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Based on observations, interviews, and record reviews during the course of the complaint investigation, the Condition of Participation: Patient Rights was not met as evidenced by the hospital's failure to provide sufficient interventions to ensure each patient's rights were protected.

Refer to:

A144: Failure to ensure that patients have the right to receive care in a safe setting.

A154: Failure to ensure patients were free from coercion by staff, that restraints were appropriately applied as evidenced by the use of handcuffs, and that comprehensive assessments of a patients for the use of both chemical and physical restraints were completed.

A174: Failure to ensure that restraints were discontinued at the earliest possible time.

A179: Failure to show evidence that a physician, licensed independent provider (LIP), and/or trained registered nurse (RN), had conducted a one hour face to face assessment after initiation of a chemical and/or physical restraint.

Based on observation, interview, and record review the hospital failed to assess for the use of an electric bed for a psychiatric patient who had access to bed controls and who was able to mobilize the bed to utilize as a barricade; failed to ensure rooms which were occupied by psychiatric patients were free of equipment and items that could cause self-harm or harm to staff; and failed to monitor visitors resulting in inappropriate behaviors with the potential to cause increased agitation and potential for harm for 3 of 10 applicable patients (Patient #1, Patient #3, and Patient #4). Findings include:

1. Per review of a nursing triage note from 7/31/18, Patient #1 arrived at the the Emergency Department (ED) at 12:38 PM by a Northwestern Counseling and Support Services (NCSS) clinician who advised that the patient was experiencing psychosis and needed medical clearance. Upon review of the physician's progress notes from 7/31/18, the patient was medically cleared and awaiting placement for inpatient treatment at a psychiatric facility. Per review of the nursing progress notes from 8/2/18 at 8:30 AM, "Pt (patient) sitting on floor pushing buttons on the bed, pt then unlocked the bed. This RN (Registered Nurse) told pt to stop pushing the buttons on the bed and leave the bed locked in place. This RN went around to the right side of the bed and locked the bed. Pt grabbed the lower left safety rail and began shaking the rail. Security officers x 2 went into room pt then grabbed the side rail and shoved the bed across the room. Security officers wrestled pt to the ground and pinned pt down on the ground. RN called the police for assistance". Upon further review of the nursing progress notes, at 8:40 AM, 4 police officers and 3 security guards were at the patient's bed side and the crisis clinician was called to evaluate the patient. At least one police officer and two security guards remained at the patient's bedside until approximately 11:30 AM. Per interview on 9/12/18 at 8:47 AM with ED RN #1, s/he stated that a safe environment meant that prior to a patient entering the room; it would be cleared of any items/objects that could be used to harm one-self and/or others. S/he stated that s/he helped to prep the room for this patient to ensure that the room was safe due to the patient's potentially volatile state. S/he stated that patients who had a longer length of stay in the ED were moved into the room with a hospital bed for their comfort. S/he confirmed that the patient unlocked the bed and shoved it across the room creating a potential barricade; and that s/he failed to completely assess the bed as a potential safety hazard. S/he stated that the patient had episodes in which s/he had escalated quickly and became violent. S/he stated that the patient had assaulted security guards at least 2 times prior to this incident and that the police had been called for staff and other patients' safety.

2. Patient #3 was admitted to the ED on 9/8/18 with a psychiatric diagnosis of bipolar and a history of noncompliance with prescribed medication and treatment. Prior to admission, Patient #3 was demonstrating erratic and severe agitation requiring emergency intervention by law enforcement. Patient #3 was evaluated by a Crisis screener from NCSS and it was determined s/he was in need of psychiatric hospitalization under involuntary status. Admission to a psychiatric hospital was pending due to a lack of bed availability. While awaiting placement, Patient #3 was held in the Emergency Department (ED) for 10 days and experienced episodes of agitation, mania, delusions, resisting care, threatening staff, refusing medication and required restraints and involuntary emergency medication. During this period of time, there was a failure of ED staff to ensure care was provided in a safe setting.

a). Patient #3 was permitted visitors to include a significant other who on 9/9/18 increased Patient #3's agitation resulting in hypersexual behavior. During a tour of the ED with the ED nurse manager on 9/10/18 at 2:20 PM, Sheriff's department staff were observed sitting outside Room #9 and Patient #3 was observed laying on a stretcher in a darkened Room #9 with significant other laying beside the patient with arms partially covered by a sheet. The ED nurse manager acknowledged what was observed was inappropriate and unsafe. After the surveyor's observation, ED Physician Documentation for 9/10/18 at 15:40 states the patient's significant other "....presented back to the emergency department and climbed on the stretcher and was on the stretcher snuggling with her/him.....". The significant other was informed Patient #3 had an acute psychiatric illness and "...it was unsafe for her/him to be on the stretcher...." with Patient #3.
b). Per Ongoing Care Note dated 9/09/18 at 18:01, Security was called to Patient #3's room because patient was throwing things. Patient had been provided a water bottle which s/he gestured to throw at staff and was attempting to reach for the vital signs monitoring equipment attached to a mobile pole that had been left in Patient #3's room. If the patient had obtained access to the monitoring equipment, the potential for harm could have resulted with injury to staff and/or the patient. Per interview on 9/11/18 at 3:50 PM the ED nurse manager confirmed the vital signs monitoring equipment should not have been left in Patient #3's room due to a safety risk and potential for harm.
c). Per Ongoing Care Note/Nursing Mental Health Documentation dated 9/9/18 at 22:30, Patient #3 was found with a black garbage bag wrapped around his/her wrist. Despite the fact Patient #3 was delusional with unpredictable behaviors, safety checks conducted by ED staff of Patient #3's assigned ED room noted a failure to identify the importance of removing all plastic bags which could be used for self harm.

3. Per record review on 8/4/18, Patient #4 was brought to the ED with suicidal ideation's. Per review of nursing progress notes for Patient #4 at 10:05 PM, the patient was refusing to give up his/her belongings. The patient was informed that it was the hospital policy that for anyone coming in with suicidal ideation's, s/he would need to change into a gown for his/her safety. At 10:45 PM, the patient asked for a sandwich and a drink. At 10:58 PM, the patient had attempted to leave the facility and the physician informed the patient that s/he was not allowed to leave until s/he had been evaluated by crisis. The patient eventually agreed to put on gown and remove his/her belongings. At 11:10 PM, the patient was given a turkey sandwich, a yogurt, a ginger ale, and a bottle of water. Per interview on 9/12/18 at approximately 9:00 AM with a RN, the ED Nurse Manager, and Manager of Regulatory Affairs, they confirmed that a water bottle cap could be used in a potentially harmful way and that Patient #4 should not have had a water bottle at his/her bedside while on suicide precautions.

Per review of the policy, "Suicidal or Emotionally Ill Patient, Care of, C. Procedure for Maintaining a Safe Environment, 7. Remove the following items if present in the room: a. phone, b. call bell, c. hygiene supplies stored in bathroom, d. trash can liner, e. laundry hampers, f. all sharps or potential sharps from patient room, g. all cords form room: BP machine, phone, call light (replace with dummy plug), suction tubing, 02 tubing, etc. when not medically necessary, h. all non-essential furniture from room (waste baskets, chairs, night stand, linen receptacles, etc.)".

Based on interview and record review the hospital failed to ensure that patients were free from staff coercion regarding the use of police presence in the emergency department when they were not cooperative and for the purpose of submitting to involuntary medication; failed to appropriately use a restraint as evidenced by the use of handcuffs; and failed to conduct a comprehensive assessment for the use of a chemical and/or physical restraint for 2 of 10 applicable patients (Patient #1 and Patient #3). Findings include:

1. Per review of nursing progress notes from 8/1/18 at 4:55 PM, Patient #1 tried to leave his/her ED room. Security had asked the patient to return to the room and the patient had refused. The patient started to push past the security officer and the officer stepped in front of the patient. The patient grabbed a keyboard from the computer outside his/her door and struck the screen of the computer several times, and then struck the keyboard on the wall. Security grabbed the patient and they wrestled around in the room with the security officer hitting his/her head on the wall during the interaction. Eventually, the security officer was able to get the patient on to the hospital bed and the patient calmed. The local police and crisis were called. At 5:00 PM the police were at the patient's bedside. At 5:40 PM, crisis was in the room evaluating the patient. At 6:00 PM, the police remained at the patient's bed side. At 8:00 PM, the police informed the staff that they were short staffed, "administration contacted to have officers on standby, pt calm at this time ....awaiting call back from administration for further plan of security support". At 8:45 PM, "sleeping. awaiting local law enforcement sign on for bedside standby". At 9:30 PM, "security updated on patient care plan to call PD immediately if patient awakens". At 11:30 PM, "pd arrived briefly for assessment of pt. pt awoke momentarily. pt fell back to sleep". Per interview on 9/10/18 at approximately 1:23 PM with the Chief Nursing Officer (CNO) and Manager of Regulatory Affairs, they stated that police were only called when the staff was feeling unsafe. The police were not utilized to manage patients; the police were there to support the staff. On 9/11/18 at approximately 4:00 PM during an interview with the ED Nurse Manager, s/he stated that when police show their presence, it was comforting to visitors and other patients. S/he stated that when the situation goes beyond the security guards' capacity the police were called; and that generally when the police walk into the department, patients' tend to change their actions.

Per nursing notes on 8/2/18 at 12:15 AM, "2 security officers continue at bedside for standby, PD and sheriffs unable to have officer standby due to staffing. pt sleeping". On 8/2/18 at 8:30 AM, "Pt (patient) sitting on floor pushing buttons on the bed, pt then unlocked the bed. This RN told pt to stop pushing the buttons on the bed and leave the bed locked in place. This RN went around to the right side of the bed and locked the bed. Pt grabbed the lower left safety rail and began shaking the rail. Security officers x 2 went into room pt then grabbed the side rail and shoved the bed across the room. Security officers wrestled pt to the ground and pinned down pt down on the ground. RN called the police for assistance". Upon further review of the nursing progress notes, at 8:40 AM, 4 police officers and 3 security guards were at the patient's bed side and the crisis clinician was called to evaluate the patient. At least one police officer and two security guards remained at the patient's bed side until approximately 11:30 AM. Per interview on 9/12/18 at 8:47 AM with ED RN #1, s/he stated that Patient #1 had episodes in which s/he had escalated quickly and became violent. S/he stated that the patient had assaulted security guards at least 2 times prior to this incident and that the police had been called for staff and other patients' safety.

On 8/2/18 at 4:15 PM the nursing progress notes read, "Shortly after this RN leaving room patient ran out of room unprompted without saying anything and sheriffs tackled patient to floor outside of room and handcuffed" him/her "to facilitate getting" him/her "off the floor and into the room ...Patient requesting to keep handcuffs on .....This RN told patient would check on" him/her "shortly and handcuffs would be removed when" his/her "meal tray came for dinner". At 4:49 PM, the handcuffs were removed by the sheriffs. Per interview on 9/11/18 at approximately 4:00 PM with the ED Nurse Manager, s/he stated that the hospital did not use handcuffs as restraints. S/he stated that the staff kept the handcuffs on Patient #1 because s/he had requested to leave them on. Per interview on 9/12/18 at 11:22 AM with a ED RN #3, s/he stated that while the patient was handcuffed, the patient willingly took medication to help him/her calm down. S/he stated that s/he had asked the sheriffs' to remove the handcuffs from the patient; however, the patient requested to keep the handcuffs on. The RN confirmed that handcuffs were not an appropriate type of restraint; and that the patient was not given the option to have an appropriate restraint applied.

2. Patient #3 was admitted to the ED on 9/8/18 with a psychiatric diagnosis of bipolar and a history of noncompliance with prescribed medication and treatment. It was determined after a crisis screening Patient 3 required psychiatric hospitalization. While awaiting involuntary placement, Patient #3 was held in the Emergency Department (ED) for 10 days and experienced episodes of agitation, mania, delusions, resisting care and refusing medication. During this period of time, Patient #1 was subjected to staff coercion regarding the use of police presence. On 9/8/18 at 17:00 Patient #3 Nursing Mental Health Documentation states one of the ED physicians informed Patient #3 that because s/he was "...acting angry and aggressive" staff will need to administer an injection. The note further states "...s/he can either sit on the bed and take the injection or s/he needs to be restrained to the bed and then given the injection.. Pt stated s/he would not hurt anyone and would be compliant". Meanwhile at the time of the discussion and at the entrance to patient's room stood 3 St. Alban's Police Officers and 2 county Sheriffs. The patient was then administered the involuntary medication.

On 09/09/18 at 23:00 Nursing Mental Health Documentation states:" Pt. continues to be agitated. Walking around room-punching his/her fist in his/her hand. Discussed with MD. Decision to medicate--St. Alban's police called stand by assistance" At 09/09/18 at 23:31 a follow-up note states: "Two St. Alban's PD and two NMC security guards at bedside for medication administration by two RNs-patient cooperative with the RN and team for medication." Per telephone interview on 9/12/18 at 10:40 AM a security guard involved in the medication administration stated ED staff waited specifically for the police to arrive for the purpose of "showing presence" in front of Patient #3 who did not want the medication to be administered but did comply and allowed staff to perform procedure. Per interview on 9/12/18 at 11:20 AM, ED RN #2 confirmed s/he has called police "...as a back-up to our security" and further stated staff would call police "...to be present and once they are present patients will react...patient will calm down and listen."

Based on staff interview and record review the hospital failed to ensure restraints were discontinued at the earliest time possible for 2 of 10 applicable patients. (Patients #1 and #3). Findings include:

1. Per review of the nursing progress notes from 8/4/18 at 10:40 AM, Patient #1 was pacing in the room. At 10:55 the "pt walked out of bedroom ....tried to push past security, was assisted to the floor by security and ed technician ...police department called, code green called". Due to the patient's violent and aggressive behavior, the patient was administered a chemical restraint of 2 milligrams (mg) Ativan (medication for anxiety) IM (intramuscularly) and 10 mg of Zyprexa (antipsychotic medication) IM; and bilateral upper extremity neoprene restraints were applied. At 11:38 AM, the patient was reassessed by the nursing staff and was "resting". At 12:20 PM, the patient was reassessed and was "resting". At 1:00 PM, the patient was "sleeping". At 1:26 PM, the patient remained "sleeping". At 1:50 PM, the patient was "resting no acute distress". At 1:53 PM, the bilateral upper extremity restraints were removed. Per interview on 9/11/18 at approximately 4:00 PM with the ED Nurse Manager, s/he stated that restraints should be removed when the patient was calm and cooperative and no one was in danger. S/he confirmed that Patient #1 was noted by the nursing staff to be "resting/sleeping" from 11:38 AM until 1:50 PM and that the restraints were not removed at the earliest possible time.

2. During the time Patient #3 was held in the ED awaiting psychiatric placement, restraints were utilized by staff over a period of 2 days. After the application of bilateral upper extremity restraints on 9/8/18 at 20:10, nursing staff conducted 15 minute observations of Patient #3 which were documented within the Restraint Observation Sheet . On 9/8/18 at 21:45 "Patient Behavior" is documented as "resting" and at 22:00 the patient was "beginning to fall asleep". At 22:15, 22:45; and 23:00 patient continued to sleep and/or resting. At 23:30; 23:45; and 09/09/18 at 00:00; 00:10 Physical Re-Assessment notes Patient #3 is "resting & drowsy". At 00:29 the right wrist restraint is removed and the left wrist restraint remains. After a brief period of agitation, Patient #3 returns to sleep at 01:15; 01:30; 01:45; and 02:00. Patient #3 has periods of agitation but returns to sleeping/resting and at 04:10 although cooperative, nursing reapplies the right wrist restraint and removes the left wrist restraint. From 04:16 through 05:30 Patient #3's behavior was again described as "resting" and "sleeping". Patient remained in 1 restraint and continued in a pattern of some agitation associated with the restraint followed by sleeping which continued from 08:45 through 11:34 during which time the patient's behavior was documented as "resting". It was not until 13:00 on 9/9/18 that the patient was freed from the 1 extremity restraint. There was a lack of evidence to demonstrate Patient #3 remained a threat to the immediate physical safety of self or others specifically when Patient #3 remained calm, resting and or sleeping for periods greater than 2.50 hours.

Based on interview and record review the hospital failed to show evidence that a physician, licensed independent provider (LIP), and/or trained registered nurse (RN), had conducted a one hour face to face assessment after initiation of a chemical and/or physical restraint for 2 of 10 applicable patients (Patient #1 and Patient #3). Findings include:

1. Per review of the nursing progress notes from 8/4/18 at 10:40 AM, Patient #1 was pacing in the room. At 10:55 the "pt walked out of bedroom ....tried to push past security, was assisted to the floor by security and ed technician ...police department called, code green called". Due to the patient's violent and aggressive behavior, the patient was administered a chemical restraint of 2 milligrams (mg) Ativan (medication for anxiety) IM (intramuscularly) and 10 mg of Zyprexa (antipsychotic medication) IM; and bilateral upper extremity neoprene restraints were applied. Per review of the physician progress notes from 8/4/18, there was no evidence that a one hour face to face assessment was done for Patient #1 after chemical and physical restraints were applied. Per interview on 9/12/18 at 9:14 AM with the Manager of Regulatory Affairs, s/he confirmed that there was no evidence that a one hour face to face assessment was done for Patient #1 by a physician after chemical and physical restraints were applied.

2. Although the documentation titled Physician Orders: Restraint state for "Violent/Behavioral Standard" "Physician must assess patient face-to-face and sign order within 1 hour of restraint application" there was no evidence in Patient #3's medical record to indicate an assessment was conducted by a physician after the application of restraints on 9/8/18 at 20:10 and chemical restraints at 20:27. There was a failure to address the patient's reaction to the chemical and physical restraints, the patient's medical and behavioral condition after the application of restraints and the administration of Zyprexa 10 mg IM, and whether there was a need to continue the use of restraints.

Based on interview and record review the hospital's Quality Assurance and Improvement Program (QA/PI) failed to analyze the incidence, prevalence, and the severity of the use of chemical and/or physical restraints in the Emergency Department and throughout the hospital; and as a result failed to identify opportunities for improvement. Findings include:

1. Per review of nursing progress notes from 8/2/18, Patient #1 tried to leave his/her ED room and was tackled to the floor by sheriffs and handcuffed. The patient willingly took medication to help him/her calm down; however, had asked to keep the handcuffs on. Per interview on 9/11/18 at approximately 4:00 PM with the ED Nurse Manager, s/he stated that the hospital did not use handcuffs as restraints; and that the handcuffs were kept on the patient because s/he had requested to keep them on. Per interview on 9/12/18 at 11:22 AM with ED RN#3, s/he stated that s/he had asked the sheriffs to remove the handcuffs; however, the patient requested to keep them on. S/he confirmed that the handcuffs were not an appropriate type of restraint; and that the patient did not have the opportunity to have an appropriate restraint applied. On 8/4/18 at 10:55 AM, Patient #1 had chemical and physical restraints applied due to violent and aggressive behavior. Per review of the nursing progress notes from 8/4/18 at 11:38 AM to 1:50 PM the patient was either "resting, sleeping, and/or in no acute distress". The restraints were removed from Patient #1 at 1:53 PM. There was approximately over 2 hours of time where the patient demonstrated that s/he was not violent and/or aggressive; and that restraints could have been removed. During the interview with the ED Nurse Manager on 9/11/18 at approximately 4:00 PM, s/he confirmed that the restraints for Patient #1 were not removed at the earliest time possible. Per review of the physician progress notes from 8/4/18, there was no evidence that a one hour face to face assessment was done after the restraints were applied to Patient #1. This was confirmed by the Manager of Regulatory Affairs on 9/12/18 at 9:14 AM.

2. Patient #3 was admitted to the ED on 9/8/18 with a psychiatric diagnosis of bipolar and a history of noncompliance with prescribed medication and treatment. It was determined after a crisis screening Patient #3 required psychiatric hospitalization. While awaiting involuntary placement, Patient #3 was held in the Emergency Department (ED) for 10 days and experienced episodes of agitation, mania, delusions, resisting care and refusing medication. During this time frame, Patient #3 was placed in physical restraints and also was administered chemical restraints. During administration of involuntary medication, St. Alban's police became involved "as a presence". There was also a failure to discontinue restraints at the earliest possible time when medical record review noted Patient #3 was resting and/or sleeping on 9/9/18 while remaining in a wrist restraint. If a quality review had been effectively conducted, it would have also been noted that there was a failure by a physician, licensed independent provider (LIP), and/or trained registered nurse (RN), to conduct a one hour face to face assessment after initiation of a chemical and/or physical restraint for Patient #3.

Per interview on 9/12/18 at approximately 1:30 PM with the Manager of Regulatory Affairs and Director of Quality, they stated that there had been some challenges with data collection for analyzing restraint use as the facility was using both paper and electronic documents. They stated that it was the Unit Nurse Manager's responsibility to review restraint use monthly and report out to the patient care committee. They stated that some random audits had been done; however, the hospital did not have a consistent, robust way to analyze the incidence, prevalence, and severity of restraint use. They confirmed that with each of these cases there were opportunities for improvement.

Refer to Tags: A- 0154; A-0174; A-179

Based on observations, interviews, and record reviews during the course of the complaint investigation, the Condition of Participation: Emergency Services was not met as evidenced by the failure of the hospital to ensure there was sufficiently trained staff to address behavioral management as evidenced by the periodic use of law enforcement presence for standby for potentially violent and/or self-destructive patients; and use of police presence during involuntary medication administration for 2 of 10 applicable patients (Patient #1, Patient #3). Findings include:

1. Per review of nursing progress notes from 8/1/18 at 4:55 PM, Patient #1 tried to leave his/her ED room. Security had asked the patient to return to the room and the patient had refused. The patient started to push past the security officer and the officer stepped in front of the patient. The patient grabbed a keyboard from the computer outside his/her door and struck the screen of the computer several times, and then struck the keyboard on the wall. Security grabbed the patient and they wrestled around in the room with the security officer hitting his/her head on the wall during the interaction. Eventually, the security officer was able to get the patient on to the hospital bed and the patient calmed. The local police and crisis were called. At 5:00 PM the police were at the patient's bedside. At 5:40 PM, crisis was in the room evaluating the patient. At 6:00 PM, the police remained at the patient's bed side. At 8:00 PM, the police informed the staff that they were short staffed, "administration contacted to have officers on standby, pt calm at this time ....awaiting call back from administration for further plan of security support". At 8:45 PM, "sleeping. awaiting local law enforcement sign on for bedside standby". At 9:30 PM, "security updated on patient care plan to call PD immediately if patient awakens". At 11:30 PM, "pd arrived briefly for assessment of pt. pt awoke momentarily. pt fell back to sleep". Per interview on 9/10/18 at approximately 1:23 PM with the Chief Nursing Officer (CNO) and Manager of Regulatory Affairs, they stated that police were only called when the staff was feeling unsafe. The police were not utilized to manage patients; the police were there to support the staff. On 9/11/18 at approximately 4:00 PM during an interview with the ED Nurse Manager, s/he stated that when police show their presence, it was comforting to visitors and other patients. S/he stated that when the situation goes beyond the security guards' capacity the police were called; and that generally when the police walk into the department, patients' tend to change their actions.

Per nursing notes on 8/2/18 at 12:15 AM, "2 security officers continue at bedside for standby, PD and sheriffs unable to have officer standby due to staffing. pt sleeping". On 8/2/18 at 8:30 AM, "Pt (patient) sitting on floor pushing buttons on the bed, pt then unlocked the bed. This RN told pt to stop pushing the buttons on the bed and leave the bed locked in place. This RN went around to the right side of the bed and locked the bed. Pt grabbed the lower left safety rail and began shaking the rail. Security officers x 2 went into room pt then grabbed the side rail and shoved the bed across the room. Security officers wrestled pt to the ground and pinned down pt down on the ground. RN called the police for assistance". Upon further review of the nursing progress notes, at 8:40 AM, 4 police officers and 3 security guards were at the patient's bed side and the crisis clinician was called to evaluate the patient. At least one police officer and two security guards remained at the patient's bed side until approximately 11:30 AM. Per interview on 9/12/18 at 8:47 AM with ED RN #1, s/he stated that Patient #1 had episodes in which s/he had escalated quickly and became violent. S/he stated that the patient had assaulted security guards at least 2 times prior to this incident and that the police had been called for staff and other patients' safety.

2. Patient #3 was admitted to the ED on 9/8/18 with a psychiatric diagnosis of bipolar and a history of noncompliance with prescribed medication and treatment. It was determined after a crisis screening Patient #3 required psychiatric hospitalization. While awaiting involuntary placement, Patient #3 was held in the Emergency Department (ED) for 10 days and experienced episodes of agitation, mania, delusions, resisting care and refusing medication. During this period of time, Patient #1 was subjected to staff coercion regarding the use of police presence. On 9/8/18 at 17:00 Nursing Mental Health Documentation states one of the ED physicians informed Patient #3 that because s/he was "...acting angry and aggressive" staff will need to administer an injection. The note further states "...s/he can either sit on the bed and take the injection or s/he needs to be restrained to the bed and then given the injection. Pt stated s/he would not hurt anyone and would be compliant". Meanwhile during the time of the discussion between ED nursing staff and Patient #3, at the door entrance stood 3 St. Alban's Police Officers and 2 county Sheriffs. The patient was then administered the involuntary medication of Zyprexa (antipsychotic) 10 mg. IM

On 09/09/18 at 23:00 Nursing Mental Health Documentation states:" Pt. continues to be agitated. Walking around room-punching his/her fist in his/her hand. Discussed with MD. Decision to medicate--St. Alban's police called stand by assistance" At 09/09/18 at 23:31 a follow-up note states: "Two St. Alban's PD and two NMC security guards at bedside for medication administration by two RNs-patient cooperative with the RN and team for medication." The patient was administered Zyprexa 20 mg. IM. Per interview on 9/12/18 at 10:40 AM, Security guard #1 confirmed that at times with past events in the ED the St. Alban's police would be utilized to assist staff to hold down a patient in an emergent behavioral situation. During the events on 9/8/18 and 9/9/18 involving Patient #3, the police remained " a show of presence". Per interview on 9/12/18 at 11:20 AM, ED RN #2 confirmed s/he has called police "...as a back-up to our security" and further stated staff would call police "...to be present and once they are present patients will react...patient will calm down and listen." In addition, per ED Physician Documentation in regards to ED staffing and the use of restraints for Patient #3; On 9/9/18 at 06:53 s/he states: "May be worth trying him/her off restraints during the day if adequate security is present to manage him/her if s/he tried to leave".

Per interview on 9/11/18 at 3:02 PM with the Director of Facilities and the Manager of Security, they stated that all of the security officers take the MANDT training which was a type of training that focuses on preventing, deescalating and if necessary intervening when the behavior of an individual poses a threat of harm to themselves and/or others. The Manager of Security stated that security's role was to maintain one to one observation, patrol the facility, check parking lots, check other buildings that that hospital owns, and help to maintain outside community relations. Per the Director of Facilities, s/he stated that security would coordinate with the local police department when necessary; however, the police would only be called with acts that were possibly criminal in nature; and that it was not very often that police were called.

Per review of the hospital education transcripts for the security guards, there was evidence that only 2 of 6 staff members had MANDT training. Per interview on 9/12/18 at 2:28 PM with the Manager of Regulatory affairs, s/he confirmed that only 2 of the 6 security officers had MANDT training. S/he stated that it was the hospital's goal to have everyone trained within the year.