff DD appeared to talk with the patient and shook his finger at the patient's face.
- After a few minutes the patient appeared calm and was assisted to a standing position.
- The patient calmly walked down the hallway while Staff AA and DD held onto him.
- Patient #21 was assisted to his ED bed by Staff AA, without resistance or struggle. The patient sat on the bed calmly, and did not fight or try to get up.
- Staff DD removed the restraints from a bag, appeared to talk to the patient and pointed his finger at the patient and the bed.
- Patient #21 laid down onto the bed without resistance or assistance, repositioned his pillow, crossed his legs and appeared to be comfortable. Staff started to apply restraints to his ankles and when they started to place the restraints over the patient's wrists, he tried to get up.
- Staff J, Security Officer, entered the room and positioned his body across Patient #21's abdomen. The patient shifted to his left side, Staff AA held the patient's shoulder and neck.
- While Patient #21 was physically held down, Staff DD drive stunned (the end of the Taser is held against the body of the person intended to be tased, and when the trigger is pulled, is intended to cause pain) an area on the patient's abdomen with the Taser. Patient #21 placed his hand over the area of the abdomen that was drive stunned.
- While Patient #21 was physically held down, Staff DD drive stunned the patient a second time in the abdomen. The patient attempted to push the Taser away from his abdomen when he was drive stunned for the second time.

Staff DD, Security Officer, used the Taser in a threatening and intimidating manner when he shook the Taser and his finger in the patients' face and used it in a manner that delivered a drive-stun to the patient while he was physically held down.

During an interview on 01/08/19 at 2:00 PM, Staff DD, stated the following:
- The patient did fine while his family was with him.
- "When the patient came to the ED doorway, I shoved him back out into the hallway."
- When the patient was on the floor in the hallway, he took the Taser out of the holster and told the patient he would use the Taser if the patient did not cooperate.
- The reason he drive stunned the patient was because the patient continued to resist and fight.
- Security officers were trained to use the Taser as the last resort.
- He received Taser Recertification training on 12/11/18.
- He finished working his shift on 12/27/18 and had continued to work every scheduled shift since the incident.

Review of Staff DD's time card showed that he worked on 12/27/18 from 1:53 PM to 11:20 PM, and then again on 12/28/18, 12/30/18, 12/31/18 and 01/01/19.

The event occurred on 12/27/18 at 8:30 PM, Staff DD finished his shift and continued to work his scheduled shifts after the event. The facility failed to ensure that Staff DD was not allowed to return to patient care until a thorough investigation was completed.

During an interview on 01/07/19 at 4:20 PM, Staff K, Security Director, stated that he felt like his staff followed policy and acted appropriately. He did not feel that any reeducation was needed after the incident.

During an interview on 01/08/19 at 4:05 PM, Staff D, Regulatory Compliance, stated she found out about the use of the Taser in the ED on 12/28/18 (one day after the incident) and when she reviewed the video with Staff K and Staff C, Quality Director, they felt the incident was handled very well and did not see any signs of abuse.

The facility failed to recognize the abuse to Patient #21 which allowed Staff DD to continue to work and have the potential to abuse other patients.

Based on interview, record review, policy review and digital video recording review, the facility failed to adequately investigate allegations of staff to patient abuse, and identify staff to patient abuse for one patient (#21) of one patient reviewed for abuse. This failure placed all patients in the facility at risk for abuse and neglect by staff. The facility census was 104.

Findings included:

1. Review of the facility's policy titled, "Response to Allegation of Abuse or Neglect on Hospital Premises," revised 09/15/17, showed the following:
- All patients have a right to be free from all forms of abuse or neglect, and protected if abuse or neglect is alleged or suspected to have occurred on hospital premises.
- Mental abuse is humiliation, harassment, shaming and threats of punishment.
- Physical abuse is hitting, slapping, punching, or kicking also includes controlling behaviors through corporal punishment.
- After receiving an allegation of abuse or neglect occurring on hospital premises, an internal investigation is initiated by Quality Management in collaboration with other departments as deemed necessary, and completed as quickly as possible.

Review of the facility's policy titled, "Tasers, (electrical weapon, used to stun a person through the delivery of electrical current) " reviewed 04/12/17, showed the directive for Security staff to do the following:
- To deploy and use the Taser only as a last resort to protect the safety of hospital staff, other patients, and visitors.
- The Taser shall not be used as a tool of coercion to intimidate an individual into compliance with simple requests or directions by an officer, or for means of subduing a patient in order to place them in restraints or seclusion, or to prevent elopement of a patient who does not present the threat of harm to himself/herself or others.
- Authorized personnel may use a Taser when circumstances known and perceived to the individual officer at the time indicate that the application of the Taser is reasonable to subdue or control a violent or physically aggressive subject who poses a credible threat to officers or others.
- The Taser may also be used in a drive-stun (the Taser is held against the individual's body and is intended to cause pain without incapacitating the individual) capacity with a fired cartridge in the device or when the Taser is not loaded with a cartridge.

Review of Patient #21's Medical Record dated 12/27/18, showed the following:
- He was a 51 year old male brought to the Emergency Department (ED) by his daughter at 3:30 PM.
- He was seen by Staff HH, Physician at 3:37 PM and diagnosed with psychosis (a mental disorder characterized by a disconnection from reality). Bizarre delusional disorder (a serious mental illness in which a person cannot tell what was real from what was imagined) present and the patient does occasionally respond to internal stimuli (hears/responds to voices in his head). The patient had a history of schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), but did not take his psychiatric medications.
- Every 15 minute staff documentation of continuous video monitoring showed that the patient was calm until 8:00 PM.
- At 8:00 PM, Staff Z documented that the patient was more agitated. Staff Z obtained an order from Staff HH for Zyprexa (medication used to treat certain mental/mood conditions, such as schizophrenia).
- At 8:15 PM, Staff Z documented that she told the patient that a urine was needed to expedite the care process and would straight cath (insertion of flexible tube in the bladder to drain urine, and immediately removed) the patient if he could not urinate.
- At 8:20 PM, Zyprexa was administered to the patient by mouth.
- At 8:25 PM, Staff Z documented that the patient proceeded to the ED nurses' station (referred to as "center court"), combative, and refused to cooperate.
- At 8:30 PM, Staff Z documented that the patient was placed in four point restraints.

Review of the facility's video recording titled, "Security Incident Report (SIR) Taser Deployment," showed the following:
- The recording did not include date or time or audio.
- Patient #21 opened the door to the ED center court.
- As the patient opened the door, Staff DD, Security Officer, tried to forcefully push him out the door into the hallway, Staff AA, Registered Nurse (RN) Charge Nurse, grabbed Patient #21's left shoulder.
- The patient was pulled backward into the hallway, while his feet drug on the floor.
- The patient was brought to the floor and laid on the floor, and Staff AA knelt next to the patient and positioned his left elbow in the patient's lower chest and abdomen.
- Staff DD removed his Taser from the holster (holds an object when worn on the body) and shook it in Patient #21's face.
- Staff CC, ED unit technician, leaned over the patient's upper legs and groin area. Three was a staff member who held the patient's lower legs.
- Staff DD left the area and returned with a bag of what appeared to be restraints, and placed them in the patient's room.
- Staff DD returned to the patient and knelt beside him, and relieved Staff Z of her hold of the patient's right arm and shoulder. The patient did not attempt to move, Staff DD held the patient's right wrist.
- Staff DD appeared to talk with the patient and shook his finger at the patient's face.
- The patient appeared calm and was assisted to a standing position and calmly walked down the hallway with Staff AA and DD, who held onto him.
- Patient #21 was assisted to the bed in his room by Staff AA. The patient did not resist or struggle. The patient sat on the bed calmly, and did not fight or try to get up.
- With Staff Z and CC in the room, Staff DD removed the restraints from the bag, appeared to talk to the patient and pointed his finger at the patient and the bed. .
- Patient #21 laid down onto the bed without resistance or assistance, repositioned his pillow, crossed his legs and appeared to be comfortable. Staff started to apply restraints to his ankles, and when they started to place the restraints over the patient's wrists, he tried to get up.
- Staff AA, RN positioned the patient's head onto the bed and placed his right arm around the patient's neck to hold him still.
- Staff J, Security Officer, entered the room and positioned his body across Patient #21's abdomen. The patient shifted to his left side, Staff AA held the patient's shoulder and neck.
- While Patient #21 was physically held down, Staff DD drive stunned (the end of the Taser is held against the body of the person intended to be tased, and when the trigger is pulled, is intended to cause pain) an area on the patient's abdomen with the Taser. Patient #21 placed his hand over the area of the abdomen that was drive stunned.
- While Patient #21 was physically held down, Staff DD drive stunned the patient a second time in the abdomen. The patient attempted to push the Taser away from his abdomen when drive stunned for the second time.
- The patient struggled against Staff J, DD and Staff AA, and maneuvered onto his stomach.
- While Patient #21 was on his stomach, Staff AA held the patient's neck and shoulders, Staff DD leaned over the patient's upper and mid back, and Staff J leaned over the patient's lower back and buttocks area.
- Medications ordered by Staff HH, physician, were administered into the back of the patient's legs. The medications included Geodon (medication used to manage disorders of thought, including paranoia, seeing/hearing things that are not there, and false ideas about what is taking place or who one is) 10 milligrams (mg, unit of measure) Intramuscular (IM, within the muscle), Diphenhydramine (causes drowsiness) 50 mg IM and Lorazepam (anti-anxiety medication) 2 mg IM.
- The patient continued to be positioned on his stomach. Staff J placed his right elbow in the patient's back and leaned on the patient. The patient did not appear to show aggression or fight against the staff.
- The patient continued to be positioned on his stomach. Restraints were placed on his ankles.
- Additional medication was ordered by Staff HH and was administered IM in each leg. A total of 400 mg of Ketamine (induces a trance-like state while providing pain relief, sedation and memory loss) was given.
- The patient continued to be positioned on his stomach. Staff J placed his left elbow into the patient's back.
- While the patient was on his stomach, Staff J removed handcuffs from Staff DD's pants pocket and forcefully pulled the patient's right arm behind his back and placed one handcuff on the patient. Attempts were made to place the left hand in the handcuff, but the handcuff malfunctioned and was not able to be used. The patient did not move or resist.
- Staff turned the patient over onto his back. Patient #21 showed little physical movement, and his eyes were closed.
- Patient #21 was transported to another area. The patient continued to show little physical movement, and his eyes remained closed.

For nine minutes and 16 seconds, Patient #21 was positioned on his stomach in a physical hold (to restrict a person's movement, through physically applying pressure to their body), while three male staff leaned over the patient's shoulders, back and buttocks, and a female staff member held his ankles. This had the potential to lead to asphyxiation (suffocation, the state or process of being deprived of oxygen, which can result in loss of consciousness or death) of the patient.

After Patient #21 was brought back to his room he sat on his bed was not aggressive and did not fight staff. He laid down on his bed and appeared to make himself comfortable. The patient was not allowed to de-escalate from being held down in the hallway before he was physically held down, unnecessarily drive stunned twice by Staff DD, and placed in restraints.

Review of the facility's self-report documents titled, "Investigation of Taser Use in ED," reported 12/28/18, showed the following Root Cause Analysis (RCA, internal investigation of unexpected or high risk events, to determine the cause of the event an prevent future occupancies):
- RCA was done on 12/28/18 at 2:00 PM.
- It was attended by the Chief Medical Officer, Interim Chief Nursing Officer, Staff K, Security Director, Staff I, ED Director, Staff C, Quality Director, Staff CC, ED Unit Technician, Staff Z, ED RN and Staff DD, Security Officer.
- Statements were obtained from Staff DD, Z and CC.
- The outcome from the RCA was that the patient was aggressive and violent after several verbal attempts to deescalate the patient verbally and with physical force. The patient was drive stunned to maintain a safe environment for patient and staff. The police department was notified of the use of the Taser.
- Opportunities were to review and refine policy "Behavioral Health and or Alcohol, Drug, Intoxicated Patient Standard of Care" with an interdisciplinary approach.

Staff J, Security Officer who attempted to place hand cuffs on Patient #21 and Staff AA, ED Charge nurse who used improper physical holds on the patient, were not present at the RCA.

Review of the facility's document titled, "ED/Critical Care Education Plan," dated 01/03/19, showed the education provided to staff did not include:
- De-escalation techniques;
- Appropriate care and management of the psychiatric patient;
- Taser use;
- Handcuff use; or
- Abuse, definitions, immediate removal of staff after allegations or the reporting process.

During an interview on 01/07/19 at 4:20 PM, Staff K, Security Director, stated that he felt his staff followed policy and acted appropriately with Patient #21, and that reeducation was not needed after the incident.

During an interview on 01/09/18 at 9:05 AM, Staff KK, Security Officer, S.T.A.R.R. (Self Training and Responsible Restraints) Trainer stated that drive-stun was more of a pain compliance and he felt with the number of people in the room and the fact that the patient was lying down and not moving that he would have hoped that the Taser would not have needed to have been used.

During an interview on 01/08/19 at 4:05 PM, Staff D, Regulatory Compliance, stated the following:
- She found out about the use of the Taser in the ED on 12/28/18, one day after the incident.
- She reviewed the video with Staff K, Security Director and Staff C, Quality Director, and they felt the incident was handled very well and did not see any signs of abuse, therefore, Staff DD was allowed to continue to work.
- The reason staff attempted to place Patient #21 in restraints after he sat on the bed in his room, was to straight cath (the act of removing urine from the bladder by inserting a tube into the body where urine is expelled) the patient to obtain a urine sample.

The facility failed to recognize and fully investigate the abuse of Patient #21, when Staff DD physically and mentally abused the patient and other staff used improper physical holds and handcuffs. This failure allowed Staff DD to continue to work and placed all patients at risk for further abuse.















32280

Based on interview, record review, policy review and video review, the facility failed to follow their internal policy and protect one patient (#21) of one patient reviewed, when security Taser (electrical weapon, used to stun a person through the delivery of electrical current) drive-stunned (when a Taser is held against the body and is intended to cause pain without incapacitating) the patient while he was held down by staff. This failure placed all patients at risk for their safety. The facility census was 104.

Findings included:

1. Review of the facility's policy titled, "Restraint and Seclusion Guidelines," reviewed 08/28/18, showed the directive for staff to do the following:
- Restraint use should consider how the intervention affects the patient, including whether the restraint causes physical discomfort or emotional distress.
- The basic rights of human dignity and respect should be maintained and physical well- being should be preserved.
- Restraint and seclusion is not to be used as a means of coercion, discipline, convenience or retaliation by staff or in a manner that causes physical discomfort or harm to the patient.
- Restraint or seclusion may be used in clinically appropriate and adequately justified situations to protect the patient, a staff member or others from harm/injury when less restrictive or alternative interventions fail or are determined to be ineffective.
- Less restrictive or alternative interventions attempted may include reorientation, redirection of activity, safe wandering, medication review, remove from disturbing environment, asking family to stay with patient.

Review of the facility's policy titled, "Tasers," reviewed 04/12/17, showed the following directive for Security staff:
- The purpose is to establish guidelines for the decision to deploy the Taser as a last resort in preventing violence and injury to staff and subject(s), or a criminal act;
- The Taser shall not be used as a tool of coercion to intimidate and individual into compliance with simple requests or directions by an officer, or for means of subduing a patient in order to place them in restraints or seclusion, or to prevent elopement of a patient who does not present the threat of harm to himself/herself or others.
- The Taser may also be used in a drive-stun (where the Taser is held against the person and is intended to cause pain without incapacitating) capacity.
- Although not absolutely prohibited, officers should give additional consideration to the unique circumstances involved prior to applying the Taser to individuals who are restrained.
- Authorized personnel may use a Taser when circumstances known and perceived to the individual officer at the time indicate that the application of the Taser is reasonable to subdue or control a violent or physically aggressive subject regardless of age, who poses a credible threat to officers or others.

Review of the facility's undated video recording titled, "Security Incident Report Taser Deployment," showed the following:
- Patient #21 was seen entering a room while he was escorted by two staff members and was cooperative when he was laid down onto the bed.
- He repositioned his pillow then crossed his legs and appeared to be comfortable;
- Staff members attempted to place four point (both arms and legs) restraints on the patient, and the patient resisted, so they performed a physical hold (physical intervention to restrain a person so that they are unable to move);
- Staff DD, Security Officer removed his Taser from his holster (holds an object when worn on the body) and placed the Taser against the patient's abdomen.
- Patient #21 placed his hand over the Tased area; and
- Staff DD placed the Taser onto the patient's abdomen for a second time and the patient attempted to push the Taser away.

Staff DD did not follow the facility's Taser policy when he used the Taser to drive-stun Patient #21 while he was physically restrained by staff.

During an interview on 01/08/19 at 12:42 PM, Staff DD, Security Officer stated the following:
- The patient was taken into the room but was "still fighting" and he tased the patient for two to three seconds;
- He pulled the Taser back and the patient stated that he was done;
- The patient rolled over and the staff prepared to apply restraints for medication administration; and
- He drive-stunned the patient because he continued to struggle and it was "all they could do" to keep him laying down.

During an interview on 01/08/19 at 5:15 PM, Staff K, Security Director, stated that he had viewed the DVD recording and felt that the actions taken by Staff DD, Security Officer were appropriate.

During an interview on 01/09/18 at 9:05 AM, Staff KK, Security Officer, S.T.A.R.R. (Self Training and Responsible Restraints) Trainer stated that drive-stun was more of a pain compliance and he felt with the number of people in the room and the fact that the patient was lying down and not moving, that he would have hoped that the Taser would not have been necessary.

Staff DD, Security Officer used the Taser in the drive-stun capacity on Patient #21 while he was being held down onto the bed by staff. The patient did not struggle or resist staff, until staff placed hands on the patient, and the Taser was used.