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Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to protect a patient from abusive forms of restraints. See deficiency at A-0154.

An immediate jeopardy (IJ) was identified on 1/24/2024 at 42 CFR 482.13 Patient Rights, due to the hospital's failure to protect patient from the use of abusive restraint. Subsequently, capsaicin spray (temporarily causes burning and pain when in contact with eyes) and handcuffs were used on Pt. #1, resulting in pain, redness swelling to the eyes and abrasion. These law enforcement practices are not appropriate health care restraint interventions.

The IJ was announced on 01/24/2024 at 3:00 PM, during a meeting with the Risk Manager, Manager of Clinical Integration, Manager of the Clinical Decision Unit (CDU), Deputy General Counsel, Infection Prevention, Security Manager, Administrator, Facility Manager, Emergency Department (ED) Manager, ED Director, and Chief Operating Officer. The IJ was not removed by the survey exit date of 01/24/2024.

Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) patients that required de-escalation and emergency safety interventions, the hospital failed to protect a patient from abusive forms of restraints. Subsequently, pepper spray (capsaicin spray -temporarily causes burning, pain, and tears when comes into contact with eyes) and handcuffs were used on Pt. #1, resulting in an abrasion to the neck and scratches to neck, chin, and eyes.

Finding include:

1. The hospital's policy titled, "Restraints and Seclusion for Violent or Self-Destructive Behavior" (revised 04/14/23) was reviewed and required, "A. ... (name of hospital) believes that all patients have the right to be free from Restraints or Seclusion, of any form ... B. The use of Restraints and Seclusion will only occur after less restrictive alternatives have been deemed ineffective ... C. Restraints and Seclusion will only be used with an order from a licensed independent provider ... in which there is an assessed need for its use ... E. During the use of Restraints and/or Seclusion, the patient ' s rights, dignity, and well-being will be protected and respected ...Exceptions, A. The use of handcuffs, manacles, shackles, other chain-type Restraint devices, or other restrictive devise applied by law enforcement for custody, detention, and public safety reasons are not considered Restraints ..."

2. The hospital's education to security staff titled, "Essentials of Aggression Management in Healthcare" (undated) "The Aggression Continuum: Step 6: the person is physically violent: Observable Behavior: Physically attacks you in some form: Your Response: Change to self-defense/survival mode; Discontinue efforts to de-escalate and escape! ... Patient Control: Tactics to maximize patient management while minimizing injury to patients and other providers ... Defensive Tactics ... should interventional or physical take down using force be required, the minimum force necessary will be applied ..."

3. On 01/19/2024, the clinical record of Pt.#1 was reviewed. Pt.#1 presented to the emergency department (ED) on 01/08/2024 at 7:21 PM, with a chief complaint of numbness and slurred speech. The clinical record included the following:

-On 1/8/2024 at 10:08 PM, the Medical Screening Exam was completed. On 1/9/2024, Pt. #1 was admitted to the Clinical Decision Unit (CDU) for further monitoring. On 1/9/24 at 3:57 AM, physician documented the CT (computerized tomography) scan of the brain was negative for hemorrhage or mass. Pt. #1 was stable for discharge.

-History and Physical dated 01/09/2024 at 1:03 PM, "(Pt.#1) presented possible TIA (transient ischemic attack) workup) (Pt.#1) has chronic pain issues. Unfortunately (Pt.#1) was not cooperative or pleasant with history during my examination. (Pt.#1) keeps demanding to see higher ups, my boss, CEO, threatening to call lawyers. Imaging studies, labs, previous chart reviewed by me. Reviewed the current workup with (Pt.#1) patient. No acute issues that need to be addressed in the hospital. MRI brain negative. (Pt.#1) does have chronic pain for which (Pt.#1) was established with pain clinic ... (Pt.#1) was dismissed as (Pt.#1) violated the contract ... asking for suboxone (used to treat narcotic dependence) refill which we agreed to provide but later on asking for Norco (opioid pain medication) ... have seen (Pt.#1) up and walking and moving on the bed without difficulty although (Pt.#1) complains that (Pt.#1) could not move (Pt.#1 ' s) legs or bend given back pain ... At this time, I do not see any need for further acute inpatient hospital intervention ... can be discharged home and establish with a ... pain clinic outpatient ... will give prescription for suboxone ... to last for 10 days. I am not comfortable giving him any other pain medications given (Pt.#1 ' s) history ... and inconsistent symptoms ..."

-Nursing Note dated 1/9/2024 at 1:22 PM, indicated that Pt. #1 was upset and was refusing to be discharged and wanted to speak to "highest doctor here.".

-Nursing Note dated 01/09/2024 at 4:00 PM, "Patient advocate relayed message that patient made the following statement: 'I work as a roofer. If you discharge me, I will go to work tomorrow and jump off the roof to end my life so that my family can sue (name of hospital) for malpractice.' Charge Nurse was asked to contact (physician) to inform about the patient's statements, risk management was notified per (physician's) request. Petition completed for patient by this RN."

-Nursing Note dated 01/09/2024 at 4:15 PM, "Spoke to (Pt.#1 ' s) sister, at nurse ' s station and provided update on (Pt.#1 ' s) plan of care, states (Pt.#1) always makes threats like these, expressed interest in having (Pt.#1) transferred to a behavioral facility."

-Nursing Note dated 01/09/2024 at 6:30 PM, "Received call from Nursing staff to help with an upset patient (Pt.#1) at 5:25 PM on 1/9/24 ... went to talk to this upset patient (Pt.#1) as to why (Pt.#1) could not leave the hospital due to (Pt.#1 ' s) statement (Pt.#1) made about killing self. Upon de-escalating this situation, (Pt.#1) made statement about fighting with our security ... The supervisors again tried to reason with this patient ... be evaluated by the psychiatrist for (Pt.#1 ' s) safety ... The Aurora Police arrived about 5:50 PM. They spoke with patient ... was still being uncooperative ... was restrained by security ... during the restraining process pepper spray was used ... it was noted that patient had cuts to (Pt.#1 ' s) neck after placed in bed. (Pt.#1 ' s) eyes were flushed by nursing with the assistance of security."

-Psychiatry Consultation note dated 01/10/2024 at 5:39 PM, "... Psychiatry consulted as patient had become uncooperative and agitated with staff prior to discharge ... required to be placed in restraints and given Haldol (antipsychotic) due to (Pt.#1 ' s) agitation and threatening behavior ... seen today in a more cooperative mood. (Pt.#1) was calm and stated that (Pt.#1) made the statement in frustration ... adamant of not having any suicidal or homicidal ideations ... At this time (Pt.#1) is not an acute danger to self or others and is stable to be discharged per psych [psychiatry]..."

4. On 01/19/2024, at approximately 11:00 AM, the hospital provided an incident report dated 01/09/2024, and included, "Incident Occurrence Date/Time: 01/09/24 at 7:33 PM, "... Pt. #1 continued to try to fight security so (E#2-Security Officer)) said 'Gas ... Gas (capsaicin spray) ... Once sprayed (Pt.#1), Security was able to get (Pt. #1) under control and onto the bed on (Pt. #1) stomach ... Ofc (E#6) was able to assist (E#1) in getting handcuffs on (Pt.#1) ... The patient (Pt.#1) sustained a scratch on the left side of (Pt. #1) neck, a scratch near right chin, a scratch by (Pt. #1) right eye, and an abrasion on the back of (Pt. #1) neck at an unknown point during the extended struggle."

5. On 01/19/2024 at 12:10 PM, an interview was conducted with a Security Officer (E#2). E#2 stated that E#2 had a capture shield ready in case they needed, it. The Nursing Supervisor and other clinical staff tried to deescalate but were not successful. We attempted to talk to patient to change into paper gown for about 45 minutes, (Pt.#1) then took a stance as if to fight, (Pt.#1) cornered self, we (security staff) attempted several times to calm (Pt.#1) down. (Pt.#1) was trying to reach into (Pt.#1) pocket, we then went into the room with the capture shield to hold (Pt.#1) down before (Pt.#1) can get into (Pt.#1 ' s) pocket. The patient was able to throw off balance the security officer (E#4) with the shield and tried punching (E#4) when (Pt.#1) landed on top of (E#4). At this point we were trying to get the (E#4) from underneath (Pt.#1). (Pt.#1) was standing over (E#4) while on ground. We were able to pin (Pt.#1) into chair, but (Pt.#1) kept trying to fight and hit the security officers, and not following commands to stop fighting. Given the nature of (Pt.#1 ' s) threats, (E#2) deployed the capsaicin spray at (Pt.#1 ' s) eyes after (E#2) let other security officers know (E#2) was going deploy it. We were attempting to get him away from wall, but (Pt.#1) was still fighting and was not letting go of the officer (E#3). We were eventually able to get (Pt.#1) on the bed face down. I was directly behind him; another officer had (Pt.#1 ' s) arms. We continued to give verbal commands to stop fighting, (Pt.#1) was not saying much. APD was standing by but not physically helping us. (Pt.#1) was still trying to wrestle (Pt.#1 ' s) hands free; (E#2) called out for handcuffs. E#2 stated that all security officers have pepper spray and handcuffs."

6. On 01/19/2024 at 1:05 PM, an interview was conducted with a Charge Nurse (E#7). E#7 stated, "I got a call from the supervisor that (Pt.#1) was going to be in observation. There were many ER notes about the patient being abusive and making threats towards staff and wanting to speak with the CEO. There was a safety alert from previous encounters in (Pt.#1 ' s) chart ... (I (E#7) asked for security to be present when (Pt.#1) was told that (Pt.#1) was no longer being discharged and was being petitioned, in case (Pt.#1) did not take it well. This was around 6 PM, security was not visible to the patient at this time, they were standing by in case. When the patient was told that based on (Pt.#1 ' s) statement to patient experience representative, (Pt.#1) immediately became visibly agitated. (Pt.#1) was using profanity and stating (Pt.#1) was leaving. Security officers stood by doorway and calmly explained that (Pt.#1) could not leave. (Pt.#1) approached one of the security officers and (Pt.#1) threatened him. (Pt.#1) would not back down, verbal de-escalation was attempted by clinical and security staff. The patient was peppered sprayed at some point, (E#7) was not present when this happened, (E#7) realized it after (Pt.#1) was handcuffed and they asked us if there was any medication to give to (Pt.#1) to calm (Pt.#1) down. (Pt.#1 ' s) eyes were swollen, had a laceration to the clavicle area and face."

7. On 01/19/2024 at approximately 1:45 PM, an interview was conducted with the Director of Facilities Manager of Security Services (E#12). E#12 stated that all security officers are trained to use de-escalation techniques and proper use of Capsaicin spray and handcuffs upon hire and annually. Physical contact to control patients is the last resort.

8. On 01/19/2024 at 2:20 PM, an interview was conducted with the Lead Security Officer (E#1). E#1 stated that Security Officers were called to CDU due to potential that (Pt.#1) may become agitated due to not being discharged due to a suicidal statement (Pt.#1) had made. E#1 stated that (E#1) peeked into the room and (Pt.#1) was packing up to leave, E#1 told (Pt.#1) was not allowed to leave due to being petitioned and (Pt.#1) started becoming verbally aggressive using profanity ... (Security Officer) got the capture shield ready with one officer on each side so each staff can take a limb, but (Pt.#1) was in a corner, and it was bad position. E#1 asked (Pt.#1) one more time to please follow their commands. (Pt.#1) got into a fighting stance and approached us as (Pt.#1) was digging into (Pt.#1 ' s) pocket. The other security officer was trying to hold a limb, but (Pt.#1) kept getting loose and somehow (Pt.#1) landed on top of one of the security officers (E#4). We were able to get (Pt.#1) on a chair while (Pt.#1) was still fighting, I could not see from my position, E#1 heard E#2 call out gas (2 times) and then (Pt.#1) was pepper sprayed. We then placed (Pt.#1) on the bed on his stomach, cuffed (Pt.#1) then turned him over to sitting position.

9. On 01/23/2024 at 10:45 AM, an interview was conducted with a Security Officer (E#4). E#4 stated that physical contact is the very last resort, after clinical staff have tried to verbally de-escalate. E#4 stated that Security Officers were called to CDU for (Pt.#1) due to (Pt.#1) had made a suicidal statement to a staff and (Pt.#1) wanted to leave. We explained that due to the statement (Pt.#1) made (Pt.#1) could not leave, (Pt.#1) was adamant and was threatening to leave, at whatever cost if we tried to stop (Pt.#1). (Pt.#1) said (Pt.#1) would kick our assess. (Pt.#1) called the police on is cell phone, and the (PD) dispatcher and the house supervisor spoke to (Pt.#1) about not being able to be released due to being petitioned and required to be evaluated, but (Pt.#1) was very clear about leaving. We had to use the security shield (clear shield that covers from shoulders to below waist) ...E#4 used the shield to hold (Pt.#1) against the wall, but (Pt.#1) kept fighting, and E#4 ended up underneath (Pt.#1) and had to be pulled from underneath. (Pt.#1) was sprayed by another security officer (E#2), which is when they were able to apply handcuffs and put (Pt.#1) on the bed.

10. On 01/23/2024 at approximately 10:50 AM, the Director of Quality and Regulation (E #14) was interviewed. E #14 stated that there was no education or in-services conducted due to no incident or complaint/grievance filed by (Pt.#1). The patient did not report any allegation of abuse, our security officer was the one that was injured while preventing (Pt.#1) from leaving the hospital.

11. On 01/23/2024 at 1:30 PM, an interview was conducted with a Psychiatrist (MD#1). Security may be called to standby in case we need help giving the medication. As far as pepper spray and handcuff use this is the first time, it has happened, it is not a common occurrence. If a patient is not responding to verbal de-escalation, the next best option would be to medicate, and avoid using pepper spray or handcuffs."

12. On 01/23/2024 at 1:50 PM, an interview was conducted with a Registered Nurse (E#8). E#8 stated that (Pt.#1) was assigned to (E#8) from the ED due to stroke like symptoms. All the imaging tests and labs were negative, but (Pt.#1) still had pain and was under observation. Shortly after (Pt.#1) arrived, (E#8) was informed that (Pt.#1) was being discharged, this made (Pt.#1) very upset and stated (Pt.#1) was not leaving. The patient advocate came up to speak with (Pt.#1) because (Pt.#1) was upset, and (Pt.#1) made a statement to her about going to work the next day and falling off a roof so (Pt.#1) can die, and family can sue the hospital. (E#8) was not present when (Pt.#1) made this statement. However, E#8 notified the attending who advised that we reach out the risk manager who then advised that due to this statement (Pt.#1) should be certified and petitioned and evaluated by the psychiatrist. When (E#8) went to inform (Pt.#1) that (Pt.#1) was not being discharged and had to change into paper scrubs and (Pt.#1 ' s) belongings had to be removed due to the statement (Pt.#1) made, (Pt.#1) got very belligerent and aggressive and was attempting to leave. We could not allow (Pt.#1) to leave due to the certificate and petition, at this time (Pt.#1) was calling the APD. They arrived and were with (Pt.#1) for about 20 to 30 minutes trying to explain the process of certification & petition. (Pt.#1) did not respond to APD, they stated they were stepping away and stated they would let hospital follow their protocol. Security officers entered the room, at that point (E#8) and the house supervisor stepped out of the room. E#8 did not see what happened, with the pepper spray but after they (security officers) gained control of (Pt.#1) they asked me to clean out (Pt.#1 ' s) eyes. (Pt.#1 ' s) eyes were swollen and red, there was a small nick on his neck and his chin. E#8 gave (Pt.#1) a shot of Haldol after (Pt.#1) was placed in four-point restraints.