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.

Based on a review of two restraint/seclusion events, it was revealed that the hospital failed to include all parts of the face to face for patient #6 who was secluded.

Patient #6 (P6) was a young adult who presented to the emergency department with an altered mental status inclusive of hallucinations. An emergency department procedure (provider) note of 1133 stated, "patient is behavior abruptly escalated. (P6) is throwing furniture. (P6) is speaking completely neurologically. We will sedate with B-52 Place the patient on seclusion." The order and initiation time for the seclusion was 1138, 5 minutes after the provider note was written. As such, the provider could not document the patient reaction to the intervention, or if the intervention needed to continue at that time. Therefore, the face to face was incomplete.
Based on a review of hospital Restraints and Seclusion policy (revised 2/21/2018), the Security Augmentation Proposal, and the Use of Defensive Force Policy, along with interviews and review of the personnel files for five contracted and one regular security personnel, it was determined that the hospital 1) failed to standardize healthcare restraint processes throughout the hospital per policy and clinical oversight; and 2) failed to define and implement appropriate human resources training of employed security guards and contracted armed guards related to healthcare restraints; and, 3) allowed security to exercise law enforcement decision-making without law enforcement powers.

Hospital Restraints and Seclusion policy (revised 2/21/2018) revealed in part:

1) "I. POLICY This policy will provide a consistent, standardized hospital-wide procedure for the assessment, application and evaluation of the use of restraints."

Interview with the Security Manager on December 18, 2018 at approximately 1430 revealed that nursing received one type of hospital physical restraint training through Hospital Trainers, and that security guards received a different type of physical restraint training taught by contracted armed security guards (CAG). Therefore, nursing and security staff received differing types of physical restraint training for which nursing could not give clinical oversight.

To compare types of restraint training, requests were made during the survey for illustrated/video or other visual aids showing the actual security restraint training by CAG. No visual examples were provided. All CAG training is written in the student manual, or is verbally conveyed. Actual holds are demonstrated in the classroom. The unillustrated student manual for hospital security revealed printed information in part, of conditions which would require a defensive "use of counter strikes," and other defensive moves such as "brachial stun," which are not otherwise described.

Additionally, the CAG training included the use of unapproved, non-therapeutic "defensive restraint techniques" including nerve pressure points. Three examples were "hypoglossal - base of jaw, does not hyperextend the neck, or obstruct the airway; Mandibular Angle - behind the ear where the jaw and skull meet; and Infra-orbital - under the nose." The CAG training did not differentiate between using these techniques on patients or non-patients. The curriculum and training materials for the clinical restraint class did not include mention of these techniques, making it impossible for clinical staff to provide direction or oversight for safe and appropriate use. The CAG training program revealed that contrary to restraint policy, there was no consistent, standardized hospital-wide procedure related to restraints.

On request of 11/18/18 at approximately 0945, security guard #1 (SG1) demonstrated on the surveyor how SG1 was trained by the CAG company to take a subject to the floor. By twisting the wrist/arm of the surveyor lightly behind the surveyor back, this effectively demonstrated how a subject could be controlled and taken to the floor in a prone position. SG1 then stated that the head of the subject would be turned to the side and then the subject would be placed in a recovery position on the side. While SG1 described positioning in order to protect the airway, any training involving the twisting of an arm, and intentional placement of a subject into a prone position failed to meet healthcare restraint standards. No content related to arm-twisting or prone positioning was found in the supplied CAG training materials. Review of all materials given failed to demonstrate that hospital security and CAG were given any baseline training in the safe and appropriate use of restraints in a therapeutic environment.

2) A request for the contracted armed guard (CAG) contract produced an unsigned "Security Augmentation Proposal" (SAP) dated November 28, 2017. The SAP described in part, " ...will provide one armed officer dedicated to the Emergency Department unless a different area is specified ...The officer will be armed with a pistol, but will have his handgun concealed." No further clarification as to how the guard would secure the gun was found.

Part of the SAP stated, "The officer may act on own autonomous decision making during incidents that are clearly escalating or may result in severe bodily harm or death." That meant that the CAG, who was not an actual law enforcement "officer," was free, without obtaining clinical direction, to decide what situations required CAG actions, up to, and including the use of deadly force. If for example, a patient was striking out, the CAG could alone decide to intervene with whatever use of force the CAG determined the situation to require.

The SAP went on, "In addition, the officers may be asked to assist in dealing with violent visitors, patient, or other violent individuals as directed by clinical or security staff." This meant that security could direct the CAG instead of clinical staff who, per healthcare standards, should initiate and retain oversight of restraint interventions. The statement also failed to make a distinction between patients and others, which is also within the scope of clinicians to determine.

The SAP went on to say in part, " ...due to the fact that the officers are not (Hospital) employees, discretion will be exercised to assure no violation of CMS/TJC regulations take place." This statement was vague and carried no assurance of compliance with regulation, particularly related to a lack of training as follows:

"All officers will be required to sit through a (Hospital) orientation and complete their competencies per protocol." No protocol was found supporting this statement. A request for the personnel files of CAG personnel returned only one file, that of a former staff member whose orientation dated to his/her employment as regular hospital staff. The former hospital employee's file had a hospital training transcript. The only information provided for the other four CAGs consisted of security certification and permits to carry handguns, one of which was expired. Per the SAP, "(CAG) will be trained in-house to the standard expected and be familiarized with the unique aspects of providing security at a hospital, In addition to their already extensive training, officers will also be introduced to CMS and Joint Commission regulations, sentinel events, environmental issue specific to the healthcare environment, and active threat response options." No evidence of this training was provided despite repeated requests during the survey. No hospital orientation of any kind, nor training as described in the SAP existed, and no CAG job description further outlined or clarified CAG duties. Therefore, the hospital failed to train CAG to expected healthcare standards.

3) A "Security Use of Defensive Force Policy" (UDF) (revised 5/16) stated in part, "Use of Defensive Force: (Hospital Security) b. If a security situation involves a visitor or staff member of (hospital), intervention may be of a law enforcement nature. If a security situation involves a patient, intervention by a Security Officer shall be of a health care nature only, unless and until a situation involving a patient escalates to a point where intervention of a law enforcement nature is reasonably necessary under the circumstances." This meant that the hospital allowed security in part, to determine 1) who was a patient vs. a visitor; and 2) when a situation would become law enforcement in nature despite the fact that security had no law enforcement training or official powers. Additionally, determining who was a patient was out of the scope of security and failed to include individuals on hospital grounds who might have sought medical care.

The policy made a statement under "VI. Definitions iii. "Any rule, regulation, or policy of any agency of the state or any ordinance, resolution, rule, or policy of any country, municipality, or other political subdivision of the state which is in conflict with this Code section shall be null, void, and no force and effect." It is unknown what this paragraph means, or what policy element it defends, but as a hospital policy, the entire UDF policy was subject to State and Federal regulation.

The policy went on to describe a proposed continuum of force which included such elements as, " ...pain compliance or high level stunning techniques ..."
Under X. b. Use of Non-Deadly Force i. An officer in the performance of his/her duty can use non-deadly force: ...when making lawful arrests and searches. This again refers to law enforcement powers which hospital SG do not have.

In summary, the hospital demonstrated a disparity between types of restraint training, which did not consistently meet healthcare standards, cannot consistently be clinically monitored, and did not necessarily seek clinical authorization. Armed Security Guards had been brought on as restraint trainers of security staff, none of whom received hospital restraint training. Armed security guards had not also been oriented to the hospital or trained in healthcare restraint. Further, according to policy, the hospital had an expectation that security could independently identify patients from all others, and independently identify law enforcement situations where no law enforcement powers existed. While there is no evidence that any patients were harmed as a result of these situations or overuse of force, the lack of consistent training and clinician-led restraint practices failed to provide a safe setting for restraint events or other patient-security interactions.
Based on staff interviews and a review of five open and five closed medical records during a complaint survey on 12/18/18, it was determined that the hospital failed to provide the second Important Message from Medicare (IMM) for four of four Medicare recipients (patients 6, 7, 9, and 10). Further, the hospital had no current policy delineating responsibility for providing the second IMM, and had provided no oversight of the process.

According to interviews with two case managers on 12/18/18, the responsiblity for providing the second IMM was given to the finance department several months ago. At that point, Case Management eliminated the second IMM from their policies and eliminated the checklist item for the second IMM from the department's internal quality oversight process. No current policy could be found.

The medical records of four medicare recipients admitted in October 2018 were reviewed. Each of the four had the initial IMM only.
Based on a review of quality assurance and infection control documentation during the survey on December 18, 2018, it was determined that the hospital's QA plan and process did not include reviewing and updating the water management plan.

The water management plan in use by the hospital at the time of the survey was dated 5/31/11. There was no evidence that the plan was reviewed or updated with 2017 recommendations from the Center for Disease Control and Prevention or 2018 recommendations from CMS related to Legionella water testing. In addition, in November, 2018, the hospital identified an outbreak of a bacterial infection that may have had a water source. While subsequent testing failed to identify the water system as the source of the outbreak, there is no evidence that the outbreak spurred the hospital to revise its water management plan.
Based on interview and review of personnel documentation, it was determined that Cardiopulmonary Resuscitation (CPR) training was not a requirement for hospital security or for contracted security who apply physical and/or mechanical restraints.

On 12/18/2018 at approximately 1430, discussion with the Manager of Security/Emergency Management revealed that the hospital did not require CPR for hospital employed and contracted security staff. Review of the scant documentation related to contracted security staff revealed one contracted guard to be a licensed paramedic who would necessarily have CPR certification. However, the hospital failed to mandate CPR certifications for the balance of employed and contracted security staff who would be involved in restraint practices.

See also Tag A-144.