The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on a review of a hospital contract for security services of an off duty law enforcement officer (LEO), it was revealed that the Governing Body failed to define specific and ongoing quality evaluations related to the contract.

The hospital entered into a contract with off duty law enforcement officers to augment their security staff. The contract in part, notes an area of "General Compliance" which reveals that the LEO "Shall perform its obligations under this Agreement in a manner that complies with Centers for Medicare and Medicaid Services ...." The contract listed multiple regulatory agencies and obligations to which the LEO must comply, but asked for no material demonstration of ongoing quality measures.

Based on this, the Governing Body could not give appropriate oversight to the contracted service, nor evaluate the contracted services compliance with conditions of participation.
Based on hospital policy, a review of select emergency department employee files and patient #1's record, it was revealed that the hospital failed to train a contracted hospital employee law enforcement officer (LEO) in safe restraint/seclusion processes as utilized by emergency department staff which contributed to an injury of patient #1.

A review by the surveyor of the Hospital policy "Restraint and Physical Hold (approved 12/9/2016) on December 12, 2017, revealed in part, "Only trained staff may apply a physical hold ..."

A review of the medical record revealed that Patient #1 was an adult who self-presented to the emergency department (ED) in November 2017 at 2234 with suicidal ideations and homicidal ideations, and reported taking some action towards a homicidal plan. After being in an assigned ED room for some time, patient #1 attempted to elope from the hospital. A nursing technician (tech) attempted to stop patient #1 who then assaulted the nursing tech. A contracted law enforcement officer (LEO) attempted to stop patient #1 and was also assaulted by patient #1. According to documentation, the LEO manually restrained patient #1 against the wall. Other documentation related to this period stated in part, "(Patient #1) suffered a laceration to the back of her head when (patient #1) was pushed against the wall ..."

Disparate documentation revealed a physician note of 0038, which stated in part, "Pt suddenly started screaming "Beep, beep, beep!" and stated that beeping was reminding her of (a previous trauma) ... Attempts to speak with (patient #1) calmly failed, pt assaulted LEO and RN staff, punching and kicking, and was restrained... During this, pt threw back head and struck back of head against wall. No LOC (loss of consciousness). Small 0.5 abrasion/laceration to posterior scalp. No spine injury, no abd (abdominal) injury, encounter was entirely witnessed by me. Pt screaming racial slurs and also cursing incessantly ..."

A request for the LEO hospital restraint training revealed no training as was received by other ED hospital staff upon orientation and annually. Based on this and per policy, the LEO was not trained on hospital approved techniques to safely restrain patients. Due to varying accounts by staff about the restraint episode it could not be determined if the LEO lack of training contributed to the patient's injury.