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Based on interview and record review, the facility failed to ensure a patient was free from physical abuse when a security guard used his weapon to restrain a patient during de-escalation resulting in risk of serious injury, harm, impairment, or death to one of ten patient (P1) reviewed for patient rights. P1 became verbally aggressive and had clenched fists when security guard (SG)-A used his TASER. SG-A unholstered his TASER and pointed it at P1, then holstered it, then pointed and deployed the TASER.

As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13.

An immediate jeopardy was issued at A0154. See A0154 for additional information.

Based on interview and record review, the facility failed to ensure a patient was free from physical abuse when a security guard used his weapon to restrain a patient during de-escalation resulting in risk of serious injury, harm, impairment, or death to one of ten patient (P1) reviewed for patient rights. P1 became verbally aggressive and had clenched fists when security guard (SG)-A used his TASER. SG-A unholstered his TASER and pointed it at P1, then holstered it, then pointed and deployed the TASER.

The immediate jeopardy began on 4/26/25 when SG-A tased P1 when attempting to restrain P1 and was identified on 5/13/25. The Quality Systems Director, Chief Compliance Officer, and Director of Security and Emergency Department were notified of the immediate jeopardy on 5/13/25 at 4:42 p.m. The immediate jeopardy was removed on 5/14/25 but noncompliance remained at a condition level.

Findings include:

Video footage dated 04/26/25 of security guard (SG)-A tasing P1 was reviewed on 5/8/25 at 1:03 p.m. with security captain (SC) and security director (SD)-A. The video footage did not have audio. The video identified on 4/26/25 at 11:18:11 a.m., P1 was exiting his room and walking towards the elevators. Between 11:18:11 and 11:19:46 medical staff were talking with P1 while walking in the hall and P1 was attempting to get on the elevator. At 11:21:00, SG-A and SG-B were seen by the elevator. P1 was in the corner of the elevator, shaking his head, but not moving his arms. At 11:23:24, SG-C was seen approaching the elevator. At 11:25:03, P1 took off his shirt. At 11:25:13, P1 threw his hands up near his face, SG-A drew his TASER and pointed the taser at P1's right upper thigh and right side of abdomen near his naval. The TASER laser was on P1 until SG-A took the TASER off him at 11:28:14. At 11:31:22, P1 was seen leaning his head back against the wall while looking up at the ceiling. At 11:38:02, SG-A turned his TASER laser back on and pointing the TASER on P1's right upper thigh and right side of abdomen near his naval. At 11:38:14, SG-A was seen deploying his TASER. At 11:38:18, P1 was seen falling to the floor in the elevator and P1 ripped out a TASER probe from his thigh and abdomen. Security was seen moving into the elevator to attempt to hold P1. Between 11:38:18 and 11:39:21, SG-A, SG-B, and SG-C were seen escorting P1 back to his room. SG-A was on P1's left side of body with P1's left arm behind his back. SG-B was on P1's right side holding his right arm behind P1's back. SG-C was following behind the patient and SG-A and SG-B. P1 resisting the hold escort by thrashing his arms during the hold and P1 would stop walking, digging his heels into the floor. At 11:39:21, P1 is seen entering his room. There was no video into P1's room.

P1's medical records indicated P1 was admitted to the hospital on 4/25/25 for an intentional overdose. P1 arrived at the hospital via ambulance from home. P1 was 6 feet and 5 inches tall and weighed two-hundred fifteen pounds. The hospital did not have any prior diagnoses listed.

P1's Violence Risk Assessment dated 4/25/25 indicated P1 did not have a history of violence towards others.

P1's provider progress note dated 4/26/25 at 10:00 a.m. indicated medical director (MD)-A met with P1 advising him he was recommending P1 go to an inpatient psychiatric unit given his depressive thoughts and recent overdose. P1 was adamant that he did not want to be in the hospital, and that he would try to leave the hospital to attend a basketball game. MD-A attempted to discuss with P1 about his 72-hour hold. MD-A indicated that he was later informed of P1 attempting to elope, a code green was called, and P1 was tasered in the elevator. MD-A stated given the situation, P1 would need a high acuity bed, in which the hospital did not currently have room, so P1 would need to go to another hospital.

P1's provider progress note dated 4/26/25 at 12:04 p.m. indicated MD-B stated he was called to the code green involving P1. MD-B stated P1 continued to escalate threats towards the SG's while standing in the elevator. SG's attempted to talk to P1 for "approximately 15 minutes". P1 was told by SG's that he would be tased if he continued to threaten violence. SG's tased P1 and escorted him back to his room where he was given emergency medications and was placed in restraints.

P1's incident report dated 4/26/25 written by SG-A indicated SG-A responded to a code green on 4/26/25 at 11:22 a.m. to 3-west elevators. P1 was attempting to elope while being on a 72-hour medical hold. P1 presented agitated and verbally aggressive. P1 threatened to punch and fight any SG's who would attempt to stop him from eloping. While P1 was standing in a defensive stance with his fist "bald up" and standing in the corner of the elevator, SG-A pulled out his TASER and pointed it at P1 while continuing to de-escalate the situation. SG-A and other SG's attempted to plea with P1 for over 25-30 minutes to walk off the elevator and walk back to his room. Due to P1 being bigger in size and taller than most of the staff members involved, SG-A made the decision for the safety of all hospital staff involved to deploy his TASER and "fire" at P1. The TASER strike hit P1 in the upper stomach and high. P1 dropped to the floor inside the elevator. SG-A, SG-B, and SG-C assisted medical staff by escorting P1 back to his room, assisted with delivering medications, and put P1 in restraints.

P1's incident report dated 4/26/25 written by SG-B indicated SG-B responded to a code green involving P1 who was trying to elope. SG-B and SG-C were the first on the scene. SG-B attempted to empathize with P1 for over 30-40 minutes to start complying with the SG's and medical staff's request, but P1 was adamant about wanting to leave the hospital. P1 was observed getting agitated and was "in deep thought and looking down the whole time, making eye contact a few times". SG-B changed the tactic and began getting more assertive to start "getting the patient to comply". P1 stated "come on, I'm ready to take all y'all on". SG-A withdrew his TASER, activated it, and pointed the lasers at P1, continuing to plea with P1 to comply, and holstered his TASER. SG-A informed P1 that if he was going to holster his TASER, P1 needed to cooperate. A few minutes later, SG-A and SG-C discussed and realized that P1 was not going to cooperate, and if the SG's were to go "hands on" it would most likely lead to one of the SG's getting hurt. P1 was 6'6" and 240 pounds. SG-A drew his TASER, activated the TASER, and discharged. The TASER was deployed and struck P1 in the abdomen area and thigh. After a successful deployment, P1 ripped the TASER probe that struck in the thigh area and P1 dropped to the ground right away. SG-B entered the elevator and positioned himself behind P1, placing his hands under P1's arms, while SG-A and SG-C each grabbed one of P1's legs and transported P1 back to his room. After getting P1 back to his room, P1 was placed in 4-point restraint and continued to resist.

P1's incident report dated 4/26/25 written by SG-C indicated SG-A and SG-B responded to a call from dispatch while P1 was in the elevator. A few minutes later, a code green was called and that is when SG-C responded to the scene. P1 was standing in the elevator, and SG-A and SG-B were asking P1 to leave the elevator and go back to his room, but he refused to do so; P1 was agitated and refusing to go back to his room. P1 was in a fighting posture. P1 kept saying he wanted to go home and that nobody could stop him. SG-C explained to P1 that he was on a hold and that he could not go home. P1 threated to fight any SG. SG-A pulled out his TASER and pointed it at P1. P1 was warned and was saying "tase me, tase me". P1 kept threatening SG's verbally and P1 did not show any will at this time. At that point SG-A decided to tase P1 and as soon as P1 was tased, SG-B and SG-C rushed into the elevator to hold P1's arms while SG-A held both of his legs as they escorted P1 back to his room, put him on his bed, and put him into restraints.

P1's medical records dated 4/26/25 at 12:00 p.m. indicated P1 was assessed after the incident. The assessment included observation and vital signs. No injuries were noted.

A hospital report titled Vulnerable Adult Investigation Report dated 4/28/25 indicated the risk management team was alerted that a TASER deployment occurred involving P1. The use of force review was being scheduled by the security department in accordance with the policy. Risk management confirmed with human resources (HR) that SG-A was placed on administrative leave pending the investigation. The report named SG-A as the alleged perpetrator who had been employed at the hospital since 5/31/22. SG-A served as a SG, field training officer, and shift lead. SG-A was the lead SG on the code green call. In conclusion, P1 met the statutory requirements of a vulnerable adult. After reviewing the event, it gave the risk management team reason to believe maltreatment may have occurred and the state agency was notified of the event.

A hospital report titled Alleged Abuse/Neglect of Patient report dated 4/28/25 indicated the event was reviewed and it was determined that this event would benefit from a multi-disciplinary adverse health event review with the clinical care team involved in P1's hospitalization. The determination meeting was scheduled for 5/6/25 to organize next steps.

Email correspondence dated 5/13/25 at 10:19 a.m. indicated QSD-A received an email on 5/5/25 form SG-D stating SG-B was invited to a scenario-based use of force training on 5/31/25 and 6/7/25. SG-D's email stated this use of force training was mandatory. This email did not include SG-C.

Email correspondence on 5/14/25 at 11:45 a.m., QSD-A stated she was unable to send the surveyor an electronic copy of the vulnerable adult investigation report or the alleged abuse/neglect of patient report stating they were peer review protected.

Security schedule dated 5/25/25 through 5/14/25 indicated SG-A worked 4 shifts during this time, SG-B worked 11 shifts during this time, and SG-C worked 12 shifts during this period.

SG-A's personnel file indicated he was hired at the hospital as a SG on 5/31/22. A team member performance discussion dated 5/29/24 indicated SG-D's goal for SG-A was to find a more regulated demeanor when situations arise causing concern; SG-A's heightened emotion had an impact on the security team as they looked to SG-A for guidance. On 3/1/24, SG-A signed a memo stating he understand and read the use of force policy. On 9/5/24, SG-A had an incident of excessive use of force when he responded to a call about an agitated patient and SG-A entered the room rapidly and aggressively and shoved the patient onto the bed. SG-A proceeded to grab the patient's scrub top and pinned him to the bed and placed his forearm on the patient's neck. The corrosive action was effectively immediate, SG-A was expected to improve and sustain his performance following the appropriate procedures and policies set forth by the hospital. Failure to comply with any process or procedure set forth by the hospital could have resulted in continuation of the performance improvement process up to and including termination of employment. SG-A signed this performance improvement review on 11/6/24. SG-A had completed his Workplace Violence online training on 2/2/25, Emergency Response & Equipment Safety online training on 1/30/25, Patient Care & Safety online training on 1/30/25, and Security Use of Force policy review on 4/17/24.

SG-B's personnel file indicated SG-B was hired at the hospital as a SG on 2/17/25. SG-B received his TASER certification on 2/24/25. On 2/17/25, SG-B was trained on code green per his orientation packet on 4/2/25. SG-B completed his Emergency Response & Equipment online training on 2/18/25 and Patient Care & Safety online training on 2/18/15. SG-B did not have any incidents of excessive use of force on file.

SG-C's personnel file indicated SG-C was hired at the hospital as a SG on 1/2/23. SG-C received his TASER certification on 11/5/24. SG-C completed his Workplace Violence online training on 1/8/25, Patient Care & Safety online training on 12/30/24, Emergency Response & Equipment Safety online training on 12/11/24, and Security Use of Force policy review on 3/16/24. SG-C did not have any incidents of excessive use of force on file.

During an interview at on 5/8/25 at 2:26 p.m. SG-A stated he had talked with P1 in the elevator for about 20-30 minutes. Later in the interview SG-A stated he had talked to P1 in the elevator for 25-40 minutes. P1 threatened to punch and "swing" at the SG's if they escorted P1 out of the elevator. That is when it was decided SG-A would tase P1 and escort him back to his room. P1 continued to say that he did not want to be in the hospital. SG-A stated he tased and did not go "hands on" with P1 because P1 was a "strong individual", and he did not want to risk anyone getting hurt. He did not think P1 was going to be disabled or die because the TASER was used but he was nervous that P1 was going to punch him. SG-A stated he was trained on use of force annually and was current on his use of force training. He was never re-educated on use of force after this incident or put on an administrative leave. SG-A stated he is no longer employed at the hospital because found another job, not because of this incident or being terminated.

During an interview on 5/12/25 at 9:25 a.m., SG-B stated during the code green, he was the one that was mostly talking with P1. He attempted to de-escalate the situation but did not get a response from P1 other than he wanted to go home. P1 looked like he was in deep thought and was looking down with his hands clenched and his jaw was tight. SG-B attempted to de-escalate the situation for 25-40 minutes. He talked to SG-A and stated P1 was not cooperating and asked what else SG's could do to de-escalate the situation. SG-B was still in training at the time. SG-B stated he wanted to try different tactics. P1 stated he was "going to take all of us out". SG-A pulled out his TASER and tased P1. SG-B stated there was nothing he could do. He did not go "hands on" with P1 because SG's believed one of them would get hurt in the process because P1 was taller and weighed more than them. SG-B stated "P1 really wanted to get tased. He said that he wanted it." He did not feel threatened, but he thought SG-A felt threatened. After the incident, SG-B had a conversation with SG-D about the use of force policy. SG-B stated he started in his position on 2/28/25.

During an interview on 5/12/25 at 9:48 a.m., SG-C stated the goal in a code green (aggressive patient call) is to de-escalate the situation without harming the patient, staff, or other patients. On 4/26/25 SG-C was on a different call when a code green was called for P1. When SG-C arrived at the scene P1 was in the elevator and SG-A and SG-B were "begging" him to come out of the elevator. P1 was clenching his fists and stating he wanted to go home. SG-A told P1 did not leave the elevator that he would have to tase him while pointing his TASER at him. P1 took his shift off and had "tense" posturing. At one point SG-A holstered his TASER and P1 calmed down "a little bit". SG-C stated SG-A stated that SG's should not go "hands on" with the patient because he did not want one of us getting hurt. SG's did not continue talking to P1 while he was in the elevator because "everyone was scared". SG-C stated SG's did not have any other option other than to tase P1. SG-A tased P1 and P1 was escorted back to his room where SG's and medical staff put P1 in restraints.

During an interview on 5/12/25 at 11:14 a.m., SG-E stated if he were to respond to a code green, he would have continued to de-escalate the situation by verbally talking with the patient. If his verbal de-escalation were not working, he would use a hand technique called a blanket hold to escort the patient back to his room. If a patient were still resisting the SG's, they would call the local police department to respond. SG-E stated if a patient started to physically fight SG's, which is when he would deploy his TASER. In the situation regarding P1, he would not have used his TASER because P1 was not hurting anyone, and the SG's did not verbally de-escalate the situation long enough to justify deploying the TASER.

During an interview on 5/12/25 at 11:30 a.m., SG-F stated if he were responding to a code green and verbal de-escalation was not working, he would try to have another SG attempt to verbally de-escalate the situation to see if another SG's verbal de-escalation would work. If medical personnel stated they were attempting to get the patient back to his room, SG-F would question why the patient needs to go back to his room. If a patient were on a hold in the hospital, they do not have to be in their room unless the medical personnel were attempting to give them emergent medications. SG-F stated if a patient had clenched fists, it does not necessarily mean that the patient was aggressive; maybe the patient could have a medical aliment that their fists hurt or could not move his fists. If the patient took off their shirt in an elevator, he would not see that as a threat and would not deploy his TASER.

During an interview on 5/12/25 at 11:43 a.m., SG-G stated is she was in that situation and verbal de-escalation was not working with one SG, she would try switching SG's to see if that would work. If that did not work with the patient, she would have let P1 sit in the elevator for a while. If P1 would not have come out after a while, she would have called the local police department. SG-G stated the use of a TASER should be the SG's last resort. SG-A was the supervisor. SG-A continued to work the rest of his shirt. SG-A resigned from his position due to finding another job. After the incident, there was some conversations with SG-A, SG-B, and SG-C but she was not part of those conversations.

During an interview on 5/12/25 at 12:00 p.m., security director (SD)-A stated the hospital has a policy where they have to review situations of weapon use within 3 days. SD-A stated he would have liked to see more de-escalation until there was an attack on a SG before TASER deployment. SG-A initially gave a two week notice of his resignation from his position, which was accepted himself and the administrative team. The resignation was effective immediately. Administration scheduled the use of force training for SG's that needed their annual training. SD-A stated he did not interview SG-A about his thought process during the incident. SD-A stated SC-A was completing education for the security team.

During an interview on 5/12/25 at 12:34 p.m., security captain (SC)-A stated after the incident involving the deployment of the TASER, he received a call from an unknown SG stating SG-A used his TASER on a patient. SC-A spoke with SG-D who confirmed SG-A deployed his TASER on P1. SC-A stated he did not know the extent of the situation until he came in on 4/28/25 and watched the video footage. The situation is not what the hospital trains the SG's on. A review of the incident was done, and it was determined it was a performance issue by SG-A. SC-A stated the security team has a training on use of force in "about a week". The education will be on how to use TASERs, when the SG's use their TASERs, and scenario-based training. The training was scheduled prior to this incident on 4/26/25. SC-A stated he did not put SG-A on an administration leave because SG-A had turned in his two week's notice and SC-A consulted with HR who stated SG-A's resignation was approved, but for immediate resignation. SC-A stated he delegated training SG's to SG-D about the use of TASERs.

During an interview on 5/12/25 at 1:51 p.m., SG-D stated before this incident occurred, the security team already had a use of force training date set in place for 5/31/25 and 6/7/25. Following this use of force incident, SG-D spoke with SG-B about the incident and reviewed the use of force policy and training, as well as watched the video footage of the incident. The conversation included what situations a TASER should be deployed and when a TASER should not be deployed. SG-D stated SG-B would be attending the use of force training on 5/31/25 and 6/7/25. SG-D stated she had a conversation with SG-C about not "overstepping" the lead when making decisions on a call and that he should have "went hands on" with the patient following the TASER deployment. SG-D did not have a conversation with SG-C about TASER use because he was not the SG who deployed his TASER. SG-D stated the TASER deployment was an inappropriate use of force.

During an interview on 5/12/25 at 2:27 p.m., administrative manager (AM)-A stated a patient's nurse is medically responsible for the patient during a code green.

During an interview on 5/12/25 at 3:54 p.m., MD-B stated when P1 was tased, he was concerned that P1 could have had cardiac arrythmias that could have led to P1 feeling dizzy, fainting, or increased anxiety.

Attempts to contact registered nurse (RN)-A on 5/12/24 at 11:28 a.m. and 2:12 p.m. with no success.

During an interview on 5/12/25 at 3:46 p.m., quality systems director (QSD)-A stated a determination meeting is pulling the stakeholders together following a report. This meeting needs to happen within 3 days of the incident. QSD-A stated a determination meeting is a "quick huddle" to determine the next steps in the review. The adverse health event review was scheduled for 6/6/25 to review the event.

During an interview on 5/13/25 at 10:46 a.m., nursing assistant (NA)-A stated she was providing 1:1 support for P1 during the time of the incident. P1 started to get agitated after he had met with the behavioral health provider who stated P1 could not leave due to being on a hold and that P1 needed to go to an inpatient behavioral health unit at another hospital. When P1 started getting agitated, she had called RN-A into the room to assist in de-escalating the situation. NA-A and RN-A talked to P1 in his room for "less than 10 minutes" before P1 left the room. P1 continued to say that he did not want to hurt NA-A or RN-A but that he wanted to go home. Once P1 attempted to enter the elevators additional medical staff attempted to de-escalate the situation and once that was not working, they called a code green. NA-A does not remember who called the code green. Once the code green was called, security responded. P1 was not making eye contact and did not say anything besides him wanting to leave. Due to SG's being in the doorway of the elevator, NA-A was unable to see when SG's deployed their TASER or what happened prior to the deployment. NA-A stated she was behind the SG's to one of the sides of the elevators during this incident.

Attempts to contact RN-A on 5/13/24 at 7:29 p.m. and 7:58 p.m. with no success.

The hospital's TASER policy dated 12/22/17 indicated the use of a TASER against an individual is permitted only in situations as outlined in the Security Use of Force policy. The policy indicated SG's must use their discretion in determining whether to draw or deploy a TASER against any individual. Use of a TASER in any situation must be in accordance with the policy, the Security Use of Force policy, and the SG's training. Designated staff members are required to be certified in TASER instruction and re-certified every two years by a national TASER certification organization. Annual use of force training is required of all SG's, which includes training on the use of the TASER. The use of a TASER is permitted only under in situations outlined by the Security Use of Force policy. Whenever possible and practical, prior to deploying the TASER, SG's shall give a verbal warning to the aggressor that states who they are and what they want the aggressor to do.

The hospital's Code Green policy and procedure dated 2/9/21 indicated during a code green, interventions would be initiated in the least restrictive fashion and intensified to the level of intervention that is both necessary and reasonable to maintain, regain or control the situation for the purpose of preventing injuries to the patients, staff, and visitors.

The hospital's System Security Use of Force policy dated 2/28/24 indicated the policy provides guidelines to refuse the risk of violent behavior from any individuals of the hospital by outlining the continuum of actions necessary to maintain a violence free environment. The continuum of action is appropriate where the SG believes an emergency situation puts the hospital at risk for substantial or great bodily harm. The policy defines great bodily harm as a bodily injury which creates a high probability of death, or which causes serious permanent disfigurement, or which cause a permanent or protracted loss or impairment of the function of any bodily member or organ or other serious bodily harm. SG's would use the minimal degree of force necessary to effectively bring the incident under control. SG's must engage in reasonable use of force interventions when presented with circumstances such as assault, theft, damage to property, or disorderly conduct or violent attach. This includes using force when necessary to protect the welfare of the aggressor or others. The use of force is never used as a means to coercion, discipline, convenience, or retaliation against any person, including the patient. Weapons and handcuffs are security tool interventions and are not to be used on patients. Force would be administered to prevent and minimize physical harm and maximize safety. If a weapon is used by a SG on a person to protect people or the hospital property and community from imminent risk of substantial or great bodily harm, the SG would contact law enforcement, requesting a response to the emergency situation. The use of weapons would be solely in response to an emergency situation of imminent risk of substantial or great bodily harm with possible factors such as weather all avenues of de-escalation have reasonably been exhausted, the behavior of the person upon which force is to be used, actions or other people who may be present, physical odds against the SG, the feasible or availability of alternative actions, whether the patient armed or is able to become armed, the presence of other SG's, and any variable listed in the use of force continuum. SG's may choose to distance themselves and others from a dangerous person, calling for law enforcement support and/or other supporting team members as appropriate depending on totality of circumstances of the aggressive or violent person. The use of force interventions on a patient includes a continuum. The least level of force is physical presence of one or more SG's. The next level is verbal de-escalation or verbal comments. The next level is soft handed control techniques such as therapeutic redirection, escorts, or join locks. The next level is restraint devices. The next level is security tools such as TASER, chemical agent, hard control techniques, or baton. This level requires an immediate emergency situation when the patient presents danger of substantial or great bodily harm to themselves or others. The next level is the local law enforcement.

The immediate jeopardy that began on 4/26/25 was removed on 5/14/25 when the facility revised their System Use of Force policy and procedure on 5/14/25 to include a statement stating security tools would not be used as a restraint device and clarified steps to include SG's would be placed on immediate administrative leave when security tools are used. The facility also had a one-to-one conversation with SG-B and SG-C about the incident and the expectations around the use of force. SG-B and SG-C attested their understanding of the use of force expectations. The facility updated the use of force education module on 5/14/25 to include policy review and attestation of expectations, as well as updated testing questions to include more robust scenarios to demonstrate competency. The facility completed a security meeting with the SG's that were currently on shift about the changes to the System Use of Force policy and procedure as well as expectations on when to use a TASER and when not to use a TASER, the steps to take when responding to a code green, and the steps required after deployment of the TASER. The facility updated the electronic training module to be completed at the beginning of SG's shift starting 5/14/25. The facility updated the Use of Force training modules to occur semiannually when it was previously scheduled annually. The facility would email a memo to all security and clinical staff regarding changes to the System Security Use of Force policy and use of force expectations on 5/15/25. The noncompliance remained at a lower scope and severity at level D because the System Use of Force policy did not include SG's would not use security tools as a restraint device or that the SG would be relieved of their shift after use of security tools and placed on administration leave immediately. During interviews, SG-B and SG-C were unaware of the additional steps SG's should take prior to TASER deployment.