HospitalInspections.org

Based on interviews and record reviews, the Hospital failed to provide care in a safe setting for one of ten sampled patients (Patient #3), who was assaulted by Hospital staff during a restraint application.

Findings include:

The Department received an allegation that Hospital ' s Public Security Officer assaulted a 14-year-old patient (later identified as Patient #3) who resided in a residential program and had a diagnosis of autism, by striking him/her in the head "seven times" during an Emergency Department (ED) visit on 10/4/22.

Review of the Department of Public Health ' s (DPH) Health Care Facility Reporting System (HCFRS), indicated that the Hospital submitted a Report, dated 10/17/22, indicating that on 10/04/22, an ED Technician and Patient #3 separately alleged that during a restraint, Public Security Officer (PSO) #1, hit Patient #3 (14-year-old) in the face several times.

Review of Patient # 3 ' s medical record indicated that he/she presented to the Hospital ' s ED Behavioral Health Unit (BHU) in October 2022, for suicidal and homicidal statements, and displaying verbal and physical aggressive behaviors.  

Review of the Hospital ' s Internal Investigation, dated 10/4/22, indicated that Public Security Officer (PSO) #1, struck/used heel palm strikes to Patient #3 ' s face three times during an altercation in the ED.

There was no documentation that an altercation or assault took place, and medical record review did not demonstrate/document the need for Patient #3 to be struck in the head/face three times by PSO #1.

During an interview on 11/3/22 at 8:00 A.M., and throughout the Survey, the Chief Nursing Officer (CNO) acknowledged that on 10/4/22, PSO #1 hit/used a heel palm strike to Patient #3 ' s face several times. The CNO said a root cause analysis was not completed for this incident. The CNO said that the Human Resources Department and the Internal Use of Force Committee reviewed the incident and had no findings.

During an interview on 11/7/22 at 8:40 A.M., and throughout the Survey, the Public Safety Manager and Senior Director of Support Services said the Hospital did not identify any issues with how staff implemented the Use of Force Policy on 10/4/22.

The Hospital failed to provide care in a safe setting, leaving vulnerable patients at risk for physical assault while being cared for in the Behavioral Health Unit within the Emergency Department.