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Based on clinical record review, review of incident report, review of policy and procedure, and interview, it was determined the facility failed to follow its own policies to ensure the patient was free from physical and mental abuse, and free from restraint of any form imposed by coercion in that one (Pt #2) of 10 (#1-10) patients was forcibly placed onto his bed, held down by three Police Officers, and threatened with the use of a Taser which was turned on and placed on Pt #2's chest. The failed practice did not ensure the patient was free from physical and mental abuse, and coercion, and had the likelihood to affect any patient admitted to the Emergency Department. Tag A-0154,

Based on clinical record review, review of incident report, review of policy and procedure, and interview, it was determined that the facility failed to follow its own policies to ensure the patient was free from physical and mental abuse, and free from restraint of any form imposed by coercion in that one (Pt #2) of 10 (#1-10) patients was forcibly placed onto his bed, held down by three Police Officers, and threatened with the use of a Taser which was turned on and placed on Pt #2's chest. The failed practice did not ensure the patient was free from physical, mental abuse and coercion and had the likelihood to affect any patient admitted to the Emergency Department..


Findings:

A. Review of the clinical record on 09/16/2020 at 9:00 AM showed:

1) Pt #2's initial assessment on 07/11/2020 at 2:05 AM, showed that the patient's behavior was calm and cooperative, mood was within defined limits, affect was appropriate to circumstances, and Pt #2 denied thoughts of harming himself or others.

2) Review of the Emergency Department (ED) Physicians Note dated 07/11/20 ( No time, attestation signed by ED Physician #1 on 07/15/2020 at 8:57 AM) showed, Pt #2's Psychiatric/Behavioral was positive for sleep disturbance, negative for agitation, confusion, and suicidal ideas. Physician ED note continued with comment that "a well appearing male walking around the Behavior Emergency Evaluation (BEE) area of the ED a lot. He is able to speak with the provider but does not always answer questions asked. He has pressured speech and appears agitated. (Pt #2) was initially placed on 1 hour hold and then placed on 72 hour hold given Pt is manic. Given his agitation, given IM (intramuscular) Zyprexa. Psychiatry was consulted who stated they believed Pt was safe for d/c (discharge) home and was not holdable at this time."

3) Documentation showed no evidence of Crisis Prevention Intervention (CPI) de-escalation interventions documented in the clinical record.

4) Documentation showed no evidence of a physician's order for restraint.


B. Review of the police report on 07/11/20 from 2:18 AM to 2:55 AM, showed that four officers responded to a request to assist with patient control in the ED.

1) Facility Police Officer #1 documented that "on arrival, I observed a black male in the hallway who was pacing back and forth. Staff stated he had refused the medicinal shot they offered and that the patient later identified as (Named) was becoming agitated and exaggerating his movements. I then requested additional units. (Officer #4), (Officer #2), and (Officer #3) arrived on the scene. (Officer #2) also had "a Taser with him." Once they arrived we entered the hallway and we began to approach (Pt #2). He asked "are ya'll coming for me?" To which I replied, yes. Once I reached his room he put his cellphone in his pocket, which medical staff did not try to confiscate. He then tensed his body when I placed my hand on his left arm after I told him to get in the room. (Pt #2) was standing in the doorway. At this point (Pt #2) was not obeying commands to get in the room and on his bed. I then entered the room and grabbed his right arm. Once in the room (Pt #2) knelt on the ground when (Officer #2) entered the room pointing the Taser at (Pt #2). (Officer #2) told (Pt #2) to get on the bed. (Pt #2) was still passively resisting and refused. (Officer #3) then grabbed hold of his arms and moved him towards the bed. (Officer #3) and I managed to place (Pt #2) on the bed, however (Pt #2) kept moving around. We then got (Pt #2) on his back and (Officer #3) took control of his right arm while I took control of his left by placing him in a wrist lock in order to gain compliance. I also placed my left knee on his left hip in order to prevent him from lifting his body and legs in an attempt to prevent medical staff from administering a shot. At this point (Officer #2) had his Taser on (Pt #2)'s chest and was ordered not to move. (Physician #2) then placed (Pt #2) on 72 hour hold a short time later.

2) Facility Police Officer #2 documented on his arrival to the ED "many medical staff members expressed that (Pt #2) was noncompliant and if he fights he will be a hand full because of his strength. While I was waiting outside (Pt #2's) door one medical staff member returned with Velcro restraints and shortly thereafter the physician arrived and stated she was ready to medicate. Officers and medical staff entered the room and (Pt #2) was standing just outside the door of room 33. (Pt #2) stated "are ya'll coming for me?" I replied if you comply with the medical staff everything will be fine but he immediately started arguing with another officer and things escalated very quickly. Because of (Pt #2's) strength, I turned on the Taser and placed the dots on his chest and he stopped wrestling. When the incident started to escalate again, I tried to aim the Taser but could not get a good site on (Pt #2) because of the other two officers. I stepped in where (Pt #2) could see me and placed the Taser in his view, on his chest with the hope that he would calm down. (Pt #2) was medicated while two officers held his arms and other medical staff held his legs and I stood within his view with the Taser (in dry stun mode) in case we should lose control.

3) Facility Police Officer #3 documented "as (Officer #1) grabbed hold of (Pt #2) and (Officer #2) retrieved his Taser, lining the dots on (Pt #2's) chest. (Officer #2) informed (Pt #2) that if he continued to resist he would be Tased. (Officer #2) informed (Pt #2) that the medication was not (Pt #2)'s decision due to being placed on a medical hold."

4) Facility Officer # 4 documented "upon arrival I see (Officer #1 and #3) on either side of the doorway preventing the patient from exiting the room. The whole time the patient is being passively aggressive stating that he is doing as they are telling while still attempting to leave the room. Medical staff advised that he was on a hold and they needed to get the patients personal items from him that were not allowed in the area and the patient was refusing to hand over the items. At this point (Officer #2) removed his Taser and pointed it in the direction of the patient stating loudly taser, taser, taser."


C. Review of the Policies and Procedures showed the following:

1) S-15 TASER Policy showed: "ECDs (electronic control devices) may only be used by certified and trained UAMS Police Officers to control or subdue violent or potentially violent individuals on UAMS property. The use of an ECD may not be used to coerce or threaten a patient into restraints or seclusion. The ECD is not a substitute for proper de-escalation techniques. It should never be used in the following manner: as a form of punishment, to coerce or obtain information, as a pain compliance tool to gain cooperation over passive resistance, to coerce or threaten a subject into medical restraints or seclusion."

2) Use of Force policy showed: "the levels of physical force authorized by the UAMS Police Department in ascending order are: Physical presence and verbal persuasion, Physical restraint/soft empty hand control tactics or OC (oleoresin Capsicum) spray/chemical agents, Physical restraint/hard empty hand control tactics, Taser X-26 electronic control device or Jaycor Pepperball System. The Taser will not be used: punitively for the purpose of coercion or in any unjustified manner."

3) Restraints and Seclusion policy showed: "Physical Holding: holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint."

4) Patient Rights and Responsibilities policy showed: "patients have the right to receive care in a safe setting, free from all forms of abuse or harassment."

5) Requested policy on de-escalation from the facility, facility provided De- escalation Skills Quick sheets that showed to "start with the least restrictive measures before using more restrictive measures, such as seclusion. Report the technique used to de-escalate and the patient's response. Document the procedure in the patient's record. Do not make a show of force."


D. Interviews:

1) During an interview with the Director of Accreditation and Regulatory Compliance on 09/15/20 at 9:50 AM, he stated that security does not carry Tasers but UAMS police may have Tasers. If a problem occurred in the ED, the UAMS Police would be involved. When asked if the ED has video, he responded yes but the video is only kept for 4-5 weeks unless there is a reason to keep it. He stated the Information Technology (IT) department says the last video from the ED is dated 08/09/20.

2) During an interview with Police Captain #1 on 09/15/20 at 10:00 AM, he stated some officers carry Tasers and some do not, usually supervisors do.

3) During an interview with the ED Liaison on 09/15/20 at 12:49 PM and on 09/16/20 at 2:00 PM, he stated that he reviewed the ED video prior to its disposal and Pt #2 was never tased only had the Taser pointed at him due to Pt #2's behavior issues. He stated that the officers entered the room to assist with restraining patient. On 09/16/20 he stated that when reviewing the video Pt#2's behavior was active, in and out of the hallway walking around on his cell phone, not sitting still. When asked if Pt #2 displayed any violent behavior he responded "no."

4) During an interview with ED Physician #1 on 09/16/20 at 2:10 PM, she stated Pt#2's behavior was manic, hyperactive, walking, inappropriate speech, and agitated. She stated that Pt #2 told her he was having hallucinations and that he sometimes could not tell them from reality. When asked what is a 1-hour detention order, ED Physician #1 stated it is used when more time is needed to assess a patient and that she ordered it because Pt #2 was attempting to leave the ED and she felt Pt #2 was not safe to leave. The 1-hour detention order triggers the physician to call the UAMS police. When asked about de-escalation techniques, ED Physician #1 stated that initially nurses and the resident attempted to verbally de-escalate, she stated they talked him back to his room and she ordered PO (by mouth) Zyprexa and Pt #2 refused so she changed the order to IM ( intramuscular) injection. ED Physician #1 stated that by the time the Psychiatrist evaluated the patient he had already had the IM Zyprexa which led the Psychiatrist to let Pt #2 be discharged home.

5) During an interview with Registered Nurse (RN) #2 on 09/16/20 at 3:37 PM, she stated Pt #2 appeared manic, disorganized, with rapid speech and was initially calm and cooperative before going back to the Psychiatric holding area of the ED. As soon as we initiated the Psych protocol, he became withdrawn, irritated, and refused to change his clothes, becoming uncooperative. When asked what de-escalation interventions where implemented prior to calling the Police, she stated that nursing attempted to explain the process/protocol to Pt #2, offered him water, and to turn the lights down low. When asked where these intervention would be documented, she stated sometimes on a blank note, but I am not sure it is documented. RN #2 stated that things continued to escalate and P t#2 was telling staff he was a boxer and that she was afraid of Pt #2 and wanted more people present to give him the IM Injection. When asked if she saw a Taser in the room she stated she was not sure. RN #2 stated Pt #2 was more cooperative with improved speech and mood after the injection.

E. The above findings in A, B, C, and D were verified with the Director of Accreditation and Regulatory Compliance on 09/21/20 at 10:20 AM.