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Based on interview and document review, the facility failed to ensure 1 of 10 patients (P1) was free from abuse when a security officer (SO)-A punched P1 in the back of the head three times.

As a result of these failures, the deficient practices resulted in an immediate jeopardy (IJ). The hospital was found out of compliance with Condition of Participation Patient Rights at 42 CFR 482.13.

The IJ began on 8/29/24 at approximately 9:26 p.m. when SO-A and SO-B responded to a staff request for assistance to place P1 into restraints. P1 was agitated and refused to cooperate with staff and security officers. P1 bit SO-A after being placed into a manual hold, and would not release the bite. SO-A punched P1 in the back of the head three times to get P1 to release the bite. On 9/13/24 at 4:30 p.m. the hospital president, chief nursing officer, accreditation and regulatory compliance manager, patient safety manager, director of security, patient safety specialist, and senior director of regulatory and quality were notified of the IJ.

The immediate jeopardy that began on 9/13/24, was removed on 9/16/24, when it was verified the facility implemented the following corrective actions with updating Preventing, Identifying, Investigating, and Reporting Maltreatment of a Vulnerable Adult policy to integrate with the Security Officer Use of Force Interventions policy and include education of security officers about said policies. Updated the Use of Force policy to distinguish between offensive and defensive force, identify that offensive force is prohibited, prohibit the use of closed handed strikes, and created a Managing Violence in the Care Environment reference document. Re-educated all security officer regarding abuse prevention, use of restraints, approved and non-approved methods of force to subdue patients, and related policy revisions prior to starting their next shift. Completed security officer attestations of the receipt and understanding of this education. This was verified through observation, interview and document review.

Findings include:

See A-0145: Based on interview and document review, the facility failed to ensure 1 of 10 patients (P1) was free from abuse when a security officer (SO)-A punched P1 in the back of the head three times.

Based on interview and document review, the facility failed to ensure 1 of 10 patients (P1) was free from abuse when a security officer (SO)-A punched P1 in the back of the head three times during an incident.

Findings include:

On 8/30/24, a Vulnerable Adult Maltreatment Report submitted by the hospital outlined P1 was admitted to a medical unit for evaluation/treatment following a jump from a second floor and self-inflicted lacerations on 8/28/24. On 8/29/24, P1 was agitated (kicking, yelling, spitting) and required restraints to prevent self-harm and/or harm to others. P1 arrived to the mental health unit at 4:15 p.m. in restraints, was transferred to a restraint chair and then was transitioned to seclusion at 8:45 p.m. While in seclusion, P1 attempted to rip off his cast (on his foot) and a bandage on his neck. Security and staff attempted to intervene at which time P1 assaulted security officer and required physical intervention.

On 8/28/24, an emergency medicine visit note indicated P1 presented to the emergency department (ED) with emergency medical services following a jump out of a two-story building with self-inflicted knife wounds. P1's diagnoses included laceration of neck, closed fracture of nasal bone, right foot fracture and self-inflicted harm/suicidality.

On 8/29/24, a psychiatry consult note indicated P1 also had diagnosis of schizoaffective disorder bipolar type.

On 8/29/24 at 5:08 p.m. a nursing progress note indicated P1 was placed in four-point restraints (restraints on both wrists and both ankles) at 2:45 p.m. due to agitation, uncontrollable thrashing, screaming, and attempting to bite self and staff. P1 was transferred to a mental health unit at 4:00 p.m. and placed into the restraint chair.

On 8/30/24 at 12:56 a.m. a nursing progress note indicated P1 was removed from the restraint chair and placed into the seclusion room at 8:45 p.m. At 9:20 p.m., P1 became irritable, verbally abusive and ignored redirection. Security was called. P1 continued to be agitated and presented clenched fists towards security officers. P1 was placed in a physical hold after lunging at security officers. P1 bit a security guard and would not release the bite.

On 8/30/24 at 2:48 a.m. a facility security report indicated security officers called to assist with P1 in the seclusion room at 9:26 p.m. The narrative text written by SO-A indicated P1 was in the seclusion room tearing off bandages from the wound to his ankle. SO-A and SO-B attempted to place P1 in a hold, but all lost balance and fell on the bed. P1 bit SO-A on the right forearm and would not let go. SO-A "threw 3-4 closed fist punched to the back of [P1's] head, but it was ineffective." SO-A decided to push as hard as he could onto P1's head hoping he would let go of the bite. Eventually, P1 loosened the bite. The narrative text written by SO-B indicated P1 bit SO-A's right forearm and would not let go. The bite became severe, and SO-A did closed fist defensive strikes to the area of the bite. SO-B drew his Taser and yelled, "TASER, TASER, TASER!!" SO-A was able to push off from P1's bite and stepped away. SO-B did not deploy the Taser.

On 9/13/24 at 9:33 a.m. director of security (DS)-A stated the facility had not done an internal investigation of SO-A punching P1. The training currently provided to security officers did not include the use of closed hand strikes. in a follow-up interview at 2:30 p.m. DS-A stated it would have been appropriate to use the Taser or chemical spray on P1 if he had not released the bite, since P1 was actively assaulting SO-A.

On 9/13/24, at 1:56 p.m. SO-B stated he was with SO-A when they were trying to get P1 into the restraint chair. He was ready to deploy his Taser when P1 released the bite on SO-A's arm. He did not receive any re-education from the facility.

On 9/13/24 at 2:32 p.m. senior director of regulatory and quality (DRQ)-A stated the maltreatment of a vulnerable adult policy does not address use of force.

Attempts made to interview SO-A were unsuccessful.

The facility Preventing, Identifying, Investigating, and Reporting Maltreatment of a Vulnerable Adult dated 5/11/23, lacked identification of use of force.