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.

JOHNSTON HEALTH 509 BRIGHT LEAF BLVD SMITHFIELD, NC 27577 May 15, 2014
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0208
Based on hospital policy reviews, Memo reviews, personnel file reviews, and staff interviews, the hospital failed to ensure education/training records for Security Staff (to include Off-Duty Law Enforcement Officers) contained documentation of training and demonstration of competency for restraint and seclusion and non-physical intervention skills that were successfully completed for 1 of 2 Security Staff files reviewed (Deputy #1).

The findings include:

Review of current hospital policy "Restraint: Physical and Chemical Restraint and Seclusion for Behavioral Health Care (Violent or Self-Destructive Behavior)", Policy Number: 6010.16.10.H, revised 03/01/2014, revealed "PURPOSE: ...to protect the patient's and/or others' health and safety while preserving the patient's dignity, human rights, and well-being. PROCEDURE: ...Staff Training and Competence Staff shall be trained and able to demonstrate competency in the application of restraints, monitoring, assessment, and providing care for a patient in restraints before performing any of these actions, as part of orientation, and annually thereafter. 1. Training requirements for all direct care staff. In order to minimize the use of physical and chemical restraint and seclusion, all direct care staff as well as any other staff involved in the use of physical and chemical restraint and seclusion shall receive initial orientation and annual inservice training in and demonstrate an understanding a. of the underlying causes of threatening behaviors exhibited by the patients; b. that sometimes a patient may exhibit an aggressive behavior that is related to a medical condition and not related to his or her emotional condition...; c. strategies to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require restraint or seclusion. d. of the use of non-physical intervention skills such as de-escalation, mediation, self-protection, time-out and other techniques, and e. recognizing sings of physical and psychological distress in patients who are being held, restrained, or secluded. 2. Training requirements for staff who are authorized to physically apply restraint or seclusion. Staff who are authorized to physically apply restraint or seclusion shall receive the training and demonstrate the competence cited in 1a through 1e above, and also shall receive annual training in and demonstrate competence in the safe use of restraint, including: a. physical holding techniques, b. take-down procedures, and c. the safe application and removal of all types of physical restraints.

Review on 05/15/2014 of a "MEMO" dated 06/12/2012 from Administrative Management Staff (AMS) #3 to a Captain at the local Sheriff's Office revealed "The following guidelines are established for Law Enforcement while in the performance of duty in (Hospital A) Emergency Department ...*Appropriately and effectively intervenes when unruly, abusive, combative, threatening or armed persons are encountered in the Emergency Department ...*Education: Must be current on required education/training standards as a Deputy Sheriff. Be familiar with....emergency codes and knowledge of basic orientation booklet provided by the hospital. ..."

Telephone Interview on May 15, 2014 at 1021 with Deputy #1 revealed he works for the hospital as an off-duty law enforcement officer (LEO) with the Security Department. Interview revealed he has not received CPI/NCI (nonphysical intervention) training from the hospital. Interview revealed he has not received restraint and seclusion training from the hospital. Interview revealed he has been working at the hospital "a little over a year." Interview revealed he works 1 to 2 times per month in the ED.

A request was made on 05/15/2014 to review the personnel file for Deputy #1. No file was provided by Human Resources Staff prior to survey exit.

Interview on May 15, 2014 at 1441 with AMS #5 revealed "I do not have a personnel file on (Deputy #1)." Interview revealed "I cannot give you a real good explanation." Interview revealed the Deputy is not considered an employee of the hospital. Interview revealed the Deputy is paid via check from the hospital's accounts payable fund. Interview revealed the Sheriff Deputies are issued a 1099 form for tax purposes. Interview revealed there is no job description for the Sheriff Deputies. Interview revealed the Sheriff Deputies are not held to the same standards as hospital employees. Interview revealed all full-time, part-time, and as needed positions in the hospital require a job description. Interview revealed the Human Resources department has not approved a job description for the Sheriff Deputies (off-duty law enforcement officers).

Interview on May 14, 2014 at 1519 with AMS #2 and AMS #3 revealed off-duty law enforcement officers (LEO) are used at the (main) campus only. Interview revealed they have been used since July 2012. Interview revealed they are off-duty Sheriff Deputies. Interview revealed there is no written contract with the Deputy or Sheriff's Office to provide the security service. Interview revealed the LEOs are considered independent contractors. Interview revealed the LEOs do not sign a contract. Interview revealed the Deputies receive paychecks from the hospital. Interview revealed the off-duty LEOs are not Security Officers. Interview revealed "they were brought into provide a safe environment in the emergency department." Interview revealed they are posted in the emergency department lobby and patrol the treatment area. Interview revealed they are on duty Friday, Saturday, and Sunday from 1800 to 0600. Interview revealed they follow hospital policies when they are not acting as a law enforcement officer. Interview revealed the LEOs do not receive restraint and seclusion or CPI training from the hospital. Interview revealed the hospital relies on the training the LEOs receive from the Sheriff Office. Interview revealed restraint training is included in the CPI training provided to the Security Officers. Interview revealed LEO's do not attend hospital orientation or annual inservices. Interview revealed they receive the same information given to on-duty officers for forensic patients.

Review on 05/15/2014 of documents contained in the Forensic Information packet given to LEO's revealed 1. a Confidentiality Agreement, 2. a Security Policy, 3. a Forensic Information Guide. Review failed to reveal any available documentation regarding Restraint and Seclusion and Non-physical intervention (CPI/NCI) Training.

Consequently, the hospital failed to provide any available documentation Deputy #1 had documented training and demonstration of competency for restraint and seclusion and non-physical intervention skills that were successfully completed.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy reviews, medical record reviews, interviews with physician and staff, the Emergency Department (ED) nursing staff failed to provide nursing supervision in a manner to ensure a patient injury was reported to the ED physician for evaluation prior to discharge for 1 of 4 ED records reviewed (#1).

The findings include:

Review of current hospital policy "Assessment and Reassessment", Policy Number: 6230.1.8.H, reviewed 11/2013 revealed "...Reassessment: ...*Timing of reassessments should reflect the patients' status at any given moment they are in the treatment area, remembering that a patient's priority/acuity can change. ..."

Closed ED record review on 05/14/2014 for Patient #1 revealed a [AGE] year old male who represented to the hospital's ED (main campus) on 04/12/2014 at 1916 (Visit #1) with a chief complaint of chest pain. A medical screening examination (MSE) was performed by a physician. The patient was subsequently discharged (D/C) at 0110 (04/13) with a diagnosis of bipolar disorder and chest wall pain, condition stable. Further record review revealed the patient re-presented to the ED (main campus) at 0120 (Visit #2) with a chief complaint of "Mental Health Evaluation" and a stated complaint of "Just D/C from ER. Patient to Front Desk requesting mental health evaluation. Stated 'feel like I want to kill myself.' Pt (patient) reports he missed his monthly Haldol inj (injection). Pt unsure when his dose was due." A MSE was performed by a physician at 0145. Review of MSE documentation revealed "31 y/o male just dc'd from er. seen for chest pain with negative w/u (work up). normal ekg, normal cxr, normal lab, negative cardiac enzymes. Comes to window states 'he wants to kill himself'. Hx of bipolar." Review of ED physician's Progress note (not dated or timed) revealed "Progress Note: ...pt given geodon (a Benzisoxazole derivative - given intramuscular (IM) for treatment of acute agitation in schizophrenic patients for whom treatment with Geodon is appropriate and who need IM antipsychotic medication for rapid control of agitation.) 20 mg (milligrams) im (intramuscular), ativan (a Benzodiazepine - sedative) 2 mg im due to threatening behavior toward staff. ivc (involuntary commitment) paper done by (Physician A)." Review of physician's orders revealed at 0215 an order for Ziprasidone Mesylate (Geodon) 20 mg vial IM/Now/One and at 0223 for Lorazepam (Ativan) Injection 2 mg vial IM/Once/One (administered as ordered by a RN.) Review revealed an Affidavit and Petition for IVC was completed and signed by the ED physician at 0220. Review of nursing documentation by RN #1 at 0212 revealed "...Swearing at staff. Security called patient physical with security. Swearing and combative with Staff, Sheriff, and Security. Standing in hall yelling and screaming." At 0220 "Patient IVC'D by (Physician A) due to combative, threatening behavior with threats to staff and himself. At 0255 "Patient assessed by mental health nurse. IVC papers delivered by JCSD (local sheriff department). At 0300 "Patient noted to have scratched his nares just under his nose on top of lip. Bleeding controlled." Review of nursing documentation by RN #2 at 0834 "mains [sic] under 1:1 observation of hospital security officer d/t (due to) IVC status." Review of nursing documentation by RN #2 at 1122 on 04/14/2014 revealed "Late Note for 4/13/2014 at 1320: ...Patient noted to have swelling to left eye. When asked what happened he at first doesn't answer question but then says I got hit by the officer last night." Review of a Behavioral Health Service ED Re-evaluation form dated 04/13/2014 at 1230 by Psychiatrist A, revealed "Current Clinical Assessment and Mental Status: First came here for chest pain, then left, and came back. he denies now saying that he wants to kill himself. He reports that he just wants to get his Haldol Dec (Deconate) shot. ...He reports that he was hit by police here in hospital. ...MSE: ...L (left) eye swollen...Provisional Diagnosis: Axis I: Bipolar Disorder NOS (not otherwise specified) ...Recommended Disposition: ...D/C home and release from petition." Review of an ED "Addendum" dated 04/13/2014 at 1334 by Physician Assistant (PA) #1 revealed "ED Departure Time of Disposition: 1335 Date of ED Disposition: Apr (April) 13, 2014 Disposition: ...D/C...Diagnosis: bipolar...Condition Stable..." Further record review revealed the patient presented to the hospital's ED (satellite campus) on 04/13/2014 at 2009 (Visit #3) with a chief complaint of "Assault." Review revealed at 2022 "Eloped prior to triage."

Interview on May 15, 2014 at 0857 with Physician A revealed he was on duty May 12-13 working 2100 to 0700. Interview revealed he performed the MSE on Patient #1 (for Visit #1 at 2305 and Visit #2 at 0145). Interview revealed he is "very familiar with the patient." Interview revealed the patient has frequent ED visits. Interview revealed he does not recall being made aware of any reported injuries by the patient or staff.

Interview on May 15, 2014 at 0930 with RN #1 she was the primary care nurse for the patient on the day he presented to the emergency department (Visit #2). Interview revealed she was working the night shift 1900 to 0700. Interview revealed she remembered the patient being angry. Interview revealed Physician A discharged the patient from the ED and the patient returned to the front desk after being discharged and stated he wanted to kill himself. Interview revealed the patient was placed back into a treatment room. Interview revealed the patient was going to be involuntary committed. Interview revealed the Security Officer went into the room. Interview revealed "the next thing I knew he was mad as hell and he was going to leave." Interview revealed she remembers SO #1, a Sheriff Deputy, and two other security officers at the room. Interview revealed a Security Officer told the patient he must get back in his bed and that he could not stand in the hall. Interview revealed the patient stated "look at me, see I got hit." Interview revealed she did not witness the security officer striking the patient. Interview revealed "there was nothing wrong with the patient's face, it looked fine." Interview revealed the patient was told to get back into the bed. Interview revealed the patient was arguing and getting physical with the Security Officer and Sheriff Deputy. Interview revealed "the patient worked himself up and needed to calm down." Interview revealed Physician A ordered Geodon and Ativan for the patient. Interview revealed, later "a lab technician (name) came out of the patient's room and told me that the patient stated he had been hit and he had blood under his nose." Interview revealed upon assessment "he had a little amount of blood under his nose above the lip, a scratch." Interview revealed "there was no swelling or deformity and his face looked fine." Interview revealed "I did not notify (Physician A) of the patient's complaint or of the blood." Interview revealed "poor (Patient #1), no one took him seriously." Interview revealed "I forgot to document he stated he had been hit in the face." Interview revealed "I should have put something in about the patient being hit." Interview revealed "I did not take the patient seriously." Interview revealed she did not complete an incident report. Interview revealed she reported off to the day nurse (RN #2). Interview confirmed Patient #1 complained of an injury and RN #1 failed to report the findings to Physician A.

Interview on May 15, 2014 at 0956 with RN #2 revealed she was working the day shift on April 13, 2014 from 0700 to 1900. Interview revealed she remembers the patient. Interview revealed he initially came in for chest pain. Then was worked up for involuntary commitment. Interview revealed the patient got "mouthy and belligerent" and the physician chose to involuntary commit the patient. Interview revealed she wrote a late entry in Patient #1's ED record on 04/14/2014 at 1122 for 04/13/2014 at 1320. Interview revealed during the day the patient had his head covered most of the time. And she did not notice anything wrong with the patient's face until discharge. Interview revealed at discharge the patient stated to her that an officer had hit him. Interview revealed the patient's left eye had swelling above and below the eye. Interview revealed she asked if the patient wanted to be evaluated. Interview revealed the patient stated no and he wanted to leave. Interview revealed "the patient had been written up for discharge, I assumed since the patient had been medically cleared, the patient would have been screened by the doctor and the injury noticed." Interview revealed "in hind sight I should have had someone look at the patient's injury." Interview revealed at shift change she had not been made aware that the patient had been hit. Interview revealed she was unaware of any reported injury. Interview revealed she did not notify the emergency department physician of the patient's injury before discharging the patient.

Telephone Interview on May 15, 2014 at 1007 with PA #1 revealed he does not recall discharging Patient #1. Interview revealed he does not recall the Psychiatrist given any report to him about any injury related to the patient's face. Interview revealed he was not aware at the time of discharge any injury was reported. Interview revealed he was made aware a couple of weeks later about the patient's injury. Interview revealed he did not reassess the patient prior to discharge interview revealed he did not order an x-ray prior to discharge. Interview revealed the patient was initially assessed by the ED physician, then assessed by the Psychiatrist and then he was asked to complete the discharge paperwork from the emergency department only. Interview confirmed PA #1 was not notified by RN #2 of any injury prior to discharge.

Review of a "Discharge Instructions" form dated 04/14/2014 at 0926 from Hospital B for Patient #1, revealed the patient was evaluated in the ED at Hospital B on 04/14/2014. Review revealed "Your diagnosis is: Facial Trauma (ED), Fracture of maxillary sinus (ED), Orbit fracture (ED), Chest wall contusion (ED)." Further review revealed "CT (computed tomography) showed the following broken bones or fractures: Left trimalar or left tripod fracture, Fracture of left zygomatic arch, Fracture of left maxillary sinus (anterior and posterior-lateral walls), Fracture of left orbit (inferior rim, floor, and lateral wall)."

NC 688
VIOLATION: CONTRACTED SERVICES Tag No: A0085
Based on Memo reviews and staff interviews, the hospital failed to provide a written contract containing the scope and nature of the services provided for the hospital's contracted off-duty Law Enforcement Officers that provide Security Services in the hospitals' Emergency Department.

Review on 05/15/2014 of a "MEMO" dated 06/12/2012 from Administrative Management Staff (AMS) #3 to a Captain at the local Sheriff's Office revealed "The following guidelines are established for Law Enforcement while in the performance of duty in (Hospital A) Emergency Department *Provides security and protection for patients, visitors and employees. *Maintains a secure environment by assisting the control of visitor access to restricted areas such as Registration, Triage, Minor Treatment and ED Treatment Area. *Monitors conduct of patients and visitors. Confronts and escorts unruly and unauthorized persons from the ER premises, as warranted. *Appropriately and effectively intervenes when unruly, abusive, combative, threatening or armed persons are encountered in the Emergency Department ...*Be visible in ED lobby for main post and patrol ED treatment area once every hour as needed ...*Law Enforcement staffing hours: Friday, Saturday and Sunday 1800-0600 hours. ..."

Telephone Interview on May 15, 2014 at 1021 with Deputy #1 revealed he works for the hospital as an off-duty law enforcement officer with the Security Department. Interview revealed he receives paychecks from the hospital. Interview revealed he has been working at the hospital "a little over a year." Interview revealed he works 1 to 2 times per month in the ED.

Interview on May 14, 2014 at 1519 with Administrative Management Staff (AMS) #2 and AMS #3 revealed off-duty law enforcement officers (LEO) are used at the (main) campus only. Interview revealed they have been used since July 2012. Interview revealed they are off-duty Sheriff Deputies. Interview revealed there is no written contract with the Deputy or Sheriff's Office to provide the security service. Interview revealed the LEOs are considered independent contractors. Interview revealed the LEOs do not sign a contract. Interview revealed the Deputies receive paychecks from the hospital. Interview revealed the off-duty LEOs are not Security Officers. Interview revealed "they were brought into provide a safe environment in the emergency department." Interview revealed they are posted in the emergency department lobby and patrol the treatment area. Interview revealed they are on duty Friday, Saturday, and Sunday from 1800 to 0600. Interview revealed they follow hospital policies when they are not acting as a law enforcement officer.

Consequently, the hospital failed to provide any available documentation of a written contract containing the scope and nature of the services provided for the hospital's contracted off-duty Law Enforcement Officers that provide Security Services in the hospitals' Emergency Department.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy reviews, medical record reviews, Occurrence Report Statement reviews, security log reviews, interviews with staff, the hospital's Emergency Department (ED) staff failed to ensure the use of restraint and/or seclusion was in accordance with the order of a physician or other licensed independent practitioner for 1 of 3 patients restrained and/or secluded for the management of violent or self destructive behaviors (#1).

The findings include:

Review of current hospital policy "Restraint: Physical and Chemical Restraint and Seclusion for Behavioral Health Care (Violent or Self-Destructive Behavior)", Policy Number: 6010.16.10.H, revised 03/01/2014, revealed "PROCEDURE: ...Physical and chemical restraint and seclusion shall be used....only when necessary and only with the utmost care in an effort to minimize the physical and psychological risks associated with their use. ...Scope This policy applies to all physical and chemical restraint and seclusion used for behavioral health care reasons. ...Definitions Physical restraint. Physical restraint is the direct application of physical force to a patient, with or without the patient's permission, to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination thereof. ...Seclusion. The involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving. ...Initiation of Restraint or Seclusion A practitioner shall order the use of physical or chemical restraint or seclusion. All physical or chemical restraint and seclusion shall be used and continued pursuant to an order by the practitioner who is primarily responsible for the individual's ongoing care, or his or her designee. ..."

Closed ED record review on 05/14/2014 for Patient #1 revealed a [AGE] year old male who represented to the hospital's ED (main campus) on 04/12/2014 at 1916 (Visit #1) with a chief complaint of chest pain. A medical screening examination (MSE) was performed by a physician. The patient was subsequently discharged (D/C) at 0110 (04/13) with a diagnosis of bipolar disorder and chest wall pain, condition stable. Further record review revealed the patient re-presented to the ED (main campus) at 0120 (Visit #2) with a chief complaint of "Mental Health Evaluation" and a stated complaint of "Just D/C from ER. Patient to Front Desk requesting mental health evaluation. Stated 'feel like I want to kill myself.' Pt (patient) reports he missed his monthly Haldol inj (injection). Pt unsure when his dose was due." A MSE was performed by a physician at 0145. Review of MSE documentation revealed "31 y/o male just dc'd from er. seen for chest pain with negative w/u (work up). normal ekg, normal cxr, normal lab, negative cardiac enzymes. Comes to window states 'he wants to kill himself'. Hx of bipolar." Review of ED physician's Progress note (not dated or timed) revealed "Progress Note: ...pt given geodon (a Benzisoxazole derivative - given intramuscular (IM) for treatment of acute agitation in schizophrenic patients for whom treatment with Geodon is appropriate and who need IM antipsychotic medication for rapid control of agitation.) 20 mg (milligrams) im (intramuscular), ativan (a Benzodiazepine - sedative) 2 mg im due to threatening behavior toward staff. ivc (involuntary commitment) paper done by (Physician name)." Review of physician's orders revealed at 0215 an order for Ziprasidone Mesylate (Geodon) 20 mg vial IM/Now/One and at 0223 for Lorazepam (Ativan) Injection 2 mg vial IM/Once/One (administered as ordered by a RN.) Review revealed an Affidavit and Petition for IVC was completed and signed by the ED physician at 0220. Review of nursing documentation by RN #1 at 0212 revealed "...Swearing at staff. Security called patient physical with security. Swearing and combative with Staff, Sheriff, and Security. Standing in hall yelling and screaming." At 0220 "Patient IVC'D by (Physician A) due to combative, threatening behavior with threats to staff and himself. At 0255 "Patient assessed by mental health nurse. IVC papers delivered by JCSD (local sheriff department). At 0300 "Patient noted to have scratched his nares just under his nose on top of lip. Bleeding controlled." Review of nursing documentation by RN #2 at 0834 "mains [sic] under 1:1 observation of hospital security officer d/t (due to) IVC status." Review of nursing documentation by RN #2 at 1122 on 04/14/2014 revealed "Late Note for 4/13/2014 at 1320: ...Patient noted to have swelling to left eye. When asked what happened he at first doesn't answer question but then says I got hit by the officer last night."

Review on 05/15/2014 of a typed statement by Security Officer (SO) #1 attached to Occurrence Report #1 dated 04/13/2014 (not timed), revealed "At approximately 0215 AM, (SO #1) who was sitting in Behavioral Health Holding (BHH) received a call from ED staff that the patient in Ed-4, (Patient #1) who was here for a Mental Health evaluation was becoming aggressive and verbally abusive towards nurses. After clearing it with RN (name) in BH-Holding, (SO #1) left the holding area while also alerting (Deputy #1) stationed in ED Lobby to respond to ED-4. (SO #1) being the first to arrive found (Patient #1) in the bed with a blanket over his head. (SO #1) attempted to address (Patient #1) who would not respond. (SO #1) removed the blanket from (Patient #1) head. (Patient #1) sat up and then became verbally abusive towards (SO #1) as (SO #1) explained that this kind of abuse towards ED staff would not be tolerated. (Patient #1) then lunged from the bed towards (SO #1). (Deputy #1) and (SO #1) placed (Patient #1) back in his bed with (Patient #1) resisting. At this time (Patient #1) was considered a danger to others. (Patient #1) then got back up and stepped outside of his room, ED-4 and (Deputy #1) asked ED staff was it ok for (Patient #1) to leave, was he voluntary or involuntary. (Deputy #1) was instructed to not let (Patient #1) leave because ED MD (Physician A) took out involuntary commitment papers. (Patient #1) then tried to exit his room multiple times and was again placed on his bed each time while resisting, by (Deputy #1)." Review of the occurrence report revealed the hand written signature of SO #1 on a line adjacent to "Person Completing Report."

Review on 05/15/2014 of a typed statement by Deputy #1 (not dated or timed), attached to Occurrence Report #1, revealed "On Sunday April 13th around 0200 hours, this officer was working off duty work at (Hospital A) in Smithfield. This officer was called to the emergency room , reference to a mental patient. This officer walked to the emergency room and found (SO #1) in room number four. A (Patient #1) was laying down on the bed inside the room. As I entered the room (Patient #1) jumped up towards (SO #1) in a threaten manner. ...(Patient #1) kept trying to get up and walk outside his room, I advised him that he could not leave his room and to lay down on the bed. He told me to get away from him and he was leaving. As I got it [sic] front of him to block him from leaving the room he pushed me a little, by using his right arm. I then pushed him backwards toward the bed. ..." Review revealed the handwritten signature of Deputy #1 on the statement.

Review on 05/15/2014 of a typed statement by SO #2 dated 04/15/2014, attached to Occurrence Report #1, revealed "On the morning of Sunday, April 13th, 2014 at around 0215 am, ...I heard on the radio (SO #1) who was in Behavioral Health Triage ask for assistance from (Deputy #1) who was working in the Emergency Department that night. ...Upon arriving in the ED I found out that Security was needed in ED-4 with a patient (Patient #1). When arriving at ED-4, ED medical staff, (SO #1), (SO #3), and (Deputy #1) were outside the room with the patient on his bed. ...I then asked ED Charge RN (RN #4) what happened and she said that Security was needed due to the patient's behavior. ...(Deputy #1) stated....he jumped out of the bed at (SO #1) and that both had to place (Patient #1) back on the bed because of his behavior, which was threatening. ...(SO #1) stated that (Patient #1) 'lunged' at him from the bed....and that he and (Deputy #1) had to place (Patient #1) back in his bed. ...(Deputy #1) stated that (Patient #1) got up and went outside of ED-4; (Deputy #1) asked ED medical staff if (Patient #21) could leave, and was he voluntary or involuntary. (Deputy #1) was instructed to not let (Patient #1) leave because MD (Physician A) had taken out involuntary commitment papers on him. (Deputy #1) stated that (Patient #1) tried to push past him multiple times and that he had to put (Patient #1) on his bed multiple times. ..."

Review on 05/15/2014 of a Security Log Report for 04-12-2104, Saturday, 1800 to 0600 (04/13) for "C-Squad" revealed "0250 (SO #1) responded to a call from the ED regarding the patient in ED-4, (Patient #1) becoming aggressive, and verbally abusive towards ED Staff. (Deputy #1) also responded to the call from ED. (SO #1) approached (Patient #1) who was under the covers in his bed and was questioned about this behavior towards ED Staff. (Patient #1) would not respond. (SO #1) removed the covers from over his head, (Patient #1) sat up and became verbally abusive towards (SO #1) who explained to him that this type of behavior was not appropriate and would not be tolerated. (Patient #1) then lunged towards (SO #1). (SO #1) and (Deputy #1) then placed (Patient #1) back on the bed due to his behavior. (Patient #1) then got up and exited his room. (Deputy #1) asked ED Staff if (Patient #1) could leave, was he voluntary or involuntary. (Deputy #1) was instructed to not let (Patient #1) leave because Dr. (Physician A) had taken involuntary commitment papers out on him due to his behavior. (Deputy #1) placed (Patient #1) back on the bed multiple times, with (Patient #1) resisting, after he tried to exit his room."

Interview on May 15, 2014 at 0857, with Physician A revealed he was on duty May 12-13 working 2100 to 0700. Interview revealed he performed the MSE on Patient #1. Interview revealed he is "very familiar with the patient." Interview revealed the patient has frequent ED visits. Interview revealed he ordered the patient to have Geodon and Ativan during his visit. Interview revealed the medication was ordered for patient and staff safety. Interview revealed the patient was "aggressive and mouthy" towards staff. The medication was ordered to calm the patient down and prevent him from hurting staff, patients, or himself. Interview revealed "the medication usually puts the patient to sleep and then everything is fine." Interview revealed he did not order any physical restraint or seclusion for Patient #1.

Interview on May 15, 2014 at 0930 with RN #1 revealed she was the primary care nurse for the patient on the day he presented to the emergency department (Visit #2). Interview revealed she was working the night shift 1900 to 0700. Interview revealed she remembered the patient being angry. Interview revealed (Physician A) discharged the patient from the ED and the patient returned to the front desk after being discharged and stated he wanted to kill himself. Interview revealed the patient was placed back into a treatment room. Interview revealed the patient was going to be involuntary committed. Interview revealed the Security Officer went into the room. Interview revealed "the next thing I knew he was mad as hell and he was going to leave." Interview revealed she remembers SO #1, a Sheriff Deputy, and two other Security Officers at the room. Interview revealed a Security Officer told the patient he must get back in his bed and that he could not stand in the hall. Interview revealed the patient was told to get back into the bed. Interview revealed the patient was arguing and getting physical with the Security Officer and Sheriff Deputy. Interview revealed "the patient worked himself up and needed to calm down." Interview revealed Physician A ordered Geodon and Ativan for the patient. Interview revealed she administered the Geodon to the patient. Interview revealed the medications were given to control the patient's behavior. Interview revealed she witnessed the Sheriff Deputy physically put the patient back on his bed and the patient was told not to get off his bed. Interview revealed the patient was not allowed to leave his room because he was IVC'd. Interview revealed the Security Officer and Sheriff Deputy stood at the doorway. Interview revealed she did not receive or obtain a physician's order for physical restraint or seclusion. Interview revealed "I did not consider this a restraint or seclusion episode."

Telephone Interview on May 15, 2014 at 1021 with Deputy #1 revealed he works for the hospital as an off-duty law enforcement officer with the Security Department. Interview revealed he was in the emergency department lobby when he was called into the treatment area on 04/13/2014. Interview revealed as he entered the room, he observed Patient #1 jumping up off the bed in a threatening manner towards SO #1. Interview revealed he was told by hospital nursing staff that the patient was under involuntary commitment and could not leave his room. Interview revealed the patient was trying to go around him and exit the room. Interview revealed he stood in front of the door and blocked the patient's exit. Interview revealed the patient pushed at him and he pushed the patient back towards the bed. Interview revealed the patient was "physically not allowed to leave." Interview revealed the patient was "pushed 2 to 3 times to get back in bed." Interview revealed the patient was given medication shots to calm down. Interview revealed Patient #1 was not under arrest.

Interview on May 15, 2014 at 1219 with Administrative Management Staff (AMS) #4 revealed a physician's order is required for the application of restraint and/or seclusion. Interview revealed the hospital's restraint and seclusion policy must be followed. Interview confirmed that involuntary confinement of Patient #1 in ED-4 and physically preventing him from leaving the room is considered seclusion. Further interview confirmed physically holding Patient #1 to place him back on the bed, with or without his permission, in order to restrict his freedom of movement is considered a physical restraint. Interview confirmed no available documentation of a physician's order for physical restraint or seclusion for Patient #1 on 04/13/2014 (Visit #2).

Consequently, record review failed to reveal any available documentation the ED nursing staff obtained a physician's or other licensed independent practitioner's order for use of restraint and/or seclusion when Patient #1 was physically held and placed back onto his bed and physically prevented from exiting his room by SO #1 and Deputy #1 on 04/13/2014 (Visit #2).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy reviews, medical record reviews, Occurrence Report Statement reviews, security log reviews, interviews with staff, the hospital's Emergency Department (ED) staff failed to ensure a one-hour face-to-face assessment was documented after the application of a restrictive intervention for 1 of 3 patients restrained and/or secluded for the management of violent or self destructive behaviors (#1).

The findings include:

Review of current hospital policy "Restraint: Physical and Chemical Restraint and Seclusion for Behavioral Health Care (Violent or Self-Destructive Behavior)", Policy Number: 6010.16.10.H, revised 03/01/2014, revealed "PROCEDURE: ...Scope This policy applies to all physical and chemical restraint and seclusion used for behavioral health care reasons. ...Definitions Physical restraint. Physical restraint is the direct application of physical force to a patient, with or without the patient's permission, to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination thereof. ...Seclusion. The involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving. ...Initiation of Restraint or Seclusion ...The practitioner shall: ...5. provide an in-person evaluation within one hour of initiation of restraint or seclusion and ...Evaluation of the Individual in Restraint or Seclusion A practitioner shall see and evaluate the individual in person (i.e., face-to-face.) A telephone call is not adequate. 1. Timeframe for the in-person evaluation of the individual by the practitioner. The practitioner who is primarily responsible for the individual's ongoing care, or his or her designee, shall conduct an in-person examination of the individual within one hour of initiation of physical and chemical restraint or seclusion. ..."

Closed ED record review on 05/14/2014 for Patient #1 revealed a [AGE] year old male who represented to the hospital's ED (main campus) on 04/12/2014 at 1916 (Visit #1) with a chief complaint of chest pain. A medical screening examination (MSE) was performed by a physician. The patient was subsequently discharged (D/C) at 0110 (04/13) with a diagnosis of bipolar disorder and chest wall pain, condition stable. Further record review revealed the patient re-presented to the ED (main campus) at 0120 (Visit #2) with a chief complaint of "Mental Health Evaluation" and a stated complaint of "Just D/C from ER. Patient to Front Desk requesting mental health evaluation. Stated 'feel like I want to kill myself.' Pt (patient) reports he missed his monthly Haldol inj (injection). Pt unsure when his dose was due." A MSE was performed by a physician at 0145. Review of MSE documentation revealed "31 y/o male just dc'd from er. seen for chest pain with negative w/u (work up). normal ekg, normal cxr, normal lab, negative cardiac enzymes. Comes to window states 'he wants to kill himself'. Hx of bipolar." Review of ED physician's Progress note (not dated or timed) revealed "Progress Note: ...pt given geodon (a Benzisoxazole derivative - given intramuscular (IM) for treatment of acute agitation in schizophrenic patients for whom treatment with Geodon is appropriate and who need IM antipsychotic medication for rapid control of agitation.) 20 mg (milligrams) im (intramuscular), ativan (a Benzodiazepine - sedative) 2 mg im due to threatening behavior toward staff. ivc (involuntary commitment) paper done by (Physician name)." Review of physician's orders revealed at 0215 an order for Ziprasidone Mesylate (Geodon) 20 mg vial IM/Now/One and at 0223 for Lorazepam (Ativan) Injection 2 mg vial IM/Once/One (administered as ordered by a RN.) Review revealed an Affidavit and Petition for IVC was completed and signed by the ED physician at 0220. Review of nursing documentation by RN #1 at 0212 revealed "...Swearing at staff. Security called patient physical with security. Swearing and combative with Staff, Sheriff, and Security. Standing in hall yelling and screaming." At 0220 "Patient IVC'D by (Physician A) due to combative, threatening behavior with threats to staff and himself. At 0255 "Patient assessed by mental health nurse. IVC papers delivered by JCSD (local sheriff department). At 0300 "Patient noted to have scratched his nares just under his nose on top of lip. Bleeding controlled." Review of nursing documentation by RN #2 at 0834 "mains [sic] under 1:1 observation of hospital security officer d/t (due to) IVC status." Review of nursing documentation by RN #2 at 1122 on 04/14/2014 revealed "Late Note for 4/13/2014 at 1320: ...Patient noted to have swelling to left eye. When asked what happened he at first doesn't answer question but then says I got hit by the officer last night."

Review on 05/15/2014 of a typed statement by Security Officer (SO) #1 attached to Occurrence Report #1 dated 04/13/2014 (not timed), revealed "At approximately 0215 AM, (SO #1) who was sitting in Behavioral Health Holding (BHH) received a call from ED staff that the patient in Ed-4, (Patient #1) who was here for a Mental Health evaluation was becoming aggressive and verbally abusive towards nurses. After clearing it with RN (name) in BH-Holding, (SO #1) left the holding area while also alerting (Deputy #1) stationed in ED Lobby to respond to ED-4. (SO #1) being the first to arrive found (Patient #1) in the bed with a blanket over his head. (SO #1) attempted to address (Patient #1) who would not respond. (SO #1) removed the blanket from (Patient #1) head. (Patient #1) sat up and then became verbally abusive towards (SO #1) as (SO #1) explained that this kind of abuse towards ED staff would not be tolerated. (Patient #1) then lunged from the bed towards (SO #1). (Deputy #1) and (SO #1) placed (Patient #1) back in his bed with (Patient #1) resisting. At this time (Patient #1) was considered a danger to others. (Patient #1) then got back up and stepped outside of his room, ED-4 and (Deputy #1) asked ED staff was it ok for (Patient #1) to leave, was he voluntary or involuntary. (Deputy #1) was instructed to not let (Patient #1) leave because ED MD (Physician A) took out involuntary commitment papers. (Patient #1) then tried to exit his room multiple times and was again placed on his bed each time while resisting, by (Deputy #1)." Review of the occurrence report revealed the hand written signature of SO #1 on a line adjacent to "Person Completing Report."

Review on 05/15/2014 of a typed statement by Deputy #1 (not dated or timed), attached to Occurrence Report #1, revealed "On Sunday April 13th around 0200 hours, this officer was working off duty work at (Hospital A) in Smithfield. This officer was called to the emergency room , reference to a mental patient. This officer walked to the emergency room and found (SO #1) in room number four. A (Patient #1) was laying down on the bed inside the room. As I entered the room (Patient #1) jumped up towards (SO #1) in a threaten manner. ...(Patient #1) kept trying to get up and walk outside his room, I advised him that he could not leave his room and to lay down on the bed. He told me to get away from him and he was leaving. As I got it [sic] front of him to block him from leaving the room he pushed me a little, by using his right arm. I then pushed him backwards toward the bed. ..." Review revealed the handwritten signature of Deputy #1 on the statement.

Review on 05/15/2014 of a typed statement by SO #2 dated 04/15/2014, attached to Occurrence Report #1, revealed "On the morning of Sunday, April 13th, 2014 at around 0215 am, ...I heard on the radio (SO #1) who was in Behavioral Health Triage ask for assistance from (Deputy #1) who was working in the Emergency Department that night. ...Upon arriving in the ED I found out that Security was needed in ED-4 with a patient (Patient #1). When arriving at ED-4, ED medical staff, (SO #1), (SO #3), and (Deputy #1) were outside the room with the patient on his bed. ...I then asked ED Charge RN (RN #4) what happened and she said that Security was needed due to the patient's behavior. ...(Deputy #1) stated....he jumped out of the bed at (SO #1) and that both had to place (Patient #1) back on the bed because of his behavior, which was threatening. ...(SO #1) stated that (Patient #1) 'lunged' at him from the bed....and that he and (Deputy #1) had to place (Patient #1) back in his bed. ...(Deputy #1) stated that (Patient #1) got up and went outside of ED-4; (Deputy #1) asked ED medical staff if (Patient #21) could leave, and was he voluntary or involuntary. (Deputy #1) was instructed to not let (Patient #1) leave because MD (Physician A) had taken out involuntary commitment papers on him. (Deputy #1) stated that (Patient #1) tried to push past him multiple times and that he had to put (Patient #1) on his bed multiple times. ..."

Review on 05/15/2014 of a Security Log Report for 04-12-2104, Saturday, 1800 to 0600 (04/13) for "C-Squad" revealed "0250 (SO #1) responded to a call from the ED regarding the patient in ED-4, (Patient #1) becoming aggressive, and verbally abusive towards ED Staff. (Deputy #1) also responded to the call from ED. (SO #1) approached (Patient #1) who was under the covers in his bed and was questioned about this behavior towards ED Staff. (Patient #1) would not respond. (SO #1) removed the covers from over his head, (Patient #1) sat up and became verbally abusive towards (SO #1) who explained to him that this type of behavior was not appropriate and would not be tolerated. (Patient #1) then lunged towards (SO #1). (SO #1) and (Deputy #1) then placed (Patient #1) back on the bed due to his behavior. (Patient #1) then got up and exited his room. (Deputy #1) asked ED Staff if (Patient #1) could leave, was he voluntary or involuntary. (Deputy #1) was instructed to not let (Patient #1) leave because Dr. (Physician A) had taken involuntary commitment papers out on him due to his behavior. (Deputy #1) placed (Patient #1) back on the bed multiple times, with (Patient #1) resisting, after he tried to exit his room."

Interview on May 15, 2014 at 0857, with Physician A revealed he was on duty May 12-13 working 2100 to 0700. Interview revealed he performed the MSE on Patient #1 (for Visit #1 at 2305 and for Visit #2 at 0145). Interview revealed he is "very familiar with the patient." Interview revealed the patient has frequent ED visits. Interview revealed he ordered the patient to have Geodon and Ativan during his visit. Interview revealed the medication was ordered for patient and staff safety. Interview revealed the patient was "aggressive and mouthy" towards staff. The medication was ordered to calm the patient down and prevent him from hurting staff, patients, or himself. Interview revealed "the medication usually puts the patient to sleep and then everything is fine." Interview revealed he did not order any physical restraint or seclusion for Patient #1. Interview revealed he believed he saw the patient again around 0300 to 0315 but did not document an assessment.

Interview on May 15, 2014 at 0930 with RN #1 revealed she was the primary care nurse for the patient on the day he presented to the emergency department (Visit #2). Interview revealed she was working the night shift 1900 to 0700. Interview revealed she remembered the patient being angry. Interview revealed (Physician A) discharged the patient from the ED and the patient returned to the front desk after being discharged and stated he wanted to kill himself. Interview revealed the patient was placed back into a treatment room. Interview revealed the patient was going to be involuntary committed. Interview revealed the Security Officer went into the room. Interview revealed "the next thing I knew he was mad as hell and he was going to leave." Interview revealed she remembers SO #1, a Sheriff Deputy, and two other Security Officers at the room. Interview revealed a Security Officer told the patient he must get back in his bed and that he could not stand in the hall. Interview revealed the patient was told to get back into the bed. Interview revealed the patient was arguing and getting physical with the Security Officer and Sheriff Deputy. Interview revealed "the patient worked himself up and needed to calm down." Interview revealed Physician A ordered Geodon and Ativan for the patient. Interview revealed she administered the Geodon to the patient. Interview revealed the medications were given to control the patient's behavior. Interview revealed she witnessed the Sheriff Deputy physically put the patient back on his bed and the patient was told not to get off his bed. Interview revealed the patient was not allowed to leave his room because he was IVC'd. Interview revealed the Security Officer and Sheriff Deputy stood at the doorway. Interview revealed she did not receive or obtain a physician's order for physical restraint or seclusion. Interview revealed "I did not consider this a restraint or seclusion episode."

Telephone Interview on May 15, 2014 at 1021 with Deputy #1 revealed he works for the hospital as an off-duty law enforcement officer with the Security Department. Interview revealed he was in the emergency department lobby when he was called into the treatment area on 04/13/2014. Interview revealed as he entered the room, he observed Patient #1 jumping up off the bed in a threatening manner towards SO #1. Interview revealed he was told by hospital nursing staff that the patient was under involuntary commitment and could not leave his room. Interview revealed the patient was trying to go around him and exit the room. Interview revealed he stood in front of the door and blocked the patient's exit. Interview revealed the patient pushed at him and he pushed the patient back towards the bed. Interview revealed the patient was "physically not allowed to leave." Interview revealed the patient was "pushed 2 to 3 times to get back in bed." Interview revealed the patient was given medication shots to calm down. Interview revealed Patient #1 was not under arrest.

Consequently, record review failed to reveal any available documentation of a one-hour face-to-face assessment performed by a Physician or other licensed independent practitioner; or trained Registered Nurse after Patient #1 was physically held (Restraint) and placed back onto his bed and physically prevented from exiting (Seclusion) his room by SO #1 and Deputy #1 on 04/13/2014 (Visit #2).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on hospital policy reviews, Memo reviews, personnel file reviews, and staff interviews, the hospital failed to ensure Security Staff (to include Off-Duty Law Enforcement Officers) were trained in the use of non-physical intervention skills for 1 of 2 Security Staff (Deputy #1) files reviewed.

The findings include:

Review of current hospital policy "Restraint: Physical and Chemical Restraint and Seclusion for Behavioral Health Care (Violent or Self-Destructive Behavior)", Policy Number: 6010.16.10.H, revised 03/01/2014, revealed "PURPOSE: ...to protect the patient's and/or others' health and safety while preserving the patient's dignity, human rights, and well-being. PROCEDURE: ...Staff Training and Competence Staff shall be trained and able to demonstrate competency in the application of restraints, monitoring, assessment, and providing care for a patient in restraints before performing any of these actions, as part of orientation, and annually thereafter. 1. Training requirements for all direct care staff. In order to minimize the use of physical and chemical restraint and seclusion, all direct care staff as well as any other staff involved in the use of physical and chemical restraint and seclusion shall receive initial orientation and annual inservice training in and demonstrate an understanding a. of the underlying causes of threatening behaviors exhibited by the patients; b. that sometimes a patient may exhibit an aggressive behavior that is related to a medical condition and not related to his or her emotional condition...; c. strategies to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require restraint or seclusion. d. of the use of non-physical intervention skills such as de-escalation, mediation, self-protection, time-out and other techniques, and e. recognizing sings of physical and psychological distress in patients who are being held, restrained, or secluded. 2. Training requirements for staff who are authorized to physically apply restraint or seclusion. Staff who are authorized to physically apply restraint or seclusion shall receive the training and demonstrate the competence cited in 1a through 1e above, and also shall receive annual training in and demonstrate competence in the safe use of restraint, including: a. physical holding techniques, b. take-down procedures, and c. the safe application and removal of all types of physical restraints.

Review on 05/15/2014 of a "MEMO" dated 06/12/2012 from Administrative Management Staff (AMS) #3 to a Captain at the local Sheriff's Office revealed "The following guidelines are established for Law Enforcement while in the performance of duty in (Hospital A) Emergency Department ...*Appropriately and effectively intervenes when unruly, abusive, combative, threatening or armed persons are encountered in the Emergency Department ...*Education: Must be current on required education/training standards as a Deputy Sheriff. Be familiar with....emergency codes and knowledge of basic orientation booklet provided by the hospital. ..."

Telephone Interview on May 15, 2014 at 1021 with Deputy #1 revealed he works for the hospital as an off-duty law enforcement officer (LEO) with the Security Department. Interview revealed he has not received CPI/NCI (nonphysical intervention) training from the hospital. Interview revealed he has not received restraint and seclusion training from the hospital. Interview revealed he has been working at the hospital "a little over a year." Interview revealed he works 1 to 2 times per month in the ED.

A request was made on 05/15/2014 to review the personnel file for Deputy #1. No file was provided by Human Resources Staff prior to survey exit.

Interview on May 15, 2014 at 1441 with AMS #5 revealed "I do not have a personnel file on (Deputy #1)." Interview revealed "I cannot give you a real good explanation." Interview revealed the Deputy is not considered an employee of the hospital. Interview revealed the Deputy is paid via check from the hospital's accounts payable fund. Interview revealed the Sheriff Deputies are issued a 1099 form for tax purposes. Interview revealed there is no job description for the Sheriff Deputies. Interview revealed the Sheriff Deputies are not held to the same standards as hospital employees. Interview revealed all full-time, part-time, and as needed positions in the hospital require a job description. Interview revealed the Human Resources department has not approved a job description for the Sheriff Deputies (off-duty law enforcement officers).

Interview on May 14, 2014 at 1519 with AMS #2 and AMS #3 revealed off-duty law enforcement officers (LEO) are used at the (main) campus only. Interview revealed they have been used since July 2012. Interview revealed they are off-duty Sheriff Deputies. Interview revealed there is no written contract with the Deputy or Sheriff's Office to provide the security service. Interview revealed the LEOs are considered independent contractors. Interview revealed the LEOs do not sign a contract. Interview revealed the Deputies receive paychecks from the hospital. Interview revealed the off-duty LEOs are not Security Officers. Interview revealed "they were brought into provide a safe environment in the emergency department." Interview revealed they are posted in the emergency department lobby and patrol the treatment area. Interview revealed they are on duty Friday, Saturday, and Sunday from 1800 to 0600. Interview revealed "they follow hospital policies when they are not acting as a law enforcement officer." Interview revealed the LEOs do not receive restraint and seclusion or CPI training from the hospital. Interview revealed the hospital relies on the training the LEOs receive from the Sheriff's Office. Interview revealed restraint training is included in the CPI training provided to the Security Officers. Interview revealed LEO's do not attend hospital orientation or annual inservices. Interview revealed they receive the same information given to on-duty officers for forensic patients.

Review on 05/15/2014 of documents contained in the Forensic Information packet given to LEO's revealed 1. a Confidentiality Agreement, 2. a Security Policy, 3. a Forensic Information Guide. Review failed to reveal any available documentation regarding Restraint and Seclusion and Non-physical intervention (CPI/NCI) Skills Training.

Consequently the hospital failed to provide any available documentation that Deputy #1 had received Restraint/Seclusion and non-physical intervention skills training.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on hospital policy reviews, Memo reviews, personnel file reviews, and staff interviews, the hospital failed to ensure Security Staff (to include Off-Duty Law Enforcement Officers) were trained in the safe application and use of restraint or seclusion for 1 of 2 Security Staff (Deputy #1) files reviewed.

The findings include:

Review of current hospital policy "Restraint: Physical and Chemical Restraint and Seclusion for Behavioral Health Care (Violent or Self-Destructive Behavior)", Policy Number: 6010.16.10.H, revised 03/01/2014, revealed "PURPOSE: ...to protect the patient's and/or others' health and safety while preserving the patient's dignity, human rights, and well-being. PROCEDURE: ...Staff Training and Competence Staff shall be trained and able to demonstrate competency in the application of restraints, monitoring, assessment, and providing care for a patient in restraints before performing any of these actions, as part of orientation, and annually thereafter. 1. Training requirements for all direct care staff. In order to minimize the use of physical and chemical restraint and seclusion, all direct care staff as well as any other staff involved in the use of physical and chemical restraint and seclusion shall receive initial orientation and annual inservice training in and demonstrate an understanding a. of the underlying causes of threatening behaviors exhibited by the patients; b. that sometimes a patient may exhibit an aggressive behavior that is related to a medical condition and not related to his or her emotional condition...; c. strategies to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require restraint or seclusion. d. of the use of non-physical intervention skills such as de-escalation, mediation, self-protection, time-out and other techniques, and e. recognizing sings of physical and psychological distress in patients who are being held, restrained, or secluded. 2. Training requirements for staff who are authorized to physically apply restraint or seclusion. Staff who are authorized to physically apply restraint or seclusion shall receive the training and demonstrate the competence cited in 1a through 1e above, and also shall receive annual training in and demonstrate competence in the safe use of restraint, including: a. physical holding techniques, b. take-down procedures, and c. the safe application and removal of all types of physical restraints.

Review on 05/15/2014 of a "MEMO" dated 06/12/2012 from Administrative Management Staff (AMS) #3 to a Captain at the local Sheriff's Office revealed "The following guidelines are established for Law Enforcement while in the performance of duty in (Hospital A) Emergency Department ...*Appropriately and effectively intervenes when unruly, abusive, combative, threatening or armed persons are encountered in the Emergency Department ...*Education: Must be current on required education/training standards as a Deputy Sheriff. Be familiar with....emergency codes and knowledge of basic orientation booklet provided by the hospital. ..."

Telephone Interview on May 15, 2014 at 1021 with Deputy #1 revealed he works for the hospital as an off-duty law enforcement officer (LEO) with the Security Department. Interview revealed he has not received CPI/NCI (nonphysical intervention) training from the hospital. Interview revealed he has not received restraint and seclusion training from the hospital. Interview revealed he has been working at the hospital "a little over a year." Interview revealed he works 1 to 2 times per month in the ED.

A request was made on 05/15/2014 to review the personnel file for Deputy #1. No file was provided by Human Resources Staff prior to survey exit.

Interview on May 15, 2014 at 1441 with AMS #5 revealed "I do not have a personnel file on (Deputy #1)." Interview revealed "I cannot give you a real good explanation." Interview revealed the Deputy is not considered an employee of the hospital. Interview revealed the Deputy is paid via check from the hospital's accounts payable fund. Interview revealed the Sheriff Deputies are issued a 1099 form for tax purposes. Interview revealed there is no job description for the Sheriff Deputies. Interview revealed the Sheriff Deputies are not held to the same standards as hospital employees. Interview revealed all full-time, part-time, and as needed positions in the hospital require a job description. Interview revealed the Human Resources department has not approved a job description for the Sheriff Deputies (off-duty law enforcement officers).

Interview on May 14, 2014 at 1519 with AMS #2 and AMS #3 revealed off-duty law enforcement officers (LEO) are used at the (main) campus only. Interview revealed they have been used since July 2012. Interview revealed they are off-duty Sheriff Deputies. Interview revealed there is no written contract with the Deputy or Sheriff's Office to provide the security service. Interview revealed the LEOs are considered independent contractors. Interview revealed the LEOs do not sign a contract. Interview revealed the Deputies receive paychecks from the hospital. Interview revealed the off-duty LEOs are not Security Officers. Interview revealed "they were brought into provide a safe environment in the emergency department." Interview revealed they are posted in the emergency department lobby and patrol the treatment area. Interview revealed they are on duty Friday, Saturday, and Sunday from 1800 to 0600. Interview revealed they follow hospital policies when they are not acting as a law enforcement officer. Interview revealed the LEOs do not receive restraint and seclusion or CPI training from the hospital. Interview revealed the hospital relies on the training the LEOs receive from the Sheriff Office. Interview revealed restraint training is included in the CPI training provided to the Security Officers. Interview revealed LEO's do not attend hospital orientation or annual inservices. Interview revealed they receive the same information given to on-duty officers for forensic patients.

Review on 05/15/2014 of documents contained in the Forensic Information packet given to LEO's revealed 1. a Confidentiality Agreement, 2. a Security Policy, 3. a Forensic Information Guide. Review failed to reveal any available documentation regarding Restraint and Seclusion and Non-physical intervention (CPI/NCI) Skills Training.

Consequently, the hospital failed to provide any available documentation that Deputy #1 had was trained in the safe application and use of restraint and seclusion used in the hospital.