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.

SAINT THOMAS MIDTOWN HOSPITAL 2000 CHURCH ST NASHVILLE, TN 37236 Nov. 25, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, review of facility documentation, medical record review, and interview, the facility failed to ensure 1 patient (#1) was free from abuse of 15 patients reviewed for abuse.

The findings include:

During the investigation it was found 1 patient (#1) was admitted to the Emergency Department (ED) on 10/18/19 with suspected unintentional overdose. The ED physician had placed the patient on a 6-401 hold (prevents the patient from leaving until the need for Emergency Involuntary Commitment can be fully evaluated) until the physician felt the patient was medically stable to be discharged . The ED charge nurse had notified the contracted security officers Patient #1 had been placed on a 6-401 hold. The ED charge nurse told the security officers Patient #1 was not a psychiatric hold, but was waiting for his wife to arrive to take him home. Two security officers entered Patient #1's room and demanded the patient disrobe, put on paper scrubs, and turn all of his personal belongings over to them. The patient did not want to put on paper scrubs or turn over his belongings to the security officers. A security officer took Patient #1's phone, the patient rose from the stretcher and an altercation ensued between the patient and the 2 security officers. At some point during the altercation, Patient #1 briefly lost consciousness. He was eventually hand cuffed. Patient #1 had reddened areas on his wrists, neck, and upper back, as well as edematous (swollen) areas on his scalp. Patient #1 sought follow-up care at another facility and was diagnosed with [DIAGNOSES REDACTED]

During a conference in the facility's board room on 11/25/19 at 3:25 PM with the facility's Chief Operating Officer (COO), Chief Nursing Officer (CNO-telephone), Chief Medical Officer, Quality Manager, Risk Manager, Director of Critical Care and Cardiac Care, Director of Medical Surgical Services, Director of Emergency Department (ED), Security Manager, and Manager of Accreditation and Regulatory Compliance, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at Requirements 482.13 Condition of Participation, Patient Rights.

During a conference in the facility's conference room on 11/25/19 at 5:48 PM with the facility's CNO, Quality Manager, Risk Manager, Director of Critical Care and Cardiac Care, Director of Emergency Department (ED), Security Manager, and Manager of Accreditation and Regulatory Compliance, the facility presented an Immediate Action Plan for the Immediate Jeopardy which included:

1. The current "Psychiatric Emergency" policy was revised to include "...Patients who are placed on a 6-401 hold will be completely undressed and placed in paper scrubs (or gown if paper scrubs are unavailable) unless discernment by MD [Medical Doctor] and RN [Registered Nurse] allows for patient to remain in his/her own clothing. If patient remains in his/her own clothing, this will [be] documented by RN and reported to security team member..."
2. An Situation, Background, Assessment, Recommendation (SBAR) communication tool was developed and shared with the Security Officer Staff and ED staff. The SBAR information included "...A recent ED event involving an ED patient with altered ability to make decisions has prompted a review of the...Abuse and Neglect Policy and ED Psychiatric Emergency Policy. In response to this event it was determined to have all ED and Security staff review both policies...Per current ED Psychiatric Emergency policy, all 640-1 [6-401] patients should be placed in paper scrubs. We have identified the need to allow ED staff to use event specific judgement about when to apply the paper scrubs. At this time, if it is determined NOT to place the patient in paper scrubs, proper documentation should be made in the medical record. All these types of patients are required to have a safety search for weapons or potentially harmful substances...If paper scrubs are NOT applied, RN is responsible for documenting. Nursing or provider will be responsible to discuss the plan of care with security...Discussion/handoff will occur between ED staff, MD [medical doctor] and security when a patient is placed on 640-1 [6-401] or 640-4 [6-404]. This will allow for collaboration in an attempt to avoid behavioral escalation of psychiatric and medical events..."
3. 100% of Security Officers and ED staff were educated on the changes to the "Psychiatric Emergency" policy. Plans were made for all ED staff on medical leave of absence to be educated on the policy changes prior to returning to work.
4. A follow-up meeting was scheduled for 12/2/10.

Review of the Immediate Action Plan revealed immediate actions were implemented by the facility and the Immediate Jeopardy was removed on 11/25/19. The facility remains out of compliance at CFR PART 482.13 Condition of Participation, Patient's Rights.

Refer to:
A-0145
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, review of facility documentation, medical record review, and interview, the facility failed to ensure 1 patient (#1) was free from abuse of 15 patients reviewed for abuse.

The findings include:

Review of the facility policy "Abuse and Neglect of Patients" revised 11/2015, revealed "...All patients have the right to be free from abuse...all Hospital employees have an obligation to protect patients, prevent abuse...Abuse is defined as the willful inflection of injury...intimidation, or punishment, with resulting physical harm, pain, or mental anguish...If an alleged perpetrator is named, the Hospital CEO [Chief Executive Officer], Chief Nursing Officer, or his/her designee should removes [remove] the person from the patient care area unless doing so would compromise the safety of the patient or other patients..."

Review of the facility policy "Psychiatric Emergency" revised 11/2019, revealed "...Until stabilization is determined by the ED [Emergency Department] MD [Medical Doctor], a Request for Immediate Examination for Emergency Admission form (referred to as 6-401) may be completed by the MD to prevent the patient from leaving until the need for Emergency Involuntary Commitment...can be fully evaluated...Patients who are placed on a 6-401 hold will be completely undressed and placed in paper scrubs (or gown if paper scrubs are unavailable) unless discernment by MD and RN [Registered Nurse] allows for patient to remain in his/her own clothing. If patient remains in his/her own clothing, this will documented by RN and reported to security team member. Patient will be searched for weapons or harmful substances. If any of these items are recovered, they will be handed off to security. Clothing and all valuables will be inventoried and secured in an area that the patient does not have access..."

Review of facility documentation at Hospital A dated 10/18/19 at 9:03 PM revealed ED staff notified the security department regarding "...a 6401 [6-401] series patient...was being belligerent and acting aggressively towards staff...needed multiple security members for combative patient..." Further review revealed an altercation occurred between security officers and Patient #1.

Medical record review of a Physician's History and Physical Assessment at Hospital A dated 10/18/19 at 8:54 PM revealed Patient #1 presented to the ED via Emergency Medical Service (EMS) on 10/18/19 because the patient fell asleep at work and was unarousable. Continued review revealed Patient #1 had taken night time cold medicine in addition to a prescribed pain medication before reporting to work. Further review revealed the patient refused any nursing interventions and blood draws and wanted to leave the ED. Continued review revealed "...because of his [Patient #1's] altered mental status...felt that he was at risk to inadvertently harm himself or others...extremely combative with staff...resisting changing out of his clothes for treatment..."

Medical record review of a Nurse's Note at Hospital A dated 10/18/19 at 9:10 PM revealed "...security at bedside to assist with 6401...PT [patient] uncooperative sts [states] 'I'm not taking my clothes off because I haven't done anything wrong'..."

Medical record review of a Physician's Note at Hospital A dated 10/18/19 at 9:13 PM revealed "...patient became extremely combative with staff...resisting changing out of his clothes for treatment...calmed down with police intervention..."

Medical record review of a Physician's Note at Hospital A dated 10/18/19 at 10:12 PM revealed "...patient became extremely agitated...required restraint..."

Medical record review of a Physician's Note at Hospital A dated 10/18/19 at 10:39 PM revealed the patient complained of right shoulder pain. Further review revealed "...recommended that we evaluate his shoulder and his neck further as [a result] of the physical altercation...he [Patient #1] declined...wanted to go to his own hospital [Hospital B] and be evaluated..." Continued review revealed the patient was discharged home.

Medical record review of an ED Physician's History and Physical assessment from Hospital B revealed Patient #1 (MDS) dated [DATE] at 2:09 AM with complaint of right arm pain, right shoulder pain, and headache. Further review revealed the patient reported he was held down on the floor/mattress (at Hospital A) with the security guard leaning into the right side of his neck, with his right upper extremity twisted behind his back. Continued review revealed Patient #1 complained of wrist abrasions from handcuffs and bruising/abrasion on scalp and back.

Medical record review of a Computerized Tomography (CT) of the Head without Contrast report at Hospital B dated 10/19/19 at 3:04 AM revealed "...subcoritcal hypodensity [area that is less dense than normal]...along the right frontal lobe is noted...MRI [Magnetic Resonance Imaging] is recommended for further evaluation to evaluate for parenchymal contusion [bruise of brain tissue]..." Further review revealed the Patient #1 was transferred to Hospital C on 10/19/19 for a MRI.

Medical record review of a Physician's History and Physical assessment at Hospital C dated 10/19/19 at 9:30 AM revealed "...Pt says the hospital security guards beat him [at Hospital A]...unsure of what was used to hit him...hit in the head at some point with metal handcuffs...denies neurologic complaints other than a minor headache..." Continued review revealed [DIAGNOSES REDACTED]tous (red) marks on the patient's neck.

Medical record review of a MRI report at Hospital C dated 10/19/19 at 11:09 AM revealed the patient had no abnormalities.

Medical record review of a Physician's Discharge Note dated 10/19/19 at 12:03 PM revealed the patient was diagnosed with [DIAGNOSES REDACTED]"

Interview with the ED Director at Hospital A on 11/5/19 at 8:30 AM, in the conference room, confirmed an altercation occurred between the security officers and Patient #1.

Telephone interview with the ED Charge Nurse #1 at Hospital A on 11/5/19 at 7:30 PM confirmed she witnessed the altercation between Security Officer #1, Security Officer #2, and Patient #1. Further interview revealed the security officers were told to stop, but the altercation with the patient continued. Continued interview revealed Patient #1 had lacerations on his forehead, right neck, right elbow, bruising on both wrists, and the patient's right shoulder was swollen.

Telephone interview with Security Officer #1 at Hospital A on 11/5/19 at 7:45 PM confirmed he and Security Officer #2 reported to the ED related to an aggressive patient. Further interview revealed Security Officer #2 wanted to put Patient #1 in paper scrubs even though the staff had told the officers the patient was only a medical hold and not a psychiatric hold. Continued interview revealed an altercation ensued when Patient #1 refused to put on the paper scrubs and Security Officer #2 took the patient's cellphone away from the patient. Further interview revealed Patient #1 lost consciousness for approximately 5 seconds "...because of the way I was holding him..." Continued interview revealed Security Officer #2 struck Patient #1 several times on the patient's right side and kicked the patient a couple of times.

Interview with the Security Manager at Hospital A on 11/6/19 at 11:15 AM, in the conference room, confirmed he was aware of the altercation between the security officers and Patient #1.

Interview with the ED Director, Security Manager, and Quality Manager at Hospital A on 11/6/19 at 11:35 AM, in the conference room, confirmed an altercation occurred between the security officers and Patient #1 on 10/18/19, resulting in injuries to Patient #1.