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Based on record reviews and interviews, the facility failed to ensure that staff followed policy to safely restrain patients for 2 (P[patient]7 and P8) out of 2 (P7 and P8) patients reviewed who experienced an incident with an employee. This deficient practice could lead to patients being injured by improper restraint use.

The findings are:

A. Record review of facility's policy titled, "Security Officers - Use of Physical Force," dated 08/30/2021 under "Guideline Steps," it stated, "Security Officers may be called to protect patients, visitors, students and staff from a violent situation prior to the arrival of Law Enforcement. Security Officers may use force ONLY when absolutely necessary to protect themselves and others from immediate and imminent bodily harm. In any such event Security Department Officers shall limit their use of force to the minimum force reasonably necessary to accomplish their intended objective, to overcome resistance encountered, and to protect themselves and others from physical harm."

B. Record review of the facility's video footage from the adult psychiatric unit 1 dated 12/19/24 at 10:04 am, revealed two security officers (S[staff] 28 and S29) stationed on the unit. At 10:04 am and 51 seconds, P8 is seen coming out of a patients room approaching S29 and punching him in the chest. At 10:04 am and 56 seconds P8 is taken to the floor by S29, medical staff arrived to assist and are seen tending to the P8. P8 can be seen laying face down on the floor, S29 is also face down with his upper body on P8. At 10:07 am, S29 stands up and the view of the P8 is obstructed in the video. At 10:09 am and 34 seconds the crash cart (cart stocked with emergency supplies such as medications and life saving equipment) is brought over to the patient and the view of P8 remains obstructed by staff attending to the scene. At 10:15 am the crash cart is removed from the scene, view of patient remains obstructed.

C. Record review of P8's medical record with an admission date of 12/03/24 revealed a "Rapid Response Team [facility's emergency response team] Note" dated 12/19/24 at 10:11 am, that revealed P8 was taken to the ground after an altercation with the security guard. Staff had to "yell at the security guard to get off the patient because the patient was 'purple and not breathing'." Patient had lost consciousness, stopped breathing for almost a minute and had lost control of his bowels. P8 was taken from psychiatric unit to the emergency department for evaluation.

D. During an interview on 08/21/25 at 10:15 am, with S(staff)24, non-clinical it was explained that the incident described in Finding B., was investigated by the facility and the actions of the security officer were found to have contributed to P8 losing consciousness.

E. During an interview on 08/21/25 at 1:45 pm, with S(staff)25, clinical, S25 recounted the incident in Finding B. and explained that P8 was stating he couldn't breathe and was struggling to get up. The security officer was holding patient down with his chest and the security officer had his arm wrapped around P8's neck. The security officer responded to the patient, "If you can talk, you can breathe."

F. Record review of P7's medical record for visit date 06/04/25 revealed that patient was discharged on 06/04/25 at 6:27 pm.

G. Record review of the facility's video footage from the emergency department lobby dated 06/04/25 at 6:09 pm and 40 seconds, revealed P7 walking out of emergency department and sitting in the lobby by the front doors. At 6:21 pm and 12 seconds a nurse walks up to patient with a clipboard and hands P7 paperwork. P7 drops the paperwork on the floor and is gesturing with two fingers in the air.The nurse picks up the paperwork from the floor and hands it to P7 again.The nurse walks away from P7 at 6:22 pm and 30 seconds and then S29, non-clinical, approaches P7, taps P7's leg and leans over P7. S29 grabs P7 by the right shoulder at 6:22 pm and 41 seconds and pulls P7 out of the chair. At 6:22 pm and 50 seconds, S29 is pushing and lifting P7 out of lobby with both hands, P7's is being lifted by S29, so his feet are unable to touch the floor in order to walk. S29 releases P7, shoves P7 and P7 stumbles. S29 and P7 converse, S29 points his finger at P7 and P7 walks away at 6:23 pm.

H. During an interview on 08/21/25 at 10:15 am, with S24, non-clinical, it was explained that the incident described in Finding G. was investigated by the facility and the actions of the security officer did not follow facility policy regarding the use of force.

Based on observation, record reviews, and interviews, the facility failed to conduct a periodic appraisal of practitioners to determine individual practitioners' qualifications and competency to perform activities within the applicable scope of practice. This deficient practice resulted in complications of a lifesaving device which may have contributed to cardiovascular decompensation (the inability of the circulatory system to maintain adequate function) in 1(P(patient)4) out of 3 (P4 through P6) charts reviewed.

The findings are:

A. Record review of P4's medical chart under, "Medical Notes," dated 08/21/25, revealed documentation showing the use of several types of equipment including ventilatory assistance equipment (a device to help restore or improve breathing function), dialysis treatment (a treatment that cleans your blood by removing waste and extra fluid when your kidneys cant) and medications prescribed to P4 as their condition changed. P4 also required ECMO (extracorporeal membrane oxygenation - a life support system that temporarily takes over the work of the heart and lungs allowing them to rest and heal) placement on 06/24/25.

B. Record review of medical provider notes dated 07/07/25, revealed the medical provider documented a "crack in connection of venous cannula (A venous cannula is a tube of the ECMO that is inserted in the large blood vessels of the neck to allow blood with low oxygen to be drawn from the veins and blood with high oxygen to be returned to the arteries) repaired by surgery with silicone glue."

C. Record review of P4's, "Medical Provider Notes," dated 07/09/25, noted "infant decompensation (inability of the heart to maintain adequate circulation) possibly related to air within the (ECMO) circuit (a sterile, plastic tubing from the patient to the ECMO machine."

D. Record review of P4's,"Medical Provider Notes," dated 07/14/25, revealed a notation by the medical provider, documenting the presence of "a large clot (a thick mass of blood that is stuck together) in the ECMO circuit."

E. Record review of P4's, "Cardiology (the branch of medicine that deals with diseases and abnormalities of the heart) Consult Notes," dated 07/15/25, revealed that the cardiologist documented a cracked cannula with the following statement: "The ECMO course has been complicated by a cracked cannula which potentially has led to air within the circuit and cardiovascular decompensation (the inability of the circulatory system to maintain adequate function).

F. Record review of P4's, "Medical Provider Notes," dated 07/20/25, revealed that the medical provider documented "Bedside RN and ECMO staff concerned about continued circuit clotting, possible decannulation (removal of plastic tubing from patient to the ECMO machine) today, 7/20/25, with possible dialysis catheter placement (the insertion of a tube into a large vein for a medical treatment that performs the normal function of kidneys)."

G. Record review of P4's, "Medical Provider Discharge (deceased) Summary," dated 07/21/25, revealed that the medical provider documented the following: "She [P4] had several circuit changes on ECMO, mainly for air entrainment (air bubbles in the circuit) from a cracked venous cannula, and once for clot burden (large blood clots) in the circuit. On 7/20/25 it was elected to separate her [P4] from ECMO after a four-week run given worsening circuit clot burden, clamp trials (short periods of removing the artificial breathing machine from a patient and allowing them to breathe on their own) that were reassuring on an oscillator (a type of machine that provides breathing assistance) and a strong hesitance to perform a fifth circuit change given the temporary deleterious (harm or damage) effects of that maneuver on her lungs (an ECMO circuit change may cause blood clots and swelling in the lungs) in the past from hyper-inflammation (increased swelling)."

H. During an interview on 08/20/25 at 9:45 am, S(Staff)3, clinical, stated she has never had a situation where an ECMO venous cannula was cracked before this incident.

I. During an observation on 08/20/25 at 10:00 am, S(Staff)9, clinical, demonstrated the components of ECMO, the cannula and the circuit. S9 demonstrated how a circuit would be changed by using 2 clamps, snipping the portion to be changed using the dull edged scissors provided, in the kit, adding a connector and linking the new tubing. A sharp instrument, like a scalpel, may damage the ECMO tubing and is not recommended.

J. During an interview with S(Staff)9, clinical, on 08/20/25 at 10:10am, she stated she attends mandatory ECMO yearly training and is an ECMO expert. S9 has the following credentials: license for Registered Respiratory Therapist, ECMO specialist for adults and pediatrics, Advanced Cardiac Life Support certification, and annual training for ECMO completed 11/08/24. She stated the training is optional for medical providers and they do not usually attend. S9 stated the hospital policy for changing a circuit on an ECMO does not involve the use of a scalpel because of the possibility of damaging the ECMO tubing.

K. During an interview with S(Staff)8, clinical, on 08/20/25 at 10:15 am, he stated he was familiar with the cracked cannula, and he was present when another provider, S(Staff)18, clinical, used a scalpel when changing a circuit and damaged the venous cannula of the ECMO on P4. S8 stated the hospital policy does not list using a scalpel when changing an ECMO circuit. S8 stated that P4 had 4 circuit changes during the hospital course.

L. During an interview with S(Staff)11, clinical, on 08/21/25 at 10:46 am, he stated he had been briefed on the incident regarding the cracked ECMO circuit. S11 stated S18 had been suspended after this incident occurred and is pending a review and determination of his fitness for duty.

M. During an interview with S(Staff)10, clinical, 08/21/25 at 11:38 am, she stated she was familiar with the case and that she is on the committee to investigate the use of a scalpel on an ECMO venous canula. She plans to complete a root cause analysis. S10 stated medical providers are not required to demonstrate their professed competencies upon hire or at any time during their employment, nor are they required to attend yearly ECMO training. S10 stated some of the reasons an ECMO circuit might be changed are blood clots that form in the tubing or air bubbles. S10 stated a circuit, unless damaged, can remain in use for about 4 weeks.

N. During an interview with S(Staff)27, non-clinical, on 08/21/25 at 12:30pm, the personnel file for S18 was requested to review ECMO training and competency but it was not provided.

O. Record review of UNM's Hospital Policy dated 03/28/23, titled "Emergent Extracorporeal membrane Oxygenation (ECMO) Circuit Change in pediatrics and Neonate" revealed that the policy applies to appropriately licensed health care providers based on their scope of practice as determined by licensure and education (ECLS [extracorporeal life support] Physicians). Under the heading "Guideline for Emergent Circuit Change" the following procedure is outlined:

1. Isolate patient from ECLS circuit. 2. Staff member to hold up ECLS lines off patient bed.
3. ECLS Physician will clean lines from cannula site towards ECLS circuit with betadine or chlorhexidine (antiseptic solution). 4. Don (put on) sterile gloves 5. Apply sterile towels underneath cleaned ECLS lines.
6. Place ECLS lines on sterile towels. 7. Don bouffant (hair covering). 8. Re-apply sterile gloves.
9. Don a sterile gown. 10. Drape patient using medium or femoral (a sterile covering that is placed at the upper thigh) drape.
11. ECLS Specialist hands over clamps, scissors, connectors, syringes, bowl, normal saline, and chlorhexidine/betadine. 12. Using sterile scissors, cut hole through drape used to access sterile lines underneath. 13. Prep lines again using betadine or chlorhexidine.
14. ECLS Specialist brings new circuit into room and hands over new sterile lines. 15. Connectors should be applied to the new ECLS circuit lines. 16. Fill Toomy (an instrument used for squirting sterile saline) syringes with sterile saline (a solution of sterile water and salt).
17. Time-out and roles identified. 18. Designated staff will clamp old circuit with two clamps each, leaving at least 3 inches in between each clamp.
19. Cut into old circuit with sterile scissors, proximal (closest to the point of attachment) to old circuit clamps, to allow space for tubing manipulation. 20. Grab new circuit and connect using wet to wet connections via saline filled Toomy syringes. 21. Remove all clamps. 22. Re-institute ECLS flow (the removal of blood from the veins to the ECMO machine for oxygen and the return of the blood to the arteries with oxygen) and sweep gas on new circuit (gas that flows from the ECMO oxygenator).
23. Check activated clotting time (ACT)(a test measuring how quickly the blood clots) and arterial blood gas (ABG)(a test that measures oxygen in the blood).

P. Record review of facilty's document labeled, "Corrective Action Plan: ECMO Review," dated 08/15/25, provided by S10, clinical, it was noted that the document listed a problem identified as "sterile scalpel utilized near cannula. Category of root cause Human factors." S10 stated this was a document she had prepared when analyzing the root cause of the cracked ECMO circuit.