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Based on staff interview and review of State compliance with the Ohio Department of Mental Health (ODMH) it was determined the hospital's Mental Health Unit failed to comply with the State of Ohio laws related to use of force according to the Ohio Administrative Code 9(OAC) 5122-14-04 (D)(1). The total hospital census on the first day of the survey was 388 patients with a psychiatric unit census of 43.

Findings include:

The hospital received notification from ODMH dated 02/05/10. The correspondence stated "This Department conducted an on-site investigation on January 29, 2010, in response to a reportable incident that occurred on January 20, 2010, on the acute inpatient psychiatric unit involving the use of force by taser by hospital law enforcement personnel. The Department is hereby placing your acute psychiatric inpatient unit, ODMH License Number 09-2384, on Probationary Status effective February 5, 2010, per the provisions of Ohio Administrative Code 9 (OAC) 5122-14-04 (D)(1) (a probationary license, which shall expire within one hundred twenty days of the date of issuance.). This action was taken due to law enforcement personnel using weapons, specifically taser and handcuffs, to subdue psychiatric inpatients seven times in less than a two year period."

The notification continued "The Department representative emphasized Ohio Administrative Code (OAC) 5122-14-10 (G)(1)(e) at the on-site investigation which states: The following shall not be used under any circumstances: weapons and law enforcement restraint devices, as defined by CMS in 42 CFR 482.13 (f) and found in Manual Publication #100-7. Medicare State Operations, used by any hospital staff or hospital -employed security or law enforcement personnel, as a means of subduing a patient to place that patient in patient restraint/seclusion. Further, the Department representative discussed the distinction between interventions for psychiatric patients in a hospital setting versus individuals who are contained for criminal purposes."

The above information was confirmed during interview on 02/24/10 at 11:00 AM with Staff A and Staff B.

This citation substantiates Complaint Number OH00053820

Based on interview with hospital staff, university police and administration, and review of medical records, review of policies and procedures, review of the agreement between the facility and the police, and review of the summary of the investigation that involved patient #1, it was determined, the hospital failed to protect and promote each patient's rights related to use of force with handcuffs and/or taser for 7 patients ( #1, #4, #5, #6, #7, #8, #9 ) from the total of 10 sampled patients reviewed and failed to notify CMS (Centers for Medicare/Medicaid Services) within the required time frame of 1 week after the death that occurred for 1 patient (#1) from the total of 10 sampled patients reviewed. The hospital failed to implement protective measures to provide a safe environment prior to the use of force using hand cuffs and/or taser. The total census of the hospital was 388 with a total census on the behavioral unit of 43.

Findings include:



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A review of the clinical record for patient #1 revealed the patient had a long history of admissions, last admitted in 2008. This history included violence and an extensive arrest record. The patient came to the hospital emergency room on 1/17/2010 for voluntary admission. The patient stated that people had not informed him/her and mumbled on about the supreme court woman in the WNBA gaining power and someone controlling his thoughts. The patient had loose, disorganized and delusional thoughts and appeared to be decompensating. For the above mentioned reason, the patient was admitted to the hospital inpatient psychiatric unit for safety and stabilization.

A review of the clinical record revealed that on 1/20/10 at 5:30 PM, an incident occurred on the behavioral health unit where a taser was used on patient #1. The nurses notes reflected that the patient became very difficult to redirect at 4:00 PM. The patient was eating dinner in the dining room when patient #1 began to verbally threaten another patient and the other patient began to argue with the patient #1. The staff pushed the panic button. Staff from other units and the physician responded. Emergency medications were ordered and patient #1 was escorted back to his room. Security/police were on the unit. The patient continued to yell and threaten staff. The patient was given emergency medications and was being escorted to the seclusion room. While in the hallway, the patient turned around and attempted to punch security/police. The patient was escorted to seclusion with increased agitation/hostile/threatening to kill staff and security/officers. Patient #1 attempted to throw the bed at the officers. At that time, control of the situation was given to the security/police. The security/police attempted to calm the patient down. The taser was pulled out and the patient was asked to sit on the bed. The patient refused and the security/police officer tased the patient. The patient continued to struggle and the patient was tased again. The patient was then lifted to the bed and put in 4 point restraints. The patient stated, "All right, I'm done". The patient took a gasp of air and became unresponsive and a code blue (emergency response) was called. Patient #1 was unresponsive and the cardiac arrest lasted for 19 minutes. A pulse was obtained and the patient was then transferred to ICU.

Patient #1 remained non responsive and was declared brain dead on January 23, 2010 at 10:20 PM. The caused of death on the stat discharge summary by the physician was uncal herniation (brain herniation) secondary to anoxic brain injury secondary to cardiogenic shock secondary to prolonged PEA (pulseless electrical activity) arrest.

Review of the police agreement was reviewed on 02/25/10 in the afternoon hours. This agreement, with the hospital and the police/security, is to provide delivery of police and security services. This policy of force is dated 2/5/09 and 01/29/09 by representatives of the University of Cincinnati and the University Hospital as an ongoing agreement.

Staff # A and B, when questioned by the surveyors on 2/25/2010 at 1:00 PM regarding the procedure for show of force and use of force, stated they are looking at the presence of the security/police as a direct trigger since it was revealed that some of these patients had a history of previous police records. Also they stated they had discussed whether to create some type of checklist monitoring, review of other triggers, and medication review in response to escalating behaviors. However staff said no changes have been made regarding those discussions. Staff further stated at this time, the direct care staff were not trained in forensic violent cases and were exploring inservice for the staff in this field.

The staff failed to ensure the safety of all patients residing in the Behavioral Unit of the hospital. The hospital failed, after these incidents were reported, to put in place corrective actions to prevent a recurrence of the use of force on patients on the unit.

Interview with the Staff C was conducted on 02/23/10 at 1:10 PM. Staff C stated the root cause analysis was initiated; however not sent due to the hospital trying to decide whether the taser incident should be considered a police action versus hospital use of force action. The cause of death has not been received from the Hamilton County Corner. The clinical report provided to the surveyors on 02/25/10 at 3:00 PM did not contain a cause of death.

Although the hospital had knowledge of Patient #1's history of violent behavior the hospital failed to assess this patient's behaviors to determine interventions to protect the patient and other patients residing on the behavioral unit. The plan of care for Patient #1 lacked identification of these behaviors or interventions to be implemented when the behaviors were exhibited.

The above mentioned incidents occurred due to the hospital's failure to implement preventative interventions prior to the deployment of force using taser and/or handcuffs. The hospital lacked evidence of any preventive measures completed in response to this incident, or any other measures put into place to prevent further occurrences of the use of force.


Please refer to A144 regarding the facility's failure to protect and promote each patient's rights related to use of force with handcuffs and/or taser for 7 patients ( #1, #4, #5, #6, #7, #8, #9 ) from the total of 10 sampled patients reviewed. The hospital failed to implement protective measures to provide a safe environment prior to the use of force using hand cuffs and/or taser.


Please refer to A154 regarding the facility's failure to notify CMS (Centers for Medicare/Medicaid Services) within the required time frame of 1 week after the death that occurred for 1 (patient #1) of 10 sampled patients reviewed. .


This citation substantiated Complaint Number OH00053820.

Based on interview with hospital staff, university police and administration, and review of medical records, review of policies and procedures, review of an agreement between the facility and the police, the summary of the investigation that involved patient #1, it was determined, the hospital failed to protect and promote each patient's rights related to use of force with handcuffs and/or taser for 7 patients ( #1, #4, #5, #6, #7, #8, #9 ) from the total of 10 sampled patients reviewed. The hospital failed to implement protective measures to provide a safe environment prior to the use of force using hand cuffs and/or taser. The total census of the hospital was 388 with a total census on the behavioral unit of 43.

Findings Include:

The hospital psychiatric unit review of the past 2 years revealed a total census of 4818 admissions. The following incidents occurred due to the hospital's failure to implement preventative interventions and/or the clinical staff maintaining the authority in escalating patient situations prior to the use of force using taser and/or handcuffs.

A review of the clinical record for patient #1 revealed the patient had a long history of admissions, last admitted in 2008. This history included violence and an extensive arrest record. The patient came to the hospital emergency room on 1/17/2010 for voluntary admission. The patient stated that people had not informed him/her and mumbled on about the supreme court woman in the WNBA gaining power and someone controlling his thoughts. The patient had loose, disorganized and delusional thoughts and appeared to be decompensating. For the above mentioned reason, the patient was admitted to the hospital inpatient psychiatric unit for safety and stabilization.

A review of the clinical record revealed that on 1/20/10 at 5:30 PM, an incident occurred on the behavioral health unit where a taser was used on patient #1. The nurses notes reflected that the patient became very difficult to redirect at 4:00 PM. The patient was eating dinner in the dining room when patient #1 began to verbally threaten another patient and the other patient began to argue with the patient #1. The staff pushed the panic button. Staff from other units and the physician responded. Emergency medications were ordered and patient #1 was escorted back to his room. Security/police were on the unit. The patient continued to yell and threaten staff. The patient was given emergency medications and was being escorted to the seclusion room. While in the hallway, the patient turned around and attempted to punch security/police. The patient was escorted to seclusion with increased agitation/hostile/threatening to kill staff and security/officers. Patient #1 attempted to throw the bed at the officers. At that time, control of the situation was given to the security/police. The security/police attempted to calm the patient down. The taser was pulled out and the patient was asked to sit on the bed. The patient refused and the security/police officer tased the patient. The patient continued to struggle and the patient was tased again. The patient was then lifted to the bed and put in 4 point restraints. The patient stated, "All right, I'm done". The patient took a gasp of air and became unresponsive and a code blue (emergency response) was called. Patient #1 was unresponsive and the cardiac arrest lasted for 19 minutes. A pulse was obtained and the patient was then transferred to ICU.

Patient #1 remained non responsive and was declared brain dead on January 23, 2010 at 10:20 PM. The caused of death on the stat discharge summary by the physician was uncal herniation (brain herniation) secondary to anoxic brain injury secondary to cardiogenic shock secondary to prolonged PEA (pulseless electrical activity) arrest.

Although the hospital had knowledge of Patient #1's history of violent behavior the hospital failed to assess this patient's behaviors to determine interventions to protect the patient and other patients resigning on the behavioral unit. The plan of care for Patient #1 lacked identification of these behaviors or interventions to be implemented when the behaviors were exhibited.

A review of the clinical record for patient #9 revealed that on 5/08/08 at 1:30 PM, an incident occurred on the behavioral health unit where handcuffs were used on patient # 9. The progress notes in the clinical record indicated that on 5/7/08 at 1:00 PM the patient became irritable, complained that his/her roommate was masturbating and the patient began to escalate at this point. This patient was well known to the behavioral health unit. The patient had a history of violence and destroying property. A "show of force" was called requesting extra security and staff. The patient continued to escalate as staff talked to him/her with security present. The patient was refusing medication and finally agreed to take the medication intramuscularly. The staff asked the patient to walk to the seclusion room. At this time the patient began to struggle with staff. Security/police were instructed to take over and manage the situation. The patient was brought down to the floor and placed in handcuffs and lifted in bed and placed in 4 point restraints (restraints on all extremities.) At that time the situation was discussed with the police and the clinical staff, the clinical staff agreed to resume control of the patient. The patient was given more medication without incident. At 3:30 PM, the patient was asleep. When the patient awoke at 5:50 PM, the University of Cincinnati Police were notified and the patient was taken to jail.

This patient was admitted to the Behavioral Health Unit on 5/6/08 because the patient was threatening the family, threw a phone at his/her sister, hostile, delusional ideas and refusing medications. The clinical record revealed that the patient had a extensive history of mental illness and a history of violence. The patient also had extensive history of hospitalizations at University hospital and was well-known to the Behavioral Unit Staff (8 West) from his prior stays.

The request for police presence when attempting medication administration was not considered prudent given the patient's history because the police could not and were not part of patient #9's treatment plan. No documentation was found that the hospital followed up on the above incident.

A review of the clinical record for patient #6 revealed that on 8/5/08 at 9:05 AM, an incident occurred on the Behavioral Health Unit where handcuffs were used on Patient #6. On 8/5/08 at 2:00 PM, the nursing progress notes reflect that the patient refused to walk to his/her room for 10 minutes of quiet time. The physician attempted to explain to the patient not to be intrusive with other patients. The patient began challenging the physician. The Security/police were notified that patient #6 would not follow the physician's direction. Security/police attempted to encourage patient #6 to go to his/her room. The patient was holding onto the doorway and not following the direction of the security/police. The patient struggled with police and staff. Handcuffs were applied to control the patient. Restraints were applied and handcuffs were removed and the patient was given medication. At 9:00 PM on 8/5/09, the patient was talking louder and would not move from the nurses' station despite the fact he/she was walked to his/her room. Security/police were called. The patient then walked to his room without problem. The use of security/police was not part of the treatment plan.

A review of the clincal record for patient #7 revealed that patient #7 was admitted on 08/21/09 via the Cincinnati police department after he/she started a fire in his apartment. Upon admission the patient was hostile and angry. The patient was probated to remain involuntarily on the inpatient psychiatric unit. On 8/22/09 at 3:00 PM, an incident occurred on the Behavioral Health Unit where handcuffs were used on patient #7. On 8/22/08 at 3:00 PM, the nursing progress notes revealed the patient was being escorted to the seclusion room when the patient laid on the floor. At that point the clinical staff handed the situation to the security/police who hand cuffed the patient as the least restrictive measure. Once in the room the clinical staff resumed care and placed the patient in 4 point restraints and gave the patient emergency medications. Earlier in the day at 4:00 AM and 2:40 PM, security/police were called as a show of force on standby due to patient acting out and yelling.

A review of the clinical record revealed that patient #8 had a history of schizophrenia and was admitted 03/31/09 with a chief complaint of violence. The patient had an extensive history of violence. The patient was brought to the hospital by the police on a" statement of belief "on a 72 hour hold. The patient apparently at his/her apartment building was walking around carrying a butcher knife and had a box of bullets in a backpack. The patient presented to the emergency department in a guarded state, refusing evaluation and treatment with a menacing demeanor.

On 4/1/09 at 11:00 AM, an incident occurred on the Behavioral Health Unit where a taser was used on Patient #8. The patient began leaning on a nurse in an intimidating manner, became increasing hostile and making threats after receiving IM injections. Patient #8 started making physical contact with staff and started fighting with police. The police tased the patient. The patient was then placed in restraints and arrested after clearance with the physician.

Clinical Staff were unable to maintain the authority in the escalating patient situation. There was no policy or procedure regarding show of force and/or use of force internal and/or external.

A review of the clinical record revealed that patient #5 had a history of explosive disorder since the third grade The patient was brought to the emergency department by the police on 04/02/09. The mobile crisis team had been called because the patient was threatening staff and residents and throwing chairs. In the emergency room the patient was agitated, pacing, verbally threatening to the staff and attempting to leave.

On 4/6/09 at 2:45 PM, an incident occurred on the Behavioral Health Unit where handcuffs were used on Patient #5. The patient became agitated at 3:00 PM and threw pillows in the hallway and kept pushing on the front door. Security/police were called with 3 officers arriving followed by 2 others. The patient continued to escalate becoming physically combative attempting to strike the police. At that point the patient was subdued and placed in handcuffs by security/police. The patient was escorted to the room. The care of the patient was given back to the clinical hospital staff and the patient was placed in 4 point restraints after security/police were used with staff to de-escalate the patient's behavior.

A review of the clinical record for patient #4 revealed that the patient was brought to the emergency department by the police on 06/11/09 after the mobile crisis team was called to evaluate him. The emergency exam described the patient as being actively psychotic, paranoid, and somewhat hostile. The patient was brought to the hospital on a 72 hour hold, however, the patient signed an in-voluntary admission document. The patient had a history of disorganized schizophrenia and psychosis. The patient was previously seen at this hospital in 1/2008 and 5/2006 and was a patient at a state psychiatric hospital in the area in 2001.

On 6/17/09 at 7:40 PM, an incident occurred on the Behavioral Health Unit where handcuffs were used on Patient #4. The clinical nursing progress notes for patient #4 revealed that on 6/17/09 the patient was involved in a confrontation with another peer and was pacing and agitated in the hallway. The patient was asked to walk to the special care area. The patient became more aggressive and threatening. The physician was called for emergency medications and security/police were called. The security/police informed the patient he/she would have to go to the special care area to calm down. The security/police guided the patient with his/her hand on small of the patient's back. The patient told the security/officer "don't touch me" and then the patient punched the security/police in the face multiple times. The staff then attempted to secure the patient and he/she continued to struggle. A second security/police arrived and attempted to secure the patient to no avail. The security/officer then deployed an ESD (electronic restraint device ) touch stun multiple times in the right flank area of the lower back. The patient was then secured and hand cuffed. The patient was discharged to the security/police holding area. The note further stated that the hospital was unable to notify patient rights advocate to evaluate patient # 4 prior to discharge due to the rapid speed in which the patient left the unit.

Review of the police agreement was reviewed on 02/25/10 in the afternoon hours. This agreement, with the hospital and the police/security, is to provide delivery of police and security services. This policy of force is dated 2/5/09 and 01/29/09 by representatives of the University of Cincinnati and the University Hospital as an ongoing agreement.

Staff #A and B, when questioned by the surveyors on 2/25/2010 at 1:00 PM regarding the procedure for show of force and use of force, stated they are looking at the presence of the security/police as a direct trigger since it was revealed that some of these patients had a history of previous police records. Also they stated they had discussed whether to create some type of checklist monitoring, review of other triggers, and medication review in response to escalating behaviors. However staff said no changes have been made regarding those discussions. Staff further stated at this time, the direct care staff were not trained in forensic violent cases and were exploring inservice for the staff in this field.

Interview with the Staff C was conducted on 02/23/10 at 1:10 PM. Staff C stated the root cause analysis was initiated; however not sent due to the hospital trying to decide whether the taser incident should be considered a police action versus hospital use of force action regarding patient #1. The cause of death for patient #1 has not been received from the Hamilton County Corner. The clinical report provided to the surveyors on 02/25/10 at 3:00 PM did not contain a cause of death.

During the survey a letter was given to the surveyors to review that the facility had written to the Ohio Department of Mental Health on 10/13/08 that indicated the hospital stated, " It was found that the use of force was consistent with both hospital policy and the University of Cincinnati Police Department's continuum of force."

The hospital is using security/police as part of the treatment plan. There is no clear difference between clinical intervention and police actions. On three occasions the staff and security/police were interacting/working together.

There was no documented evidence in place that the hospital had a sytem in place to prevent/reduce/manage the power struggles and provide least restrictive interventions for escalating behaviors.


The above mentioned incidents occurred due to the hospital's failure to implement preventative interventions prior to the deployment of force using taser and/or handcuffs. The hospital lacked evidence of any preventive measures completed in response to this incident, or any other measures put into place to prevent further occurrences of the use of force.

The staff failed to ensure the safety of all patients residing in the Behavioral Unit of the hospital. The hospital failed, after these incidents were reported, to put in place corrective actions to prevent a recurrence of the use of force on patients on the unit.


This citation substantiated Complaint Number OH00053820.

Based on interview with facility staff and review of policies and procedures the facility failed to meet the requirement for reporting a restraint/seclusion death of one (patient #1) of 10 sampled patients to CMS within the required timeframe after this patient was tasered and subsequently died. The total census of the hospital was 388 with a total census on the behavioral unit of 43.

Findings Include:

The hospital failed to ensure notification was forwarded to CMS (Centers for Medicare/Medicaid Services) within the required timeframe when a death occurred on the psychiatric unit. The regulation at 482.13 (g)(1)(iii) states "each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death. "Reasonable to assume" in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation."

Staff D stated on interview 02/23/10 in the morning hours, he/she had notified CMS of the death of Patient #1 on 02/09/10. The policy and procedure titled Medical and Behavioral Restrain, Seclusion, and Entrapment file NCA20.0 was reviewed on 02/25/10 in the morning hours. The section of (iv ) Debriefing (TUH-651)(c) for Reportable Incidents states: (i) The hospital shall report the following to CMS: (5) The office of Decedent Affairs shall respond to each report of death and notify the Office of Risk Management of each death referenced in this paragraph for reporting to CMS by telephone no later than the close of business the next business day following knowledge of the patients's death."

Please refer to A144 for further details regarding the death of patient #1.

This citation substantiated Complaint Number OH00053820.