HospitalInspections.org

Based on review of facility policies and procedures, facility documents, review of medical records (MR) and interview with staff (EMP), it was determined that the Governing Body failed to ensure that the Chief Executive Officer (A-057) managed the facility according to approved facility policies, by failing to protect and promote each patient's rights (A-115), by failing to ensure the patient has the right to receive care in a safe setting (A-144), by failing to ensure that less restrictive interventions were determined to be ineffective to protect the patient, a staff member, or others from harm before restraints or seclusion were applied (A-164), by failing to ensure that the type or technique of restraint or seclusion used was the least restrictive intervention effective to protect the patient or others from harm (A-165), and by failing to ensure that facility staff implemented safe and appropriate restraints as determined by hospital policy (A-167) in four of ten medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review of facility policy, "Patient Rights and Responsibilities," approved May 2008 revealed "III. Procedure ... 21. Patients have the right to expect good management techniques to be implemented within the organization. Patients have the right to expect reasonable safety insofar as the organization's practices and environment are concerned ... 26. The patient has right to be free from any form of restraint (physical restraint or drugs as a restraint) that is not medically necessary or is used as a means of coercion, discipline, convenience, or retaliation by staff."

Review of facility policy "Code Orange Response and Reporting," approved December 2006 revealed "IV. A. When a Code Orange situation is announced, all security officers at that facility will respond to the location of the Code Orange situation. B. Security Officers will adhere to guidelines established in the Code Orange Response Plan ... when handling patients during a Code Orange situation."

Review of facility policy "Code Orange Response Plan," approved June April 2006 revealed "III. Definitions Behavioral dyscontrol - Behavior characterized as agitated, impulsive or destructive to self, others, or to property and is due to acting out, confusion, suicide intent or an attempt to elope. IV. Procedure ... B. Response to Code Orange condition ... 4. Intervention strategies for patients include: a. verbally encouraging the patient to gain control of behavior. b. physically taking the patient to his/her room; c. remove patient to a seclusion room or quiet area; d. physically restrain the patient only as a last resort ... D. Request for Assistance - Municipal Police Department 1. Request assistance from municipal police department when an individual: A. has a weapon in his/her possession; b. is holding another individual hostage; c. is extremely violent; or d. when additional response to Code Orange is necessary."

Review of facility policy "Restraint and Seclusion for Behavioral Management," approved March 2010 revealed that "I. Policy patients have a right to a safe environment. Staff will intervene to protect patients from harming themselves or others. In an effort to prevent, reduce and strive to eliminate the use of restraints and seclusion, least restrictive alternatives/interventions to seclusion/restraint use will be attempted first. When these measures are ineffective or no longer feasible, seclusion/restraint may be utilized following established policies and procedures. The least restrictive method of seclusion/restraint that meets the patient's assessed needs will be utilized. Patient's rights, dignity, well being, and safety will be supported and maintained ... The use of restricted devices applied by law enforcement officials, such as handcuffs, is not governed by this policy."

Review of facility policy "M26 and X26 Taser" revised September 2007 revealed "I. Policy Statement ... It is the mission of the Lehigh Valley Hospital Security Department to provide for the protection of patients, visitors, physicians, and staff members, and to reduce the number of injuries from physical confrontations with violent persons. The Security Department in concert with this mission will employ the LEAST RESTRICTIVE means to control patient behaviors and to assure the health and safety of anyone on hospital property. This requires effective staff training and ongoing monitoring and assessment of use of restraints. Taser-Certified Security Department personnel will have the ability to employ non-lethal force, by means of the M26 or X26 Taser ... In accordance with CMS guidance, the use of Taser, Stun guns or like weapons against patients is not permitted ... ... III. Definitions ... M26 or X26 Taser A non-lethal handheld electronic control device, which fires two probes up to a distance of 35 feet. The electrical signal overrides the central nervous system and directly controls the skeletal muscles. This neuromuscular incapacitation causes an uncontrollable contraction of the muscle tissue, which temporarily debilitate the target. The Taser can also be touched to the subject, in a technique called a Drive Stun, causing the same, or a lesser effect ... 3. Applications ... c. when a Taser is deployed on an individual, a security officer will immediately handcuff the subject to minimize the likelihood that any further use of force will be required ... the appropriate law enforcement agency will immediately be called and charges will be filed. "

Review of facility policy "Use of Force," revised December 2006 revealed "IV. Procedure A. Security personnel who are without fault may use such force as reasonably appears necessary to protect himself/herself or a third part from the imminent use of unlawful force upon themselves and/or the third party. B. The danger of harm must be a present one. There is no right to use force if harm is merely threatened at a future time of if the "attacker" has no present ability to carry out the threat. c. Security personnel may use only the force that reasonable appears necessary to effectively bring an incident under control. D. Crime Prevention 1. Security personnel may use force to the extent that it reasonably appears necessary to prevent a felony, riot, or other serious breech of peace. 2. Security personnel may use force to apprehend a fleeing felon. The force used to apprehend must be objectively reasonable."

1) Review of facility document "CEO Report to Board of Trustees," dated March 2007 revealed "effective June 1, we will equip all our security officers with ... Taser electric stun guns."

2) Review of "COO [Chief Operating Officer] Staff Meeting Minutes," dated December 20, 2006, revealed "2. Security Issues discussion - ... presented a case for the use of vest and TAZAR guns by our security guards ... although reluctant, due to the reality of our society, approval was given to move forward with this initiative."

3) Review of MR1, MR2, MR3 and MR4 revealed that these patients had a behavorial dyscontrol event and was subject to a Taser discharge by Security staff. There was no documented evidence that restraints or seclusion were implemented prior to the use of the Taser.

4) Interview with EMP1 on September 9, 2010, confirmed that the facility approved the use of Taser electric stun guns in 2007 and that facility policy "M26 and X26 Taser" was not revised. Further interview with EMP1 confirmed there was no documented evidence that restraints or seclusion were implemented prior to the use of the Taser.

5) Telephone interview with EMP1 on September 13, 2010, confirmed that there was no documented evidence of approval for use of the Taser in the Governing Body Meeting Minutes.


Cross Reference:

482.12 (b) Chief Executive Officer
482.13 Patient Rights
482.13 (c) (2) The patient has a right to receive care in a safe setting
482.13 (e) Restraint or seclusion
482.13 (e) (2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff member, or others from harm.
482.13 (e) (3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm.

Based on review of facility policies and procedures, review of facility documents, review of medical records (MR) and interview with staff (EMP), it was determined that the Chief Executive Officer (CEO) failed to ensure a safe environment for patients who were subject to a Taser discharge or Taser drive stun in four of four medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review of facility policy, "Patient Rights and Responsibilities," approved May 2008 revealed "III. Procedure ... 21. Patients have the right to expect good management techniques to be implemented within the organization. Patients have the right to expect reasonable safety insofar as the organization's practices and environment are concerned ... 26. The patient has right to be free from any form of restraint (physical restraint or drugs as a restraint) that is not medically necessary or is used as a means of coercion, discipline, convenience, or retaliation by staff."

Review of facility policy "Code Orange Response and Reporting," approved December 2006 revealed "IV. A. When a Code Orange situation is announced, all security officers at that facility will respond to the location of the Code Orange situation. B. Security Officers will adhere to guidelines established in the Code Orange Response Plan ... when handling patients during a Code Orange situation."

Review of facility policy "Code Orange Response Plan," approved June April 2006 revealed "III. Definitions Behavioral dyscontrol - Behavior characterized as agitated, impulsive or destructive to self, others, or to property and is due to acting out, confusion, suicide intent or an attempt to elope. IV. Procedure ... B. Response to Code Orange condition ... 4. Intervention strategies for patients include: a. verbally encouraging the patient to gain control of behavior. b. physically taking the patient to his/her room; c. remove patient to a seclusion room or quiet area; d. physically restrain the patient only as a last resort ... D. Request for Assistance - Municipal Police Department 1. Request assistance from municipal police department when an individual: A. has a weapon in his/her possession; b. is holding another individual hostage; c. is extremely violent; or d. when additional response to Code Orange is necessary."

Review of facility policy "Restraint and Seclusion for Behavioral Management," approved March 2010 revealed that "I. Policy patients have a right to a safe environment. Staff will intervene to protect patients from harming themselves or others. In an effort to prevent, reduce and strive to eliminate the use of restraints and seclusion, least restrictive alternatives/interventions to seclusion/restraint use will be attempted first. When these measures are ineffective or no longer feasible, seclusion/restraint may be utilized following established policies and procedures. The least restrictive method of seclusion/restraint that meets the patient's assessed needs will be utilized. Patient's rights, dignity, well being, and safety will be supported and maintained ... The use of restricted devices applied by law enforcement officials, such as handcuffs, is not governed by this policy."

Review of facility policy "M26 and X26 Taser" revised September 2007 revealed "I. Policy Statement ... It is the mission of the Lehigh Valley Hospital Security Department to provide for the protection of patients, visitors, physicians, and staff members, and to reduce the number of injuries from physical confrontations with violent persons. The Security Department in concert with this mission will employ the LEAST RESTRICTIVE means to control patient behaviors and to assure the health and safety of anyone on hospital property. This requires effective staff training and ongoing monitoring and assessment of use of restraints. Taser-Certified Security Department personnel will have the ability to employ non-lethal force, by means of the M26 or X26 Taser ... In accordance with CMS guidance, the use of Taser, Stun guns or like weapons against patients is not permitted ... III. Definitions ... M26 or X26 Taser A non-lethal handheld electronic control device, which fires two probes up to a distance of 35 feet. The electrical signal overrides the central nervous system and directly controls the skeletal muscles. This neuromuscular incapacitation causes an uncontrollable contraction of the muscle tissue, which temporarily debilitate the target. The Taser can also be touched to the subject, in a technique called a Drive Stun, causing the same, or a lesser effect ... 3. Applications ... c. when a Taser is deployed on an individual, a security officer will immediately handcuff the subject to minimize the likelihood that any further use of force will be required ... the appropriate law enforcement agency will immediately be called and charges will be filed. "

Review of facility policy "Use of Force," revised December 2006 revealed "IV. Procedure A. Security personnel who are without fault may use such force as reasonably appears necessary to protect himself/herself or a third part from the imminent use of unlawful force upon themselves and/or the third party. B. The danger of harm must be a present one. There is no right to use force if harm is merely threatened at a future time of if the "attacker" has no present ability to carry out the threat. c. Security personnel may use only the force that reasonable appears necessary to effectively bring an incident under control. D. Crime Prevention 1. Security personnel may use force to the extent that it reasonably appears necessary to prevent a felony, riot, or other serious breech of peace. 2. Security personnel may use force to apprehend a fleeing felon. The force used to apprehend must be objectively reasonable."

1) Review of facility document "CEO Report to Board of Trustees," dated March 2007 revealed "effective June 1, we will equip all our security officers with ... Taser electric stun guns."

2) Review of MR1, MR2, MR3, MR4 revealed all these patients had a behavior dyscontrol event while a patient at the facility between December 16, 2008, through August 26, 2010. Further review of MR1, MR2, MR3 and MR4 revealed Security staff documentation that a Taser discharge or Taser Drive stun was used on each patient during the behavior dyscontrol event.

3) Interview with EMP1 on September 9, 2010, confirmed that the facility approved the use of Taser electric stun guns in 2007. Further interview with EMP1 confirmed that each patient in MR1, MR2, MR3 and MR4 was subject to a Taser discharge or Taser drive stun by Security staff during a behavorial dyscontrol event and that there was no documented evidence that restraints or seclusion were implemented prior to the use of the Taser.

4) Telephone interview with EMP1 on September 13, 2010, confirmed that there was no documented evidence of approval for use of the Taser in the Governing Body Meeting Minutes.

Based on review of facility policies and procedures, facility documents, review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to protect and promote each patient's rights for patients, failed to ensure that each patient's right to receive care in a safe setting (A-0144), failed to implement restraints or seclusion when less restrictive interventions were determined to be ineffective to protect the patient, a staff member, or others from harm (A-0164), failed to ensure that the type of restraint used was the least restrictive (A-0165), and failed to implement safe and appropriate restraint and seclusion techniques as determined by hospital policy (A-0165) in four of four medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review of facility policy, "Patient Rights and Responsibilities," approved May 2008 revealed "III. Procedure ... 28. The patient has right to be free from any form of restraint (physical restraint or drugs used as a restraint) that is not medically necessary or is used as a means of coercion, discipline, convenience, or retaliation by staff."

Review of facility policy "Code Orange Response and Reporting," approved December 2006 revealed "IV. A. When a Code Orange situation is announced, all security officers at that facility will respond to the location of the Code Orange situation. B. Security Officers will adhere to guidelines established in the Code Orange Response Plan ... when handling patients during a Code Orange situation."

Review of facility policy "Code Orange Response Plan," approved June April 2006 revealed "B. Response to Code Orange condition ... 4. Intervention strategies for patients include: a. verbally encouraging the patient to gain control of behavior. b. physically taking the patient to his/her room; c. remove patient to a seclusion room or quiet area; d. physically restrain the patient only as a last resort ... D. Request for Assistance - Municipal Police Department 1. Request assistance from municipal police department when an individual: A. has a weapon in his/her possession; b. is holding another individual hostage; c. is extremely violent; or d. when additional response to Code Orange is necessary."

Review of facility policy "Restraint and Seclusion for Behavioral Management," approved March 2010 revealed that "I. Policy patients have a right to a safe environment. Staff will intervene to protect patients from harming themselves or others. In an effort to prevent, reduce and strive to eliminate the use of restraints and seclusion, least restrictive alternatives/interventions to seclusion/restraint use will be attempted first. When these measures are ineffective or no longer feasible, seclusion/restraint may be utilized following established policies and procedures. The least restrictive method of seclusion/restraint that meets the patient's assessed needs will be utilized. Patient's rights, dignity, well being, and safety will be supported and maintained ... The use of restricted devices applied by law enforcement officials, such as handcuffs, is not governed by this policy."

Review of facility policy "M26 and X26 Taser" revised September 2007 revealed "I. Policy Statement ... It is the mission of the Lehigh Valley Hospital Security Department to provide for the protection of patients, visitors, physicians, and staff members, and to reduce the number of injuries from physical confrontations with violent persons. The Security Department in concert with this mission will employ the LEAST RESTRICTIVE means to control patient behaviors and to assure the health and safety of anyone on hospital property. This requires effective staff training and ongoing monitoring and assessment of use of restraints. Taser-Certified Security Department personnel will have the ability to employ non-lethal force, by means of the M26 or X26 Taser ... In accordance with CMS guidance, the use of Taser, Stun guns or like weapons against patients is not permitted ... ... III. Definitions ... M26 or X26 Taser A non-lethal handheld electronic control device, which fires two probes up to a distance of 35 feet. The electrical signal overrides the central nervous system and directly controls the skeletal muscles. This neuromuscular incapacitation causes an uncontrollable contraction of the muscle tissue, which temporarily debilitate the target. The Taser can also be touched to the subject, in a technique called a Drive Stun, causing the same, or a lesser effect ... 3. Applications ... c. when a Taser is deployed on an individual, a security officer will immediately handcuff the subject to minimize the likelihood that any further use of force will be required ... the appropriate law enforcement agency will immediately be called and charges will be filed. "

Review of facility policy "Use of Force," revised December 2006 revealed "IV. Procedure A. Security personnel who are without fault may use such force as reasonably appears necessary to protect himself/herself or a third part from the imminent use of unlawful force upon themselves and/or the third party. B. The danger of harm must be a present one. There is no right to use force if harm is merely threatened at a future time of if the "attacker" has no present ability to carry out the threat. c. Security personnel may use only the force that reasonable appears necessary to effectively bring an incident under control. D. Crime Prevention 1. Security personnel may use force to the extent that it reasonably appears necessary to prevent a felony, riot, or other serious breech of peace. 2. Security personnel may use force to apprehend a fleeing felon. The force used to apprehend must be objectively reasonable."

1) Review of MR1, MR2, MR3 and MR4 revealed that these patients had a behavorial dyscontrol event on August 26, 2010, August 19, 2010, August 31, 2010, and December 31, 2008, respectively and were subject to a Taser discharge by Security staff. Further review of MR1, MR2, MR3 and MR4 revealed no documented evidence that the facility staff failed to implement restraints or seclusion when less restrictive interventions were determined to be ineffective to protect the patient, a staff member, or others from harm, and failed to implement safe and appropriate restraint and seclusion techniques by using a Taser discharge (A-144, A-164, A-165, and A-167).

2) Interview with EMP1 on September 9, 2010, at approximately 4:00 PM confirmed the Taser discharge or Taser drive stun events for MR1, MR2, MR3 and MR4 and that there was no documented evidence that restraints or seclusion were implemented prior to the use of the Taser. EMP1 further confirmed that "if the staff is threatened with harm, then Security takes over and at that point the event becomes a law enforcement action and it is not a health care intervention."


Cross Reference
482.13 (c) (2) The patient has a right to receive care in a safe setting
482.13 (e) Restraint or seclusion
482.13 (e) (2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff member, or others from harm.
482.13 (e) (3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm.

Based on review of facility policies and procedures, review of facility document, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that patients received care in a safe setting in four of four medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review of facility policy "Patient Rights and Responsibilities," approved May 2008 revealed "III. Procedure ... 28. the patient has right to be free from any form of restraint (physical restraint or drugs used as a restraint) that is not medically necessary or is used as a means of coercion, discipline, convenience, or retaliation by staff. 29. The patient has the right to personal privacy, to receive care in a safe setting and to be free from all forms of abuse or harassment."

Review of facility policy "Code Orange Response and Reporting," approved December 2006 revealed "IV. A. When a Code Orange situation is announced, all security officers at that facility will respond to the location of the Code Orange situation. B. Security Officers will adhere to guidelines established in the Code Orange Response Plan ... when handling patients during a Code Orange situation."

Review of facility policy "Code Orange Response Plan," approved June 2006 revealed "B. Response to Code Orange condition ... 4. Intervention strategies for patients include: a. verbally encouraging the patient to gain control of behavior. b. physically taking the patient to his/her room; c. remove patient to a seclusion room or quiet area; d. physically restrain the patient only as a last resort ... D. Request for Assistance - Municipal Police Department 1. Request assistance from municipal police department when an individual: A. has a weapon in his/her possession; b. is holding another individual hostage; c. is extremely violent; or d. when additional response to Code Orange is necessary."

Review of facility policy "Restraint and Seclusion for Behavioral Management," approved March 2010 revealed that "I. Policy patients have a right to a safe environment. Staff will intervene to protect patients from harming themselves or others. In an effort to prevent, reduce and strive to eliminate the use of restraints and seclusion, least restrictive alternatives/interventions to seclusion/restraint use will be attempted first. When these measures are ineffective or no longer feasible, seclusion/restraint may be utilized following established policies and procedures. The least restrictive method of seclusion/restraint that meets the patient's assessed needs will be utilized. Patient's rights, dignity, well being, and safety will be supported and maintained ... The use of restricted devices applied by law enforcement officials, such as handcuffs, is not governed by this policy."

Review of facility policy "M26 and X26 Taser" revised September 2007 revealed "I. Policy Statement ... It is the mission of the Lehigh Valley Hospital Security Department to provide for the protection of patients, visitors, physicians, and staff members, and to reduce the number of injuries from physical confrontations with violent persons. The Security Department in concert with this mission will employ the LEAST RESTRICTIVE means to control patient behaviors and to assure the health and safety of anyone on hospital property. This requires effective staff training and ongoing monitoring and assessment of use of restraints. Taser-Certified Security Department personnel will have the ability to employ non-lethal force, by means of the M26 or X26 Taser ... In accordance with CMS guidance, the use of Taser, Stun guns or like weapons against patients is not permitted ... ... III. Definitions ... M26 or X26 Taser A non-lethal handheld electronic control device, which fires two probes up to a distance of 35 feet. The electrical signal overrides the central nervous system and directly controls the skeletal muscles. This neuromuscular incapacitation causes an uncontrollable contraction of the muscle tissue, which temporarily debilitate the target. The Taser can also be touched to the subject, in a technique called a Drive Stun, causing the same, or a lesser effect ... 3. Applications ... c. when a Taser is deployed on an individual, a security officer will immediately handcuff the subject to minimize the likelihood that any further use of force will be required ... the appropriate law enforcement agency will immediately be called and charges will be filed. "

Review of facility policy "Use of Force," revised December 2006 revealed "IV. Procedure A. Security personnel who are without fault may use such force as reasonably appears necessary to protect himself/herself or a third part from the imminent use of unlawful force upon themselves and/or the third party. B. The danger of harm must be a present one. There is no right to use force if harm is merely threatened at a future time of if the "attacker" has no present ability to carry out the threat. c. Security personnel may use only the force that reasonable appears necessary to effectively bring an incident under control. D. Crime Prevention 1. Security personnel may use force to the extent that it reasonably appears necessary to prevent a felony, riot, or other serious breech of peace. 2. Security personnel may use force to apprehend a fleeing felon. The force used to apprehend must be objectively reasonable."

1) Review of facility document "CEO Report to Board of Trustees," dated March 2007 revealed "effective June 1, we will equip all our security officers with ... Taser electric stun guns."

2) Review of MR1, MR2, MR3 and MR4 revealed all these patients had a behavorial dyscontrol event between December 16, 2008, and August 26, 2010, and were the subject of a Taser discharge or Taser drive stun. Further review of MR1, MR2, MR3 and MR4 revealed no documented evidence that restraints or seclusion were implemented prior to the use of a Taser discharge or Taser drive stun.

3) Interview with EMP1 on September 9, 2010, at approximately 4:00 PM confirmed a Taser discharge or Taser drive stun was used by Security staff on each patient in MR1, MR2, MR3 and MR4 and that there was no documented evidence that restraints or seclusion was implemented until after the Taser event occurred.

Based on review of review of facility policies and procedures, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to implement restraints or seclusion when less restrictive interventions were determined to be ineffective to protect the patient, a staff member, or others from harm in four of four medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review of facility policy, "Patient Rights and Responsibilities," approved May 2008 revealed "III. Procedure ... 28. The patient has right to be free from any form of restraint (physical restraint or drugs used as a restraint) that is not medically necessary or is used as a means of coercion, discipline, convenience, or retaliation by staff."

Review of facility policy "Code Orange Response and Reporting," approved December 2006 revealed "IV. A. When a Code Orange situation is announced, all security officers at that facility will respond to the location of the Code Orange situation. B. Security Officers will adhere to guidelines established in the Code Orange Response Plan ... when handling patients during a Code Orange situation."

Review of facility policy "Code Orange Response Plan," approved June 2006 revealed "B. Response to Code Orange condition ... 4. Intervention strategies for patients include: a. verbally encouraging the patient to gain control of behavior. b. physically taking the patient to his/her room; c. remove patient to a seclusion room or quiet area; d. physically restrain the patient only as a last resort ... D. Request for Assistance - Municipal Police Department 1. Request assistance from municipal police department when an individual: A. has a weapon in his/her possession; b. is holding another individual hostage; c. is extremely violent; or d. when additional response to Code Orange is necessary."

Review of facility policy "Restraint and Seclusion for Behavioral Management," approved March revealed that "I. Policy patients have a right to a safe environment. Staff will intervene to protect patients from harming themselves or others. In an effort to prevent, reduce and strive to eliminate the use of restraints and seclusion, least restrictive alternatives/interventions to seclusion/restraint use will be attempted first. When these measures are ineffective or no longer feasible, seclusion/restraint may be utilized following established policies and procedures. The least restrictive method of seclusion/restraint that meets the patient's assessed needs will be utilized. Patient's rights, dignity, well being, and safety will be supported and maintained ... The use of restricted devices applied by law enforcement officials, such as handcuffs, is not governed by this policy."

Review of facility policy "M26 and X26 Taser" revised September 2007 revealed "I. Policy Statement ... It is the mission of the Lehigh Valley Hospital Security Department to provide for the protection of patients, visitors, physicians, and staff members, and to reduce the number of injuries from physical confrontations with violent persons. The Security Department in concert with this mission will employ the LEAST RESTRICTIVE means to control patient behaviors and to assure the health and safety of anyone on hospital property. This requires effective staff training and ongoing monitoring and assessment of use of restraints. Taser-Certified Security Department personnel will have the ability to employ non-lethal force, by means of the M26 or X26 Taser ... In accordance with CMS guidance, the use of Taser, Stun guns or like weapons against patients is not permitted ... ... III. Definitions ... M26 or X26 Taser A non-lethal handheld electronic control device, which fires two probes up to a distance of 35 feet. The electrical signal overrides the central nervous system and directly controls the skeletal muscles. This neuromuscular incapacitation causes an uncontrollable contraction of the muscle tissue, which temporarily debilitate the target. The Taser can also be touched to the subject, in a technique called a Drive Stun, causing the same, or a lesser effect ... 3. Applications ... c. when a Taser is deployed on an individual, a security officer will immediately handcuff the subject to minimize the likelihood that any further use of force will be required ... the appropriate law enforcement agency will immediately be called and charges will be filed. "

Review of facility policy "Use of Force," revised December 2006 revealed "IV. Procedure A. Security personnel who are without fault may use such force as reasonably appears necessary to protect himself/herself or a third part from the imminent use of unlawful force upon themselves and/or the third party. B. The danger of harm must be a present one. There is no right to use force if harm is merely threatened at a future time of if the "attacker" has no present ability to carry out the threat. c. Security personnel may use only the force that reasonable appears necessary to effectively bring an incident under control. D. Crime Prevention 1. Security personnel may use force to the extent that it reasonably appears necessary to prevent a felony, riot, or other serious breech of peace. 2. Security personnel may use force to apprehend a fleeing felon. The force used to apprehend must be objectively reasonable."

1) Review of MR1 revealed that the patient had a behavorial dyscontrol event on August 26, 2010, and was subject to a Taser discharge by Security staff. Review of documentation for MR1 revealed that the patient was medicated with Ativan 2 mg IV three times between 00:10 and 00:46; Haldol 5 mg IV between 00:10 and 01:37; Valium 10 mg IV at 00:46 and 01:37 and was still agitated at 02:07. The Security staff was at the patient's ED bay during this two hour period and the patient was told repeatedly to stay in his room. The patient pulled out his intravenous (IV) catheter and came at the security staff at which time the security staff tasered the patient, after which the patient was placed in soft restraints. Review of physician documentation revealed the patient "needed sedation/general anesthesia for safety." The patient was intubated and admitted to the Medica/Surgical Intensive Care Unit.

2) Review of MR2 revealed this patient had a behavorial dyscontrol event on August 19, 2010, and was subject to a Taser stun and a discharge and a by Security staff. Documentation reviewed revealed the patient had refused to sign a transfusion consent unless the physician was at his bedside, due to concerns about getting an infection. The patient became agitated, and began yelling in another language at staff. A Code Orange was called by nursing staff to which security responded. The patient was using an IV pole as a weapon and had barricaded himself in the restroom. Review of Security documented revealed that staff attempted to verbally encourage the patient to gain control, without success. There is no documentation that restraint or seclusion was attempted. The patient became more agitated and a drive stun and one discharge was applied. The patient was then placed in handcuffs by security staff and brought to the ED for probe removal. The patient was then placed on 1:1 staff supervision. Further review of security documentation revealed that local police arrived on the scene after the event and took a report of the incident.

3) Review of MR3 revealed this patient had a behavorial dyscontrol event on August 31, 2009, and was subject to a Taser drive stun by Security staff. Documentation revealed the patient was quiet on arrival to the ED and then ran out of the room, slamming the door and hitting the wall and yelling. The patient was unable to be redirected. Review of the Security Report for MR3 revealed that the security staff responded to the patient who was barricaded in a room. The officer entered the room and tried to use verbal commands that were unsuccessful. The patient continued to be irate and noncompliant and started swing at the officer who intercepted the patient's punches and took the patient to the ground. A second security staff arrived to assist the first officer. The patient began fighting with both officers and at that time the second officer drive stunned the patient with a Taser. The patient was given medication and placed in 4 point restraints and a waist restraint, after the drive stun. Local police arrived to press charges.

4) Review of MR4 revealed this patient had a behavorial dyscontrol event on December 16, 2008, and was subject to a Taser discharge by Security staff. Review of the Security Report for MR4 revealed the patient was eloping from the ED and security staff pursued the patient. for fear that the patient would harm himself or others. Local police were requested for help. The patient pushed a security officer who fell onto the road then the patient began to strike the officer with his fist and began to grab for the officer's belt containing pepper spray and Taser. When told to step away from the officer a second officer warned the patient of the Taser three times before discharging the Taser into the patient. The patient was returned to the ED. Medications were given and restraints and a cervical collar were applied at that time.

5) Interview with EMP1 on September 9, 2010, at approximately 4:00 PM confirmed the Taser discharge or Taser drive stun events for MR1, MR2, MR3 and MR4 and that there was no documented evidence that restraints or seclusion was attempted prior to the use of the Taser. When questioned as to why restraints or seclusion was not implemented, EMP1 stated, "... a Code Orange is called after all medical interventions are exhausted first." EMP1 further stated that each patient in MR1, MR2, MR3 and MR4 "escalated quickly and were considered a behavior dyscontrol event and that if the staff is threatened with harm, then Security takes over and at that point the event becomes a law enforcement action and it is not a health care intervention."

Based on review of facility policy and procedures, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that the type or technique of restraint or seclusion used was the least restrictive intervention that was effective to protect the patient or others from harm for patients that had been subject to a Taser discharge or Taser drive stun in four of four medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review of facility policy, "Patient Rights and Responsibilities," approved May 2008 revealed "III. Procedure ... 28. The patient has right to be free from any form of restraint (physical restraint or drugs used as a restraint) that is not medically necessary or is used as a means of coercion, discipline, convenience, or retaliation by staff."

Review of facility policy "Code Orange Response and Reporting," approved December 2006 revealed "IV. A. When a Code Orange situation is announced, all security officers at that facility will respond to the location of the Code Orange situation. B. Security Officers will adhere to guidelines established in the Code Orange Response Plan ... when handling patients during a Code Orange situation."

Review of facility policy "Code Orange Response Plan," approved June 2006 revealed "B. Response to Code Orange condition ... 4. Intervention strategies for patients include: a. verbally encouraging the patient to gain control of behavior. b. physically taking the patient to his/her room; c. remove patient to a seclusion room or quiet area; d. physically restrain the patient only as a last resort ... D. Request for Assistance - Municipal Police Department 1. Request assistance from municipal police department when an individual: A. has a weapon in his/her possession; b. is holding another individual hostage; c. is extremely violet; or d. when additional response to Code Orange is necessary."

Review of facility policy "Restraint and Seclusion for Behavioral Management," approved March 2010 revealed that "I. Policy patients have a right to a safe environment. Staff will intervene to protect patients from harming themselves or others. In an effort to prevent, reduce and strive to eliminate the use of restraints and seclusion, least restrictive alternatives/interventions to seclusion/restraint use will be attempted first. When these measures are ineffective or no longer feasible, seclusion/restraint may be utilized following established policies and procedures. The least restrictive method of seclusion/restraint that meets the patient's assessed needs will be utilized. Patient's rights, dignity, well being, and safety will be supported and maintained ... The use of restricted devices applied by law enforcement officials, such as handcuffs, is not governed by this policy."

Review of facility policy "M26 and X26 Taser" revised September 2007 revealed "I. Policy Statement ... It is the mission of the Lehigh Valley Hospital Security Department to provide for the protection of patients, visitors, physicians, and staff members, and to reduce the number of injuries from physical confrontations with violent persons. The Security Department in concert with this mission will employ the LEAST RESTRICTIVE means to control patient behaviors and to assure the health and safety of anyone on hospital property. This requires effective staff training and ongoing monitoring and assessment of use of restraints. Taser-Certified Security Department personnel will have the ability to employ non-lethal force, by means of the M26 or X26 Taser ... In accordance with CMS guidance, the use of Taser, Stun guns or like weapons against patients is not permitted ... ... III. Definitions ... M26 or X26 Taser A non-lethal handheld electronic control device, which fires two probes up to a distance of 35 feet. The electrical signal overrides the central nervous system and directly controls the skeletal muscles. This neuromuscular incapacitation causes an uncontrollable contraction of the muscle tissue, which temporarily debilitate the target. The Taser can also be touched to the subject, in a technique called a Drive Stun, causing the same, or a lesser effect ... 3. Applications ... c. when a Taser is deployed on an individual, a security officer will immediately handcuff the subject to minimize the likelihood that any further use of force will be required ... the appropriate law enforcement agency will immediately be called and charges will be filed. "

Review of facility policy "Use of Force," revised December 2006 revealed "IV. Procedure A. Security personnel who are without fault may use such force as reasonably appears necessary to protect himself/herself or a third part from the imminent use of unlawful force upon themselves and/or the third party. B. The danger of harm must be a present one. There is no right to use force if harm is merely threatened at a future time of if the "attacker" has no present ability to carry out the threat. c. Security personnel may use only the force that reasonable appears necessary to effectively bring an incident under control. D. Crime Prevention 1. Security personnel may use force to the extent that it reasonably appears necessary to prevent a felony, riot, or other serious breech of peace. 2. Security personnel may use force to apprehend a fleeing felon. The force used to apprehend must be objectively reasonable."

1) Review of MR1 revealed that the patient had a behavorial dyscontrol event on August 26, 2010, and was subject to a Taser discharge by Security staff. Review of documentation for MR1 revealed that the patient was medicated with Ativan 2 mg IV three times between 00:10 and 00:46; Haldol 5 mg IV between 00:10 and 01:37; Valium 10 mg IV at 00:46 and 01:37 and was still agitated at 02:07. The Security staff was at the patient's ED bay during this two hour period and the patient was told repeatedly to stay in his room. The patient pulled out his intravenous (IV) catheter and came at the security staff at which time the security staff tasered the patient, after which the patient was placed in soft restraints. Review of physician documentation revealed the patient "needed sedation/general anesthesia for safety." The patient was intubated and admitted to the Medica/Surgical Intensive Care Unit. .
2) Review of MR2 revealed this patient had a behavorial dyscontrol event on August 19, 2010, and was subject to a Taser stun and a discharge and a by Security staff. Documentation reviewed revealed the patient had refused to sign a transfusion consent unless the physician was at his bedside, due to concerns about getting an infection. The patient became agitated, and began yelling in another language at staff. A Code Orange was called by nursing staff to which security responded. The patient was using an IV pole as a weapon and had barricaded himself in the restroom. Review of Security documented revealed that staff attempted to verbally encourage the patient to gain control, without success. There is no documentation that restraint or seclusion was attempted. The patient became more agitated and a drive stun and one discharge was applied. The patient was then placed in handcuffs by security staff and brought to the ED for probe removal. The patient was then placed on 1:1 staff supervision. Further review of security documentation revealed that local police arrived on the scene after the event and took a report of the incident.

3) Review of MR3 revealed this patient had a behavorial dyscontrol event on August 31, 2009, and was subject to a Taser drive stun by Security staff. Documentation revealed the patient was quiet on arrival to the ED and then ran out of the room, slamming the door and hitting the wall and yelling. The patient was unable to be redirected. Review of the Security Report for MR3 revealed that the security staff responded to the patient who was barricaded in a room. The officer entered the room and tried to use verbal commands that were unsuccessful. The patient continued to be irate and noncompliant and started swing at the officer who intercepted the patient's punches and took the patient to the ground. A second security staff arrived to assist the first officer. The patient began fighting with both officers and at that time the second officer drive stunned the patient with a Taser. The patient was given medication and placed in 4 point restraints and a waist restraint, after the drive stun. Local police arrived to press charges.

4) Review of MR4 revealed this patient had a behavorial dyscontrol event on December 16, 2008, and was subject to a Taser discharge by Security staff. Review of the Security Report for MR4 revealed the patient was eloping from the ED and security staff pursued the patient. for fear that the patient would harm himself or others. Local police were requested for help. The patient pushed a security officer who fell onto the road then the patient began to strike the officer with his fist and began to grab for the officer's belt containing pepper spray and Taser. When told to step away from the officer a second officer warned the patient of the Taser three times before discharging the Taser into the patient. The patient was returned to the ED. Medications were given and restraints and a cervical collar were applied at that time.

5) Interview with EMP1 on September 9, 2010, at approximately 4:00 PM confirmed the Taser discharge or Taser drive stun events for MR1, MR2, MR3 and MR4 and that there was no documented evidence that restraints or seclusion was attempted prior to the use of the Taser. When questioned as to why restraints or seclusion was not implemented, EMP1 stated, "... a Code Orange is called after all medical interventions are exhausted first." EMP1 further stated that each patient in MR1, MR2, MR3 and MR4 "escalated quickly and were considered a behavior dyscontrol event and that if the staff is threatened with harm, then Security takes over and at that point the event becomes a law enforcement action and it is not a health care intervention."

Based on review of Pennsylvania Department of Health's provider message board information, review of facility policies and procedures, review of medical records (MR), and interviews with facility staff (EMP), it was determined that the facility failed to implement safe and appropriate restraint and seclusion techniques as determined by hospital policy and in accordance with the Pennsylvania Department of Health's message board statement for patients that had been subject to a Taser discharge or Taser drive stun in four of four medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

Review of Pennsylvania Department of Health - Division of Acute and Ambulatory Care - "Message Board" notice to providers dated July 28, 2005, revealed, "The attached article reports on consequences of use of Taser in a California hospital. Pennsylvania hospitals are expected to employ the LEAST RESTRICTIVE means to control patient behaviors and to assure the health and safety of anyone on hospital property. This requires effective staff training and ongoing monitoring and assessment of all use of restraints and seclusion. The use of Taser, stun gun or like weapons against patients is not permitted."

Review of facility policy, "Patient Rights and Responsibilities," approved May 2008 revealed "III. Procedure ... 28. The patient has right to be free from any form of restraint (physical restraint or drugs used as a restraint) that is not medically necessary or is used as a means of coercion, discipline, convenience, or retaliation by staff."

Review of facility policy "Code Orange Response and Reporting," approved December 2006 revealed "IV. A. When a Code Orange situation is announced, all security officers at that facility will respond to the location of the Code Orange situation. B. Security Officers will adhere to guidelines established in the Code Orange Response Plan ... when handling patients during a Code Orange situation."

Review of facility policy "Code Orange Response Plan," approved June 2006 revealed "B. Response to Code Orange condition ... 4. Intervention strategies for patients include: a. verbally encouraging the patient to gain control of behavior. b. physically taking the patient to his/her room; c. remove patient to a seclusion room or quiet area; d. physically restrain the patient only as a last resort ... D. Request for Assistance - Municipal Police Department 1. Request assistance from municipal police department when an individual: A. has a weapon in his/her possession; b. is holding another individual hostage; c. is extremely violent; or d. when additional response to Code Orange is necessary."

Review of facility policy "Restraint and Seclusion for Behavioral Management," approved March 2010 revealed that "I. Policy patients have a right to a safe environment. Staff will intervene to protect patients from harming themselves or others. In an effort to prevent, reduce and strive to eliminate the use of restraints and seclusion, least restrictive alternatives/interventions to seclusion/restraint use will be attempted first. When these measures are ineffective or no longer feasible, seclusion/restraint may be utilized following established policies and procedures. The least restrictive method of seclusion/restraint that meets the patient's assessed needs will be utilized. Patient's rights, dignity, well being, and safety will be supported and maintained ... The use of restricted devices applied by law enforcement officials, such as handcuffs, is not governed by this policy."

Review of facility policy "M26 and X26 Taser" revised September 2007 revealed "I. Policy Statement ... It is the mission of the Lehigh Valley Hospital Security Department to provide for the protection of patients, visitor, physicians, and staff members, and to reduce the number of injuries from physical confrontations with violent persons. The Security Department in concert with this mission will employ the LEAST RESTRICTIVE means to control patient behaviors and to assure the health and safety of anyone on hospital property. This requires effective staff training and ongoing monitoring and assessment of use of restraints. Taser-Certified Security Department personnel will have the ability to employ non-lethal force, by means of the M26 or X26 Taser ... In accordance with CMS guidance, the use of Taser, Stun guns or like weapons against patients is not permitted ... ... III. Definitions ... M26 or X26 Taser A non-lethal handheld electronic control device, which fires two probes up to a distance of 35 feet. The electrical signal overrides the central nervous system and directly controls the skeletal muscles. This neuromuscular incapacitation causes an uncontrollable contraction of the muscle tissue, which temporarily debilitate the target. The Taser can also be touched to the subject, in a technique called a Drive Stun, causing the same, or a lesser effect ... 3. Applications ... c. when a Taser is deployed on an individual, a security officer will immediately handcuff the subject to minimize the likelihood that any further use of force will be required ... the appropriate law enforcement agency will immediately be called and charges will be filed. "

Review of facility policy "Use of Force," revised December 2006 revealed "IV. Procedure A. Security personnel who are without fault may use such force as reasonably appears necessary to protect himself/herself or a third part from the imminent use of unlawful force upon themselves and/or the third party. B. The danger of harm must be a present one. There is no right to use force if harm is merely threatened at a future time of if the "attacker" has no present ability to carry out the threat. c. Security personnel may use only the force that reasonable appears necessary to effectively bring an incident under control. D. Crime Prevention 1. Security personnel may use force to the extent that it reasonably appears necessary to prevent a felony, riot, or other serious breech of peace. 2. Security personnel may use force to apprehend a fleeing felon. The force used to apprehend must be objectively reasonable."

1) Review of MR1 revealed that the patient had a behavorial dyscontrol event on August 26, 2010, and was subject to a Taser discharge by Security staff. Review of documentation for MR1 revealed that the patient was medicated with Ativan 2 mg IV three times between 00:10 and 00:46; Haldol 5 mg IV between 00:10 and 01:37; Valium 10 mg IV at 00:46 and 01:37 and was still agitated at 02:07. The Security staff was at the patient's ED bay during this two hour period and the patient was told repeatedly to stay in his room. The patient pulled out his intravenous (IV) catheter and came at the security staff at which time the security staff tasered the patient, after which the patient was placed in soft restraints. Review of physician documentation revealed the patient "needed sedation/general anesthesia for safety." The patient was intubated and admitted to the Medica/Surgical Intensive Care Unit.

2) Review of MR2 revealed this patient had a behavorial dyscontrol event on August 19, 2010, and was subject to a Taser stun and a discharge and a by Security staff. A Code Orange was called by nursing staff to which security responded. The patient was using an IV pole as a weapon and had barricaded himself in the restroom. Review of Security documentation for MR2 revealed that Code Orange techniques were attempted but the patient became more agitated and fearing he would cause serious bodily injury to security with the IV pole, a drive stun and one discharge was applied. The patient was placed in handcuffs by security staff and taken to the ED for probe removal and was placed on 1:1 staff supervision. Further review of security documentation revealed that local police arrived on the scene after the event and took a report of the incident.

3) Review of MR3 revealed this patient had a behavorial dyscontrol event on August 31, 2009, and was subject to a Taser drive stun by Security staff. Review of the Security Report for MR3 revealed that the security staff responded to the patient who was barricaded in a room. The officer entered the room and tried to use verbal commands that were unsuccessful. When the patient continued to be irate and noncompliance and started swing at the officer; he intercepted the patient's punches and took the patient to the ground. A second security staff arrived to assist the first officer. The patient began fighting with both officers and at that time the second officer drive stunned the patient with a Taser. The patient required additional medication and was placed in restraints after the drive stun. Local police arrived to press charges.

4) Review of MR4 revealed this patient had a behavorial dyscontrol event on December 16, 2008, and was subject to a Taser discharge by Security staff. Review of the "Security Report" for MR4 revealed the patient was eloping from the ED and security staff chased the patient for fear of the patient harming himself or others. Local police were requested for help. The patient pushed a security officer who fell onto the road then the patient began to strike the officer with his fist and began to grab for the officer's belt containing his pepper spray and Taser. When the patient was told to step away from the officer a second officer warned him of the Taser three times before discharging the Taser into the patient. The patient was returned to the ED, medications were given, restraints and a cervical collar were applied at that time.

5) Interview with EMP1 on September 9, 2010, at approximately 4:00 PM confirmed the Taser events for MR1, MR2, MR3 and MR4. EMP1 confirmed that "when a Code Orange is called all medical interventions are exhausted first." When questioned as to why restraints or seclusion was not implemented, EMP1 stated, "... a Code Orange is called after all medical interventions are exhausted first." Further interview with EMP1 confirmed there was no documented evidence that restraints or seclusion was applied prior to the use the Taser. EMP1 confirmed that "if the staff is threatened with harm, then Security takes over and at that point the event becomes a law enforcement action and it is not a health care intervention."