HospitalInspections.org

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Based on interview and review of hospital policies and procedures, the hospital failed to provide for the needs of patients by not having a process to safely hand off a violent or aggressive patient from law enforcement handcuffs into hospital restraints.

Failure to provide a process and procedure to safely transfer a patient from law enforcement handcuffs to hospital restraints risks injury to patients and staff.

Findings included:

1. Review of the hospital policy titled, "Management of Patients at High Risk for Harm to Self or Others," no number, approved 09/22/22, showed that the hospital ensures a safe environment for patients and staff by identifying patients who are at risk of harm to themselves or others, assess behavioral health status, and define the components of safety precautions to assure all patients are provided care in a safe setting.

The policy defined DCR Hold when the Designated Crisis Responder (DCR) identifies a person at risk in the community and sends, via police or family, a patient to the Emergency Department (ED) for evaluation and intervention. These patients are to be treated as high risk for harm to self or others until cleared by the DCR agent.

Patients who score as high risk, will be placed on Direct Observation. High risk score patient safety precautions will include environmental safety check of the room to mitigate ligature risk with items removed and documented, patient must be placed in paper scrubs and documented, removal of patient belongings; to be secured and documented, patient will have an individual assigned to provide direct observation to ensure safety.

2. Review of the complaint subject's medical record (Patient #26) showed that the patient arrived in the ED at 2:32 PM accompanied by law enforcement. The behavioral health assessment nursing note dated 09/11/22 at 3:17 PM, showed that the patient's current safety status included violence to others and elopement risk. Thoughts of violence towards others included threats to kick nursing staff, and that patient stated they would not stay at the hospital. Mental Status Examination showed that the patient was angry, hostile, abusive, aggressive, and agitated. The nursing note dated 09/11/22 at 3:23 PM showed that the patient was observed to elope from the ED at 3:10 PM and was met in parking lot by sheriff's officer. The ED physician note dated 09/11/22 at 3:23 PM showed that the patient was on involuntary hold and was arguing, refusing to change into paper scrubs, or allow vital signs. The patient threatened to hurt the nurse and to get the nurse forcibly out of the room. The patient eloped and law enforcement was notified. Law enforcement picked the patient up in the parking lot and were taking the patient with them. Law enforcement was advised that the patient was threatening the staff and [making an] unsafe situation for the ED staff.

3. On 10/31/22 at 12:19 PM, during an interview with the investigator, a nurse working in the ED (Staff #9) stated that the complaint subject patient (Patient #26) was brought into the ED in handcuffs by a sheriff's deputy. The deputy took the handcuffs off the patient and left the ED. The deputies do not do any safety handoff. The patient refused all treatment or assessment and walked out of the ED. Staff #9 stated that they were told they are not to put hands on a patient unless they are actively hurting someone. Staff #9 also stated that with 2 nurses in the ED, there was no way they could have put the patient into 4 point restraints.

4. On 11/07/22 at 12:30 PM, during an interview with the investigator, the ED Nurse Manager (Staff #3) stated that if a patient is violent, and elopes, the staff are to let the patient go, then notify the DCR and law enforcement dispatch. If the patient was on an involuntary hold, the same process would be followed unless staff could safely restrain the patient. There is no policy or process in place for handoff from law enforcement handcuffs to hospital restraints for potentially violent patients.

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