HospitalInspections.org

Based on interview and review of records, the hospital did not ensure that 1 of 1 patient (Patient #1) received care in a safe setting in that A) Patient #1 was tasered by a hospital employed off-duty Police Officer (Personnel #6) who did not have training mandated by the hospital's own policies, and B) the "Code White" Team Leader did not have "Code White" certification that included non-aggressive approaches to patient management. These practices could affect all patients and present a risk of potential harm to the hospital's patients and staff.

Findings included:

The 12/08/10 08:59 AM physician's "History and Physical" noted that Patient #1, age 63, was admitted to the hospital on 12/08/10 with osteoarthritis of the right knee. History included osteoarthritis, diabetes, psychiatric problem/depression, liver disease with transplant, and hypertension. Patient #1 was alert with normal muscle strength and normal speech. He had pain and swelling in both his knees and his skin was intact.

The 12/08/10 10:31 AM physician's "Operative Report" noted that on 12/08/10 Patient #1 had a "right total knee arthroplasty...under good spinal anesthesia supplemented with IV (intravenous) sedation..." with no complications.

The 12/14/10 05:30 AM nurse's "Progress Notes" indicated that Patient #1 "looks confused, agitated, and violent behavior, code white initiated..." At 06:30 AM, Patient #1 was "yelling, showing violent behavior...security personnel are at bedside..."

The 12/20/10 12:30 PM nurse's "Progress Notes" indicated that Patient #1 did not recall the "Code White" and did not know that he had displayed combative behavior. Patient #1 was informed that an off-duty Police Officer had utilized his stun device "to the patient's abdomen for approximately 3-5 seconds in order to give the code white respondents sufficient time to apply the soft restraints which had been ordered by the physician ...to provide for patient and staff safety...expressed remorse that he had injured staff..."

A) During a telephone interview with Police Officer #6 on 02/10/11 at 10:30 AM, the following questions were asked by the surveyor:

1) Police Officer #6 was asked who was in the room during Patient #1's taser incident on 12/14/10. Police Officer #6 said that he was in the room with other staff members that included the Administrative Supervisor.

2) Police Officer #6 was asked who gave the order for the taser on 12/14/10. He said nobody. It was the Police Officer's decision. Police Officer #6 said that he was employed by the hospital as a Police Officer to enforce the law.

3) Police Officer #6 was asked if he was "CPI" (Nonviolent Crisis Intervention) certified by the hospital or had a certification in "Code White" before the 12/14/10 taser incident. He said "no" and that he was not certified now.

4) Police Officer #6 was asked who the "Code White" team leader was on 12/14/10. He said that he did not know who was in charge.

5) Police Officer #6 was asked if he was trained in patient rights at orientation. He said that he "didn't recall."

6) Police Officer #6 was asked if he was trained in "Code White" at orientation. He said that he was given an explanation of what the codes were, but would not go that far as to say he had training in the individual codes.

B) During a telephone interview on 02/10/11 at approximately 11:30 AM, the Administrative Supervisor (Personnel #35) was asked if she had "Code White" certification or "CPI" training/certification before Patient #1's "Code White" on 12/14/10. Personnel #35 said "no," but that she would have functioned as Team Leader in the "Code White" since she was the Nursing Administrative Supervisor. Personnel #35 said that she was working on the computer with her back to the Police Officer and Patient #1 when she heard the Police Officer say, "If you don't calm down I'll tase you again..." She did not see the taser applied and was not told that Patient #1 would be tasered.

The hospital's "Patient Rights/Responsibilities" policy THHEB-002 issued August 2009 noted, "Each employee is responsible for providing for the rights of patient..." to receive considerate care that respects the patient's personal values and belief systems.

The "Orientation and Training" policy revised 05/20/09 noted, "New Employee Orientation, or an equivalent which supports the strategic plan and meets applicable regulatory requirements ...must be completed by each employee prior to the employee reporting for work at his or her respective unit or department ...must complete the initial competencies as designated for the position before being assigned to work independently ..."

The "Code White" policy THHEB-044 revised January 2009 noted the following: "Code White- is an emergency procedure primarily implemented, as needed, to mobilize adequate numbers of clinicians, nurses, security, and/or other hospital staff to the location of behavioral emergencies within the hospital. Code White team members shall include a Code White team leader who has Code White certification ...All hospital security officers must hold Code White certification ...All hospital Administrative Supervisors must hold Code White Certification ...Staff with Code White certification may respond to any Code White; staff who are not Code White certified may respond, but will function and initiate interventions at the specific directions of the Team Leader ...balance the patient's rights as defined in regulations and accreditation standards with the hospital's responsibility to maintain safety...responsibility of all responders to follow the directions and instructions of the Code White team leader..."

The "Emergency Action Record" Attachment B of "Code White" policy THHEB-044 revised January 2009, Publication THHEB-048 Code White noted, "Code White leader is clearly identified to the team members, along with an alternative leader ...code leader gives clear instructions to the Code Team prior to intervention with the patient ...Only staff certified in non-aggressive approaches to patient management will lead in the Code White ...the patient will be restrained without injury..."

The "Nonviolent Crisis Intervention, a CPI specialized offering" participant workbook 2005 (reprinted 2010) noted, " ...trained through the Nonviolent Crisis Intervention program to provide for the Care, Welfare, Safety, and Security of everyone involved in a crisis situation...include human service providers in fields such as health care...security, law enforcement... "

The hospital representatives were given an opportunity to provide evidence of compliance with those requirements of which non-compliance was found. No further evidence was provided to the surveyor prior to exit on 02/11/11.

Based on interview and review of records, the hospital did not ensure that 2 of 5 staff members (Police Officer #6 and Administrative Supervisor #35) who were in attendance during an emergency "Code White" on 12/14/10 had the appropriate hospital training to choose the least restrictive intervention based on an individualized assessment of Patient #1's medical, or behavioral status or condition.

Patient #1 was tasered by Police Officer #6 during the 12/14/10 "Code White" and Administrative Supervisor #35 functioned as the "Code White" Team Leader. These practices could affect all patients and present a risk of potential harm to the hospital's patients and staff.

Findings included:

The 12/08/10 08:59 AM physician's "History and Physical" noted that Patient #1, age 63, was admitted to the hospital on 12/08/10 with osteoarthritis of the right knee. History included osteoarthritis, diabetes, psychiatric problem/depression, liver disease with transplant, and hypertension. Patient #1 was alert with normal muscle strength and normal speech. He had pain and swelling in both his knees and his skin was intact.

The 12/08/10 10:31 AM physician's "Operative Report" noted that on 12/08/10 Patient #1 had a "right total knee arthroplasty...under good spinal anesthesia supplemented with IV (intravenous) sedation..." with no complications.

The 12/14/10 05:30 AM nurse's "Progress Notes" indicated that Patient #1 "looks confused, agitated, and violent behavior, code white initiated..." At 06:30 AM, Patient #1 was "yelling, showing violent behavior...security personnel are at bedside..." Patient #1 was in restraints.

The 12/20/10 12:30 PM nurse's "Progress Notes" indicated that Patient #1 did not recall the "Code White" and did not know that he had displayed combative behavior. Patient #1 was informed that an off-duty Police Officer had utilized his stun device "to the patient's abdomen for approximately 3-5 seconds in order to give the code white respondents sufficient time to apply the soft restraints which had been ordered by the physician ...to provide for patient and staff safety...expressed remorse that he had injured staff..."

A) During a telephone interview with Police Officer #6 on 02/10/11 at 10:30 AM, the following questions were asked by the surveyor:

1) Police Officer #6 was asked who was in the room during Patient #1's taser incident on 12/14/10. Police Officer #6 said that he was in the room with other staff members that included the Administrative Supervisor.

2) Police Officer #6 was asked if he was "CPI" (Nonviolent Crisis Intervention) certified by the hospital or had a certification in "Code White" before the 12/14/10 taser incident. He said "no" and that he was not certified now.

3) Police Officer #6 was asked if he was trained in patient rights at orientation. He said that he "didn't recall."

4) Police Officer #6 was asked if he was trained in "Code White" at orientation. He said that he was given an explanation of what the codes were, but would not go that far as to say had training in the individual codes.

B) During a telephone interview on 02/10/11 at approximately 11:30 AM, the Administrative Supervisor (Personnel #35) was asked if she had "Code White" certification or "CPI" training/certification before Patient #1's "Code White" on 12/14/10. Personnel #35 said "no," but that she would have functioned as Team Leader in the "Code White" since she was the Nursing Administrative Supervisor.

The hospital's "Patient Rights/Responsibilities" policy THHEB-002 issued August 2009 noted, "Each employee is responsible for providing for the rights of patient .." to receive considerate care that respects the patient's personal values and belief systems.

The "Orientation and Training" policy revised 05/20/09 noted, "New Employee Orientation, or an equivalent which supports the strategic plan and meets applicable regulatory requirements ...must be completed by each employee prior to the employee reporting for work at his or her respective unit or department ...must complete the initial competencies as designated for the position before being assigned to work independently ..."

The "Code White" policy THHEB-044 revised January 2009 noted the following: "Code White- is an emergency procedure primarily implemented, as needed, to mobilize adequate numbers of clinicians, nurses, security, and/or other hospital staff to the location of behavioral emergencies within the hospital. Code White team members shall include a Code White team leader who has Code White certification ...All hospital security officers must hold Code White certification ...All hospital Administrative Supervisors must hold Code White Certification ...Staff with Code White certification may respond to any Code White; staff who are not Code White certified may respond, but will function and initiate interventions at the specific directions of the Team Leader ...balance the patient's rights as defined in regulations and accreditation standards with the hospital's responsibility to maintain safety...responsibility of all responders to follow the directions and instructions of the Code White team leader..."

The "Emergency Action Record" Attachment B of "Code White" policy THHEB-044 revised January 2009, Publication THHEB-048 Code White noted, "Code White leader is clearly identified to the team members, along with an alternative leader ...code leader gives clear instructions to the Code Team prior to intervention with the patient ...Only staff certified in non-aggressive approaches to patient management will lead in the Code White ...the patient will be restrained without injury..."

The " Nonviolent Crisis Intervention, a CPI specialized offering " participant workbook 2005 (reprinted 2010) noted, " ...trained through the Nonviolent Crisis Intervention program to provide for the Care, Welfare, Safety, and Security of everyone involved in a crisis situation...include human service providers in fields such as health care ...security, law enforcement ... "

The hospital representatives were given an opportunity to provide evidence of compliance with those requirements of which non-compliance was found. No further evidence was provided to the surveyor prior to exit on 02/11/11.