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Based on interview, record review, policy review and video review, the hospital failed to provide a safe environment, free from abuse, when they failed to protect Patient #10 from being tasered (electrical weapon, used to stun a person through the delivery of electrical current) and placed in handcuffs by law enforcement. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. The hospital census was 55.

The severity and cumulative effect of this practice resulted in the overall noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights, which resulted in a condition of Immediate Jeopardy (IJ).

As of 04/26/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- Immediate education to all employees regarding abuse and neglect prior to the start of their next shift;
- Revision of the hospital policy titled Washington (WASH) Admin Psychiatric-Behavior Health Patient Management that addressed the use of law enforcement and the role of the employees;
- Immediate education to all Emergency Department staff and physicians addressing the policy revision related to law enforcement prior to the start of their next shift; and
- Communication of changes to the Washington Police Department.

Based on interview, record review, policy review and video review, the hospital failed to provide a safe environment, free from abuse, when they failed to protect Patient #10 from being tasered (electrical weapon, used to stun a person through the delivery of electrical current) and placed in handcuffs by law enforcement (LE). This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Abuse-Neglect by a Co-worker," dated 10/12/22, showed that abuse is defined as the willful (intentional; deliberate) infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Abuse also includes verbal intimidation, inappropriately raising one's voice, cursing and threats of punishment toward a patient.

Review of the hospital's policy titled, "Use of Restraint and Seclusion for Management of Violent or Self-Destructive Behavior," dated 11/09/21, showed that patients have the right to be free from physical restraints imposed for the purposes of discipline or convenience and not required to treat the patient's medical symptoms; if severely aggressive or destructive behavior poses an imminent danger to the patient and others, contact the security department and Nursing Manager or Nursing Director, and physician orders are required for each episode of violent restraint.

Review of Patient #10's medical record dated 08/09/22 showed:
- He was an illiterate 60 year-old male that came into the Emergency Department (ED) on 08/09/22 at 4:32 AM with his sisters for audible and visual hallucinations (seeing or hearing things which are not there); he was seeing demons that were raping women, men and kids.
- The patient's sister informed the hospital that the patient had not been taking his medicine in the last six months and he had become more out of control. He wanted to kill the demons that were trying to hurt a beautiful little girl; he recently had tried to commit suicide by wrecking his van. That night the patient had wanted to burn the woods near their house to kill all the demons. He had already burned the front lawn at their home. The patient had no known psychiatric (relating to mental illness) history.
- At 4:50 AM, the ED contacted behavioral health to evaluate the patient.
- At 5:20 AM, Staff AA, RN, documented that the patient was kicking and punching things in the room and threatening his family that had brought him to the hospital. Patient #10 was hallucinating and was seeing his girlfriend on the television that was turned off and he told her to fight the devil. The patient began to escalate. Security was called and unavailable, therefore LE was called to help assist with medication administration. When the patient was approached to administer medications, the patient began threatening, fighting and kicking the staff and LE. The patient refused to follow commands of the staff or LE so the patient was then tased and then handcuffed. The patient was then sedated with three medications. The patient reportedly had no injuries.
- The patient was evaluated by a behavioral health intake coordinator which determined the patient needed inpatient psychiatric care.
- Patient #10 was discharged at 12:29 PM to an outside inpatient psychiatric hospital by ambulance with an escort by LE.

There was no documentation of when the patient was released from handcuffs. There was no documentation for a restraint order.

Review of the "Washington Police Department Offense/Incident Report, Complaint Number 22-001427," dated 08/09/22, showed LE were called to the ED for a patient who was out of control and that was causing a disturbance. The hospital called for LE because the hospital's security was unable to assist at that time. Upon arrival, they encountered a combative patient they were unable to verbally deescalate. LE was informed the patient had schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly) that he had been seeing demons and was combative with the ED staff. When the nurse attempted to give the patient an injection to help calm him, he became "irate," and attempted to fight the ED staff. The patient stated that the devil had his girlfriend, then threatened to fight LE. He stated that, "I'll start swinging on every one of you mother fuckers." The patient became more irate as they attempted again to verbally deescalate him. The patient then quickly moved to the corner of the room where LE and staff were unable to gain control of him. Patient #10 had begun throwing punches and the LE officer pulled out his taser and tased him, which was not effective on the first attempt. The officer had a clearer shot and tased the patient again on the left side of his torso. The patient went down to the ground and was then placed in handcuffs. The patient received an injection of medication to calm him. Before the medication took effect, the patient continued to talk about demons and looked at the wall and stated, "Stab him in the eyeball." The patient fell asleep shortly after without further incident. The patient was then turned back over to the care of the hospital staff. No criminal charges were brought against the patient due to his mental status at the time of the incident. Per the report, body cam footage was taken of the incident.

Review of LE body cam audio and video titled, "Axon_Body_3_video X60A1661N," dated 08/09/22, showed:
- LE arrived at 5:17 AM and was told by Staff B, RN Supervisor, that security was not available. The primary nurse, Staff AA, RN, stood in the doorway of Patient #10's room. The patient was calm, sitting on the bed without hitting or swinging his arms. LE attempted to get the patient to throw his legs up on the bed. The patient responded, "Are you going to force me to take a shot?" "Are you going to force them on me?" LE stated that if the physician ordered a shot, he had to take it. The patient refused and stated that he was going to fight all of them. "I'll beat the fuck out of all of you, I do not care how many you got!"
- At 5:19 AM, LE attempted to get the patient's full name and shook his hand. When asked what he was upset about, the patient stated, "Devil's got my girlfriend, abusing her." The patient then stated angrily, "Let go of my hand!" Staff AA, RN, stood in the doorway. LE put his hand in front of Staff AA as if to tell him to stay back. The patient was escalating and stated, "Back off, you're going to grab me and hold me down, back off!" The patient repeats, "Back off!" He became more agitated. The patient stated that he knew what they were trying to do and that he was not stupid. Patient #10 requested LE and staff to back up to the wall away from him. He said, "Stay away from me." The patient stated that he was there because his sister wanted him seen; he did not feel he needed an evaluation. Two nurses and two LE officers were in the room. The patient stated that if they came at him that he was going to start swinging on everyone. He repeated that they needed to back up several times.
- From 5:21 AM - 5:22 AM, the patient continued to ask the staff and LE to back up. The patient raised his voice and stated, "Now I am getting pissed, really bad!" Staff II, Security Officer (SO), was then seen standing in the doorway of the patient's room and available to assist, but had not. ED staff began to remove chairs from the room. The patient then gets up off the stretcher and into a corner where Staff AA, RN, lunged at the patient shoving him against the wall and pinned him there with his back turned and leaned into him. The patient began fighting and pulling the nurses hair. The nurse appeared to attempt to put the patient in a headlock. LE pulled out a taser gun and pointed it at the patient. LE threatened the patient to use the taser. The patient continued to struggle to get out of the corner of the wall. The LE officer pointed the taser at the patient's left torso and yelled, "Taser, taser!" The officer then tased the patient when he was pinned against the wall and continued to yell at the patient to stop. The patient fell to the ground yelling in pain and continued and tried to get out of the hands of Staff AA. LE instructed the patient to put his hands behind his back to handcuff him. Patient was pulled by only his right arm in attempt to get him rolled over on his stomach. The patient was then threatened to have him tased again if he refused to cooperate. The patient stated, "All you have to do is back away from me." The patient was instructed by LE to roll over on his stomach. The patient was assisted over to his stomach and placed his right arm behind his back. With the taser still pointed at the patient, LE threatened the patient again with the taser if he did not cooperate. Staff AA, RN, was then seen at the patient's doorway. The patient was then handcuffed behind his back and left on the ground.
- From 5:23 AM - 5:26 AM, the patient continued on his stomach. Staff II, SO, stood in the room and had not assisted with the patient. The taser was still on the patient and the taser gun pointed at the patient's back side of his torso. The patient sat up and stated that LE was trying to kill him and that they were going to give him a heart attack. LE stated that the patient had started swinging at people and he could not do that; they had to do it (referring to the use of the taser). The patient continued and refused to get off the floor and onto the stretcher. LE threatened that the injection could take place on the ground or on the stretcher. There were two LE officers, two RNs and a one SO in the room. The patient remained handcuffed. The patient stated that he had not wanted a shot. LE officer told Patient #10 that he was done once he had started swinging and pulling the nurse's hair. The patient agreed to get up off the floor. Staff BB, RN, gave the patient an injection of medication. The patient then sat at the end of the stretcher. Patient #10 continued to look at the television and had hallucinations. The patient was still handcuffed behind his back.
- At 5:27 AM, LE asked the patient if he had anything in his pockets and he told the patient he was going to feel around on him for objects that could harm anyone. The patient was calm and cooperative with the search.
- From 5:28 AM - 5:33 AM, the patient yelled at Staff II, SO, to get out of the way of the television. The patient continued to hallucinate while staring at the television. Patient was calm and still handcuffed. LE requested several times that the patient lay back on the stretcher. Staff II continued to lean against the wall at the doorway of the room. The patient stated that three people were not needed in the room because he was handcuffed. LE encouraged the patient to lay back in the bed so they could handcuff him to the bed.
- From 5:34 AM - 5:36 AM the patient appeared drowsy from the medication. He stated that he was not going to fight anymore, "I'm done with that part". He went on to say that it would not have happened if they were not all closing in on him. The patient's handcuffs were removed from behind his back. The patient appeared calm and medicated. LE continued to ask the patient several times to put his legs up on the bed. LE stated they only had a minute before he was going to handcuff him again behind his back. The patient was handcuffed to the bed and he laid back staring at the television.
- From 5:37 AM - 5:40 AM, LE took pictures of the patient's taser marks. Patient #10 had a hard time keeping his eyes open, cooperative and was still handcuffed to the bedrail. LE and Staff II, SO, remained at the bedside, although the patient was calm and had his eyes closed. The behavioral health intake coordinator attempted to speak to the patient via telecommunication. The patient did not respond and continued to sleep.

The video did not show the patient removed from handcuffs.

Review of a hospital document titled, "Security Staffing Aug 2022," dated 04/24/23, showed the staffing schedule for security for the night of the incident, 08/09/22. Staff II, SO, was the only SO scheduled.

During a telephone interview on 04/25/23 at 2:05 PM, Staff Y, ED Physician, stated that he was unsure when LE was called to the ED, what tactics or force they could use.

During an interview on 04/25/23 at 2:30 PM, Staff Z, ED Physician, stated that security was not available on 8/09/22 when Patient #10 was in the ED. LE was called to help out with Patient #10 and used a taser and handcuffs so medication could be administered. He stated that when LE responded, they had primary control of the patient, not ED staff. He went on to say that he did not consider that abuse because a nurse was assaulted.

During a telephone interview on 04/25/23 at 4:40 PM, Staff AA, ED RN, stated that he was the primary nurse of the patient; many nights there was only one SO for the entire hospital. The patient was in handcuffs for approximately 15 minutes before he was released.

During a telephone interview on 04/25/023 at 4:40 PM, Staff BB, ED Nurse Supervisor, stated that he was called for a violent patient that was hitting staff. LE was then called because security was not available; normally there was only one SO that worked nights at that time.

During a telephone interview on 04/25/23 at 5:40 PM, Staff CC, ED Medical Director, stated that it was appropriate to use a taser in that situation since the patient became violent.

During a concurrent video review and interview on 04/26/23 at 8:30 AM, Staff FF, Director of Public Safety, stated that generally if LE was in the patient's room, they were in charge over security.

During an interview on 04/26/23 at 11:15 AM, Staff DD, Chief Executive Officer (CEO) stated that when LE were involved, hospital staff did not control the patient.

During a telephone interview on 04/27/23 at 12:15 PM, Staff II, SO, stated that he stood back because LE was there and the nurse was head butted by the patient. He felt that he was not needed since there was already four people on the patient. He stated that the security department was always short staffed; the ED called LE all the time for assistance. The only force or tactics that SOs could use was their training to hold a patient down and secure them in restraints. He then stated that LE was in charge of the situation when they were present.

During a telephone interview on 04/27/23 at 2:45 PM, Staff FF, Public Safety Director, stated that they were understaffed at that time. He stated that medical staff usually directed the care provided to the patient. He added that he felt the outcome would have been different if it was only security assistance; security was only able to perform holds and help with restraining of patients. He stated that when LE got involved, it was difficult to tell them not to do their job; LE should have been only called in crisis mode, not for patient care.

During a telephone interview on 04/27/23 at 5:15 PM, LE Officer KK, stated that it was normal practice to handcuff a patient in the ED. He then stated that LE was in charge when they came to the hospital to assist. He was unsure when the handcuffs were removed.

During a telephone interview on 04/28/23 at 8:49 AM, Staff FF, Public Safety Director, stated that he felt it was abuse because the hospital could have waited for security to arrive before they called the police; the patient was not any harm to himself prior to the incident and a taser would never had been used. He reiterated from his previous interview that the incident would never had happened if security had responded before the police arrived.




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