HospitalInspections.org

Based on the document review and interview, the hospital failed to:

1. protect, intervene, and report immediately the physical harm and abuse inflicted on Patient #8 by non-hospital personnel.

2. have a policy or process to administer Midazolam (Versed-a benzodiazepine medication commonly used for sedation and anesthesia) and Droperidol (an antiemitic and amnesia medication with a black box warning for cardiac risks) off label (using a drug for a purpose not specifically approved by the FDA) for the use of a psychiatric behavioral medication emergency in in 2 (Patient #8, #6) of 2 patient medical records reviewed.

The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to Tag A0144

3. ensure nursing de-escalated, assessed, and reassessed 2 (Patient #4 and #5) of 2 patients after the administration of a chemical restraint.

4. ensure that only a physician ordered a chemical restraint/emergency behavioral medication as required by the Texas Administration Code, Title 26 Rule 320.119(b), and follow the hospital policy titled, "Standardized Use of Restraint and/or Seclusion" in 2 (Patient #4 and #5) of 2 medical records reviewed.

5. ensure a physician or trained Registered Nurse (RN) performed a face-to-face evaluation within 1 hour of the administration of the chemical restraint/emergency behavioral medication in 2 (Patient #4 and #5) of 2 patient medical records reviewed.

Refer to Tag A0160

Based on review and interviews, the governing body (GB) failed to ensure that an adverse patient safety event was fully investigated, and preventive actions recommended were measured, analyzed, and tracked in 1 (Patient #8) of 1 patient reviewed.

Refer to Tag A0286

Based on the document review and staff interview, the hospital failed to:

1. ensure Patient #8's right to receive care in a safe setting. The hospital failed to protect Patient #8 from physical harm and abuse by non-hospital personnel, failed to intervene during the incident, and failed to report the abuse immediately.

2. have a policy or process to administer Midazolam (Versed-a benzodiazepine medication commonly used for sedation and anesthesia) and Droperidol (an antiemetic and amnesia medication with a black box warning for cardiac risks) off label (using a drug for a purpose not specifically approved by the FDA) for the use of a psychiatric behavioral emergency in 2 (Patient #8, #6) of 2 patient charts reviewed.


The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings:

Patient #8 was transported to the hospital by EMS and escorted by Bowie County Sheriff Officers (BCSO) for medical care on 5/16/2025 after a suicide attempt. A review of the hospital's self-reported incident revealed that Patient #8 was physically abused by the BCSO and Emergency Medical Services (EMS) Personnel while in the care of the hospital.


Patient #8

A review of the medical record for Patient #8 was completed in the administrative conference room on 7/21/2025-7/23/2025 with Risk Manager (RM) Staff #9 and Staff #11 Registered Nurse (RN) navigator. The navigator assists the surveyor in navigating through the medical record.

Patient #8 was a 21-year-old male who presented to the Emergency Room (ER) on May 16, 2025. He was transported to the hospital by EMS after an alleged suicide attempt. He was escorted by 2 Bowie County Sheriff Officers (BCSO). Upon arrival, Patient #8 was noted to be handcuffed with his arms behind his back due to aggressive behavior.

A review of the Triage Nurse note documented by RN Staff #5 dated 5/16/2025 at 10:10 PM revealed that Patient #8 was, "Pt BIBA (brought in by ambulance) with BCSO at the side. C/O (complains of) ingestion of approximately 100 ibuprofen (per pt), suicidal, delirium, and aggressive behavior. Pt is handcuffed behind the back and on an EMS cot upon ED arrival. Pt is continuously yelling/screaming profanities and threatening EMS personnel and BCSO. Unable to obtain much information from pt due to aggression and belligerent outbursts. EMS reports pt has been spitting, kicking, biting, and cursing continuously, all in route and upon ED arrival. EMS reports they were called by pt mother due to pt acting delirious and threatening suicide; pt has a small abrasion to the left FA, no bleeding noted, wound is open to air. Unable to obtain full orientation status because the patient will not calm down enough to answer questions. Pt appears to be oriented to self, but unsure about other orientation status due to not being able to get answers from pt. EMS personnel and BCSO at side until pt is more calm. Physician #16 aware of pt upon ED arrival"

Patient #8 was taken to ER Room #1 by EMS and BCSO upon arrival at 10:10 PM.


A review of Physician #16's orders dated 5/16/2025 at 10:13 PM revealed Patient #8 was ordered the following medication.

Versed 5mg injection STAT (a sedative primarily used as a moderate sedation before surgery or during a procedure. This drug may cause amnesia and requires monitoring. Adverse effects: variations in blood pressure and heart rate, impaired balance and gait, sedation, respiratory depression, and retrograde amnesia. Adverse effects may be potentiated by other medications, like analgesics.) There was no indication for use. The medication administration record (MAR) stated RN Staff #5 administered the medication intramuscularly to the left anterior thigh at 10:17 PM.

Droperidol 5mg Injection STAT (an antiemetic medication used to reduce nausea and vomiting and as an amnesia agent before surgery or diagnostic procedures. It does have a black box warning for cardiac risks). There was no justification for use documented on the medication order. The MAR stated the nurse administered the medication IM to the right anterior thigh at 10:20 PM.

A review of Physician #16's note dated 5/16/2025 at 10:22 PM was as follows:

"21-year-old male (Patient #8) presents to the Emergency Department with a suicide attempt, taking 100 pills of Ibuprofen. He is escorted by EMS and police department and has been combative with first responders and arrives handcuffed, screaming at staff. The police department did not report any obvious evidence of an overdose.

Additionally, EMS reports they did not note any significant trauma. The initial call was made by the family in relation to the suicide attempt. Patient was able to be verbally de-escalated during transport, but became combative upon arriving at the ER ...He is in acute distress ...Bruising to the left face with 1 1-centimeter laceration to the left upper lip ...Tachycardia (fast heart rate) ...agitated, aggressive, hyperactive, combative ..."

Medical Decision Making

Differential diagnosis includes agitated delirium, sympathomimetic abuse, metabolic acidosis secondary to NSAID overdose, and intracranial hemorrhage. This is a 21-year-old male who arrives combative with staff and PD. In order to facilitate care after verbal de-escalation had failed medications for acute agitation were administered, including 5 mg of Versed and 5 mg of Droperidol. After this had been given but before it had taken effect patient bit his lip, which began to bleed rather profusely, compromising his airway with frequent coughing and gagging. At this time, a decision was made to intubate the patient to protect his airway and for further behavioral control. While the equipment is being prepared the medications did take effect and patient became very somnolent as expected. For this reason, sedation was avoided for RSI and simply used additional paralytics. Patient's ingestion was greater than 1 hour prior to arrival per report, no indication for activated charcoal or gastric lavage, and none was recommended by poison control, see discussion in ED workup tab. The ED workup documented on 5/16/2025 at 10:15 PM revealed Physician #16 spoke to poison control, and it was recommended to administer IV fluids and monitor for GI upset. Stated that in very high overdoses can lead to metabolic acidosis. Benzodiazepines to be administered for seizures, if any occur. Recommended 4-6 hours of observation. Case #76020695. After intubation patient has had some hypotension, which presumably will correct with sufficient IV hydration given the amount of his base deficit. He was given 2 Amps of bicarb for the short-term in the ER. Midazolam and fentanyl were preferred for PO sedation medications, anticipating that the patient will be positive for methamphetamines and unable to rule out methamphetamine overdose as the true origin of the patient's symptoms given his agitation on arrival ..." There were no documented indications that patient #8 would be positive for Methamphetamines.


A review of the documentation by RN Staff #5 on 5/16/2025 was as follows:

"10:15 PM revealed Patient #8 was handcuffed due to physical/violent aggression towards EMS and BCSO. Patient is also having to be physically held down by EMS personnel and BCSO due to kicking even while being restrained in handcuffs. Respirations 23. Physically and verbally aggressive, exaggerated, and overly dramatic. Impaired judgement with moderate confusion. Violent restraint and physical hold by BCSO and EMS personnel.

10:17 PM Patient is verbally and physically aggressive. Expressing feelings of threats. Versed 5mg IM administered to the left anterior thigh. Patient is no longer restrained due to the discontinuation of physical hold. Respirations 22. Impaired judgement with moderate confusion.

10:22 PM Behavioral Health Emergency. Physically and verbally aggressive. Droperidol 5mg IM was administered to the right anterior thigh. Patient is no longer being restrained due to discontinuation of physical hold. Respirations 21.

10:27 PM Behavioral Health Emergency. Pt is verbally and physically aggressive. Expressing feelings of threats. Physical hold discontinued-no longer meets criteria.

10:32 PM Behavioral Health Emergency. Pt is verbally and physically aggressive. Expressing feelings of threats. Pt is no longer being physically restrained due to discontinuation of the order.

10:40 PM Due to patient's extremely aggressive behavior, unable to obtain a full set of vital signs at this time. Vital signs-Temperature 98 F, Pulse 134 (normal rate 60-100), Respirations 22 (normal rate 16-20), Oxygen level 98%, Blood Pressure 157/61 (normal level 120/80) ..."

An interview was conducted with RN Staff #11 on 7/22/2025 after 11:30 AM. RN Staff #11 was asked what time the handcuffs were removed from Patient #8. RN Staff #11 stated, "On the restraint monitoring record, it shows that the restraint was released at 10:17 PM." RN Staff #11 was asked if that release was for the handcuffs or the physical hold. RN Staff #11 stated, "It must be for the hold because there is no documentation when the cuffs were released". RN Staff #11 was asked if there was any documentation that Patient #8 reportedly "bit his lip" other than the physician note. RN Staff #11 confirmed that Physician #16 was the only caregiver who documented that the patient bit his lip. There was no documentation by the nursing staff on when or if patient #8 had bitten his lip. RN Staff #11 was asked if the BCSO or the EMS personnel had hit the patient in the face and caused the 1-centimeter laceration. Staff #11 confirmed the nursing staff failed to document how or when the laceration to the cheek occurred and did not document that the patient was assaulted by EMS personnel and BCSO.


An interview with RN Staff #5 was conducted on 7/23/25 at 8:15PM. the nurse stated that when the decision was made to intubate, the physician and NP came into the patient's room and asked "what happened here? _____ (Staff #4) stated I don't know." Staff #5 did not report the incident to the physician. Staff #5 reported MD was focused on trying to protect the airway due to patient being held down and medications impairing the patient's airway.

RN Staff #5 confirmed that the BCSO and EMS were holding patient #8's legs and shoulders down to the bed while he was handcuffed. Staff #5 stated the patient was held when he came in, while he was receiving medications and afterwards until the patient was intubated. However, on 5/16/25 at 10:17pm staff #5 documented, "Patient is no longer restrained due to the discontinuation of physical hold." Staff #5 was asked why the nurses and ER staff did not apply physical restraints for the safety of the patient? Staff #5 stated "like what? Soft restraints? The surveyor stated, "any type you have in the ER to ensure the patient was safely restrained to prevent harm, soft restraints, leathers. Whatever you had." Staff #5 stated, "no. we didn't." Staff #5 confirmed the EMS personnel tried to put a mask on the patient because he was spitting but it kept coming off."




Further review of the medical record revealed RN Staff #4 started an intravenous line, and blood was collected to send to the lab for further testing. On 5/16/2025 at 10:40 PM, Patient #8 was intubated (an endotracheal tube was placed into the patient's airway to assist with breathing) with a Glidescope (a video camera used to assist with placing the endotracheal tube) by Physician #16 placed on a ventilator. A review of the Intubation note dated 5/16/2025 at 11:58 PM by Physician #16 revealed the procedure was performed in an emergent situation. Rocuronium (a fast acting paralytic medication used to intubate a patient) was administered at 10:39 PM for the intubation.

A review of the procedure note documented 5/17/2025 at 12:15 AM by Nurse Practitioner (NP) #19 revealed that a 2-centimeter laceration to the left cheek was repaired with sutures, and no complications were noted. The NP did not document on the cause of the laceration.

A review of the ER course documented by Physician #16 on 5/16/2025 at 11:32 PM revealed Patient #8 was in Metabolic Acidosis, secondary to the Ibuprofen overdose. Metabolic Acidosis is when there is too much acid in the blood, and this can be caused by an overdose of non-steroidal anti-inflammatory drugs (NSAID). Ibuprofen is an NSAID. According to the National Center for Biotechnology Information (NCBI), Ibuprofen toxicity can result in tachycardia (fast heart rate) and hypotension (low blood pressure). Symptoms include confusion, agitation, and nausea/vomiting. Patient #8's lab results revealed there was no Methamphetamines present.

Review of Patient #8's vital signs revealed that at 10:48 PM his heart rate was 139 and his blood pressure was 109/37, at 11:03 PM his heart rate was 137 and his blood pressure was 110/31, at 11:18 PM his heart rate was 145 and blood pressure was 119/33, at 11:30 PM his heart rate was 117 and blood pressure was 108/34. The patient was administered multiple doses of sodium bicarbonate (a medication used to treat metabolic acidosis) and placed on a Levophed (a medication to treat life-threatening low blood pressure) drip to control his hypotension.

A review of the NP's history and physical documented on 5/17/2025 at 12:45 AM revealed Patient #8 was admitted to the Intensive Care Unit on 5/17/2025 with profound Metabolic Acidosis, intentional ibuprofen overdose, Altered Mental Status, Acute Respiratory failure, intubated and sedated. The physical exam revealed the patient had swelling to his left jaw, laceration to the left forearm, laceration to the right hand, lacerations x 3 to the left hand, and scratches tracking down the right arm. On 5/17/2025 at 11:57 AM, the Nurse Practitioner in the ICU ordered a CT scan of the Head/Brain for an Altered Mental Status that resulted in no acute intracranial hemorrhage or skull fractures. And a non-specific finding of left periorbital soft tissue swelling. A CT Maxillofacial for facial bruising was ordered on 5/17/2025 at 12:00 PM by the NP in the ICU. The CT resulted in Nasal, left periorbital, and left facial soft tissue swelling. No acute facial fractures, globe rupture, lens dislocation, or retrobulbar hemorrhage.

During an interview on 7/23/2025, after 2:30 PM with RN Staff #11, it was confirmed that the only injuries documented by the ER nurses were the left forearm when he arrived in the ER.

A review of the hospital's Event Record #14201 was completed on 7/21/2025 with RM Staff #9 after 10:00 AM. The event record included two written statements by RN Staff #4 and RN Staff #5. The statements were as follows:

Reported by RN Staff #4 on 5/17/2025 6:47 AM:

"Upon entering the room, EMS and Law Enforcement personnel were physically restraining the patient. His behavior was violent. He was making verbal threats to rape, kill, and haunt staff. During this time, the patient was handcuffed behind the back and being physically restrained to the bed. He attempted to kick the medic that was holding down his left arm. After this attempt, the medic punched him several times on the left side of his face. While this nurse was attempting to secure an IV for sedation, the patient continued to fight EMS and Law Enforcement. The same medic asked me twice if there were cameras in the room. He asked the officer across from him who was holding down the patients left leg if his body camera was on, and if so, would he turn it off. The officer complied and turned off his body camera. The medic began again punching the patient on the left side of his face and grabbing him forcefully by the jaw. I secured the IV and walked out of the room. I returned to the room shortly after when BLS crew informed me they were suctioning blood from his mouth as he was coughing and gagging. I notified the provider who determined at that point we would need to secure the patients airway with intubation."

Reported by RN Staff #5 on 5/17/2025 6:47 AM.

"Entering the ED room 1 with (RN Staff #4); I observed the patient on EMS cot. Medic, EMT,
BLS crew, and 2 BCSO officers are surrounding patient on cot, speaking with him. Patient is handcuffed behind the back due to physical aggression (assaulting first responder staff) and threats towards EMS personnel and BCSO officers. Patient is moved from EMS cot to ED stretcher, still handcuffed behind his back. Patient continues to yell/curse/scream/threaten EMS personnel as well as BCSO officers, saying things like, "I'm going to f****** kill you! I'm going to haunt you in your mother f****** dreams! You're all sad!" Even after multiple attempts at verbal redirection from EMS personnel, BCSO officers, and hospital staff, patient is still extremely aggressive verbally and physically which he is a threat to his own safety and everyone around him. As I am trying to get report from the medic, I am at the top of the bed near the patient's head. While the medic is attempting to give me report, the patient continues to say profanity and curse at the medic. I informed the medic, "hey, I'm not really able to hear you, can we step over there (talking about away from the patient) so I can maybe hear you better?" Patient continues to shout profanity at medic, medic then pushes his hand onto patient left side of face, pushing his head into the ED stretcher; patient is still handcuffed behind his back. Other staff (EMS personnel and BCSO) are still physically restraining patient due to severity of aggression at this time. Patient continues to say profanity and curse which at this time the medic started to hit patient on left side of his face; unknown amount of times patient was hit, but at least 2-3 times if not more. Patient was continuing to shout profanity and continuing to be physically aggressive (kicking, spitting, biting) and still being physically restrained. I was able to administer IM droperidol to patient's right thigh. At some point after administering the medication, maybe 1-2min after, the patient was trying to continue to move around out of bed, the shorter BCSO hit the patient at least 2-3 times in the left side rib area. At this point in time, myself and (RN Staff #4), left out of ED room to notify (Physician #16) of medications being administered and what is our next step, to which he informs me, "let's give the meds approx. 10-15min and then if he is still very agitated, we will intubate him for his safety and ours." I went to go inform EMS personnel and BCSO of this information given by (Physician #16). Upon entering the room again, one of the EMS people are suctioning blood out of the patients mouth as well as small amount of blood on ED stretcher next to patient's mouth. I then went to inform (Physician #16) of this information, and he determined it was time to intubate."

An interview was conducted with RN Staff # 5 on 7/23/25 at 8:15 PM. Staff #5 stated that she came back into the patient room and saw the EMT suctioning the patient's mouth, but it was a little bit of saliva that was blood-tinged." There was no found documentation in the patient's chart of coughing or gagging.

The document revealed that the Administrator on call, Staff #3, was notified on 5/17/2025 at approximately 7:00 AM. Staff #3 notified the Chief Executive Officer (CEO) and CNO approximately 9:45 AM on 5/17/2025 and advised the staff that an investigation was in process. Staff #3 notified the RM, Staff #9, at approximately 9:45 AM on 5/17/2025.

An interview was conducted with Chief Nursing Officer (CNO) Staff #2 and Risk Manager (RM) Staff #9 on 7/22/2025 at 10:35 AM. Staff #9 confirmed that an incident report was completed by RN Staff #4 and RN Staff #5 on 5/17/2025 at 6:47 AM. Staff #2 stated that he contacted the BCSO and the LifeNet EMS as soon as he was made aware of the incident. Staff #2 stated that the EMS personnel were placed on administrative leave, and the BCSO contacted the Texas Rangers, who were conducting an internal investigation into the incident. Staff #2 confirmed that there was no documentation of the date and time of the conversations or who he spoke with. Staff #2 was asked if the nurses who cared for Patient #8 reported the incident to anyone. Staff #2 replied, "The charge nurse, RN Staff #10, was notified, and the incident was reported to the house supervisor at that time, who reported the incident to the administrative team". A review of the House Supervisor reports dated 5/16/2025 and 5/17/2025 did not reveal any information regarding the incident that occurred with Patient #8 during the 7:00 PM-7:00 AM shift on 5/16/2025. Staff #2 and RM Staff #9 were asked if Physician #16 was aware that Patient #8 had been physically abused by BCSO and EMS Personnel. Staff #2 could not confirm nor deny whether Physician #16 was aware of the physical abuse.

An interview was conducted with RN Staff #11 on 7/23/2025 after 11:00 AM. RN Staff #11 was asked if Patient #8 had a laceration to his face when he arrived with EMS. RN Staff #11 confirmed that the only wound that was documented on arrival was the one on his left forearm. RN Staff #11 was asked if talked with RN Staff #4 and #5 after the incident occurred. Staff #11 confirmed she had a conversation with the two RN's. RN Staff #11 was asked if the nursing staff had notified the physician that the BCSO and the EMS had physically abused the patient. RN Staff #11 confirmed there was no documentation in the medical record that the physician was notified. RN Staff #11 stated that during the time of the restraint that the nursing staff felt uncomfortable about being next to the BCSO and the EMS personnel, so they documented the restraint on paper and stayed at the foot of the bed. Staff #11 was asked if RN Staff #4 or #5 called anyone for help at the time of the incident. Staff #11 confirmed Patient #8 was not under arrest but remained handcuffed for restraint purposes due to his aggression after care was turned over to hospital staff. Staff #11 confirmed that security was not notified of the aggressive patient, and a code BERT (Behavioral Emergency Response Team) was not called. Code BERT is a team that is available 24/7 to respond to behavioral emergencies in which patients, families, or visitors require a coordinated response to diffuse a crisis situation. Staff #11 stated that the ER Department provided training on 5/29/2025 at the ER monthly staff meeting on what to do if staff were to witness a patient being abused by EMS or law enforcement. Staff #11 confirmed that staff were instructed to call 911 and give detailed information to the dispatcher. Staff #11 also stated that the same topic was discussed in the ER Huddle meeting dated 5/18/2025.


RM Staff #9 confirmed that Quality Director, Staff #12, completed a self-report to the Texas Health and Human Services on 5/23/2025. This was 7 days after the incident occurred. Staff #12 reported the incident to DSHS regarding the patient abuse by EMS personnel on 5/26/2025. This was 10 days after the incident occurred.

An interview was conducted with Assistant Chief Nursing Officer (ACNO) Staff #8 on July 23, 2025, after 2:00 PM. Staff #8 confirmed Patient#8 was not on the restraint log for the chemical restraint dated 5/16/2025.


An interview was conducted with RN Staff # 5 on 7/23/25 at 8:15 PM. Staff #5 had stated that she observed the EMT push the patient's face "hard" to the side when the patient was cursing and spitting. Staff # 5 reported that she observed the BCSO take his elbow and hit the patient 3 times in the left side. "I put my arms and hands up like whoa... wait" and decided to go get some meds. Staff #5 stated that she did not see the EMS personnel hit the patient in the face because she was out of the room getting medications but in her written statement she stated, "Patient continues to say profanity and curse which at this time the medic started to hit patient on left side of his face; unknown amount of times patient was hit, but at least 2-3 times if not more."

RN Staff #5 was asked why both nurses left the patient unattended with their abusers. Staff #5 stated, "I left to go get medications, and ____(RN Staff #4) was still in the room with the patient." In staff #5's written statement, she stated "both," meaning herself and RN Staff #4 left the patient alone with the EMT and officers after they had physically abused the patient.

RN Staff # 5 was asked why she or RN Staff #4 did not try to get help or ask the officer and EMT to leave the room. Staff #5 reported the ER was really busy, and so much was going on. She stated they did not have enough staff that night with all the "fires" going on, and she had to go intubate another patient right after intubating patient #8.

The surveyor requested an interview with RN Staff #4 on the morning of 7/23/25. CMO Staff #17 stated that she would get in touch with RN Staff #4 and #5 and let the surveyor know. In the afternoon hours, CMO Staff #17 stated that both nurses had refused to interview with the surveyor. At approximately 7:30 PM, CMO Staff #17 arrived at the lobby of the hotel where the surveyors were staying. Staff #17 stated that RN Staff #5 was working at the ER tonight and had changed her mind and wanted to speak with the surveyors. Staff #17 stated RN Staff #4 continues to refuse to talk with the surveyors.

An interview was conducted with CNO Staff #2 and RM Staff #9 on 7/23/2025 after 10:00 AM. CNO Staff #2 confirmed that the nurses acted appropriately, and RM Staff #9 stated the nurses did a great job. CNO Staff #2 confirmed there was further education in the ER on how to respond when they witness police officers or EMS personnel abusing patients.


A telephone interview was conducted with Physician #16 and CMO #17 on 8/7/2025 at 10:10 AM. Physician #16 was asked what he remembered about Patient #8. Physician #16 stated, "I remember EMS rolled the patient in on a stretcher in the hallway, and he was screaming and yelling, and EMS was having to tighten the straps on the cot. I did a quick exam at the foot of the bed and realized I was going to have to order some medications to calm him down before I could do a full exam, so I went to the desk to get the orders put in. At that time, they moved the patient into Room #1, which is one of our larger rooms. Then the nurse came and got me, telling me that the patient was bleeding, and she was worried about his airway. I went into the room and noticed that the police department was having trouble restraining him, and he had some swelling on his face, and he was bleeding and gagging on the blood, so I decided to intubate him to protect his airway". Physician #16 was asked if he knew why the patient was bleeding. He confirmed that none of the staff informed him of what happened to the patient's lip. He was asked if he was told that the patient was hit in the face by EMS and BCSO? Physician #16 stated that no staff witnessed the patient being hit by the EMS or BCSO. Physician #16 was asked why he thought that the patient was using methamphetamines. He confirmed there was no reported drug abuse, but the patient's actions and behaviors would make you think that. Physician #16 was asked if anyone from the Risk Department or anyone investigating these allegations of abuse ever talked to him regarding this patient. Physician #16 said, "This is probably the most formal discussion that I have had regarding this patient." Physician #16 stated there was enough staff, but we used the police department and EMS to help restrain the patient.


Patient #6

Patient #6 was a 75-year-old male who was transported to the ER on 6/23/2025 at 7:35 AM due to an altered mental status. A review of the triage notes by the RN revealed that the patient assaulted several staff members at his long-term care facility, including the ambulance crew.

A review of Physician #21's Physical Exam revealed Patient #6 had edema with chronic skin changes on bilateral lower extremities, was uncooperative, and agitated.


Medical Decision-Making Note dated revealed the patient was brought to the hospital by the police department after he was located a block away from the nursing home in his motorized wheelchair. He was uncooperative and refused to answer any questions. The patient believed we were asking questions to get money from him, and also believes the year is 2005. He refused ECG monitoring and medical workup despite being altered. He complied with the pulse oximetry and was found to be hypoxic (low oxygen level) and would not keep his nasal cannula on. He was given Droperidol and Versed so that he could be medically evaluated and treated, as he has had this type of behavior before. He removed his IV catheter and attempted to get out of bed to leave, even though he is non-ambulatory at baseline and refused a replacement IV.

A review of Physician #16's orders was as follows:

"6/23/2025 at 10:11 AM: Droperidol 5mg IM Once. The MAR revealed the medication was administered by RN #28 on 6/23/2025 at 10:54 AM.

6/23/2025 at 10:11 AM: Midazolam (Versed) 5mg IM Once. The MAR revealed the medication was administered by RN #28 on 6/23/2025 at 10:54 AM."

Physician #27 wrote an order on 6/23/2025 at 10:47 AM that read, "Patient may be physically constrained to facilitate medication administration for his safety."


A review of RN Staff #28's note dated 6/23/2025 at 10:20 AM was as follows:

"Medications ordered to be given due to patient experiencing delirium and potential encephalopathy".

An interview was conducted with RM Staff #9 on 7/23/2025 after 9:00 AM. RM Staff #9 was asked if physicians were required to document the justification for use when a restraint was ordered. RM Staff #9 confirmed there was no documentation for the justification of the Versed or Droperidol. RM Staff #9 was asked why these medications were administered to Patient #6. RM Staff #9 confirmed that the medications were administered as a behavior modification so that the patient could be treated medically. RM Staff #9 was asked if the Versed and Droperidol were administered as a restraint. RM Staff #9 confirmed there was no restraint documentation in the medical record, but the medications were administered for a behavioral emergency.

A review of the discharge data documented on 6/23/2025 at 3:04 PM was as follows:

"Patient #6 is a 75-year-old male admitted on 6/23/2025 with a past medical history of Chronic Obstructive Pulmonary Disorder, venous insufficiency, depression, heavy alcohol use, who presented with altered mental status, aggressive behavior, and hypoxia. CT of the head showed chronic changes without acute findings. Workup revealed a Urinary Tract Infection with pyuria. Required chemical sedation (droperidol, midazolam) for agitation ..."


An interview was conducted with Pharmacy Manager, Staff #13, on 7/23/2025 after 3:00 PM. Staff #13 was asked if the pharmacy was aware that Droperidol and Versed were being used for chemical restraints/emergency behavioral medications. Staff #13 confirmed the pharmacy was not aware that the medications were being used for chemical restraints.

An interview was conducted with the Chief Medical Officer (CMO), Staff #17, on 7/23/2025 after 3:00 PM. Staff #17 confirmed the hospital did not have a policy or process Droperidol and Versed to be administered to patients during a behavioral health emergency.



A review of the hospital policy titled, "Standardized Use of Restraint and/or Seclusion" Number: 3.080 with a revised date of 2/25 was as follows:

" ...Ill. OBJECTIVE: This policy standardizes the indications and methods for restraint and/or seclusion.

IV. POLICY STATEMENT:
CHRISTUS Health, in compliance with ethical, regulatory, and patient-focused considerations, supports the right of a patient to be free from restraints and seclusion through the promotion of safety, dignity and alternatives to the use of restraint and/or seclusion whenever possible, with the goal of being restraint/ seclusion-free.



B. Restraint Orders:

Elements of ALL Restraint/Seclusion Orders
*Orders for restraints and/or seclusion are not written as standing or PRN orders
*The restraint order includes the justification for the use of restraint and/or seclusion, the type of restraint, time limit of restraint, and specifies the limb(s) where the restraints are to be applied.
*The LP* responsible for the care of the patient, places the order for the restraint or seclusion immediately prior to the application of the device.

*TX - Physician member of m

Based on document review and interview, the hospital failed to:

1. ensure nursing de-escalated, assessed, and reassessed 2 (Patient #4 and #5) of 2 patients after the administration of a chemical restraint.

2. ensure that only a physician ordered a chemical restraint/emergency behavioral medication as required by the Texas Administration Code, Title 26 Rule 320.119(b) that states (b) only a physician member of the facility's medical staff may order restraint or seclusion. Also, the hospital failed to follow the hospital policy titled, "Standardized Use of Restraint and/or Seclusion" in 2 (Patient #4 and #5) of 2 medical records reviewed.

3. ensure a physician or trained Registered Nurse (RN) performed a face-to-face evaluation within 1 hour of the administration of the chemical restraint/emergency behavioral medication in 2 (Patient #4and #5) of 2 patient medical records reviewed.


Findings:


Patient #4
A review of the medical record was completed with Risk Manager (RM) Staff #9 on 7/23/2025 after 10:00 AM.
Patient #4 was a 64-year-old male who was brought to the Emergency Room (ER) by the police department on 7/16/2025 at 10:14 AM. Patient #4 had an order from the county judge for emergency apprehension and detention dated 7/15/2025. Patient #4 had a history of Schizophrenia and was taken into custody for erratic behavior in public.

Patient #4 was on every (q) 15-minute checks with a sitter.

A review of the medication orders revealed that Physician #27 wrote an order on 7/16/2025 at 1:32 PM for Geodon (an antipsychotic) 20 mg intramuscular (IM) and Ativan (an antianxiety medication that can cause sedation) for Psychosis. The Registered Nurse (RN) administered the medication on 7/16/2025 at 1:56 PM.

A review of the nurse's note dated 7/16/2025 at 2:00 PM was as follows:
"Received medication orders for patients' restlessness. Prepared medications. Called security. Once one security officer arrived, I asked the patient if he would be willing to take the medications by injection. Pt got upset and kept repeating "no!" Security called more officers to the room. I asked Physician #27 for permission for a pt hold to administer the medications, got approval. Once more officers arrived, and I asked the patient again if he would take the injections. Security was able to get the patient to get onto a stretcher, and the patient took medications without incident".

RM Staff #9 confirmed there was no documentation that the nurse made other attempts to de-escalate the patient before administering a chemical restraint.

A review of the medication orders revealed that Physician #29 wrote an order on 7/17/2025 at 6:04 AM for Geodon 20mg IM for Psychosis. The RN administered the medication on 7/17/2025 at 6:22 PM.
In an interview on 7/24/2025 after 9:00 AM, RN Staff #11 confirmed there was no documentation in the medical record regarding a behavioral emergency or why Patient #4 received the IM antipsychotic medication.

A review of the nurse's note dated 7/17/2025 at 11:58 AM was as follows:
"Patient is currently being verbally loud. Went into the patient's room to introduce myself & the patient yelled, get me out of here now. Notified (unknown staff's name) to order something for the patient to calm him down. On 7/17/2025 at 1:20 PM, Security called to bedside. Attempted to give pt's Droperidol IM & pt yelled "No, get away from me. I don't want to be poked with another needle. Will continue to monitor the patient & let him calm down.

Further review of the medical record revealed that Physician #29 ordered Droperidol 5mg IM and Versed 5mg IM on 7/17/2025 at 12:31 PM for agitation per hospital policy. The RN administered Versed 2mg IM on 7/17/2025 at 12:40 PM. This was 3mg less than what Physician #29 ordered. The nurse administered Droperidol 5mg IM on 7/17/2025 at 2:44 PM. This was greater than 2 hours after the order was written for a behavioral emergency.
During an interview on 7/24/2025, after 9:00 AM, RN Staff #11 confirmed the RN did not administer the correct dose of Versed. Staff #11 confirmed there was no documentation in the medical record that the order was cancelled, changed, or a new order was written for the 2mg Versed administered.

A review of the nurse's note dated 7/18/2025 was as follows:
"1:53 AM-Pt has started to stand in the doorway, screaming and yelling. Unable to understand what the patient is yelling. Pt is pointing at the nurses and security while yelling. Charge nurse, NP #19, and House supervisor notified. House Supervisor in ER during scene.
1:59 AM-TTPD (Police Department) at doorway talking to pt. Pt in bed at this time".
2:05 AM-Pt willing to let me give him a shot".

A review of the medication orders revealed Nurse Practitioner (NP) #19 ordered Geodon 20 mg injection on 7/18/2025 at 1:43 AM as a 1-time STAT dose for psychosis. A review of the Medication Administration Record revealed the nurse administered the medication on 7/18/2025 at 2:06 AM.


An interview was conducted with RN Staff #11 on 7/24/2025, after 9:00 AM. RN Staff #11 confirmed that Patient #4 received multiple chemical restraints/EBM's during his ER visit dated 7/16/2025-7/18/2025. RN Staff #11 confirmed there was no restraint documentation, to include monitoring, of Patient #4 after the administration of a chemical restraint/EBM. RN Staff #11 confirmed that Patient #4 was placed on psychiatric precautions with a sitter, but there was no restraint monitoring on the patient for any of the medications administered. Behavioral monitoring was completed every 2 hours, and the documentation included the patient's location, activity, behaviors/mood, interventions, and safety room checks of patients on psychiatric precautions. RN Staff #11 confirmed that behavioral monitoring was not the same as restraint monitoring. RN Staff #11 confirmed there was no restraint documentation or 1-hour face-to-face with any of the chemical restraints administered to Patient #4 during the ER visit dated 7/16/2025-7/18/2025. On 7/18/2025, Patient #4 was transferred to an Inpatient Psychiatric Hospital.


Patient #5
Patient #5 was an 81-year-old male who was transferred to the ER by EMS on 7/02/2025 at 8:25 PM with confusion and combativeness. Reportedly, he went after his wife with a knife. He has a known diagnosis of Dementia.

Patient #5 was on every (q) 15-minute checks with a sitter.

A review of the nurse's note dated 7/03/2025 was as follows:
"7:25 AM stated the patient was in the hall, very upset that it was past time for him to leave. Case Management (CM) was able to talk him down. He is yelling insults at the staff and yelling that security better stay close by, cause he may jump on someone.

10:25 AM stated that it appeared the patient had been hallucinating and was given Geodon IM. Shortly after the medication was administered, the patient suddenly stood up and attempted to bite my right arm. I lightly pushed the patient away, where he was now in a sitting position on the edge of the stretcher to prevent from being bitten. The patient was close to the edge of the stretcher and then fell to the floor, landing on his right side. Patient did not hit his head, no LOC. The patient does complain of right shoulder and right hip pain. NP #20 was made aware, and X-rays have been ordered. No other injuries noted".


A review of the medication orders revealed NP #20 ordered Geodon 10mg Injection STAT Once for Psychosis on 7/03/2025 at 10:40 AM. Review of the MAR revealed the medication was administered to Patient #5 on 7/03/2025 at 10:18 AM.

An interview was conducted with Risk Manager (RM) Staff #9 on 7/24/2025 after 9:00 AM. RM Staff #9 was asked if the nurses could administer a chemical restraint without a physician's order. RM Staff #9 confirmed that there must be an order from a physician to administer a chemical restraint/EBM. Staff #9 confirmed the Geodon 10mg was administered to Patient #5 as a chemical restraint/EBM without a physician's order.


A review of the nurse note dated 7/03/2025 at 9:34 PM revealed the patient was attempting to get out of bed. The nurse and the sitter attempted to de-escalate the patient. The patient started yelling and the patient "swing" (sic) at the nurse and security at the bedside.

A review of the medication order dated 7/03/2025 at 9:50 PM revealed NP #19 wrote an order for Geodon 10 mg injection STAT once for Psychosis. The MAR revealed the medication was administered by the nurse at 9:59 PM.


A review of the nurse note dated 7/04/2025 at 5:40 AM stated the patient became angry, walking in the halls, and screaming at staff. Security attempted to de-escalate the patient, and the patient did not cooperate.

A review of the medication order dated 7/04/2025 at 5:50 AM revealed NP #20 wrote an order for Geodon 10 mg injection STAT once for Psychosis. The MAR revealed the medication was administered by the nurse on 7/04/2025 at 5:53 AM.


An interview was conducted with RN Staff #11 on 7/24/2025 after 9:00 AM. RN Staff #11 confirmed the nursing staff failed to assess and reassess 2 (Patient #4 and #5) of 2 patients who received chemical restraints/EBMs. Also, Staff #11 confirmed a 1-hour face-to-face evaluation was not completed on 2 (Patient #4 and #5) of 2 patients who received a chemical restraint/EBM.

An interview was conducted with Chief Medical Officer (CMO) Staff #17 on 7/23/2025 at 2:45 PM. Chief Medical Officer (CMO) Staff #25 was asked if NPs can order chemical restraints/Emergency Behavioral Medications. CMO Staff #17 confirmed that only physicians are allowed to order those medications for behaviors, and it states it very clearly in our policy.


A review of the hospital policy titled, "Standardized Use of Restraint and/or Seclusion" Number: 3.080 with a revised date of 2/25 was as follows:

" ...Ill. OBJECTIVE: This policy standardizes the indications and methods for restraint and/or seclusion.

IV. POLICY STATEMENT:
CHRISTUS Health, in compliance with ethical, regulatory, and patient-focused considerations, supports the right of a patient to be free from restraints and seclusion through the promotion of safety, dignity, and alternatives to the use of restraint and/or seclusion whenever possible, with the goal of being restraint/ seclusion-free.



B. Restraint Orders:

Elements of ALL Restraint/Seclusion Orders
*Orders for restraints and/or seclusion are not written as standing or PRN orders
*The restraint order includes the justification for the use of restraint and/or seclusion, the type of restraint, time limit of restraint, and specifies the limb(s) where the restraints are to be applied.
*The LP* responsible for the care of the patient, places the order for the restraint or seclusion immediately prior to the application of the device.

1. Physical Hold for Forced Medication
a. A physical hold to administer medications is used only in emergency situations. This method is only utilized if less restrictive interventions have been found to be ineffective to protect the patient or others from harm.

i. Physical hold and medication are not intended to be repetitive; they are used to support the safety of the patient and associates in emergency situations.
ii. The objective of the physical hold to administer mediations is to stabilize the patient to restraints.
iii. Physical hold for forced medication is a physical restraint and requires a face-to-face evaluation and restraint monitoring for medication effectiveness and monitoring.

2. The decision to administer medication in response to a behavioral health emergency is driven by a comprehensive, individual patient assessment, including a physical assessment to identify medical problems that may be causing behavior changes in the patient.

a. Medication administered in response to a behavioral health emergency is not intended to be repetitive and is not ordered PRN.

i. In Texas, only the physician may order a single, immediate administration of a psychoactive medication(s) for a psychiatric emergency.
b. Medication administered in response to a behavioral health emergency requires a face-to-face evaluation, restraint monitoring, and evaluation of medication effectiveness.
c. Medication is not used as a means of coercion, discipline, or staff convenience or retaliation.

3 ...
c. Appropriate medication selection criteria for the standard treatment or dosage for the patient's condition includes all of the following:
i. The drug or medication is used within the pharmaceutical parameters approved by the Food and Drug Administration (FDA) and the manufacturer;
ii. The use of the drug or medication follows national practice standards; and
iii. The use of the drug or medication to treat a specific patient's clinical condition is based on that patient's symptoms, overall clinical situation, and on the physician's or other LP's knowledge of that patient's expected and actual response to the medication.

C. Notification of Attending Physician:
The attending physician responsible of the management and care of the patient shall be notified about the use of restraint as soon as possible if he/she is not the ordering physician.
l. If the face-to-face evaluation of a violent/psychiatric restrained or secluded patient is completed by a trained registered nurse or physician assistant, he/she must consult the attending physician or other LP who is responsible for the care of the patient as soon as possible after, within one hour, the completion of the 1-hour face-to-face examination ...

F. Patient Monitoring and Evaluation:
1. A physician or other LP responsible for the care of the patient must evaluate the patient in-person within one hour of the initiation of Violent/Self-Destructive restraints. This assessment 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 or seclusion
e. Guidance in identifying ways to help patient regain control
f. Revise the patient's plan of care, treatment and service as needed
g. The original order for Violent/Self-Destructive restraint or seclusion may only be renewed within the required time limits for up to a total of 24 hours. After the original order expires, a physician or other LP must see and assess the patient before issuing a new order ..."

2. The patient who is simultaneously restrained and secluded is continually monitored by trained staff either in-person or through the use of both video and audio equipment that is in close proximity to the patient ...

Assessment and Monitoring

Violent/Self-Destructive Behavior
*ALL Restraints/Seclusion every 2 hours;
*Additionally, charted every 15 minutes
*Signs of injury associated with the application of restraint/skin integrity
*Circulation/pulse (cardiac status) and range of motion in the extremities
*Respiratory status
*If medication is given in response to a behavioral health emergency, the patient is assessed every 5 minutes for the first 15 minutes, then as described above, until discontinued after one hour face to face evaluation. If physical restraints are in place, monitoring continues as described above ..."

Based on review and interviews, the governing body (GB) failed to ensure that an adverse patient safety event was fully investigated, and preventive actions recommended were measured, analyzed, and tracked in 1 (Patient #8) of 1 patient reviewed.


Findings:

Patient #8 was transported to the hospital by EMS and escorted by BCSO for medical care on 5/16/2025 after a suicide attempt. A review of the hospital's self-reported incident revealed that Patient #8 was physically abused by the Bowie County Sheriff Officers (BCSO) and Emergency Medical Services (EMS) Personnel while in the care of the hospital.

Patient #8
A review of the medical record for Patient #8 was completed in the administrative conference room on 7/21/2025-7/23/2025 with Risk Manager (RM) Staff #9 and Staff #11 Registered Nurse (RN) navigator. The navigator assists the surveyor in navigating through the medical record.

Patient #8 was a 21-year-old male who presented to the Emergency Room (ER) on May 16, 2025. He was transported to the hospital by EMS after an alleged suicide attempt. He was escorted by 2 Bowie County Sheriff Officers (BCSO). Upon arrival, Patient #8 was noted to be handcuffed with his arms behind his back due to aggressive behavior.

A review of the Triage Nurse note documented by RN Staff #5 dated 5/16/2025 at 10:10 PM revealed that Patient #8 was, "Pt BIBA (brought in by ambulance) with BCSO at the side. C/O (complains of) ingestion of approximately 100 ibuprofen (per pt), suicidal, delirium, and aggressive behavior. Pt is handcuffed behind the back and on an EMS cot upon ED arrival. Pt is continuously yelling/screaming profanities and threatening EMS personnel and BCSO. Unable to obtain much information from pt due to aggression and belligerent outbursts. EMS reports pt has been spitting, kicking, biting, and cursing continuously, all in route and upon ED arrival. EMS reports they were called by pt mother due to pt acting delirious and threatening suicide; pt has a small abrasion to the left FA, no bleeding noted, wound is open to air. Unable to obtain full orientation status because the patient will not calm down enough to answer questions. Pt appears to be oriented to self, but unsure about other orientation status due to not being able to get answers from pt. EMS personnel and BCSO at side until pt is more calm. Physician #16 aware of pt upon ED arrival"

Patient #8 was taken to ER Room #1 by EMS and BCSO upon arrival at 10:10 PM.
A review of Physician #16's orders dated 5/16/2025 at 10:13 PM revealed Patient #8 was ordered the following medication.

Versed 5mg injection STAT (a sedative primarily used as a moderate sedation before surgery or during a procedure. This drug may cause amnesia and requires monitoring. Adverse effects: variations in blood pressure and heart rate, impaired balance and gait, sedation, respiratory depression, and retrograde amnesia. Adverse effects may be potentiated by other medications, like analgesics.) There was no indication for use. The medication administration record (MAR) stated RN Staff #5 administered the medication intramuscularly to the left anterior thigh at 10:17 PM.
Droperidol 5mg Injection STAT (an antiemetic medication used to reduce nausea and vomiting and as an amnesia agent before surgery or diagnostic procedures. It does have a black box warning for cardiac risks). There was no justification for use documented on the medication order. The MAR stated the nurse administered the medication IM to the right anterior thigh at 10:20 PM.

A review of Physician #16's note dated 5/16/2025 at 10:22 PM was as follows:
"21-year-old male (Patient #8) presents to the Emergency Department with a suicide attempt, taking 100 pills of Ibuprofen. He is escorted by EMS and police department and has been combative with first responders and arrives handcuffed, screaming at staff. The police department did not report any obvious evidence of an overdose.
Additionally, EMS reports they did not note any significant trauma. The initial call was made by the family in relation to the suicide attempt. Patient was able to be verbally de-escalated during transport, but became combative upon arriving at the ER ...He is in acute distress ...Bruising to the left face with 1 1-centimeter laceration to the left upper lip ...Tachycardia (fast heart rate) ...agitated, aggressive, hyperactive, combative ..."

Medical Decision Making
Differential diagnosis includes agitated delirium, sympathomimetic abuse, metabolic acidosis secondary to NSAID overdose, and intracranial hemorrhage. This is a 21-year-old male who arrives combative with staff and PD. In order to facilitate care after verbal de-escalation had failed medications for acute agitation were administered, including 5 mg of Versed and 5 mg of Droperidol. After this had been given but before it had taken effect patient bit his lip, which began to bleed rather profusely, compromising his airway with frequent coughing and gagging. At this time, a decision was made to intubate the patient to protect his airway and for further behavioral control. While the equipment is being prepared the medications did take effect and patient became very somnolent as expected. For this reason, sedation was avoided for RSI and simply used additional paralytics. Patient's ingestion was greater than 1 hour prior to arrival per report, no indication for activated charcoal or gastric lavage, and none was recommended by poison control, see discussion in ED workup tab. The ED workup documented on 5/16/2025 at 10:15 PM revealed Physician #16 spoke to poison control, and it was recommended to administer IV fluids and monitor for GI upset. Stated that in very high overdoses can lead to metabolic acidosis. Benzodiazepines to be administered for seizures, if any occur. Recommended 4-6 hours of observation. Case #76020695. After intubation patient has had some hypotension, which presumably will correct with sufficient IV hydration given the amount of his base deficit. He was given 2 Amps of bicarb for the short-term in the ER. Midazolam and fentanyl were preferred for PO sedation medications, anticipating that the patient will be positive for methamphetamines and unable to rule out methamphetamine overdose as the true origin of the patient's symptoms given his agitation on arrival ..." There were no documented indications that patient #8 would be positive for Methamphetamines.

A review of the documentation by RN Staff #5 on 5/16/2025 was as follows:

"10:15 PM revealed Patient #8 was handcuffed due to physical/violent aggression towards EMS and BCSO. Patient is also having to be physically held down by EMS personnel and BCSO due to kicking even while being restrained in handcuffs. Respirations 23. Physically and verbally aggressive, exaggerated, and overly dramatic. Impaired judgement with moderate confusion. Violent restraint and physical hold by BCSO and EMS personnel.
10:17 PM Patient is verbally and physically aggressive. Expressing feelings of threats. Versed 5mg IM administered to the left anterior thigh. Patient is no longer restrained due to the discontinuation of physical hold. Respirations 22. Impaired judgement with moderate confusion.

10:22 PM Behavioral Health Emergency. Physically and verbally aggressive. Droperidol 5mg IM was administered to the right anterior thigh. Patient is no longer being restrained due to discontinuation of physical hold. Respirations 21.

10:27 PM Behavioral Health Emergency. Pt is verbally and physically aggressive. Expressing feelings of threats. Physical hold discontinued-no longer meets criteria.

10:32 PM Behavioral Health Emergency. Pt is verbally and physically aggressive. Expressing feelings of threats. Pt is no longer being physically restrained due to discontinuation of the order.

10:40 PM Due to patient's extremely aggressive behavior, unable to obtain a full set of vital signs at this time. Vital signs-Temperature 98 F, Pulse 134 (normal rate 60-100), Respirations 22 (normal rate 16-20), Oxygen level 98%, Blood Pressure 157/61 (normal level 120/80) ..."

An interview was conducted with RN Staff #11 on 7/22/2025 after 11:30 AM. RN Staff #11 was asked what time the handcuffs were removed from Patient #8. RN Staff #11 stated, "On the restraint monitoring record, it shows that the restraint was released at 10:17 PM." RN Staff #11 was asked if that release was for the handcuffs or the physical hold. RN Staff #11 stated, "It must be for the hold because there is no documentation when the cuffs were released". RN Staff #11 was asked if there was any documentation that Patient #8 reportedly "bit his lip" other than the physician note. RN Staff #11 confirmed that Physician #16 was the only caregiver who documented that the patient bit his lip. There was no documentation by the nursing staff on when or if patient #8 had bitten his lip. RN Staff #11 was asked if the BCSO or the EMS personnel had hit the patient in the face and caused the 1-centimeter laceration. Staff #11 confirmed the nursing staff failed to document how or when the laceration to the cheek occurred nor that the patient was assaulted by EMS personnel and BCSO.

An interview with RN Staff #5 was conducted on 7/23/25 at 8:15PM. the nurse stated that when the decision was made to intubate, the physician and NP came into the patient's room and asked "what happened here? _____ (Staff #4) stated I don't know." Staff #5 did not report the incident to the physician. Staff #5 reported MD was focused on trying to protect the airway due to patient being held down and medications impairing the patient's airway.
RN Staff #5 confirmed that the BCSO and EMS were holding patient #8's legs and shoulders down to the bed while he was handcuffed. Staff #5 stated the patient was held when he came in, while he was receiving medications and afterwards until the patient was intubated. However, on 5/16/25 at 10:17pm staff #5 documented, "Patient is no longer restrained due to the discontinuation of physical hold." Staff #5 was asked why the nurses and ER staff did not apply physical restraints for the safety of the patient? Staff #5 stated "like what? Soft restraints? The surveyor stated, "any type you have in the ER to ensure the patient was safely restrained to prevent harm, soft restraints, leathers. Whatever you had." Staff #5 stated, "no. we didn't." Staff #5 confirmed the EMS personnel tried to put a mask on the patient because he was spitting but it kept coming off."

Further review of the medical record revealed RN Staff #4 started an intravenous line, and blood was collected to send to the lab for further testing. On 5/16/2025 at 10:40 PM, Patient #8 was intubated (an endotracheal tube was placed into the patient's airway to assist with breathing) with a Glide scope (a video camera used to assist with placing the endotracheal tube) by Physician #16 placed on a ventilator. A review of the Intubation note dated 5/16/2025 at 11:58 PM by Physician #16 revealed the procedure was performed in an emergent situation. Rocuronium (a fast-acting paralytic medication used to intubate a patient) was administered at 10:39 PM for the intubation.

A review of the procedure note documented 5/17/2025 at 12:15 AM by Nurse Practitioner (NP) #19 revealed that a 2-centimeter laceration to the left cheek was repaired with sutures, and no complications were noted. The NP did not document on the cause of the laceration.

A review of the ER course documented by Physician #16 on 5/16/2025 at 11:32 PM revealed Patient #8 was in Metabolic Acidosis, secondary to the Ibuprofen overdose. Metabolic Acidosis is when there is too much acid in the blood, and this can be caused by an overdose of non-steroidal anti-inflammatory drugs (NSAID). Ibuprofen is an NSAID. According to NCBI, Ibuprofen toxicity can result in tachycardia (fast heart rate) and hypotension (low blood pressure). Symptoms include confusion, agitation, and nausea/vomiting. Patient #8's lab results revealed there was no Methamphetamines present.

Review of Patient #8's vital signs revealed that at 10:48 PM his heart rate was 139 and his blood pressure was 109/37, at 11:03 PM his heart rate was 137 and his blood pressure was 110/31, at 11:18 PM his heart rate was 145 and blood pressure was 119/33, at 11:30 PM his heart rate was 117 and blood pressure was 108/34. The patient was administered multiple doses of sodium bicarbonate (a medication used to treat metabolic acidosis) and placed on a Levophed (a medication to treat life-threatening low blood pressure) drip to control his hypotension.
A review of the NP's history and physical documented on 5/17/2025 at 12:45 AM revealed Patient #8 was admitted to the Intensive Care Unit on 5/17/2025 with profound Metabolic Acidosis, intentional ibuprofen overdose, Altered Mental Status, Acute Respiratory failure, intubated and sedated. The physical exam revealed the patient had swelling to his left jaw, laceration to the left forearm, laceration to the right hand, lacerations x 3 to the left hand, and scratches tracking down the right arm. On 5/17/2025 at 11:57 AM, the Nurse Practitioner in the ICU ordered a CT scan of the Head/Brain for an Altered Mental Status that resulted in no acute intracranial hemorrhage or skull fractures. And a non-specific finding of left periorbital soft tissue swelling. A CT Maxillofacial for facial bruising was ordered on 5/17/2025 at 12:00 PM by the NP in the ICU. The CT resulted in Nasal, left periorbital, and left facial soft tissue swelling. No acute facial fractures, globe rupture, lens dislocation, or retrobulbar hemorrhage.

During an interview on 7/23/2025, after 2:30 PM with RN Staff #11, it was confirmed that the only injuries documented by the ER nurses were the left forearm when he arrived in the ER.

A review of the hospital's Event Record #14201 was completed on 7/21/2025 with RM Staff #9 after 10:00 AM. The event record included two written statements by RN Staff #4 and RN Staff #5. The statements were as follows:

Reported by RN Staff #4 on 5/17/2025 6:47 AM:

"Upon entering the room, EMS and Law Enforcement personnel were physically restraining the patient. His behavior was violent. He was making verbal threats to rape, kill, and haunt staff. During this time, the patient was handcuffed behind the back and being physically restrained to the bed. He attempted to kick the medic that was holding down his left arm. After this attempt, the medic punched him several times on the left side of his face. While this nurse was attempting to secure an IV for sedation, the patient continued to fight EMS and Law Enforcement. The same medic asked me twice if there were cameras in the room. He asked the officer across from him who was holding down the patients left leg if his body camera was on, and if so, would he turn it off. The officer complied and turned off his body camera. The medic began again punching the patient on the left side of his face and grabbing him forcefully by the jaw. I secured the IV and walked out of the room. I returned to the room shortly after when BLS crew informed me they were suctioning blood from his mouth as he was coughing and gagging. I notified the provider who determined at that point we would need to secure the patients airway with intubation."
Reported by RN Staff #5 on 5/17/2025 6:47 AM.

"Entering the ED room 1 with (RN Staff #4); I observed the patient on EMS cot. Medic, EMT, BLS crew, and 2 BCSO officers are surrounding patient on cot, speaking with him. Patient is handcuffed behind the back due to physical aggression (assaulting first responder staff) and threats towards EMS personnel and BCSO officers. Patient is moved from EMS cot to ED stretcher, still handcuffed behind his back. Patient continues to yell/curse/scream/threaten EMS personnel as well as BCSO officers, saying things like, "I'm going to f****** kill you! I'm going to haunt you in your mother f****** dreams! You're all sad!" Even after multiple attempts at verbal redirection from EMS personnel, BCSO officers, and hospital staff, patient is still extremely aggressive verbally and physically which he is a threat to his own safety and everyone around him. As I am trying to get report from the medic, I am at the top of the bed near the patient's head. While the medic is attempting to give me report, the patient continues to say profanity and curse at the medic. I informed the medic, "hey, I'm not really able to hear you, can we step over there (talking about away from the patient) so I can maybe hear you better?" Patient continues to shout profanity at medic, medic then pushes his hand onto patient left side of face, pushing his head into the ED stretcher; patient is still handcuffed behind his back. Other staff (EMS personnel and BCSO) are still physically restraining patient due to severity of aggression at this time. Patient continues to say profanity and curse which at this time the medic started to hit patient on left side of his face; unknown amount of times patient was hit, but at least 2-3 times if not more. Patient was continuing to shout profanity and continuing to be physically aggressive (kicking, spitting, biting) and still being physically restrained. I was able to administer IM droperidol to patient's right thigh. At some point after administering the medication, maybe 1-2min after, the patient was trying to continue to move around out of bed, the shorter BCSO hit the patient at least 2-3 times in the left side rib area. At this point in time, myself and (RN Staff #4), left out of ED room to notify (Physician #16) of medications being administered and what is our next step, to which he informs me, "let's give the meds approx. 10-15min and then if he is still very agitated, we will intubate him for his safety and ours." I went to go inform EMS personnel and BCSO of this information given by (Physician #16). Upon entering the room again, one of the EMS people are suctioning blood out of the patients mouth as well as small amount of blood on ED stretcher next to patient's mouth. I then went to inform (Physician #16) of this information, and he determined it was time to intubate."

An interview was conducted with RN Staff # 5 on 7/23/25 at 8:15 PM. Staff #5 stated that she came back into the patient room and saw the EMT suctioning the patient's mouth, but it was a little bit of saliva that was blood-tinged." There was no found documentation in the patient's chart of coughing or gagging.

The document revealed that the Administrator on call, Staff #3, was notified on 5/17/2025 at approximately 7:00 AM. Staff #3 notified the Chief Executive Officer (CEO) and CNO approximately 9:45 AM on 5/17/2025 and advised the staff that an investigation was in process. Staff #3 notified the RM, Staff #9, at approximately 9:45 AM on 5/17/2025.

An interview was conducted with Chief Nursing Officer (CNO) Staff #2 and Risk Manager (RM) Staff #9 on 7/22/2025 at 10:35 AM. Staff #9 confirmed that an incident report was completed by RN Staff #4 and RN Staff #5 on 5/17/2025 at 6:47 AM. Staff #2 stated that he contacted the BCSO and the LifeNet EMS as soon as he was made aware of the incident. Staff #2 stated that the EMS personnel were placed on administrative leave, and the BCSO contacted the Texas Rangers, who were conducting an internal investigation into the incident. Staff #2 confirmed that there was no documentation of the date and time of the conversations or who he spoke with. Staff #2 was asked if the nurses who cared for Patient #8 reported the incident to anyone. Staff #2 replied, "The charge nurse, RN Staff #10, was notified, and the incident was reported to the house supervisor at that time, who reported the incident to the administrative team". A review of the House Supervisor reports dated 5/16/2025 and 5/17/2025 did not reveal any information regarding the incident that occurred with Patient #8 during the 7:00 PM-7:00 AM shift on 5/16/2025. Staff #2 and RM Staff #9 were asked if Physician #16 was aware that Patient #8 had been physically abused by BCSO and EMS Personnel. Staff #2 could not confirm nor deny whether Physician #16 was aware of the physical abuse.

An interview was conducted with RN Staff #11 ER Clinical Director on 7/23/2025 after 11:00 AM. RN Staff #11 was asked if Patient #8 had a laceration to his face when he arrived with EMS. RN Staff #11 confirmed that the only wound that was documented on arrival was the one on his left forearm. RN Staff #11 was asked if talked with RN Staff #4 and #5 after the incident occurred. Staff #11 confirmed she had a conversation with the two RN's. RN Staff #11 was asked if the nursing staff had notified the physician that the BCSO and the EMS had physically abused the patient. RN Staff #11 confirmed there was no documentation in the medical record that the physician was notified. RN Staff #11 stated that during the time of the restraint that the nursing staff felt uncomfortable about being next to the BCSO and the EMS personnel, so they documented the restraint on paper and stayed at the foot of the bed. Staff #11 was asked if RN Staff #4 or #5 called anyone for help at the time of the incident. Staff #11 confirmed Patient #8 was not under arrest but remained handcuffed for restraint purposes due to his aggression after care was turned over to hospital staff. Staff #11 confirmed that security was not notified of the aggressive patient, and a code BERT (Behavioral Emergency Response Team) was not called. Code BERT is a team that is available 24/7 to respond to behavioral emergencies in which patients, families, or visitors require a coordinated response to diffuse a crisis situation. Staff #11 stated that the ER Department provided training on 5/29/2025 at the ER monthly staff meeting on what to do if staff were to witness a patient being abused by EMS or law enforcement. Staff #11 confirmed that staff were instructed to call 911 and give detailed information to the dispatcher. Staff #11 also stated that the same topic was discussed in the ER Huddle meeting dated 5/18/2025.

RM Staff #9 confirmed that Quality Director, Staff #12, completed a self-report to the Texas Health and Human Services on 5/23/2025. This was 7 days after the incident occurred. Staff #12 reported the incident to DSHS regarding the patient abuse by EMS personnel on 5/26/2025. This was 10 days after the incident occurred.


An interview was conducted with Assistant Chief Nursing Officer (ACNO) Staff #8 on July 23, 2025, after 2:00 PM. Staff #8 confirmed Patient#8 was not on the restraint log for the chemical restraint dated 5/16/2025.
An interview was conducted with RN Staff # 5 on 7/23/25 at 8:15 PM. Staff #5 had stated that she observed the EMT push the patient's face "hard" to the side when the patient was cursing and spitting. Staff # 5 reported that she observed the BCSO take his elbow and hit the patient 3 times in the left side. "I put my arms and hands up like whoa... wait" and decided to go get some meds. Staff #5 stated that she did not see the EMS personnel hit the patient in the face because she was out of the room getting medications but in her written statement she stated, "Patient continues to say profanity and curse which at this time the medic started to hit patient on left side of his face; unknown amount of times patient was hit, but at least 2-3 times if not more."

RN Staff #5 was asked why both nurses left the patient unattended with their abusers. Staff #5 stated, "I left to go get medications, and ____(RN Staff #4) was still in the room with the patient." In staff #5's written statement, she stated "both," meaning herself and RN Staff #4 left the patient alone with the EMT and officers after they had physically abused the patient.

RN Staff # 5 was asked why she or RN Staff #4 did not try to get help or ask the officer and EMT to leave the room. Staff #5 reported the ER was really busy, and so much was going on. She stated they did not have enough staff that night with all the "fires" going on, and she had to go intubate another patient right after intubating patient #8.
The surveyor requested an interview with RN Staff #4 on the morning of 7/23/25. CMO Staff #17 stated that she would get in touch with RN Staff #4 and #5 and let the surveyor know. In the afternoon hours, CMO Staff #17 stated that both nurses had refused to interview with the surveyor. At approximately 7:30 PM, CMO Staff #17 arrived at the lobby of the hotel where the surveyors were staying. Staff #17 stated that RN Staff #5 was working at the ER tonight and had changed her mind and wanted to speak with the surveyors. Staff #17 stated RN Staff #4 continues to refuse to talk with the surveyors.

An interview was conducted with CNO Staff #2 and RM Staff #9 on 7/23/2025 after 10:00 AM. CNO Staff #2 confirmed that the nurses acted appropriately, and RM Staff #9 stated the nurses did a great job. CNO Staff #2 confirmed there was further education in the ER on how to respond when they witness police officers or EMS personnel abusing patients.


A telephone interview was conducted with Physician #16 and CMO #17 on 8/7/2025 at 10:10 AM. Physician #16 was asked what he remembered about Patient #8. Physician #16 stated, "I remember EMS rolled the patient in on a stretcher in the hallway, and he was screaming and yelling, and EMS was having to tighten the straps on the cot. I did a quick exam at the foot of the bed and realized I was going to have to order some medications to calm him down before I could do a full exam, so I went to the desk to get the orders put in. At that time, they moved the patient into Room #1, which is one of our larger rooms. Then the nurse came and got me, telling me that the patient was bleeding, and she was worried about his airway. I went into the room and noticed that the police department was having trouble restraining him, and he had some swelling on his face, and he was bleeding and gagging on the blood, so I decided to intubate him to protect his airway". Physician #16 was asked if he knew why the patient was bleeding. He confirmed that none of the staff informed him of what happened to the patient's lip. He was asked if he was told that the patient was hit in the face by EMS and BCSO? Physician #16 stated that no staff witnessed the patient being hit by the EMS or BCSO. Physician #16 was asked why he thought that the patient was using methamphetamines. He confirmed there was no reported drug abuse, but the patient's actions and behaviors would make you think that. Physician #16 was asked if anyone from the Risk Department or anyone investigating these allegations of abuse ever talked to him regarding this patient. Physician #16 said, "This is probably the most formal discussion that I have had regarding this patient." Physician #16 stated there was enough staff, but we used the police department and EMS to help restrain the patient.

An interview was conducted on 7/23/25 at 2:46 pm with Staff #9. Staff #9 was asked if she had completed an RCA (Root Cause Analysis) for the adverse patient event. Staff #9 reported that she and the administrative staff had conversations about the incident, but Staff #9 confirmed there were no meeting minutes or a sign-in sheet for a meeting. Staff #9 showed the surveyors a fishbone diagram to show the problems identified. There was no additional information on how the findings were determined to affect patient safety, analysis of the event and failures that contributed to the event, or preventive actions taken to ensure this patient abuse would not recur, or how any implementations were being measured, analyzed, and tracked. Staff #9 was asked if she had interviewed the nursing staff involved, and she reported that she had met with the nurses but did not ask for any other information because the nurses had filed an incident report. Staff #9 was not able to provide a written statement, or any meeting minutes held with the nursing staff involved. There was no written evidence that Staff #9 had met and interviewed the treating physician or Nurse Practitioner. Staff #9 stated that she felt the nurses had done a good job, and the outcome of the sentinel event was for the staff to call 911 next time they have this type of incident. There was no other monitoring information available.

According to the facility policy and procedure "Root cause analysis-Sentinel Events and Serious Safety Events" stated,

" II. SCOPE: This Policy applies to CHRISTUS St. Michael Health System and CHRISTUS St. Michael Hospital -Atlanta.

Ill. OBJECTIVE
Describes a standardized system for conducting Root Cause Analysis investigation of patient safety events to assist in identification of health system failures that may not be immediately apparent at initial review.

IV. POLICY STATEMENT:
CHRISTUS Health is committed to build a safety culture through engagement of all Associates by sharing safety knowledge and actions to mitigate the risk of safety events. Pursuant to quality and patient safety committee (regardless of name of the committee) direction, as well as the direction of the Board, certain committees of the facility will engage in quality and patient safety review of certain events via various methods designed to investigate quality and patient safety with the intent of improving quality and patient safety. All investigation carried out is done at the request of and for the benefit of the quality and patient safety committees (regardless of the name of the committee) as requested by the facility Board and the system Board. This policy addresses one type of systematized approach. However, the existence of a policy to delineate this process does not remove or lessen the privileges that attach to this type of investigation or create waiver. Within this broader context, the Root Cause Analysis Policy describes a standardized system for conducting Root Cause Analysis investigation of patient safety events to assist in identification of health system. Identifying root causes of patient safety events reveals underlying reasons leading to preventable errors.

V. DEFINITIONS:
A. Root Cause Analysis - a systematic technique to prevent reoccurrence, as a process of continuous improvement, to find underlying physical and procedural problems, to guide organizational change and to promote a safety culture.
B. Sentinel Event - a patient safety event (not primarily related to the natural course of the patient's illness or underlying conditions) that reaches a patient and causes serious harm. See Appendix A: Joint Commission List of Sentinel Events
C. Plan-Do-Study-Act method - a way to test a change that is implemented via a corrective action plan. The PDSA cycle is preferred quality management method for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).

VI. PROCESS OR PROCEDURES:
A. Identification and Assessment of Events
CHRISTUS Health promotes patient safety management analysis based on a severity assessment code as indicated in the Patient Safety Event Management Analysis Guidelines. All sentinel events and high-risk serious safety events will undergo a rigorous root cause analysis methodology.
B. Root Cause Analysis Methodology
CHRISTUS Health Quality Team has adopted Root Cause Analysis Guidelines based on evidence-based practice. The guidelines serve as a framework for the RCA.
C. Reporting
1. The facility risk manager/appropriate designee will, upon learning of events requiring RCA, shall notify the facility leadership, and system quality leadership using the available Internal Reporting of Serious Patient Safety Event (IRSPSE) Process/Form.
2. The Facility's Quality Committee will approve the completed Root Cause Analysis and monitor the plan.
D. Action Plan
Action Plans will follow the Plan-Do-Study-Act (PDSA) Methodology.

VII. REGULATIONS/REQUIREMENTS:
The Joint Commission, https ://www. iointcommission .org/-/media/tjc/ documents/ resources/patientsafety-topics/sentinelevent/ rca framework 101017 .pdf?db=web&hash=B2B439317 A20C3D1982F9FBB94E1724B."

According to the Joint Commission's requirements regarding Root Cause Analysis (RCA) following a Sentinel Event. These expectations are outlined in their Sentinel Event Policy and Patient Safety Systems standards and are mandatory for accredited healthcare organizations.
When is an RCA Required?
- Must be conducted within 45 days of the organization becoming aware of a sentinel event.
- A sentinel event is an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof.

RC