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.

METHODIST HEALTHCARE MEMPHIS HOSPITALS 1265 UNION AVE SUITE 700 MEMPHIS, TN 38104 March 1, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy review, document review and interview, the Governing Body failed to assume responsibility and provide oversight of the hospital's quality of care, patient rights, QAPI program. The failure of the Governing Body to assume responsibility and provide oversight to ensure patients were kept safe and protected during emergency treatment resulted in a fractured arm for one of one (Patient #1) patients and placed all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY. Additionally, the Governing Body's failure to respond to assure appropriate training was instituted to secure a safe setting for provision of care demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients ongoing.


The findings included:

1. The Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible and ensured the safety of the patients in the hospital.
Refer to A 057.

2. The Governing Body failed to ensure policies were implemented, all patients received appropriate care and services in a safe setting, were protected at all times, and their patient rights, dignity, and well-being were preserved.
Refer to A 0115, A 0144 and A 0145.

3. The Governing Body failed to ensure the Quality Assessment Performance Improvement (QAPI) committee analyzed and reviewed all adverse patient events and implemented preventative actions to ensure the events did not reoccur.
Refer to A 0263 and A 0286.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on facility document review, policy review, record review, observation and interview, the Chief Executive Officer (CEO) failed to be responsible for the management of the hospital, ensure staff provided care to vulnerable patients in a safe environment and patients rights were promoted for 1 of 1 (Patient #1) sampled patients whose rights were violated resulting in a fractured arm.

The findings included:

1. Review of the Safety Operations Committee meeting minutes for 1/14/16 documented a reportable adverse event occurred on 3/21/15 in which baton use by a security officer did not align with facility policy and procedure. Crisis Prevention Intervention (CPI) training was to be completed by 5/5/15. There was no documentation that the CPI training had been completed by 5/15/15. The only Security specific training required of the officers was the continued use of the basic baton and aerosol training.

2. Review of an email dated 2/25/16 from the Chief Operating Officer revealed "...Prior to... [December 2015] the only Security specific training required for our officers was the basic baton and basic aerosol training..."

3. Review of 2/25/16 at 5:55 PM email from the Chief Operating Officer to the surveyor revealed training cards for Security Officers #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17 and 18 for completed training and certification for basic baton training and basic aerosol training with no completion date.

Review of basic aerosol training materials revealed the following facts about aerosols: The aerosols effect the eyes, face, respiratory system and skin pigmentation. The physical actions include rigid muscles, auditory exclusions, tunnel vision, basic fear, blindness and suffocation.

Review of basic baton training materials revealed the following about baton usage: The use of a baton works on the motor nerves. Motor nerve points regulate the neural impulses that control the movement of muscles. When these signals are interrupted, there is a high intensity of pain, motor dysfunction/temporary paralysis of a particular muscle group, a sympathetic flexing response of the opposite unaffected joint.

Refer to A 286.

2. A second reportable adverse event concerning a security officer occurred on 12/23/15. Review of the patient's medical record revealed Patient #1 was admitted to the Emergency Department (ED) on 12/23/15 via ambulance after passing out from too many alcoholic beverages. The patient was triaged and medical care initiated including lab work which revealed a blood alcohol level of 374 (the reference range used by the facility was less than or equal to 3 was normal). According to nursing documentation the patient eventually became agitated and Security was called to the ED. The Security Officer grabbed the patients left wrist and the patient kicked out at the Security Officer. A loud "pop" was heard and the patient yelled his arm was broken. Review of the security officer's personnel file revealed the security officer had not received CPI training.

As a result of the incident, Patient #1 sustained an oblique comminuted fracture of the distal shaft of the ulna. The patient's arm was splinted and he was discharged with orders for follow-up with an orthopedic physician.

3. There was no documentation the CEO had investigated the incident to determine the root cause in order to implement appropriate interventions and follow up to ensure patient's received care in a safe environment and were free of abuse.
Refer to A 144, A 145 and A 286.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, medical record review and interview, the facility failed to protect patients' rights in all areas of the hospital, to provide freedom from abuse and to provide care in a safe setting for all facility patients.

Failure by the facility to provide freedom from abuse and care in a safe setting resulted in a SERIOUS AND IMMEDIATE THREAT for all facility patients.

The findings included:

1. The facility failed to provide care in a safe setting for vulnerable patients presenting to the hospital Emergency Department.
Refer to A 0144.

2. The facility failed to protect all patients from abuse.
Refer to A 0145.

3. The facility failed to analyze contributing factors and implement measures in order to prevent patient abuse.
Refer to A 0286
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the Emergency Medical Services (EMS) report, policy review, medical record review, video recording review and interview, the hospital failed to ensure vulnerable patients received care in a safe manner for 1 of 1 (Patient #1) sampled patients who sustained injury while in the care of the hospital. Failure of the hospital to ensure patients were kept safe during emergency treatment resulted in a fractured arm for Patient #1 and placed all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY. Additionally, the hospital's failure to respond with appropriate interventions to secure a safe setting for provision of care demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients is ongoing.

The findings included:

1. Review of the facility's policy "Security Management Plan" reviewed 1/2011 and 5/2015, effective date 1/1997, and revised 5/2012 and 2/2013 revealed, "[Hospital name] exists to benefit the people of our region by promoting good health, and by healing, caring and comforting... [Hospital] maintains a security management program that is designed to provide a safe and secure physical environment free of hazards and risks for patients... The purpose of the Security Management Plan is to define the program to minimize the risk of injury or property loss involving patients, visitors... Training hospital Associates is critical to their performance. Associates are trained to recognize and report either potential or actual incidents to ensure a timely response. Associates in security-sensitive areas are familiarized with the protective measures designed for those areas and their responsibilities to assist in protection of patients, visitors..."

2. Review of the EMS report dated 12/23/15 revealed EMS arrived on the scene at 1:46 AM to find a [AGE] year old male sitting in the yard. "...The pt [patient] mother stated that the pt started drinking alcohol and had too much. The pt was responsive to verbal stimuli only..." The patient was transported to the hospital. The EMS report documented the patient's vital signs were within normal limits and blood glucose level was 90. The patient received 300 milliliters of normal saline en-route to the hospital.

3. Medical record review for Patient #1 revealed the patient was a [AGE] year old male who arrived at the hospital's ED by EMS on 12/23/15 at 3:20 AM. The ED notes documented, "[Patient #1] passed out after drinking too many Busch beers. 'my dad died yesterday and I have a lot going on'..."

4. Review of the ED Nursing notes dated 12/23/15 revealed the following:
3:20 AM- ED Triage Assessment form documented the patient's visit reason as Intoxicated.
3:25 AM - Registered Nurse (RN) #2 documented labs were drawn. Results of the blood alcohol level were 374 milligrams per deciliter (mg/dl). The reference range (the range negative for alcohol) used by the laboratory was < = 3 (less than or equal to 3).
3:59 AM - RN #2's assessment completed. There was no documentation the patient was exhibiting inappropriate behaviors.
7:05 AM - Care of the patient was transferred to the day shift nurse, RN #1. There was no documentation from 3:59 AM to 7:05 AM that the patient was exhibiting inappropriate behaviors.
7:15 AM - RN #1 documented "pt removed own int [intermittent access]. dressing applied. pt agitated yelling out. spoke with pt in the attempts to calm down. pt somewhat better at this time."
7:45 AM - "pt refusing additional int. [Physician #1] notified. Awaiting orders"
7:55 AM - "[Physician #1] at bs [bedside]."
8:00 AM - "pt out of rm [room]. Remains slightly agitated at this time. Pt informed to return to bed. Pt slow to comply."
8:45 AM - "pt continues to yell off and on. pt verbal with staff. pt informed to calm down."
9:00 AM - "pt argumentative with staff standing in doorway. Security called. pt placed back in bed and was informed to stay in bed until [Physician #1] notified."
9:05 AM - "pt standing outside of doorway, aggitated [agitated]/arguementative [argumentative] with staff. Mother at bs at this time. pt informed to go back to room as it is unsafe in hallway. pt refused. pt yelling derrogatory [derogatory] remarks to staff. Security called back to room."
9:15 AM - "[Name of Security Officer #1], security at bs. pt yelling at staff/now clinging to door handle. [Name of Security Officer #1] grasping L [left] wrist to control pt. pt began to push [Name of Security Officer #1] away and swung L arm around. [Name of Security Officer #1] requested pt to stop acting this way. pt noncompliant at this time. pt continues with foul language now directed at [Name of Security Officer #1]. [Name of Security Officer #1] pulled on pt L wrist to assist pt back to bed. pt kicked leg up with possible attempt to kick [Name of Security Officer #1] or to lock foot around door. Heard a loud 'pop'. pt yelled out. 'you broke my arm you MF!" Mother ran to pt to calm him down. Pt placed in wc [wheelchair]. I exited rm [room] to inform [Physician #1]. "
9:19 AM - "[Physician #1] at bs for eval [evaluation]. Security remains at bs."
9:25 AM - "pt transport to xray per wc [wheelchair] per edt [emergency department technician] with security escort (Security Officer #18)."
9:30 AM - "spoke with [name], mother of pt. r/t [related to] poc [plan of care]. Verbalized understanding."
9:33 AM - "pt returned from xray. In speaking with pt. pt remains mildly agitated, however is calm enough to have an intelligent conversation. pt somewhat apologetic at this time."
9:55 AM - "...pt medicated with Tylenol 650 mg po."
10:00 AM - "...int to RAC [right antecubital]...no status change. will continue to monitor."
10:30 AM - "pt with continue pain. [Physician #1] notified. Orders received and completed."
10:35 AM - "splint/sling to L arm. pt tolerated procedure well."
11:52 AM - pt was discharged home with his mother.

5. Review of ED Provider Notes dated 12/23/15 revealed the following documentation by Physician #1:
7:55 AM - "... Chief Complaint from Nursing Triage Note: 12/23/15 3:20 AM ... passed out after drinking too many Busch beers. 'my dad died yesterday and I have a lot going on'. The patient presents with alcohol intoxication. The onset was unknown... Pt states that his father just died yesterday. Usually drinks two beers daily but today he thinks he drank about six beers. Doesn't remember much after that, just remembers waking up in the emergency room . States he does not know what he's doing here... Laboratory results... Serum Ethyl Alcohol 374 milligrams per deciliter (mg/dl) CRIT [critical value] ... "
9:11 AM - "called to room - pts mother is now here and is able to take him home. Pt is belligerent right now, arguing and cursing. Security guard is present. Trying to calm situation at this point. Pt is medically cleared for discharge home now that his mother is here and can take him home (preveious plan was behavioral health for drunk tank as he had been unable to get a ride before)"
9:16 AM - "Called to room again. Pt complaining of left forearm pain. Per report of security guard and nurse present at this time, patient (who remains intoxicated and is currently very belligerent) was holding onto the door with one arm and trying to kick the security guard. The security guard took hold of his left arm to try to hold him off and a pop was heard, then pt c/o [complained] pain. Will xray forearm now."
9:45 AM - "xray has been completed and film reviewed (final read pending)- ulnar shaft fracture noted, ortho [orthopedics] paged for consult, awaiting callback."
10:15 AM - "Arm rechecked... distal mobility and sensation intact. Mild swelling... No gross deformity..." Physician #1 ordered the following: Norco (hydrocodone bitartrate) 7.5 mg-325 mg tablet now and apply Left arm Posterior splint. "Discussed results w patient including ortho recs. Posterior splint to be placed, then ok to dc home with mother to f/u w ortho outpatient. Patient advised against alcohol abuse... Diagnosis: Acute alcohol intoxication, Left ulnar fracture... Condition: Stable Disposition: Medically cleared, discharged ... home. Patient was given the following educational materials: ALCOHOL INTOXICATION, ALCOHOL ABUSE, FRACTURE, Upper Extremity. Follow up with Physician #2 within 5 to 7 days... Discharge patient... Home, with mother after splint placement..."

6. Review of the x-ray report dated 12/23/15 at 9:18 AM revealed, "Clinical Information: Left arm pain, fracture...There is an oblique comminuted [shattered] fractures of the distal shaft of the ulna. The radius appears to be intact."

7. Review of the facility video (no audio recording) of the ED for 12/23/15 beginning 9:03 AM revealed Patient #1 standing in the hallway in front of his room in the ED talking. At 9:05 AM, Patient #1 is assisted into the room by Registered Nurse (RN) #1 with Security Officer #1 present. RN #1 and Security Officer #1 assist Patient #1 into his ED room on different occasions. At 9:13 AM Patient #1's mother arrived at the doorway of Patient #1's room. She is observed in the hallway with RN #1. At 9:14 AM Patient #1 and his mother are standing in front of the patient's room. The mother is observed shaking her finger at Patient #1. Patient #1 and his mother, Security Officer #1 and RN #1 are observed to enter the patient's room. At 9:15 AM Physician #1 is observed talking to the patient's mother. At 9:16 AM, Security Officer #1 is observed outside of the patient room attempting to close the door but unable to do so. Security Officer #1 turns around to see why the door will not close. Security Guard #1 entered the patient's room, followed by RN #1. The RN came out of the patient's room, and returned with the physician.

8. During an interview in the conference room of North campus on 2/24/16 at 9:25 AM, RN #1 stated Patient #1 was "...belligerent, yelling, cussing... whole 9 yards... called [Security Officer #1] trying to get him to calm down, [Patient #1 became] more angered... [Security Officer #1] grabbed him [Patient #1], heard 'pop'..."

During a telephone interview on 2/25/16 at 8:06 AM, Patient #1 stated he told the Security Officer #1 he was leaving, and Security Officer #1 told him he was not leaving. The patient stated he put his foot in the door. He stated Security Officer #1 walked over to him, grabbed his arm and snapped it. The patient stated he called Security Officer #1 "...Mr. Clean, I guess he didn't like that. He was a tall, bald guy in a white shirt... Guess I shouldn't have said it... my father had passed away December 21st..." The patient stated the x-ray showed his arm was broken.

During a telephone interview on 2/25/16 at 8:40 AM, Security Officer #1 stated, "I was assaulted by this patient. He hit me, punched me, kicked me ... this patient was out of control. He was combative. They called for Security and I responded... He assaulted me... he accidentally got his arm broke..." There was no documentation in the medical record Security Officer #1 had been hit, punched or kicked.

The Security Officer Supervisor provided the surveyor with a list of security staff and the date of the most recent department specific training the officers attended. There was no documentation of continuing education on department specific security issues for security officers between October 2014 and January 2016.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, video recording review and interview, the hospital staff failed to adhere to policies to ensure vulnerable patients were protected at all times and their rights, dignity and well-being were preserved for 1 of 1 (Patient #1) sampled patients whose right to be free from abuse was violated. Failure of follow policies and procedures, protect patients from abuse and to treat patients with dignity and respect resulted in Patient #1 sustaining a fracture of the arm from inappropriately applied restraining measures and placed all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY. Additionally, the hospital's failure to respond with appropriate interventions to ensure patients are safe from abuse demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients is ongoing

The findings included:

1. Review of the facility's policy "Security Management Plan" reviewed 1/2011 and 5/2015, effective date 1/1997, and revised 5/2012 and 2/2013 revealed, "[Hospital name] exists to benefit the people of our region by promoting good health, and by healing, caring and comforting... [Hospital] maintains a security management program that is designed to provide a safe and secure physical environment free of hazards and risks for patients... The purpose of the Security Management Plan is to define the program to minimize the risk of injury or property loss involving patients, visitors... Training hospital Associates is critical to their performance. Associates are trained to recognize and report either potential or actual incidents to ensure a timely response. Associates in security-sensitive areas are familiarized with the protective measures designed for those areas and their responsibilities to assist in protection of patients, visitors... The following areas are currently designated as sensitive areas based on historical precedence, internal assessments, patient information (HIPPA), or a high level of security from government and other regulations or standards... Emergency Department [ED] - high level of transient traffic... Personnel are reminded during their annual education about those areas of the facility that have been designated as security-sensitive. Associates assigned to work in sensitive areas receive department level continuing education on an annual basis that focuses on special precautions or responses that pertain to their area... All Associates are required to complete annual training... Department Directors are responsible for orientating Associates upon initial hire, and annually on department specific security issue..."

2. Medical record review for Patient #1 revealed the patient was a [AGE] year old male who arrived at the hospital's ED by Emergency Medical Services (EMS) on 12/23/15 at 3:20 AM after passing out in a family member's yard. The ED notes documented, "[Patient #1] passed out after drinking too many Busch beers. 'my dad died yesterday and I have a lot going on'..." The ED Triage Assessment form documented the reason for ED visit as Intoxicated. A blood alcohol level was drawn and the results were 374 (reference range used by this facility is less than or equal to 3 as being negative for alcohol).
At 9:00 AM the nursing notes documented " pt argumentative with staff standing in doorway. Security called. pt placed back in bed and was informed to stay in bed until [Physician #1] notified."
At 9:15 AM the nursing notes documented Security Officer #1 attempted to get the patient to return to the bed, grabbed the patients left wrist and a loud "pop" was heard. The patient yelled that his arm was broken.

3. Review of ED Provider Notes dated 12/23/15 at 9:11 AM revealed Physician #1 was "called to room - pts mother is now here and is able to take him home. Pt is belligerent right now, arguing and cursing. Security guard is present. Trying to calm situation at this point. Pt is medically cleared for discharge home now that his mother is here and can take him home (previous plan was behavioral health for drunk tank as he had been unable to get a ride before) "

4. Review of the facility video (no audio recording) of the ED for 12/23/15 beginning 9:03 AM revealed Patient #1 standing in the hallway in front of his room in the ED talking. At 9:05 AM, Patient #1 is assisted into the room by Registered Nurse (RN) #1 with Security Officer #1 present. RN #1 and Security Officer #1 assist Patient #1 into his ED room on different occasions. At 9:13 AM Patient #1's mother arrived at the doorway of Patient #1's room. She is observed in the hallway with RN #1. At 9:14 AM Patient #1 and his mother are standing in front of the patient's room. The mother is observed shaking her finger at Patient #1. Patient #1 and his mother, Security Officer #1 and RN #1 are observed to enter the patient's room. At 9:15 AM Physician #1 is observed talking to the patient's mother. At 9:16 AM, Security Officer #1 is observed outside of the patient room attempting to close the door but unable to do so. Security Officer #1 turns around to see why the door will not close. Security Guard #1 entered the patient's room, followed by RN #1. The RN came out of the patient's room, and returns with the physician.
There was no observation on the video the patient was belligerent, combative, or exhibiting inappropriate behavioral activity.

5. Review of the clinical documentation dated 12/23/15 revealed Physician #1 was called to Patient #1's room at 9:16 AM, "...Pt complaining of left forearm pain. Per report of security guard and nurse present at this time, patient (who remains intoxicated and is currently very belligerent) was holding onto the door with one arm and trying to kick the security guard. The security guard took hold of his left arm to try to hold him off and a pop was heard, then pt c/o [complained] pain. Will xray forearm now."

6. Review of the x-ray report dated 12/23/15 at 9:18 AM revealed, "Clinical Information: Left arm pain, fracture ...There is an oblique comminuted [shattered] fractures of the distal shaft of the ulna. The radius appears to be intact."

7. Review of a list of the hospital's Security Department personnel revealed 17 Security Officers and a Supervisor were employed at the hospital. The Security Officer Supervisor provided the surveyor with a list of security staff and the date of the most recent department specific training the officers attended. There was no documentation of annual continuing education on department specific security issues for the following officers:
Security Officer #1's date of hire was 4/17/16. There was no documentation of department level specific training.
Security Officer #2's date of hire was 7/2/12. The last annual department level specific training was documented 1/2014. There was no documentation of continuing education on an annual basis.
Security Officer #3's date of hire was 11/11/13. The last department level specific training was documented 1/2014. There was no documentation of continuing education on an annual basis.
Security Officer #4's date of hire was 9/15/14. The last department level specific training was documented 10/2014. There was no documentation of continuing education on an annual basis.
Security Officer #5's date of hire was 12/19/90. The last department level specific training was documented 4/2012. There was no documentation of continuing education on an annual basis.
Security Officer #6's date of hire was 6/18/12. The last department level specific training was documented 8/2012. There was no documentation of continuing education on an annual basis.
Security Officer #9's date of hire was 10/22/01. The last department level specific training was documented 5/2012. There was no documentation of continuing education on an annual basis.
Security Officer #10's date of hire was 12/06/10. The last department level specific training was documented 12/2010. There was no documentation of continuing education on an annual basis.
Security Officer #12 s date of hire was 8/8/82. The last department level specific training was documented 12/2010. There was no documentation of continuing education on an annual basis.
Security Officer #15's date of hire was 9/28/15. There was no documentation of department level specific training.
Security Officer #16's date of hire was 8/2/10. The last department level specific training was documented 1/2014. There was no documentation of continuing education on an annual basis.
Security Officer #17's date of hire was 6/4/12. The last department level specific training was documented 7/2013. There was no documentation of continuing education on an annual basis.

8. During an interview on 2/24/16 at 9:50 AM in the hospital's classroom, the Security Officer Supervisor stated security officers were trained in, "...de-escalation, use of force, tactics, and checked-off for aerosol and baton..."

During an interview on 2/24/16 at 10:30 AM in the classroom, the Security Officer Supervisor stated the officers received training yearly to review paper work and maneuvers. The Security Officer Supervisor was asked if he had any documentation of staff attending the yearly reviews. The Security officer Supervisor stated he did not have documentation of this training. The surveyor asked if Human Resources kept a copy of Security Officer training and he stated no, that was kept by the Security Department. When the surveyor asked the Security Officer Supervisor about the incident between Patient #1 and Security Officer #1, he stated he had no behavior problems with Security Officer #1.

During a telephone interview on 2/25/16 at 8:40 AM when Security officer #1 was asked what his job responsibilities were he stated, "...I was supervisor of security... had numerous duties... taught CPI (Crisis Prevention Intervention) classes... self-defense instructor... last class taught was November or December 2015... " When the surveyor asked Security Officer #1 what happened during his interaction with Patient #1, he stated the patient "was out of control. He was combative... He assaulted me ... he accidently got his arm broke..."

9. Review of an email dated 2/25/16 from the Chief Operating Officer (COO) to the surveyor revealed "...Prior to... [December 2015] the only Security specific training required for our officers was the basic baton and basic aerosol training..."
VIOLATION: QAPI Tag No: A0263
Based on facility policy review, document review and interview, the facility failed to ensure it maintained an effective and on-going Quality Assessment and Performance Improvement (QAPI) program to prevent adverse patient events. The failure by the facility to provide appropriate and timely interventions to secure a safe setting for the provision of care and prevention of abuse placed all vulnerable patients at risk for SERIOUS INJURY resulting in IMMEDIATE JEOPARDY. The hospitals' continued failure to intervene with appropriate and timely interventions to secure a safe setting for the provision of care demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients is ongoing.

The findings included:

1. The facility failed to ensure the QAPI committee implemented appropriate preventative actions to secure a safe environment and prevent abuse.
Refer to A 0286
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on facility policy, facility document review, record review, observation and interview, the Quality Assessment and Performance Improvement (QAPI) committee failed to ensure an ongoing hospital-wide program that identified, fully analyzed and addressed all contributing factors related to adverse events resulting in 1 of 1 (Patient #1) experiencing a fractured arm. The failure of the QAPI committee to analyze the causes resulted in the facility's failure to implement corrective actions to ensure patient injury did not reoccur, resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and/or death. The hospitals' continued failure to fully analyze and address factors with appropriate and timely interventions to secure a safe setting for the provision of care demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients is ongoing.



The findings included:

1. Review of the facility policy, "Use of Force-Security" effective 8/3/09 documented, "...One common definition of reasonable force is simply not to be excessive, under the circumstances... Use of Force Continuum is broken down into six broad levels. Each level is designed to have an elastic factor as the need for force changes as the situation evolves. It is common for the level for force to go from level two to level three and back again in a matter of seconds. The force level should always be appropriate for the circumstances and adjust up and down as the situation requires... Level Two: ...The right combination of words in combination with officer presence can de-escalate a tense situation and prevent the need for a physical altercation. Training and experience improves the ability of a security officer to communicate effectively with everyone including the police... Level Three - Control Holds & Restraints. Certain situation may arise where words alone does not reduce the aggression. Sometimes security guards and security officers will need to get involved physically. At this level, minimal force would involve the use of bare hands to guide, hold and restrain... A baton can only be used at this level as a self-defense mechanism to block blows or temporarily restrain... Level Four - Chemical Agents. Sometimes when... violent or threatening, more extreme, but non-deadly measures must be used in defense to bring the suspect under control... Before moving to level four, it is assumed that other less physical measures had been tried or was deemed inappropriate. ... Even though considered non-deadly, chemical sprays can cause a severe reaction and even death... with medical or allergic conditions... Training is the Key- To fully understand the force continuum it must be periodically discussed and reviewed by security supervisors. Practical exercises will help re-enforce the training and cause the reactions to become more appropriate instead of instinctual. In a crisis situation, fear and adrenalin have a way of accelerating the force continuum. Practice and ongoing training exercises will ease the effects of stress and make the safe outcome more predictable..."

2. Review of the Safety Operations Committee meeting minutes for 1/14/16 documented a reportable adverse event of physical abuse on 3/21/15. The adverse event was, "inappropriate interaction by a Security Officer with a emergency room patient, use of the baton did not align with the policy and procedure". There was no other information regarding this adverse event. There was no documentation the committee had fully analyzed the root cause of the abuse by the security officer.
The Action Plan to prevent the abuse from recurring was Crisis Prevention and Intervention (CPI) training and in-service which was to be completed by 5/5/15. There was no documentation the training and in-service had been completed by 5/15/15.

The Safety Operations Committee meeting minutes for 1/14/16 documented a second reportable adverse event of physical abuse on 12/23/15. The event was documented as, "intoxicated ED patient became belligerent and Security Office assistance was requested; a hand wrist grab was used in attempt to control patient resulting in injury to patient. An x-ray revealed a comminuted fracture to the distal shaft of the ulna. The patient received immediate treatment and discharged home with Ortho [orthopedic] follow-up".
The Action Plans for the second adverse event were CPI and de-escalation training for the security department and ED Leadership. This was to be completed by 1/13/16.

There was no documentation the CPI training and de-escalation training for the Security officers and ED leadership was completed by 1/13/16. There was no documentation QAPI had implemented measures to ensure the adverse events were corrected and would not re-occur prior to the surveyors visit on 2/22/16 for these two allegations of abuse.

3. Medical record review for Patient #1 revealed the patient arrived at the ED via ambulance on 12/23/15 at 3:20 AM after passing out in a family member's yard. A blood alcohol level was drawn and the results were 374 (reference range used by this facility is less than or equal to 3 as being negative for alcohol). There was no documentation from the time of the patient's arrival until 9:00 AM the patient was agitated.
At 9:00 AM the nursing notes documented the patient became agitated, was argumentative with staff and a Security Officer was called to the ED.
At 9:15 AM the nursing notes documented the Security Officer #1 attempted to get the patient to return to the bed, grabbed the patients left wrist and a loud "pop" was heard. The patient yelled that his arm was broken. An xray revealed the patient had sustained a fractured left arm.

4. Review of the hospital video footage (no audio recording) which recorded the hallway of the ED and the entrance to the patient's room on 12/23/15 beginning 9:03 AM revealed Patient #1 was standing in the hallway in front of his room. The patient appeared to be talking.
At 9:05 AM Patient #1 was assisted back inside his room by Registered Nurse (RN) #1 with Security Officer #1 present. The video showed RN #1 and Security Officer #1 assisting Patient #1 back into his ED room on several occasions.
At 9:13 AM Patient #1's mother was observed in the entrance/doorway of Patient #1's room. The patient's mother appeared to be talking with RN #1.
At 9:14 AM it appeared Patient #1 and his mother were talking. The mother was observed shaking her finger at Patient #1. Patient #1, the patient's mother, the Security Officer #1 and RN #1 were observed entering the patient's room.
At 9:15 AM Physician #1 was observed talking to the patient's mother.
At 9:16 AM Security Officer #1 was observed walking out of the patient's room into the hallway and attempting to close the door of the patient's room but unable. It appeared the patient's hand was holding the door preventing the door from closing. Security officer #1 re-entered the patient's room followed by RN #1. Within a few seconds RN #1 came out of the patient's room and returned immediately with Physician #1.

There was no observation on the video recording footage the patient was experiencing behaviors.

5. The facility's investigation determined the cause of the incident was the security officer. The facility terminated Security Officer #1's employment. The Committee Action Plans were CPI and de-escalation training for the Security Officers and ED leadership to be completed by 1/13/16. There was no documentation the CPI training and de-escalation training for the Security officers and ED leadership was completed by 1/13/16. There was no documentation QAPI had implemented action plans/interventions to ensure security officers were trained in CPI and de-escalation training or conducted oversight to ensure the abuse did not recur ongoing.

6. Review of an email dated 2/25/16 from the Chief Operating Officer to this surveyor revealed "...Prior to... [December 2015] the only Security specific training required for our officers was the basic baton and basic aerosol training..."

7. Review of 2/25/16 at 5:55 PM email from the Chief Operating Officer to the surveyor revealed training cards for Security Officers #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17 and 18 for completed training and certification for basic baton training and basic aerosol training with no completion date.

8. Review of basic aerosol training materials provided by the hospital revealed the following facts about aerosols:
The aerosols effect the eyes, face, respiratory system and skin pigmentation. The physical actions include rigid muscles, auditory exclusions, tunnel vision, basic fear, blindness and suffocation.

Review of basic baton training materials provided by the hospital revealed the following about baton usage: The use of a baton works on the motor nerves. Motor nerve points regulate the neural impulses that control the movement of muscles. When these signals are interrupted, there is a high intensity of pain, motor dysfunction/temporary paralysis of a particular muscle group, a sympathetic flexing response of the opposite unaffected joint.

9. Review of a list of Security Department personnel reviewed by the surveyor on 2/24/16 revealed there were 17 Security Officers and a Supervisor. The Security Officer Supervisor provided the surveyor with a list of staff and the date of the most recent department specific training the officers attended. There was no documentation of annual continuing education on department specific security issues for the following officers:

Security Officer #1's date of hire was 4/17/16. There was no documentation of department level specific training.
Security Officer #2's date of hire was 7/2/12. The last annual department level specific training was documented 1/2014. There was no documentation of continuing education on an annual basis.
Security Officer #3's date of hire was 11/11/13. The last department level specific training was documented 1/2014. There was no documentation of continuing education on an annual basis.
Security Officer #4's date of hire was 9/15/14. The last department level specific training was documented 10/2014. There was no documentation of continuing education on an annual basis.
Security Officer #5's date of hire was 12/19/90. The last department level specific training was documented 4/2012. There was no documentation of continuing education on an annual basis.
Security Officer #6's date of hire was 6/18/12. The last department level specific training was documented 8/2012. There was no documentation of continuing education on an annual basis.
Security Officer #9's date of hire was 10/22/01. The last department level specific training was documented 5/2012. There was no documentation of continuing education on an annual basis.
Security Officer #10's date of hire was 12/06/10. The last department level specific training was documented 12/2010. There was no documentation of continuing education on an annual basis.
Security Officer #12's date of hire was 8/8/82. The last department level specific training was documented 12/2010. There was no documentation of continuing education on an annual basis.
Security Officer #15's date of hire was 9/28/15. There was no documentation of department level specific training.
Security Officer #16's date of hire was 8/2/10. The last department level specific training was documented 1/2014. There was no documentation of continuing education on an annual basis.
Security Officer #17's date of hire was 6/4/12. The last department level specific training was documented 7/2013. There was no documentation of continuing education on an annual basis.


10. During an interview on 2/22/16 at 11:30 AM in the Administrative conference room when questioned by the surveyor about the technique Security officer #1 had used on Patient #1 the Risk Manager from a satellite hospital campus stated, "...[name of Security Officer #1] was from the prison system... used a hold that was approved in prison... If person doesn't fight or push against you, then no problem... Pushing against person causes torsion of bone..."

11. During an interview on 2/24/16 at 9:50 AM in the hospital classroom the Security Officer Supervisor stated Security Officer #1 had working experience in the penal system for 20 plus years as well as serving as a policeman in another State.

12. During an interview on 2/24/16 at 10:30 AM in the hospital classroom the Security Officer Supervisor stated the Security officers received training yearly to review paperwork and maneuvers. He stated the facility began using CPI training in 2010. The Security Officer Supervisor was asked if he had any documentation of staff attending the annual training reviews. The Security officer Supervisor stated there was no documentation of the annual review training.

13. There was no documentation the QAPI committee analyzed mitigating factors which created the potential for patient abuse and, implement preventive and corrective action plans that were developed by the committee. The committee continued to allow the use of batons by Security Officers providing them with the baton and aerosol training although it had been identified the Security officers had failed to follow hospital policies and procedures for the use of force.
Refer to A 115, A 144, A 145