HospitalInspections.org

Based on record reviews, and interviews, the facility failed to protect a patient's right to receive care in a safe setting when, the facility's security officers did not comply with the medical staff's multiple requests to release a patient's face while restraining a physically violent patient. This failure to respond to the medical staff's instructions, placed the patient at risk of injury and death during a restraint hold.

Findings include:

Review of the facility provided, "Security - Restraint Procedure" (Last Revised 4/6/2021) reflected,
"Policy Statement
Ascension Security Department personnel may be authorized to use physical force and or assist with the application of restraints under the following conditions.
Procedures
1. Security may assist in the restraint of a physically violent patient:
A. To protect themselves or others from immediate harm
B. At the direction of a Peace Officer
C. At the lawful direction of a Registered Nurse or Physician in accordance with Ascension Restraint and Safety Policy."

Review of the facility provided, "Patient Rights and Responsibilities" (Last Revised 5/16/2023) reflected,
"The purpose of this policy is to establish the rights and responsibilities for patients who receive care in any Ascension Seton facility.
Be free from seclusion and restraints of any form that are not medical necessary."

During an interview, on the afternoon of 7/31/23 in an administrative conference room, Staff #3, ED MD stated, "The patient (Patient #1) came in for a psychiatric evaluation. We did a medical clearance, the nurse to nurse had been given, she was cleared to go to an inpatient psychiatric facility. I heard the patient became upset about where she was going, she was coming outside into the hallway yelling. She had been here before; I knew she becomes upset with security. She became physical. We were able to calm her. We (the physician and security) talked about a method to let her go."

During a telephone interview on the morning of 7/31/23, Patient #1 stated, "They were pushing my face into the bed, I couldn't breathe."

Review of the facility provided Security Officer Incident Report, dated 6/14/23 and authored by Staff #8, SO (security officer) reflected, "Staff #8, SO held Patient #1 by the left arm and shoulder, Staff #5, SO held left leg, and Staff #6, SO held right leg. I held the patients right arm, [sic] and placed my hand palm up on Patient #1's left cheek to prevent her from biting, spitting, and headbutting anyone. During this time, I gave repeated verbal commands for subject to stop her assault. Patient #1 continued to attempt to kick and strike security. I directed Staff #8, SO to contact Austin Police Department (APD) at approximately 2003. When restraining the subject, I directed Staff #8, SO to ask clinical what the plan was. Staff #11, RN responded by stating clinical would not place restraints on Subject as she had stated they made her uncomfortable and she would fight. While continuing to physically restrain the subject, Staff #13, Charge Nurse (CN) approached my left side. CN Staff #13 touched my left forearm while stating, "Let her go." I verbally directed CN Staff #13 not to touch me, twice. CN Staff#13 continued to verbally demand I release the Subject, at which point CN Staff #13 then grabbed my left forearm with both hands and began pulling on my arm while telling me to let the subject go. I warned CN Staff #13 to let go of my arm. Staff #8, SO then directed CN Staff #13 to not touch any of us (security). After a moment CN Staff #13 released my forearm and left ED 16. Doctor (Dr.) Staff #3, ED MD then approached my left side telling the Subject to calm down and security will let you go, and stated to security, "Let go of her." I asked Staff #3, ED MD what her plan was and she responded with, "To release the patient and leave the room." I began verbally directing, one at a time, to release a limb. During this the Subject would attempt to strike, kick, and headbutt security officers. Eventually I directed all security officers to let Subject go and leave the room.


During an interview, on the afternoon of 7/31/23 in an administrative conference room, when asked who oversaw the patient's care during the incident, Security or the Medical staff, Staff #1, Risk Manger stated in part, "The physician unless the patient is under police custody." When asked if staff may question and intercede questionable hold methods, Staff #1 stated, "We are planning on doing simulations with nursing and security to communicate during incidents. The staff should be able to tap the officer on the shoulder to let them know there is a concern."