HospitalInspections.org

Based on review of document, video surveillance tape, and staff interview, it was determined that the hospital failed to ensure that patients received care in a safe setting.
Specifically: (a) The hospital failed to protect a patient from physical abuse by security staff, when the patient attempted to elope from the Emergency Department (ED). (Patient MR#1)
(b) A patient was restrained by security staff without an order from a physician and in violation of the facility's policy and procedure. This was found for 1 of 10 medical records of patients who were restrained. (Patient MR#2 )

Findings include:

See citations: Tag A 145; Tag A 0168.

Based on review of document, facility security videotape, and staff interview, it was determined that the hospital failed to ensure that patients are protected from all forms of abuse and harassment. Specific reference is made to the excessive use of force applied by security officers. This was found for 1 out of 10 patients who were identified as being on security watch.

The failure to monitor the use of force by security officers may have placed patients at risk for potential harm.


Findings include:

Patient's medical record (MR#1) identified that on 11/9/15 at 6:19 PM the patient presented to the ED by EMS (Emergency Medical Services) - Ambulance for "intoxication," and was placed on security watch by the triage nurse for safety.

Review of the emergency room video tape verified an incident on 11/9/2015 at approximately 7:18 PM, in which a Security officer used his arms to prevent Patient MR#1 from leaving the ED. It was observed on tape that the officer pushed the patient away from him, and the patient fell backwards hitting the floor. The site Director of Security and the Supervising Director of Security were present, and acknowledged the video to be a true and accurate recording.

Review of the incident interview summaries from the facility, found that the security officers reported that the guard was attempting to block the patient's egress from the ED hallway when the patient leaned into the guard's chest and fell backward when he resisted. The involved officer was no longer employed by the hospital but the facility submitted a written statement to the survey team. The officer wrote that in attempting to block the patient from leaving, he "gently pushed her back to prevent her from using her body weight to push him out of the way to block the patient from elopement."

Review of hospital policies found no guidelines for the use of force by security officers.

Based on review of document and staff interview, it was determined that the hospital failed to ensure that physical restraints were applied in accordance with hospital policies and procedures.

As result, security officers placed a patient in 4 point restraints without a physician's order or nursing supervision, which placed the patient at substantial risk for serious harm.


Findings include:

Review of the facility Occurrence Report, dated 10/07/2015, ER Room B2, identified: on 10/07/2015 at 7:15 AM, "patient was placed in 4 point restraints without nurses awareness or doctor's order. Patient had tried to leave room and hospital. He attempted to hit and swing at staff. He also threw urine at two of the security officers." The incident was documented by the nursing supervisor who entered the ED and noted that the patient was restrained.

Patient's medical record (MR#2) identified that on 10/06/15 at 9:27 PM, 24 y/o male was brought to the ED by his mother with a Chief Complaint of Behavioral Disorder; History of Autism, Mental Retardation, Intermittent Explosive Disorder. Plan of Care included 1:1 Security observation.


During interview on 12/17 /15 at 2:00 PM, the ED Staff RN, who received report on the patient involved with this incident, stated that on 10/7/15 at approximately 7: 00 AM, she observed the patient "prone on the floor of the ED hallway between Room B1 and B2, with four (4) security officers each holding an extremity ( ankles and wrists )." She further noted that the nursing staff instructed the security officers to keep the patient on the floor until urine was cleaned off the floor. The patient had thrown a full urinal at the security officers . The patient was administered Thorazine 50 mgs (a major tranquilizer) and Ativan 2mg, (anti-anxiety drug ) IM by the RN at 7:14 AM, with security officers holding the patient's limbs. The patient was carried by his limbs from the hallway into ED Room B by four (4) security guards and placed on the captains bed (wooden Mental Health approved beds). She stated that she had no knowledge that restraints were applied by the security officers.

At interview with the Security Supervisor on 12/17 /15 at 3:00 PM, he acknowledged that he issued the order for security staff to place the patient in four (4) point leather restraints. He further stated that he did not notify any clinical staff of this action. He also stated that he does not wait for clinical supervision of take downs or restraints because nursing staff do not respond to such requests in a timely manner, if at all.


Review of the hospital policy titled "Restraints," issued 11/2013 and last reviewed 5/2015, stated, "Restraints may only be ordered by an attending physician, resident, physician's assistant or nurse practitioner credentialed by Montefiore Mount Vernon." The policy also stated, "Restraints may only be applied by qualified staff who are competent in restraint application." The policy does not delineate the type of qualified staff.