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Based on interview, record review and review of the facility's policy it was determined the facility failed to ensure patients were free from abuse. Patient #1, one (1) of ten (10) sampled patients, was abused by two (2) facility staff. The facility failed to remove the two (2) staff from direct patient care during investigation of the abuse and the facility failed to re-train staff on abuse following the incident.

Refer to Standard Tag A145

Based on interview, open and closed record review, video film review, and review of facility policies, it was determined the facility failed to protect one (1) of ten (10) sampled patients, Patient #1, from abuse. Review of the video film of the incident revealed two (2) facility security guards grabbed Patient #1's head and forcefully pushed his/her head down onto a gurney while he/she was in five (5) point restraints. The facility failed to protect patients from abuse during the investigation of the abuse by allowing the two (2) alleged perpetrators to continue working in direct care positions while the investigation of abuse was conducted. The facility also failed to re-train staff on prevention (including protection of patients during an abuse investigation), intervention and detection of abuse.

The findings include:

Review of a facility policy, 9.0 Progressive Discipline (undated) revealed: "In the event of a critical offense, the employee may be suspended. . .as long as reasonably necessary to complete an investigation." Included in this policy was Examples of Critical Offenses which revealed: "Physical assault, which may include offensive touching of any person during working hours or on hospital property". Review of the facility policy, Command Notification Policy, Revised 05/2011 revealed: ". . .the Director of Security will be called and consulted for a critical offense of an officer being placed on suspension". Review of the facility policy, Patient Rights and Responsibilities, dated 03/10 revealed: 4. "The patient has the right to be free from all forms of abuse or harassment".

Review of the video film of the incident, on 08/11/11 at 8:10 AM, revealed Patient #1 lying supine on a gurney in a seclusion room of the Emergency Psychiatric Services (EPS) Department with four (4) facility security guards in attendance. The patient's wrists and ankles were restrained with hard restraints and a strap restraint was in place across his/her chest and thighs. Two (2) security guards were on each side of the patient. The guard nearest the right wrist of the patient, Guard #2, untied the wrist restraint and the patient raised his/her head off the gurney approximately thirty (30) degrees. There was no audio feed for this video film but Patient #1 was seen moving his/her mouth the entire time as if talking. When Patient #1 raised his/her head off the gurney, the guard on the patient's left, Guard #1, immediately grabbed the patient's head, turned it to the left, and pushed it down onto the gurney. While continuing to hold the patient's head down, Guard #1 brought his right knee up and pressed it onto the patient's head. Simultaneously, Guard #2 used his two (2) hands to assist in holding down the patient's head. The event lasted approximately one (1) minute forty five (45) seconds after which Guard #1 and Guard #2 released the patient's head and left the seclusion room. The two (2) security guards stationed at Patient #1's feet did not participate in holding him/her and remained in the seclusion room with the patient after Guard #1 and Guard #2 had left the room.

Record review for Patient #1, on 08/11/11, revealed the patient was brought to the EPS by city police officers on 07/26/11 at 2:05 AM, was triaged at the Emergency Department entrance, and escorted by two (2) security guards to the EPS Department. Review of the nursing notes dated 07/26/11 at 3:00 AM revealed Patient #1 was verbally abusive while in the EPS waiting room, threw a cup of water on another patient, and could not be verbally redirected. The nursing notes indicated Patient #1 was asked by the EPS nurse if he/she would like to go to the seclusion room to quiet him/her self and Patient #1 said he/she would. Patient #1 was escorted by Guard #1 and Guard #2 to the seclusion room. However, while on the way, the nursing notes indicated Patient #1 became verbally abusive to the guards and attempted to throw punches at the guards (there was no video film of this occurrence). Nursing notes further revealed Patient #1 was then escorted on foot into the seclusion room and was placed in wrist, ankle, chest, and thigh restraints. Review of the EPS Attending M.D. (medical doctor) note, dated 07/26/11 at 11:05 AM, revealed: (Patient #1) "reported security guards 'beat him up', the M.D. discussed this with the facility patient representative, and the patient representative told the M.D. she and the security Captain would review the video tapes and investigate Patient #1's complaints." The M.D. note also revealed Patient #1 reported shoulder/wrist pain and the patient had a full range of motion. Review of a Social Worker Evaluation, dated 07/26/11 at 10:50 AM revealed: . ."upon interview, patient (Patient #1) stated that he was unhappy with how he was treated when he came in to EPS. Patient stated he felt they (security guards) used excessive force with him and he had multiple physical complaints that treatment."

Interview with RN #2, on 08/10/11 at 8:30 AM, revealed all patients who were brought to the Emergency Department by the police or emergency medical services, and were triaged as needing emergency psychiatric services, were escorted to the EPS Department by facility security guards.

Interview with the Director of Risk Management, on 08/10/11 at 8:35 AM, revealed the facility concluded patient abuse after the facility investigation. She stated the facility recognized the alleged perpetrators should have been suspended immediately and they were not. The Director of Risk Management also stated the facility re-trained the supervisory officer on duty at the time of the incident (who was informed of suspected patient abuse) regarding rules for employee suspension, but did not re-train him on prevention, intervention, and detection of abuse. She further stated this was the only employee re-trained on immediate suspension of employees alleged to have abused a patient and this re-training was not documented. The Director of Risk Management revealed the two security guards who remained in the seclusion room with Patient #1 did not report suspected patient abuse and they should have. She said the facility re-trained on seclusion and restraint but did not re-train on prevention of abuse (to include protection of patients during an investigation of abuse) and intervention and detection of abuse and indicated she was aware this should have been done.

Interview with RN #4, on 08/10/11 at 8:50 AM revealed he was responsible to re-train the nursing staff in the EPS Department following the incident involving Patient #1 and the security guards on 07/26/11. He provided a copy of the in-service he had presented titled EPS Restraint Initiation - Nursing Responsibilities. Objective: To clarify the RN's role in restraint initiation. He stated he did not re-train the nursing staff on prevention of abuse (to include protection of patients during an investigation of abuse) and intervention and detection of abuse.

Interview with a Certified Assistant in the EPS Department, on 08/10/11 at 8:58 AM, revealed she was re-trained on restraint and seclusion after the incident with Patient #1 and the security guards but not on prevention of abuse (to include protection of patients during an investigation of abuse) and intervention and detection of abuse.

Interview with Officer #3, on 08/10/11 at 9:00 AM, revealed he was aware of the incident of patient abuse which occurred on 07/26/11 in the EPS Department. He stated he was re-trained on restraint and seclusion with a read and sign memo after the incident, but he was not re-trained on prevention of abuse (to include protection of patients during an investigation of abuse) and intervention and detection of abuse.

Interview with RN #3, on 08/10/11 at 9:15 AM, revealed she received an in-service after the incident involving Patient #1 in the EPS Department regarding restraint and seclusion but not on prevention of abuse (to include protection of patients during an investigation of abuse) and intervention and detection of abuse.

Telephone interview with RN #1, on 08/10/11 at 6:45 PM, revealed she was assigned to Patient #1 at the time of the incident of suspected abuse on 07/26/11 but she was not in the seclusion room at the time of the incident. She stated she should have been as that was the facility policy, but she had to check on her other patients. She also stated she was re-trained on restraint and seclusion but not re-trained on prevention of abuse (to include protection of patients during an investigation of abuse) and intervention and detection of abuse.

Interview with the Captain of the security guards, on 08/11/11 at 8:45 AM, revealed he should have been notified of the incident between Patient #1 and security guards, at the time of the incident on 07/26/11. He stated he would have suspended the alleged perpetrators (Guard #1 and Guard #2) immediately. The Captain indicated facility security guards would respond immediately in the event of a patient to patient incident involving physical assault and local police would be notified. However, he felt this was handled differently because it was an incident between security guards and a patient. He stated he did not contact the local police when he was informed of the incident with Patient #1 because it had been reported by the patient to local police. He stated he viewed the video film of the incident of Guard #1, Guard #2, and Patient #1 and he should have re-trained all of the security staff on prevention of abuse (to include protection of patients during an investigation of abuse) and intervention and detection of abuse.

Telephone interview with the security supervisor in the facility at the time of the incident, Sargeant #1, on 08/11/11 at 12:10 PM, revealed he was notified by Dispatcher #1 immediately when the dispatcher saw suspected patient abuse, but he did not suspend Guard #1 and Guard #2 from duty. He stated he took Guard #1 and Guard #2 outside and had a talk with them regarding proper restraint of a patient. He reported Guard #1 continued to work in the Emergency Department and Guard #2 continued to work on bike patrol until the end of their shifts (three (3) hours). He stated Guard #1 and Guard #2 were not removed from direct patient care after the allegation of patient abuse and he recognized they should have been to protect all facility patients.

Interview with the Vice President of Operations Improvement, on 08/11/11 at 4:30 PM, revealed the facility investigation concluded the incident with Patient #1 on 07/26/11 was abuse, but the facility did not re-train on prevention of abuse (to include protection of patients during an investigation of abuse) and intervention and detection of abuse. She stated it was the intent of the facility when they re-trained on restraint and seclusion, however, she could see that it should have been documented. She indicated it was an area the facility could improve on in the future.

Telephone interview with Patient #1., on 08/19/11 at 11:00 AM, revealed he/she was upset over the incident at the facility on 07/26/11 in the EPS Department. Patient #1 stated he/she was treated too harshly by the security guards in the seclusion room and had physical problems resulting from that treatment. Patient #1 also stated he/she almost blacked out when his/her head was held down by the security guards and he/she had a problem with the right eye, with the throat and swallowing, and with headaches following the incident.