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.
|LIBERTY HOSPITAL||2525 GLENN HENDREN DR LIBERTY, MO 64069||July 26, 2012|
|VIOLATION: PATIENT RIGHTS||Tag No: A0115|
|Based on observation, interview, record review and policy review the facility failed:
-To use the least restrictive restraint method to effectively restrain the patients when tasers and/or chemical restraints were used by security to restrain one patient (#2) of three current patients and used a taser and handcuffs to restrain one patient (#1) of two discharged patients reviewed. The use of tasers (a device, when deployed, causes an electric current to subdue a person) and/or handcuffs should only be used after less restrictive interventions have failed. Tasers can cause injury due to the electric current, barbs, falls, or unknown medical conditions of the patient. -To identify tasers or handcuffs as restraints. Tasers are considered weapons and if a weapon is used by security in a facility the situation should be handled as a criminal activity and the perpetrator should be placed in the custody of local law enforcement.
-To identify analgesic medications (Fentanyl, typically used to treat patients with severe pain; Propofol, used for intubation and maintenance of anesthesia; and succinylcholine, used for short-term paralysis usually to facilitate intubation), used to manage the behaviors and restrict the freedom of movement for Patient #2 was a chemical restraint. Chemical restraints are not considered standardized treatment to control combative behavior for this patient's psychiatric history.
The severity and cumulative effect of not utilizing the least restrictive, most appropriate restraint by using tasers, handcuffs and medications as forms of restraint resulted in the facility being out of compliance with 42 CFR 482.13 - Condition of Participation: Patient's Rights. Subsequently the situation constituted a condition of immediate jeopardy (IJ). The facility submitted a verbal commitment to immediately cease and desist using tasers on 07/26/12. After the facility submitted an interim plan of correction, the State Agency notified facility administration by phone of the abated IJ on 07/27/12. The facility census was 203.
Please refer to tags A0160 and A0165.
|VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION||Tag No: A0160|
|Based on interview and record review the facility failed to identify chemically restraining, sedating medications as a chemical restraint and failed to follow their policy regarding no use of chemical restraints, and failed to document non-restraining methods for behavior management for one (Patient #2) of three current patients reviewed with restraints. The facility census was 203.
1. Review of the facility policy titled, "Restraints for Behavioral Health," dated 06/2009 showed the following:
-Patients have the right to freedom of movement, freedom of choice, comfort, optimal health, dignity, privacy and a safe and therapeutic environment.
-Chemical restraints are defined as medication used as a restriction to manage a patient's behavior or restrict a patient's freedom of movement, and is not a standard treatment or dosage for the patient's condition.
-Chemical restraint is not used in this facility.
2. Review of Patient #2's Emergency Department (ED) Triage form dated 07/13/12 showed the patient had a history of depressive disorder, a history of psychosis (a mental disorder whereby the patient has loss of contact with reality, often with delusions and hallucinations), and seizures. The patient took antidepressants (medications given to manage depression) regularly. The patient had not taken Seroquel (an anti-psychotic), Ativan (an anti-anxiety), or Versed (a sedative) before, or on a regular basis. The ED triage form also showed:
-The patient was brought to the ED on 07/13/12 because a family member found the patient crawling on the floor, confused and the patient had seizure-like activity.
-The patient had abrasions to the head, scalp, face, arms and legs, with large abrasions to the left knee and lower legs on admission to the ED (from crawling on the floor in his home.)
-The patient became agitated and combative (screaming, uncooperative and nonsensical). Physician W documented the patient was sedated with Versed, Fentanyl (used to support anesthesia) and Succinylcholine (used to support anesthesia-a muscle relaxant) and intubated (a tube placed into the throat to allow mechanical breathing to occur-via a ventilator [breathing machine]) on 07/13/12 at midnight. The patient had not taken Versed, Fentanyl or Succinylcholine to treat any of his medical conditions in the past.
3. During a telephone interview on 08/17/12 at 8:04 AM, Staff W, ED physician stated the following:
-An ambulance call came in regarding Patient #2, indicating the patient had a syncopal episode (passed out), possible head injury, drug use (prescription), and abrasions to his legs.
-Staff W stated that he felt the patient's signs and symptoms were related to psychosis of some kind, or a brain bleed and he needed to get emergent studies completed in order to assess this patient's condition to prevent possible deterioration into acidosis (an increase in the body's chemical balance). Staff W decided to prepare the patient for intubation.
4. Review of the patient's ED record showed the patient was transferred to the Intensive Care Unit (ICU), on a ventilator, on 07/14/12 at 2:33 AM.
5. Review of an ICU nurses' note dated 07/15/12 at 6:34 PM, showed the patient was extubated (breathing tube removed), date and time unknown, and then became increasing confused and agitated. Staff administered Seroquel orally, 400 mg at 2:37 PM, Ativan intravenously (IV) 2 mg at 3:16 PM, and Versed IV 10 mg at 3:30 PM in an attempt to control the patient's behaviors.
6. During a telephone interview on 08/15/12 at 10:00 AM, Staff S, ED physician, stated the following:
-Staff S was summoned to the ICU to assist with the care of Patient #2 on 07/15/12 because the patient was, "out of control."
-Staff S stated that the patient had been given 2 mg of Ativan prior to his (Staff S's) arrival in the ICU.
-Staff S stated that ICU staff administered 20 mg of Geodon (an anti-psychotic) to the patient, 5 mg of Haldol (an anti-psychotic), and another 2 mg of Ativan. Even though the patient did not swing at staff or attempt to hit them, (other than an instance whereby the patient pushed away a nurse's hands, Staff M, prior to Staff S's arrival in the ICU) these medications were administered in an attempt to control the patient's behaviors.
-Staff S stated that he reviewed the patient's history, medications and clinical status and he decided to sedate and intubate the patient.
-Staff S stated the Geodon, Haldol and Ativan were given to control the patient's behaviors. He did consider these medications a possible chemical restraint.
-Staff S stated that he was not aware of the patient's medical diagnosis, or if there was one, at the time of his involvement with the patient's care in the ICU.
7. Review of an ICU nurses' note dated 07/15/12 at 6:34 PM showed, "Despite best non-invasive measures [non-invasive measures not documented] and medication related efforts [Seroquel, Ativan and Versed] patient still very combative, ... multiple meds given for agitation... patient was re-intubated on sedation".
(The patient was sedated with Versed, Fentanyl and Succinylcholine, which are not considered standardized treatment to control combative behaviors on a patient with this psychiatric history). These medications rendered the patient unable to move freely, at will. Therefore, this constituted a chemical restraint per facility policy, and per regulatory language.
Staff failed to follow their policy by administering medications intended to sedate or control behaviors, which were not standardly utilized to treat this patient's behavioral conditions. The facility policy stated they did not use chemical restraints. Staff failed to document alternatives they tried prior to administration of chemical restraints, and facility staff failed to identify these medications as chemical restraints.
|VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION||Tag No: A0165|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, record review and policy review the facility failed to use the least restrictive restraint, and/or the lowest degree of force necessary to effectively control behaviors before resorting to the use of a Tasers (a device, when deployed, causes an electric current to subdue a person) to restrain one patient (#2) of three current patients and security used a taser and handcuffs to restrain one patient (#1) of two discharged patients. The use of tasers and/or handcuffs should only be used after less restrictive interventions have failed. Tasers can cause injury due to the electric current, barbs, falls, or unknown medical conditions of [DIAGNOSES REDACTED]. The use of handcuffs are considered law enforcement restraint devices and are not considered safe or appropriate restraint interventions by facility staff. The facility census was 203.
1. Review of the facility policy titled "Restraints for Behavioral Health" dated 06/2009 showed the following:
-Patients have the right to freedom of movement, freedom of choice, comfort, optimal health, dignity, privacy and a safe and therapeutic environment. Therefore, restraint should be used only when alternative interventions have been determined to be unsuccessful.
-Physical restraints are defined as any manual method of physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to freely move his or her arms, legs, body, or head.
-Forensic restraints for non medical reasons are shackles/handcuffs that are placed on a patient by authorized law enforcement personnel according to their agency's policies and procedures. Patients under forensic restraints are monitored by law enforcement personnel.
-All staff who provide direct care, and any other staff (including security officers), must have ongoing education and training in the proper and safe use of restraint or seclusion application, techniques, and alternative methods for handling behavior, symptoms and situations that traditionally have been treated through the use of restraint.
2. Review of an undated Non Violent Crisis Intervention hand book, provided by the facility, as presented by the National Crisis Prevention Institute (CPI - training to recognize and de-escalate potentially violent situations in order to provide the best care, safety, and security at any given moment to individuals even in violent moments) showed:
-Invasion or encroachment of personal space tends to heighten or escalate anxiety.
-Invading an individual's "personal space" during a crisis development situation tends to minimize your chances of defusing the situation and maximize the chances of escalating the situation.
3. Review of a facility-provided power-point educational packet for patient restraints, dated 2011, showed a physical restraint is any manual method, mechanical device, material, and equipment that immobilizes the ability of a patient to freely move legs, arms, body or head. Staff should try the least restrictive measure, and document what they tried.
4. Review of the facility policy titled, "Use of Force" dated 01/2010 showed the following:
-To define the circumstances under which the use of force by a Security Officer is justified.
-A Security Officer is authorized to use non deadly force to protect himself/herself or another person from physical harm; to restrain or subject (subdue) a person resisting a lawful arrest; or to bring an unlawful or unsafe situation under control in the following manner.
-The use of force necessary to control a situation or individual will be appropriate under the following circumstances:
-Whenever the clear and present danger of bodily injury to the Security Officer or another person is immediately present.
-When attempting to control a violent patient (person).
Carrying of Weapons:
-Security Officers are authorized to carry X26 Taser and chemical restraints (such as pepper spray), as a deterrent to criminal activity and to provide a means of protecting themselves and others.
Use of Force:
-Security Officers will use only the degree of force that appears reasonably necessary to bring an incident under control before resorting to the use of restraints.
-Use of physical strength and skill.
5. Review of a facility-provided Taser power-point educational brochure, dated 12/03/11, showed the following:
-When possible, avoid chest shots with Electronic Control Devices (ECDs-Tasers).
-The ECD can produce physiologic or metabolic effects, and is considered a stressful event.
-Reasonable effort should be made to minimize the number of ECD exposures and resulting effects.
-Officer must reasonably perceive subject to be an immediate threat of harm/injury or fleeing risk from serious offense.
-Multiple ECD applications cannot be justified solely on the grounds that a suspect fails to comply with a command.
-Any decision to apply multiple ECD applications must take into consideration whether a suspect is capable of complying with officers' commands.
-Document your justification for multiple, repeated ECD exposures.
-ECD used frequently causes people to fall and even from ground level, can cause serious injuries.
The facility-provided Taser power-point educational brochure, did not give direction to security staff when to tase a patient and/or when to stun the patient with the taser for pain control.
6. Review of an emergency department (ED) Triage form, dated 07/13/12, showed Patient #2 had a history of depressive disorder, a history of psychosis (a mental disorder whereby the patient has loss of contact with reality, often with delusions and hallucinations) and a history of seizures.
The ED triage form also showed:
-The patient was brought to the ED because a family member found the patient crawling on the floor, confused and the patient had seizure-like activity.
-The patient had abrasions to the head, scalp, face and arms, with large abrasions to the left knee and lower legs on admission (thought to be from seizure activity and crawling around on the floor in his home).
-The patient became agitated and combative (screaming, uncooperative and nonsensical). ED Physician W documented patient sedated and intubated (a tube placed into the throat to allow mechanical breathing to occur-via a ventilator,breathing machine) on 07/13/12 at midnight. The ED record showed the indications for sedation and intubation included head injury (abrasions to head, scalp and face), inability to protect airway (how the patient was unable to protect airway not documented), and combative behavior.
7. Review of the patient's ED record showed the patient was transferred to the Intensive Care Unit (ICU), on a ventilator, on 07/14/12 at 2:33 AM.
8. Review of an ICU nurses' note dated 07/15/12 at 6:34 PM, showed the patient was quiet and then extubated (breathing tube removed), time unknown, and became increasing confused and agitated.
9. Review of the Security Shift Activity Log, dated 07/15/12, showed ICU staff called security to the unit at 2:40 PM to assist nursing staff with Patient #2, due to the patient's combativeness/noncompliance.
10. Review of a Hospital Security Report, dated 07/15/12, showed the following:
-Upon arrival to the ICU on 07/15/12 at 2:40 PM, Staff A, security officer, observed Staff M, RN, trying to keep Patient #2 from leaving his room and refusing to respond to commands to get into bed.
-Patient #2 pulled out his IV (intravenous, giving medicine or fluid into the vein), Staff B, security officer, grabbed the patient's arm when Patient #2 swung a fist at Staff B.
-Patient #2 followed commands to get on the bed, and then became confrontational by calling the officers names and refused to comply with the security officers requests. Staff A deployed a full five second cycle of the taser at the patient hitting him in the upper left shoulder.
-Patient #2 fell to the floor; got up and failed to comply with security commands again. Security tased the patient a second time. (The facility policy dictates that multiple applications of the taser cannot be justified solely on the grounds that a patient fails to comply with a command.)
-The patient again fell to the floor.
-Patient #2 sat on the bed for a moment, then lunged at Staff A. Security tased the patient a third time.
-Patient #2 then complied and a Code Gray (a security code which is an overhead page requesting assistance) was called and numerous staff responded to assist, after the patient had been tased by security three times.
-Security tased Patient #2 a fourth time by drive stunning (a pain control restraint technique by deploying the taser without firing the projectiles) on the right inner thigh while security applied mechanical restraints.
11. During an interview on 07/26/12 at 9:32 AM, Staff K, Registered Nurse (RN) stated that on 07/15/12, she witnessed the patient pacing in his room, wanting to leave the facility, the patient had pulled out his IV and pulled away from another nurse (Staff M) who tried to stop the bleeding from the IV site. ICU nursing staff called security for assistance. Two security officers came and entered Patient #2's room. Patient #2 moved toward Staff B, security officer, so Staff B deployed the taser. The patient sat on the bed, then rose and again moved toward Staff B. Staff B tased the patient again, causing the patient to fall on his knees, re-opening the patient's knee abrasions. Staff K stated that medications were given prior to the taser episode, but mentioned no other de-escalation/CPI techniques used by the staff. Staff K stated that she had not received any CPI training.
Even though facility policy dictated repeated use of a taser should be avoided and to avoid targeting the chest area, security entered this patient's room, and tased this patient multiple times and in the chest area.
12. During a telephone interview on 07/25/12 at 1:55 PM, Staff B, Security Officer stated the following:
-Staff B and another Security Officer entered Patient #2's room at the request of nursing.
-Staff B stated that nursing had administered four types of sedatives to this patient before he arrived.
-The patient would not follow commands by the nurse or Staff B.
-Staff B asked the patient to settle down, the patient got on the bed for about three to five seconds, then tried to leave the room.
-Staff B stated that the patient had pulled out his IV and there was blood everywhere. The nurse was trying to follow the patient to dress the bleeding IV site, as the patient was wandering around the room, cussing.
-The patient smacked at the nurse (Staff M) and Staff B grabbed the patient's wrists.
-The patient looked wild and pushed Staff B toward the window in the room.
-The patient fell on top of Staff B.
-They got up and the two security officers, Staff B and Staff A could not control the patient.
-Staff B stated that Patient #2 was tased by Staff A three to four times before they were able to put one ankle and one wrist restraint on the patient.
13. During a telephone interview on 07/25/12 at 2:20 PM Staff A, Security Officer, stated the following:
-He and another officer responded to a radio call from the Intensive Care Unit (ICU). He stated that he was told the patient (Patient #2) was unstable and wanted to leave.
-When he and another officer (Staff B) arrived at the patient's room the patient was walking around the room and was very agitated. The patient on one or two occasions tried to push past the security officers to get out of the room. The security officer stated that he stood in the doorway and tried to reason with the patient. (Staff A stated that he tried to gain a level of rapport with any patient, going into their world, talking to them, as a less restrictive method of control.) Staff A stated that he and Staff B were the only two security officers on duty that day, so he could not call for more back-up assistance.
-The patient pulled the IV out of his arm. The nurse (Staff M) tried to stop the bleeding and the patient tried to hit the nurse.
-The other officer tried to grab the patient but the patient pinned the officer to the window.
- Staff A pulled the taser out of his holster while trying to talk to the patient but the patient did not release the other officer and Staff A deployed the taser, hitting the patient in the chest.
-The patient fell to the floor and then got up and came after the officer. He then deployed the taser a second time.
-The patient fell to the floor and was on the floor for a minute or two and got up and fell into the bed.
-The patient jumped at Staff A and the security officer deployed the taser a third time and the patient fell back onto the bed.
-Security attempted to put leather restraints on the patient, but they were unsuccessful due to the patient's combativeness.
-Staff A then used the taser as a stun gun to make the patient comply by inflicting pain, hitting the patient's inner right thigh.
14. Review of the ICU nurses' note dated 07/15/12 at 6:34 PM showed, patient still very combative, was tased by security. Physician S re-intubated the patient.
15. During an interview on 07/25/12 at 10:30 AM Staff S, ED physician, stated that he went to the ICU on 07/15/12. He stated that when he got to the patient's room he observed two security officers and a nurse in the room. He stated that he talked to the patient and asked him to lie on the bed which the patient briefly did. The physician ordered Ativan (an antianxiety), Haldol (an antipsychotic medication) IM (into the muscle) and Geodon, (an antipsychotic) for the patient. The physician stated that he asked the patient what else they could do for him and the patient requested a soda. The patient also talked with his spouse on the phone and became more upset. The physician stated that the patient began to sweat profusely. He determined the patient might be in danger of rhabdomyolysis (a condition in which damaged skeletal muscle cell tissue breaks down and are released into the bloodstream which may result in shock) and he sedated and intubated the patient (insertion of a tube into the airway for the purpose of providing air.)
16. Review of a nurses' note dated 07/15/12, at 4:00 PM, showed that the patient's knee abrasions had been re-opened, he had taser burn marks on his upper right chest, and reddened armpits and groin, all resulting from the tasing event.
17. Observation and interview on 07/25/12 at 11:00 AM, showed Patient #2 sitting in a recliner chair, unrestrained, in the ICU. The patient was oriented to person and place but did not recall the tasing event or anything leading up to it. The patient voluntarily lifted his pants legs to reveal multiple scabbed areas on the left knee and both lower legs.
18. During an interview on 07/25/12 at 9:32 AM, Staff J, RN, stated that the patient had been in an enclosure bed (a bed with a full netting-type enclosure over it) plus in bilateral (both) wrist restraints until 07/22/12. The patient remained in bilateral wrist restraints until the physician ordered a sitter at sometime on 07/23/12.
19. During an interview on 07/26/12 at 10:40 AM, Staff F, the RN caring for the patient at the time of the tasing, stated that the patient was increasingly jerky, not physically aggressive, but abrasive with a "look" in his eyes. Staff F stated that the patient was not following commands, pacing and pulling at medical lines. Staff F stated that she tried to console the patient with the television, and by pushing him around the unit in a wheelchair. Staff F stated that Staff M, another unit RN, felt threatened by the patient because he pushed her arms away, so Staff M called security.
20. During an interview on 07/26/12 at 1:00 PM, Staff P, the patient's primary care physician, stated the staff did not not have an order to keep Patient #2 in his room on 07/15/12, even though that is what staff tried to do. Staff P stated that she did not assess (a face to face evaluation for a behavioral restraint) the patient after the taser event until the next day (07/16/12) sometime between 9:00 AM and 10:00 AM. The physician stated that the patient remained sedated and intubated for an additional three days, after being tased. [Review of the nurses' notes showed the patient remained intubated to control potential behavior.] Staff P stated that after speaking with the patient's family, sedation of the patient was slowly decreased and the patient was extubated on 07/18/12. The physician stated that she thought the patient possibly had suffered an anoxic brain injury related to a prolonged seizure
Physician P stated that she felt tasing may be necessary for very violent patients to protect staff and others. She stated that she was aware of Tasers being used in the recent past. Physician P stated that as a result of the patient's taser events, the patient suffered additional scratches, bruises on the chest, a fingernail scratch, as well as worsening of the abrasions on his knee and legs, requiring ointment and a dressing.
21. During interviews on 07/25/12 at 9:35 AM and 10:30 AM, Staff I, the ICU Director, stated that the patient had become violent (up out of bed, swinging at staff and attempting to throw furniture) on 07/15/12 and she was notified by the assigned charge nurse that the patient had been tased by security officer, Staff A. Staff I stated that the nursing staff have been directed to contact security immediately when behaviors escalate, so harm to self or others can be prevented. Staff I stated security had been trained to handle patients with behaviors.
22. During an interview on 07/25/12 at 9:20 AM Staff N, Security Lead, stated that all certified officers carry tasers. He stated that a patient (Patient #2) had been tased on July 15, 2012 in the ICU.
23. During an interview on 07/25/12 at 9:43 AM, Staff G, the Risk Manager, stated that the security officers are trained in CPI (training to recognize and de-escalate potentially violent situations). Staff G stated that security staff apply restraints to prevent injury to staff. Staff G stated that the security officers carry tasers and handcuffs. Staff G stated that tasers were not considered restraints and were used on patients that lunged and were highly violent after repeated attempts to de-escalate. She stated that police are notified after the event.
24. During an interview on 07/25/12 at 9:45 AM Staff U, Director of Security, stated that all security officers are certified by the local Police Department every two years to carry a taser and there are no definitive rules for when an officer is to use a taser but it is on a case by case basis. He stated that his department does not keep a log of taser use. The use of tasers are tracked by incident reports, which are sent to the Risk Manager.
25. During an interview on 07/25/12 at 10:20 AM Staff V, local Police Department Officer, stated that training for certification was given by the police department, but on the mechanics of the taser. He stated that the training did not include when or how to use it. He stated that would be in the hospital's policies.
26. During an interview on 07/25/12 at 10:10 AM Staff N, Security Lead, stated that they were instructed during training to shoot at the greatest muscle mass which would be below the chest but it was not always possible to avoid shooting the chest.
27. During a telephone interview on 08/14/12 at 3:00 PM, Staff X, Psychiatrist, stated the following:
-Staff X was familiar with Patient #2, both as an outpatient before the hospitalization on [DATE], and while hospitalized .
-Staff X had been seeing the patient since 2007.
-Staff X saw the patient shortly prior to the patient's 07/14/12 hospitalization , and the patient was stable and had been on the same medications for several years without problems.
-Staff X received a consult request for the patient on 07/16/12, to see related to agitation; however, he did not see him until 07/18/12. The patient was intubated at the time so he had to rely on other consults/documentation, and patient history, to complete the evaluation. After review of the patient's record, Staff X stated that he felt the medications given in the ED were used for both medical treatment and for control of behaviors. Staff X stated the patient was volatile (per the record), and could have harmed himself, as he was confused.
-Staff X stated the patient was given Ativan, Geodon, and Haldol, then Fentanyl (a sedative) and Versed (a sedative) for intubation. Staff X stated that he believed the sedation could have caused an airway compromise, resulting in the need for intubation.
-Staff X stated that, to this date (08/14/12), no conclusive diagnosis had been made regarding this patient's hospitalization . However, Staff X stated [DIAGNOSES REDACTED] (a condition caused by taking multiple medications, which can be fatal), which the neurologist felt was plausible, was treated appropriately (withdrawal of medications) and the patient improved.
-Staff X also felt it was plausible the patient suffered an anoxic brain injury related to seizure activity.
-Staff X stated that he was aware of the patient being tased, after the fact. Staff X stated the use of a taser was not something he had ever seen done before. In his experience, multiple staff respond (as many as necessary) to hold the patient down so an injection can be given.
28. Review of a facility-provided list dated 07/25/12, of restraint injuries from 04/01/12 through 07/25/12, showed no reported restraint injuries; however, record review showed an injury to Patient #2 related to the Taser use on 07/15/12.
29. Review of a Security Incident Report dated 08/22/11 at 8:26 PM, showed the following:
-Patient #1 arrived via ambulance to the ED with a complaint/diagnosis of [DIAGNOSES REDACTED]
-Patient #1 became actively aggressive, stating he was leaving because he could not smoke.
-Security officer, Staff E placed himself in front of the doors so the patient could not leave.
-Patient #1 began walking in circles toward Staff E, raising his arms threateningly.
-Security Officer, Staff E, drew his Taser, the patient walked away, then came back and when about two feet away Staff E deployed his Taser.
-Patient #1 fell to the ground and another security officer handcuffed the patient.
30. During a telephone interview on 07/27/12 at 11:52 AM, Security Officer, Staff E stated the following:
-Patient #1 wanted to smoke and became upset when told he could not leave the premises.
-Patient #1 advanced toward Staff E, and Staff E pulled his Taser in warning.
-Patient #1 ran toward the other security officer, and back toward Staff E so Staff E deployed his Taser when Patient #1 was approximately two feet away.
-The Taser probes struck the patient in the mid-body.
-The patient fell to the ground. Security staff placed Patient #1 on a gurney and put him in four-point leather restraints
-Staff E stated his past training (at another facility) directed him to involve nursing staff, plus other staff as a team approach to de-escalate an agitated patient; however, this hospital left this task up to security staff alone.
31. Review of the patient's ED nurses' assessment, dated 08/21/11, showed the patient suffered a 0.5 centimeter laceration at the right lateral eyebrow from the fall related to the tasing event.
32. Staff failed to utilize the least restrictive, most appropriate measure when they handcuffed the patient and also tased the patient to subdue him. As a result of the tasing, the patient fell to the floor and sustained a laceration to the head. In spite of CPI nonharmful training, security staff resorted to a harmful method of restraint, even though it is not recommended by the training and/or policy.