HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to
- Remove one staff member (A) from patient interaction, after he used a non-approved Crisis Prevention Institute (CPI, a type of training whereby staff use physical holds which restrict a person's movement) technique, and dragged one clinic outpatient (#1) of one outpatient reviewed, down a hall, which resulted in patient injury (carpet burn). (A-0144)
- Provide immediate reeducation of approved CPI techniques to staff to prevent reoccurrence. (A-0144)
- Immediately and throughly investigate the incident which involved the use of the non-approved CPI technique. (A-0145)

These deficient practices resulted in the hospital's non-compliance with specific requirements found at §482.13 Condition of Participation: Patient's Rights. The hospital census was 292.

Based on observation, interview, record review and policy review, the hospital failed remove one Security Officer (SO) staff (A) from patient interaction, after he used a non-approved Crisis Prevention Institute (CPI, a type of training whereby staff use physical holds which restrict a person's movement) technique, and dragged one clinic outpatient (#1) of one outpatient reviewed, down a hall, which resulted in patient injury (carpet burn). The hospital also failed to provide immediate reeducation of approved CPI techniques to Staff A, to prevent reoccurrence. This failed practice had the potential to create an unsafe environment for all patients. The hospital census was 292.

Findings included:

1. Review of the hospital's undated power point titled, "Non-Violent Crisis Intervention," which was provided to all staff enrolled in the course, showed the goals for CPI included:
- Prevent and de-escalate crisis situations;
- Influence behavior;
- Promote problem-solving and decision making;
- Respond safely and effectively to difficult, disruptive or potentially assaultive behaviors;
- Maintain professionalism; and
- Promote Care, Welfare, Safety and Security for ALL in the environment.

Review of the CPI Participant Workbook dated 2015, showed that physical interventions may be considered to minimize harm, such as higher-level holding (a physical intervention necessary to restrict a person's range of movement in relation to high-risk behavior). This type of hold was designed to restrict a person's ability to move away from staff and prevent the person being held from causing significant harm to self or others.

Review of the CPI power point and workbook showed that transporting a patient backwards was not included as an acceptable technique.

Review of the hospital's policy titled, "Patient Abuse, Neglect and Harassment in the Health Care Setting: Assessment, Investigation and Reporting," dated 06/07/19, showed that patients have the right and expectation to receive health care services, care and treatment in a safe setting, and remain free at all times from abuse, neglect and harassment. In consult with Risk Management and Human Resources, for the protection of patients and involved personnel, patient care providers involved in matters of patient abuse, neglect and/or harassment may be relieved of patient care responsibilities and excused from patient care areas of the hospital pending a prompt investigation.

Review of the email dated 01/24/20 that Patient #1 sent to Staff E, Registered Nurse (RN), Risk Specialist, showed that:
- Patient #1 identified himself as a 69 year-old who was deaf and unable to read lips or speak, and presented to the hospital's Outpatient Clinic on 01/16/20 for a follow-up appointment.
- When the patient presented at the registration desk, he asked the registrar where his interpreter was because he had requested for an interpreter in advance, when he was asked by the registrar if he had brought his own interpreter with him, he became furious and hit the registrar's desk.
- When he requested to see the registrar's boss, she called for security because of his angry behavior and to assist the patient to resolve his issues.
- When the SO arrived at the registration cubicle, the registrar gave the note that the patient had written to the SO, but the SO would not give the note back so he could communicate with the SO.
- The patient took the SO's paper (the SO had a notebook that he used to write reports in) but the SO took it away from the patient, so the patient hit the SO because the SO did not allow him to communicate by writing notes on paper.
- The SO then hit the patient in his face.
- The patient was in a wheelchair and when he fell down, the SO pulled on the patient's coat and "dragged" the patient's body away from the registration area down the hall and threw the patient out the door. The SO "dragged" the patient for approximately 15 minutes.
- As a result of being "dragged" down the hall, the patient's back was "blood raw".

During an interview on 02/11/20 at 12:01 PM, Language Interpreter H, stated that when he entered the outpatient clinic, Staff A, SO, and the patient were in the entryway and the patient was on the floor on his back. Staff A added that he believed the incident with the patient could have been prevented if the outpatient clinic staff had informed the patient that his interpreter had not arrived to the clinic yet and that registration staff would wait until the interpreter arrived to assist with communication between the patient and registration staff.

Observation on 02/11/20 at 10:00 AM of the Outpatient Clinic were the incident between Patient #1 and Staff A, SO, showed that the floor in the vestibule, waiting area, greeter area, registration cubicles and outpatient clinics had carpet throughout.

Review of the hospital's document titled, "Event Report," dated 01/21/20, showed:
- Patient #1 was deaf and communicated by using sign language, presented to the hospital's Outpatient Clinic on 01/16/20 at 10:15 AM for a follow-up appointment.
- When the patient presented to the registration desk, his interpreter was not present to assist with communication between the patient and registrar.
- When the patient realized his interpreter was not on-site, he became upset, began to yell loudly and pounded on the registrar's desk with his hand.
- The registrar attempted to communicate with the patient by utilizing hand written notes but the patient continued to be threatening and aggressive toward the registrar.
- The registrar requested for security to be notified to assist with the patient.
- When the SO arrived, he attempted to communicate with the patient by using a note pad, however, the patient's behavior continued to escalate and was asked to wait for his interpreter to arrive to assist with communication.
- When the patient was asked to wait for his interpreter, he started yelling obscenities at the SO and registrar.
- The patient assaulted the SO, so the SO attempted to remove the patient from the registration cubicle, but the patient grabbed onto the desk and refused to let go.
- When the SO tried to move the wheelchair that the patient sat in, the patient reared backward causing it to tip over on one side, so the SO placed his arms through the patient's and "dragged" the patient away from the registration desk and down the hall to the vestibule.
- When the Director of Security arrived, he interviewed the patient and offered to call for medical assistance but the patient refused.
- Emergency Medical Services (EMS, ambulance staff) arrived and attempted to evaluate the patient but he only allowed them to take his vital signs (blood pressure, heart rate, respiration and temperature) which were within normal limits. The patient had EMS take a picture of his lower back and buttocks (bottom) with his phone.
- The patient called for a ride and the Director of Security assigned another SO to stay with the patient until his ride arrived and the patient was safely transported off hospital property.

Review of the hospital's undated document titled, "CPI Review of Event," reflected that the hospital did not recognize that when Staff A, SO, dragged the patient down the hall, it was not an approved CPI technique, and that the patient sustained a carpet burn from the inappropriate technique.

During an interview on 02/11/20 at 10:38 AM, Staff B, Customer Services Assistant (Outpatient Clinic), stated that she observed Staff A, SO, stand behind the patient and "drag" the patient backwards towards the vestibule. The patient's legs were stretched out in front of him, touching the floor, and his buttocks (bottom) also appeared to drag against the floor. The patient's pants came down some while he was dragged and could have resulted in a carpet burn to his lower back and upper buttock area.

During an interview on 02/11/20 at 3:55 PM, Staff F, Registration Assistant Supervisor, stated that she observed Staff A, SO, "pulling" the patient backwards away from her cubicle.

During an interview on 02/11/20 at 11:03 AM, Staff A, SO, stated that:
- His approach during interaction with Patient #1 included communication through written notes, de-escalation, and techniques learned during CPI education/training, however, all his attempts to resolve the patient's concerns were ineffective.
- His attempts to solve the patient's concerns only appeared to increase the patient's agitation, so Staff A, SO, tried to remove the patient from the registrar's cubicle.
- The patient's behaviors escalated, then reared back in the wheelchair causing it to tip over on one side, so Staff A placed his arms through the patient's and lifted him up and out of the wheelchair.
- He removed the patient from the registration cubicle by "dragging" the patient backwards down the hall towards the vestibule.
- As he "dragged" the patient down the hall, the patient's legs were stretched out in front of him and were sliding against the carpet flooring. He was not sure if the patient's buttocks or lower back touched the floor during the transfer, however, it was possible that the patient received a carpet burn during the process of removing him from the registration area by being moved backwards towards the vestibule.
- He received CPI training/education during orientation, annually and received additional training from the local police.
- The facility did not perform a debriefing with him or provide CPI re-education/training of acceptable techniques after the incident with the patient.

Review of the hospital's documents showed that no re-education/training of appropriate CPI techniques was provided to the SO immediately following the event.

During an interview on 02/11/20 at 5:29 PM, Staff G, Director of Security, stated that:
- He was a CPI training instructor and provided CPI education/training for hospital staff.
- He believed it was acceptable for Staff A, SO, to remove the patient by "dragging" him backwards.
- He acknowledged that approved CPI techniques did not include removing a patient from an area by backwards transportation.
- There was nothing in CPI training that stated it was an acceptable technique to remove a patient by dragging them backwards.
- He allowed Staff A, SO, to work the following day, because he did not believe that Staff A had abused the patient (Staff E, RN, Risk Management Coordinator, did not initiate an investigation until 01/21/20, five days after the incident had occurred on 01/16/20). Staff A was not removed from duties until the completion of Staff E's investigation into the alleged allegation of staff to patient abuse and was allowed to continue to work his scheduled shifts).

Hospital staff failed to recognize that removing a patient by "dragging" them backwards was not an acceptable CPI technique, and therefore failed to remove the staff member while an investigation was pending. The technique used resulted in patient injury.

Based on observation, interview, record review and policy review, the hospital failed to immediately and thoroughly investigate one staff (A) who used a non-approved Crisis Prevention Institute (CPI, a type of training whereby staff use physical hold which restrict a person's movement) technique which resulted in the injury of one clinic outpatient (#1) of one outpatient reviewed. This failure had the potential to place all patients that required CPI, at risk for their health and safety. The hospital census was 292.

Findings included:

1. Review of the hospital's policy titled, "Patient Abuse, Neglect and Harassment in the Health care Setting: Assessment, Investigation and Reporting," dated 06/07/19 showed:
- Patients have the right and expectation to receive health care services, care and treatment in a safe setting and remain free at all times from abuse, neglect and harassment.
- This policy sets forth the procedures to be followed to ensure that instances of alleged patient abuse, neglect and harassment committed in the hospital, including all outpatient departments, are appropriately identified and investigated.
- Investigations into suspected abuse, neglect or harassment of patients should involve individual interviews with all identified and potential witnesses, as well as other relevant individuals with potentially relevant information.

Review of the CPI Participant Workbook dated 2015, showed that:
- Risk Behavior is the total loss of control, which may result in physical behavior that presents a risk to self or others.
- At this point physical interventions may be considered to minimize harm.
- Higher-Level Holding is a physical intervention necessary to restrict a person's range of movement in relation to high-risk behavior.
- This type of hold was designed to restrict a person's ability to move away from staff and prevent the person being held from causing significant harm to self or others.

Review of the CPI workbook showed that transporting a patient backwards was not included as an acceptable technique to remove a disruptive person from the environment to prevent harm to self and others.

Review of the hospital's document titled, "Event Report," dated 01/21/20, showed:
- Patient #1, was deaf and communicated by using sign language, presented to the hospital's Outpatient Clinic on 01/16/20 at 10:15 AM for a follow-up appointment.
- When the patient presented to the registration desk to sign in for his scheduled appointment, his interpreter was not present to assist with communication between the patient and registrar. When the patient realized his interpreter was not on-site he became upset, began to yell loudly and pounded on the registrar's desk with his hand.
- The registrar requested for security to be notified to assist with the patient.
- When the SO arrived on the scene he attempted to communicate with the patient, however, the patient's behavior continued to escalate and was asked to wait for his interpreter to arrive to assist with communication.
- The patient's behavior continued to escalate and he physically assaulted the SO, the SO attempted to remove the patient from the registration cubicle but the patient grabbed onto the desk and refused to let go.
- When the SO tried to move the wheelchair that the patient sat in, the patient reared backward causing it to tip over on one side, so the SO placed his arms through the patient's and "dragged" the patient away from the registration desk and down the hall to the vestibule.
- Emergency Medical Services (EMS, ambulance staff) arrived and the patient had EMS take a picture of his lower back and buttocks (bottom) with his phone.

Review of the hospital's document titled, "CPI Review of Event," undated, showed hospital staff failed to recognize and identify in the report that Staff A, SO, removed the patient from the registrar's cubicle by "dragging" the patient down the hall backwards to the vestibule. Removing a patient per dragging them backwards was not an appropriate approved CPI technique when removing an aggressive disruptive patient from the environment.

Review of the hospital's documents showed that no re-education/training of appropriate CPI techniques was provided to the SO immediately following the event because supervisory staff did not recognize that removing a patient by "dragging" him backwards was not an acceptable CPI technique.

Review of the email dated 01/24/20 that Patient #1 sent to Staff E, Registered Nurse (RN), Risk Specialist, showed that:
- The patient identified himself as a 69 year-old that was deaf and unable to read lips or speak that presented to the hospital's Outpatient Clinic on 01/16/20 for a follow-up appointment.
- When the patient presented at the registration desk, he asked the registrar where his interpreter was because he had requested for an interpreter in advance, when he was asked by the registrar if he had brought his own interpreter with him, he became furious and hit the registrar's desk.
- When he requested to see the registrar's boss, she called for security because of his angry behavior and to assist the patient to resolve his issues.
- The patient did not believe the SO was informed that he was deaf and communicated by writing notes to staff.
- When the patient took the SO's paper (the SO had a notebook that he used to write reports in) away from him the SO took it back from him, so the patient hit the SO because the SO did not allow him to communicate by writing notes on paper.
- The SO then hit the patient in his face.
- The patient was in a wheelchair and fell down, then the SO pulled on the patient's coat and "dragged" the patient's body away from the registration area down the hall and threw the patient out the door. The SO "dragged" the patient for approximately 15 minutes.
- As a result of being "dragged" down the hall, the patient's back was "blood raw".

During an interview on 02/11/20 at 12:01 PM, Language Interpreter H, stated that when he entered the outpatient clinic, Staff A, SO, and the patient were in the entryway and the patient was on the floor on his back. Staff A added that he believed the incident with the patient could have been prevented if the outpatient clinic staff had informed the patient that his interpreter had not arrived to the clinic yet and that registration staff would wait until the interpreter arrived to assist with communication between the patient and registration staff.

Observation on 02/11/20 at 10:00 AM of the Outpatient Clinic were the incident between Patient #1 and Staff A, SO, showed that the floor in the vestibule, waiting area, greeter area, registration cubicles and outpatient clinics had carpet throughout.

During an interview on 02/11/20 at 10:38 AM, Staff B, Customer Services Assistant
(Outpatient Clinic), stated that:
- She assisted the patient to registration cubicle #4 and when he arrived at the cubicle he asked Staff F, Registration Supervisor Assistant, where his interpreter was and when she informed him she did not know, the patient became angry, slammed his hand on her desk, and pointed/shook his middle finger in close proximity of Staff F's face.
- She observed Staff A, SO, stand behind the patient and "drag" the patient backwards away from Staff F's registration cubicle towards the vestibule.
- As Staff A, SO, "dragged" the patient backwards, the patient's legs were stretched out in front of him touching the floor and his buttocks also appeared to "drag" against the floor.
- The patient's pants came down some while he was "dragged" and could have resulted in the patient obtaining a carpet burn to his lower back and upper buttock area.

During an interview on 02/11/20 at 11:03 AM, Staff A, SO, stated that:
- He received a call that the Outpatient Clinic needed security assistance with a disruptive patient that refused to leave.
- When he arrived at registration cubicle #4, he observed the patient sitting in a wheelchair with his upper body (from the waist up) leaning in towards the registration desk, was "snatching" paper off the desk and his body language presented as threatening and aggressive towards Staff F, Registration Supervisor Assistant. When he observed the patient's actions and aggressive behavior towards Staff F, his main focus was for Staff F's safety.
- All his attempts to resolve the patient's concerns were ineffective and only appeared to increase the patient's agitation, so Staff A, SO, tried to remove the patient from the registrar's cubicle, but the wheelchair would not move and the patient held onto the edge of the registration desk with his hands and would not release his grasp.
- The patient's behaviors continued to escalate and the patient physically assaulted Staff A and called him "nigger" and "big nose". The patient then reared back in the wheelchair causing it to tip over on one side, so Staff A placed his arms through the patient's and lifted him up and out of the wheelchair. The act of placing Staff A's arms through the patient's was in an attempt to prevent the patient from harming himself, Staff A and Staff F.
- He removed the patient from the registration cubicle by "dragging" the patient backwards down the hall towards the vestibule.
- As he "dragged" the patient down the hall, the patient's legs were stretched out in front of him and was touching the carpet flooring. He was not sure if the patient's buttocks or lower back touched the floor during the transfer, however, it was possible that the patient received a carpet burn during the process of removing him from the registration area by being moved backwards towards the vestibule.
- His main goal during the incident with the patient was to keep the patient safe along with staff and other patients in the outpatient clinic.
- He received CPI training/education during orientation, annually and received additional training from the local police.
- The facility did not perform a debriefing with him or provide CPI re-education/training of acceptable techniques after the incident with the patient.

During an interview on 02/11/20 at 3:55 PM, Staff F, Registration Assistant Supervisor, stated that:
- She was the registrar working when Patient #1 presented to her cubicle to register for his scheduled appointment.
- She was not aware that the patient was deaf when he presented to her cubicle.
- The patient made a gesture and she asked him if he needed an interpreter and when she asked the patient about needing an interpreter, the patient began to "slam" his hands on her desk and "snatching" items off the desk.
- The patient wrote on a piece of paper and asked where his interpreter was and when she informed him the outpatient campus did not have one and did the patient have an interpreter, the patient responded, "Why would you ask me a dumb question like that?"
- The patient then "shook" his middle finger in her face and called her a "bitch".
- She felt threatened by the patient's aggressive behavior towards her because she had never experienced that much aggression from a patient before, so she requested Staff B, Customer Services Assistant, to call security.
- When Staff A, SO, arrived at her cubicle, he turned the patient's wheelchair towards him and asked the patient what was going on? The patient then "grabbed" the edge of the cubicle and "grabbed" Staff A's notebook out of his hand. Staff A removed the notebook from the patient and the patient "lunged" forward at Staff A and raised himself up out of the wheelchair towards Staff A.
- Staff A, SO, attempted to find out what was going on with the patient before he removed the patient from her cubicle. She observed Staff A, SO, "pulling" the patient backwards away from her cubicle.

During an interview on 02/11/20 at 5:29 PM, Staff G, Director of Security, stated that:
- He was a CPI training instructor and provided CPI education/training for hospital staff.
- He acknowledged that approved CPI techniques did not include removing a patient from an area by backwards transportation, however, due to the patient's presentation and resistance against Staff A, SO, Staff A, SO, had performed the best option available given the current situation of the patient's aggressive and threatening behavior and the need to remove the disruptive patient from the registration cubicle to a safe area in the vestibule away from other staff, patients and visitors.
- He believed it was acceptable for Staff A, SO, to remove the patient by "dragging" him backwards given the current situation and the patient's aggressive threatening behaviors towards Staff A and Staff F. There was nothing in CPI training that states it was an acceptable technique to remove a patient by "dragging" them backwards.

During an interview on 02/11/20 at 4:13 PM, Staff E, RN, Risk Management Coordinator, stated that:
- She did not interview Staff F, Registration Assistant Supervisor, which was the registrar that interacted and witnessed the incident that occurred at the outpatient clinic between Staff A, SO, and the patient.
- Since the outpatient clinic did not have video capabilities, she pieced together the events that took place through interviews from staff witnesses.
- This incident started out as a security event with a visitor because the patient had not been registered as a patient when the incident took place.
- This incident did not come to her attention until 01/21/20 and that the patient possibly sustained an injury related to the incident involving the SO (five days after the incident happened on 01/16/20).
- She did not consider this incident as an abuse case, so she did not follow-up with an Situation-a concise statement of the problem; Background-pertinent and brief information related to the situation; Assessment-analysis and considerations of options, what you found/think; and Recommendation-action requested/recommended, what you want (SBAR, a technique used to facilitate prompt and appropriate communication).

The hospital failed to:
- Recognize that when Staff A, SO, removed the patient by "dragging" him backwards down a carpeted hall was not an acceptable CPI technique provided in training/education.
- Interview a key witness when they did not interview Staff F, Registration Assistant Supervisor, when she was the registrar that interacted and observed the events/incident that took place between the patient and SO.
- Immediately re-educate/train Staff A, SO, after the incident with Patient #1 and failed to re-educate/train other security staff after the incident.
- Recognize that a patient being "dragged" backwards as a patient abuse case when the patient reported possible injury (carpet burn) that resulted from the incident.

This resulted in an incomplete investigation that placed all patients at risk for their safety and health.