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Based on review of documentation, interviews, observations and view of Hospital surveillance video tape of the incident, the Hospital failed to ensure that all patients had the right to be free from physical or mental abuse and corporal punishment. The Hospital failed to ensure that all patients had the right to be free from restraint or seclusion, of any form, imposed as as means of coercion, discipline, convenience or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others, and must be discontinued at the earliest possible time.

According to the regulatory interpretive guidelines associated with this regulation and consultation with CMS Administrative staff, "The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention and public safety are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients."

Findings included:

Background information:

On 8/19/10, the Hospital reported that a Patient, who presented to the Emergency Department [ED] on 7/21/10 at midnight after an ingestion of an unknown amount of medications with the intent to commit suicide, had a bruised wrist after Campus Police Officers handcuffed the Patient to prevent her from eloping from the ED.

Review of the Hospital report indicated that the Patient was placed on a Section 12 A [involuntary commitment based on intent to inflict self-harm. Persons must undergo a mental health evaluation]. After sleeping through the night, the Patient received a telephone call around 9:30 am that caused the Patient to be agitated. At 10 am, the Patient attempted to flee the ED. The ED Physician called the Campus Police to stop the Patient because she had not completed the mental health evaluation. As the Patient was running, the Patient passed an on-duty Campus Police Officer who began to walk behind the Patient. As the Patient went through the final set of ED doors into the main lobby/waiting area, a woman and her three children attempted to pass, so the Officer placed himself between the Family and Patient to protect the Children. The Patient began swinging at the Campus Police Officer, was kicking, flailing and spitting . When the Patient continued to resist, the Campus Police Officer performed a take down maneuver. Once the Patient was on the floor, the Campus Police Officer put his knee to her mid back and put the Patient's hands behind her back and placed handcuffs on to walk the Patient to the Emergency Mental Health Services [EMHS] area.

Once the Patient was in the Emergency Mental Health Services area, the Patient complained of head, neck and shoulder pain. The Patient also complained of a bruised and swollen right wrist. The ED Nurse and Physician were called to the EMHS area and evaluated the Patient's injuries. An x-ray of the wrist was obtained which indicated no acute traumatic injury or fracture.

The mental health evaluation was completed and the Patient was admitted for inpatient psychiatric care on a Section 12 B [involuntary inpatient admission for treatment] based on continued intent to inflict self-harm.

1) Review of the Hospital Policy titled: "Handcuffing: Section I, Purpose", indicated that the use of handcuffs are used as a law enforcement restraint device and the use of handcuffs are also governed by the internal policy of the Police Department. Under Section III titled: "Definitions", indicated that "Handcuffs are metal temporary forensic restraining devices only authorized for usage by Police Officers intended for law enforcement to restrict and control an individual's actions and provide safety and security for patients, staff and visitors".

Section 12; MGL c 123 - "Pursuant to this statute, a police officer, who believes that failure to hospitalize a person would create a likelihood of serious harm by reason of mental illness, may restrain such person and apply for hospitalization for the person". Section V. A. 1) indicated that attempts shall be made to implement less restrictive devices such as verbal de-escalation techniques, to get the individual to comply with requests without the use of restraint devices, such as handcuffs. 2) Officers will evaluate the need for handcuffs as a law enforcement restraint device based on possible risks and benefits to this individual and safety of others in the area. The officers, with input from the hospital staff (if appropriate), will make the decision that there is no less restrictive alternative. Section B. 1) indicated that handcuffs are to be utilized only by law enforcement officers and shall be applied with caution to prevent injury to the individual being handcuffed.


2) The Chief of the Police Department was interviewed by telephone on 8/25/10 at 11:30 am and in person on 8/30/10 at 9:55 am. The Chief of Police said the Officers are not State Troopers, but similar to the local Police Department. They hold legal status as Police Officers and have the same rights and responsibilities as a town or city Officer. The Police Chief said the Police Department protects the lands owned by the Hospital and Medical School. The Police Chief said that all Police Officers are trained in de-escalation techniques and hold Crisis Prevention Institute [CPI] certification. The Police Chief said all Officers are trained in safe handcuff technique at the Police Academy. Training to update skills are conducted yearly.

The Police Chief said the Section 12 status allows the Police Officers to transport persons against their will. The Police Chief said the use of handcuffs are legal to use emergently to restrain and or transport a person against their will to receive medical and/or mental health care. The Police Chief said the two Police Officers did not file assault and battery charges or arrest the Patient for assaulting them, even though her actions were criminal. The Police Chief said the Officers used the handcuffs for the shortest period of time to control the Patient's attacks and prevent her from leaving the exit doors.

The Police Chief said the first Police Officer arrived, [ #1] and tried to subdue the Patient. The second Police Officer [#2] was called as back up and Police Officer #1 held the Patient's hands behind her back and Police Officer #2 applied the handcuffs. The Police Chief said that usually, two Officers are assigned to the ED area: one inside the clinical area and the other in the ED lobby/main waiting area. Both Officers were assigned to the ED area that day of the incident. The Police Chief said the Patient's behavior warranted the use of handcuffs - it was for emergency restraint on a Patient who was on Section 12 A and the Police Officers have legal authority to use the handcuffs, just as they would in the community to bring a person in for care and treatment. The Officers were informed by the ED Nurse the Patient was on Section 12 A status and was eloping. The Patient was aggressive and assaulting the Officers and there was a Mother with three small children in the immediate area with several patients and visitors surrounding. The Police Chief said the Officers actions were warranted and appropriate for their safety as well. The Police Chief said the Officers did not arrest the Patient, but they could have because kicking, punching and spitting are assault and battery actions/aggression towards Officers, that are criminal in nature. The Police Chief said that their policies are based on the Massachusetts Police Institute "Model Policy" that is based on legislation and is modified to their particular department. The Police Chief said that Section 12 status requires that the person is under involuntary control for personal safety and if attempts are made to flee, they legally are obligated to return the person. The Police Chief said that if the Officers had not detained the Patient and she had eloped and harmed herself, we would be having another discussion entirely. The Police Chief said the public would have demanded why didn't the Officers stop the Patient. The Police Chief said this situation is different from other Hospital ED settings in that security guards with no legal authority are utilized.

3) The Police Chief provided video surveillance of the incident for review. There were only two views were from cameras stationed outside the EMHS door and immediately inside the door. The Police Chief said the actual handcuffing process was not recorded because there is no camera in the hallway where that incident occurred.

The first view was of the two Police Officers walking with the Patient on either side of her. The Patient was observed to have her hands behind her back and the walk was normal paced and it appeared that no one was talking. There was a very short wait outside the door and then the door was opened and they entered. The video clip was very short.

The second view was inside the EMHS area and two clinicians are observed to come to the door. Several patients are observed in the area watching. The Psychiatrist is observed in the area talking to a patient. According to the tape, the time is 10:01 am. Once the Patient is inside, the two Police Officers stand to the side, away from the Patient, but still on either side, several feet away. The Patient is observed to raise her head to point to the ceiling and it appears that she is yelling or talking. Persons are gathering. The Patient walks quickly towards Officer #1, who is several feet away from her and no mouth movements are noted on his face, and kicks him in the groin/thigh area. Police Officer #1 first steps away then grabs the Patient's arm and turns her away from him and brings her to the wall, facing the wall, away from others in the immediate area. As the Patient is brought towards the wall, she bends her head forward and her head has contact with the wall. As the Patient is observed to be held against the wall, the Patient appears to be talking/yelling? and is gesturing with her head - banging her head into the wall several times. PO #1 is holding her hands, but not in contact with her body. The Patient continues to struggle and is moved into the room where the Patient is no longer visible. PO #1 walks out the door at 10:05 am.