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.

REX HOSPITAL 4420 LAKE BOONE TRAIL RALEIGH, NC 27607 March 20, 2015
VIOLATION: GOVERNING BODY Tag No: A0043
Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews,the hospital's leadership failed to provide oversight and have systems in place to ensure the protection and promotion of Patients' Rights; failed to have an organized Nursing Service; and failed to provide Emergency Services to meet the patients' needs.

The findings include:

1. The hospital's staff failed to protect and promote patients' rights for a safe environment for 1 of 1 psychiatric patients (#5) tasered and restrained for the management of violent and self-destructive behaviors in the hospital's emergency department and failed to obtain renewal orders for 1 of 1 in-patients (#10) restrained for for the management of non-violent and non-self-destructive behaviors.

~cross refer to 482.13 Patient Rights Condition - Tag A0115.

2. The hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure registered nursing staff supervised and evaluated patient care for 1 of 1 psychiatric patients (#5) in the hospital's emergency department.

~cross refer to 482.23 Nursing Services Condition - Tag A0385.

3. The hospital's staff failed to meet the emergency needs for 1 of 1 psychiatric patients (#5) in accordance with the hospital's policy and procedures.

~cross refer to 482.55 Emergency Services Condition - Tag A1100.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital's staff failed to protect and promote patients' rights for a safe environment for 1 of 1 psychiatric patients (#5) tasered and restrained for the management of violent and self-destructive behaviors in the hospital's emergency department and failed to obtain renewal orders for 1 of 1 in-patients (#10) restrained for for the management of non-violent and non-self-destructive behaviors.

The findings include:

1. The hospital's staff failed to assure care in a safe environment by allowing TASER weapons to be used by the hospital's non-law enforcement security staff (PSO) as a means of subduing a psychiatric patient in order to place the patient in restraints and failed to discontinue restraints at the earliest possible time for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors.

~cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144

2. The hospital's staff failed to ensure TASER weapons were not used by non-law enforcement security staff as a means of subduing a psychiatric patient in order to place the patient in restraints; and failed to ensure restraints were not imposed as a means of coercion, discipline, convenience, or retaliation by staff and were discontinued at the earliest possible time for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors that was not placed into custody of law enforcement while in the Emergency Department and transferred to a Psychiatric Hospital for treatment and stabilization.

~cross refer to 482.13(e) Patient Rights Standard: Tag A0154

3. The hospital's staff failed to obtain renewal orders for patients restrained in the management of non-violent and non-self-destructive behaviors for 1 of 1 patients in non-violent restraints (#10).

~cross refer to 482.13(e)(8) Patient Rights Standard: Tag A0173

4. The hospital's staff failed to ensure restraints were discontinued at the earliest possible time for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors.

~cross refer to 482.13(e)(9) Patient Rights Standard: Tag A0174
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital's staff failed to assure care in a safe environment by allowing TASER weapons to be used by the hospital's non-law enforcement security staff (PSO) as a means of subduing a psychiatric patient in order to place the patient in restraints and failed to discontinue restraints at the earliest possible time for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors.

The findings include:

Review of current hospital policy "Patient Rights And Responsibilities" last revised 08/28/2014 revealed "...Patient Rights and Responsibilities ...16. Be free from abuse, neglect and harassment... 17. Be free from restraint and seclusion that is not medically required or is used inappropriately. ..."

Review of current hospital policy "Restraint and Seclusion" revised 06/20/2014 revealed "Areas Affected: All Patient Care Areas PHILOSOPHY STATEMENT: (Name) Hospital is committed to providing a least restrictive, safe, and appropriate environment for all individuals. ...restraint use is limited to those circumstances where the patient is identified as being a t risk for injury to self or others and alternative safety measures have been evaluated and deemed inadequate. ...DEFINITIONS OF RESTRAINT AND SECLUSION: Restraint: 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 of the two. ...RESTRAINT MANAGEMENT GOALS: A. Restraints are only used when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others. B. Restraints are not used a s a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used when less restrictive interventions are ineffective and if used, the least restrictive form of restraint is used to protect the physical safety of the patient, staff, or others. D. Restraints are discontinued at the earliest possible time regardless of the scheduled expiration of the order. E. Restraints will be applied using the proper technique based on the type of restraint. F. The appropriate restraint plan of care will be initiated for the patient. G. Physicians/LIP is responsible for ordering the restraints. PRN restraint orders are not acceptable. ...I. Patients will be monitored, evaluated, and re-evaluated according to the Restraint Protocol. ..."

Review of current hospital policy "Restraint Management Protocol, 2466-1" last revised 06/20/2014 revealed "Definitions: A. Physical Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Examples are a vest, soft wrist or ankle restraints, mittens (if tied), leather restraints... Categories of Restraints/Indications for Use: ...B. Violent or Self-Destructive Behavior (Behavioral) Restraints: 1. A clinical justification, other than those identified as non-violent or non-self-destructive behavior, to protect the patient from injury to self or others because of an emotional or behavioral disorder where the behavior may be violent or aggressive. RESPONSIBILITIES: A. Violent/Self-Destructive Behavior (Behavioral) Restraints: 1. Physician/Licensed Independent Practitioner (LIP)*: a. Order for restraints at initiation. b. Face to face assessment of the need for restraint initiation within one hour and ongoing assessment of the continued need for restraints. c. Renewal order for continued justification for restraints. d. Review and evaluation of current medications to identify and minimize the use of medications that place a patient at risk for restraint use. ...3. Staff Nurse: a. Identification of the patient at risk for restraints, the behavior/symptoms that the patient is exhibiting, and the initiation of pre-restraint alternative interventions that may reduce both the need and duration of restraint use. b. Restraint initiation and management. c. Calls the attending physician/LIP for a restraint order. d. Notifies the attending physician that restraints have been initiated if he/she was not the ordering physician of the restraint as soon as possible**. e. Regular scheduled reassessment of the patient in restraints to justify continued validity of restraint use with the potential to discontinue or reduce the level of restraint evaluated. ...GENERAL RESTRAINT INFORMATION: A. PRN and standing orders for any category of restraint is not acceptable. B. Restraints are not used as a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used only when other less restrictive interventions are ineffective. If restraints are employed, the least restrictive restraint to protect the patient's/other's physical safety is used. D. The restraint should be discontinued by the staff nurse at the earliest possible time regardless of the scheduled expiration of the order. Discontnued Criteria includes: ...2. Violent/Self Destructive a. No physical aggression b. Rational/compliant/follows directions c. Patient calm/asleep d. Transferred to secure area ...VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR RESTRAINT (BEHAVIORAL) MANAGEMENT: ...Physician Order: 1. A staff nurse may apply restraints in an emergency situation prior to obtaining a physician order but the physician/LIP should be contacted immediately and notified that restraints have been initiated. ...2. Any patient restraint within one hour after the initiation of restraints by a physician/LIP or Specially Trained Nurse who will evaluate the continued need for restraint. ...3. The face to face assessment conducted within one hour includes the following: a. An evaluation of the patient's immediate situation. b. The patient's reaction to the intervention. c. The patient's medical and behavioral condition. d. The need to continue or terminate the restraint. 4. Renewal orders must be obtained every 2 hours for patients 9-17 years of age and every 4 hours for ages 18 and older. Orders may be renewed for a maximum of 24 consecutive hours at which time a physician/LIP reassessment is required. 5. Every 24 hours a physician/LIP must complete a face to face assessment before writing a new order. 6. If a restraint is discontinued prior to the expiration of the order, a new order must be obtained to re-initiate restraints. C. Routine Monitoring/Patient Care: 1. Patients will have continuous, direct one on one observation at all times by a staff nurse, NA, or PCT. Continuous observation and psychological status/visual check (i.e. affect/behavior) will be documented every 15 minutes. 2. Routine checks will be monitored and documented every 2 hours by a staff nurse, NA, or PCT. Routine checks includes: ROM, elimination, fluids, circulation/skin integrity, and food/meal. 3. The continued justification for restraints or a less restrictive form of restraints will be assessed and documented every 4 hours by the staff nurse. ..."

Review of current hospital policy "1700-05, Restraints" last revised 04/14/2014 revealed "...1. Restraint Assistance A. A Protective Services officer may be called upon to assist the health care team in restraining a patient. The officer provides assistance within the scope of Patient Care Services Restraint policy (refer to the Patient Care Services Policy Manual). B. Upon arriving at the scene, the officer will make contact with the person(s) requesting assistance. 1. If an officer comes upon a scene with staff struggling with a patient, the officer immediately offers assistance. 2. If an officer comes upon a scene and there appears to be no imminent danger to the patient or the staff, the responding officer(s) will seek guidance from the health care team on the level of physical contact and method of restraint. C. The officer assists the staff by immobilizing the patient's arms and legs while the staff secures the restraints. D. If the staff is unfamiliar with the restraints, then the officer will secure the restraints. ..."

Review of current hospital policy "1400-20 Electronic Control Device (TASER) last revised 04/14/2014 revealed "...Protective Services officers have an obligation to protect all staff, patients, and visitors against violence while on campus. ...Therefore, officers trained in the use of electronic control devices (TASER) will be allowed to possess, and in accordance with the Protective Service Policy 1400-05, Use of Force Guidelines, deploy the TASER to subdue violent or resistive subjects as required in the line of duty. ...B. ...2. Only personnel who have completed the departmentally approved class will be allowed to carry and deploy the TASER devices while on duty. ...C. TASER and the Use of Force. 1. Deployment of the TASER constitutes use of force as proved in Protective Services Policy 1400-05, Use of Force Guidelines. 2. The TASER is an electronic control device utilizing a Neuro-Muscular Incapacitation system. Its use is designed to incapacitate by over-riding and disrupting the sensory nervous system and the motor nervous system (causing uncontrollable contractions of the muscle tissue). ...4. The TASER may be deployed against a subject only if one or more of the following situations exist: a. Subject is physically assaulting someone. This includes infliction of self-harm. b. Subject is displaying behaviors that would lead a reasonable person to believe that a physical assault will occur imminently, including self-harming behavior. c. If in the officer's opinion, there is a very real possibility of injury occurring to officers, bystanders, or the subject, every effort is made to take the subject into custody by other means. 5. Deployment of the TASER: d. The subject against whom the TASER was discharged should always be handcuffed....immediately after discharge. The officer who deployed the TASER should immediately call for backup if backup is not already present. Allow the other officers to handcuff the subject, and be prepared to further discharge the TASER if the subject becomes violent before he/she can be handcuffed. If backup is not available, the officer will ensure that the subject has submitted before trying trying to apply handcuffs. If the subject refuses to submit, the officer will maintain a safe distance and control the subject by verbal commands and/or TASER discharges until backup arrives. If the subject refuses to submit to the officer's commands after being shot with the TASER, it is possible that the handcuffing may need to proceed while the TASER is being discharged into the subject. e. An alternative method of deployment is "Drive Stun," where the TASER, either without a cartridge or with an expended cartridge, is pressed against the subject and TASER is discharged . ..."

Review of current hospital policy "1400-05, Use of Force Guidelines" last revised 05/17/2013 revealed "...The Protective Services Officer has duties that will be performed to provide for the safety of patients, staff, and visitors; and if force is necessary to perform these duties, the minimum amount of force is authorized. Before using physical force, officers must exhaust every other available means of performing their duties. 1. A. Approach every situation with an attitude of confidence, impartiality, and courtesy, The officer's attitude and remarks must not provide anger in the subject. B. A timely call for assistance and a quick response of back-up can also calm a situation. C. In extreme situations, a show of superior numbers is sometimes needed to calm a situation. 2. Evaluating a Situation A. Any decision reached in the evaluation and resolution of a situation requires utilization of skills, training, and knowledge pertinent to the situation. ...B. Officers should not enter confrontations they are certain to lose. In such situations, the officer's primary concern should be for the safe evacuation of patients, staff and visitors from a violent environment to a defensible area and await arrival of backup. ... C. Once safely withdrawn the officer should call for assistance from the (name) Police Department... 3. Use of Force A. Patient-Specific Guidelines 1. Weapons will not be used by Protective Services as means of managing control of a patient for the purposes of medical care. 2. If a weapon is used by Protective Services on a patient to protect people or hospital property from harm, the incident will be handled as a criminal activity. Law enforcement will be called to respond within the intent of placing the patient in their custody. ..."

Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number ; Date/Time Received - 01/29/2015 at 0939; Time Arrived - 0940; Nature of Incident - 38-Patient Restraint; Location of Incident - Emergency Department Treatment Area 25; and Action Taken "OFFICER (PSO #1) USED TASER ON ED BE [sic] 25 (Patient #5). ...PATIENT PLACED IN LEATHER RESTRAINTS."

Review on 03/18/2015 of Patient Safety Event Report RTW 11 involving Patient #5, dated 01/29/2015 at 1010; reported by RN #10, revealed on 01/29/2015 at 0930 "At about 9:30am on 1/29/2015 IVC (involuntary commitment) csn# 5 in ER bed 25 was agitated, and verbally aggressive initially. Pt cussing at sitter and staff. Pt stated that he does not like black people. Security was called. Pt then spit on then [sic] spit on [Sitter #1] (the pt's sitter) clothing. Primary RN (RN #8) was aware of the situation and had med (medication) requested pt's PRN (as needed) med that had to come up from the main pharmacy. x1 (times one) Security officer was at bedside awaiting for other officers. Other security officers arrive. Pt stormed outside of the room and assaulted Officer [PSO #1] (pt punched and [sic] him in the face and scratched him in the face) pt was tackled to the ground in the hallway by Security Officers and (RN #9). While pt was being tackled pt punched Officer (PSO #2) in the forehead. Pt had to be tasered by Protective services staff. Team Leader (RN #11); (PSO Director #1); (ED Director #1) were made aware of the situation. ...Dr. (MD #3) was made aware and he gave order for restraint usage. Pt was placed in 4 point restraints. ...". Review revealed the event occurred in the ED Patient Care Area.

Review on 03/18/2015 of Patient Safety Event Report CLI 38 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #1, revealed on 01/29/2015 at 0940 "At 0939 hrs (hours), reporting officer, (PSO #1) was dispatched to assist with patient in ED bed 25. Once arriving I was told IVC patient (Patient #5) spitted [sic] at his sitter and Officer (PSO #4). While I was talking with his nurse (RN #8), (Patient #5) swung and hit Officer (PSO #2) over his left eye causing a bruise. Officer (PSO #4) and I (PSO #1) forced (Patient #5) to the floor and asked him several time to relax and stop kicking. After (Patient #5) wouldn't get under control and kicked Officer (PSO #2) and (RN #9) I deployed my taser and dry stunned (Patient #5) in back of left side. Afterward he complied and stopped kicking and was escorted to bed 25 and placed in four point restraints." Review revealed the event occurred in the ED hallway.

Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number 2; Date/Time Received - 02/03/2015 at 1149; Time Arrived - 1149; Nature of Incident - 04-Disorderly; Location of Incident - ED bed 25; and Action Taken "bed 25 ivc (involuntary commitment) out of control. ...(PSO #3) had to dry stun the pt in the leg to gain control. ..."

Review on 03/18/2015 of Patient Safety Event Report KPI 22 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #3, revealed on 02/03/2015 at 1145 "When approached ED bed 25 I saw the patient swing his left arm towards Team Leader (PSO #1). The patient struck Team Leader (PSO #1) in the face and eye several time [sic]. I approached the patient at that time and dry stun him. After the patient was dry stun Team Leader (PSO #1), Officer (PSO #5), and Charge Officer (PSO #3) was able to put the restraints on the patient arms without further incident." Review revealed the event occurred in the ED Patient Room.

Closed medical record review on 03/18/2015 for Patient #5 revealed a [AGE] year old male (MDS) dated [DATE] at 1104 via ambulance. Review revealed the patient was placed into treatment room 25 and was triaged at bedside by a Registered Nurse (RN). The patient was assigned an acuity of "Emergent." Review revealed an arrival complaint of "IVC." Review of a triage note by RN #12 at 1111 revealed "Pt was just released from prison yesterday and sent immediately to (Mental Health Crisis Center). Pt sent to ED due to being too violent as he was verbally aggressive to staff members at (Mental Health Crisis Center). Pt answering questions for nurse. Guard at bedside." Review revealed a past medical history (PMH) of Schizophrenia, Post Traumatic Stress Disorder (PTSD), and Personality Disorder. Review revealed documentation of multiple past psychiatric hospitalization s. Review revealed the patient remained in the ED and was transferred to a Psychiatric hospital on [DATE] at 1427 (17 days later). Review revealed while in the ED a TASER weapon was used on the patient on 01/29/2015 at ~0940 and 02/03/2015 at ~1145 and the patient was placed into 4 point leather restraints for the management of violent and self-destructive behaviors. Review revealed the TASER weapon was used on the patient by hospital-employed Protective Services Officers who were not sworn law enforcement officers.

Review of ED Provider Notes by MD #15 dated 01/24/2015 at 1111, revealed the patient presented with a chief complaint of "Paranoia." Review of HPI (history of present illness) revealed "(Patient #5) is a 23 y.o. (year old) male who presents after being assessed at the crisis center. It [sic] been in jail and then sent to the crisis center for psychiatric evaluation. He has a history of antisocial personality as well as schizophrenia and poor compliance with his medications. He apparently became agitated after conversation with his mother today and wanted to be sent to the emergency department. Upon my interviewing he is calm and cooperative. He denies any active hallucinations. he denies a desire to harm himself or others at present. Involuntary Commitment. ...PHYSICAL EXAM: ...General: No acute distress. ...Neuro: ...He is alert and oriented x3 (to person, place, time) Psych (Psychiatric): He has somewhat of a flat affect. He is cooperative. ...I've consulted psychiatry to see the patient while here. ...FINAL IMPRESSION: 1 Acute psychosis 2. Schizophrenia.

Review of Psychiatric Consult Note by Psychiatrist #1 dated 01/24/2015 at 1217, revealed the reason for consult was "Psychosis." Review of HPI revealed "...ENGLISH speaking male with a history of schizophrenia, PTSD, alcohol use, hx of severely aggressive behavior towards family, hx of assault on EMS (emergency medical services) staff, police officers. Longstanding medication noncompliance. Recently released from jail after 30 day sentence for assaultive behavior towards family. Sent directly to (Mental Health Crisis Center) on a petition due to making threats over the phone to harm father, concern for ongoing psychosis. Subsequently sent to (Hospital A) on IVC due to need for 'higher level of care.' Per my review of available records, he was agitated, yelling after a phone call with mother and decision was made that he needed to be in the ER. RN notes indicated he was threatening staff, yelling and gesturing in a hallway. I saw the patient today in the ER. He was calm and able to talk without yelling or profanity. Tells me the zyprexa and klonopin (psychiatric medications) are helping him with anger, admits he has a problem with anger. ...He does note that he can get overwhelmed with paranoid thoughts about conspiracies against him, ...Currently without specific violent thoughts or inclinations. Past Psychiatric History: Hx of multiple psych hospitalization s at many facilities, with psychotic d/o dx dating back to [AGE]. ...Mental Status Exam: A and O (alert and oriented) to name, place, situation. Able to tell me month and year along with his age. Makes fair eye contact with interviewer. Speech is monotone but normal volume, easily comprehensible. Mood is fair, affect somewhat blunted. No tangentially. Denies AH/VH (auditory/visual hallucinations). Insight limited. Endorses some paranoia but notes thoughts about other being out to hurt him are better on medication. Assessment: ...admitted with schizophrenia, violent behaviors. IVC'd from jail for threatening behaviors towards family. Sent from (Mental Health Crisis Center) due to escalating agitation, felt unsafe to manage in that setting. Currently calm and accepting medications, potential to escalate quickly based on his history... Diagnoses: Axis I Hx of schizophrenia, paranoid type, r/o (rule out) alcohol use d/o. Hx of PTSD. Axis II r/o antisocial personality traits vs (versus) disorder... Plan: ...4) Maintain IVC, initiate search for inpt psych and maintain sitter/suicide precautions while here. Disposition: Recommend transfer to inpatient psychiatric unit as available, indicated, and medically appropriate. Recommendations have been communicated to primary team. ..."

Review of an ED Note by RN #22 dated 01/29/2015 at 0440, revealed "Pt requesting leather restraints for both ankles and rt (right) wrist. ..."

Review of an ED Progress Note by MD #3 dated 01/29/2015 at 0757, revealed "Overnight the patient asked for restraints as he felt he might become violent, was temporarily in 3-point restraints, currently out of restraints. ...He remains medically clear for transfer to an appropriate psychiatric facility when one becomes available. ..."

Review of an ED Note by RN #11 dated 01/29/2015 at 0900, revealed "Pt up in room spitting at sitter and security. Pt not willing to back up or sit down. Dr. (MD #3) called as well as additional security staff. Pt then swung at security officer and ran into hall way outside room. Pt restrained by security and brought back to room and net placed over face. Pt then placed in 4 point leathers at Dr. (MD #3) verbal order at 0940."

Review of an ED Note by RN #8 dated 01/29/2015 at 0951, revealed "Pt also placed in vest restraint at this time."

Review of an ED Note by RN #8 dated 01/29/2015 at 0956, revealed "Pt was tazed [sic] (TASER weapon) by security. 2 staff members were injured in the event. (PSO Director #1) director of security at the scene. Dr. (Psychiatrist #2) in room at this time."

Review of a Progress Note by Psychiatrist #7 dated 01/29/2015 at 1018, revealed "Pt seen and chart reviewed. Case discussed with staff. 20 yo man with schizophrenia and h/o (history of) severe violence who is now in our ED with severe agitation and psychosis with very frequent highly violent outbursts with multiple assaults on staff. Pt again has become highly agitated and required tasing (TASER weapon) to be contained. He requires emergent medication for protection of patient and staff due to high risk of dangerousness."

Review of an Psychiatric Progress Note by Psychiatrist #2 dated 01/29/2015 at 1053, revealed "...Patient required leather restraints overnight, which he requested due to feeling like he could lose-control. He was calmer later in the night... After breakfast, he appeared to be at his baseline, but suddenly became aggressive and assaulted the sitter and a security guard. He is now again in leather restraints. ...He told me that when he starts to feel out of control he needs to have a therapist at his bedside, because talking constantly down. He was not able to identify any ways in which she can prevent himself from becoming suddenly assaultive. ...Mental Status Exam: ...Behavior: Calm....and Polite ...Mood: Anxious Affect: Calm and Decreased range, a little tearful while visiting with his mother ...Orientation: Oriented to person, place, time, and general circumstances ...Impulse Control: Impaired ...Assessment: ...he has escalated quickly, and with no warnings, on multiple occasions. ...Today he was assaultive to the point where he was tasered (TASER weapon) by security and is now again in leather restraints. He requires emergency forced medications on a standing basis, for his own safety and that of others. ..."

Review of an ED Progress Note by MD #3 dated 01/29/2015 at 1313, revealed "The patient's behavior escalated to the point of physical confrontation with our security staff. This required manual intervention and the use of electrical stun gun (TASER weapon) by the security staff. Patient was able to be brought back to his room and others. I spoke with the patient is not complaining of any pain and he is awake and alert. We'll place him on monitors. ..."

Review of an ED Note by RN #9 dated 01/31/2015 at 0800 revealed "...kerlix wrapped around bilat (bilateral) wrists and ankles prophylacticly to prevent skin breakdown as pt has been in leather restraints > (greater than) 24 hours."

Review of a Psychiatric Progress Note by Psychiatrist #2 dated 01/31/2015 at 1054, revealed "...He refused medications twice yesterday, remains in leather restraints. ...I explained to him that unless he can accept Thorazine (antipsychotic) orally, we have no choice but to administered intramuscularly for his safety and the safety of the staff here, given the level of violence displayed over the last week. ...Mental Status Exam: ...Behavior: Calm, Direct eye contact and Polite but more pushy today ...Mood: anxious ...Affect: Calm and Decreased range, a little irritable ...Orientation: Oriented to person, place, situation, general circumstances ...Impulse Control: Impaired. ...Assessment: ...history of violent behavior, threatening towards the family and towards staff, currently on the waiting list for (name) Hospital; he has escalated quickly, and with no warnings, on multiple occasions. ...Thorazine intramuscular was quiet helpful, but he started refusing, and 2 doses were held yesterday. I believe he remains in imminent danger to himself or others, and that we have no choice but to force medications if he is to remain in restraints in the emergency room , given there are no beds at (name) Hospital yet. I am concerned about him having to be in leather restraints around the clock, and would prefer for him to be mildly sedated from the Thorazine, so that at least some of the restraints can be released periodically. ...Plan: "...6. We continue to recommend inpatient psych care, with highest priority given the severity of his aggression and likely frequent requirement for force medication. At this time, he continues to require around the clock restraints."

Review of an ED Progress Note by MD#3 dated 01/31/2015 at 1113, revealed "The patient remains in the emergency department under IVC papers. This morning the patient denies any complaints or pain. ...Nursing staff have noted he has refused to take some of his oral medications. This patient has a history of violent outbursts and he continues to refuse medications may require us to give intramuscular medications to protect the safety of our staff and others around this patient. Given his history of violent behavior he presents an imminent [sic] threat to those around him if he does not take his medications. Due to this threat he remains restrained. I evaluated the patient in person and feel restraints are warranted and they remain in place. This patient remains medically clear for transfer to a psychiatric facility when one becomes available. In the meantime we will continue to provide supportive c [sic]with one-to-one continuous observation and attempts to provide a safe environment. ...Because of his leather restraints the patient is essentially immobilized, I will add Lovenox (prevents blood clots) 40 mg (milligrams) daily for DVT (deep vein thrombosis) prophylaxis, this should be continued until he is allowed to ambulate again. ..."

Review of an ED Note by RN #13 dated 01/31/2015 at 2223, revealed "(Hospital A) management advised this RN that pt is not to come out of restraints. Directive acknowledged. Pt allowed supervised ROM of all extremities one at a time... Pt reports pain anterior L (left) knee, ice pack applied. Pt remains cooperative about restraints and expresses wants to come out of restraints. ..."

Review of an ED Progress Note by MD #8 dated 02/01/2015 at 0045, revealed "This is a progress note for a patient being held on IVC paperwork... He has been maintained in 4 point leather restraints due to assault of staff that has occurred during his stay in the ED. I have evaluated the patient, he is oriented x 3 (person, place, time) and cooperative. He has no pain or symptoms of pressure ulcers. He is not agitated. At this time, I believe he could have a trial of rotating 2-pint restraints to prevent skin breakdown. I have discussed this plan with the patient, he is aware that any attempts to remove his restrains will result in returning to 4-point restraints. I have discussed this with [PSO Director #1] (Security Supervisor) as well as [name] (House Supervisor), they are in agreement with this plan."

Review of an Psychiatric Progress Note by Psychiatrist #3 dated 02/01/2015 at 1003, revealed "...He is calm and cooperative today. However, given his extremely unpredictable violent behaviors in the recent past, i.e. Assaulted (Hospital A) staff within the past week, we will continue 2-point restraint for the safety of himself and other patients and staff in ED. Pt has been taking his Thorazine yesterday, and is calmer now. ...He understands that if he refuses Thorazine orally, we have no choice but to administered intramuscularly for his safety and the safety of the staff here, given the level of violence displayed over the last week. ...Mental Status Exam: ...Behavior: Calm, Direct eye contact and Polite but more pushy today ...Mood: Anxious ...Affect: Calm and Decreased range, a little irritable ...Orientation: Oriented to person, place, situation, and general circumstances ...Impulse Control: Impaired. ...Assessment: ...history of violent behavior, threatening towards the family and towards staff, currently on the waiting list for (name) Hospital; he has escalated quickly, and with no warnings, on multiple occasions. ...I believe he remains in imminent danger to himself or others, and that we have no choice but to force medications if he is to remain in restraints in the emergency room , given there are no beds at (name) Hospital yet. I am concerned about him having to be in leather restraints around the clock, and would prefer for him to be mildly sedated from the Thorazine, so that at least some of the restraints can be released periodically. ...Plan: "...6. We continue to recommend inpatient psych care, with highest priority given the severity of his aggression and likely frequent requirement for force medication. At this time, he continues to require around the clock restraints."

Review of an Psychiatric Progress Note by Psychiatrist #4 dated 02/02/2015 at 1206, revealed "...He is more calm and cooperative today. ...Given his extremely unpredictable violent behaviors in the recent past, i.e. Assaulted (Hospital A) staff within the past week, we will continue 2-point restraint for the safety of himself and other patients and staff in ED. ...Mental Status Exam: ...Behavior: Calm, Direct eye contact and Polite but more pushy today ...Mood: Anxious ...Affect: Calm and Decreased range, a little irritable ...Orientation: Oriented to person, place, situation, and general circumstances ...Impulse Control: Impaired.
...Assessment: ...history of violent behavior, threatening towards the family and towards staff, currently on the waiting list for (name) Hospital; he has escalated quickly, and with no warnings, on multiple occasions. ...I believe he remains in imminent danger to himself or others, and that we have no choice but to force medications if he is to remain in restraints in th
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital's staff failed to ensure TASER weapons were not used by non-law enforcement security staff as a means of subduing a psychiatric patient in order to place the patient in restraints; and failed to ensure restraints were not imposed as a means of coercion, discipline, convenience, or retaliation by staff and were discontinued at the earliest possible time for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors that was not placed into custody of law enforcement while in the Emergency Department and transferred to a Psychiatric Hospital for treatment and stabilization.

The findings include:

Review of current hospital policy "Patient Rights And Responsibilities" last revised 08/28/2014 revealed "...Patient Rights and Responsibilities ...16. Be free from abuse, neglect and harassment... 17. Be free from restraint and seclusion that is not medically required or is used inappropriately. ..."

Review of current hospital policy "Restraint and Seclusion" revised 06/20/2014 revealed "Areas Affected: All Patient Care Areas PHILOSOPHY STATEMENT: (Name) Hospital is committed to providing a least restrictive, safe, and appropriate environment for all individuals. ...restraint use is limited to those circumstances where the patient is identified as being a t risk for injury to self or others and alternative safety measures have been evaluated and deemed inadequate. ...DEFINITIONS OF RESTRAINT AND SECLUSION: Restraint: 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 of the two. ...RESTRAINT MANAGEMENT GOALS: A. Restraints are only used when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others. B. Restraints are not used a s a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used when less restrictive interventions are ineffective and if used, the least restrictive form of restraint is used to protect the physical safety of the patient, staff, or others. D. Restraints are discontinued at the earliest possible time regardless of the scheduled expiration of the order. E. Restraints will be applied using the proper technique based on the type of restraint. F. The appropriate restraint plan of care will be initiated for the patient. G. Physicians/LIP is responsible for ordering the restraints. PRN restraint orders are not acceptable. ...I. Patients will be monitored, evaluated, and re-evaluated according to the Restraint Protocol. ..."

Review of current hospital policy "Restraint Management Protocol, 2466-1" last revised 06/20/2014 revealed "Definitions: A. Physical Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Examples are a vest, soft wrist or ankle restraints, mittens (if tied), leather restraints... Categories of Restraints/Indications for Use: ...B. Violent or Self-Destructive Behavior (Behavioral) Restraints: 1. A clinical justification, other than those identified as non-violent or non-self-destructive behavior, to protect the patient from injury to self or others because of an emotional or behavioral disorder where the behavior may be violent or aggressive. RESPONSIBILITIES: A. Violent/Self-Destructive Behavior (Behavioral) Restraints: 1. Physician/Licensed Independent Practitioner (LIP)*: a. Order for restraints at initiation. b. Face to face assessment of the need for restraint initiation within one hour and ongoing assessment of the continued need for restraints. c. Renewal order for continued justification for restraints. d. Review and evaluation of current medications to identify and minimize the use of medications that place a patient at risk for restraint use. ...3. Staff Nurse: a. Identification of the patient at risk for restraints, the behavior/symptoms that the patient is exhibiting, and the initiation of pre-restraint alternative interventions that may reduce both the need and duration of restraint use. b. Restraint initiation and management. c. Calls the attending physician/LIP for a restraint order. d. Notifies the attending physician that restraints have been initiated if he/she was not the ordering physician of the restraint as soon as possible**. e. Regular scheduled reassessment of the patient in restraints to justify continued validity of restraint use with the potential to discontinue or reduce the level of restraint evaluated. ...GENERAL RESTRAINT INFORMATION: A. PRN and standing orders for any category of restraint is not acceptable. B. Restraints are not used as a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used only when other less restrictive interventions are ineffective. If restraints are employed, the least restrictive restraint to protect the patient's/other's physical safety is used. D. The restraint should be discontinued by the staff nurse at the earliest possible time regardless of the scheduled expiration of the order. Discontnued Criteria includes: ...2. Violent/Self Destructive a. No physical aggression b. Rational/compliant/follows directions c. Patient calm/asleep d. Transferred to secure area ...VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR RESTRAINT (BEHAVIORAL) MANAGEMENT: ...Physician Order: 1. A staff nurse may apply restraints in an emergency situation prior to obtaining a physician order but the physician/LIP should be contacted immediately and notified that restraints have been initiated. ...2. Any patient restraint within one hour after the initiation of restraints by a physician/LIP or Specially Trained Nurse who will evaluate the continued need for restraint. ...3. The face to face assessment conducted within one hour includes the following: a. An evaluation of the patient's immediate situation. b. The patient's reaction to the intervention. c. The patient's medical and behavioral condition. d. The need to continue or terminate the restraint. 4. Renewal orders must be obtained every 2 hours for patients 9-17 years of age and every 4 hours for ages 18 and older. Orders may be renewed for a maximum of 24 consecutive hours at which time a physician/LIP reassessment is required. 5. Every 24 hours a physician/LIP must complete a face to face assessment before writing a new order. 6. If a restraint is discontinued prior to the expiration of the order, a new order must be obtained to re-initiate restraints. C. Routine Monitoring/Patient Care: 1. Patients will have continuous, direct one on one observation at all times by a staff nurse, NA, or PCT. Continuous observation and psychological status/visual check (i.e. affect/behavior) will be documented every 15 minutes. 2. Routine checks will be monitored and documented every 2 hours by a staff nurse, NA, or PCT. Routine checks includes: ROM, elimination, fluids, circulation/skin integrity, and food/meal. 3. The continued justification for restraints or a less restrictive form of restraints will be assessed and documented every 4 hours by the staff nurse. ..."

Review of current hospital policy "1700-05, Restraints" last revised 04/14/2014 revealed "...1. Restraint Assistance A. A Protective Services officer may be called upon to assist the health care team in restraining a patient. The officer provides assistance within the scope of Patient Care Services Restraint policy (refer to the Patient Care Services Policy Manual). B. Upon arriving at the scene, the officer will make contact with the person(s) requesting assistance. 1. If an officer comes upon a scene with staff struggling with a patient, the officer immediately offers assistance. 2. If an officer comes upon a scene and there appears to be no imminent danger to the patient or the staff, the responding officer(s) will seek guidance from the health care team on the level of physical contact and method of restraint. C. The officer assists the staff by immobilizing the patient's arms and legs while the staff secures the restraints. D. If the staff is unfamiliar with the restraints, then the officer will secure the restraints. ..."

Review of current hospital policy "1400-20 Electronic Control Device (TASER) last revised 04/14/2014 revealed "...Protective Services officers have an obligation to protect all staff, patients, and visitors against violence while on campus. ...Therefore, officers trained in the use of electronic control devices (TASER) will be allowed to possess, and in accordance with the Protective Service Policy 1400-05, Use of Force Guidelines, deploy the TASER to subdue violent or resistive subjects as required in the line of duty. ...B. ...2. Only personnel who have completed the departmentally approved class will be allowed to carry and deploy the TASER devices while on duty. ...C. TASER and the Use of Force. 1. Deployment of the TASER constitutes use of force as proved in Protective Services Policy 1400-05, Use of Force Guidelines. 2. The TASER is an electronic control device utilizing a Neuro-Muscular Incapacitation system. Its use is designed to incapacitate by over-riding and disrupting the sensory nervous system and the motor nervous system (causing uncontrollable contractions of the muscle tissue). ...4. The TASER may be deployed against a subject only if one or more of the following situations exist: a. Subject is physically assaulting someone. This includes infliction of self-harm. b. Subject is displaying behaviors that would lead a reasonable person to believe that a physical assault will occur imminently, including self-harming behavior. c. If in the officer's opinion, there is a very real possibility of injury occurring to officers, bystanders, or the subject, every effort is made to take the subject into custody by other means. 5. Deployment of the TASER: d. The subject against whom the TASER was discharged should always be handcuffed....immediately after discharge. The officer who deployed the TASER should immediately call for backup if backup is not already present. Allow the other officers to handcuff the subject, and be prepared to further discharge the TASER if the subject becomes violent before he/she can be handcuffed. If backup is not available, the officer will ensure that the subject has submitted before trying trying to apply handcuffs. If the subject refuses to submit, the officer will maintain a safe distance and control the subject by verbal commands and/or TASER discharges until backup arrives. If the subject refuses to submit to the officer's commands after being shot with the TASER, it is possible that the handcuffing may need to proceed while the TASER is being discharged into the subject. e. An alternative method of deployment is "Drive Stun," where the TASER, either without a cartridge or with an expended cartridge, is pressed against the subject and TASER is discharged . ..."

Review of current hospital policy "1400-05, Use of Force Guidelines" last revised 05/17/2013 revealed "...The Protective Services Officer has duties that will be performed to provide for the safety of patients, staff, and visitors; and if force is necessary to perform these duties, the minimum amount of force is authorized. Before using physical force, officers must exhaust every other available means of performing their duties. 1. A. Approach every situation with an attitude of confidence, impartiality, and courtesy, The officer's attitude and remarks must not provide anger in the subject. B. A timely call for assistance and a quick response of back-up can also calm a situation. C. In extreme situations, a show of superior numbers is sometimes needed to calm a situation. 2. Evaluating a Situation A. Any decision reached in the evaluation and resolution of a situation requires utilization of skills, training, and knowledge pertinent to the situation. ...B. Officers should not enter confrontations they are certain to lose. In such situations, the officer's primary concern should be for the safe evacuation of patients, staff and visitors from a violent environment to a defensible area and await arrival of backup. ... C. Once safely withdrawn the officer should call for assistance from the (name) Police Department... 3. Use of Force A. Patient-Specific Guidelines 1. Weapons will not be used by Protective Services as means of managing control of a patient for the purposes of medical care. 2. If a weapon is used by Protective Services on a patient to protect people or hospital property from harm, the incident will be handled as a criminal activity. Law enforcement will be called to respond within the intent of placing the patient in their custody. ..."

Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number ; Date/Time Received - 01/29/2015 at 0939; Time Arrived - 0940; Nature of Incident - 38-Patient Restraint; Location of Incident - Emergency Department Treatment Area 25; and Action Taken "OFFICER (PSO #1) USED TASER ON ED BE [sic] 25 (Patient #5). ...PATIENT PLACED IN LEATHER RESTRAINTS."

Review on 03/18/2015 of Patient Safety Event Report RTW 11 involving Patient #5, dated 01/29/2015 at 1010; reported by RN #10, revealed on 01/29/2015 at 0930 "At about 9:30am on 1/29/2015 IVC (involuntary commitment) csn# 5 in ER bed 25 was agitated, and verbally aggressive initially. Pt cussing at sitter and staff. Pt stated that he does not like black people. Security was called. Pt then spit on then [sic] spit on [Sitter #1] (the pt's sitter) clothing. Primary RN (RN #8) was aware of the situation and had med (medication) requested pt's PRN (as needed) med that had to come up from the main pharmacy. x1 (times one) Security officer was at bedside awaiting for other officers. Other security officers arrive. Pt stormed outside of the room and assaulted Officer [PSO #1] (pt punched and [sic] him in the face and scratched him in the face) pt was tackled to the ground in the hallway by Security Officers and (RN #9). While pt was being tackled pt punched Officer (PSO #2) in the forehead. Pt had to be tasered by Protective services staff. Team Leader (RN #11); (PSO Director #1); (ED Director #1) were made aware of the situation. ...Dr. (MD #3) was made aware and he gave order for restraint usage. Pt was placed in 4 point restraints. ...". Review revealed the event occurred in the ED Patient Care Area.

Review on 03/18/2015 of Patient Safety Event Report CLI 38 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #1, revealed on 01/29/2015 at 0940 "At 0939 hrs (hours), reporting officer, (PSO #1) was dispatched to assist with patient in ED bed 25. Once arriving I was told IVC patient (Patient #5) spitted [sic] at his sitter and Officer (PSO #4). While I was talking with his nurse (RN #8), (Patient #5) swung and hit Officer (PSO #2) over his left eye causing a bruise. Officer (PSO #4) and I (PSO #1) forced (Patient #5) to the floor and asked him several time to relax and stop kicking. After (Patient #5) wouldn't get under control and kicked Officer (PSO #2) and (RN #9) I deployed my taser and dry stunned (Patient #5) in back of left side. Afterward he complied and stopped kicking and was escorted to bed 25 and placed in four point restraints." Review revealed the event occurred in the ED hallway.

Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number 2; Date/Time Received - 02/03/2015 at 1149; Time Arrived - 1149; Nature of Incident - 04-Disorderly; Location of Incident - ED bed 25; and Action Taken "bed 25 ivc (involuntary commitment) out of control. ...(PSO #3) had to dry stun the pt in the leg to gain control. ..."

Review on 03/18/2015 of Patient Safety Event Report KPI 22 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #3, revealed on 02/03/2015 at 1145 "When approached ED bed 25 I saw the patient swing his left arm towards Team Leader (PSO #1). The patient struck Team Leader (PSO #1) in the face and eye several time [sic]. I approached the patient at that time and dry stun him. After the patient was dry stun Team Leader (PSO #1), Officer (PSO #5), and Charge Officer (PSO #3) was able to put the restraints on the patient arms without further incident." Review revealed the event occurred in the ED Patient Room.

Closed medical record review on 03/18/2015 for Patient #5 revealed a [AGE] year old male (MDS) dated [DATE] at 1104 via ambulance. Review revealed the patient was placed into treatment room 25 and was triaged at bedside by a Registered Nurse (RN). The patient was assigned an acuity of "Emergent." Review revealed an arrival complaint of "IVC." Review of a triage note by RN #12 at 1111 revealed "Pt was just released from prison yesterday and sent immediately to (Mental Health Crisis Center). Pt sent to ED due to being too violent as he was verbally aggressive to staff members at (Mental Health Crisis Center). Pt answering questions for nurse. Guard at bedside." Review revealed a past medical history (PMH) of Schizophrenia, Post Traumatic Stress Disorder (PTSD), and Personality Disorder. Review revealed documentation of multiple past psychiatric hospitalization s. Review revealed the patient remained in the ED and was transferred to a Psychiatric hospital on [DATE] at 1427 (17 days later). Review revealed while in the ED a TASER weapon was used on the patient on 01/29/2015 at ~0940 and 02/03/2015 at ~1145 and the patient was placed into 4 point leather restraints for the management of violent and self-destructive behaviors. Review revealed the TASER weapon was used on the patient by hospital-employed Protective Services Officers who were not sworn law enforcement officers.

Review of ED Provider Notes by MD #15 dated 01/24/2015 at 1111, revealed the patient presented with a chief complaint of "Paranoia." Review of HPI (history of present illness) revealed "(Patient #5) is a 23 y.o. (year old) male who presents after being assessed at the crisis center. It [sic] been in jail and then sent to the crisis center for psychiatric evaluation. He has a history of antisocial personality as well as schizophrenia and poor compliance with his medications. He apparently became agitated after conversation with his mother today and wanted to be sent to the emergency department. Upon my interviewing he is calm and cooperative. He denies any active hallucinations. he denies a desire to harm himself or others at present. Involuntary Commitment. ...PHYSICAL EXAM: ...General: No acute distress. ...Neuro: ...He is alert and oriented x3 (to person, place, time) Psych (Psychiatric): He has somewhat of a flat affect. He is cooperative. ...I've consulted psychiatry to see the patient while here. ...FINAL IMPRESSION: 1 Acute psychosis 2. Schizophrenia.

Review of Psychiatric Consult Note by Psychiatrist #1 dated 01/24/2015 at 1217, revealed the reason for consult was "Psychosis." Review of HPI revealed "...ENGLISH speaking male with a history of schizophrenia, PTSD, alcohol use, hx of severely aggressive behavior towards family, hx of assault on EMS (emergency medical services) staff, police officers. Longstanding medication noncompliance. Recently released from jail after 30 day sentence for assaultive behavior towards family. Sent directly to (Mental Health Crisis Center) on a petition due to making threats over the phone to harm father, concern for ongoing psychosis. Subsequently sent to (Hospital A) on IVC due to need for 'higher level of care.' Per my review of available records, he was agitated, yelling after a phone call with mother and decision was made that he needed to be in the ER. RN notes indicated he was threatening staff, yelling and gesturing in a hallway. I saw the patient today in the ER. He was calm and able to talk without yelling or profanity. Tells me the zyprexa and klonopin (psychiatric medications) are helping him with anger, admits he has a problem with anger. ...He does note that he can get overwhelmed with paranoid thoughts about conspiracies against him, ...Currently without specific violent thoughts or inclinations. Past Psychiatric History: Hx of multiple psych hospitalization s at many facilities, with psychotic d/o dx dating back to [AGE]. ...Mental Status Exam: A and O (alert and oriented) to name, place, situation. Able to tell me month and year along with his age. Makes fair eye contact with interviewer. Speech is monotone but normal volume, easily comprehensible. Mood is fair, affect somewhat blunted. No tangentially. Denies AH/VH (auditory/visual hallucinations). Insight limited. Endorses some paranoia but notes thoughts about other being out to hurt him are better on medication. Assessment: ...admitted with schizophrenia, violent behaviors. IVC'd from jail for threatening behaviors towards family. Sent from (Mental Health Crisis Center) due to escalating agitation, felt unsafe to manage in that setting. Currently calm and accepting medications, potential to escalate quickly based on his history... Diagnoses: Axis I Hx of schizophrenia, paranoid type, r/o (rule out) alcohol use d/o. Hx of PTSD. Axis II r/o antisocial personality traits vs (versus) disorder... Plan: ...4) Maintain IVC, initiate search for inpt psych and maintain sitter/suicide precautions while here. Disposition: Recommend transfer to inpatient psychiatric unit as available, indicated, and medically appropriate. Recommendations have been communicated to primary team. ..."

Review of an ED Note (Nursing) by RN #12 dated 01/24/2015 at 1505, revealed "...Pt calm with sitter at bedside."

Review of an ED Note by RN #13 dated 01/24/2015 at 2000, revealed "Pt expresses want to remain compliant with treatment plans and has agreed to take all prescribed meds and denies aggressive ideation. Pt appears calm and compliant...".

Review of an ED Note by RN #14 dated 01/25/2015 at 0730, revealed "Pt eating breakfast and brushing teeth. Sitter at bedside. Safe environment maintained. No needs at this time."

Review of an ED Progress Note (Provider) by MD #4 dated 01/25/2015 at 0731, revealed "(Patient #5) remains here in the ED on a psychiatric hold/IVC papers awaiting inpt. (inpatient) psychiatric placement. He has had an uneventful night and is resting this morning. VSS (vital signs stable). Meds have been ordered by Psychiatry. We will continue to follow the patients medical needs and Psychiatry will see to his mental health issues. The pt. was sent from (Mental Health Crisis Center) on IVC papers as a result of aggression and violence, so we presently have a security guard outside pts room."

Review of a Psychiatric Progress Note (Provider) by Psychiatrist #1 dated 01/25/2015 at 1012, revealed "...Pt without episode of violent [sic] outburst or aggression overnight. ...He acknowledges that anger is his primary issue and he has to keep the anger under control if he is to stay out of prison or other locked facilities. ...Mental Status Exam: Patient is alert and oriented x3. He has a somewhat intense affect but is fairly pleasant and cooperative with the interviewer. ...Plan: ...2) Continue referral process... I do have some concerns based on my experience over 11 years with attempted referrals in similar cases that it could be quite a lengthy period of time before the patient is accepted to (name) Hospital, we have had cases where it is been over a month before and acceptance is obtained. ..."

Review of an ED Note by RN #14 dated 01/25/2015 at 1300, revealed "Pt used PRS (Patient Relations Specialist) phone and called his mother. Pt appropriate. No incident."

Review of an ED Note by RN #14 dated 01/25/2015 at 1520, revealed "Pt calling out numerous times for this RN in hallway. This RN has seen pt multiple times and explained to him that yelling out for me into the hallway is not appropriate. Pt singing loudly in his room. Pt calms down when this RN goes into room and speaks with him. No needs at this time. Sitter at bedside. Safe environment maintained."

Review of an ED Note by RN #14 dated 01/25/2015 at 1539, revealed "Sitter notified security outside room that he wanted to sit at doorway because he the patient 'is coming at me.' This RN into room. Pt laying in bed. Is having increasing agitation but agreed to take Atarax and IM Benadryl. ...PRS at bedside talking with pt. Pt calmed down with presence of this RN and....PRS."

Review of an ED Note by RN #14 dated 01/25/2015 at 1758, revealed "Pt yelled out into the hall 'hey fat ass' calling one of my coworkers. Also told the secretary that 'I am going to kill my father because he put me here.' This RN went in to room to ask him not to call out into the hall and use the call bell instead. Said 'you're hot I want to talk to you' referring to this RN. Calling out multiple times for medication. Notified pt when he could next have meds."

Review of an ED Note by RN #14 dated 01/25/2015 at 1848, revealed "See previous notes for pt behavior. Security continues to be at bedside. Sitter at bedside in doorway. Safe environment maintained. Pt appears to be more respectful now after staff notifying pt his behavior was disrespectful and would not be tolerated."

Review of an ED Note by RN #15 dated 01/25/2015 at 1922, revealed "Pt is cooperative in room. (name) sitter is outside the room. Security at bedside. ..."

Review of an ED Note by RN #15 dated 01/25/2015 at 2123, revealed "Pt stating that he is going to 'hurt the sitter.' Pt states that he is eventually going to 'assault everyone in the ER and go back to jail.' this RN medicated patient. Talked with patient at length about his feelings. Sitters changed. (name), ED tech (technician) is sitting with patient. Pt is agreeable to this. Patient continues to express his feelings but remains non violent."

Review of an ED Note by RN #15 dated 01/26/2015 at 0014, revealed "Pt states that he wants to hurt himself and others in the ER. Pt continues to call his sitter 'stupid ni***r.' patient continues to ask for medications. Dr. (MD #5) notified and will go in room to eval (evaluate) pt."

Review of an ED Note by RN #15 dated 01/26/2015 at 0023, revealed "Security still at bedside with patient, Dr. (MD #5) will go in room later to eval. Dr. (MD #5) stated only one security guard because others will agitate the patient. Will continue to monitor."

Review of an ED Note by RN #15 dated 01/26/2015 at 0037, revealed "This RN also spoke to Dr. (MD #5) about pts increase in agitation and the need for the pt to be seen d/t (due to) pts threats of harm. MD states he is aware and will go see pt."

Review of an ED Note by RN #15 dated 01/26/2015 at 0050, revealed "Dr. (MD #5) in to eval patient. New orders placed. Will medicate patient and continue to monitor."

Review of an ED Progress Note by MD #5 dated 01/26/2015 at 0057, revealed "I was advised by nursing patient was having increased agitation and aggressive behavior to staff. He has received his scheduled doses of medications. He reportedly was threatening to the sitter. On my examination patient was generally cooperative. He was questioned what was triggering his agitation and he advises that he was told he might be 'here for 30 days'. I reassured him that that's not typically the case. He appeared generally cooperative during this interaction. I asked him if he would like something to 'calm him down'. He agreed that it could help. ...he was in agreement and states he would be cooperative. ..."

Review of an ED Note by RN #15 dated 01/26/2015 at 0212, revealed "Patient resting. Assessed safety of the room throughout shift. Patient encouraged to express feelings and talk about why he felt aggressive during this shift. ...Patient is still under IVC paperwork. ..."

Review of an ED Progress Note by MD #4 dated 01/26/2015 at 0806, revealed "(Patient #5) remains on an involuntary commitment hold awaiting inpatient psychiatric placement. Patient is awake and is eating breakfast this morning. he states he has no complaints at this time. He states he is hoping to be able to be discharged from here, and is to talk with the psychiatrist regarding getting his medications on an appropriate regimen. The patient did apparently have an episode of increased agitation and aggression last night with the staff. However he is calm at this time. He states he had an uneventful night and has no complaints this morning. ..."

Review of an ED Note by RN #16 dated 01/26/2015 at 1020, revealed "Patient self reports increased agitation that is obvious to this RN as well Patient stating 'the black people and racists are making me stay here'. This RN redirected his statements back at his behavior and his actions leading to the current issues. This RN reiterated intolerance for racial slurs and curse words being directed at sitter and staff."

Review of an Psychiatric Progress Note by Psychiatrist #2 dated 01/26/2015 at 1149, revealed "...The patient has been intermittently agitated, requiring when necessary's (as needed medications). ...He has been verbally abusive towards the staff. Mental Status Exam: ...Behavior: Calm....and Polite ...Mood: Anxious Affect: Calm and Decreased range ...Orientation: Oriented to person, place, time, and general circumstances ..."

Review of an ED Note by RN #16 dated 01/26/2015 at 1227, revealed "Patient hit and struck security officer in the nose and additionally attempted to headbutt him. Patient immediately put in 4 point leather restraints. Patient cursing at staff during process. Patient states 'I want to be in restraints'. Explained to patient that he was now in restraints and would remain in restraints until his behavior improved. Patient states 'when I get out of restraints I am going to kill you all'."

Review of an ED Progress Note by MD #4 dated 01/26/2015 at 1253 revealed "The patient became more aggressive at around noon today. He punched a security guard (TS) in the face. The patient had [sic] placed into 4. (4 point) restraints. He was given IM (intramuscular) Zyprexa (antipsychotic). He received IM Benadryl (antihistamine) a few hours ago. We will monitor the patient and provide additional medications or treatments to prevent aggressive behaviors. We will try to get the patient out of restraints and [sic] possible while maintaining the safety of the staff."

Review of an ED Note by RN #16 dated 01/26/2015 at 1310, revealed "Patient now spitting at staff and all over the floor. Mask placed on patient. MD aware of situation."

Review of an ED Note by RN #16 dated 01/26/2015 at 1530, revealed "Attempted to remove spit mask to allow patient to eat. Patient began spiting at sitter. Spit hood placed at this time."

Review of an ED Note by RN #16 dated 01/26/2015 at 1700, revealed "Patient assisted with eating dinner without incident. Spit hood replaced when finished."

Review of an ED Note by RN #16 dated 01/26/2015 at 1815, revealed "Patient continuing to fling, curse, spit and scream curse words at staff, sitter and security. Patient able to remove spit mask by maneuvering upper body to get hand to the spit mask and removing it. MD notified and order for posey vest and mittens. Security called and additional restraints placed. Patient continuing to threaten staff. Patient states 'I am going to kill all you f**kers'."

Review of an ED Note by RN #16 dated 01/26/2015 at 1854, revealed "Patient asking for restraints and spit mask to be removed. Explained to patient that his behavior was not compatible with that occurring but encouraged patient to continue attempts to remain calm."

Review of an ED Note by RN #16 dated 01/26/2015 at 2035, revealed "Pt removed spit mask, spit at sitter, (name), and called him a 'F**king Ni***r'. Spit mask was reapplied. Pt was unsuccessful at making saliva contact with sitter."

Review of an ED Note by RN #17 dated 01/26/2015 at 2300, revealed "Release of restraint - limb by limb trial. RUE (right upper extremity) and LLE (left lower extremity) have been released on a trial ba
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
Based on hospital policy and procedure reviews, medical record review and staff interviews, the hospital's staff failed to obtain renewal orders for patients restrained in the management of non-violent and non-self destructive behaviors for 1 of 1 patients in non-violent restraints (#10).

The findings include:

Review of current hospital policy "Restraint Management Protocol, 2466-1" last revised 06/20/2014, revealed, "Definitions: A. Physical Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, leg, body or head freely. ...Categories of Restraints/Indications for Use: A. Non-Violent or Non-Self-Destructive Behavior (Medical Surgical) Restraints: 1. Restraints used in medical care, and in situations in which behavior changes are caused by medical conditions or symptoms to protect the patient from injury to self or others. ...RESPONSIBILITIES: ...B. Non-Violent/Non-Self Destructive Behavior (MED/SURG) Restraints: 1. Physician/Licensed Independent Practitioner (LIP) a. Order for restraint at initiation. ...GENERAL RESTRAINT INFORMATION: ...D. The restraint should be discontinued by the staff nurse at the earliest possible time regardless of the scheduled expiration of the order. Discontinue Criteria includes: 1. Non-violent/ Non-Self Destructive. a. Patient compliant/able to follow directions. ...NON-VIOLENT OR NON-SELF DESTRUCTIVE BEHAVIOR RESTRAINT (MED/SURG) MANAGEMENT: ...B. PHYSICIAN ORDERS: ...2. An order of renewal is not required if the staff nurse assesses the justification for continuing the restraint every 4 hours and adheres to the discontinuation criteria. 3. If the restraint has been discontinued based on the criteria a new order must be obtained if the restraints must be reapplied. ..."

Open medical record review of Patient #10 revealed the patient was transferred to the facility on 03/14/2015 for a diagnosis of sepsis and respiratory failure. Record review revealed the patient was intubated (artificial airway to assist with breathing) at the transferring facility. Medical record review revealed the patient was placed in bilateral soft wrist restraints at 2100 on 03/14/2015. The non-violent or non-self destructive restraint order was obtained at 2148 on 03/14/2015. Record review revealed the patient remained in restraints on 3/15/2015, 3/16/2015/, 3/17/2015 and current date of record review of 3/18/2015. Record review revealed no renewal order for restraints.

Interview on 3/18/2015 at 1430 with Clinical Educator #1 revealed "Nurses renew justification of restraints every four (4) hours after physician initial order. New physician order only needed after restraint discontinued". Interview confirmed renewal orders for restraints not obtained for 03/15/2015, 03/16/2015, 03/17/2015 and 03/18/2015.

Interview on 03/19/2015 at 1305 with Clinical Educator #2 revealed "Restraint policy does not have a renewal timeframe. Non-violent restraints do not expire, their practice changed before 06/14/2014. Interview revealed "practice and policy changed when The Joint Commission changed their guidelines on restraints".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital' staff failed to ensure restraints were discontinued at the earliest possible time for 1 of 1 psychiatric patients (Patient #5) with a known history of violent and self-destructive behaviors .

The findings include:

Review of current hospital policy "Patient Rights And Responsibilities" last revised 08/28/2014 revealed "...Patient Rights and Responsibilities ...16. Be free from abuse, neglect and harassment... 17. Be free from restraint and seclusion that is not medically required or is used inappropriately. ..."

Review of current hospital policy "Restraint and Seclusion" revised 06/20/2014 revealed "Areas Affected: All Patient Care Areas PHILOSOPHY STATEMENT: (Name) Hospital is committed to providing a least restrictive, safe, and appropriate environment for all individuals. ...restraint use is limited to those circumstances where the patient is identified as being a t risk for injury to self or others and alternative safety measures have been evaluated and deemed inadequate. ...DEFINITIONS OF RESTRAINT AND SECLUSION: Restraint: 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 of the two. ...RESTRAINT MANAGEMENT GOALS: ...D. Restraints are discontinued at the earliest possible time regardless of the scheduled expiration of the order. ..."

Review of current hospital policy "Restraint Management Protocol, 2466-1" last revised 06/20/2014 revealed "Definitions: A. Physical Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Examples are a vest, soft wrist or ankle restraints, mittens (if tied), leather restraints... Categories of Restraints/Indications for Use: ...B. Violent or Self-Destructive Behavior (Behavioral) Restraints: ...GENERAL RESTRAINT INFORMATION: ...D. The restraint should be discontinued by the staff nurse at the earliest possible time regardless of the scheduled expiration of the order. Discontnued Criteria includes: ...2. Violent/Self Destructive a. No physical aggression b. Rational/compliant/follows directions c. Patient calm/asleep d. Transferred to secure area ..."

Closed medical record review on 03/18/2015 for Patient #5 revealed a [AGE] year old male (MDS) dated [DATE] at 1104 via ambulance. Review revealed the patient was placed into treatment room 25 and was triaged at bedside by a Registered Nurse (RN). The patient was assigned an acuity of "Emergent." Review revealed an arrival complaint of "IVC." Review of a triage note by RN #12 at 1111 revealed "Pt was just released from prison yesterday and sent immediately to (Mental Health Crisis Center). Pt sent to ED due to being too violent as he was verbally aggressive to staff members at (Mental Health Crisis Center). Pt answering questions for nurse. Guard at bedside." Review revealed a past medical history (PMH) of Schizophrenia, Post Traumatic Stress Disorder (PTSD), and Personality Disorder. Review revealed documentation of multiple past psychiatric hospitalization s. Review revealed the patient remained in the ED and was transferred to a Psychiatric hospital on [DATE] at 1427 (17 days later). Review revealed while in the ED a TASER weapon was used on the patient on 01/29/2015 at ~0940 and 02/03/2015 at ~1145 and the patient was placed into 4 point leather restraints for the management of violent and self-destructive behaviors. Review revealed the TASER weapon was used on the patient by hospital-employed Protective Services Officers who were not sworn law enforcement officers.

Review of ED Provider Notes by MD #15 dated 01/24/2015 at 1111, revealed the patient presented with a chief complaint of "Paranoia." Review of HPI (history of present illness) revealed "(Patient #5) is a 23 y.o. (year old) male who presents after being assessed at the crisis center. It [sic] been in jail and then sent to the crisis center for psychiatric evaluation. He has a history of antisocial personality as well as schizophrenia and poor compliance with his medications. He apparently became agitated after conversation with his mother today and wanted to be sent to the emergency department. Upon my interviewing he is calm and cooperative. He denies any active hallucinations. he denies a desire to harm himself or others at present. Involuntary Commitment. ...PHYSICAL EXAM: ...General: No acute distress. ...Neuro: ...He is alert and oriented x3 (to person, place, time) Psych (Psychiatric): He has somewhat of a flat affect. He is cooperative. ...I've consulted psychiatry to see the patient while here. ...FINAL IMPRESSION: 1 Acute psychosis 2. Schizophrenia.

Review of Psychiatric Consult Note by Psychiatrist #1 dated 01/24/2015 at 1217, revealed the reason for consult was "Psychosis." Review of HPI revealed "...ENGLISH speaking male with a history of schizophrenia, PTSD, alcohol use, hx of severely aggressive behavior towards family, hx of assault on EMS (emergency medical services) staff, police officers. Longstanding medication noncompliance. Recently released from jail after 30 day sentence for assaultive behavior towards family. Sent directly to (Mental Health Crisis Center) on a petition due to making threats over the phone to harm father, concern for ongoing psychosis. Subsequently sent to (Hospital A) on IVC due to need for 'higher level of care.' Per my review of available records, he was agitated, yelling after a phone call with mother and decision was made that he needed to be in the ER. RN notes indicated he was threatening staff, yelling and gesturing in a hallway. I saw the patient today in the ER. He was calm and able to talk without yelling or profanity. Tells me the zyprexa and klonopin (psychiatric medications) are helping him with anger, admits he has a problem with anger. ...He does note that he can get overwhelmed with paranoid thoughts about conspiracies against him, ...Currently without specific violent thoughts or inclinations. Past Psychiatric History: Hx of multiple psych hospitalization s at many facilities, with psychotic d/o dx dating back to [AGE]. ...Mental Status Exam: A and O (alert and oriented) to name, place, situation. Able to tell me month and year along with his age. Makes fair eye contact with interviewer. Speech is monotone but normal volume, easily comprehensible. Mood is fair, affect somewhat blunted. No tangentially. Denies AH/VH (auditory/visual hallucinations). Insight limited. Endorses some paranoia but notes thoughts about other being out to hurt him are better on medication. Assessment: ...admitted with schizophrenia, violent behaviors. IVC'd from jail for threatening behaviors towards family. Sent from (Mental Health Crisis Center) due to escalating agitation, felt unsafe to manage in that setting. Currently calm and accepting medications, potential to escalate quickly based on his history... Diagnoses: Axis I Hx of schizophrenia, paranoid type, r/o (rule out) alcohol use d/o. Hx of PTSD. Axis II r/o antisocial personality traits vs (versus) disorder... Plan: ...4) Maintain IVC, initiate search for inpt psych and maintain sitter/suicide precautions while here. Disposition: Recommend transfer to inpatient psychiatric unit as available, indicated, and medically appropriate. Recommendations have been communicated to primary team. ..."

Review of an ED Note by RN #16 dated 01/26/2015 at 1227, revealed "Patient hit and struck security officer in the nose and additionally attempted to headbutt him. Patient immediately put in 4 point leather restraints. Patient cursing at staff during process. Patient states 'I want to be in restraints'. Explained to patient that he was now in restraints and would remain in restraints until his behavior improved. Patient states 'when I get out of restraints I am going to kill you all'."

Review of an ED Progress Note by MD #4 dated 01/26/2015 at 1253 revealed "The patient became more aggressive at around noon today. He punched a security guard (TS) in the face. The patient had [sic] placed into 4. (4 point) restraints. He was given IM (intramuscular) Zyprexa (antipsychotic). He received IM Benadryl (antihistamine) a few hours ago. We will monitor the patient and provide additional medications or treatments to prevent aggressive behaviors. We will try to get the patient out of restraints and [sic] possible while maintaining the safety of the staff."

Review of an ED Note by RN #16 dated 01/26/2015 at 1310, revealed "Patient now spitting at staff and all over the floor. Mask placed on patient. MD aware of situation."

Review of an ED Note by RN #16 dated 01/26/2015 at 1815, revealed "Patient continuing to fling, curse, spit and scream curse words at staff, sitter and security. Patient able to remove spit mask by maneuvering upper body to get hand to the spit mask and removing it. MD notified and order for posey vest and mittens. Security called and additional restraints placed. Patient continuing to threaten staff. Patient states 'I am going to kill all you f**kers'."

Review of an ED Note by RN #16 dated 01/26/2015 at 1854, revealed "Patient asking for restraints and spit mask to be removed. Explained to patient that his behavior was not compatible with that occurring but encouraged patient to continue attempts to remain calm."

Review of an ED Note by RN #16 dated 01/26/2015 at 2035, revealed "Pt removed spit mask, spit at sitter, (name), and called him a 'F**king Ni***r'. Spit mask was reapplied. Pt was unsuccessful at making saliva contact with sitter."

Review of an ED Note by RN #17 dated 01/26/2015 at 2300, revealed "Release of restraint - limb by limb trial. RUE (right upper extremity) and LLE (left lower extremity) have been released on a trial basis. Pt has also had oral care by brushing of teeth and has voided by use of urinal. pt has agreed to cooperate and understands that any harm against self or others will require the continued use of restraints on those extremities. Sitter at bedside. Will continue to monitor."

Review of an ED Note by RN #17 dated 01/27/2015 at 0210, revealed "Pt was given box lunch, crackers and a soda. Pt has been compliant. Down to last limb by trail for D/C (discontinue) of restraints. Will continue to monitor."

Review of an ED Note by RN #17 dated 01/27/2015 at 0230, revealed "Pt compliant, no observable reason to believe that pt is an immediate danger to self or others. Pt verbalizes understanding of D/C of restraints and agrees to contract for safety and agrees to report to this RN or other ED staff if he feels distressed and has feelings of harming self or others. Pt denies SI/HI (suicidal/homicidal ideation) and any visual/audio hallucinations. Pt. Has had all restraints removed. MD (MD #16) aware. Pt has sitter (name) at bedside.

Review of an ED Psychiatric Progress Note by MD #6 dated 01/27/2015 at 0818, revealed "This is an ongoing psychiatric progress note for patient who is in the emergency department awaiting psychiatric placement and currently on IVC paperwork. ...The patient had been agitated and violent yesterday. Throughout the evening he slowly came off 4 point leather restraints and is now unrestrained. ...Addendum @ (at) 10:58 AM: Psychiatry, Dr. (name), evaluated the patient. Apparently during or shortly after the patient's evaluation by psychiatry, Dr. (name), the patient got increasingly agitated. He got increasingly violent at that time he began spitting again. Security was called. Dir. (Director) of nursing, (ED Director #1), and director of security, (PSO Director #1), were both present in the emergency department. At this time the patient had [sic] be placed back into 4. (4 point) leather restraints. Any evaluation or interaction with this patient will need to be accompanied by security per nursing and security director."

Review of an ED Note by RN #18 dated 01/27/2015 at 1030, revealed "Patient became agitated after being seen by psy (psychiatry). Security here. Patient spit in sitters face. Patient placed in four point restraints."

Review of an ED Note by RN #19 dated 01/27/2015 at 1115, revealed "...Pt remains in 4pt (4 point) leather restraints, vest and spit hood. Plan of care reviewed with pt, restraint parameters reviewed, pt voices understanding but appears somewhat delayed in responses. Plethora of staff at bedside including security gaurdsX3 [sic], rpd (local police department), risk management, PRS and ED TL (team leader) briefing this RN of safety precautions. Pt intermittently aggressive and cooperative, verbalizes intent to kill his parents and staff members present. pt medicated per orders without issue, security present for admin. (administration)."

Review of an ED Note by RN #19 dated 01/27/2015 at 1400, revealed "Pt much more complaint with POC (plan of care), trial in progress to remove restraints. Pt at [sic] 70% of lunch tray, toileted without issue. Pt states understanding that his behavior is inappropriate at times and this RN encourages to discuss needs and feelings before escalating. Boundaries set and reviewed, pt to attempt a nap on his side. Sitter and security remain in doorway, room devoid of potentially harmful objects."

Review of an ED Note by RN #19 dated 01/27/2015 at 1600, revealed "ED rounds completed, pt compliant with behavior health policies. ...Bed linens changed, new clothing provided, pt appreciative of comfort measures rendered. Security guard and sitter remain within doorway of pts room in direct view of pt. Pt not in restraints at this time, verbalizes that he needs to remain calm and non violent to remain out of them. ..."

Review of an ED Note by RN #21 dated 01/28/2015 at 1105, revealed "Patient starting to exhibit symptoms of anxiety. Talking fast, telling this RN about his 'enemies'. Dr. (Psychiatrist #2) notified via telephone, new orders received... Dr. (MD #6) also notified. ..."

Review of an ED Note by RN #11 dated 01/28/2015 at 1200, revealed "...Patient was anxious and restless, stated 'I am out of control and need to be restrained'. ED Security (PSO #5) and sitter (name) witnessed this request. Dr. (MD #6) notified, orders received, restraints applied. ..."

Review of an ED Note by RN #22 dated 01/29/2015 at 0440, revealed "Pt requesting leather restraints for both ankles and rt (right) wrist. ..."

Review of an ED Progress Note by MD #3 dated 01/29/2015 at 0757, revealed "Overnight the patient asked for restraints as he felt he might become violent, was temporarily in 3-point restraints, currently out of restraints. ...He remains medically clear for transfer to an appropriate psychiatric facility when one becomes available. ..."

Review of an ED Note by RN #8 dated 01/29/2015 at 1543, revealed "...Pt asking to be removed from restraints. Pt request denies [sic], pt reminded of incident earlier today in which staff was hurt and pt restrained. Pt not wiling to 'behave' per himself."

Review of an ED Note by RN #8 dated 01/29/2015 at 1752, revealed "Pt eating dinner. Wrist Restraints remain off at this time."

Review of an ED Note by RN #8 dated 01/29/2015 at 1815, revealed "Leather wrist restraints re applied as pt increased agitation occurred. Dr. (MD #14) aware."

Review of an ED Note by RN #8 dated 01/29/2015 at 1830, revealed "Pt remained safe from harming self or others after incident early this am. Pt in restrains [sic] with q (every) 15 minutes checks. Upper limb leathers removed temporarily at dinner time with verbal contract with pt. Pt did not remain without incident and wrist restraints re applied. Sitter and security officer at bedside and room entrance throughout the shift. ...Voided in urinal. ..."

Review of an ED Note by RN #19 dated 01/29/2015 at 1915, revealed "...Pt continues to be in 4pt (4 Point) leather restrains [sic]... Toileting offered... Pt drowsy but able to communicate that he understands that he needs to be in the restraints at this time. ..."

Review of an ED Note by RN #19 dated 01/29/2015 at 2200, revealed "Pt attempting to rest at this time, no longer in restraints. Cooperative at this time..."

Review of an ED Note by RN #8 dated 01/30/2015 at 1007, revealed "Pt currently asleep, sitter and security guard at bedside."

Review of an ED Progress Note by MD #7 dated 01/30/2015 at 1319, revealed "Patient is still awaiting IVC placement. Patient has been in 4. (4 point) restraints since dayshift started this morning. Yesterday patient had a violent outburst which is....documented. On exam he is currently calm and cooperative. Nursing reports he has had no acute issues this morning for overnight. ..."

Review of and ED Note by RN #8 dated 01/30/2015 at 1625, revealed "Pt currently asleep. Sitter at bedside, security by room. Siderails up x 2. Pt remains in restraints per MD order."

Review of an ED Note by RN #8 dated 01/30/2015 at 1829, revealed "...Sitter at bedside during the entire shift. ...Restraints remained in place. ..."

Review of an ED Note by RN #23 dated 01/30/2015 at 1915, revealed "Resting quietly...Patient in four points leather restrains [sic] with vest posey in place on my arrival. Instructed by charge nurse not to remove restraints. Left arm released to ROM (range of motion) and eating/voiding needs."

Review of an ED Note by RN #24 dated 01/31/2015 at 0128, revealed "This RN relieving sitter for dinner break. Patient remains in restraints; eyes closed; resting quietly..."

Review of an ED Note by RN #24 dated 01/31/2015 at 0300, revealed "...Sitter at bedside. Patient remains in 4 point restraints as ordered by MD for safety of staff, per report. Patient dozing off and on. ...Cooperative."

Review of an ED Note by RN #24 dated 01/31/2015 at 0504, revealed "Patient resting quietly with eyes closed... Remains in 4 point restraints as ordered by MD."

Review of an ED Note by RN #9 dated 01/31/2015 at 0800 revealed "...kerlix wrapped around bilat (bilateral) wrists and ankles prophylacticly to prevent skin breakdown as pt has been in leather restraints > (greater than) 24 hours."

Review of a Psychiatric Progress Note by Psychiatrist #2 dated 01/31/2015 at 1054, revealed "...remains in leather restraints. ...Mental Status Exam: ...Behavior: Calm, Direct eye contact and Polite but more pushy today ...Mood: anxious ...Affect: Calm and Decreased range, a little irritable ...Orientation: Oriented to person, place, situation, general circumstances ...Impulse Control: Impaired. ...Assessment: ...I believe he remains in imminent danger to himself or others, and that we have no choice but to force medications if he is to remain in restraints in the emergency room , given there are no beds at (name) Hospital yet. I am concerned about him having to be in leather restraints around the clock, and would prefer for him to be mildly sedated from the Thorazine, so that at least some of the restraints can be released periodically. ...Plan: "...6. ...At this time, he continues to require around the clock restraints."

Review of an ED Progress Note by MD#3 dated 01/31/2015 at 1113, revealed "The patient remains in the emergency department under IVC papers. This morning the patient denies any complaints or pain. ...This patient has a history of violent outbursts and he continues to refuse medications may require us to give intramuscular medications to protect the safety of our staff and others around this patient. Given his history of violent behavior he presents an iminemt [sic] threat to those around him if he does not take his medications. Due to this threat he remains restrained. I evaluated the patient in person and feel restraints are warranted and they remain in place. ...In the meantime we will continue to provide supportive c [sic]with one-to-one continuous observation and attempts to provide a safe environment. ...Because of his leather restraints the patient is essentially immobilized, I will add Lovenox (prevents blood clots) 40 mg (milligrams) daily for DVT (deep vein thrombosis) prophylaxis, this should be continued until he is allowed to ambulate again. ..."

Review of an ED Progress Note by MD #9 dated 01/31/2015 at 1957, revealed "I've evaluated the patient for continuance of restraints. ...He is alert and talkative. He is not agitated at this time. I believe he is safe to continue in restraints."

Review of an ED Note by RN #13 dated 01/31/2015 at 2223, revealed "(Hospital A) management advised this RN that pt is not to come out of restraints. Directive acknowledged. Pt allowed supervised ROM of all extremities one at a time... Pt reports pain anterior L (left) knee, ice pack applied. Pt remains cooperative about restraints and expresses wants to come out of restraints. ..."

Review of an ED Progress Note by MD #8 dated 02/01/2015 at 0045, revealed "This is a progress note for a patient being held on IVC paperwork... He has been maintained in 4 point leather restraints due to assault of staff that has occurred during his stay in the ED. I have evaluated the patient, he is oriented x 3 (person, place, time) and cooperative. ...He is not agitated. At this time, I believe he could have a trial of rotating 2-pint restraints to prevent skin breakdown. I have discussed this plan with the patient, he is aware that any attempts to remove his restrains will result in returning to 4-point restraints. I have discussed this with [PSO Director #1] (Security Supervisor) as well as [name] (House Supervisor), they are in agreement with this plan."

Review of an ED Note by RN #13 dated 02/01/2015 at 0100, revealed "...Per MD order, pt in 2 point restraints. Freed extremities moving freely, will rotate restraints periodically. Charge Nurse has also been made aware."

Review of an ED Note by RN #25 dated 02/01/2015 at 0700, revealed "Patient resting comfortably in bed with 2-point restraints in place. Sleeping... Sitter at the door for safety and security outside door."

Review of an ED Note by RN #25 dated 02/01/2015 at 0829, revealed "Awake and calm."

Review of an ED Progress Note by MD #10 dated 02/01/2015 at 0923, revealed "...Final report he has been violent with staff, requiring 4. (4 point) restraints, which were recently downgraded to 2 point restraints. Report patient has been calm and cooperative over the past 24 hours. ...On exam this morning....he is in 2 point restraints, resting with his head covered, but removes the cover when I address him. His speech is calm, fluent. He appears comfortable. ..."

Review of an Psychiatric Progress Note by Psychiatrist #3 dated 02/01/2015 at 1003, revealed "...He is calm and cooperative today. However, given his extremely unpredictable violent behaviors in the recent past, i.e. Assaulted (Hospital A) staff within the past week, we will continue 2-point restraint for the safety of himself and other patients and staff in ED. Pt has been taking his Thorazine yesterday, and is calmer now. ...He understands that if he refuses Thorazine orally, we have no choice but to administered intramuscularly for his safety and the safety of the staff here, given the level of violence displayed over the last week. ...Mental Status Exam: ...Behavior: Calm, Direct eye contact and Polite but more pushy today ...Mood: Anxious ...Affect: Calm and Decreased range, a little irritable ...Orientation: Oriented to person, place, situation, and general circumstances ...Impulse Control: Impaired. ...Assessment: ...history of violent behavior, threatening towards the family and towards staff, currently on the waiting list for (name) Hospital; he has escalated quickly, and with no warnings, on multiple occasions. ...I believe he remains in imminent danger to himself or others, and that we have no choice but to force medications if he is to remain in restraints in the emergency room , given there are no beds at (name) Hospital yet. I am concerned about him having to be in leather restraints around the clock, and would prefer for him to be mildly sedated from the Thorazine, so that at least some of the restraints can be released periodically. ...Plan: "...6. ...At this time, he continues to require around the clock restraints."

Review of an ED Note by RN #27 dated 02/01/2015 at 2300 and 02/02/2015 at 0300, and 0415, revealed "Patient sleeping..."

Review of an ED Note by RN #27 dated 02/02/2015 at 0639, revealed "...Patient has slept for the entire time this RN has been responsible for him. All points of restraint were checked for redness and/or breakdown. This RN did not wake the patient to change the position of the restraints to keep from agitating him. ..."

Review of an Psychiatric Progress Note by Psychiatrist #4 dated 02/02/2015 at 1206, revealed "...He is more calm and cooperative today. ...Given his extremely unpredictable violent behaviors in the recent past, i.e. Assaulted (Hospital A) staff within the past week, we will continue 2-point restraint for the safety of himself and other patients and staff in ED. ...Mental Status Exam: ...Behavior: Calm, Direct eye contact and Polite but more pushy today ...Mood: Anxious ...Affect: Calm and Decreased range, a little irritable ...Orientation: Oriented to person, place, situation, and general circumstances ...Impulse Control: Impaired.
...Assessment: ...history of violent behavior, threatening towards the family and towards staff, currently on the waiting list for (name) Hospital; he has escalated quickly, and with no warnings, on multiple occasions. ...I believe he remains in imminent danger to himself or others, and that we have no choice but to force medications if he is to remain in restraints in the emergency room , given there are no beds at (name) Hospital yet. I am concerned about him having to be in leather restraints around the clock, and would prefer for him to be mildly sedated from the Thorazine, so that at least some of the restraints can be released periodically. ...Plan: "...6. ...At this time, he continues to require around the clock restraints."

Review of an ED Progress Note by MD #10 dated 02/02/2015 at 1658, revealed "This is a daily progress note for a patient being held on IVC paper work. He remains on 2 point restraints, and is been cooperative and calm over the past 24 hours. ...He ate well today. Currently he states that he is dong fine and he is without any complaint or requests. He is sitting up watching TV with a bedside sitter. ..."

Review of an ED Note by RN #8 dated 02/02/2015 at 1821, revealed "...Sitter and....security officer at bedside. ...Pt cooperative. ...Restraints documentation completed. ..."

Review of an ED Note by RN #28 dated 02/02/2015 at 2129, revealed "...requested to make a phone call, per security phone privileges have been revoked. ...2 point leather restraints remain in place along with vest. Per ED director, due to pts past behavior, at least 2 leather restraints to be in place at all times. Pt calm and cooperative at this time. Sitter remains at bedside. ..."

Review of an ED Note by RN #28 dated 02/03/2015 at 0400, revealed "Pt has been sleeping since around 0115. (MD #8) completed a bedside assessment at 0000 and noted pt to be agitated. Aware that leather restraints are being rotated q4 (every 4) hrs with one ankle and one wrist restraint in place at all times. Per (MD #8), due to pts agitation, no rotations are needed at this time. Will rotate restraints when pt is awake and cooperative. ..."

Review of a Psychiatric Progress Note by Psychiatrist #5 dated 02/03/2015 at 1157, revealed "...He remains in two point restraints due to severe aggression and assaultive behavior. ...He denied thoughts of harming himself or others at present. After this writer had left the room, the patient called her back in....Unfortunately, approximately one hour later, he was again displaying agitation and Thorazine was required. Patient spit on staff during this intervention. ...Mental Status Exam: ...Behavior: Calm, Direct eye contact and Polite ...Mood: Anxious ...Affect: Calm and Decreased range, a little irritable and sullen ...Orientation: Oriented to person, place, situation, and general circumstances ...Impulse Control: Impaired. ...Assessment: ...history of violent behavior, threatening towards the family and towards staff, currently on the waiting list for (name) Hospital; he has escalated quickly, and with no warnings, on multiple occasions. ...No overt psychosis on today's exam....I believe he remains in imminent danger to himself or others, and that we have no choice but to force medications if he is to remain in restraints in the emergency room , given there are no beds at (name) Hospital yet. Regarding leather restraints, it would be preferable for him to be mildly sedated from the Thorazine, so that at least some of the restraints can be released periodically. ...Plan: ...7. ...At this time, he continues to require around the clock restraints."

Review of an ED Note by RN #30 dated 02/03/2015 at 1900, revealed "Security remains sitting outside pt's door along with sitter... Pt lying on stretcher with head of stretcher slightly elevated...pt appears in no distress. Remains in leather restraints and all restraints checked..."

Review of an ED Note by RN #30 dated 02/03/2015 at 2000, revealed "Restraint order renewed by MD."

Review of an ED Note by RN #30 dated 02/03/2015 at 2206, revealed "Patient awake; remains in restraints due to violet behavior. Request a few crackers and something to drink; Into give pt water accompanied by security; pt sitting up in bed with spit mask on but able to drink via straw without spitting or difficulty swallowing. ...Male nurse in room to assit pt with urinal."

Review of an ED Note by RN #30 dated 02/04/2015 at 0643, revealed "Patient resting with both eyes closed; appears no distress; sitter at bedside. Pt remains in restraints."

Review of an ED Progress Note by MD #6 dated 02/04/205 at 0813, revealed "...The patient did have escalation yesterday and assaulted a provider. He was placed in 4. (4 point) leather restraints in which he has remained. ...The patient is sleeping at this time. ...He remains in leather restraints which I have renewed at this time. Approximately one hour after initial note nursing staff and security are in the room. He states that he has no other needs or concerns at this time."

Review of a Psychiatric Progress Note by Psychiatrist #2 dated 02/04/2015 at 1237, revealed "...The patient continues to attempt to negotiate medications, attempting to refuse them at times, but this morning he was more cooperative. He slept overnight. He allowed the sitter to help feed him. He was polite and the nurse gave him medication, but then he started to scream at the sitter, yelling at the sitter not to come close, and then he told the RN 'please give me Thorazine'. He looked at the sitter and said 'I need help'. With the presence of security officers in the room he received that injection, his regular medications, and was then quite. He has continued to require a mask in order to [sic] unpredictable behavior... He remains in 4 pint restraints. ...Mental Status Exam: ...Behavior: Calm, Cooperative, Direct eye contact and Polite ...Mood: Anxious ...Affect: Anxious and Blunted ...Orientation: Oriented to person, place, situation, and general circumstances ...Impulse Control: Impaired. ...Assessment: ...At this time he remains highly dangerous, unpredictable, paranoid, and cannot be released to the community. ...Plan: ...5. ...At this time, he continues to require around-the-clock restraints for everyone's safety, including his own."

Review of an ED Note by RN #19 dated 02/04/2015 at 2200, revealed "...pt calm for most of shift, had some sporadic outbursts but nothing sustained or specific. No acts or threats of violence this shift. ...Pt voided multiple times throughout shift, was hand fed lunch dinner and even snack by tech and this RN. Pt remains in 4 point leather restraints and vest at the request of ED Director, ED security director, attending ED MD and attending psych MD, pt aware of need for restraints and compliant with plan. ...Security guard and sitter remain at doorway to room at all times..."

Review of an ED Note by RN #31 dated 02/04/2015 at 23
VIOLATION: NURSING SERVICES Tag No: A0385
Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure registered nursing staff supervised and evaluated patient care for 1 of 1 psychiatric patients (#5) in the hospital's emergency department.

The findings include:

The hospital's nursing staff failed to provide supervision to ensure coordination and communication between emergency services and security services (PSO) in order to render safe care for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors who was tasered while in the Emergency Department by non-law enforcement security staff.

~cross refer to 482.23(b)(3) Nursing Services Standard - Tag A0395.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital's nursing staff failed to provide supervision to ensure coordination and communication between emergency services and security services (PSO) in order to render appropriate care for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors who was tasered while in the Emergency Department by non-law enforcement security staff.

The findings include:

Review of current hospital policy "Patient Rights And Responsibilities" last revised 08/28/2014 revealed "...Patient Rights and Responsibilities ...16. Be free from abuse, neglect and harassment... 17. Be free from restraint and seclusion that is not medically required or is used inappropriately. ..."

Review of current hospital policy "Restraint and Seclusion" revised 06/20/2014 revealed "Areas Affected: All Patient Care Areas PHILOSOPHY STATEMENT: (Name) Hospital is committed to providing a least restrictive, safe, and appropriate environment for all individuals. ...restraint use is limited to those circumstances where the patient is identified as being a t risk for injury to self or others and alternative safety measures have been evaluated and deemed inadequate. ...DEFINITIONS OF RESTRAINT AND SECLUSION: Restraint: 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 of the two. ...RESTRAINT MANAGEMENT GOALS: A. Restraints are only used when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others. B. Restraints are not used a s a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used when less restrictive interventions are ineffective and if used, the least restrictive form of restraint is used to protect the physical safety of the patient, staff, or others. D. Restraints are discontinued at the earliest possible time regardless of the scheduled expiration of the order. E. Restraints will be applied using the proper technique based on the type of restraint. F. The appropriate restraint plan of care will be initiated for the patient. G. Physicians/LIP is responsible for ordering the restraints. PRN restraint orders are not acceptable. ...I. Patients will be monitored, evaluated, and re-evaluated according to the Restraint Protocol. ..."

Review of current hospital policy "Restraint Management Protocol, 2466-1" last revised 06/20/2014 revealed "Definitions: A. Physical Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Examples are a vest, soft wrist or ankle restraints, mittens (if tied), leather restraints... Categories of Restraints/Indications for Use: ...B. Violent or Self-Destructive Behavior (Behavioral) Restraints: 1. A clinical justification, other than those identified as non-violent or non-self-destructive behavior, to protect the patient from injury to self or others because of an emotional or behavioral disorder where the behavior may be violent or aggressive. RESPONSIBILITIES: A. Violent/Self-Destructive Behavior (Behavioral) Restraints: 1. Physician/Licensed Independent Practitioner (LIP)*: a. Order for restraints at initiation. b. Face to face assessment of the need for restraint initiation within one hour and ongoing assessment of the continued need for restraints. c. Renewal order for continued justification for restraints. d. Review and evaluation of current medications to identify and minimize the use of medications that place a patient at risk for restraint use. ...3. Staff Nurse: a. Identification of the patient at risk for restraints, the behavior/symptoms that the patient is exhibiting, and the initiation of pre-restraint alternative interventions that may reduce both the need and duration of restraint use. b. Restraint initiation and management. c. Calls the attending physician/LIP for a restraint order. d. Notifies the attending physician that restraints have been initiated if he/she was not the ordering physician of the restraint as soon as possible**. e. Regular scheduled reassessment of the patient in restraints to justify continued validity of restraint use with the potential to discontinue or reduce the level of restraint evaluated. ...GENERAL RESTRAINT INFORMATION: A. PRN and standing orders for any category of restraint is not acceptable. B. Restraints are not used as a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used only when other less restrictive interventions are ineffective. If restraints are employed, the least restrictive restraint to protect the patient's/other's physical safety is used. D. The restraint should be discontinued by the staff nurse at the earliest possible time regardless of the scheduled expiration of the order. Discontnued Criteria includes: ...2. Violent/Self Destructive a. No physical aggression b. Rational/compliant/follows directions c. Patient calm/asleep d. Transferred to secure area ...VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR RESTRAINT (BEHAVIORAL) MANAGEMENT: ...Physician Order: 1. A staff nurse may apply restraints in an emergency situation prior to obtaining a physician order but the physician/LIP should be contacted immediately and notified that restraints have been initiated. ...2. Any patient restraint within one hour after the initiation of restraints by a physician/LIP or Specially Trained Nurse who will evaluate the continued need for restraint. ...3. The face to face assessment conducted within one hour includes the following: a. An evaluation of the patient's immediate situation. b. The patient's reaction to the intervention. c. The patient's medical and behavioral condition. d. The need to continue or terminate the restraint. 4. Renewal orders must be obtained every 2 hours for patients 9-17 years of age and every 4 hours for ages 18 and older. Orders may be renewed for a maximum of 24 consecutive hours at which time a physician/LIP reassessment is required. 5. Every 24 hours a physician/LIP must complete a face to face assessment before writing a new order. 6. If a restraint is discontinued prior to the expiration of the order, a new order must be obtained to re-initiate restraints. C. Routine Monitoring/Patient Care: 1. Patients will have continuous, direct one on one observation at all times by a staff nurse, NA, or PCT. Continuous observation and psychological status/visual check (i.e. affect/behavior) will be documented every 15 minutes. 2. Routine checks will be monitored and documented every 2 hours by a staff nurse, NA, or PCT. Routine checks includes: ROM, elimination, fluids, circulation/skin integrity, and food/meal. 3. The continued justification for restraints or a less restrictive form of restraints will be assessed and documented every 4 hours by the staff nurse. ..."

Review of current hospital policy "1700-05, Restraints" last revised 04/14/2014 revealed "...1. Restraint Assistance A. A Protective Services officer may be called upon to assist the health care team in restraining a patient. The officer provides assistance within the scope of Patient Care Services Restraint policy (refer to the Patient Care Services Policy Manual). B. Upon arriving at the scene, the officer will make contact with the person(s) requesting assistance. 1. If an officer comes upon a scene with staff struggling with a patient, the officer immediately offers assistance. 2. If an officer comes upon a scene and there appears to be no imminent danger to the patient or the staff, the responding officer(s) will seek guidance from the health care team on the level of physical contact and method of restraint. C. The officer assists the staff by immobilizing the patient's arms and legs while the staff secures the restraints. D. If the staff is unfamiliar with the restraints, then the officer will secure the restraints. ..."

Review of current hospital policy "1400-20 Electronic Control Device (TASER) last revised 04/14/2014 revealed "...Protective Services officers have an obligation to protect all staff, patients, and visitors against violence while on campus. ...Therefore, officers trained in the use of electronic control devices (TASER) will be allowed to possess, and in accordance with the Protective Service Policy 1400-05, Use of Force Guidelines, deploy the TASER to subdue violent or resistive subjects as required in the line of duty. ...B. ...2. Only personnel who have completed the departmentally approved class will be allowed to carry and deploy the TASER devices while on duty. ...C. TASER and the Use of Force. 1. Deployment of the TASER constitutes use of force as proved in Protective Services Policy 1400-05, Use of Force Guidelines. 2. The TASER is an electronic control device utilizing a Neuro-Muscular Incapacitation system. Its use is designed to incapacitate by over-riding and disrupting the sensory nervous system and the motor nervous system (causing uncontrollable contractions of the muscle tissue). ...4. The TASER may be deployed against a subject only if one or more of the following situations exist: a. Subject is physically assaulting someone. This includes infliction of self-harm. b. Subject is displaying behaviors that would lead a reasonable person to believe that a physical assault will occur imminently, including self-harming behavior. c. If in the officer's opinion, there is a very real possibility of injury occurring to officers, bystanders, or the subject, every effort is made to take the subject into custody by other means. 5. Deployment of the TASER: d. The subject against whom the TASER was discharged should always be handcuffed....immediately after discharge. The officer who deployed the TASER should immediately call for backup if backup is not already present. Allow the other officers to handcuff the subject, and be prepared to further discharge the TASER if the subject becomes violent before he/she can be handcuffed. If backup is not available, the officer will ensure that the subject has submitted before trying trying to apply handcuffs. If the subject refuses to submit, the officer will maintain a safe distance and control the subject by verbal commands and/or TASER discharges until backup arrives. If the subject refuses to submit to the officer's commands after being shot with the TASER, it is possible that the handcuffing may need to proceed while the TASER is being discharged into the subject. e. An alternative method of deployment is "Drive Stun," where the TASER, either without a cartridge or with an expended cartridge, is pressed against the subject and TASER is discharged . ..."

Review of current hospital policy "1400-05, Use of Force Guidelines" last revised 05/17/2013 revealed "...The Protective Services Officer has duties that will be performed to provide for the safety of patients, staff, and visitors; and if force is necessary to perform these duties, the minimum amount of force is authorized. Before using physical force, officers must exhaust every other available means of performing their duties. 1. A. Approach every situation with an attitude of confidence, impartiality, and courtesy, The officer's attitude and remarks must not provide anger in the subject. B. A timely call for assistance and a quick response of back-up can also calm a situation. C. In extreme situations, a show of superior numbers is sometimes needed to calm a situation. 2. Evaluating a Situation A. Any decision reached in the evaluation and resolution of a situation requires utilization of skills, training, and knowledge pertinent to the situation. ...B. Officers should not enter confrontations they are certain to lose. In such situations, the officer's primary concern should be for the safe evacuation of patients, staff and visitors from a violent environment to a defensible area and await arrival of backup. ... C. Once safely withdrawn the officer should call for assistance from the (name) Police Department... 3. Use of Force A. Patient-Specific Guidelines 1. Weapons will not be used by Protective Services as means of managing control of a patient for the purposes of medical care. 2. If a weapon is used by Protective Services on a patient to protect people or hospital property from harm, the incident will be handled as a criminal activity. Law enforcement will be called to respond within the intent of placing the patient in their custody. ..."

Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number ; Date/Time Received - 01/29/2015 at 0939; Time Arrived - 0940; Nature of Incident - 38-Patient Restraint; Location of Incident - Emergency Department Treatment Area 25; and Action Taken "OFFICER (PSO #1) USED TASER ON ED BE [sic] 25 (Patient #5). ...PATIENT PLACED IN LEATHER RESTRAINTS."

Review on 03/18/2015 of Patient Safety Event Report RTW 11 involving Patient #5, dated 01/29/2015 at 1010; reported by RN #10, revealed on 01/29/2015 at 0930 "At about 9:30am on 1/29/2015 IVC (involuntary commitment) csn# 5 in ER bed 25 was agitated, and verbally aggressive initially. Pt cussing at sitter and staff. Pt stated that he does not like black people. Security was called. Pt then spit on then [sic] spit on [Sitter #1] (the pt's sitter) clothing. Primary RN (RN #8) was aware of the situation and had med (medication) requested pt's PRN (as needed) med that had to come up from the main pharmacy. x1 (times one) Security officer was at bedside awaiting for other officers. Other security officers arrive. Pt stormed outside of the room and assaulted Officer [PSO #1] (pt punched and [sic] him in the face and scratched him in the face) pt was tackled to the ground in the hallway by Security Officers and (RN #9). While pt was being tackled pt punched Officer (PSO #2) in the forehead. Pt had to be tasered by Protective services staff. Team Leader (RN #11); (PSO Director #1); (ED Director #1) were made aware of the situation. ...Dr. (MD #3) was made aware and he gave order for restraint usage. Pt was placed in 4 point restraints. ...". Review revealed the event occurred in the ED Patient Care Area.

Review on 03/18/2015 of Patient Safety Event Report CLI 38 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #1, revealed on 01/29/2015 at 0940 "At 0939 hrs (hours), reporting officer, (PSO #1) was dispatched to assist with patient in ED bed 25. Once arriving I was told IVC patient (Patient #5) spitted [sic] at his sitter and Officer (PSO #4). While I was talking with his nurse (RN #8), (Patient #5) swung and hit Officer (PSO #2) over his left eye causing a bruise. Officer (PSO #4) and I (PSO #1) forced (Patient #5) to the floor and asked him several time to relax and stop kicking. After (Patient #5) wouldn't get under control and kicked Officer (PSO #2) and (RN #9) I deployed my taser and dry stunned (Patient #5) in back of left side. Afterward he complied and stopped kicking and was escorted to bed 25 and placed in four point restraints." Review revealed the event occurred in the ED hallway.

Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number 2; Date/Time Received - 02/03/2015 at 1149; Time Arrived - 1149; Nature of Incident - 04-Disorderly; Location of Incident - ED bed 25; and Action Taken "bed 25 ivc (involuntary commitment) out of control. ...(PSO #3) had to dry stun the pt in the leg to gain control. ..."

Review on 03/18/2015 of Patient Safety Event Report KPI 22 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #3, revealed on 02/03/2015 at 1145 "When approached ED bed 25 I saw the patient swing his left arm towards Team Leader (PSO #1). The patient struck Team Leader (PSO #1) in the face and eye several time [sic]. I approached the patient at that time and dry stun him. After the patient was dry stun Team Leader (PSO #1), Officer (PSO #5), and Charge Officer (PSO #3) was able to put the restraints on the patient arms without further incident." Review revealed the event occurred in the ED Patient Room.

Closed medical record review on 03/18/2015 for Patient #5 revealed a [AGE] year old male (MDS) dated [DATE] at 1104 via ambulance. Review revealed the patient was placed into treatment room 25 and was triaged at bedside by a Registered Nurse (RN). The patient was assigned an acuity of "Emergent." Review revealed an arrival complaint of "IVC." Review of a triage note by RN #12 at 1111 revealed "Pt was just released from prison yesterday and sent immediately to (Mental Health Crisis Center). Pt sent to ED due to being too violent as he was verbally aggressive to staff members at (Mental Health Crisis Center). Pt answering questions for nurse. Guard at bedside." Review revealed a past medical history (PMH) of Schizophrenia, Post Traumatic Stress Disorder (PTSD), and Personality Disorder. Review revealed documentation of multiple past psychiatric hospitalization s. Review revealed the patient remained in the ED and was transferred to a Psychiatric hospital on [DATE] at 1427 (17 days later). Review revealed while in the ED a TASER weapon was used on the patient on 01/29/2015 at ~0940 and 02/03/2015 at ~1145 and the patient was placed into 4 point leather restraints for the management of violent and self-destructive behaviors. Review revealed the TASER weapon was used on the patient by hospital-employed Protective Services Officers who were not sworn law enforcement officers.

Review of ED Provider Notes by MD #15 dated 01/24/2015 at 1111, revealed the patient presented with a chief complaint of "Paranoia." Review of HPI (history of present illness) revealed "(Patient #5) is a 23 y.o. (year old) male who presents after being assessed at the crisis center. It [sic] been in jail and then sent to the crisis center for psychiatric evaluation. He has a history of antisocial personality as well as schizophrenia and poor compliance with his medications. He apparently became agitated after conversation with his mother today and wanted to be sent to the emergency department. Upon my interviewing he is calm and cooperative. He denies any active hallucinations. he denies a desire to harm himself or others at present. Involuntary Commitment. ...PHYSICAL EXAM: ...General: No acute distress. ...Neuro: ...He is alert and oriented x3 (to person, place, time) Psych (Psychiatric): He has somewhat of a flat affect. He is cooperative. ...I've consulted psychiatry to see the patient while here. ...FINAL IMPRESSION: 1 Acute psychosis 2. Schizophrenia.

Review of Psychiatric Consult Note by Psychiatrist #1 dated 01/24/2015 at 1217, revealed the reason for consult was "Psychosis." Review of HPI revealed "...ENGLISH speaking male with a history of schizophrenia, PTSD, alcohol use, hx of severely aggressive behavior towards family, hx of assault on EMS (emergency medical services) staff, police officers. Longstanding medication noncompliance. Recently released from jail after 30 day sentence for assaultive behavior towards family. Sent directly to (Mental Health Crisis Center) on a petition due to making threats over the phone to harm father, concern for ongoing psychosis. Subsequently sent to (Hospital A) on IVC due to need for 'higher level of care.' Per my review of available records, he was agitated, yelling after a phone call with mother and decision was made that he needed to be in the ER. RN notes indicated he was threatening staff, yelling and gesturing in a hallway. I saw the patient today in the ER. He was calm and able to talk without yelling or profanity. Tells me the zyprexa and klonopin (psychiatric medications) are helping him with anger, admits he has a problem with anger. ...He does note that he can get overwhelmed with paranoid thoughts about conspiracies against him, ...Currently without specific violent thoughts or inclinations. Past Psychiatric History: Hx of multiple psych hospitalization s at many facilities, with psychotic d/o dx dating back to [AGE]. ...Mental Status Exam: A and O (alert and oriented) to name, place, situation. Able to tell me month and year along with his age. Makes fair eye contact with interviewer. Speech is monotone but normal volume, easily comprehensible. Mood is fair, affect somewhat blunted. No tangentially. Denies AH/VH (auditory/visual hallucinations). Insight limited. Endorses some paranoia but notes thoughts about other being out to hurt him are better on medication. Assessment: ...admitted with schizophrenia, violent behaviors. IVC'd from jail for threatening behaviors towards family. Sent from (Mental Health Crisis Center) due to escalating agitation, felt unsafe to manage in that setting. Currently calm and accepting medications, potential to escalate quickly based on his history... Diagnoses: Axis I Hx of schizophrenia, paranoid type, r/o (rule out) alcohol use d/o. Hx of PTSD. Axis II r/o antisocial personality traits vs (versus) disorder... Plan: ...4) Maintain IVC, initiate search for inpt psych and maintain sitter/suicide precautions while here. Disposition: Recommend transfer to inpatient psychiatric unit as available, indicated, and medically appropriate. Recommendations have been communicated to primary team. ..."

Review of an ED Note (Nursing) by RN #12 dated 01/24/2015 at 1505, revealed "...Pt calm with sitter at bedside."

Review of an ED Note by RN #13 dated 01/24/2015 at 2000, revealed "Pt expresses want to remain compliant with treatment plans and has agreed to take all prescribed meds and denies aggressive ideation. Pt appears calm and compliant...".

Review of an ED Note by RN #14 dated 01/25/2015 at 0730, revealed "Pt eating breakfast and brushing teeth. Sitter at bedside. Safe environment maintained. No needs at this time."

Review of an ED Progress Note (Provider) by MD #4 dated 01/25/2015 at 0731, revealed "(Patient #5) remains here in the ED on a psychiatric hold/IVC papers awaiting inpt. (inpatient) psychiatric placement. He has had an uneventful night and is resting this morning. VSS (vital signs stable). Meds have been ordered by Psychiatry. We will continue to follow the patients medical needs and Psychiatry will see to his mental health issues. The pt. was sent from (Mental Health Crisis Center) on IVC papers as a result of aggression and violence, so we presently have a security guard outside pts room."

Review of a Psychiatric Progress Note (Provider) by Psychiatrist #1 dated 01/25/2015 at 1012, revealed "...Pt without episode of violent [sic] outburst or aggression overnight. ...He acknowledges that anger is his primary issue and he has to keep the anger under control if he is to stay out of prison or other locked facilities. ...Mental Status Exam: Patient is alert and oriented x3. He has a somewhat intense affect but is fairly pleasant and cooperative with the interviewer. ...Plan: ...2) Continue referral process... I do have some concerns based on my experience over 11 years with attempted referrals in similar cases that it could be quite a lengthy period of time before the patient is accepted to (name) Hospital, we have had cases where it is been over a month before and acceptance is obtained. ..."

Review of an ED Note by RN #14 dated 01/25/2015 at 1300, revealed "Pt used PRS (Patient Relations Specialist) phone and called his mother. Pt appropriate. No incident."

Review of an ED Note by RN #14 dated 01/25/2015 at 1520, revealed "Pt calling out numerous times for this RN in hallway. This RN has seen pt multiple times and explained to him that yelling out for me into the hallway is not appropriate. Pt singing loudly in his room. Pt calms down when this RN goes into room and speaks with him. No needs at this time. Sitter at bedside. Safe environment maintained."

Review of an ED Note by RN #14 dated 01/25/2015 at 1539, revealed "Sitter notified security outside room that he wanted to sit at doorway because he the patient 'is coming at me.' This RN into room. Pt laying in bed. Is having increasing agitation but agreed to take Atarax and IM Benadryl. ...PRS at bedside talking with pt. Pt calmed down with presence of this RN and....PRS."

Review of an ED Note by RN #14 dated 01/25/2015 at 1758, revealed "Pt yelled out into the hall 'hey fat ass' calling one of my coworkers. Also told the secretary that 'I am going to kill my father because he put me here.' This RN went in to room to ask him not to call out into the hall and use the call bell instead. Said 'you're hot I want to talk to you' referring to this RN. Calling out multiple times for medication. Notified pt when he could next have meds."

Review of an ED Note by RN #14 dated 01/25/2015 at 1848, revealed "See previous notes for pt behavior. Security continues to be at bedside. Sitter at bedside in doorway. Safe environment maintained. Pt appears to be more respectful now after staff notifying pt his behavior was disrespectful and would not be tolerated."

Review of an ED Note by RN #15 dated 01/25/2015 at 1922, revealed "Pt is cooperative in room. (name) sitter is outside the room. Security at bedside. ..."

Review of an ED Note by RN #15 dated 01/25/2015 at 2123, revealed "Pt stating that he is going to 'hurt the sitter.' Pt states that he is eventually going to 'assault everyone in the ER and go back to jail.' this RN medicated patient. Talked with patient at length about his feelings. Sitters changed. (name), ED tech (technician) is sitting with patient. Pt is agreeable to this. Patient continues to express his feelings but remains non violent."

Review of an ED Note by RN #15 dated 01/26/2015 at 0014, revealed "Pt states that he wants to hurt himself and others in the ER. Pt continues to call his sitter 'stupid ni***r.' patient continues to ask for medications. Dr. (MD #5) notified and will go in room to eval (evaluate) pt."

Review of an ED Note by RN #15 dated 01/26/2015 at 0023, revealed "Security still at bedside with patient, Dr. (MD #5) will go in room later to eval. Dr. (MD #5) stated only one security guard because others will agitate the patient. Will continue to monitor."

Review of an ED Note by RN #15 dated 01/26/2015 at 0037, revealed "This RN also spoke to Dr. (MD #5) about pts increase in agitation and the need for the pt to be seen d/t (due to) pts threats of harm. MD states he is aware and will go see pt."

Review of an ED Note by RN #15 dated 01/26/2015 at 0050, revealed "Dr. (MD #5) in to eval patient. New orders placed. Will medicate patient and continue to monitor."

Review of an ED Progress Note by MD #5 dated 01/26/2015 at 0057, revealed "I was advised by nursing patient was having increased agitation and aggressive behavior to staff. He has received his scheduled doses of medications. He reportedly was threatening to the sitter. On my examination patient was generally cooperative. He was questioned what was triggering his agitation and he advises that he was told he might be 'here for 30 days'. I reassured him that that's not typically the case. He appeared generally cooperative during this interaction. I asked him if he would like something to 'calm him down'. He agreed that it could help. ...he was in agreement and states he would be cooperative. ..."

Review of an ED Note by RN #15 dated 01/26/2015 at 0212, revealed "Patient resting. Assessed safety of the room throughout shift. Patient encouraged to express feelings and talk about why he felt aggressive during this shift. ...Patient is still under IVC paperwork. ..."

Review of an ED Progress Note by MD #4 dated 01/26/2015 at 0806, revealed "(Patient #5) remains on an involuntary commitment hold awaiting inpatient psychiatric placement. Patient is awake and is eating breakfast this morning. he states he has no complaints at this time. He states he is hoping to be able to be discharged from here, and is to talk with the psychiatrist regarding getting his medications on an appropriate regimen. The patient did apparently have an episode of increased agitation and aggression last night with the staff. However he is calm at this time. He states he had an uneventful night and has no complaints this morning. ..."

Review of an ED Note by RN #16 dated 01/26/2015 at 1020, revealed "Patient self reports increased agitation that is obvious to this RN as well Patient stating 'the black people and racists are making me stay here'. This RN redirected his statements back at his behavior and his actions leading to the current issues. This RN reiterated intolerance for racial slurs and curse words being directed at sitter and staff."

Review of an Psychiatric Progress Note by Psychiatrist #2 dated 01/26/2015 at 1149, revealed "...The patient has been intermittently agitated, requiring when necessary's (as needed medications). ...He has been verbally abusive towards the staff. Mental Status Exam: ...Behavior: Calm....and Polite ...Mood: Anxious Affect: Calm and Decreased range ...Orientation: Oriented to person, place, time, and general circumstances ..."

Review of an ED Note by RN #16 dated 01/26/2015 at 1227, revealed "Patient hit and struck security officer in the nose and additionally attempted to headbutt him. Patient immediately put in 4 point leather restraints. Patient cursing at staff during process. Patient states 'I want to be in restraints'. Explained to patient that he was now in restraints and would remain in restraints until his behavior improved. Patient states 'when I get out of restraints I am going to kill you all'."

Review of an ED Progress Note by MD #4 dated 01/26/2015 at 1253 revealed "The patient became more aggressive at around noon today. He punched a security guard (TS) in the face. The patient had [sic] placed into 4. (4 point) restraints. He was given IM (intramuscular) Zyprexa (antipsychotic). He received IM Benadryl (antihistamine) a few hours ago. We will monitor the patient and provide additional medications or treatments to prevent aggressive behaviors. We will try to get the patient out of restraints and [sic] possible while maintaining the safety of the staff."

Review of an ED Note by RN #16 dated 01/26/2015 at 1310, revealed "Patient now spitting at staff and all over the floor. Mask placed on patient. MD aware of situation."

Review of an ED Note by RN #16 dated 01/26/2015 at 1530, revealed "Attempted to remove spit mask to allow patient to eat. Patient began spiting at sitter. Spit hood placed at this time."

Review of an ED Note by RN #16 dated 01/26/2015 at 1700, revealed "Patient assisted with eating dinner without incident. Spit hood replaced when finished."

Review of an ED Note by RN #16 dated 01/26/2015 at 1815, revealed "Patient continuing to fling, curse, spit and scream curse words at staff, sitter and security. Patient able to remove spit mask by maneuvering upper body to get hand to the spit mask and removing it. MD notified and order for posey vest and mittens. Security called and additional restraints placed. Patient continuing to threaten staff. Patient states 'I am going to kill all you f**kers'."

Review of an ED Note by RN #16 dated 01/26/2015 at 1854, revealed "Patient asking for restraints and spit mask to be removed. Explained to patient that his behavior was not compatible with that occurring but encouraged patient to continue attempts to remain calm."

Review of an ED Note by RN #16 dated 01/26/2015 at 2035, revealed "Pt removed spit mask, spit at sitter, (name), and called him a 'F**king Ni***r'. Spit mask was reapplied. Pt was unsuccessful at making saliva contact with sitter."

Review of an ED Note by RN #17 dated 01/26/2015 at 2300, revealed "Release of restraint - limb by limb trial. RUE (right upper extremity) and LLE (left lower extremity) have been released on a trial basis. Pt has also had oral care by brushing of teeth and has voided by use of urinal. pt has agreed to cooperate and understands that any harm against self or others will require the continued use of restraints on those extremities. Sitter at bedsi
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital's staff failed to meet the emergency needs for 1 of 1 psychiatric patients (#5) in accordance with the hospital's policy and procedures.

The findings include:

The hospital's staff failed to ensure coordination and communication between emergency services and security services (PSO) in order to render safe care for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors who was tasered while in the Emergency Department by non-law enforcement security staff.

~cross refer to 482.55)(2) (a Emergency Services Standard - Tag A1103.
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure reviews, Protective Services Officer (PSO) report reviews, patient safety event report reviews, medical record review and staff interviews, the hospital's staff failed to ensure coordination and communication between emergency services and security services (PSO) in order to render safe care for 1 of 1 psychiatric patients (#5) with a known history of violent and self-destructive behaviors who was tasered while in the Emergency Department by non-law enforcement security staff.

The findings include:

Review of current hospital policy "Patient Rights And Responsibilities" last revised 08/28/2014 revealed "...Patient Rights and Responsibilities ...16. Be free from abuse, neglect and harassment... 17. Be free from restraint and seclusion that is not medically required or is used inappropriately. ..."

Review of current hospital policy "Restraint and Seclusion" revised 06/20/2014 revealed "Areas Affected: All Patient Care Areas PHILOSOPHY STATEMENT: (Name) Hospital is committed to providing a least restrictive, safe, and appropriate environment for all individuals. ...restraint use is limited to those circumstances where the patient is identified as being a t risk for injury to self or others and alternative safety measures have been evaluated and deemed inadequate. ...DEFINITIONS OF RESTRAINT AND SECLUSION: Restraint: 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 of the two. ...RESTRAINT MANAGEMENT GOALS: A. Restraints are only used when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others. B. Restraints are not used a s a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used when less restrictive interventions are ineffective and if used, the least restrictive form of restraint is used to protect the physical safety of the patient, staff, or others. D. Restraints are discontinued at the earliest possible time regardless of the scheduled expiration of the order. E. Restraints will be applied using the proper technique based on the type of restraint. F. The appropriate restraint plan of care will be initiated for the patient. G. Physicians/LIP is responsible for ordering the restraints. PRN restraint orders are not acceptable. ...I. Patients will be monitored, evaluated, and re-evaluated according to the Restraint Protocol. ..."

Review of current hospital policy "Restraint Management Protocol, 2466-1" last revised 06/20/2014 revealed "Definitions: A. Physical Restraints: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Examples are a vest, soft wrist or ankle restraints, mittens (if tied), leather restraints... Categories of Restraints/Indications for Use: ...B. Violent or Self-Destructive Behavior (Behavioral) Restraints: 1. A clinical justification, other than those identified as non-violent or non-self-destructive behavior, to protect the patient from injury to self or others because of an emotional or behavioral disorder where the behavior may be violent or aggressive. RESPONSIBILITIES: A. Violent/Self-Destructive Behavior (Behavioral) Restraints: 1. Physician/Licensed Independent Practitioner (LIP)*: a. Order for restraints at initiation. b. Face to face assessment of the need for restraint initiation within one hour and ongoing assessment of the continued need for restraints. c. Renewal order for continued justification for restraints. d. Review and evaluation of current medications to identify and minimize the use of medications that place a patient at risk for restraint use. ...3. Staff Nurse: a. Identification of the patient at risk for restraints, the behavior/symptoms that the patient is exhibiting, and the initiation of pre-restraint alternative interventions that may reduce both the need and duration of restraint use. b. Restraint initiation and management. c. Calls the attending physician/LIP for a restraint order. d. Notifies the attending physician that restraints have been initiated if he/she was not the ordering physician of the restraint as soon as possible**. e. Regular scheduled reassessment of the patient in restraints to justify continued validity of restraint use with the potential to discontinue or reduce the level of restraint evaluated. ...GENERAL RESTRAINT INFORMATION: A. PRN and standing orders for any category of restraint is not acceptable. B. Restraints are not used as a means of coercion, discipline, convenience, or staff retaliation. C. Restraints are used only when other less restrictive interventions are ineffective. If restraints are employed, the least restrictive restraint to protect the patient's/other's physical safety is used. D. The restraint should be discontinued by the staff nurse at the earliest possible time regardless of the scheduled expiration of the order. Discontnued Criteria includes: ...2. Violent/Self Destructive a. No physical aggression b. Rational/compliant/follows directions c. Patient calm/asleep d. Transferred to secure area ...VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR RESTRAINT (BEHAVIORAL) MANAGEMENT: ...Physician Order: 1. A staff nurse may apply restraints in an emergency situation prior to obtaining a physician order but the physician/LIP should be contacted immediately and notified that restraints have been initiated. ...2. Any patient restraint within one hour after the initiation of restraints by a physician/LIP or Specially Trained Nurse who will evaluate the continued need for restraint. ...3. The face to face assessment conducted within one hour includes the following: a. An evaluation of the patient's immediate situation. b. The patient's reaction to the intervention. c. The patient's medical and behavioral condition. d. The need to continue or terminate the restraint. 4. Renewal orders must be obtained every 2 hours for patients 9-17 years of age and every 4 hours for ages 18 and older. Orders may be renewed for a maximum of 24 consecutive hours at which time a physician/LIP reassessment is required. 5. Every 24 hours a physician/LIP must complete a face to face assessment before writing a new order. 6. If a restraint is discontinued prior to the expiration of the order, a new order must be obtained to re-initiate restraints. C. Routine Monitoring/Patient Care: 1. Patients will have continuous, direct one on one observation at all times by a staff nurse, NA, or PCT. Continuous observation and psychological status/visual check (i.e. affect/behavior) will be documented every 15 minutes. 2. Routine checks will be monitored and documented every 2 hours by a staff nurse, NA, or PCT. Routine checks includes: ROM, elimination, fluids, circulation/skin integrity, and food/meal. 3. The continued justification for restraints or a less restrictive form of restraints will be assessed and documented every 4 hours by the staff nurse. ..."

Review of current hospital policy "1700-05, Restraints" last revised 04/14/2014 revealed "...1. Restraint Assistance A. A Protective Services officer may be called upon to assist the health care team in restraining a patient. The officer provides assistance within the scope of Patient Care Services Restraint policy (refer to the Patient Care Services Policy Manual). B. Upon arriving at the scene, the officer will make contact with the person(s) requesting assistance. 1. If an officer comes upon a scene with staff struggling with a patient, the officer immediately offers assistance. 2. If an officer comes upon a scene and there appears to be no imminent danger to the patient or the staff, the responding officer(s) will seek guidance from the health care team on the level of physical contact and method of restraint. C. The officer assists the staff by immobilizing the patient's arms and legs while the staff secures the restraints. D. If the staff is unfamiliar with the restraints, then the officer will secure the restraints. ..."

Review of current hospital policy "1400-20 Electronic Control Device (TASER) last revised 04/14/2014 revealed "...Protective Services officers have an obligation to protect all staff, patients, and visitors against violence while on campus. ...Therefore, officers trained in the use of electronic control devices (TASER) will be allowed to possess, and in accordance with the Protective Service Policy 1400-05, Use of Force Guidelines, deploy the TASER to subdue violent or resistive subjects as required in the line of duty. ...B. ...2. Only personnel who have completed the departmentally approved class will be allowed to carry and deploy the TASER devices while on duty. ...C. TASER and the Use of Force. 1. Deployment of the TASER constitutes use of force as proved in Protective Services Policy 1400-05, Use of Force Guidelines. 2. The TASER is an electronic control device utilizing a Neuro-Muscular Incapacitation system. Its use is designed to incapacitate by over-riding and disrupting the sensory nervous system and the motor nervous system (causing uncontrollable contractions of the muscle tissue). ...4. The TASER may be deployed against a subject only if one or more of the following situations exist: a. Subject is physically assaulting someone. This includes infliction of self-harm. b. Subject is displaying behaviors that would lead a reasonable person to believe that a physical assault will occur imminently, including self-harming behavior. c. If in the officer's opinion, there is a very real possibility of injury occurring to officers, bystanders, or the subject, every effort is made to take the subject into custody by other means. 5. Deployment of the TASER: d. The subject against whom the TASER was discharged should always be handcuffed....immediately after discharge. The officer who deployed the TASER should immediately call for backup if backup is not already present. Allow the other officers to handcuff the subject, and be prepared to further discharge the TASER if the subject becomes violent before he/she can be handcuffed. If backup is not available, the officer will ensure that the subject has submitted before trying trying to apply handcuffs. If the subject refuses to submit, the officer will maintain a safe distance and control the subject by verbal commands and/or TASER discharges until backup arrives. If the subject refuses to submit to the officer's commands after being shot with the TASER, it is possible that the handcuffing may need to proceed while the TASER is being discharged into the subject. e. An alternative method of deployment is "Drive Stun," where the TASER, either without a cartridge or with an expended cartridge, is pressed against the subject and TASER is discharged . ..."

Review of current hospital policy "1400-05, Use of Force Guidelines" last revised 05/17/2013 revealed "...The Protective Services Officer has duties that will be performed to provide for the safety of patients, staff, and visitors; and if force is necessary to perform these duties, the minimum amount of force is authorized. Before using physical force, officers must exhaust every other available means of performing their duties. 1. A. Approach every situation with an attitude of confidence, impartiality, and courtesy, The officer's attitude and remarks must not provide anger in the subject. B. A timely call for assistance and a quick response of back-up can also calm a situation. C. In extreme situations, a show of superior numbers is sometimes needed to calm a situation. 2. Evaluating a Situation A. Any decision reached in the evaluation and resolution of a situation requires utilization of skills, training, and knowledge pertinent to the situation. ...B. Officers should not enter confrontations they are certain to lose. In such situations, the officer's primary concern should be for the safe evacuation of patients, staff and visitors from a violent environment to a defensible area and await arrival of backup. ... C. Once safely withdrawn the officer should call for assistance from the (name) Police Department... 3. Use of Force A. Patient-Specific Guidelines 1. Weapons will not be used by Protective Services as means of managing control of a patient for the purposes of medical care. 2. If a weapon is used by Protective Services on a patient to protect people or hospital property from harm, the incident will be handled as a criminal activity. Law enforcement will be called to respond within the intent of placing the patient in their custody. ..."

Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number ; Date/Time Received - 01/29/2015 at 0939; Time Arrived - 0940; Nature of Incident - 38-Patient Restraint; Location of Incident - Emergency Department Treatment Area 25; and Action Taken "OFFICER (PSO #1) USED TASER ON ED BE [sic] 25 (Patient #5). ...PATIENT PLACED IN LEATHER RESTRAINTS."

Review on 03/18/2015 of Patient Safety Event Report RTW 11 involving Patient #5, dated 01/29/2015 at 1010; reported by RN #10, revealed on 01/29/2015 at 0930 "At about 9:30am on 1/29/2015 IVC (involuntary commitment) csn# 5 in ER bed 25 was agitated, and verbally aggressive initially. Pt cussing at sitter and staff. Pt stated that he does not like black people. Security was called. Pt then spit on then [sic] spit on [Sitter #1] (the pt's sitter) clothing. Primary RN (RN #8) was aware of the situation and had med (medication) requested pt's PRN (as needed) med that had to come up from the main pharmacy. x1 (times one) Security officer was at bedside awaiting for other officers. Other security officers arrive. Pt stormed outside of the room and assaulted Officer [PSO #1] (pt punched and [sic] him in the face and scratched him in the face) pt was tackled to the ground in the hallway by Security Officers and (RN #9). While pt was being tackled pt punched Officer (PSO #2) in the forehead. Pt had to be tasered by Protective services staff. Team Leader (RN #11); (PSO Director #1); (ED Director #1) were made aware of the situation. ...Dr. (MD #3) was made aware and he gave order for restraint usage. Pt was placed in 4 point restraints. ...". Review revealed the event occurred in the ED Patient Care Area.

Review on 03/18/2015 of Patient Safety Event Report CLI 38 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #1, revealed on 01/29/2015 at 0940 "At 0939 hrs (hours), reporting officer, (PSO #1) was dispatched to assist with patient in ED bed 25. Once arriving I was told IVC patient (Patient #5) spitted [sic] at his sitter and Officer (PSO #4). While I was talking with his nurse (RN #8), (Patient #5) swung and hit Officer (PSO #2) over his left eye causing a bruise. Officer (PSO #4) and I (PSO #1) forced (Patient #5) to the floor and asked him several time to relax and stop kicking. After (Patient #5) wouldn't get under control and kicked Officer (PSO #2) and (RN #9) I deployed my taser and dry stunned (Patient #5) in back of left side. Afterward he complied and stopped kicking and was escorted to bed 25 and placed in four point restraints." Review revealed the event occurred in the ED hallway.

Review on 03/18/2015 of a Protective Services Operations Report revealed, Case Number 2; Date/Time Received - 02/03/2015 at 1149; Time Arrived - 1149; Nature of Incident - 04-Disorderly; Location of Incident - ED bed 25; and Action Taken "bed 25 ivc (involuntary commitment) out of control. ...(PSO #3) had to dry stun the pt in the leg to gain control. ..."

Review on 03/18/2015 of Patient Safety Event Report KPI 22 involving Patient #5, dated 02/04/2015 at 1325; reported by PSO #3, revealed on 02/03/2015 at 1145 "When approached ED bed 25 I saw the patient swing his left arm towards Team Leader (PSO #1). The patient struck Team Leader (PSO #1) in the face and eye several time [sic]. I approached the patient at that time and dry stun him. After the patient was dry stun Team Leader (PSO #1), Officer (PSO #5), and Charge Officer (PSO #3) was able to put the restraints on the patient arms without further incident." Review revealed the event occurred in the ED Patient Room.

Closed medical record review on 03/18/2015 for Patient #5 revealed a [AGE] year old male (MDS) dated [DATE] at 1104 via ambulance. Review revealed the patient was placed into treatment room 25 and was triaged at bedside by a Registered Nurse (RN). The patient was assigned an acuity of "Emergent." Review revealed an arrival complaint of "IVC." Review of a triage note by RN #12 at 1111 revealed "Pt was just released from prison yesterday and sent immediately to (Mental Health Crisis Center). Pt sent to ED due to being too violent as he was verbally aggressive to staff members at (Mental Health Crisis Center). Pt answering questions for nurse. Guard at bedside." Review revealed a past medical history (PMH) of Schizophrenia, Post Traumatic Stress Disorder (PTSD), and Personality Disorder. Review revealed documentation of multiple past psychiatric hospitalization s. Review revealed the patient remained in the ED and was transferred to a Psychiatric hospital on [DATE] at 1427 (17 days later). Review revealed while in the ED a TASER weapon was used on the patient on 01/29/2015 at ~0940 and 02/03/2015 at ~1145 and the patient was placed into 4 point leather restraints for the management of violent and self-destructive behaviors. Review revealed the TASER weapon was used on the patient by hospital-employed Protective Services Officers who were not sworn law enforcement officers.

Review of ED Provider Notes by MD #15 dated 01/24/2015 at 1111, revealed the patient presented with a chief complaint of "Paranoia." Review of HPI (history of present illness) revealed "(Patient #5) is a 23 y.o. (year old) male who presents after being assessed at the crisis center. It [sic] been in jail and then sent to the crisis center for psychiatric evaluation. He has a history of antisocial personality as well as schizophrenia and poor compliance with his medications. He apparently became agitated after conversation with his mother today and wanted to be sent to the emergency department. Upon my interviewing he is calm and cooperative. He denies any active hallucinations. he denies a desire to harm himself or others at present. Involuntary Commitment. ...PHYSICAL EXAM: ...General: No acute distress. ...Neuro: ...He is alert and oriented x3 (to person, place, time) Psych (Psychiatric): He has somewhat of a flat affect. He is cooperative. ...I've consulted psychiatry to see the patient while here. ...FINAL IMPRESSION: 1 Acute psychosis 2. Schizophrenia.

Review of Psychiatric Consult Note by Psychiatrist #1 dated 01/24/2015 at 1217, revealed the reason for consult was "Psychosis." Review of HPI revealed "...ENGLISH speaking male with a history of schizophrenia, PTSD, alcohol use, hx of severely aggressive behavior towards family, hx of assault on EMS (emergency medical services) staff, police officers. Longstanding medication noncompliance. Recently released from jail after 30 day sentence for assaultive behavior towards family. Sent directly to (Mental Health Crisis Center) on a petition due to making threats over the phone to harm father, concern for ongoing psychosis. Subsequently sent to (Hospital A) on IVC due to need for 'higher level of care.' Per my review of available records, he was agitated, yelling after a phone call with mother and decision was made that he needed to be in the ER. RN notes indicated he was threatening staff, yelling and gesturing in a hallway. I saw the patient today in the ER. He was calm and able to talk without yelling or profanity. Tells me the zyprexa and klonopin (psychiatric medications) are helping him with anger, admits he has a problem with anger. ...He does note that he can get overwhelmed with paranoid thoughts about conspiracies against him, ...Currently without specific violent thoughts or inclinations. Past Psychiatric History: Hx of multiple psych hospitalization s at many facilities, with psychotic d/o dx dating back to [AGE]. ...Mental Status Exam: A and O (alert and oriented) to name, place, situation. Able to tell me month and year along with his age. Makes fair eye contact with interviewer. Speech is monotone but normal volume, easily comprehensible. Mood is fair, affect somewhat blunted. No tangentially. Denies AH/VH (auditory/visual hallucinations). Insight limited. Endorses some paranoia but notes thoughts about other being out to hurt him are better on medication. Assessment: ...admitted with schizophrenia, violent behaviors. IVC'd from jail for threatening behaviors towards family. Sent from (Mental Health Crisis Center) due to escalating agitation, felt unsafe to manage in that setting. Currently calm and accepting medications, potential to escalate quickly based on his history... Diagnoses: Axis I Hx of schizophrenia, paranoid type, r/o (rule out) alcohol use d/o. Hx of PTSD. Axis II r/o antisocial personality traits vs (versus) disorder... Plan: ...4) Maintain IVC, initiate search for inpt psych and maintain sitter/suicide precautions while here. Disposition: Recommend transfer to inpatient psychiatric unit as available, indicated, and medically appropriate. Recommendations have been communicated to primary team. ..."

Review of an ED Note (Nursing) by RN #12 dated 01/24/2015 at 1505, revealed "...Pt calm with sitter at bedside."

Review of an ED Note by RN #13 dated 01/24/2015 at 2000, revealed "Pt expresses want to remain compliant with treatment plans and has agreed to take all prescribed meds and denies aggressive ideation. Pt appears calm and compliant...".

Review of an ED Note by RN #14 dated 01/25/2015 at 0730, revealed "Pt eating breakfast and brushing teeth. Sitter at bedside. Safe environment maintained. No needs at this time."

Review of an ED Progress Note (Provider) by MD #4 dated 01/25/2015 at 0731, revealed "(Patient #5) remains here in the ED on a psychiatric hold/IVC papers awaiting inpt. (inpatient) psychiatric placement. He has had an uneventful night and is resting this morning. VSS (vital signs stable). Meds have been ordered by Psychiatry. We will continue to follow the patients medical needs and Psychiatry will see to his mental health issues. The pt. was sent from (Mental Health Crisis Center) on IVC papers as a result of aggression and violence, so we presently have a security guard outside pts room."

Review of a Psychiatric Progress Note (Provider) by Psychiatrist #1 dated 01/25/2015 at 1012, revealed "...Pt without episode of violent [sic] outburst or aggression overnight. ...He acknowledges that anger is his primary issue and he has to keep the anger under control if he is to stay out of prison or other locked facilities. ...Mental Status Exam: Patient is alert and oriented x3. He has a somewhat intense affect but is fairly pleasant and cooperative with the interviewer. ...Plan: ...2) Continue referral process... I do have some concerns based on my experience over 11 years with attempted referrals in similar cases that it could be quite a lengthy period of time before the patient is accepted to (name) Hospital, we have had cases where it is been over a month before and acceptance is obtained. ..."

Review of an ED Note by RN #14 dated 01/25/2015 at 1300, revealed "Pt used PRS (Patient Relations Specialist) phone and called his mother. Pt appropriate. No incident."

Review of an ED Note by RN #14 dated 01/25/2015 at 1520, revealed "Pt calling out numerous times for this RN in hallway. This RN has seen pt multiple times and explained to him that yelling out for me into the hallway is not appropriate. Pt singing loudly in his room. Pt calms down when this RN goes into room and speaks with him. No needs at this time. Sitter at bedside. Safe environment maintained."

Review of an ED Note by RN #14 dated 01/25/2015 at 1539, revealed "Sitter notified security outside room that he wanted to sit at doorway because he the patient 'is coming at me.' This RN into room. Pt laying in bed. Is having increasing agitation but agreed to take Atarax and IM Benadryl. ...PRS at bedside talking with pt. Pt calmed down with presence of this RN and....PRS."

Review of an ED Note by RN #14 dated 01/25/2015 at 1758, revealed "Pt yelled out into the hall 'hey fat ass' calling one of my coworkers. Also told the secretary that 'I am going to kill my father because he put me here.' This RN went in to room to ask him not to call out into the hall and use the call bell instead. Said 'you're hot I want to talk to you' referring to this RN. Calling out multiple times for medication. Notified pt when he could next have meds."

Review of an ED Note by RN #14 dated 01/25/2015 at 1848, revealed "See previous notes for pt behavior. Security continues to be at bedside. Sitter at bedside in doorway. Safe environment maintained. Pt appears to be more respectful now after staff notifying pt his behavior was disrespectful and would not be tolerated."

Review of an ED Note by RN #15 dated 01/25/2015 at 1922, revealed "Pt is cooperative in room. (name) sitter is outside the room. Security at bedside. ..."

Review of an ED Note by RN #15 dated 01/25/2015 at 2123, revealed "Pt stating that he is going to 'hurt the sitter.' Pt states that he is eventually going to 'assault everyone in the ER and go back to jail.' this RN medicated patient. Talked with patient at length about his feelings. Sitters changed. (name), ED tech (technician) is sitting with patient. Pt is agreeable to this. Patient continues to express his feelings but remains non violent."

Review of an ED Note by RN #15 dated 01/26/2015 at 0014, revealed "Pt states that he wants to hurt himself and others in the ER. Pt continues to call his sitter 'stupid ni***r.' patient continues to ask for medications. Dr. (MD #5) notified and will go in room to eval (evaluate) pt."

Review of an ED Note by RN #15 dated 01/26/2015 at 0023, revealed "Security still at bedside with patient, Dr. (MD #5) will go in room later to eval. Dr. (MD #5) stated only one security guard because others will agitate the patient. Will continue to monitor."

Review of an ED Note by RN #15 dated 01/26/2015 at 0037, revealed "This RN also spoke to Dr. (MD #5) about pts increase in agitation and the need for the pt to be seen d/t (due to) pts threats of harm. MD states he is aware and will go see pt."

Review of an ED Note by RN #15 dated 01/26/2015 at 0050, revealed "Dr. (MD #5) in to eval patient. New orders placed. Will medicate patient and continue to monitor."

Review of an ED Progress Note by MD #5 dated 01/26/2015 at 0057, revealed "I was advised by nursing patient was having increased agitation and aggressive behavior to staff. He has received his scheduled doses of medications. He reportedly was threatening to the sitter. On my examination patient was generally cooperative. He was questioned what was triggering his agitation and he advises that he was told he might be 'here for 30 days'. I reassured him that that's not typically the case. He appeared generally cooperative during this interaction. I asked him if he would like something to 'calm him down'. He agreed that it could help. ...he was in agreement and states he would be cooperative. ..."

Review of an ED Note by RN #15 dated 01/26/2015 at 0212, revealed "Patient resting. Assessed safety of the room throughout shift. Patient encouraged to express feelings and talk about why he felt aggressive during this shift. ...Patient is still under IVC paperwork. ..."

Review of an ED Progress Note by MD #4 dated 01/26/2015 at 0806, revealed "(Patient #5) remains on an involuntary commitment hold awaiting inpatient psychiatric placement. Patient is awake and is eating breakfast this morning. he states he has no complaints at this time. He states he is hoping to be able to be discharged from here, and is to talk with the psychiatrist regarding getting his medications on an appropriate regimen. The patient did apparently have an episode of increased agitation and aggression last night with the staff. However he is calm at this time. He states he had an uneventful night and has no complaints this morning. ..."

Review of an ED Note by RN #16 dated 01/26/2015 at 1020, revealed "Patient self reports increased agitation that is obvious to this RN as well Patient stating 'the black people and racists are making me stay here'. This RN redirected his statements back at his behavior and his actions leading to the current issues. This RN reiterated intolerance for racial slurs and curse words being directed at sitter and staff."

Review of an Psychiatric Progress Note by Psychiatrist #2 dated 01/26/2015 at 1149, revealed "...The patient has been intermittently agitated, requiring when necessary's (as needed medications). ...He has been verbally abusive towards the staff. Mental Status Exam: ...Behavior: Calm....and Polite ...Mood: Anxious Affect: Calm and Decreased range ...Orientation: Oriented to person, place, time, and general circumstances ..."

Review of an ED Note by RN #16 dated 01/26/2015 at 1227, revealed "Patient hit and struck security officer in the nose and additionally attempted to headbutt him. Patient immediately put in 4 point leather restraints. Patient cursing at staff during process. Patient states 'I want to be in restraints'. Explained to patient that he was now in restraints and would remain in restraints until his behavior improved. Patient states 'when I get out of restraints I am going to kill you all'."

Review of an ED Progress Note by MD #4 dated 01/26/2015 at 1253 revealed "The patient became more aggressive at around noon today. He punched a security guard (TS) in the face. The patient had [sic] placed into 4. (4 point) restraints. He was given IM (intramuscular) Zyprexa (antipsychotic). He received IM Benadryl (antihistamine) a few hours ago. We will monitor the patient and provide additional medications or treatments to prevent aggressive behaviors. We will try to get the patient out of restraints and [sic] possible while maintaining the safety of the staff."

Review of an ED Note by RN #16 dated 01/26/2015 at 1310, revealed "Patient now spitting at staff and all over the floor. Mask placed on patient. MD aware of situation."

Review of an ED Note by RN #16 dated 01/26/2015 at 1530, revealed "Attempted to remove spit mask to allow patient to eat. Patient began spiting at sitter. Spit hood placed at this time."

Review of an ED Note by RN #16 dated 01/26/2015 at 1700, revealed "Patient assisted with eating dinner without incident. Spit hood replaced when finished."

Review of an ED Note by RN #16 dated 01/26/2015 at 1815, revealed "Patient continuing to fling, curse, spit and scream curse words at staff, sitter and security. Patient able to remove spit mask by maneuvering upper body to get hand to the spit mask and removing it. MD notified and order for posey vest and mittens. Security called and additional restraints placed. Patient continuing to threaten staff. Patient states 'I am going to kill all you f**kers'."

Review of an ED Note by RN #16 dated 01/26/2015 at 1854, revealed "Patient asking for restraints and spit mask to be removed. Explained to patient that his behavior was not compatible with that occurring but encouraged patient to continue attempts to remain calm."

Review of an ED Note by RN #16 dated 01/26/2015 at 2035, revealed "Pt removed spit mask, spit at sitter, (name), and called him a 'F**king Ni***r'. Spit mask was reapplied. Pt was unsuccessful at making saliva contact with sitter."

Review of an ED Note by RN #17 dated 01/26/2015 at 2300, revealed "Release of restraint - limb by limb trial. RUE (right upper extremity) and LLE (left lower extremity) have been released on a trial basis. Pt has also had oral care by brushing of teeth and has voided by use of urinal. pt has agreed to cooperate and understands that any harm against self or others will require the continued use of restraints on those extremities. Sitter at bedside. Will continue to monitor."

Revie