HospitalInspections.org

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.635 Provision of Services was out of compliance.

C-1044- The person principally responsible for the operation of the CAH under §485.627(b)(2) of this chapter is also responsible for the following: (i) Services furnished in the CAH whether or not they are furnished under arrangements or agreements. (ii) Ensuring that a contractor of services (including one for shared services and joint ventures) furnishes services that enable the CAH to comply with all applicable conditions of participation and standards for the contracted services. Based on observations, interviews, and document reviews, the facility failed to ensure contracted services enabled the facility to provide care in a safe and effective manner. (Cross-reference C-2523)

Based on observations, interviews, and document reviews, the facility failed to ensure contracted services enabled the facility to provide care in a safe and effective manner. (Cross-reference C-2523)

Findings include:

Reference:

The Governing Board Bylaws read, the chief executive officer (CEO) shall be responsible for the employment of any additional staff in a manner consistent with the Board of Directors Governing Policies.

1. The facility failed to ensure the contracted security company had policies, procedures, job descriptions, training, competencies, and standards in place to ensure care was provided in a safe and effective manner.

A. Observations

i. On 5/28/25 at 9:35 a.m., an observation conducted in the Emergency Department (ED) revealed security guard (Guard) #6 was by themself in the ED. During the observation, Guard #6 stated they had not finished their new hire orientation and it was their third day of employment. Guard #6 also stated they would be alone until their preceptor arrived at 12:00 p.m. Guard #6 further stated they had not worked as a security guard prior to working at the facility, and had no formal training on how to interact with behavioral health patients who presented to the facility.

B. Document Review

i. Review of email correspondence sent to chief nursing officer (CNO) #4 from the human resources manager on 5/28/25 at 4:18 p.m. included required information for employees at the facility. The required information included background information, Colorado Adult Protective Services (CAPS) checks, reference checks, employment verification, job descriptions, statements of confidentiality, company policies signed by employees, policy manual acknowledgement, skills, and competencies.

After multiple requests, the facility was unable to provide personnel files, policies, procedures, job descriptions, training, competencies, and standards in place to ensure care was provided in a safe and effective manner by security personnel.

ii. Review of the security provider contract read they provided security services for crowd management and control, door and perimeter security, and roving (mobile) security coverage. The contract further stated security personnel were trained to handle issues at the facility and assisted local law enforcement interactions when needed. Lastly, security personnel were trained to meet the facility's security needs.

However, the security contract did not state what qualifications personnel were required to have to provide safe and effective care to patients. The contract also lacked provisions for personnel training for restraint use, restraint competencies, use-of-force practices, and personnel scope of practice.

C. Interviews

i. On 6/3/25 at 8:05 a.m., an interview was conducted with CNO #4. CNO #4 stated the security provider trained security personnel and performed new hire orientations. Additionally, CNO #4 stated they did not know what security personnel duties were and what policies were in place to guide them.

ii. On 6/3/25 at 8:45 a.m., an interview was conducted with the CEO #5. CEO #5 stated the facility did not require the security provider to provide education, training, or personnel records to the facility. CEO #5 further stated they had not provided facility oversight for the contracted security services. Additionally, CEO #5 stated they were not aware of the facility's responsibility to provide oversight, or the need to establish policies, procedures, and job descriptions for the contracted security personnel who worked at the facility.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.614 Patient Rights was out of compliance.

C-2523- The patient has the right to receive care in a safe setting. Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure physical holds were not used as a physical restraint according to facility policy. This failure was identified in one of one medical records reviewed of a patient in which a physical hold was implemented by security staff. (Patient #21) (Cross-reference C-1044)

Based on interviews and document reviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure physical holds were not used as a physical restraint according to facility policy. This failure was identified in one of one medical records reviewed of a patient in which a physical hold was implemented by security staff. (Patient #21) (Cross-reference C-1044)

Findings include:

Facility policy:

The Restraints policy read, physical holds were not authorized by the hospital.

The Definitions section of the policy defined restraint as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely. Holding a patient in a manner that restricts the patient's movement against his/her will, including a therapeutic hold, is a restraint.

1. The facility failed to ensure security personnel did not utilize bodily force (physical holds or physical take-downs) to restrain patients.

A. Document Review

i. Medical record review revealed, on 3/14/25 at 6:27 p.m., Patient #21 presented to the Emergency Department (ED) by ambulance for homicidal ideations. At 6:30 p.m., registered nurse (RN) #9 conducted a safety sweep and removed all hazardous items from the room, and Patient #21 was placed in the room. Patient #21 changed into paper scrubs and a sitter was placed with the patient for one to one monitoring.

Review of the nursing progress note entered by RN #9 revealed at 7:33 p.m., Patient #21 stood up beside the bed, ran toward the door in an attempt to leave the room, and yelled threats of physical harm at Physician #2. Security guard (Guard) #7 intervened, and both the patient and Guard #7 ended up on the ground. Patient #21 continued to yell, punch, and kick while restrained on the ground.

ii. Review of the Security Daily Activity Sheet revealed Guard #7 documented a physical altercation involving Patient #21 on 3/14/25.

According to the altercation report completed by Guard #7, at 7:27 p.m. Patient #21 charged toward the door of their ED room while shouting threats of physical harm toward Physician #2. Guard #7 was the sitter assigned to the patient. When the patient charged the door, Guard #7 physically grabbed the patient causing them both to fall to the ground. Once on the ground, Guard #7 forcibly secured Patient #21's upper body by holding the patient's arms around their torso. Guard #7 then wrapped their legs around Patient #21's waist to physically control and restrain the patient on the ground. While restrained, RN #9 administered 10 mg of Haldol (a medication used to calm a patient) intramuscularly into Patient #21's right thigh.

The medical record review and Guard #7's altercation report contrasted with the Restraints policy which read, any physical hold that restricts a patient's movement against their will, including therapeutic holds, was a restraint. Additionally, the policy read physical holds were not approved for use within the facility.

iii. Upon request, the facility was unable to provide evidence it had established a use-of-force policy or scope of practice, training and education for security to use physical holds as a restraint. This lack of training and policy guidance contributed to the physical holding of Patient #21.

B. Interviews

i. On 5/28/25 at 12:45 p.m., an interview was conducted with Guard #1. Guard #1 stated they were a former police officer and the current owner of the contracted security company used at the facility. Guard #1 stated as a former police officer they had been trained how to use physical holds as a restraint. Guard #1 stated they trained all security staff on how to implement and use physical holds in the hospital. Guard #1 stated physical holds were used as a restraint by the security staff at the hospital. Guard #1 stated since they were the owner of the security company they determined what training and education the security staff received.

Guard #1's interview contrasted with the Restraints policy which read, the use of physical holds was not authorized in the hospital.

ii. On 5/29/25 at 11:09 a.m., an interview was conducted with chief nursing officer (CNO) #4. CNO #4 stated security guards did not perform physical holds on patients. CNO #4 stated they had not been informed Guard #7 had physically restrained Patient #21 on 3/14/25.

iii. On 5/29/25 at 11:10 a.m., an interview was conducted with the Chief Executive Officer (CEO) #5. CEO #5 stated they were unaware of the event in which Guard #7 had physically restrained Patient #21. CEO #5 stated the physical holding of Patient #21 was considered a patient safety event.

CEO #5 also stated the facility had not established policies, procedures, or workflows for security staff, and did not require the security company to notify the hospital when a safety event occurred. CEO #5 stated they had not developed or implemented a formal oversight process for security personnel and believed facility oversight was not needed.