HospitalInspections.org

Based on policy review, document review and interview, the Governing Body failed to assume responsibility and provide oversight of the hospital's quality of care, patient rights, and QAPI program. The failure of the Governing Body to assume responsibility and provide oversight to ensure patients were kept safe and protected during emergency treatment resulted in abuse of 1 of 1 (Patient #4) sampled vulnerable patients in the emergency department and placed all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY. Additionally, the Governing Body's failure to respond to assure appropriate training was instituted to secure a safe setting for provision of care demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients ongoing.


The findings included:

1. The Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible and ensured the safety of the patients in the hospital.
Refer to A 057.

2. The Governing Body failed to ensure policies were implemented, all patients received appropriate care and services in a safe setting, were protected at all times from all forms of abuse, and their patient rights, dignity, and well-being were preserved.
Refer to A 0115, A 0144 and A 0145.

3. The Governing Body failed to ensure the Quality Assessment Performance Improvement (QAPI) committee analyzed and reviewed all adverse patient events and implemented preventative actions to ensure the events did not reoccur.
Refer to A 0286 and A 0263.

Based on facility document review, policy review, record review, observation and interview, the Chief Executive Officer (CEO) failed to be responsible for the management of the hospital, ensure staff provided appropriate care to all vulnerable patients in a safe environment and patients rights were promoted for 1 of 1 (Patient #4) sampled patients whose rights were violated resulting in patient abuse.

The findings included:

1. Review of the facility's "Patient Abuse" policy revealed, "...[Name of the Facility] strives to ensure that patients are protected and free from neglect and abuse..."

2. Medical record review revealed Patient #4 was a 39 year old male that presented to the emergency department (ED) on 1/14/16 at 5:59 PM with the complaint that he had been in a physical altercation, had been slammed to the ground and had a stick broken over his left arm. The patient had a past medical history of Malingering, Paranoid Schizophrenia, Bipolar Disorder and Forearm Lacerations.

Review of the Triage Assessment at 6:02 PM revealed the patient had complaints of pain to the head, face, right hand and left arm. The nurse documented the patient had scratches to his face, a cut to the right index finger.

During the patient's ED visit from 1/14/16 at 5:59 PM to 1/15/16 at 5:23 AM the nurses documented the patient was homeless, unkempt, irritable, agitated, had speech rambling, and thought people were talking about him. The nurse documented the patient "pulled his penis out began swinging it" around in front of a visitor. The assessment revealed the patient had been off his medications and refused to take them. There was no documentation of what medications the patient had been on.

On 1/14/16 at 7:40 PM Security Officer #4 (SO) was assigned to sit with the patient related to his yelling, irritability and thinking someone was talking about him. SO #4 stated later that he had been hit by Patient #4. There was no documentation of this incidence or that the SO had reported the incidence with Patient #4.

On 1/14/16 at 9:25 PM an employee of a mental health hospital came to the ED to perform an assessment of Patient #4's mental status for involuntary admission to a mental hospital. The mental health hospital employee recommended involuntary admission due to the patient was homeless, out of touch with reality, aggressive, hit a security officer and sexually acting out with the diagnoses of Schizophrenia Affective Disorder.

On 1/15/16 at 12:00 AM SO #1 arrived to sit with the patient. At 12:10 AM the patient began yelling which led to SO #1 requesting assistance from SOs #2 and #3. SO #2 and Patient #4 started standing face to face yelling at each other. SO #2 attempted to force Patient #4 back in the bed at which time an altercation between them evolved. Patient #4 in turn hit SO #2. SO #1 and SO #3 were observed by nursing holding Patient #4 on the floor while SO #2 kicked the patient in the head several times. This patient abuse was witnessed by 2 nurses. As a result of the incident, Patient #4 sustained a hematoma to the head.

3. The facility's investigation of the incident between the SOs and Patient #4 revealed the patient wanted to stand up because he was hurting. There was no documentation the patient's pain was addressed. The facility's investigation documented they were going to implement re-training of the SOs to be completed by March 30th 2016 and activate an Employee Assistance Program for the SOs. There was no documentation what the facility was implementing immediately to ensure SOs did not abuse vulnerable patients.

There was no documentation the facility developed and implemented a plan of monitoring the SOs to ensure abuse did not reoccur. There was no plan developed and implemented to ensure the SOs were knowledgeable of the facility's policies and procedures on abuse or of the appropriate interventions for patients who experienced mental problems or behaviors. There was no documentation the facility had developed and implemented measures.

4. There was no documentation the CEO was an active leader in the development of appropriate action plans and interventions to ensure patients of the facility were not abused by SOs. The CEO failed to play an active role in the prevention of abuse of the facility's patients.

Refer to A144, 145 and 263

Based on document review, medical record review and interview, the facility failed to protect patients' rights, to provide freedom from abuse and to provide care in a safe setting for all facility patients.

Failure by the facility to provide freedom from abuse and care in a safe setting resulted in a SERIOUS AND IMMEDIATE THREAT for all facility patients.

The findings included:

1. The facility failed to provide care in a safe setting for vulnerable patients presenting to the hospital Emergency Department.
Refer to A 0144.

2. The facility failed to protect all patients from abuse.
Refer to A 0145.

3. The facility failed to implement measures in order to prevent patient abuse.
Refer to A 0286

Based on policy review, document review, medical record review, observation and interview, the hospital failed to ensure vulnerable patients received care in a safe manner for 1 of 1 (Patient #4) sampled patients who was abused while in the care of the hospital. Failure of the hospital to ensure patients were kept safe during emergency treatment resulted in patient abuse for Patient #4 and placed all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY. Additionally, the hospital's failure to respond with appropriate interventions to secure a safe setting for provision of care demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients is ongoing.

The findings included:

1. Review of the facility's "Patient Abuse" policy revealed, "...[Name of the Facility] strives to ensure that patients are protected and free from neglect and abuse...Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or neglect...B. Director/Risk Management/Quality Responsibility for staff members. 1. Risk Management and/or Quality will assign the parties responsible for conducting the investigation...A Root Cause Analysis (RCA) will be completed within 45 days for any substantiated abuse/neglect event as assigned by Risk Manager or Quality...When there is evidence to support patient abuse/neglect, the appropriate corrective actions will be taken ..."

Review of the facility's "Prevention and Reporting of Patient Abuse" in-service protocol revealed, "...Patients with the highest risk of abuse include those with mental health disorders...impaired cognition...Patients that display challenging characteristics such as combativeness, resistant behaviors, or require large amounts of attention/monitoring increase the risk for abuse...Staff members involved in an allegation of abuse will be immediately removed from the patient care area..."

Review of the "Nonviolent Crisis Intervention" Crisis Prevention Institute (CPI) training handbook, used for training revealed, "...Dangers of Restraints...Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breathe. This includes sitting or lying across a person's back or stomach. When someone is lying facedown, even pressure to the arms and legs can impact that person's ability to breathe effectively..."

Review of the "Restraint: Violent/Self-Destructive (V/SD) and Seclusion" policy revealed, "...The [Name of the hospital] directs efforts to prevent and reduce the use of restraint/seclusion. Every patient has the right to be free from any physical restraint unless their safety or the safety of others is in jeopardy. The use of alternative methods is required before applying restraints and efforts should focus on preventing and reducing the use of restraint. The use of restraint requires utilization of the least restrictive measures based on the clinical assessment by the treating physician/Licensed Independent Practitioner (LIP) that restraint/seclusion is necessary...To provide guidelines for the use of restraints for the protection of the individual patient and provide a safe environment for all patients in order to protect and preserve the patient's rights, dignity and well-being during the use of restraint...General Guidelines...The Registered Nurse (RN) may initiate restraint/seclusion use and must be justified by an appropriate assessment and/or the immediate need to sustain medical treatment and/or prevent self harm. The Attending Physician must be notified within 1 hour of application. 2. Written authorization for restraint/seclusion by the responsible physician/LIP must be done within 4 hours from restrain/seclusion application...Must be assigned to a trained staff member...12. There must be documentation of this in the medical record that includes: Least restrictive interventions, Conditions or symptoms that warrant interventions...3. Documentation should include but is not limited to the following: Type of order...Type of restraint...Face to face evaluation..."

2. Medical record review revealed Patient #4 was a 39 year old male who presented to the emergency department (ED) on 1/14/16 at 5:59 PM with the complaint he had been in a physical altercation, had been slammed to the ground and had a stick broken over his left arm. The nurse documented the patient had scratches to his face and a cut to the right index finger. The patient was placed in Room #2 beside the nursing station.

Review of the nursing and physician ED notes dated 1/14/16 revealed the following:
6:02 PM - The nursing Triage Assessment revealed the patient had a past medical history of Bipolar, Schizophrenia and Malingering. The patient had complaints of pain in the head, face left arm and right hand.

6:58 PM - 7:09 PM - RN #3 documented the patient was restless, anxious, agitated, and unkempt. RN #3 documented the patient had small lacerations to the right cheek, right eyelid, "frontal area" and right hand. The patient had swelling to the frontal area and noted to have scars on the forearm from cutting. The patient stated he was at the ED yesterday because of "sudden memory loss."

7:40 PM - RN #2 documented the patient was irritable and yelling out, and voiced that someone was talking about him.

7:40 PM - RN #2 documented the patient's mood was irritable, was yelling out, stated people were talking about him and had rambling speech. Security was notified and Security Officer #4 (SO) came to sit with the patient. The patient was moved to Room #13, because staff thought it may be quieter for the patient. ED Room #13 was at the end of the hall and had 3 stretchers to accommodate 3 patients.

At 7:42 PM the patient reported he had to "...'PEE' and proceeds to stand up and pull his penis out and started swinging it."

8:17 PM - The physician noted the Family Nurse Practitioner (FNP) #1 documented the patient was experiencing auditory hallucinations and delusions, and the patient's insight and judgement were poor.

8:22 PM - 8:25 PM - RN #2 documented the patient was refusing all services at this time, but did agree to speak with a representative for a local mental health hospital.

9:25 PM - 9:45 PM - The mental health hospital's crisis employee arrived and was at the patient's bedside conducting an evaluation. The evaluation documented the patient was aggressive, out of touch with reality, had disorganized thoughts, sexually acting out and rapid mood changes. The evaluation revealed the patient had hit a security officer (SO), (there was no documentation the patient had hit a SO at this time), appeared to be responding to internal stimuli and feels like everyone is out to get him. The evaluation stated the patient had not been taking his medications and was recently discharged from a psychiatric hospital. The evaluation recommended an involuntary admission to a psychiatric hospital.

9:13 PM - A physician's note revealed FNP #1 documented the patient was having a manic/psychotic episode and ordered Ativan 1 milligram (mg) intramuscular (IM) and could repeat in 1 hour if needed.

There was no documentation the patient received treatment for the behaviors of agitation, restlessness, anxiousness, hearing voices, hallucinations and irritability from 7:40 PM to 9:13 PM on 1/14/16.

9:41 PM - The patient received the ordered Ativan 1 mg IM.

10:29 - RN #2 documented the patient was in no apparent distress and SO #7 was at the patient's bedside.

11:45 PM - RN #2 documented the patient was yelling for a nurse. The patient was agitated and stated he wanted to leave.

On 1/15/16 at 12:10 AM RN #2 documented the patient was again yelling. SO #1 (who had relieved SO #7 at 12:00 AM) called for assistance and SOs #2 and 3 responded and stayed in the room with SO #1 and Patient #4.

12:15 AM - RN #2 documented Patient #4 and SO #2 were confrontational and standing face to face. There was no documentation why the RN didn't intervene at this time and remove SO #2 from the area.

12:19 AM - RN #2 documented the patient was still face to face with SO #2 and became combative with SO #2. RN #2 left to get an injection of Ativan to administer to the patient.

12:20 AM - RN #2 documented she returned to administer the Ativan and witnessed the patient on the floor with SO #3 on the patient's back. SO #3 had his knee in the patient's back and hand on the patient's head, holding the patient down. There was no documentation why the SO failed to follow the hospital policy and not use his own body to hold a patient down.
RN #2 documented she administered the Ativan and then she noticed the patient had a new abrasion and new hematoma to the left side of his forehead. RN#2 notified FNP #1 of the new findings. There was no documentation FNP #1 assessed the patient at this time.

12:57 AM - FNP #1 ordered a Computerized Tomography (CT) scan. Review of the CT scan dated 1/15/16 at 12:57 AM revealed, "...IMPRESSION: No acute intracranial abnormality. Moderate-sized left frontal scalp hematoma."

1:56 AM - the ED physicians' notes revealed FNP #1 documented that the RN had informed the FNP of the patient being combative with the security guard and the patient possibly had new injuries. The FNP documented, "...Pt [patient] has some swelling to the left side of head..."

There was no documentation the FNP or a physician saw the patient until 1:56 AM, 1 hour and 26 minutes after the incident. There was no documentation of a nursing or physician/LIP assessment for use of the restraints. There was no physician/LIP order for the use of the restraints in accordance with facility policy.

The patient was discharged from the ED on 1/15/16 at 5:23 AM, approximately 11 hours after he presented to the ED.

4. Review of the facility's investigation of the altercation between Patient #4 and SOs #1, #2 and #3 revealed the following:

SO #1 came onto duty on 1/15/16 at 12:00 midnight and had been informed by the previous shift SO #7 that he needed to watch the patient.
During a telephone interview on 2/29/16 at 11:10 AM SO #1 stated, "He [Patient #4] was a psych [psychiatric] patient. A co-worker [at shift change] said he was hostile. Heard he had previously jumped on him and pulled his penis out. So I called for back up [when the patient began to become combative]." The patient became combative and SO #1 called for assistance. In response to the call, SOs #2 and #3 arrived in the ED to assist SO #1.

RN #2's facility statement revealed while she had gone to draw up the medication of Ativan, Patient #4 hit SO #2. The three Security Officers (#1, 2 and 3) grabbed the patient and held the patient on the floor. RN #2 left to alert her manager. When RN #2 returned with RN #4, Patient #4 was on the floor with SO #3 on top of the patient. SO #3 had his knee on the patient's back and was holding the patient's head down. SO #2 then began to repeatedly kick the patient in the head and face, while yelling and cursing at the patient. The RN informed the SOs to stop and the RN administered the medication. The RN reported that SO #3 continued to "subdue" the patient. The RN left to get her supervisor.

RN #4's facility statement revealed there was yelling noted and SOs #1, 2 and 3 were present with the Patient #4. The patient was lying face down on the floor, being restrained by SOs #1 and 3. The third SO #2 was standing in front of the patient. SO #2 appeared very agitated, was bleeding from the mouth and stated "This bastard hit me." The patient continued to yell and SO #2 proceeded to kick the patient in the face and head multiple (3-4) times. SO #2 then stated, "He shouldn't of hit me." The SOs were instructed to stop immediately. The patient was bleeding from the mouth and continued to yell. RN #4 noted an order was obtained to administer Ativan to the patient. The patient attempted to spit on the staff. The patient continued yelling and the SOs continued to yell at the patient, escalating the situation.

RN #5's, who was the Nurse Manger, facility statement revealed when she arrived there was blood on the floor and SOs #1, 2 and 3 were yelling at Patient #4. Patient #4 was yelling, "Stop, stop, I'm not doing anything, get off me, get off me!" RN #5 told the Security Supervisor to have SO #2 leave the ED area. RN #5 noted that SO #2 continued to stay for 20 minutes after he was requested to leave the area.

SO #1's facility statement revealed his shift started on 1/15/16 at 12:00 AM and that he had relieved SO #7. He stated that SO #7 told him to watch the patient carefully. SO #1 stated he asked the ED clerk what had been going on and that the ED clerk told him the patient had already hit SO #7 in the head (There was no documentation of this occurring and no intervention put into place to prevent this). SO #1 reported that the patient got out of his bed and walked over to another patient's bed, pulled out "his private part" and tried to grab a visitor's hand. SO #1 called for assistance. SOs #2 and 3 arrived for assistance. The patient was talking real loud and hit SO #2 in the mouth and they (SOs #1 and 3) "took him [Patient #4] down" to the floor "with CPI [Crisis Prevention Institute] training."
There was no documentation the facility interviewed SO #7 or the ED tech.

SO #2's facility statement revealed he was called for assistance with a patient. SO #2 stated that he and SO #3 responded. SO #2 stated he asked Patient #4 "to get in the bed and the patient swung and hit me in the mouth causing my mouth to bleed and lower jaw to swell." The SO documented the patient continued to fight and they "subdued him on the floor." The nurse gave the patient a shot and the patient got on the bed. SO #2 stated the Security Supervisor arrived and he left the unit.

SO #3's facility statement revealed that Patient #4 hit SO #2 in the mouth and they were forced to take the patient down to the floor.

5. During an interview on 2/10/16 at 9:00 AM in the hospital conference room the Risk Manager stated SOs #1 and #2 had been trained in Crisis Prevention Intervention (CPI) training and SO#3 had not been trained in CPI.

During an interview on 2/10/16 at 11:25 AM in the hospital conference room the Director of Security stated he had been informed there had been 2 other incidents with Patient #4 on the 4:00 PM to 12:00 AM shift on 1/14/16 prior to the incident with SOs #1, 2 and 3. The Director of Security stated these previous altercations with those SOs on 1/14/16 had not been reported, documented or investigated and he did not know which Security Officers were involved in these incidents.
There was no documentation the facility investigated what had occurred on the previous shift or interviewed those staff.

During an interview on 2/11/16 at 8:30 AM in the hospital conference room SO #6 was interviewed regarding the incidents that occurred with the patient on the 4:00 PM - 12:00 AM shift. SO #6 stated he heard a call for assistance and went to the ED. SO #6 stated, "...Got to the CCA [Critical Care Assessment area of the ED], patient hit the officer [SO #4] in the jaw and patient was restrained on the stretcher...2 officers were holding his arms down. The SO did not recall the names of the other SOs.

During an interview on 2/23/16 at 8:40 AM in the hospital conference room SO #4 stated he was the SO that stayed with Patient #4 for the 4:00 PM - 12:00 AM shift. SO #4 stated the patient was "agitated, restless, refused treatments." The SO stated the patient "became aggressive and attacked me...struck me..." SO #4 stated the ED technician (the SO couldn't recall the ED technician's name) and himself had to hold the patient to safety on the stretcher, "held his arms down". SO #4 stated another SO [Security Officer #7] came and relieved him, "...because I was upset...mad..." SO #4 stated, "They [patients] usually let up when several [Security Officers] show up." SO #4 was asked why he was mad, the SO stated, "Wouldn't it make you mad? [being hit by a patient]." There was no documentation of this incident or that SO #4 had reported this incident.

During an interview on 2/23/16 at 8:50 AM in the conference room SO #5 stated when he arrived, "...[Name of SO #4] was holding one arm down and the tech [ED technician] had the other arm..."

During an interview on 2/23/16 at 9:00 AM in the hospital conference room RN #4 stated, "...[Name of SO #2] kicks him [Patient #4] 3 to 4 times on the head and face...[Name of SO #2] said the bastard shouldn't have hit me...".

During an interview on 2/23/16 at 9:15 AM in the hospital conference room RN #5 stated she had read her facility investigation statement and verified it was correct. RN #5 stated, "...He [Patient #4] did get disruptive, but would calm down if you talk to him."

During an interview on 2/23/16 at 10:00 AM in the hospital conference room RN #2 stated, "...went back with [name of RN #4] and they [Security officers #1 and 3] had him [Patient #4] on the ground. [Name of SO #2] was kicking the patient in the head. We told them to stop...gave the injection [to the patient]...sat him on the bed [stretcher]...[name of SO #2] was pacing, upset and exchanging words with the patient..." RN #2 stated she and RN #4 left the room to get a supervisor and when they returned, "the officers had the patient up against the wall..."
There was no documentation the patient was immediately protected from the SOs.

During an interview on 2/24/16 at 12:00 PM in the hospital conference room the Director of Security (DOS) stated there were a total of 43 SOs working at the facility. The DOS provided this surveyor with inservice training records that revealed 19 of the 43 SOs have received the new patient abuse, dealing with psychiatric patients and CPI training.

During a telephone interview on 3/2/16 at 3:30 PM SO #2 stated, "...Got a unit call for help in CCA [Critical Care Assessment]. The patient was up out of bed and had an incident with his private parts. I asked him to get in the bed. He came at me and hit me in the mouth and broke my tooth...We've had problems with him fighting before at [name of a mental health hospital]. I didn't hit or kick him. I'm the one that was hurt. What are you going to do for me?"

During a telephone interview on 3/2/16 at 3:20 PM SO #3 stated, "...called for assistance...me and another officer responded...patient started yelling and up and hit the other officer [SO #2]...I can't remember if he [SO #2] hit the patient...don't remember anything said...I got him [Patient #4] by the arm and swept his feet out from under him and got him to the floor. You know like a wrestling move".

There was no documentation the facility conducted a thorough investigation, determined the root cause and implemented interventions to address the previous alleged incidents on 1/14/16 from the 4:00 PM - 12:00 AM shift where it was alleged Patient #4 had hit 2 officers and had to be restrained.

7. Review of the facility's root cause analysis (RCA) findings that was concluded on 1/21/16 revealed "...An organizational discussion on whether officers can be authorized to carry weapons in specific areas or whether officers carry foam or hand cuffs ect., will need to occur..." The findings also revealed the patient wanted to get off the stretcher and stand up because he was hurting.

The facility's Action Plan included an Employee Assistance program (EAP) for the SOs and to require the SOs to take a refresher course on CPI training by March 30th. There was no documentaion the action plan had been implemented.
There was no documentation the facility developed and implemented action plans to prevent the occurrence of abuse by SOs before the end date of March 30th for retraining SOs on CPI. There was no documentation the facility's staff had been re-inserviced on the facility's abuse, prevention and reporting policies and procedures.
There was no documentation how the facility was going to monitor to ensure the SOs did not abuse patients, or what measures were going to be implemented.
There was no documentation the remaining 24 SOs currently working in the facility, received retraining to address patient abuse, mental health patients or CPI refresher courses.
There was no documentation all SOs have had specific training on dealing with psychiatric patients. There was no documentation all SOs have had refresher training to be able to recognize patient abuse. There is no documentation an EAP program was implemented and available to the SOs. There was no documentation a plan or procedure had been developed and implemented to address more appropriate locations to reduce stimuli for patient's experiencing psychotic episodes.
There was no documentation the facility's RCA identified and developed an action plan for the SOs who were directed to leave the area however remained for 20 more minutes escalating an abusive and intimidating environment.
There was no documentation the facility identified the failure to follow the restraint policy and implemented interventions.

Based on facility policy, document review, record review and interview, the facility failed to protect vulnerable patients from all forms of abuse for 1 of 1 (Patient #4) sampled patients who sustained abuse while in the care of the hospital. The failure of the facility to ensure patients were free from all forms of abuse resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries.
Additionally, the hospital's failure to respond with appropriate interventions to ensure patients are safe from abuse demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients is ongoing.

The findings included:

1. Review of the facility's "Patient Abuse" policy revealed, "...[Name of the Facility] strives to ensure that patients are protected and free from neglect and abuse...Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or neglect...B. Director/Risk Management/Quality Responsibility for staff members. 1. Risk Management and/or Quality will assign the parties responsible for conducting the investigation...A Root Cause Analysis (RCA) will be completed within 45 days for any substantiated abuse/neglect event as assigned by Risk Manager or Quality...When there is evidence to support patient abuse/neglect, the appropriate corrective actions will be taken ..."

Review of the facility's "Prevention and Reporting of Patient Abuse" in-service protocol revealed, "...Patients with the highest risk of abuse include those with mental health disorders...impaired cognition...Patients that display challenging characteristics such as combativeness, resistant behaviors, or require large amounts of attention/monitoring increase the risk for abuse...Staff members involved in an allegation of abuse will be immediately removed from the patient care area..."

2. Record review revealed Patient #4 was a 39 year old male who presented to the emergency department (ED) on 1/14/16 at 5:59 PM with the complaint he had been in a physical altercation, had been slammed to the ground and had a stick broken over his left arm. The nurse documented the patient had scratches to his face, and a cut to the right index finger.

Review of the ED Triage Assessment at 6:02 PM revealed the patient had complaints of pain to the head, face, right hand and left arm. The patient had a past medical history of Malingering, Paranoid Schizophrenia, Bipolar Disorder and Forearm Laceration.

Review of the nursing and physician ED notes revealed the following events occurred while the patient was in the ED:
6:52 PM - RN #3 documented the patient complained of pain in the left arm, right hand, face and head. The RN described the patient as, "Appears unkempt, Behavior is agitated, anxious, restless...".

6:58 PM - RN #3 documented, "pt [patient] noted with laceration to rt [right] cheek, small 1 cm [centimeter] lac [laceration] to rt eyelid. 1 cm lac to rt frontal area with swelling noted and swelling noted to left frontal area. rt hand 2nd digit [finger] noted with laceration to int [interior] aspect near 2nd knuckle...pt has 12 lead stickers noted to body, arms. pt states he was seen in the ER [ED] yesterday for 'sudden memory loss'. pt cannot recall what discharge instructions or dx [diagnosis]. pt wants to 'see someone about gynecomastia [enlargement of the glandular tissue of the male breast] and fix it'. pt noted with scars to f/a [forearm] from cutting. pt denies thought of self harm..."

7:09 PM - RN #3 documented, "...Pt's mood is irritable...speech is rambling..."

7:40 PM - RN #2 documented, "Patient's mood is irritable...Pt yelling out and asking if someone is talking about him; Pt reassured that no one is talking about him; Pt continues to voice that someone is talking about him...speech is rambling...Security notified and will come sit with him."

7:42 PM- RN #2 documented, "...Behavior is Pt reports he has to 'PEE' [urinate] and proceeds to stand up and pull his penis out and started swinging it".

7:43 PM - RN #2 documented, "Security [Security Officer #4] at bedside to sit with pt."

8:17 PM - The physican notes revealed Family Nurse Practitioner (FNP) #1 documented, "...Positive for auditory hallucinations... Judgement/Insight is impaired. Delusions/Hallucinations are present...speaks to person at bedside...was recently discharged from [name of a mental health hospital]".

8:22 PM - RN #2 documented, "...Pt is refusing all services at this time including wound care...Pt reports he does not take his meds and will not take his meds."

8:25 PM - RN #2 documented, "...Pt agrees to speak with someone from [name of a mental health hospital] at this time..."

9:25 PM - 9:45 PM - The mental health hospital employee documented the patient was, "...aggressive...hit security officer...out of touch with reality...The patient said he was assaulted...says someone slammed him to the ground...The patient was recently discharged from a local mental health institution...off psych [psychiatric] meds for months. Disorganized thoughts... out of touch with reality. Sexually acting out in the ER [ED]...appears to be responding to internal stimuli...feels like everyone is out to get him...Rapid mood changes/aggressive...". The mental health hospital employee made recommendations for an involuntary admission to a mental health hospital.

A physican's note at 9:13 PM documented,"...Pt is having manic/psychotic episode..."

9:41 PM - The patient was administered Ativan 1 milligram (mg) per intramuscular (IM) injection. Physician's order obtained was for "Ativan 1 mg IM once; PRN agitation, may repeat x 1 hour".

10:29 PM - "...Patient appears in no apparent distress...Security remains at bedside..."

11:45 PM - RN # 2 documented, "...Pt noted to be yelling for a nurse. This RN at pt's bedside; Pt appears to be agitated and standing at the end of stretcher. Rambling and reporting that he wants to leave. Pt advised that this RN will notify provider [the name of the mental health hospital that the patient was waiting to be transferred to] Pt then sits down on stretcher and seems less agitated."

SO #4 was initially assigned to sit with the patient form 7:40 PM to 12:00 AM midnight. During his shift, SO #4 was hit by Patient #4, was relieved at an unknown time by SO #7. SO #7 remained with the patient until his shift change at 12:00 AM midnight. This was not reported or investigated by the facility.
On 1/15/16 at 12:00 AM, shift change, SO #1 reported to the ED and relieved SO #7.

On 1/15/16 at 12:10 AM - RN #2 documented, "Pt can be heard at nurses station yelling again, security [Security Officer #1] at nurses station inquiring about final dispo [disposition] plan for pt, security advised that pt is awaiting further dispo plan per [name of mental health hospital]". SO #1 called for assistance due to Patient #4 yelling. SOs #2 and 3 responded and stayed in Patient #4's room along with SO #2.

12:15 AM - RN #2 documented, "This RN at bedside and pt noted to be confrontational with security [Security Officer #2] standing face to face and yelling, this RN to Omni Cell [medication cart] to pull ordered Ativan".
There was no documentation why RN #2 didn't have SO #2 leave the area at this time due to SO #2 and Patient #4 standing face to face and yelling at Patient #4.

12:19 AM - RN #2 documented, "This RN at beside to attempt to administer ordered Ativan, Pt still face to face with security [Security Officer #2], Pt asked by this RN if it would be okay for me to give him Ativan, Pt agrees with medication administration, while this RN was attempting to draw up medication pt became combative with security [Security Officer #2], this RN back to nurses station to advise charge nurse [RN #5] that pt is actively combative with security [Security Officer #2]."

12:20 AM - RN #2 documented, "RN back at bedside to again attempt to administer ordered Ativan, [there was no documentation the ED physician had been made aware of the behaviors of Patient #4 or an additional order for Ativan] Pt found on ground with one security guard [Security Officer #3] on his [Patient #4's] back being held down, Ativan given, pt noted to have a new abrasion and hematoma noted to left forehead...Abrasion sustained to left temple hematoma noted to left forehead."

12:57 AM A Computerized tomography (CT) scan was ordered by FNP #1. There was no documentation the FNP or a physician assessed the patient until 1/15/16 at 1:56 AM.

At 1:56 AM the ED Physician documented, "...Informed by RN [registered nurse] that pt was combative and security was at bedside. states that possible new injuries were noticed. Pt has some swelling to left side of head. no new abrasions noted."

Review of the CT scan results revealed the patient had suffered a "...Moderate-sized left frontal scalp hematoma."

Record review revealed the patient was transferred to the mental health hospital on 1/15/16 at 5:23 AM, approximately 11 hours after he presented to the ED.

3. The facility's investigation with the SOs revealed the following:
SO #1 revealed SO #1's shift started at 12:00 AM and he relieved SO #7. SO #1's statement revealed, "...[name of SO #7] told me to watch this patient carefully, so I asked the clerk [ED unknown clerk] in trauma what was up. She [clerk] told me he [Patient #4] hit [name of SO #7] in the head [There was no documentation of a prior incident with Patient #4 and other SOs].
He [Patient #4] got out of his bed and walked to [another patient's bed] and pulled his private part out to the visitor...and grab her hand. That when I call...[Names of SO #2 and 3] respond. He was talking real loud and just hit [name of SO #2] in the mouth. We took him [Patient #4] down to the ground with CPI training."

The facility's investigation of SO #2's revealed the SO stated, "...called for an outrage patient I [SO #2's name] responded...and asked the patient to get in the bed and the patient swung and hit me in the mouth causing my mouth to bleed and lower jaw to swell...[The names of SO #1, #2 and #3] and the patient continued to fight until we subdued him on the floor. After being subdued the nurse gave the patient a shot and the patient get on the bed himself..[name of security supervisor] responded and I exited the area."

The facility's investigation of Security Officer #3 revealed the SO stated, "...so the accused [Patient #4] stepped up and hit him [SO #2] in the mouth, so we was forced to take him down to the ground..."

There was no documentation the facility investigated or interviewed SO #7 who alleged Patient #4 had hit them on a previous shift.

4. The facility's investigation with nursing revealed the following:
The facility's summary of what RN #2 stated regarding the altercation between Patient #4 and the SOs was, "...While the nurse was drawing up the medication the patient punched [name of SO #2]. At that time the three security officers [SO #1, 2 and 3] grabbed at the patient. The nurse left the room to alert her PCC [Patient Care Coordinator]...[name of RN #2] returns to the bedside with co-worker [RN #4]. At this time the patient was found on the floor with one security guard [Security Officer #3] on top of him [Patient #4] with a knee on his [the patient's] back and his [the patient's] head held down. [Name of SO #2] began to repeatedly kick the patient in the head while cursing and yelling at the patient. [Name of SO #2] was told to stop [by the nurse] and the patient was then medicated. One security officer [Security officer #3] continued to subdue patient....She [Charge Nurse, RN #5] came to the bedside with [initials of RN #2 and #4] and noted that patient was now being held down by multiple security guards..."

The facility's summary of what RN #4 stated regarding Patient #4 and the SOs was, "...Yelling noted from area and three (3) security guards [SOs #1, 2 and 3] were present. Patient was lying face down on the ground being restrained by two (2) officers [names of SO #1 and #3]. The third officer [name of SO #2] was standing in front of patient. Officer [name of SO #2] appeared very agitated and bleeding from the mouth stated, 'This bastard hit me'. The patient continued to yell while being restrained. [Name of SO #2] then proceeded to kick the patient in the face and head multiple times [3-4]...[name of SO #2] responded 'He shouldn't of hit me!!'...instructed officer to stop immediately. The patient was noted to be bleeding from the mouth but continued to yell...Two officers [Security Officer #1 and 3] continued to restrain patient...Orders received for STAT IM Ativan [there was no documentation of a physician's order for the Ativan]...Injection given...Patient attempted to spit on staff...Patient continued yelling and security continued to yell at the patient and escalate the situation..."

The facility's summary of the Nurse Manager's (RN #5) statement was, "...There was blood on the floor and they all [SOs #1, 2 and 3] were yelling at the patient and the patient was yelling 'Stop, stop, I'm not doing anything, get off me, get off me!'...Charge [nurse - RN #5] requested that Supervisor [Security Officer Supervisor] have...specifically [name of SO #2] to leave the area...Ten (10) minutes later all officers still on unit...The patient continued to be agitated at the presence of everyone still in the area. Approx. [approximately] 10 [more] minutes later [name of SO #2] was observed leaving the area...". This was a total of 20 minutes later after first being asked to leave the unit. There was no documentation why the Security officers had not left the area as instructed.

5. The surveyor's interviews with nursing, risk management and the SOs revealed the following:
During an interview on 2/23/16 at 9:00 AM in the hospital conference room RN #4 stated, "...[Name of SO #2] kicks him [Patient #4] 3 to 4 times on the head and face...[Name of SO #2] said the bastard shouldn't have hit me..."

During an interview on 2/23/16 at 9:15 AM in the hospital conference room RN #5 stated she had read her facility investigation statement and verified it was correct. RN #5 stated, "...He [Patient #4] did get disruptive, but would calm down if you talk to him..."

During an interview on 2/23/16 at 10:00 AM in the hospital conference room RN #2 stated, "...went back with [name of RN #4] and they [Security officers #1 and 3] had him [Patient #4] on the ground. [Name of SO #2] was kicking the patient in the head. We told them to stop...gave the injection [to the patient]...sat him on the bed [stretcher]...[name of SO #2] was pacing, upset and exchanging words with the patient..." RN #2 stated she and RN #4 left the room to get a supervisor and when they returned, "the officers had the patient up against the wall..."

During a telephone interview on 3/2/16 at 3:30 PM SO #2 stated, "...Got a unit call for help in CCA [critical care assessment area of the ED]. The patient was up out of bed and had an incident with his private parts. I asked him to get in the bed. He came at me and hit me in the mouth and broke my tooth...We've had problems with him fighting before at [name of a mental health hospital]. I didn't hit or kick him. I'm the one that was hurt. What are you going to do for me?"

During a telephone interview on 3/2/16 at 3:20 PM SO #3 stated, "...called for assistance...me and another officer responded...patient started yelling and up and hit the other officer [SO #2]...I can't remember if he [SO #2] hit the patient...don't remember anything said...I got him [Patient #4] by the arm and swept his feet out from under him and got him to the floor. You know like a wrestling move".

During an interview on 2/10/16 at 9:00 AM in the conference room the Risk Manager stated SOs #1 and #2 had been trained in Crisis Prevention Intervention (CPI) training and SO#3 had not been trained in CPI.

During an interview on 2/24/16 at 12:00 PM in the hospital conference room the Director of Security (DOS) stated there were a total of 43 SOs working at the facility. The DOS provided this surveyor with inservice training records that revealed 19 of the 43 SOs had received the new patient abuse, dealing with psychiatric patients and CPI training given since the incident on 1/15/16.

6. During the investigation of the incident with SOs #1, #2 and #3, the surveyor noticed the mental health employee had reference in his notes about Patient #4 hitting a security officer. This reference of hitting was prior to the incident being investigated. The mental employee was not available for interview.

On 2/10/16 at 11:25 AM in the hospital conference room, this surveyor questioned the Director of Security (DOS) and asked him if was aware of another incident with Patient #4 prior to the incident with SOs #1, #2 and
#3. The DOS stated he had been informed there had been an alleged incident with Patient #4 and 2 other SOs on a prior shift. The DOS stated he was told that a previous incident had occurred on 1/14/16 on the 4:00 PM to 12:00 AM shift. The DOS stated the previous incident with the SOs on 1/14/16 had not been reported, documented or investigated and he did not know which Security Officers were involved in these incidents.

The surveyor questioned who were the SOs that were on duty the day and shift of the alleged prior incident with Patient #4. The surveyor was informed by the Risk Manager the SOs allegedly involved were SOs #4, #5, #6 and #7. This surveyor requested to speak with SOs #4, #5. #6 and #7.

During an interview on 2/11/16 at 8:30 AM in the hospital conference room SO #6 was asked about the incident that occurred with the Patient #4 on 1/14/16 from the 4:00 PM - 12:00 AM shift. SO #6 stated he heard a call for assistance and went to the ED. SO #6 stated, "...Got to the CCA, patient hit the officer [SO #4] in the jaw and patient was restrained on the stretcher...2 officers were holding his arms down. The SO could not recall who the SOs were. There was no documentation this incident occurred or was reported and investigated.

During an interview on 2/23/16 at 8:40 AM in the hospital conference room SO #4 stated he was the SO that stayed with Patient #4 for the 4:00 PM - 12:00 AM shift. SO #4 stated the patient was "agitated, restless, refused treatments. The SO stated the patient "became aggressive and attacked me...struck me..." SO #4 stated the ED technician [the SO couldn't recall the ED technician's name] and himself had to hold the patient to safety on the stretcher, "held his arms down". SO #4 stated another SO [SO #7] came and relieved him, "...because I was upset...mad..." SO #4 stated, "The [patients] usually let up when several [Security Officers] show up." SO #4 was asked why he was mad and the SO stated, "Wouldn't it make you mad?" There was no documentation this SO reported the incident.

During an interview on 2/23/16 at 8:50 AM in the conference room SO #5 stated when he arrived, "...[Name of SO #4] was holding one arm down and the tech [ED technician] had the other arm..." There was no documentation the SO reported this incident.

SO #7 was not available for interview.

6. Review of the facility's root cause analysis (RCA) findings regarding the 1/15/16 incident, concluded on 1/21/16, revealed "...An organizational discussion on whether officers can be authorized to carry weapons in specific areas or whether officers carry foam or hand cuffs ect., will need to occur..." The findings also revealed the patient wanted to get off the stretcher and stand up because he was hurting.

The facility's Action Plan included an Employee Assistance program (EAP) for the SOs and to require the SOs to take a refresher course on CPI training by March 30th.
There was no documentation what the facility's action plans were to prevent the occurrence of abuse by SOs during the meantime before the SOs received their updated training by the due date of end date of March 30th.
There was no documentation how the facility was going to monitor the SOs to ensure the SOs did not abuse patients, how the facility was going to ensure all SOs used the appropriate techniques for holding a patient, or what measures were going to be implemented.
There was no documentation the remaining 24 SOs currently working in the facility had received retraining to address patient abuse, mental health patients or CPI refresher courses.

There was no documentation all SOs have had specific training on dealing with mental health patients. There was no documentation all SOs have had refresher training to be able to recognize patient abuse. There was no documentation an EAP program was implemented and available to the SOs. There was no documentation a plan or procedure had been developed and implemented to address more appropriate locations to reduce stimuli for patient's experiencing psychotic episodes.
There was no documentation the facility's RCA identified and developed an action plan for the SOs who were directed to leave the area however remained for 20 more minutes escalating an abusive and intimidating environment.

Based on facility policy review, document review and interview, the facility failed to ensure it maintained an effective and on-going Quality Assessment and Performance Improvement (QAPI) program to prevent adverse patient events. The failure by the facility to provide appropriate and timely interventions to secure a safe setting for the provision of care and prevention of abuse placed all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY. The hospitals' continued failure to intervene with appropriate and timely interventions to secure a safe setting for the provision of care demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients is ongoing.

The findings included:

1. The facility failed to ensure the QAPI committee implemented appropriate preventative actions to secure a safe environment and prevent abuse.
Refer to A 0286

Based on facility policy, facility document review, record review and interview, the Quality Assessment and Performance Improvement (QAPI) committee failed to ensure an ongoing hospital-wide program that identified, fully analyzed and addressed all contributing factors related to adverse events resulting in 1 of 1 (Patient #4) experiencing abuse. The failure of the QAPI committee to analyze the causes resulted in the facility's failure to implement corrective actions to ensure patient abuse and injury did not reoccur, resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and/or death. The hospitals' continued failure to fully analyze and address factors with appropriate and timely interventions to secure a safe setting for the provision of care demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients is ongoing.

The findings included:

1. Review of the facility's "Patient Abuse" policy revealed, "...[Name of the Facility] strives to ensure that patients are protected and free from neglect and abuse...B. Director/Risk Management/Quality Responsibility for staff members. 1. Risk Management and/or Quality will assign the parties responsible for conducting the investigation...A Root Cause Analysis (RCA) will be completed within 45 days for any substantiated abuse/neglect event as assigned by Risk Manager or Quality...When there is evidence to support patient abuse/neglect, the appropriate corrective actions will be taken ..."

Review of the facility's "Prevention and Reporting of Patient Abuse" in-service protocol revealed, "...Patients with the highest risk of abuse include those with mental health disorders...impaired cognition...Patients that display challenging characteristics such as combativeness, resistant behaviors, or require large amounts of attention/monitoring increase the risk for abuse...Staff members involved in an allegation of abuse will be immediately removed from the patient care area..."

Review of the "Restraint: Violent/Self-Destructive (V/SD) and Seclusion" policy revealed, "...Every patient has the right to be free from any physical restraint...The use of restraint requires utilization of the least restrictive measures...The Registered Nurse (RN) may initiate restraint/seclusion use and must be justified by an appropriate assessment and/or the immediate need to sustain medical treatment and/or prevent self harm. The Attending Physician must be notified within 1 hour of application. 2. Written authorization for restraint/seclusion by the responsible physician/LIP must be done within 4 hours from restrain/seclusion application...Must be assigned to a trained staff member...Documentation should include but is not limited to the following: Type of order...Type of restraint..."

2. Medical record review revealed Patient #4 presented to the emergency department (ED) on 1/14/16 at 5:59 PM with the complaint he had been in a physical altercation, had been slammed to the ground and had a stick broken over his left arm. The patient had scratches to his face, and a cut to the right index finger.

Record review revealed the patient had a history of Malingering, Schizophrenia and Bipolar. The patient was in the ED from 1/14/16 at 5:59 PM to 1/15/16 at 5:23 AM. Based on facility training, the patient was at risk of abuse.

During the patient's stay from 1/14/15 at 5:59 PM - 9:41 PM the patient was documented to be combative, yelling, hearing people talking about him and was aggressive. The mental health evaluation documented the patient to be out of touch with reality, had disorganized thoughts, hit a security officer, responding to internal stimuli and had not been taking his medications. The mental health evaluation recommended an involuntary psych hospital admission. The physician documented the patient was having a manic/psychotic episode.

There was no documentation the patient received treatment for the behaviors of agitation, restlessness, anxiousness, hearing voices hallucinations and irritability from 7:40 PM - 9:13 PM on 1/14/16. At 9:41 PM the patient was administered Ativan 1 mg.

At 11:45 PM on 1/14/16 the patient began yelling, became agitated, combative and wanted to leave.

On 1/15/16 at 12:10 AM Security Officer (SO) #1, who began sitting with the patient at 12:00 AM, called for assistance. SOs # 2 and 3 responded to assist. SO #2 told the patient to get on the stretcher, the patient hit SO #2 in the mouth. SOs #1 and 3 took the patient down to the floor and SO #3 put his knee on the patient's back and hand on his head to hold him down on the floor. SO #2 was agitated, cursed and began kicking the patient in the head and face, while he was being held down. The nurse instructed the SOs to stop and let the patient up. After the incident, SO #2 stayed in patient's area for 20 minutes after being asked to leave.
The patient sustained repeated kicks to the head resulting in a hematoma and abuse, the patient was also at risk of breathing problems related to the inappropriate restraining of the patient. There was no assessments or physician/LIP orders for the patient to be restrained on the floor.

Record review revealed the patient was transferred to the psychiatric hospital on 1/15/16 at 5:23 AM, approximately 11 hours after he presented to the ED.

3. The Root Cause Analysis (RCA) was concluded on 1/21/16. The facility's investigation determined the "Conclusion/Summary of findings" revealed, "...Based on the findings of the investigation and RCA it is concluded that this incident could possibly have been prevented with the following...Officers being fully trained in CPI during orientation...Officer having specific training on dealing with the psychiatric patient...Officer having specific knowledge on recognition of patient abuse...Contractually requiring that vendor provide EAP for any officer involved in serious or traumatic incidents...Facility moving the patient to a more appropriate location to reduce stimuli that could cause the patient to escalate..."

The RCA revealed "...An organizational discussion on whether officers can be authorized to carry weapons in specific areas or whether officers carry foam or hand cuffs ect., will need to occur..." The findings also revealed the patient wanted to get off the stretcher and stand up because he was hurting.

The facility's "Patient Abuse" policy revealed a RCA is to be developed in 45 days. Other than removing the abuser immediately, the policy fails to ensure potentially serious issues requiring immediate interventions were promoted by the policy and not waiting the 45 days.

The facility's Action Plan included an Employee Assistance program (EAP) for the SOs and to require the SOs to take a refresher course on CPI training by March 30th.
There was no documentation what the facility's action plans were to prevent the occurrence of abuse by SOs before the end date of March 30th.
There was no documentation how the facility was going to monitor to ensure the SO did not abuse patients, or what measures were going to be implemented.
There was no documentation the remaining 24 SOs currently working in the facility, received retraining to address patient abuse, mental health patients or CPI refresher courses.
There was no documentation all SOs have had specific training on dealing with psychiatric patients. There was no documentation all SOs have had refresher training to be able to recognize patient abuse.
There was no documentation a plan or procedure had been developed and implemented to address more appropriate locations to reduce stimuli for patient's experiencing psychotic episodes.
There was no documentation the facility's RCA identified and developed an action plan for the SOs who were directed to leave the area however remained for 20 more minutes escalating an abusive and intimidating environment.
There was no documentation the facility's RCA identified and developed an action plan to address the previous incidents that occurred on 1/14/16.
There was no documentation the facility's RCA identified and developed an action plan to address restraint assessments and orders in accordance with facility policy.
There was no documentation the facility's RCA identified and developed an action plan to ensure patients' complaints of pain.

There was no documentation the QAPI committee analyzed all factors which created the potential for patient abuse and, implement preventive and corrective action plans that were developed by the committee.
Refer to A 115, A 144, A 145