HospitalInspections.org

Based on observation, medical record review, staff interviews, review of video surveillance, and review of facility documents, it was determined the facility failed to ensure that staff utilize de-escalation techniques with patients in accordance with training and education.

Findings include:

On 08/08/2025 at 10:15 AM, Staff (S)6 confirmed that all Emergency Department (ED) staff receive de-escalation training as part of annual learning.

At 11:46 AM, upon request, S15 provided an incident report and stated that the facility has security footage of the incident. The incident report indicated that P1 attempted to elope from the ED on 07/29/25 at 9:20 PM and pulled the fire alarm. S21 arrived at the scene and attempted to prevent P1 from eloping. However, S21 was assaulted by P1 multiple times. Staff members present lowered P1 to the ground, P1 began spitting at staff. P1 was transferred to a stretcher, and restraints were applied.

At 12:03 PM, a review of the video surveillance of the 07/29/2025 incident was conducted in the presence of S4 and S15, who confirmed respectively that they were able to identify P1 and staff in the video.

Camera view location "Hallway Stairwell 17" dated 07/29/25 at 9:15 PM, revealed the following: S24, S25, S30, and S33 followed P1 as he/she leaves the ED, attempting to redirect P1 back to the ED by gesturing towards the doorway with hands guiding P1 on his/her shoulder. P1 then pulled the fire alarm, attempted to swing his/her arm towards S30, and shoved S30 away. S21 appeared from behind P1 and wrapped his/her arms around the back of P1's neck. P1 escaped from S21's hold and struck S21 multiples times in the face with closed fists. P1 was lowered to the floor by S24, S25, and S30 and was held down with assistance from S33 until more help arrived. P1 was transported back to the ED. P1's face was covered with towels and was unable to be visualized.

At 12:27 PM, during an interview with S15, it was stated that S21's handling of P1 was "inconsistent with Iron Temple training (De-Escalation Training). S15 stated that a more appropriate hold would have been to grab an appendage, such as a wrist. S15 stated that S21 has been out on leave since the incident and was scheduled to return to work on 08/15/25. S15 stated that S21 will need to retake Response Control Training (RCT). S15 stated that all security officers are required to become certified in RCT upon hire. The certification is good for two years, but security officers were also required to have a monthly RCT skills assessment.

At 1:32 PM, S15 stated that all security officers have arranged for retraining and that by the end of the week 80% of all security staff will have completed RCT retraining.

P1's medical record was reviewed in the presence of S12, and revealed the following:

On 07/03/2025, P1's maxillofacial CT scan study result stated, "... partial left globe rupture with minimal blood in the posterior chamber. 2. Left lateral facial/periorbital/supraorbital soft tissue hematoma 3. Left lamina papyracea fracture ..."

The Physician's ED Course note by S34, dated 07/03/2025 at 1:03 AM, stated, " ... I reevaluated patient at bedside. Patient is no longer agitated and is now letting me examine [his/her] face I have informed [him/her] that [he/she] has an injury to the globe. I have explained that [he/she] will likely need to be transferred for several injuries of the face/eye. On examination, [he/she] has profound periorbital edema with ecchymoses. Eyelids are swollen and patient is unable to open [his/her] left eye secondary to swelling of the lids. With very limited pressure, attempted to lightly retract eyelids, but unable to do so ..."

Upon request, S1 provided documentation that all staff involved in the incident with P1 on 07/29/25 were up-to-date with de-escalation training.

On 08/11/2025 at 09:47 AM, upon interview, S33 stated they were not able to see P1's face while on the floor. S33 stated that P1 was laying on his/her left side while on the floor. S33 heard someone tell P1 "stop spitting." S33 stated that someone had placed a towel over P1's face to protect the staff from being spat on.

A review of the staff education content titled, "Iron Temple Response Control Techniques" dated 2025 revealed the following:

"The Safe State is the central concept of the RCT Program. It refers to a physical and psychological state in which an individual is no longer exhibiting behavior or intent that poses a danger to themselves, to staff, or to others in the surrounding environment. Achieving a Safe State may involve verbal redirection, strategic positioning, or only when necessary, controlled embracing techniques ..."

" ... Terminology and Key Concepts: ... 3. Embracing Techniques: low impact, compassionate holds that communicate support rather than control used to reduce resistance and help an individual feel secure. 4. Point of Contact: The first part of the individual's body you make intentional contact with. Key points: wrist, elbow, and upper torso ..."

" ...Stabilization and Leverage ... to avoid spitting ... lightly place your palm on the patient's cheekbone and gently turn their head away from you."

Facility policy titled, "Patient Rights and Responsibilities" effective date: 07/26/2024 stated, " ... The patient has a right to receive care in a safe setting ..."

At 2:00 PM, the above findings were confirmed with S1, S12, S13, S15, S16, S17, S18, S19, and S20.