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BLOUNT MEMORIAL HOSPITAL 907 E LAMAR ALEXANDER PARKWAY MARYVILLE, TN 37804 March 3, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility policy, medical record review, review of incident reports, review of facility documentation, and interview, the facility failed to ensure a weapon was not used in application of a restraint for 1 patient (#1) of 5 patients reviewed.

The facility was cited for not being in substantial compliance with the Condition of Participation related to failing to ensure use of safe restraints appropriate for patients in a hospital setting.

Please refer to A 154.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of incident reports, review of facility documents, and interview, the facility failed to ensure a weapon was not used in application of a restraint for 1 patient (#1) of 5 patients reviewed.

The findings included:

Review of facility policy Adult Abuse, Neglect and Exploitation, last revised on 8/26/14, revealed "...definitions: abuse: can be physical, sexual, and emotional and generally involves more extreme forms of harm to the dependent adult, including infliction of pain, injury, mental anguish, unreasonable confinement or other cruel treatment..."

Review of facility policy "Conducted Energy Weapon (X26 Taser)" with a revision date of 4/7/15 revealed "...Purpose: the purpose of this procedure to authorize the use of a Conducted Energy Weapon (Taser) as a control measure for all certified [hospitla] Officers. All [hospital] Security Officers must meet and comply with the requirements of this procedure...the Taser X-26 is a conducted energy weapon [CEW], an electronic incapacitation device. It is a defensive weapon, which is listed in the force continuum at the same level as aerosol chemical sprays...(A) the decision to use the CEW is based on the same criteria an officer uses when selection to deploy chemical spray or a baton...the use of the CEW must be reasonable and necessary..."

Medical record review revealed Patient #1 was admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Medical record review of the ER (emergency room ) Adult Worksheet dated 1/31/16 revealed the patient's home medications included oxycodone (narcotic) 10 milligrams (mg) every 6 hours, oxymorphone (narcotic) extended release 20 mg twice a day, and zolpidem (also known as ambien, a sedative used for sleep) 10 mg every night.

Medical record review of the nurse's notes revealed Patient #1 had been in the Intensive Care Unit (ICU) from 2/1/16 until he was transferred to the Cardiac Respiratory Unit (CRU) on 2/2/16 around 6:00 PM.

Review of a Use of Force Report dated 2/3/16 at 3:54 AM revealed "...resisted restraint by trying to escape from the bed...took X26 taser out of holster and removed cartridge...active aggression: patient assaulted [named officer] by striking him in the face...deployed X26 Taser for one cycle to upper right shoulder...subjects son and wife stated the subject had an altered mental status, seeing and hearing things that weren't there and thinking he was somewhere he wasn't...reason for use of force...to defend reporting officer, to restrain for subjects safety, to defend another person..."

Medical record review of a Nurses Note dated 2/3/16 at 3:55 AM (less than 12 hours after being transferred to the floor from ICU), revealed "...patient confused and attempting to get out of bed. Threatened wife that he was going to hit her. Nurse went into room and patient combative and argumentative with staff..." Further review revealed "...Code Green [code to summons help for combative patient] called at 3:55 AM...patient sat back in bed...NP [nurse practitioner] called..."

Medical record review of a Rapid Response/Code note dated 2/3/16 at 3:57 AM revealed "...patient confused and attempting to get out of bed. Threatened wife that he was going to hit her. Nurse went into room and patient combative and argumentative with staff...Physician notified 2/3/16 at 4:06 AM..."

Medical record review of a nurse's note dated 2/3/16 revealed "...4:05 AM...wrist restraint applied...patient continuing trying to get out bed, being combative with staff and trying to get out of bed and refusing to wear oxygen with audible wheezing...restraints applied to both wrists..."

Review of a Security Incident Report dated 2/3/16, written by Officer #1, revealed the event started at 3:54 AM and ended at 4:50 AM. Further review revealed "...on Wednesday, February 3, 2016, at approximately 3:53 [AM] PBX [operator] announced a Code Green...[Officer #2] and I [Officer #1] responded. Upon our arrival to the room, I observed the patient, [Patient #1] attempting to stand from his bed, actively fighting, medical staff was attempting to restrain him. I tackled [Patient #1] to his bed and used my body to restrain him. [Officer #2] moved to control his left arm...House Supervisor and Room Nurse RN [Registered Nurse] moved to control his legs. During the restraint [Patient #1] began to push us off of him, I pulled my [type of 26 Taser]...[Patient #1] attempted to strike me, glancing off me and hitting [Officer #2] in the face. Being concerned for officer safety and that of staff I deployed a drive stun to upper right shoulder of [Patient #1] which allowed us to gain control of him. The threat of future use of force calmed [Patient #1] long enough to apply wrist restraints and calming medication..."

Medical record review of a Cardiology Progress note dated 2/3/16 at 8:49 AM, revealed, "...Patient is extremely confused and combative this morning, which is a major change from yesterday. Wife states that she is extremely concerned..."

Medical record review of a Pulmonary Progress note dated 2/3/16 at 8:59 AM, revealed, "Patient is lying in bed in restraints. Apparently last night the patient became violent and a code green was called. This is an acute mental status change from his previous mental state...continues to be verbally abusive to those around him. His family states this is significantly out of character for him...he is confused with visual hallucinations...Apparently he had acute mental status change around 3 AM. According to wife the patient was very agitated and he was trying to hit her. He also try to get security; there the patient was given Haldol [antipsychotic], benzodiazepine [antianxiety] without benefit. The patient was given Dilaudid [narcotic] which apparently was the only medicine that helped...He apparently takes narcotics at home for chronic pain. This could represent narcotic withdrawal. Other possibility would be alcohol withdrawal; apparently he used to be alcoholic many years back but according to him and his wife he has not had any alcohol for several years; this possibility is remote however is not totally excluded...He is currently delirious...Steroids also could be contributing; we will reduce the dose...Monitor the patient closely in the intensive care unit...Patient needs closer monitoring than can be provided on the floor due to his acute mental status changes. We will therefore transfer him to intensive care unit..."

Medical record review of the nurse's notes revealed Patient #1 remained in wrist restraints due to being impulsive, combative, confused, and agitated until the patient was transferred back to ICU on 2/3/16 around 12:00 PM.

Medical record review of a Medicine Progress Record dated 2/3/16 at 5:40 PM, revealed, "Was agitated early morning was pulling off IV [intravenous] line and was trying to get out of bed...Patient has not received any of her his pain medication since admitted . Has history of chronic pain and multiple back and neck surgery...Chronic pai[DIAGNOSES REDACTED]...on multiple narcotics...restart his pain medications..."

Review of a Patient Advocate Interview worksheet dated 2/3/16 revealed "...I was working in the SICU [surgical intensive care unit] when RN came to me and with him was a female lady who wanted to talk with me. I asked her how I could help her. She told me that the patient [#1] was tazed by security last night while he was a pt. [patient] in CRU and the family wanted to know why..."

Medical record review of a Critical Care Progress Noted dated 2/4/16 at 8:32 AM, revealed, "...Pt's [DIAGNOSES REDACTED] [a brain functioning disorder] resolved this am [morning]...I am not sure what exactly happened the night before he could have had a reaction to morphine or he had narcotic withdrawal or even reaction to Ambien or steroids...At this point he seems alert oriented very appropriate. He cannot recall any of the events that happened the night before..."

Medical record review of a Cardiology Progress Noted dated 2/4/16 at 9:10 AM, revealed, "...On the night of 2/2 patient became extremely confused and violent and was found to be going through narcotic withdrawal...Patient is doing much better...pleasant, alert, and oriented, lying in bed reading a book..."

Medical record review of a Neurology Progress Note dated 2/4/16 at 1:04 PM revealed, "...significant improvement mental status...He's not remember the events from the prior few days...acute mental status changes most likely secondary to narcotic withdrawal..."

Medical record review of a Skin Assessment for Patient #1 dated 2/5/16 at 5:30 PM revealed "...color appropriate for patient...good skin elasticity and turgor...patient tazed by security on 2/4/16 x3 [3 times]...red raised areas across trunk with ecchymosis..."

Telephone interview with a family member of Patient #1 on 2/10/16 at 1:00 PM, revealed "...when I arrived at the facility there were 2 security guards, a male nurse and a male...in the room...[Patient #1] was in restraints and he was scared to death...we found later in the evening that security had tased him 3 times while he was on the floor due to...being combative and confused...the doctor told us he was tased in the right shoulder...there were marks on his side which looked like taser marks..." Continued interview revealed "...when I spoke with the Director of Security he told me that...was tased 1 time and it was viewed as a safety issue..."

Interview with the facility's Risk Manager (RM) on 2/17/16 at 10:20 AM, in the conference room, revealed patient [#1] had become agitated during the night shift and the patient's wife had called on the call light requesting for help after her husband had become confused and agitated. Continued interview revealed "...a code green was called after the patient became combative...security was trying to get him into the bed and the patient hit [Officer #2] in the cheek right at the eye...the patient was tased to the right shoulder by [Officer #1] and the staff was able to place the patient in wrist restraints after the taser..."

Telephone interview with RN #1 on 2/17/16 at 1:15 PM, revealed the patient was alert at the beginning of the shift. Further interview revealed around 3:45 AM the patient's wife called on the call light, asked for help, and indicated the patient was trying to get out of the bed. Further interview revealed "...when I got in the room the patient was not himself...he was standing at the bedside and kept saying he wanted a book...he had required assistance with getting up to the bathroom prior to the incident...he was combative and trying to get out of the room..." Further interview revealed "...we called a Code Green...the house supervisor and security came...security and the house supervisor were trying to get him settled...they got him back to the bed and he tried to hit the officer with his arm...one of the security guards moved and he hit the other one in the face above the left eye...it was then the officer tased him in the right shoulder which calmed the patient down immediately...we then put him in the wrist restraints..." Further interview revealed "...the officer told the patient he was going to tase him if he did not calm down...he only tased him 1 time..."

Interview with Officer #1 (who was the officer who fired the taser to the patient) on 2/17/16 at 2:00 PM, in the conference room, revealed the officer responded to a Code Green on 2/3/15. Further interview revealed "...when I went into the room the nursing staff was physically attending to the patient...he was pushing and shoving and was at the edge of the bed...I thought he was going to physically assault his wife...he grabbed me and I moved on top of him...he was still trying to get up and get out of the room..." Further interview revealed "...his limbs were thrashing and he was physically aggressive...he said he was going to hurt someone, I am not sure who he was talking about, he was completely altered claiming he was at his house..." Continued interview revealed "...he was trying to push me off of him...he shoved the nurse across the room from the back and I told him if he didn't calm down I'm going to have to tase you...when he swung at me I took my taser out and pulled the safety off..." Further interview confirmed the officer deployed the taser using a 4 second drive stun to the right shoulder of Patient #1. Further interview confirmed the patient was never in police custody.

Interview with the Director of Security on 2/17/16 at 2:20 PM, in the conference room, revealed the facility does have a policy to use tasers. Continued interview confirmed the officer used the taser on a combative patient and the patient was not in police custody. Further interview revealed "...review of the Taser reports confirmed the gun was deployed on 2/3/16...the record shows the drive stun was deployed for 5 seconds and then turned off..."

Interview with Patient #1's physician on 2/17/16 at 2:30 PM, in the conference room, revealed the patient had stopped taking his prescribed pain medications prior to his admission to the facility. Further interview revealed the patient was suffering from drug withdrawal and had been on multiple pain medications prior to his admission. Further interview revealed "...the patient had an acute mental status change probably from an acute narcotic withdrawal...he had received the medications the night before but I am not sure what actually set the patient off...it could have been the narcotics, the Ambien or the steroids or a combination...the pain medications were ordered on admission but they were held several times due to his blood pressure, acute respiratory status, decreased swallowing sensation and decreased mentation while in the ICU..."

Interview with Officer #2 on 2/17/16 at 2:45 PM, in the conference room, revealed the officer responded to a Code Green in the patient's room during the night shift of 2/3/16. Further interview revealed the nursing staff were trying to get the patient back in the bed after the patient had suddenly become combative and confused. Continued interview revealed the patient did not calm down and his combativeness was worsening to the point where the patient was trying to hit the staff with his fist. Further interview revealed "...we [security officers] assisted the staff in getting the patient back to the bed...[Officer #1] had him pinned down on the bed...I went to left side of the bed to assist and [Officer #1] had hold of his right side...he swung his fist and missed [Officer #1] but he hit me in the face...it was then [Officer #1] took his taser out of the holster and engaged it and after that he deployed a drive stun to the patient's shoulder..." Further interview revealed "...the patient's [family member] came in shortly after that...he said...this is not like him at all..." Continued interview revealed "...he was confused...we assisted the nursing staff in placing the wrist restraints on the patient..."

Telephone interview with the 2/3/16 nursing supervisor on 2/17/16 at 3:00 PM, revealed he responded to a Code Green on CRU, which was early in the morning. Further interview revealed "...when I walked into the room the RN was in the room and the patient was trying to get out of the bed...he was very confused...he was not coherent at all...security showed up about the same time and the more we tried to reason with the patient the worse he got...he got up out the bed by himself, normally he required assistance..." Further interview revealed "...the officer tased the patient to the right shoulder one time and the patient became compliant...we applied bilateral soft wrist restraints..."

Interview with the 2nd shift Security supervisor, on 2/18/16 at 2:40 PM, in the conference room, revealed the officer spoke with [Patient #1's] family on 2/4/16 in the ICU lounge. Further interview revealed "...spoke with the son...he stated he would like to know why the patient was tased by an officer...he stated he [the patient] was disoriented in the room..."

Telephone interview with RN #2 (who worked in the ICU on 2/3/16, the day after the taser was used on the patient) on 2/29/16 at 4:00 PM, revealed "...the patient came to the unit on 2/3/16 with bilateral wrist restraints already in place...he was confused and disoriented...the son did make mention that his father was tased while on the floor the night before...the family said to me that there were marks on his skin and asked me to look...there were red marks on his flank but I could not determine anything other than that..."