HospitalInspections.org

Based on interview, policy review and medical record review, the facility failed to ensure patients have a right to receive care in a safe setting in the emergency department for one (Patient # 2) of 10 patients reviewed. The average daily census in the emergency room was 120.

Findings include:

Review of the facility's policy for Locking of Weapons and Law Enforcement Devices Before Entering the Behavioral Unit, last reviewed on 04/21/15, revealed the policy indicated law enforcement devices are prohibited in the psychiatric department to provide a safe environment for patients, families and staff.

1. Patient #2 arrived at the emergency department by emergency medical services (EMS) on 08/26/15 at 10:29 PM. Review of the emergency department record revealed the arrival complaint for Patient #2 was the patient was found naked behind a gas station and patient verbalized he/she smoked "wet" (street name for marijuana dipped in liquid PCP). Patient #2 was triaged at 10:32 PM at ESI-2 (high acuity level) and was taken to room 10 (behavioral room) in the emergency department (ED).

Review of the history and physical (H&P) for Patient #2 revealed the H&P was done by an ED physician at 10:50 PM. The physical exam indicted Patient #2 was oriented to person, place and time. The physical also indicated Patient #2 had a disheveled appearance. Further review revealed Patient #2 appeared slightly anxious and slightly paranoid.

Further review of the emergency department (ED) record revealed on 08/27/15 at 12:38 AM, Staff E (registered nurse) documented upon exiting an ED room, Staff E heard a commotion from Patient #2's room door. Another RN and a patient care nursing assistant were redirecting Patient #2 back to his/her room. The record indicated there was a Staff D (police officer contracted by hospital), security and the hospital's police officer at Patient #2's door on standby. These officers were directing the patient back to his/her room. The note indicated the patient stated "all I gotta do is pee". The note indicated the patient was seated on his/her bed, as Staff E regowned the patient and provided the patient with a urinal. Staff E indicated in the note he/she went into Patient #2's room to collect the filled urinal. At this time, the patient was getting out of bed and stated "they got guns, they got guns". Patient #2 went to the door of his/her room, despite Staff E's efforts to direct him/her back to his/her room. As the patient came out of his/her room, the patient addressed the hospital's contracted and the hospital's staff police officers and stated "What's up with the guns? What's up with the guns?" Staff D redirected patient back to his/her room, but the patient was becoming increasingly anxious and delusional. Security and police officers accompanied the patient to his/her room. Staff D attempted to reorient Patient #2 as to why he/she was in the ED. The note indicated Patient #2 was hyperfocused on the officers and began stripping out of his/her gown as the RN attempted to keep the patient's gown on. The patient was saying he/she was putting the gown on, but was removing the gown. Further review of the note indicated Patient #2 suddenly lunged at the officer and the patient became extremely aggressive. Staff E indicated he/she heard the officer yell out "he is going for my gun! He is going for my gun!" Staff D and patient were struggling against the wall of the room with the patient gripping Staff D's gun trying to unholster the gun. The other two officers joined the struggle, but the patient seemed to have superhuman strength at the time. All three officers were trying to get the patient to let go of the gun with no success. The officers were having trouble restraining the patient, as the patient was brought to the floor. The note also indicated Staff E attempted to immobilize the patient's legs with his/her body as the patient kicked and flailed, in an effort to prevent the patient from unholstering the gun. The patient grabbed a discharged taser, as Staff E was slammed head first into the wall during the struggle. Patient #2 was still on the floor and Staff E was still trying to restraint the patient's legs, as the patient was trying to tase whomever he/she could reach. The patient was able to tase each police officer, which caused the police officers to back away due to the effects of the taser. Staff E confirmed he/she had let go of the patient's legs and went to a corner of the room. The note indicated the patient came after Staff E with an active taser. Patient #2 tased Staff E on the right hip, as Staff E dived toward the door. At that time, Staff E heard someone call out "I have to shoot" and then "There is nothing else we can do". Staff E left the patient's room and heard a gun shot. The scene was secured, emergency treatment had begun and the patient was transferred to the room used for trauma patients.

Interview with Staff A on 09/15/15 at 9:40 AM confirmed the hospital had a contract with the city for an armed police officer. Staff A confirmed Staff D fired his/her weapon at Patient #2 causing the patient's injury. Staff A stated on 09/15/15 at 2:45 PM the hospital had a policy prohibiting police officers from taking their weapons into the behavioral health unit. Staff A confirmed the behavioral health unit was the only area of the hospital officers are not permitted to carry weapons. Staff A confirmed there were no policies on the presence of armed police officers in the rooms or presence of a patient with delusions, except for the behavioral unit.