HospitalInspections.org

Based on facility policy review, medical record review, review of incident reports, review of a video surveillance recording, review of a Use of Force Report, review of a facility system improvement form, and interviews, the facility failed to ensure a contracted security service followed the facility policy for use of a conducted electrical weapon (taser) and failed to ensure a weapon was not used to gain compliance of 1 Emergency Department (ED) psychiatric patient (Patient #1) of 5 ED psychiatric patients reviewed.

The findings include:

Review of Facility A's policy titled "Conducted Electrical Weapon (CEW) or Taser," revised 4/2016, showed "...The purpose of this procedure is to provide security officers...with guidance concerning the use of a Conducted Electrical Weapon (CEW). Security officers...may use a CEW, provided such use is consistent with this policy, the [Facility A] Use of Force policy, and applicable law and regulations...The Taser [weapon which causes temporary paralysis] is an intermediate measure on the Use of Force Continuum set forth in the [Facility A] Use of Force Policy. It should NEVER be used in the following manner...As a form of discipline or punishment...Against a subject who is already restrained and under control...To coerce or obtain information from a subject...As a pain compliance tool to gain cooperation over passive resistance...The Taser may be used only when physical force is appropriate under [Facility A] Use of Force policy; empty hand soft control techniques have failed to bring about the subject's compliance; the subject has made known his/her intentions to actively resist compliance efforts; and the subject poses a physical risk to self or others...Absent exceptional circumstances, the Taser should not be used on individuals an officer knows to be...Under the age of 18..."

Review of Facility A's policy titled "Use of Force," revised 8/2019, showed "...It is the policy of the hospital that security officers will use only the degree of force that appears reasonably necessary to bring an incident under control...All security officers will exhaust every other reasonable means of force which includes but is not limited to verbal communication focused on de-escalation before resorting to any means of physical force..."

Review of Facility A's policy titled "Harm to Self/Others and Safety Interventions in the Emergency Department," revised 2/2021, showed "...Patients have the right to a safe and healthy treatment environment...Safety Interventions...HIGH RISK NON-SUICIDAL PATIENT INTERVENTIONS...Used for other mental health issues or violent/aggressive patient at risk to harm to others or self-patients...Patient Attire...Complete Safety Checklist. Patient may be left in own clothes or placed in hospital garments, as appropriate...Safety Checklist...Notify Security...Remove all patient belongings from the room including: cell phone, medications, and clothing. Patient belongings and medications should be inventoried and secured away from the patient...Place patient in approved hospital attire..."

Medical record review of an ED triage note dated 10/18/2021 at 6:55 PM showed Patient #1 was 15 years old and was transported to the ED by the police department after they were called by adolescent mobile crisis to go to the patient's home. Patient #1 reported his medication had been changed but did not provide any further information. The patient was triaged as a level 2 (emergent) on the Emergency Severity Index (ESI) system (a 5-level system used to categorize ED patients) and was assessed as high risk non-suicidal due to primary or secondary behavioral/psychotic complaints that put the patient at risk of harm to others.

Medical record review of a Certificate of Need (CON) for Emergency Involuntary Admission showed Patient #1 was examined by an ED physician on 10/18/2021 at 6:55 PM. Further review showed "...Patient [Patient #1] showing extremely violent behavior that has escalated from earlier today. He struck his teacher and barricaded himself in the bathroom at school. He was violent toward family members. When confronted by police he barricaded himself in his room..." Continued review showed Patient #1 was not stable for outpatient therapy. Patient #1's diagnoses included Intellectual Disability (IQ [intelligence quotient] 68), Disregulated Mood Disorder, Separation Anxiety, and Oppositional Defiance Disorder.

Medical record review of an ED Nurse's Note dated 10/18/2021 showed the nurse had arrived for the 7:00 PM-7:00 AM shift and noticed the day shift team lead was "...having problems convincing [Patient #1] to change his clothing and have him place his belongings in a bag, despite her [shift team lead] repeatedly telling him [Patient #1] that it is the hospital's policy...I heard what sounded like a scuffle behind me. I turned around and [Patient #1] was holding onto [named security officers] belt and grabbing for his gun. I heard [named officers] repeatedly telling Patient #1 to let go of the belt and to stop trying to grab the gun. After a short struggle, I saw [named officer] deploy his taser on [Patient #1]..."

Review of the facility's video surveillance recording dated 10/18/2021 from 6:17 PM-6:37 PM (video surveillance footage times are 38 minutes off from the real time Patient #1 presented in the ED; actual time frame was 6:55 PM-7:15 PM) showed the following:
6:17 PM-6:22 PM: Patient #1 entered the ED with the police department. The patient was taken to a hall bed in the ED (approximately 10 feet from the nurses' station). The police spoke with the Registered Nurse (RN) and left the patient's bedside. The patient was sitting on the edge of the bed talking to the RN and was cooperative with the RN taking his vital signs.
6:22 PM: The RN motioned for the security officer. The security officer approached Patient #1's bedside (approximately 3 feet from patient) and began talking with the patient. The patient continued to sit on the edge of the bed and was conversing with the officer.
6:24 PM: Second security officer arrived in the ED and began speaking with Patient #1. The RN briefly left the bedside and returned with what appeared to be scrubs. The security officers continued to speak with the patient while he was sitting on the edge of the bed.
6:26 PM: Third security officer arrived in the ED and stood to the side of Patient #1's bedside. A police officer and a police dog (K9 unit) arrived in the ED and was positioned approximately 6 feet to the right of the patient's bedside. The 3 security officers and the RN continued to speak with the patient while the K9 officer stood to the side. The patient continued to sit on the edge of the bed.
6:28 PM: The third security officer moved to the side and further away from the patient.
6:29 PM: The K9 unit relocated to approximately 10 feet in front of the patient next to the nurses' station. Patient #1 continued to sit on the side of the bed.
6:31 PM: Two security officers and the RN continued to speak with Patient #1. The patient remained seated on the edge of the bed.
6:33 PM: Patient #1 removed his shoes. The patient continued to sit on the edge of the bed. A security officer handed the patient an armband and the patient put the armband on his right arm.
6:36 PM 31 seconds to 6:36 PM 36 seconds: Patient #1 continued to sit on the edge of the bed. Two security officers approached each side of the patient and attempted to escort the patient by sliding an arm under each arm of Patient #1. Patient #1 immediately began resisting; kicked the security officer positioned on the patient's right in the stomach; slapped or hit at the security officer on the patient's left side and swung to hit the security officer on the head. Two of the security officers and Patient #1 went to the floor. During the struggle Patient #1's right hand was noted to be at the security officer's waist, near the duty belt (belt which holds security officer's weapons). It was unclear if the patient was reaching for the security officer's weapon or if the patient had his hand on the weapon. The K9 dog was held back by his handler. He was barking but made no contact with the patient.
6:36 PM 40 seconds: The taser was deployed by the security guard, striking the patient.
6:37 PM: The security officers gained control of Patient #1.
Patient #1 was assisted back to the bed after the incident.

Review of a Use of Force Report dated 10/18/2021 at 6:40 PM showed "...patient [Patient #1] was in hall bed 3 where [named RN] met him [Patient #1] to explain policy for psychiatric patients...[named RN] informed the patient he would have to relinquish his cell phone so it could be locked up with his clothing and returned once he was discharged...After [Patient #1] refused to surrender his belongings, [the RN] motioned for [named security officer] for assistance...[named security officer] tried talking to the patient...At this time [named sergeant] walked up and ask what was going on...radioed for K9 officer [Use of Force policy does not mention use of K9 officers]...All officers present gave the patient multiple directives to surrender his phone and change into the required garments...After [Patient #1] refused the officers directives, they made an attempt to escort him to the restroom...[Patient #1] became combative, kicking [named officer] in his midsection and struck [named sergeant] in the face with an open hand...[named officer and sergeant] went to the floor while attempting to gain compliance...While on the ground, the patient grabbed [named officers] duty belt. The patient continued to fight and raised his hand and appeared to be going to strike [named sergeant]...[named security officer] deployed his Taser into left side of the patient's [Patient #1] body in the left shoulder area, below the shoulder blade..."

Review of Facility A's system improvement report dated 10/18/2021 at 7:53 PM showed the date and time of event was 10/18/2021 at 7:05 PM. "...Type of Pt [patient] Action Event: Patient Combative...Informed patient we needed him to change and have security inventory his belongings per hospital protocol. Patient refused to change after multiple request...security then attempted to escort pt [patient] to bathroom to change and pt. became agitated and violent. Pt. then kicked [named officer] in the abdomen and punched [named sergeant] in the head...pt. grabbed [named officer] belt with taser and other weapons...Despite verbal attempts to convince patient to release the belt he did not and a taser was deployed by security..."

Medical record review of an ED Physician's History of Present Illness electronically dated and signed on 10/18/2021 at 10:44 PM showed Patient #1 had barricaded himself in his bedroom after threatening his younger sibling and mother. Patient #1's physical exam showed "...Combative. Not willing to get changed in to hospital gown. Becomes combative and violent toward staff...Head...atraumatic...Neck...full ROM [range of motion]...Skin...intact...Neurologic...Moving all extremities well. Voice/speech normal...Psychiatric...Combative and not willing to give a history..." Patient #1's diagnoses was documented as Violent Behavior. The patient was medically cleared for psychiatric evaluation.

Medical record review of ED Physician's documentation dated 10/19/2021 at 11:02 AM showed Patient #1's Family Member #1 was concerned about the taser sites on the patient. There were "...puncture sites and abrasions seen on the left flank. These are consistent with Taser barbs that were removed..." There were no signs of infection at the sites.

Medical record review of ED Physician's documentation on 10/19/2021 at 1:38 PM showed Patient #1's Family Member #1 expressed concerns about the treatment Patient #1 had received on 10/18/2021. "...According to [Family Member #1], [Patient #1] is becoming anxious and she is concerned that if she leaves, he might have another episode..."

During an interview on 10/21/2021 at 1:45 PM, Physician #1 stated the nurse was trying to get Patient #1 to change into scrubs and Patient #1 was yelling at the nurses. The physician stated he did not witness the event but was made aware the patient had been tased. Physician #1 assessed the patient after the event and reported the patient complained of some pain in his leg but was able to move his leg and could bear weight. There were no injuries to the patient.

During an interview on 10/21/2021 at 2:10 PM, Registered Nurse (RN) #1 stated Patient #1 was informed he would need to change his clothes and his belongings would be locked up with security. Patient #1 told RN #1 he would change his clothes, but he would not give up his phone. He then told her he would not change his clothes or give up his phone. RN #1 stated the security officer tried to build a rapport with Patient #1 and convince the patient to change clothes. Another officer tried to convince the patient to change, reiterating it was for the patient's safety and was hospital policy. Patient #1 got really agitated after the security officers attempted to escort the patient to the restroom. "...He freaked out...came up off the bed..." and kicked one of the officers in the abdomen. RN #1 saw Patient #1 grab a security officer's belt. A security officer was "...telling him to let go of the belt, let go of the belt...he would not let go..." RN #1 then heard someone say "...taser, taser, taser..."

During an interview on 10/21/2021 at 2:30 PM, Security Officer #2 stated Patient #1 was refusing to change his clothes and to give up his cell phone. The security officers and the RN tried to convince the patient to comply with the facility policy for psychiatric patients to remove his clothes and hand over his belongings. Security Officer #2 was able to convince Patient #1 to remove his shoes but was unable to convince him to change clothes. Security Officer #3 made the decision for the security officers to escort Patient #1 to the restroom. Upon physical contact, Patient #1 began swinging at the security officers and kicked an officer. The patient got out of the security officers grasp and was grabbing at the security officer's belt as they were going down. Security Officer #2 told Patient #1 to stop resisting. He then heard Security Officer #4 say "...taser, taser, taser..." before the taser was deployed.

During an interview on 10/21/2021 at 3:10 PM, Security Officer #4 stated the police officer who transported Patient #1 to the ED reported the patient had been calm. Security Officer #4 reported the RN motioned for him, so he approached the patient's bedside. Security Officer #4 tried talking with the patient, explained the procedure, and explained it was hospital policy to change his clothes and to give up his cell phone. Patient #1 refused to comply. Security Officer #4 stated 4 security officers and the nurse had given verbal directives to the patient, but he still refused. Two officers attempted a soft touch approach (hand open and placed under the patient's arms) to escort the patient to the restroom. Patient #1 immediately became aggressive. Security Officer #4 stated Patient #1 was reaching for another security officer's weapon and had his hand in a fist to punch the officer. Security Officer #4 called out "...taser, taser, taser..." and deployed the taser toward Patient #1. Security Officer #4 asked Patient #1 if he was hurt. "...He [Patient #1] said no..." and that he wanted his mom.

During a telephone interview on 10/21/2021 at 6:55 PM, RN #2 stated Patient #1 had 2 spots on his back from the taser.

During a telephone interview on 10/21/2021 at 7:50 PM, Security Officer #3 stated he entered the ED and spoke with another security officer about Patient #1 not wanting to do what the staff were requesting him to do. Security Officer #3 stated he talked to Patient #1 and tried to convince him to comply with the facility policy of changing clothes and handing over his cell phone. Security Officer #3 called for assistance to try to talk to Patient #1. When the security officers tried to escort the patient to the restroom, the patient became combative and hit Security Officer #3 in the head. Security Officer #3 and Security Officer #1 wrapped their arms around Patient #1 and landed on the floor. Security Officer #3 stated "...I remember hearing taser, taser, taser..." Security Officer #3 reported he was on the opposite side of the patient and did not see Patient #1 reach for Security Officer #1's duty belt.

During a telephone interview on 10/22/2021 at 12:30 PM, Security Officer #1 stated he was called to the ED for a patient refusing to change clothes and refusal to hand over belongings. Security Officer #1 reported all the officers tried to convince Patient #1 to comply with the request to change clothes, but the patient refused. It was determined the security officers would escort the patient to the restroom. Security Officer #1 reported he and another security officer approached each side of the patient and used soft hand approach (slide hands under the patient's arms). Patient #1 immediately started resisting and kicked Security Officer #1 in the stomach. "...He grabbed my duty belt, but I was able to remove his hands...I believe he was trying to get away..." Security Officer #1 reported a taser was deployed by another security officer. Patient #1 was assisted back to the bed after the taser barbs were removed.

During a telephone interview on 10/25/2021 at 2:50 PM, the Risk Manager stated "...I can see how 4 authority figures standing in front of him [Patient #1] could appear intimidating, but I don't think there was willful intent of intimidating..." Continued interview revealed the facility did not have a specific policy which addressed patient de-escalation.

During a telephone interview on 11/1/2021 at 9:25 AM, Security Officer #1 stated Patient #1 was refusing to follow commands but was not showing violent behavior when he (Security Officer #1) arrived in the ED. Patient #1 immediately began resisting and kicked Security Officer #1 in the stomach when 2 security officers attempted to escort the patient to the restroom. "...He grabbed my duty belt, but I was able to remove his hands...I believe he was trying to get away..." Patient #1 was tased by another officer. "...In my opinion, I feel like we had enough officers to get him to the ground and control him without tasing him..."

During a telephone interview on 11/1/2021 at 10:25 AM, RN #1 stated Patient #1 had not shown violent behaviors in the ED until the security officers attempted to escort him to the restroom to change clothes.

In summary, the facility failed to ensure a contracted security service officer followed their policy titled "Conducted Electrical Weapon (CEW) or Taser" when the security officer tased a 15-year-old (Patient #1) in the ED on 10/18/2021. The facility policy stated "...Absent exceptional circumstances, the Taser should not be used on individuals an officer knows to be...Under the age of 18..." There were no identified criteria listed in the policy as to what constituted "...exceptional circumstances..." The policy did not address de-escalation of the patient prior to use of the Taser.

The facility policy titled " Use of Force" states security officers should focus on de-escalation before resorting to any means of physical force. There was no documentation of the de-escalating techniques used by the facility before the security officers used the taser on Patient #1.

Review of the safety interventions for high-risk non-suicidal patients listed in the facility policy "Harm to Self/Others and Safety Interventions in the Emergency Department," showed there was no criteria to determine when it would be appropriate to permit a patient to be left in his or her own clothes versus being placed in hospital garments. Review of the safety checklist shows the patient's belongings, including clothing must be removed from the patient's room which contradicts the option to leave the patient in his or her own clothes.

The facility did not have a policy to specifically address de-escalation of psychiatric patients nor did it have a policy regarding the use of a K9 unit during interactions with patients in the facility.

Based on facility policy review, medical record review, review of incident reports, and interviews the facility failed to follow the facility policy for use of a conducted electrical weapon (taser) and failed to ensure excessive use of force was not used to gain compliance of 1 Emergency Department (ED) psychiatric patient (Patient #1) of 5 ED psychiatric patients reviewed.

The findings include:

Patient #1 was transported by the police department to the ED on 10/18/2021 at 6:55 PM after the patient had experienced behavioral changes and aggressive behavior following a decrease in maintenance medication the patient was taking for control of psychiatric disorders. At approximately 7:14 PM, Patient #1 refused to change into scrubs and to hand over his cell phone. Patient #1 became combative when security officers attempted to escort the patient to the restroom to change into scrubs. A physical altercation between Patient #1 and the security officers occurred and a taser was used on Patient #1 to gain the patient's compliance.

Please refer to A-0154 for further details.

Based on facility policy review, medical record review, review of incident reports, Use of Force Report review, video surveillance recording review, and interviews, the facility failed to follow the facility policy for use of a conducted electrical weapon (taser) and failed to ensure a weapon was not used to gain compliance of 1 Emergency Department (ED) psychiatric patient (Patient #1) of 5 ED psychiatric patients reviewed.

The findings include:

Review of Facility A's policy "Conducted Electrical Weapon (CEW) or Taser", revised 4/2016 showed "...The purpose of this procedure is to provide security officers...with guidance concerning the use of a Conducted Electrical Weapon (CEW). Security officers ...may use a CEW, provided such use is consistent with this policy, the [Facility A] Use of Force policy, and applicable law and regulations...The Taser [weapon which causes temporary paralysis] is an intermediate measure on the Use of Force Continuum set forth in the [Facility A] Use of Force Policy. It should NEVER be used in the following manner...As a form of discipline or punishment...Against a subject who is already restrained and under control...To coerce or obtain information from a subject...As a pain compliance tool to gain cooperation over passive resistance...Absent exceptional circumstances, the Taser should not be used on individuals an officer knows to be...Under the age of 18..."

Review of Facility A's policy "Use of Force", revised 8/2019 showed "...It is the policy of the hospital that security officers will use only the degree of force that appears reasonably necessary to bring an incident under control...All security officers will exhaust every other reasonable means of force which includes but is not limited to verbal communication focused on de-escalation before resorting to any means of physical force..."

Review of Facility A's policy "Harm to Self/Others and Safety Interventions in the Emergency Department", revised 2/2021 showed "...Patients have the right to a safe and healthy treatment environment...Safety Interventions...HIGH RISK NON-SUICIDAL PATIENT INTERVENTIONS...Used for other mental health issues or violent/aggressive patient at risk to harm to others or self-patients...Patient Attire...Patient may be left in own clothes or placed in hospital garments, as appropriate...Safety Checklist...Notify Security...Remove all patient belonging from the room including: cell phone, medications, and clothing. Patient belongings and medications should be inventoried and secured away from the patient...Place patient in approved hospital attire..."

Medical record review of an ED triage note dated 10/18/2021 at 6:55 PM showed Patient #1 was 15 years old and was transported to the ED by the police department after they were called by adolescent mobile crisis to go to the patient's home. Patient #1 reported his medication had been changed but did not provide any further information. The patient was triaged as a level 2 (emergent) on the Emergency Severity Index (ESI) system (a 5-level system used to categorize ED patients) and was assessed as high risk non-suicidal due to primary or secondary behavioral/psychotic complaints that put the patient at risk of harm to others.

Medical record review of a Certificate of Need (CON) for Emergency Involuntary Admission showed Patient #1 was examined by an ED physician on 10/18/2021 at 6:55 PM. "...Patient [Patient #1] showing extremely violent behavior that has escalated from earlier today. He struck his teacher and barricaded himself in the bathroom at school. He was violent toward family members. When confronted by police he barricaded himself in his room..." Continued review showed Patient #1 was not stable for outpatient therapy. Continued review showed Patient #1's diagnoses included Intellectual Disability (IQ [intelligence quotient] 68), Disregulated Mood Disorder, Separation Anxiety, and Oppositional Defiance Disorder.

Medical record review of an ED Nurses' Note dated 10/18/2021 showed the nurse had arrived for the 7:00 PM-7:00 AM shift and noticed the day shift team lead was "...having problems convincing [Patient #1] to change his clothing and have him place his belongings in a bag, despite her repeatedly telling him that it is the hospital's policy...I heard what sounded like a scuffle behind me. I turned around and [Patient #1] was holding onto [named security officers] belt and grabbing for his gun. I heard [named officers] repeatedly telling Patient #1 to let go of the belt and to stop trying to grab the gun. After a short struggle, I saw [named officer] deploy his taser on [Patient #1]..." The patient continued to resist changing his clothes but eventually consented. He was escorted to the restroom and changed clothes while the nurse and security officers waited outside of the restroom. A Geodon intramuscular (IM) injection was administered to the patient with the patient's permission.

Review of the facility's video surveillance recording for 10/18/2021 from 6:17 PM-6:37 PM (video surveillance footage times are 38 minutes off from the real time Patient #1 presented in the ED; actual time frame was 6:55 PM-7:15 PM) showed the following:
6:17 PM-6:22 PM: Patient #1 entered the ED with the police department. The patient was taken to a hall bed in the ED (approximately 10 feet from the nurses' station). The police spoke with the Registered Nurse (RN) and left the patient's bedside. The patient was sitting on the edge of the bed, talking to the RN and was cooperative with vital signs.
6:22 PM: The RN motioned for the security officer. The security officer approached Patient #1's bedside (approximately 3 feet from patient) and began talking with the patient. The patient continued to sit on the edge of the bed and was conversing with the officer.
6:24 PM: Second security officer arrived in the ED and began speaking with Patient #1. The RN briefly left the bedside and returned with what appeared to be scrubs. The security officers continued to speak with the patient while he was sitting on the edge of the bed.
6:26 PM: Third security officer arrived in the ED and stood to the side of Patient #1's bedside. A K9 unit (officer and K9) arrived in the ED and was positioned approximately 6 feet to the right of the patient's bedside. The 3 security officers and the RN continued to speak with the patient while the K9 officer stood to the side. The patient continued to sit on the edge of the bed.
6:28 PM: The 3rd security officer moved to the side and further away from the patient.
6:29 PM: The K9 unit relocated to approximately 10 feet in front of the patient next to the nurses' station. Patient #1 continued to sit on the side of the bed.
6:31 PM: Two security officers and the RN continued to speak with Patient #1. The patient remained seated on the edge of the bed.
6:33 PM: Patient #1 removed his shoes. The patient continued to sit on the edge of the bed. A security officer handed the patient an armband and the patient put the armband on his right arm.
6:36 PM 31 seconds-6:36 PM 36 seconds: Patient #1 continued to sit on the edge of the bed. Two security officers approached each side of the patient and attempted to escort the patient by sliding an arm under each arm of Patient #1. Patient #1 immediately began resisting; kicked the security officer on the patient's right in the stomach; slapped or hit at the security officer on the left; and swung to hit the head of the officer on the left. Two of the security officers and Patient #1 went to the floor. During the struggle Patient #1's right hand was noted to be at the security officer's waist, near the duty belt (belt which holds security officers weapons). It was unclear if the patient was reaching or had his hand on the security officer's weapon. The K9 was held back by his handler. He was barking but made no contact with the patient.
6:36 PM 40 seconds: The taser was deployed striking the patient.
6:37 PM: The security officers gained control of Patient #1.
Patient #1 was assisted back to the bed after the incident.

Review of a Use of Force Report dated 10/18/2021 at 6:40 PM showed "...patient [Patient #1] was in hall bed 3 where [named RN] met him to explain policy for psychiatric patients...[named RN] informed the patient he would have to relinquish his cell phone so it could be locked up with his clothing and returned once he was discharged...After [Patient #1] refused to surrender his belongings, [RN] motioned for [named security officer] for assistance...[named security officer] tried talking to the patient...At this time [named sergeant] walked up and ask what was going on...radioed for K9 officer [Use of Force policy does not mention use of K9 officers]...All officers present gave the patient multiple directives to surrender his phone and change into the required garments...After [Patient #1] refused the officers directives, they made an attempt to escort him to the restroom...[Patient #1] became combative, kicking [named officer] in his midsection and struck [named sergeant] in the face with an open hand...[named officer and sergeant] went to the floor while attempting to gain compliance...While on the ground, the patient grabbed [named officers] duty belt. The patient continued to fight and raised his hand and appeared to be going to strike [named sergeant]...[named security officer] deployed his Taser into left side of the patient's [Patient #1] body in the left shoulder area, below the shoulder blade..."

Review of Facility A's system improvement report dated 10/18/2021 at 7:53 PM showed the date and time of event was 10/18/2021 at 7:05 PM. "...Type of Pt [patient] Action Event: Patient Combative...Informed patient we needed him to change and have security inventory his belongings per hospital protocol. Patient refused to change after multiple request...security then attempted to escort pt [patient] to bathroom to change and pt. became agitated and violent. Pt. then kicked [named officer] in the abdomen and punched [named sergeant] in the head...pt. grabbed [named officer] belt with taser and other weapons...Despite verbal attempts to convince patient to release the belt he did not and a taser was deployed by security..."

Medical record review of an ED physician history of present illness electronically dated and signed on 10/18/2021 at 10:44 PM showed Patient #1 had barricaded himself in his bedroom after threatening his younger sibling and mother. Patient #1's physical exam showed "...Combative. Not willing to get changed in to hospital gown. Becomes combative and violent toward staff...Head...atraumatic...Neck...full ROM [range of motion]...Skin...intact...Neurologic...Moving all extremities well. Voice/speech normal...Psychiatric...Combative and not willing to give a history..." Patient #1's diagnoses was documented as Violent Behavior. The patient was medically cleared for psychiatric evaluation.

Medical record review of ED physician documentation on 10/19/2021 at 11:02 AM showed Patient #1's Family Member #1 was concerned about the taser sites on the patient. There were "...puncture sites and abrasions seen on the left flank. These are consistent with Taser barbs that were removed..." There were no signs of infection at the sites.

Medical record review of ED physician documentation on 10/19/2021 at 1:38 PM showed Patient #1's Family Member #1 expressed concerns about the treatment Patient #1 had received on 10/18/2021. "...According to [Family Member #1], [Patient #1] is becoming anxious and she is concerned that if she leaves, he might have another episode..." Family Member #1 reported Patient #1's physician had decreased the patient's Seroquel and Patient #1 had not been getting the right amount of sleep since the medication change.

Medical record review of Facility B's Behavioral Health Initial Psychiatric Assessment dated 10/20/2021 at 9:07 AM showed Patient #1's diagnoses included Mild Intellectual Deficiency, Attention Deficit Hyperactivity Disorder, and Bipolar Disorder.

During an interview on 10/21/2021 at 1:45 PM, in the ED, Physician #1 stated the nurse was trying to get Patient #1 to change into scrubs and Patient #1 was yelling at the nurses when he first saw him. Patient #1 permitted the physician to assess him but would not provide any information. The physician stated he did not witness the event but was made aware the patient had been tased. Physician #1 assessed the patient after the event and reported the patient complained of some pain in his leg but was able to move his leg and could bear weight. There were no injuries to the patient.

During an interview on 10/21/2021 at 2:10 PM, in the ED, Registered Nurse (RN) #1 stated Patient #1 was informed he would need to change his clothes and his belongings would be locked up with security. Patient #1 told RN #1 he would change his clothes, but he would not give up his phone. He then told her he would not change his clothes or give up his phone. RN #1 stated the security officer tried to build a rapport with Patient #1 and convince the patient to change clothes. Another officer tried to convince the patient to change, reiterating it was for the patient's safety and was hospital policy. Patient #1 got really agitated after the security officers attempted to escort the patient to the restroom. "...He freaked out...came up off the bed..." and kicked one of the officers in the abdomen. RN #1 saw Patient #1 grab a security officer's belt. A security officer was "...telling him to let go of the belt, let go of the belt...he would not let go..." She then heard "...taser, taser, taser..." RN #1 was able to get the patient's phone when he went to the restroom to change clothes.

During an interview on 10/21/2021 at 2:30 PM, in the ED, Security Officer #2 stated Patient #1 was refusing to change his clothes and to give up his cell phone. The security officers and the RN tried to convince the patient to comply with the facility policy for psychiatric patients to remove his clothes and hand over his belongings. Security Officer #2 was able to convince Patient #1 to remove his shoes but was unable to convince him to change clothes. Security Officer #3 made the decision for the security officers to escort Patient #1 to the restroom. Upon physical contact, Patient #1 began swinging at the security officers and kicked an officer. The patient got out of the security officers grasp and was grabbing at the security officer's belt as they were going down. Security Officer #2 told Patient #1 to stop resisting. He then heard Security Officer #4 say "...taser, taser, taser..." before the taser was deployed.

During an interview on 10/21/2021 at 3:10 PM, in the conference room, Security Officer #4 stated the police officer who transported Patient #1 to the ED reported the patient had been calm. Security Officer #4 reported the RN motioned for him, so he approached the patient's bedside. Security Officer #4 tried talking with the patient, explained the procedure, and explained it was hospital policy to change his clothes and to give up his cell phone. Patient #1 refused to comply. Security Officer #4 stated 4 security officers and the nurse had given verbal directives to the patient, but he still refused. Two officers attempted a soft touch approach (hand open and placed under the patient's arms) to escort the patient to the restroom. Patient #1 immediately became aggressive. Security Officer #4 stated Patient #1 was reaching for another security officer's weapon and had his hand in a fist to punch the officer. Security Officer #4 called out "...taser, taser, taser..." and deployed the taser toward Patient #1. Security Officer #4 asked Patient #1 if he was hurt. "He [Patient #1] said no..." and that he wanted his mom.

During a telephone interview on 10/21/2021 at 6:55 PM, RN #2 stated after Patient #1 was tased, she was able to walk the patient to the restroom with security, and the patient changed clothes while she and the security officers waited outside the restroom door. RN #2 stated Patient #1 had 2 spots on his back from the taser.

During a telephone interview on 10/21/2021 at 7:50 PM, Security Officer #3 stated he entered the ED and spoke with another security officer about Patient #1 not wanting to do what the staff were requesting. Security Officer #3 stated he talked to Patient #1 and tried to convince him to comply with the facility policy of changing clothes and handing over his cell phone. Security Officer #3 called for assistance to try to talk to Patient #1. When the security officers tried to escort the patient to the restroom, the patient became combative and hit Security Officer #3 in the head. Security Officer #3 and Security Officer #1 wrapped their arms around Patient #1 and landed on the floor. Security Officer #3 stated "...I remember hearing taser, taser, taser..." Security Officer #3 reported he was on the opposite side of the patient and did not see Patient #1 reach for Security Officer #1's duty belt.

During a telephone interview on 10/22/2021 at 12:30 PM, Security Officer #1 stated he was called to the ED for a patient refusing to change clothes and refusal to hand over belongings. Security Officer #1 reported all the officers tried to convince Patient #1 to comply with the request to change clothes, but the patient refused. It was determined the security officers would escort the patient to the restroom. Security Officer #1 reported he and another security officer approached each side of the patient and used soft hand approach (slide hands under the patient's arms). Patient #1 immediately started resisting and kicked Security Officer #1 in the stomach. "...He grabbed my duty belt, but I was able to remove his hands...I believe he was trying to get away..." Security Officer #1 reported a taser was deployed by another security officer. Patient #1 was assisted back to the bed after the taser barbs were removed.

During a telephone interview on 10/25/2021 at 2:50 PM, the Risk Manager stated "...I can see how 4 authority figures standing in front of him [Patient #1] could appear intimidating, but I don't think there was willful intent of intimidating..."

During a telephone interview on 11/1/2021 at 9:25 AM, Security Officer #1 stated Patient #1 was refusing to follow commands but was not showing violent behavior when he (Security Officer #1) arrived in the ED. Patient #1 immediately began resisting and kicked Security Officer #1 in the stomach when 2 security officers attempted to escort the patient to the restroom. "...He grabbed my duty belt, but I was able to remove his hands...I believe he was trying to get away..." Patient #1 was tased by another officer. "...In my opinion, I feel like we had enough officers to get him to the ground and control him without tasing him..."

During a telephone interview on 11/1/2021 at 10:25 AM, RN #1 stated Patient #1 had not shown violent behaviors in the ED until the security officers attempted to escort him to the restroom to change clothes.

The facility failed to follow their policy titled "Conducted Electrical Weapon (CEW) or Taser" when facility security tased a 15 year old patient (Patient #1) in the ED on on 10/18/2021. The facility policy stated a Taser should not be used on individuals under the age of 18.