HospitalInspections.org

Based on facility policy review, medical record review, facility event report review, observation of a digital video recording, and interviews, the facility failed to ensure care was provided in a safe setting for 1 Emergency Department (ED) patient (#1) of 7 ED patients reviewed.

The findings include:

During the survey it was found 1 patient (#1) was admitted to the Emergency Department (ED) on 6/15/19 at 6:37 PM for "...CHECK FOR DRUGS AND BIPOLAR..." The patient was also having thoughts of Suicidal Ideation (SI) and the facility initiated an involuntary commitment of the patient to a psychiatric facility. While Patient #1 was being held in the ED waiting on an available bed in a psychiatric facility he became combative and attempted to leave the ED. The patient was tased (a pistol shaped weapon which uses an electric current via darts and wires to incapacitate an individual) by a security officer as an intervention to the patient's behavior and to aid the facility in restraining the patient. Patient #1 was not under the custody of local law enforcement at any time while he was in the ED.

During a conference in the facility's administration conference room on 8/15/19 at 8:30 AM with the facility's Chief Executive Officer, the facility's Chief Nursing Officer, and the facility's Vice President of Quality, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at Requirement 482.13 Condition of Participation, Patient Rights. The facility's failure to protect Patient #1 from the use of a weapon resulted in Patient #1 being stunned with a taser on 6/16/19.

During a conference in the facility's administration conference room on 8/15/19 at 12:30 PM with the facility's Chief Executive Officer, the facility's Chief Nursing Officer, and the facility's Vice President of Quality, the facility presented an Immediate Action Plan for the Immediate Jeopardy which included:

1. The current "Use of Force Policy" was amended to include the statement "...Weapons include but are not limited to...tasers...Use of weapons by security staff is to be used as law enforcement action only, never in a health care intervention. Weapons are not to be used by hospital staff as a means of subduing a patient in order to place that patient in restraints or seclusion..."
2. 100% of Security Officers and ED staff were educated on the changes to the "Use of Force Policy." Plans were made for all off duty ED staff to be educated on the policy changes prior to returning to work.
3. A Behavior Emergency Response Team (BERT) was implemented in July 2019, which includes a team of nurses trained in the de-escalation and management of behavioral patients. The team responds to behavioral/psychiatric patients when they begin to show symptoms of violent or other disruptive behavior and interventions are put in place to avoid the escalation of the behaviors. ED staff have been educated on the activation of the BERT team. Security Officers and ED Staff have been educated on the availability, purpose, and use of the BERT team.
4. A Weapons/Use of Force Checklist was developed 8/15/19 to monitor and evaluate the use of any weapons of force on patients. Starting 8/15/19 all incidents involving the use of force or a weapon will be reviewed and evaluated by administration using the check list.
5. 100% of Security staff completed a return demonstration/competency of the steps outlined in the Use of Force Policy.

Review of the Immediate Action Plan revealed the immediate actions were implemented by the facility and the Immediate Jeopardy was removed on 8/15/19. The facility remains out of compliance at CFR PART 482.13 Condition of Participation Patient's Rights.


Please refer to A-0154.

Based on facility policy review, medical record review, review of a facility event report, review of a digital video recording, and interviews, the facility failed to ensure a weapon was not used as an intervention to restrain 1 patient (#1) of 7 patients reviewed for restraints.

The findings include:

Review of facility policy titled "Patient Rights and Responsibilities," last revised on 9/2018, revealed "...We adopt and affirm the following rights of patients/clients who receive services from our facilities...To receive ethical, high-quality, safe and professional care...To safe and sanitary accommodations...To be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff..."

Review of facility policy titled "Taser [a hand-held pistol shaped weapon that uses an electric current via darts and wires to incapacitate an individual] Use Procedure Policy," last reviewed 6/2017, revealed "...To establish proper procedures for the carrying, use, deployment and aftercare of Taser Devices...Use on Hospital Patients - The only time a taser device shall be used on a patient inside the hospital is when a patient becomes a physical threat to others or himself/herself..."

Medical review revealed Patient #1 was admitted to the Emergency Department (ED) on 6/15/19 at 6:37 PM for "...Stated Complaint...NEED CHECK FOR DRUGS AND BIPOLAR..."

Medical record review of a Nurse's Triage Record dated 6/15/19 at 6:43 PM revealed "...PRESENTS HYPERVERBAL [highly verbal]. MANIC [extremely elevated] MOOD. PATIENT IS UNABLE TO PUT A COHESIVE THOUGHT TOGETHER..."

Medical record review of an ED Physician's Note dated 6/15/19 at 6:50 PM revealed "...Chief Complaint Anxious, Bizarre Behavior, Manic, Suicidal Ideation...Patient brought by parents to the emergency department for possible...psychiatric problems...Patient is currently hyperverbal but will answer direct questions...Patient admits to having thoughts of killing himself with a knife...thoughts of killing everybody else...everyone is trying to kill me..."

Medical record review of a Nurse's Note dated 6/16/19 at 5:00 AM revealed "...PT [patient] BECAME INCREASINGLY MORE BOISTEROUS AND ANGRY. PT WAS TRYING TO RUN AWAY. NOTIFIED SECURITY TO HELP CALM HIM DOWN. PT BECAME VIOLENT WITH STAFF AND SECURITY. PT WAS GIVEN MULTIPLE CHANCES TO COMPLY AND STOP BEING VIOLENT. PT THEN TRIED TO RUSH OUT THE DOOR TOWARDS OTHER STAFF. SECURITY NOTIFIED PT THAT [Security] WOULD TAZE [tase] HIM IF HE DIDN'T GET BACK IN BED...PT RECEIVED TAZER TO BACK. PT WAS THEN CRAWLING ON THE GROUND AND TRYING TO RUN AWAY. PT STARTED TRYING TO GO INTO OTHER PT ROOMS AND PULLING ON DOOR HANDLES. PT WAS THEN ESCORTED BACK TO HIS ROOM WITH MULTIPLE STAFF AND SECURITY. PT WAS STILL VIOLENT. RESTRAINTS WERE PLACED ON PT PER MD [Medical Doctor] ORDER. PT WAS ALSO GIVEN MEDICATION..."

Medical record review of a Nurse's Note dated 6/16/19 at 5:10 AM revealed "...PT BECOMING AGITATED AND ATTEMPTING TO RUN OUT OF THE ROOM AND BOLT TOWARDS STAFF MEMBERS. SECURITY AT BEDSIDE AND STATING THAT THEY WILL TAZE HIM IF HE DOES NOT GET IN THE ROOM. MULTIPLE ATTEMPTS FOR PT TO COOPERATE WITH STAFF BEFORE BEING TAZED. STILL UNCOOPERATIVE. SECURITY DELIVERED MULTIPLE TASE TO PT AND PT STILL TRYING TO RUN AWAY. MULTIPLE MALE STAFF MEMBERS CARRIED PT BACK TO ROOM WITH SECURITY FOLLOWING BEHIND. MEDS [medications] ORDERED...GIVEN BY RN [Registered Nurse]. MULTIPLE STAFF MEMBERS TAKEN TO RESTRAIN PT EVEN AFTER MEDS. PT RESTRAINT ORDERS PLACED. PT PUT IN HARD RESTRAINTS [restraints made with a vinyl fabric] AT THIS TIME BY RN..."

Medical record review of a Physician's Note dated 6/16/19 at 5:11 AM revealed "...Patient became agitated and attempted to run out of the department. Security prior to my intervention taste [tased] the patient at least twice. Patient then physically subdued...given 20 mg [milligrams] of IM [intramuscular injection] Geodon [anti-psychotic medication]..."

Medical record review of a Physician's Note dated 6/19/19 at 12:15 PM revealed "...Patient did have repeat tele-psychiatry evaluation...After his evaluation, he [psychiatrist] felt the patient was very calm and would be stable for discharge home..." Continued review at 12:21 PM revealed "...The patient will be discharged home in stable condition..."

Medical record review revealed no documentation Patient #1 was placed in the custody of local law enforcement while a patient in the facility.

Review of a "Risk360 Event Detail Report" dated 6/16/19 at 5:05 AM revealed "...Security responded to ER [Emergency Room]...to find Pt...in the hall trying to leave. Myself and [another security officer] and a nurse physically escorted him back to the room where he continued to be combative and uncooperative. He was swinging his fists and biting at staff. He struck myself and [other security officer] several times and grabbed ahold of one of the staff by the shirt and hit the staff as well. Since we could not maintain control of the patient physically, I stated that I would Tase him and advised Medical Staff to get a safe distance from the patient. I drew my taser and told the patient that he needed to stay on the bed or he would be tased. He got up and came at me and I kept him back with my free hand and warned him again. He then rushed past me and entered the hall way. At which point I fired my taser in his back. It connected and he fell to the floor. A nurse said they were getting a wheelchair for him and I told him to stay on the ground until the wheelchair arrived or I would use the taser again. He did not comply and I cycled it again and it worked. I advised him again that he needed to stay on the ground, but he got up. Apparently a barb came loose while he was on the floor and it was no longer connected, so nothing happened when I cycled it again. I then fired my second cartridge, but it did not make a full connection. The patient then ran to the end of the hall where he stopped. It appeared he was going to come back to his room, but he instead ran to another patient's room and tried to enter it. My partner [named security officer] drew her taser, but there wasn't a clear shot as medical staff had grabbed ahold of him and were trying to restrain him. I assisted Medical Staff in bringing the patient back to room...he was restrained to the bed and medicated..."

Review of a video recording dated 6/16/19 at 5:06 AM revealed Patient #1 was in the ED hallway and walking away from security officers and ED staff. Continued review revealed a Security Officer deployed a taser from several feet behind the patient and the patient feel limp to the floor. Further review revealed the patient lay on the ED floor for approximately 45 seconds and then got up and started walking away from Security and ED staff. Continued review revealed the security officer appeared to fire the taser a second time at Patient #1, but there was no visible effect on the patient.

Interview with the Security Director on 8/13/19 at 10:00 AM, in the Quality Conference room, confirmed the use of tasers on patients by security officers was an approved action by the facility if the patient was violent or a danger to themselves, other patients, or staff.

Telephone interview with RN #1 on 8/14/19 at 7:10 AM revealed the RN remembered Patient #1. Continued interview revealed the patient tried to leave his room and security was called. Further interview revealed the patient became combative and was hitting, kicking, and shouting at the staff. Continued interview revealed a security officer fired a taser, hitting the patient in the back, and the patient fell to the floor for a short time. Further interview revealed the patient got back onto his feet and attempted to leave the ED and the Security Officer attempted to tase the patient again, but the taser did not work. Continued interview revealed Patient #1 was physically held by ED staff and then lifted and carried back to his room by staff and placed in restraints. Further interview confirmed the patient was tased once during the incident.

Interview with the Vice President of Quality on 8/12/19 at 3:30 PM, in the Quality Conference Room, confirmed Security Officers used tasers on patients in cases where the patient's safety or the safety of other patients was at risk.