HospitalInspections.org

Based on a review of the hospital oversight of security staff, restraint policy, job description for employed off-duty police officers (ODPO), and the hospital use of force policy, it was determined that the hospital failed to 1) identify that the use of "Forensic restrictions" (hand cuffs and other) were forms of restraint; 2) identify ODPO weaponry as restraints and the likelihood and freedom of the ODPO to use hand cuffs as restraint; 3) define the role of clinicians to assess the need for healthcare restraints in those presenting in handcuffs, and; 4) provide a Use of Force (UOF) policy in which clinical decision-making and oversight directs to use of manual holds by security.

1) Hospital "Behavioral Health Services Restraints For Violent/Self-Destructive Behavior (Original Date 11/17/2016)" revealed in part, "2.6. The following are not considered restraints: 2.6.1. Forensic and correction restrictions used by law enforcement personnel." This meant that clinicians were not required to view handcuffs (and other restricting police weaponry) as restraints.

2) The hospital employs ODPO who work in full uniform and carry police weaponry such as guns, hand-cuffs, and other police weaponry. ODPOs are positioned at the entrance of the emergency department, and make walking rounds of hospital areas. Review of the ODPO job description revealed no provision for ODPOs to restrain. However, the job description also included in part, "Monitors conduct of patients and visitors on hospital premises; confronts unauthorized persons for questioning as needed ...Makes an arrest when needed." While ODPO's do not have a job description provision for restraint, other job description elements reveal an unrealistic expectation that the ODPO would not have occasion to restrain.

The combined information of the restraint policy and ODPO job description meant that the ODPO could freely, and without clinical decision-making or oversight, use handcuffs (or other weaponry) for restraint purposes. This existed in the daily setting of patients presenting with behavioral health and medical conditions which produce acting-out behaviors that may require restraint processes during treatment. While some individuals who act-out on hospital premises may not be patients, it was not within the scope of the ODPO to make determinations of who was and was not a patient, a decision usually necessitating clinical oversight for which no provision in policy or job description was noted.

3) Additionally, for patients who presented to the hospital under community police escort while in handcuffs, clinical staff had a responsibility to assess for transition to healthcare restraints. However, by restraint policy definition, clinical staff could ignore the handcuffs on a patient. Further, it was not necessary to determine if a patient was under police arrest or detention. Finally, clinical staff had no responsibility to transition patients not under arrest to healthcare restraint, or to release the patient from all restraints.

4) A Use of Force policy (UOF) (effective September 29, 2014) revealed in part under Use of Force Continuum: "(Hospital) Security is present to assist patient care staff and is not to assume control of the medical incident. Unit specific patient care staff should be present throughout the incident to provide direction and observation. However, if the situation changes to the point that harm can occur to our staff or patients officer shall then assume control to prevent injury to others". This UOF provision departed from the regulatory requirement of clinical decision-making and oversight.

In summary, the mis-identification of police forensic restrictive weaponry as not being a form of restraint allowed a suspension of clinical decision-making for the need to transition a violent patient to hospital-approved healthcare restraints. Further, the UOF policy allowed suspension of clinical decision-making for decision-making of security. Despite a lack of evidence of any injuries occurring with these policies, neither met regulatory requirements for clinical oversight of approved healthcare restraints. This lack of oversight and clinical involvement in patient treatment which created an unsafe environment.