HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the Condition of Participation for Patient Rights by failing to ensure each patient's rights were protected and promoted as evidenced by:

1. Failing to ensure the development and implementation of policies/procedures regarding the use of taser weapons/stun guns and handcuffs on patients who exhibited uncontrollable behavior after presenting to either the hospital's emergency department and/or after admission to the hospital for 3 of 3 sampled patients (#1, #2, #3) who had been tased by hospital security guards. (See deficiency cited at A0144)

2. Failing to have a hospital policy that required the 60 Security Guards employed by the hospital to receive training in Intervention & Management of Aggressive Behavior (IMAB), or in any other method for handling high-risk behavior in a therapeutic setting, despite the fact that the Security Guards are required, expected to, and routinely intervene in such situations. The hospital has no policy or procedure in place that would prevent the use of stun devices and/or handcuffs as a means to restrain patients who exhibit threatening behaviors while seeking medical care in the emergency room or when hospitalized for 3 of 3 patients (#1, #2, #3) whose records were reviewed for the use of taser weapons. (See deficiency cited at A0144)

3. Failing to ensure hospital staff enforced each Patient's Rights by failing to ensure that appropriate health care interventions were used by security guards in the hospital as evidenced by:
1) the use of a weapon (stun gun) to control patient's behaviors prior to the application of restraints for Patient's #1 #2, and #3. The stun gun device was used on Patient's #1, #2 and #3 when they exhibited uncontrolled and threatening behaviors while seeking medical care in the hospital;
2) the use of a weapon (hand cuffs) to control patient's behaviors after the use of a weapon (stun gum) for Patient's #1 and #2. The hand cuffs were used on Patient's #1 and #2 when they exhibited uncontrolled and threatening behaviors while seeking medical care in the hospital;
3) manually restraining a patient to control the patient's aggressive behavior while seeking medical care in the hospital for Patient #4. (See findings at A0154)

4. Failing to ensure hospital staff enforced each patient's right to refuse medical treatment when Patient #2, who was admitted to the hospital for emergency medical treatment, left an inpatient unit of the hospital and was chased by a security office and a taser gun was used on the patient until he could be handcuffed and returned to the hospital. This incident occurred in a location which was not part of the hospital campus. This was evident in 1of 7 records reviewed for the use of stun guns, (Patient #2). (See deficiency cited at A0154)

5. Failing to ensure that the hospital maintained a true and accurate description of the patient's treatment as evidenced by the medical records of Patient #1, #2, #3, not reflecting the use of a stun gun to control the patient's aggressive behaviors when the patient was seeking medical treatment in the emergency room or while hospitalized. This failure occurred for 3 of 3 patients, (#1, #2, #3) out of a sample of 7 records reviewed for documentation of restraints. (See deficiency cited at A0187)

Based on record reviews and interviews, the hospital failed to meet the Condition of Participation for Patient Rights by failing to ensure each patient's rights were protected and promoted as evidenced by:

1. Failing to ensure the development and implementation of policies/procedures regarding the use of taser weapons/stun guns and handcuffs on patients who exhibit uncontrollable behavior when presenting to either the hospital's emergency department and/or after admission to the hospital. This failure was evident for 3 of 3 sampled patients (#1, #2, #3) who had been tased by hospital security guards. (See deficiency cited at A0144)

2. Failing to have a hospital policy that required the 60 Security Guards employed by the hospital to receive training in Intervention & Management of Aggressive Behavior (IMAB), or in any other method for handling high-risk behavior in a therapeutic setting, despite the fact that the Security Guards are required, expected to, and routinely intervene in such situations. The hospital has no policy or procedure in place that would prevent the use of stun devices and/or handcuffs as a means to restrain patients who exhibit threatening behaviors while seeking medical care in the emergency room or when hospitalized for 3 of 3 patients (#1, #2, #3) whose records were reviewed for the use of taser weapons.

The hospital's policy/procedure titled "Restraints" (Policy Number: 06-13-005) was reviewed. The policy/procedure was presented as the current policy/procedure relating to the use of restraints in the hospital. The policy/procedure documents "It is the responsibility of the organization to provide all patient care staff with education regarding the reduction of restraint use and preferred alternatives to the use of restraints". The policy/procedure indicates that IMAB (Interventions and Management in Aggressive Behavior) is the hospital's approved crisis intervention curriculum for managing occurrences utilizing the least restrictive measures. There were no hospital policies/procedures submitted relating to the use of taser/stun guns, handcuffs, or shackles used by the security officers. (See deficiency cited at A0144)

3. Failing to ensure hospital staff enforced each Patient's Rights by failing to ensure that appropriate health care interventions were used by security guards in the hospital as evidenced by:
a) the use of a weapon (stun gun) to control patient's behaviors prior to the application of restraints for Patient's #1 #2, and #3. The stun gun device was used on Patient's #1, #2 and #3 when they exhibited uncontrolled and threatening behaviors while seeking medical care in the hospital;
b) the use of a weapon (hand cuffs) to control patient's behaviors after the use of a weapon (stun gum) for Patient's #1 and #2. The hand cuffs were used on Patient's #1 and #2 when they exhibited uncontrolled and threatening behaviors while seeking medical care in the hospital; and
c) manually restraining a patient to control the patient's aggressive behavior while seeking medical care in the hospital for Patient #4. (See findings at A0154)

4. Failing to ensure hospital staff enforced each patient's right to refuse medical treatment when Patient #2, who was admitted to the hospital for emergency medical treatment, left an inpatient unit of the hospital and was chased by a security officer and a taser gun was used on the patient until he could be handcuffed and returned to the hospital. This incident occurred in a location which was not part of the hospital campus. This was evident in 1of 7 records reviewed for the use of stun guns, (Patient #2). (See deficiency cited at A0154)

5. Failing to ensure that the hospital maintained a true and accurate description of the patient's treatment as evidenced by the medical records of Patient #1, #2, #3, not reflecting the use of a stun gun to control the patient's aggressive behaviors when the patient was seeking medical treatment in the emergency room or while hospitalized. This failure occurred for 3 of 3 patients, (#1, #2, #3) out of a sample of 7 records reviewed for documentation of restraints. (See deficiency cited at A0187)

25452


Based on record reviews and interviews, the hospital:
1. failed to ensure the development and implementation of policies/procedures regarding the use of taser weapons/stun guns and handcuffs on patients who exhibited uncontrollable behavior after presenting to either the hospital's emergency department and/or after admission to the hospital for 3 of 3 sampled patients who had been tased by hospital security guards;

2. failed to have a hospital policy that required the 60 Security Guards employed by the hospital were trained in Interventions & (and) Management of Aggressive Behavior (IMAB), or in any other method for handling high-risk behavior in a therapeutic setting, despite the fact that the Security Guards are required, expected to, and routinely intervene in such situations. The IMAB was the hospital ' s approved crisis curriculum to all patient care staff regarding the reduction of restraint use and the alternatives to the use of restraints as per the hospital ' s current " Restraint " policy. The hospital has no policy or procedure in place that would prevent the use of stun devices and/or handcuffs as a means to restrain patients who exhibit threatening behaviors while seeking medical care in the emergency room or when hospitalized for 3 of 3 patients whose records were reviewed for the use of taser weapons.(#1, #2, #3). Findings:

Review of the Report of Unusual Occurrence for 2010 revealed 3 occurrences where patients had been tasered and/or tasered and handcuffed. Patient #1 had been tased and handcuffed on 7/27/10, Patient #2 had been tased and handcuffed on 8/6/10 and Patient #3 had been tased on 7/25/10 for aggressive behavior.

The hospital's policy/procedure titled, "Restraints" (Policy Number: 06-13-005) was reviewed. The policy/procedure was presented as the current policy/procedure relating to the use of restraints in the hospital. The policy/procedure documents, "It is the responsibility of the organization to provide all patient care staff with education regarding the reduction of restraint use and preferred alternatives to the use of restraints". The policy/procedure indicates that IMAB (Interventions & Management of Aggressive Behavior) is the hospital's approved crisis intervention curriculum for managing occurrences utilizing the least restrictive measures. There were no hospital policies/procedures submitted relating to the use of taser/stun guns, handcuffs, or shackles used by the security officers.

An interview was held with S7 Security Officer on 8/19/10 at 1:07 pm in the presence of S23 Lieutenant Colonel. S7 indicated he had received general orientation when he was hired to work as a Security Guard for the hospital about 6 years ago. S7 further indicated he had not received IMAB training from the hospital nor had he received training on the least restrictive use of restraints.

An interview was held with S8 Security Officer on 8/19/10 at 2:12 pm in the presence of S23 Lieutenant Colonel Sheriff's Office. She indicated she had received no training from the hospital on the use of stun guns and had received no IMAB training from the hospital since she was hired as a Security Officer 5 years ago.

An interview was held with S9 Detail Security Supervisor on 8/19/10 at 1:45 pm in the presence of S23 Lieutenant Colonel Sheriff's Office. He indicated that Security Guards notify him twenty-four hours a day/ seven days a week of assaults, battery on staff, fire alarms, tasing or any additional violations. He added that security would deploy their stun gun if there was physical danger to a patient, staff or security officer. S9 Detail Security Supervisor indicated the hospital offers general orientation to Security Guards but does not offer IMAB training to Security Guards that are hospital employees.

An interview was held with S10 Security on 8/19/10 at 2:20 pm in the presence of S23 Lieutenant Colonel Sheriff's Office. He indicated patient #2 was tasered two times and handcuffed on 8/6/10. He reported that he had to use the taser gun and handcuffs on the patient when the patient eloped from the hospital. He further reported that he did not have assistance from another security officer that he had single handedly seized the patient using the taser gun and handcuffs. He indicated he did not recall receiving IMAB training from the hospital.

An interview was held with S17 Security on 8/19/10 at 2:00 pm in the presence of S23 Lieutenant Colonel Sheriff's Office. S17 indicated he was hired to work as a Security Guard for the hospital about 4 to 5 years ago. He added that he works as a Security Guard approximately 10 days per month for 6 to 12 hour shifts. S17 reported he had not received IMAB training from the hospital.

An interview was held with S18 Security Officer on 8/19/10 at 2:05 pm in the presence of S23 Lieutenant Colonel Sheriff's Office. S18 indicated he was hired to work as a Security Guard for the hospital about 8 years ago. He added that he had not received IMAB training from the hospital.

An interview was held with S4, Risk Management of 8/17/10 at 1:25 pm. She indicated the hospital had no policy or criteria for taser/stun guns used by the Security Officers employed by the hospital. S4 further indicated that information related to taser/stun guns was not incorporated into the hospital by-laws nor did they have policies/procedures related to the use of these weapons. She further indicated the hospital did not have a policy/procedure for the use of hand cuffs for a patient that was a non-prisoner. She added the hospital employs five Security Officers to be on duty at all times, 24 hours per day 7 days per week. S4 reported Security Guards should receive IMAB training like all other staff. S4 reported that 3 patients had been tasered by Security Guards in 2010 on 7/25/10, 7/27/10 and 8/6/10.

An interview was held with S11 MD Medical Director of Emergency Room on 8/18/10 at 2:40 pm. He indicated handcuffs are only allowed to be used in the hospital on prisoners. He further indicated he was not aware that patients in the Emergency Room had been tased by Security Officers.

The personnel records of S7 (Security Officer), S8 (Security Officer), S9 (Security Officer), S10 (Security Officer), S17 (Security Officer), and S18 (Security Officer) were reviewed. This review revealed no documented evidence to indicate that the hospital had provided education/training in IMAB (Interventions and Management in Aggressive Behavior) for these employees.

In interview with S2, Director of Nursing on 8/20/10 at 9:20 am, he indicated IMAB classes are offered to all direct care personnel in the hospital. S2 indicated the hospital did not have a policy or procedure for the use of hand cuffs for a patient that was a non-prisoner nor for the use of taser weapons that were used on patients in the hospital. He indicated the Security Guards employed by the hospital do have interactions with patients. He further indicated that he was not aware the Security Guards did not receive IMAB training by the hospital.

25452

Based on record reviews and interviews, the hospital failed to ensure hospital staff enforced Patient's Rights by:

1. Failing to ensure hospital staff enforced each Patient's Rights by failing to ensure that appropriate health care interventions were used by security guards in the hospital as evidenced by:
a) the use of a weapon (stun gun) to control patient's behaviors prior to the application of restraints for Patient's #1 #2, and #3. The stun gun device was used on Patient's #1, #2 and #3 when they exhibited uncontrolled and threatening behaviors while seeking medical care in the hospital;
b) the use of a weapon (hand cuffs) to control patient's behaviors after the use of a weapon (stun gum) for Patient's #1 and #2. The hand cuffs were used on Patient's #1 and #2 when they exhibited uncontrolled and threatening behaviors while seeking medical care in the hospital;
c) manually restraining a patient to control the patient's aggressive behavior while seeking medical care in the hospital for Patient #4; and

2. Failing to ensure hospital staff enforced each patient's right to refuse medical treatment when Patient #2, who was admitted to the hospital for emergency medical treatment, left an inpatient unit of the hospital and was chased by a security office and a taser gun was used on the patient until he could be handcuffed and returned to the hospital. This incident occurred in a location which was not part of the hospital campus. This was evident in 1of 7 records reviewed for the use of stun guns, (Patient #2).
Findings:

Patient #1

Review of the medical record revealed that Patient #1 had a history of schizophrenia and was taken to the emergency room on 7/26/10 at 12:40 pm with an Order of Protective Custody signed by the Coroner/Deputy Coroner on 7/26/10 for an evaluation due to bizarre behavior, noncompliance with medications, and hallucinations. The emergency room record revealed the patient was found to be not oriented and had no insight into his condition, he was unaware of the need for treatment or medications had an inappropriate mood and a flat affect. Further review of the medical record revealed a Physician Emergency Certificate signed on 07/26/10 at 4:00 pm. Review of the nurse's notes on 7/27/10 at 4:40 am revealed in part "...a report was called to Facility A for the patient to be transported. Further review of the nurse's notes revealed at 4:55 am on 07/27/10 an officer was present to assist to transfer the patient. Patient #1 refused to leave, became violent striking at the staff, security was at the bedside, tased patient, patient back in bed and the patient was escorted to exit ambulating steady, no respiratory distress noted, patient cooperating and got into the Secured Patient Delivery unit..."

Review of the Security Department Report of Unusual Occurrences completed by S17 Security on 7/27/10 at 5:00 am revealed in part "...Security was advised by the overhead and by the emergency room head nurse that security assistance was needed in the emergency room. Patient #1 was a PEC patient that was refusing to be transported by Secured Patient Delivery. The patient was observed actively swinging his hands and standing aggressively at the staff. The patient was given several loud verbal commands to sit down onto the bed. The patient continued to gesture at security violently with clinched fists and to act out aggressively. In an attempt to calm the patient down, S7 displayed his taser to the patient while advising him to comply to securities commands to sit down. Patient #1 aggressively advanced and struggled with security. S7 dry stunned the patient with a short five second burst, then double lock handcuffed and restrained the patient while the medical staff dressed the patient for transport. The patient was then escorted by security to the security patient delivery vehicle without incident ..."

An interview was held with S17 Security on 8/18/10 at 2:00 pm in the presence of S23 Lieutenant Colonel Sheriff's Office. He indicated he had written the Report of Unusual Occurrence on Patient #1 on 07/27/10 at 5:00 am. After a view of the Report of Unusual Occurrence S17 Security indicated he did recall this incident. He indicated the patient was refusing to go with the transport and that the patient was standing and going toward the nurse with increased agitation. S17 Security indicated Patient #1 told him, "You are going to have to tase me." He indicated he believed the patient was dry stunned by S7 Security once then handcuffed. He added the patient was then escorted out of the building to the transport vehicle calm and the handcuffs were removed.

An interview was held with S7 Security on 8/18/10 at 1:07 pm in the presence of S23 Lieutenant Colonel Sheriff's Office. After review of the Report of Unusual Occurrence he indicated he did remember the incident and that he had tased the patient on a low amp dry stun gun, with no probes deployed, to the pressure point on the side of his neck. S7 reported Patient #1 was a big man who was aggressive and would not comply after several commands by several Security Officers. S7 indicated Patient #1 was still aggressive and was tased again. Following the second use of the stun gun, Patient #1 was then handcuffed behind his back and calmed down.

An interview was held with S23, Lieutenant Colonel Sheriff's Office on 8/18/10 at 1:30 pm. He indicated the maximum voltage on the stun/taser gun is 50,000 volts which is used to propel the electricity from the stun gun to the patient. S23 reported when the stun gun/taser comes in contact with a person the voltage of electricity received is 1200 volts.

Review of the Restraint log for July 2010 revealed Patient #1 was not listed. Review of the Safety Occurrence Report Section IV dated 7/27/10 under restraints revealed documentation that no restraints were used on Patient #1.

An interview was held with S4, Risk Management and S5, RN Quality on 8/18/10 at 9:20 am. They indicated the use of a taser and the use of hand cuffs on patients are restraints. S5 further indicated she had signed off on this form but added the form was not correctly completed since the patient had been tased and that was a form of restraint.

Patient #2

Review of the medical record revealed Patient #2 was an inpatient on unit 2-South on 8/5/10 at 1:20 pm. with diagnoses that included encephalopathy and seizure disorder. Further review of the nurses notes dated/timed 8/6/10 at 8:40 am read, "Patient yelling @ (at) family (,) nurse, stating - "I'm leaving, I was drugged". Patient begins walking to 2 north stating "satin killed my mother", attempted to reorient patient security & (and) MD (physician) paged..." was documented by S13LPN. At 08:50 am (0850) on 8/6/10, "...Security present; patient refusing to go to room; threatening staff. Patient went down stairs, security followed..." was recorded by S13LPN. "..."Notified by staff that patient was - brought to ER (emergency room); patient tased by - security. MD aware" was documented at 9:05 am (0905) by S13LPN. Further review of the notes revealed, "Patient returned from ER via wheelchair /c (with) security & nurse; MD present; - abrasion to above (L) (left) eye, (L) abdomen, & (L) knee; sites cleaned & gauze applied. Patient drowsy, calm; respirations even & unlabored. Will - continue to monitor" was recorded at 9:20 am (0920) by S13LPN.

The nurse's note dated/timed 8/6/10 at 9:05 am (0905) were reviewed and read, "Pt (patient) to ER /c security. Two Taser probes noted to (L) chest wall. S14 MD name d /c medication at BS (bedside) for probe removal. Pt yelling, making threats, acting violent towards staff. Will monitor" was documented by S21EDRN.

Further review of the Physician Emergency Certificate (PEC) revealed Patient #2 had a history of seizure disorders with an altered mental status. He had previous non-compliance with seizure medications. The patient fled hospital room and hospital. He was chased by security - tased and brought back. The patient was disoriented; combative and aggressive; had auditory hallucinations and delusions was recorded by S14MD on 8/6/10 at 10:00 am.

Review of the Coroner's Emergency Certificate (CEC) revealed the patient was evaluated due to his altered mental status and bizarre behavior was signed by the Coroner/Deputy on 8/6/10 at 6:25 pm (1825). Further review revealed the patient was combative, delusional, hallucinating.

The Report of Unusual Occurrence recorded by S10, Security Officer was completed on 8/6/10 at 9:00 am (0900) revealed in part "...Deputies were contacted by S12, RN Manager/Charge Nurse named, who stated there was an irate patient and security was needed. Upon exiting the elevator on second floor, I could hear the voice of an unknown male yelling. As I entered 2-South I observed patient, #2 (named), causing a disturbance by yeling, (yelling), pacing back and forth by the nursing station. I was contacted by nurse, S12RN (named) who stated this patient was trying to leave and due to his unstable mental condition they were not allowing him to leave. As I turned to contact the patient he ran out of the exit door, and Nurse, S12 (named), advised he needed to come back. I followed the patient down the stairs, thru (through) the housekeeping exit door and out the building. I followed him through the parking lot and observed him heading towards the rear exit gate by Quiada Mae Drive. When the patient discovered me he stopped running and started saying I was the one who hurt his mother and he came at me with his fist clenched and his arms in a fighting position. I told the patient to stop but he ingored (ignored) my orders and approached me. I then used my taser to stop the patients(') aggression towards me and he fell to the ground hitting his head. The patient was taken to the E.R. where he was treated for his injuries and the taser probes were removed. The patient was then taken back to 2-South when he was seen by Dr. S14 (named). see EBRSO file #10-54325 for a detailed report...". Further review of Unusual Occurrence Report for patient #2 revealed there was no documentation that the patient was tasered a second time and handcuffed by S10, Security Officer towards the rear gate by Quiada Mae Drive that was located at the back of the hospital's parking lot on 8/6/10.

S10, Security Officer was interviewed in the presence of S23, Lieutenant Colonel Sheriff's Office on 8/19/10 from 2:20pm to 2:30pm. S10 indicated he had written the Report of Unusual Occurrence for Patient #2 on 08/06/10 at 9:00 am. After reviewing the Report of Unusual Occurrence, S10 recalled from memory this incident. He indicated the nurse, (S12, named) called for assistance with the patient on 2-south. He continued S12 informed me that the patient was yelling at staff, yelling at his family, was trying to leave the unit, and not being cooperative. He indicated he heard a male yelling and screaming when he got out of the elevator on the second floor. He recalled the patient was standing by the nurses ' station on the other side of the unit when he saw the exit door close behind the patient. He chased the patient down the flight of stairs across the parking lot and out the building. He continued following the patient through the parking lot and was heading towards the rear exit gate by Quiada Mae Drive in the hospital's parking lot. S10 indicated that while the patient was running to the rear gate located at the back of the hospital, the patient turned and saw the deputy and he "freaked out". The patient then slowed down running towards the rear gate and began calling the deputy "the devil". The patient stated the deputy (S10) was trying to keep the patient from his momma. S10 continued that the patient was at the rear exit gate when the patient came at the deputy with fist clenched and arms in a fighting position. The Deputy indicated that he pulled his taser gun at this moment and informed the patient to stop but the patient kept coming at me; the patient ignored the deputies' orders and approached the deputy. He indicated that he deployed the taser gun into the patient's anterior chest area. The deputy recalled that the patient fell to the ground and the patient did not stop his fall onto the pavement. S10 recalled the patient got up and came at him (S10) a second time. S10 then deployed the stun gun a second time. He indicated that the stun /taser gun deploys 2 probes into an area on the patient usually the anterior chest area. These 2 probes are connected to the gun by about 10 feet of wire. The gun is deployed and it shoots the electricity through the wires connected to the 2 probes. The stun/taser gun can administer electricity to the patients as needed or deployed by the deputy. S10 indicated that the 2 probes embedded in the patient's chest area must be removed by a physician. S10 indicated that he handcuffed the patient after he had tased the patient the second time. S10 reported that he did have a radio in which he could have called for assistance from another deputy. He did not provide a reason why he did not request or call for back up assistance during his chase of the patient. He indicated that he had tasered the patient 2 times and handcuffed the patient to prevent the patient from harming himself and/or the deputy. He recalled the patient hitting his head when he fell to the pavement. He indicated that he transported the patient from the rear exit gate at Quiada Drive back to the ER. He recalled the patient was treated for his head injuries and the taser probes were removed in the ER. He indicated that he removed the handcuffs from the patient after he returned the patient to the ER. He recalled the patient became compliant after he had handcuffed the patient. He indicated that he brought the patient to 2-South in a wheelchair. He reported that the patient saw the Dr. (S14 named) after he brought the patient to the unit, 2-South.

An interview on 8/19/10 at 1:25 pm, S23, Lt. Colonel indicated that the stun gun has a maximum propel arc of 50,000 volts of electricity to deploy the 2 probes. He further indicated that the patient receives 1200 volts of electricity when the 2 probes make contact with the patient.

Review of the Restraint log for July and August of 2010 revealed Patient #2 was not listed. Review of the Safety Occurrence Report Section IV dated 7/27/10 under restraints revealed documentation that no restraints were used on Patient #2.

An interview was held with S4, Risk Management and S5, RN Quality on 8/18/10 at 9:20 am. They indicated the use of a taser and the use of hand cuffs on patients are restraints. S5 further indicated she had signed off on this form but added the form was not correctly completed since the patient had been tased, handcuffed and that these were forms of restraints.

Patient #3

Review of the medical record for Patient #3 revealed he was admitted to the emergency room on 7/23/10 at 11:50 am by police on a Coroners ' Emergency Certificate for paranoid behavior and speaking to vampires.

Review of the Report of Unusual Occurrence on 7/25/10 at 5:07 pm revealed in part "... Patient #3 was not complying with their orders and getting loud and disrespectful to the ER staff. The patient was highly upset. He slapped the Security Guard's hand out of the way. The patient was restrained by Security by holding his wrists so that he could be tied down to the bed by the nursing staff. S8 arrived, saw the struggle and stunned the patient in the torso..."

An interview was held with S8, Security Officer on 8/18/10 at 2:12 pm in the presence of S23. After review of the Report of Unusual Occurrence on 7/25/10 at 5:07 pm she indicated she did recall this incident. S8 indicated there were 2 Security Officers in the emergency room with Patient #3 when she was called for help with this patient. She added the patient had refused his medication, was not complying, fighting with staff and was escalating. S8 reported she dry stunned the patient in the back of his leg and he calmed down.

An interview was held with S9, Security Detail Supervisor on 8/18/10 at 1:45 pm in the presence of S23. He indicated that Security notify him twenty four hours a day/ seven days a week of assaults, battery on staff, fire alarms, tasing or any additional violations. He added that security would deploy their stun gun if there was physical danger to a patient, staff or security officer.

Review of the Restraint log for July 2010 revealed Patient #3 was not listed as having been restrained. Review of the Safety Occurrence Report Section IV dated 7/25/10 under restraints revealed documentation that no restraints were used on Patient #3.

Patient #4

Review of the medical record revealed she was admitted to the Emergency Department on 7/20/10 with suicidal ideations on a Coroners ' Emergency Certificate.

Review of the Report of Unusual Occurrence completed by S18 Security on 7/21/10 at 12:00 am revealed "...ER staff notified security of the patient. Security restrain patient while ER staff inserted medication into Patient #4's IV..."

Review of the medical record revealed no documentation patient #4 had been restrained by security.

An interview was held with S18 Security on 8/19/10 at 2:10 pm. After review of the Report of Unusual Occurrence he completed on 7/21/10 at 12:00 am. S18 indicated he did recall this incident. He further indicated there were 3 deputies at the patient ' s bedside. S18 reported 2 deputies manually held the patients arms and that he held the patient's leg. He indicated the documentation on report he completed did not include the manner nor the number of deputies that restrained the patient.

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #4, she indicated there was no documentation in the nurses notes of the method used in the Emergency Department to restrain the patient. She added that she expected the nursing staff to document all findings in the medical record.

An interview was held with S4, Risk Management and S5, RN Quality on 8/18/10 at 9:20 am. They indicated the use of a taser and the use of hand cuffs on patients are restraints. S4 further indicated she had signed off on this form on 8/3/10 but added the form was not correctly completed since the patient had been tased and that was a form of restraint.

An interview was held with S4, Risk Management of 8/17/10 at 1:25 pm. She indicated the hospital had no policy or criteria for taser/stun guns used by the 60 Security Officers employed by the hospital. S4 further indicated that information related to taser/stun guns was not incorporated into the hospital by-laws nor did they have policies/procedures related to the use of these weapons. She further indicated the hospital did not have a policy/procedure for the use of hand cuffs for a patient that was a non-prisoner. She added the hospital employees five Security Officers to be on duty at all times, 24 hours per day seven days per week. S4 reported 3 patients had been tasered by Security Guards in 2010.

An interview was held with S11 MD Medical Director of Emergency Room on 8/18/10 at 2:40 pm. He indicated handcuffs are only allowed to be used in the hospital on prisoners. He further indicated he was not aware that patients in the Emergency Room had been tased by Security Officers.

In interview with S2, Director of Nursing on 8/20/10 at 9:20 am, he indicated IMAB classes are offered to all direct care personnel in the hospital. S2 indicated the hospital did not have a policy or procedure for the use of hand cuffs for a patient that was a non-prisoner nor for the use of taser weapons that were used on patients in the hospital.

Review of the policy titled, "Restraints", Policy Number: 06-13-005, effective date of 03/07, revision date of 04/09, origin date of 7/68, with no reviewed or reference dates, pages 1 to 13, read in part, "...To promote freedom from physical restraints while protecting the patient from injury. To provide a standard of practice in the use of physical restraints that promotes safety, encourages less restrictive measures and preserves patient rights, dignity, and well-being. Policy-D. It is the responsibility of the organization to provide all patient care staff with education regarding the reduction of restraint use and preferred alternatives to the use of restraints. Staff will also be educated on the appropriate use, application, and care of the patient should a restraint be used as a last resort. New employees who will provide direct patient care will receive training and competency assessment during new employee orientation. Current employees who provide direct patient care will receive on-going education and assessment as part of annual competency evaluations. All education shall encourage the use of alternative non-restraint approaches and the use of the least restrictive, safest, and most effective method of restraint if these alternatives are unsuccessful....
A. physical restraint is defined as the direct application of physical force to a patient with or without the individual's permission to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination thereof.....I. IMAB (Interventions and Management in Aggressive Behavior) - is the hospital's approved crisis intervention curriculum for managing occurrences utilizing the least restrictive measures....Education for clinical staff will include proper application and care of individuals with any type of device, either restraint or a device that is an alternative to a restraint. Use of devices in the following clinical situations does not fall within the definitions of restraints in this policy. They are not considered to be restraints when they are used as follows:
D. Forensic or security reasons - The use of restraining devices are used by correctional officers. Examples are handcuffs and foot shackles. However, the policy applies whenever restraints are applied for clinical purposes to a patient from a correctional institution. Procedure-
1. Staff responds to the event
2. Staff does a visual evaluation of the current situation
3. The staff attempts to de-escalate the situation using the IMAB training techniques which
emphasize:
a. being supportive and empathetic to the individual
b. taking into account the person's age, cultural, and individual needs
c. answering information seeking questions
d. ignoring challenging questions and redirecting the individual
e. respecting personal space
f. being aware of body position and language
g. keeping all non-verbal cues non-threatening
h. permitting verbal venting if possible and determining what the patient is really trying
to say
i. remaining calm and professional at all times
j. setting clear and simple limits
If de-escalation techniques are not effective, staff will initiate the following:
1. Determine if additional staff is needed
2. Initiate the hospital Security Code White, if additional staff is needed
3. Verbal de-escalation techniques should be continued. If unsuccessful in assisting the
patient in regaining control, the license nurse or LIP makes the assessment that includes:
a. the determination if the behavior is related to medical-surgical healing or behavioral
health issues
c. appropriate alternatives to restraints...
d. appropriate least restrictive restraining device that will meet the needs of the exhibited
behavior of the patient
G. Training Requirements
2. All clinical staff is trained in the use of restraints.
Training curriculum will include:
a. underlying causes of behaviors
b. underlying medical factors that are related to behavior
c. how one's own behavior can affect the behavior of the patient
d. recognition of individual, cultural, and developmental backgrounds that may affect the
patient's response to physical contact
e. criteria for the use of restraints, including the education of the patient/family
f. management of behavior using the least restrictive measures and alternative methods
first
g. signs of physical distress in individuals who are being restrained
h. maintaining respect and dignity for individuals in restraints
i. safe application and removal of physical restraints
j. techniques to assist patients to regain control
k. criteria for discontinuation of restraints
l. use of first aid techniques and certification in use of cardiopulmonary resuscitation,
including required periodic recertification
3. For clinical staff, restraint education is part of the initial orientation of newly hired
employees. Safe and appropriate utilization of restraints is included in the annual competency
evaluation.
4. The Restraint Competency Record is utilized to document initial and annual competency...".

Based on record reviews and interviews, the hospital 5. Failing to ensure that the hospital maintained a true and accurate description of the patient's treatment as evidenced by the medical records of Patient #1, #2, #3, not reflecting the use of a stun gun to control the patient's aggressive behaviors when the patient was seeking medical treatment in the emergency room or while hospitalized. This failure occurred for 3 of 3 patients, (#1, #2, #3) out of a sample of 7 records reviewed for documentation of restraints.
Findings:

Patient #1

Review of the medical record revealed that Patient #1 had a history of schizophrenia and was taken to the emergency room on 7/26/10 at 12:40 pm with an Order of Protective Custody signed by the Coroner/Deputy Coroner on 7/26/10 for an evaluation due to bizarre behavior, noncompliance with medications, and hallucinations. The emergency room record revealed the patient was found to be not oriented and had no insight into his condition, he was unaware of the need for treatment or medications had an inappropriate mood and a flat affect. Further review of the medical record revealed a Physician Emergency Certificate signed on 07/26/10 at 4:00 pm. Review of the nurse's notes on 7/27/10 at 4:40 am revealed in part "...a report was called to Facility A for the patient to be transported. Further review of the nurse's notes revealed at 4:55 am on 07/27/10 an officer was present to assist to transfer the patient. Patient #1 refused to leave, became violent striking at the staff, security was at the bedside, tased patient, patient back in bed and the patient was escorted to exit ambulating steady, no respiratory distress noted, patient cooperating and got into the Secured Patient Delivery unit..." Further review of the medical record revealed that last physician orders entered into the medical record for patient #1 were on 07/26/10 at 9:40 pm. There was no documentation in the medical record that Patient #1 had been assessed by the nursing staff or medical staff following the use of the taser/stun gun on 07/27/10 at 5:00 am.

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #1, she indicated there was no documentation the patient had been reassessed by the nursing staff after he had been tased. S3RN further indicated she expected the nurses in the emergency department to obtain vital signs on the patient after he had been tased.

An interview was held with S11 MD Medical Director of Emergency Room on 8/18/10 at 2:40 pm. After review of the medical record for Patient #1, he indicated there was no documentation by the medical staff that the patient had been evaluated after being tased. He further indicated he would have expected a physician note in the medical record related to the tasing as well as a reassessment of the patient.

Patient#2

Review of the medical record for Patient #2 revealed he presented to the hospital's emergence room on 8/4/10 and was admitted into the hospital on 8/5/10 at 1:20pm. Review of the Physician's Admission Orders dated/timed 8/5/10 at 1:20pm revealed, Patient #2 was admitted to unit 2-south with the following diagnosis, " encephalopathy and seizure disorders " . Further review of the record revealed S13 Licensed Practical Nurse (LPN) documented in the nurses notes that the "patient was yelling " at staff at 8:40 am (0840) on 8/6/10. He was documented by the nurse, (S13) that he was pacing back and forth between the two units, (north and south) that were located at opposite ends on the unit. The patient then headed towards the opposite end of the unit, 2-north at 8:50am. She then attempted to reorient the patient and tried to get him to return to unit. The patient began yelling at S13. S13 attempted to reorient the patient and ask him to return to the unit. At 8:50 am, S12RN Manager called security to assist with returning the patient to the unit. S10, Security Officer arrived on unit at 8:50am." Further review of the nurses notes revealed the "Security Officer (S10) arrived on the unit and was observed leaving the unit through the exit door located on the unit at 8:50am " .

Review of the "Report of Unusual Occurrence" dated/timed 8/6/10 at 9:00am, recorded by S10, Security Officer revealed, "The security officer (S10) followed the patient out through the exit door located on the other side of the unit. The patient ran down the flight of stairs that lead to a parking lot located outside of the hospital. At the rear of this parking lot, was an exit gate that leads to a street that was not the hospital's grounds. As the patient was running through the parking lot, he slowed down running and turned to look to see if anyone was following him. The patient then saw Security Officer (S10) was following behind him. The patient slowed down as he reached the rear exit gate at the edge of the parking lot. He then turned and ran towards the officer with his fist clinched and in fighting position. The officer at this given moment pulled his taser/stun gun out. The patient continued running towards the officer. The officer instructed the patient to stop. The patient continued running at the officer. The officer then tased the patient and 2 probes were dispensed from the gun that went through the patient ' s white tee shirt and were engaged in the patient ' s anterior chest area with about 10 feet of wire connected to the officer ' s stun gun. The patient fell to the pavement after the 2 probes embedded into his chest area and about 1200 volts of electricity was dispensed upon contact with the patient ' s chest area. The patient did not try to stop his fall to the pavement with his hands. He hit his head when he fell on the pavement. The patient then stood right back up and ran at the officer, again. The officer then tased the patient a second time and applied handcuffs to the patient while he was lying on the ground. The patient became was brought back by S10 to the Emergency Room. The officer removed the handcuffs from the patient in the Emergency Room after the patient calmed down. The 2 stun/taser probes were removed from the patient's anterior chest wall by the physician in the Emergency Room"

Further review of the notes documented by the nursing staff, S13LPN and S21RN, Emergency Room on 8/6/10 revealed no documentation in the record that Patient #2 had been reassessed by the nursing or medical staff following the use of the taser/stun gun and the application of handcuffs on 08/06/10 at 9:00 am.

The Progress Notes documented by S14, MD dated/timed 8/6/10 at 10:00 am were reviewed. Further review of the notes revealed there was no documentation that the physician had reassessed #2 following the use of the taser/stun gun and handcuffs on 08/06/10 at 9:00 am.

An interview was held with S3 RN, Emergency Room Manager on 8/19/10 at 2:00 pm. After review of the medical record for Patient #2, she indicated there was no documentation the patient was in the Emergency Room on 8/6/10. S3 RN added that she recalled the patient was not seen by the Emergency Room Physician but that he was assessed by his inpatient physician, S14, MD on unit 2-south following the use of the taser/gun and handcuffs. S3 indicated there was no documented evidence in the nurses notes recorded by S21RN Emergency Room that #2 was reassessed after he had been tased and handcuffed on 8/6/10 at 9:00am. S3RN further indicated that she would expect the nurses in the emergency department to obtain vital signs and complete a head to toe assessment of a patient after the patient had been tased and handcuffed.

In interview on 8/19/10 from 8:30 am through 9:10 am, S13LPN reviewed Patient #2's medical record. She indicated there was no documentation in #2's record that she reassessed the patient following the use of the taser/stun gun and handcuffs on 08/06/10 at 9:00 am.

An interview on 8/19/10 from 9:45 am to 10:10 am was conducted with S12, RN Manager. After review of the medical record for Patient #2, she indicated there was no documentation the patient was reassessed by the nursing staff on unit 2-south, nurses in the emergency room and/or medical staff after Patient #2 had been tased and handcuffed on 8/6/10 at 9:00am. S12RN further indicated that she would expect the nurses on the unit to obtain vital signs from the patient upon his return to the unit and to complete an assessment of the patient's anterior chest where the probes from the taser gun had been removed.

In interview on 8/19/10 from 9:15 am to 9:40 am, S14MD reviewed Patient #2 ' s medical record. He indicated there was no documentation that the patient was reassessed by the nursing staff after he had been tased and handcuffed on 8/6/10 at 9:00am. S14 further indicated that he had reassessed the patient while in the emergency room. He reported there was no documentation in his Progress Notes dated/timed 8/6/10 at 10:00 am that he had reassessed the patient after he had been tased and handcuffed on 8/6/10 at 9:00am.

An interview was held with S11 Medical Director of Emergency Room on 8/19/10 at 2:40 pm. After review of the medical record for Patient #2, he indicated there was no documentation by the medical staff that the patient had been evaluated after being tased and handcuffed by the security officer. He further indicated he would have expected a physician's note in the medical record related to the use of the taser on the patient as well as a reassessment of the patient.

Patient #3
Review of the medical record for Patient #3 revealed he was admitted to the emergency room on 7/23/10 at 11:50 am by police on a Coroners ' Emergency Certificate for paranoid behavior and speaking to vampires.
Review of the Report of Unusual Occurrence on 7/25/10 at 5:07 pm revealed in part "... Patient #3 was not complying with their orders and getting loud and disrespectful to the ER staff. The patient was highly upset. He slapped the Security Guard's hand out of the way. The patient was restrained by Security by holding his wrists so that he could be tied down to the bed by the nursing staff. S8 arrived, saw the struggle and stunned the patient in the torso..."

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #3, she indicated there was no documentation in the nurses notes that the patient had been tased or that the patient had been reassessed by the nursing staff after he had been tased. S3RN further indicated she expected the nurses in the emergency department to obtain vital signs on the patient after he had been tased. She added that she expected the nursing staff to document all findings in the medical record.

An interview was held with S11 MD Medical Director of Emergency Room on 8/18/10 at 2:40 pm. After review of the medical record for Patient #1, he indicated there was no documentation by the medical staff that the patient had been tased or evaluated after being tased. He further indicated he would have expected a physician note in the medical record related to the use of the taser as well as a reassessment of the patient.








25452

Based on record reviews and interviews, the hospital failed to ensure a patient had vital signs taken and a complete assessment had been performed when the patient returned to the medical surgical unit after he had been tased and handcuffed as evidenced by no documentation for 1 of 3 sampled patients reviewed for the documentation of taser/stun gun and/or handcuffs out of a total of 7 patients records reviewed, (#2). Findings:

Review of #2 ' s entire medical record revealed there was no documentation that the patient (#2) had been reassessed by the nursing (S13LPN, S21RN ED) and/or medical staff (S14MD) following the use of the taser/stun gun and handcuffs on 08/06/10 at 9:00 am.

In interview on 8/19/10 from 8:30 am through 9:10 am, S13LPN reviewed Patient #2's medical record on 8/6/10. S13LPN indicated she had provided Patient #2 nursing care on the medical surgical unit on 8/6/10. She indicated that she got report from a nurse, (but was unable to identify the nurse) that the patient had been tasered in the emergency room and that the patient was on his way back to the unit with security. She indicated that she had performed a head to toe assessment of the patient when he arrived to the unit from the emergency room at 9:20am. She reviewed her notes timed 9:20 am. She indicated that the patient sustained abrasions/wounds to his left eye, left abdomen and left knee when he eloped. She indicated that the patient received injuries during his elopement from the hospital. She reported that the patient had been tased. She did not know that the patient had been handcuffed, too. She verified the patient was assessed by her at 9:00am, 9:20 am, and 11:00 am. She confirmed the patient ' s vitals signs were recorded at 7:45 am (0745), and 12:00 pm (1200). She verified there was no documented evidence the patient ' s vital signs were assessed after the patient was tasered and handcuffed at 9:00am. She indicated there was no documented evidence in #2 ' s record that she had assessed the taser area and/or handcuff sites following the use of the taser/stun gun and handcuffs on patient #2 on 08/06/10 at 9:00 am.

During an interview on 8/19/10 from 9:15 am to 9:40 am, S14MD reviewed Patient #2 ' s medical record. He indicated there was no documentation that the patient was reassessed by the nursing staff after he had been tased and handcuffed on 8/6/10 at 9:00am.

An interview was held with S3 RN, Emergency Room Manager on 8/19/10 at 2:00 pm. After review of the medical record for Patient #2, she indicated there was no documentation the patient was in the Emergency Room on 8/6/10. S3 indicated there was no documented evidence in the nurses notes recorded by S21RN Emergency Room that #2 was reassessed after he had been tased and handcuffed on 8/6/10 at 9:00am. S3RN further indicated that she would expect the nurses in the emergency department to obtain vital signs and complete a head to toe assessment of a patient after the patient had been tased and handcuffed as well as an inspection of sites to include the tased area and handcuffs.

During an interview on 8/19/10 from 9:45 am to 10:10 am, S12, RN Manager reviewed the medical record for Patient #2. She indicated there was no documentation of the patient ' s tased areas and/or handcuff sites that reassessed by the nursing staff on unit 2-south, nurses in the emergency room and/or medical staff after Patient #2 had been tased and handcuffed on 8/6/10 at 9:00am. S12RN further indicated that she would expect the nurses on the unit to obtain vital signs from the patient upon his return to the unit and to complete an assessment of the patient's anterior chest where the probes from the taser stun gun had been removed and assessed for injuries.

In interview with S2, DON on 8/20/10 at 9:00 am, he indicated there was no documentation in the nurses notes that Patient #2 had vital signs taken or that a complete assessment had been performed when the patient was returned to the medical surgical unit, 2-South on 8/6/10 at 9:20 am after he had been tased and handcuffed. He added that the nursing documentation revealed that the patient had been on the medical surgical unit for 2 hours before the first vital signs had been obtained. He continued the patient's assessment of the areas of the taser/stun gun and handcuff sites should had been performed upon his arrival to the unit.

25452


Based on record reviews and interviews, the hospital failed to maintain a true and accurate description of the patient's treatment as evidenced by the medical record not reflecting the use of a Stun Device to control the patient's behavior prior to the application of restraints when the patient was in the Emergency Department seeking medical treatment for 2 of 2 patients reviewed where a Stun Device was used, for 1 of 1 patient that was manually held down to control behavior in the Emergency Department, and for 1 of 1 patient that eloped from the hospital, (#1, #2, #3, #4).
Findings:

Patient #1:

Review of the medical record revealed that Patient #1 had a history of schizophrenia and was taken to the emergency room on 7/26/10 at 12:40 pm with an Order of Protective Custody signed by the Coroner/Deputy Coroner on 7/26/10 for an evaluation due to bizarre behavior, noncompliance with medications, and hallucinations. The emergency room record revealed the patient was found to be not oriented and had no insight into his condition, he was unaware of the need for treatment or medications had an inappropriate mood and a flat affect. Further review of the medical record revealed a Physician Emergency Certificate signed on 07/26/10 at 4:00 pm. Review of the nurse's notes on 7/27/10 at 4:40 am revealed in part "...a report was called to Facility A for the patient to be transported. Further review of the nurse's notes revealed at 4:55 am on 07/27/10 an officer was present to assist to transfer the patient. Patient #1 refused to leave, became violent striking at the staff, security was at the bedside, tased patient, patient back in bed and the patient was escorted to exit ambulating steady, no respiratory distress noted, patient cooperating and got into the Secured Patient Delivery unit..."

Further review of the medical record revealed that last physician orders entered into the medical record for patient #1 were on 07/26/10 at 9:40 pm.

Record review revealed no documentation in the medical record that Patient #1 had been tased and handcuffed on 07/27/10 at 5:00 am.

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #1, she indicated there was no documentation the patient had been tased and handcuffed on 07/27/10 at 5:00 am. She added that she expected the nursing staff to document all findings in the medical record.

An interview was held with S11 MD Medical Director of Emergency Room on 8/18/10 at 2:40 pm. After review of the medical record for Patient #1, he indicated there was no documentation by the medical staff that the patient had been tased and handcuffed on 07/27/10 at 5:00 am. He further indicated he would have expected a physician note in the medical record related to the tasing as well as a reassessment of the patient.

Patient #2:

Review of the medical record revealed Patient #2 was admitted to the hospital with the diagnosis of encephalopathy and seizure disorders on 8/5/10 at 1:20 pm. Further review of the nurses notes dated/timed 8/6/10 at 8:40 am (0840) revealed, the "patient was yelling at staff, paced back and forth between the north and south units. At 8:50am, S13LPN attempted to reorient the patient, S12RN Manager called security and S10, Security Officer arrived on unit." When the Security Officer (S10) arrived on the unit, the patient ran out of an exit door, down the stairs, across the parking lot and the officer followed the patient. The patient ran towards the rear gate and turned around and ran at the security officer (S10). The officer then tased the patient and the patient fell to the ground without embracing his fall to the pavement. The patient then got up from the ground and ran at the officer. The officer then tased the patient a second time and handcuffed the patient. The patient became calm after the handcuffs were applied. S10 then brought the patient to the Emergency Room. The officer removed the handcuffs from the patient in the Emergency Room and the 2 stun/taser probes were removed from the patient's anterior chest wall by the physician.

Further review of the medical record revealed there was no documentation that Patient #2 had been tased two times and handcuffed by S10, Security Officer on 08/06/10 at 9:00 am.

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #2, she indicated there was no documentation the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am. She added that she expected the nursing staff to document all findings in the medical record.

Review of the notes on 8/6/10 at 9:00am and 11:00am by S13LPN revealed there was no documentation the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am. Further review of the notes on 8/6/10 at 9:12am, and 9:18am by S21RN, (Emergency Department Nurse) revealed there was no documentation the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am.

In interview on 8/19/10 from 8:30 am through 9:10 am, S13LPN reviewed Patient #2's medical record. She indicated there was no documentation in #2's record that he had been tased two times and handcuffed on 08/06/10 at 9:00 am.

An interview on 8/19/10 from 9:45 am to 10:10 am was conducted with S12, RN Manager. After review of the medical record for Patient #2, she indicated there was no documentation by the nursing or medical staff that the patient had been tasered two times and handcuffed on 8/6/10 at 9:00am. S12RN further indicated that she expected the nursing staff to document all findings in the medical record

The Progress Notes recorded by S14, Internal Medicine Residency dated/timed 8/6/10 at 10:00 am were reviewed and revealed there was no documentation the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am.

In interview on 8/19/10 from 9:15 am to 9:40 am, S14, Internal Medicine Resident reviewed the medical record for Patient #2. He indicated there was no documentation in the record that the nursing staff on unit 2-south or emergency room had reassessed the patient after he had been tased two times and handcuffed on 8/6/10 at 9:00am. S14 further indicated there was no documentation in his Progress Notes to indicate that the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am.

An interview was held with S11 Medical Director of Emergency Room on 8/19/10 at 2:40 pm. After review of the medical record for Patient #2, he indicated there was no documentation by the medical staff that the patient had been tased and handcuffed on 08/06/10 at 9:00 am. He further indicated he would have expected a physician note in the medical record related to the use of the taser on the patient as well as a reassessment of the patient after the use of the taser gun.

Patient #3:

Review of the medical record for Patient #3 revealed he was admitted to the emergency room on 7/23/10 at 11:50 am by police on a Coroners ' Emergency Certificate for paranoid behavior and speaking to vampires.

Review of the Report of Unusual Occurrence on 7/25/10 at 5:07 pm revealed in part "... Patient #3 was not complying with their orders and getting loud and disrespectful to the ER staff. The patient was highly upset. He slapped the Security Guard's hand out of the way. The patient was restrained by Security by holding his wrists so that he could be tied down to the bed by the nursing staff. S8 arrived, saw the struggle and stunned the patient in the torso..."

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #3, she indicated there was no documentation in the nurses notes that the patient had been tased. She added that she expected the nursing staff to document all findings in the medical record.

An interview was held with S11 MD Medical Director of Emergency Room on 8/18/10 at 2:40 pm. After review of the medical record for Patient #1, he indicated there was no documentation by the medical staff that the patient had been tased or evaluated after being tased. He further indicated he would have expected a physician note in the medical record related to the use of the taser on the patient as well as a reassessment of the patient after the use of the taser gun.

Patient #4:

Review of the medical record revealed she was admitted to the Emergency Department on 7/20/10 with suicidal ideations on a Coroners ' Emergency Certificate.

Review of the Report of Unusual Occurrence completed by S18 Security on 7/21/10 at 12:00 am revealed "...ER staff notified security of the patient. Security restrain patient while ER staff inserted medication into Patient #4's IV..."

Review of the medical record revealed no documentation patient #4 had been restrained by security.

An interview was held with S18 Security on 8/19/10 at 2:10 pm. After review of the Report of Unusual Occurrence he completed on 7/21/10 at 12:00 am. S18 indicated he did recall this incident. He further indicated there were 3 deputies at the patient ' s bedside. S18 reported 2 deputies manually held the patients arms and that he held the patient's leg. He indicated the documentation on report he completed did not include the manner nor the number of deputies that restrained the patient.

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #4, she indicated there was no documentation in the nurses notes of the method used in the Emergency Department to restrain the patient. She added that she expected the nursing staff to document all findings in the medical record.

Based on record reviews and interviews, the hospital:
1) failed to ensure the Emergency Services had policy and procedures for the use of taser and/or stun guns, hand cuffs and manually restraining patients as evidenced by the hospital's security officers using:
a) a taser and/or stun gun to control patient's aggressive behaviors while seeking medical treatment in the hospital for 3 of 3 patients, (#1, #2, #3) reviewed for the use of restraints out of a total sample of 7 patients records reviewed for the common factor of use of restraints,
b) hand cuffs to control patient's aggressive behaviors while seeking medical treatment in the hospital for 2 of 3 patients, (#1, #2) reviewed for the use of restraints out of a total sample of 7 patients records reviewed for the common factor of use of restraints,
c) manually restrained a patient to control the patient's aggressive behavior while seeking medical treatment in the hospital for 1 of 3 patients, (#4) reviewed for the use of restraints out of a total sample of 7 patients records reviewed for the common factor of use of restraints; and

2) failed to ensure that all treatment performed in the Emergency Department (ED) by ED personnel is documented and included as part of the patient's legal medical record as evidenced by having no documentation in the record that the use of:
a) a taser and/or stun gun to control patient's aggressive behaviors while seeking medical treatment in the hospital for 3 of 3 patients, (#1, #2, #3) reviewed for the use of restraints out of a total sample of 7 patients records reviewed for the common factor of use of restraints,
b) hand cuffs to control patient's aggressive behaviors while seeking medical treatment in the hospital for 2 of 3 patients, (#1, #2) reviewed for the use of restraints out of a total sample of 7 patients records reviewed for the common factor of use of restraints,
c) manually restrained a patient to control the patient's aggressive behavior while seeking medical treatment in the hospital for 1 of 3 patients, (#4) reviewed for the use of restraints out of a total sample of 7 patients records reviewed for the common factor of use of restraints.
Findings:

Patient #1:

Review of the medical record revealed that Patient #1 had a history of schizophrenia and was taken to the emergency room on 7/26/10 at 12:40 pm with an Order of Protective Custody signed by the Coroner/Deputy Coroner on 7/26/10 for an evaluation due to bizarre behavior, noncompliance with medications, and hallucinations. Further review of the medical record revealed a Physician Emergency Certificate signed on 07/26/10 at 4:00 pm. Review of the nurse's notes on 7/27/10 at 4:40 am revealed in part "...a report was called to Facility A for the patient to be transported. Further review of the nurse's notes revealed at 4:55 am on 07/27/10 an officer was present to assist to transfer the patient. Patient #1 refused to leave, became violent striking at the staff, security was at the bedside, tased patient, patient back in bed and the patient was escorted to exit ambulating steady, no respiratory distress noted, patient cooperating and got into the Secured Patient Delivery unit..."

Record review revealed no documentation in the medical record that Patient #1 had been tased and handcuffed on 07/27/10 at 5:00 am.

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #1, she indicated there was no documentation the patient had been tased and handcuffed on 07/27/10 at 5:00 am. She added that she expected the nursing staff to document all findings in the medical record.

An interview was held with S11 MD Medical Director of Emergency Room on 8/18/10 at 2:40 pm. After review of the medical record for Patient #1, he indicated there was no documentation by the medical staff that the patient had been tased and handcuffed on 07/27/10 at 5:00 am. He further indicated he would have expected a physician note in the medical record related to the tasing as well as a reassessment of the patient.

Patient #2:

Review of the medical record revealed Patient #2 was admitted to the hospital with the diagnosis of encephalopathy and seizure disorders on 8/5/10 at 1:20 pm. Further review of the nurses notes dated/timed 8/6/10 at 8:40 am (0840) revealed, the "patient was yelling at staff, paced back and forth between the north and south units. At 8:50am, S13LPN attempted to reorient the patient, S12RN Manager called security and S10, Security Officer arrived on unit." When the Security Officer (S10) arrived on the unit, the patient ran out of an exit door, down the stairs, across the parking lot and the officer followed the patient. The patient ran towards the rear gate and turned around and ran at the security officer (S10). The officer then tased the patient and the patient fell to the ground without embracing his fall to the pavement. The patient then got up from the ground and ran at the officer. The officer then tased the patient a second time and handcuffed the patient. The patient became calm after the handcuffs were applied. S10 then brought the patient to the Emergency Room. The officer removed the handcuffs from the patient in the Emergency Room and the 2 stun/taser probes were removed from the patient's anterior chest wall by the physician.

Further review of the medical record revealed there was no documentation that Patient #2 had been tased two times and handcuffed by S10, Security Officer on 08/06/10 at 9:00 am.

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #2, she indicated there was no documentation the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am. She added that she expected the nursing staff to document all findings in the medical record.

Review of the notes on 8/6/10 at 9:00am and 11:00am by S13LPN revealed there was no documentation the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am. Further review of the notes on 8/6/10 at 9:12am, and 9:18am by S21RN, (Emergency Department Nurse) revealed there was no documentation the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am.

In interview on 8/19/10 from 8:30 am through 9:10 am, S13LPN reviewed Patient #2's medical record. She indicated there was no documentation in #2's record that he had been tased two times and handcuffed on 08/06/10 at 9:00 am.

An interview on 8/19/10 from 9:45 am to 10:10 am was conducted with S12, RN Manager. After review of the medical record for Patient #2, she indicated there was no documentation by the nursing or medical staff that the patient had been tasered two times and handcuffed on 8/6/10 at 9:00am. S12RN further indicated that she expected the nursing staff to document all findings in the medical record

The Progress Notes recorded by S14, Internal Medicine Residency dated/timed 8/6/10 at 10:00 am were reviewed and revealed there was no documentation the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am.

In interview on 8/19/10 from 9:15 am to 9:40 am, S14, Internal Medicine Resident reviewed the medical record for Patient #2. He indicated there was no documentation in the record that the nursing staff on unit 2-south or emergency room had reassessed the patient after he had been tased two times and handcuffed on 8/6/10 at 9:00am. S14 further indicated there was no documentation in his Progress Notes to indicate that the patient had been tased two times and handcuffed on 08/06/10 at 9:00 am.

An interview was held with S11 Medical Director of Emergency Room on 8/19/10 at 2:40 pm. After review of the medical record for Patient #2, he indicated there was no documentation by the medical staff that the patient had been tased and handcuffed on 08/06/10 at 9:00 am. He further indicated he would have expected a physician note in the medical record related to the use of the taser on the patient as well as a reassessment of the patient after the use of the taser gun.

Patient #3:

Review of the medical record for Patient #3 revealed he was admitted to the emergency room on 7/23/10 at 11:50 am by police on a Coroners ' Emergency Certificate for paranoid behavior and speaking to vampires.

Review of the Report of Unusual Occurrence on 7/25/10 at 5:07 pm revealed in part "... Patient #3 was not complying with their orders and getting loud and disrespectful to the ER staff. The patient was highly upset. He slapped the Security Guard's hand out of the way. The patient was restrained by Security by holding his wrists so that he could be tied down to the bed by the nursing staff. S8 arrived, saw the struggle and stunned the patient in the torso..."

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #3, she indicated there was no documentation in the nurses notes that the patient had been tased. She added that she expected the nursing staff to document all findings in the medical record.

An interview was held with S11 MD Medical Director of Emergency Room on 8/18/10 at 2:40 pm. After review of the medical record for Patient #1, he indicated there was no documentation by the medical staff that the patient had been tased or evaluated after being tased. He further indicated he would have expected a physician note in the medical record related to the use of the taser on the patient as well as a reassessment of the patient after the use of the taser gun.

Patient #4:

Review of the medical record revealed she was admitted to the Emergency Department on 7/20/10 with suicidal ideations on a Coroners ' Emergency Certificate.

Review of the Report of Unusual Occurrence completed by S18 Security on 7/21/10 at 12:00 am revealed "...ER staff notified security of the patient. Security restrain patient while ER staff inserted medication into Patient #4's IV..."

Review of the medical record revealed no documentation patient #4 had been restrained by security.

An interview was held with S18 Security on 8/19/10 at 2:10 pm. After review of the Report of Unusual Occurrence he completed on 7/21/10 at 12:00 am. S18 indicated he did recall this incident. He further indicated there were 3 deputies at the patient ' s bedside. S18 reported 2 deputies manually held the patients arms and that he held the patient's leg. He indicated the documentation on report he completed did not include the manner nor the number of deputies that restrained the patient.

An interview was held with S3 RN Emergency Room Manager on 8/18/10 at 2:00 pm. After review of the medical record for Patient #4, she indicated there was no documentation in the nurses notes of the method used in the Emergency Department to restrain the patient. She added that she expected the nursing staff to document all findings in the medical record.

Based on record reviews and interviews, the hospital failed to ensure ongoing quality improvement was maintained by:
1) failing to ensure event reports were completed and analyzed with tracking and trending for all "Code Whites" in the hospital as per hospital policy; and
2) failing to ensure event reports were completed and analyzed with tracking and trending for all uses of Stun Devices in the hospital as per hospital policy for 1 of 3 patients in which a stun device was used on patient #2 out of a total of 7 sampled patients.
Findings:

1) Failing to ensure event reports were completed and analyzed with tracking and trending for all "Code Whites" in the hospital as per hospital policy:

Review of the hospital's Log of the Codes for July and August of 2010 revealed Code Whites had been called on 7/2/10 (x1), 7/13/10 (x1), 7/20/10 (x1), 7/21/10 (x1), 8/6/10 (x2), and 8/13/10 (x1). Review of hospital security s "Unusual Occurrence Reports " and hospital personnel's "Safety Occurrence Reports" for August, 2010 revealed no documented evidence that these reports had been completed for the events that occurred on 8/6/10 at 2:45pm (1445) or 6:18pm (1815) for Patient #2. This findings were confirmed in interviews conducted on 8/19/10 with S2 Director on Nursing from 8:50 am to 9:15 am, S4 Risk Manager at 12:50 pm, S5 Quality Director 2:35 pm, S10 Security Officer from 2:20 pm to 2:30 pm, S12 RN Manager from 9:45 am to 10:10 am, and S13 Licensed Practical Nurse from 8:30 am to 9:10 am. They indicated the Code White Log had never been compared to the Event Reports to ensure all Code Whites were reported. They further indicated the Event Reports were used for problem identification and track/trending purposes and without complete data the analysis of Code Whites would be inaccurate.

Review of the hospital policy titled, "Security Management Plan (CODE WHITE), Policy Number: 31-06-00, Origin date of 2/93, Reviewed and Revision date of 06/10, page 8 of 13, EC.2.10.7, "The security officer or designee completes and Unusual Occurrence Report to accurately document the details/facts. The Unusual Occurrence Report is submitted to the hospital Security Director " .

2) Failing to ensure event reports were completed and analyzed with tracking and trending for all uses of Stun Devices in the hospital as per hospital policy for 1 of 3 patients in which a stun device was used on patient #2 out of a total of 7 sampled patients:

Review of the medical record for Patient #2 revealed the patient was admitted to the hospital through the Emergency Department on 8/5/2010 at 1320 (1:20 pm) with diagnoses that included encephalopathy and seizure disorders. Patient #2 was transported to the hospital's Emergency Department by local ambulance and the triage vital signs were recorded at 2010 (8:10 pm) with an Acuity 3 level (Urgent Situation: a patient can safely wait until a bed is available). The Triage documentation revealed in part, "Presenting complaint: Presenting complaint: section was blank. Nursing documentation revealed "2010 (8:10 pm) per (brought in by) EMS (local ambulance). Pt. (Patient) c/o (complaints of) having thoughts. Pt emotional @ (at) times. Pt denies SI (suicidal ideation), HI (homicidal ideations) or hallucinations. " . Patient is alert/awake, cooperative, no behavioral disorders, Oriented to person, place and time. Pt to Isolation (room in the emergency department) per EMS. Physician at bedside at 9:00 pm (2100). Internal Medicine Team at bedside at 11:20 pm (2320) and 1:15 am (0115). Admitted/transferred to 213-2 (inpatient room located on unit 2-South)". Further review of the emergency department medical record revealed no documented evidence of a Stun Device used on Patient #2 in the emergency department on 8/4/10 at 8:10 pm (2010) through 8/5/10 at 3:00am (0300).

Review of the nurses initial admission documentation dated/timed 8/5/10 at 3:05 am (0305) revealed Patient #2 was transferred from the emergency room at 3:00 am (0300) and admitted on unit 2-South at 3:05 am. Further review of the nurse documentation revealed Patient #2 was "alert/awake, cooperative, no behavioral disorders, and a history of seizure disorder. #2 was documented as oriented to person, place and time ". The patient ' s mental status of alert/awake, cooperative, oriented to person, place and time with no behavior disorders remained unchanged from 8/5/10 at 3:05 am to 8/6/10 at 7:45 am (0745).

Review of S13LPN nursing documentation dated/timed 8/6/10 at 2:45 pm (1445) read, " Patient agitated, stating- " I ' m leaving"; trying to get out of- bed; reoriented. Patient still attempting to leave room; Security @ (at) bedside; MD (physician) notified." Further review of S13's documentation at 6:15 pm (1815) read, "Patient agitated, attempting to- leave room. Security paged" and at 6:30 pm (1830) read, "Security present; patient back in bed; MD on floor".

During a face-to-face interview on 8/19/2010 from 8:30 am through 9:10 am, S13LPN indicated she remembered the incidents with Patient #2 on 8/6/10 at 2:45 pm (1445) and 6:15 pm (1815) when security was called because the patient was attempting to leave the room and wife was holding him back. The patient became agitated with the wife trying to stop him from leaving. There was altercation between the wife and patient. S13LPN defined a code white is physical fighting. S13 indicated the altercation between the patient and his spouse was physical contact in which a code white should have been initiated. S12 further indicated that she did not fill out an Occurrence Report for both incidents between the patient and his spouse on 8/6/10. She reported a Safety Occurrence Report is filled out with any incidents such as if the patient was tasered, fell, and altercation between the patient and spouse. S12 indicated that she did not follow the policy for code white or safety occurrence reporting with patient #2's incidents at 2:45pm and 615pm.

In an interview on 8/19/10 from 9:45 am to 10:10 am with RN Manager (S12) was conducted. S12RN reviewed S13LPN's nurse documentation on 8/6/10 at 2:45 pm, 6:15 pm, and 6:30 pm. S12RN denied prior knowledge that security was called because there was altercation between the patient and the spouse at 2:45 pm and 6:30 pm. She indicated there was no Safety Occurrence Report filed by S13LPN when security was contacted to respond to the 2 incidents that occurred between the patient and his spouse at 2:45 pm and 6:30 pm. She further indicated there was no documentation that a Code White was called by S13LPN in which security was contacted to respond to the 2 events that occurred between the patient and his spouse at 2:45 pm and 6:30 pm on 8/6/10. She indicated the nursing staff does not have to call a "Code White" when there is violence between a patient, visitors and/or staff. She added the staff may call security on the direct telephone line rather than go through the operator.

An interview was conducted on 8/19/10 at 2:35 pm with S5 QA Director. S5 indicated there was no documentation a Code White was called on patient #2 at 2:45 pm (1445), 6:15 pm (1815), or 6:30 pm (1830). She indicated there was no documentation of the Unusual Occurrence Reports or Safety Occurrence Reports on the 2 incidents for patient #2 on 8/6/10 at 2:45 pm, or 6:30 pm when security was contacted by nursing staff. She reported the nursing staff did not follow the policy for Safety Occurrence Reporting or Code White for the 2 events that occurred with the patient at 2:45 pm and 6:30 pm. She indicated the security officers did not follow the policy for filing an Unusual Occurrence Report on both events with the patient at 2:45 pm and 6:30 pm.

During an interview on 8/19/10 from 2:20 pm to 2:30 pm, S10 Security Officer recalled from memory that security was contacted to respond to patient #2 on unit 2-South on a second incident during his shift that ended at 7:00pm. He indicated that he went to assist the other two officers with the patient on the unit because he had to use the stun gun to taser the patient two times with the stun gun then handcuff him during the patient's earlier elopement from the hospital at 9:00 am. S10 Security Officer indicated that when the patient saw him arrive, Patient #2 called him "the devil" and went back to bed. He reported the patient became cooperative and security departed the unit. He indicated all occurrences in which security is called whether by code and/or direct telephone lines would initiate that an Unusual Occurrence Report to be filed by the officer(s) that responded to the call on the unit and/or in the hospital.

In an interview on 8/19/10 from 8:50 am through 9:15 am, S2 DON indicated there was no documentation that a Code White was called by S13 LPN for Patient #2 at 2:45 pm (1445), 6:15 pm (1815), or 6:30 pm (1830) on 8/6/10. He further indicated there was no documentation of the Unusual Occurrence Reports filed by the security officers after they assisted in the 2 events with the patient at 2:45 pm and 6:30 pm. He reported there was no documentation of the Safety Occurrence Reports for the 2 incidents with #2 on 8/6/10 at 2:45 pm, or 6:30 pm when security was contacted by nursing staff, S13 on 8/6/10. He indicated that a Safety Occurrence Report is generated any time that an incident occurs with staff, a patient, and/or visitor that is out of the normal operation of the hospital. He indicated that the conflict between the patient and spouse would be out of the routine, normal operation of the hospital and that the nurse should have filled out a Safety Occurrence Report on both events at 2:45 pm and 6:30 pm. S2 indicated that a Code White is called for an actual incident occurring and/or to prevent an event from occurring. He indicated the 2 events that occurred between the patient and spouse were actual events that were occurred in which a "Code White" should have been called by S13 LPN according to the hospital policy. He reported the security officers did not follow the policy for Unusual Occurrence Report on both events with the patient at 2:45 pm and 6:30 pm.

Review of the policy titled, " Security Management Plan " , Policy Number: 31-06-00, Policy Number: #31-06-01, Origin and Effective Dates: 2/93, Review and Revision Dates: 06/10, EC.2.10.1, page 2 of 13, EC.2.10.2, page 3 of 13, EC.2.10.3, page 3 of 13, EC.2.10.7, page 8 of 13, EC.9.10.1, page 11 of 13, EC.9.20, page 11 of 13, EC.9.30, page 12 of 13, presented as the hospital ' s current " Security " policy on 8/17/10 at 2:25 pm, revealed, " The Security Management Plan describes how Earl K. Lon Medical Center establishes and maintains a Security Management Plan to protect staff, patients and visitors from harm. The plan provides processes for: EC.2.10.1 ...addressing security issues concerning patients, visitors, personnel; Security issues concerning patients, visitors, personnel are documented by the " Unusual Occurrence Report " (UOR), " Safety Occurrence Report or Opportunity for Change " forms. These concerns are reported by the Security Officer to the Chief Executive Officer, and the Safety/Risk Management Department on a monthly basis. EC.2.10.2 ...leadership's designation of personnel responsible for developing, implementing, and monitoring the security management plan; Policy #31-06-01 The Hospital Chief Executive Officer shall appoint a Security Officer. EC.2.10.3 ...conducting risk assessment that proactively evaluates the impact of internal physical systems on patient safety ...EC.2.10.7 ...Security procedures to address actions taken in the event of a security incident ...Staff at Earl K. Long Medical Center in the area of the situation notifies the switchboard operator by dialing 1100 and requests a " CODE WHITE " be announced. The switchboard announces " Code WHITE " and identifies the area of the situation. Security personnel responds immediately to the area, assesses the situation and initiates appropriate action. The security officer or designee completes the Unusual Occurrence Report to accurately document the details/facts. The Unusual Occurrence Report is submitted to the hospital detail supervisor and to the hospital Security Director. The Security Director shall report Security incidents to the Safety Department, the CEO, COO and the Environment of Care Committee. EC.9.10.1 ...reporting and investigation all security incidents involving patients, visitors, personnel. Security shall report at least bi-monthly to the Environment of Care Committee any security incidents involving patients, visitors, and personnel. The Environment of Care Committee ' s conclusions, recommendations, actions taken, and the monitored effectiveness of actions taken shall be reported to appropriate individuals at least bi-monthly. All incidents of an emergency nature, which require immediate actions, must be reported to the supervisor or in their absence, the House Supervisor. Reporting and investigating all security incidents involving patients, visitors, and personnel is established through the mechanism of reporting and routing all unusual occurrence reports, concerns and summaries to the Chief Executive Officer. Immediately following the incident, the employee/medical staff is to initiate the Safety Occurrence Report, documenting the occurrence/incident. All incidents of an emergency nature, which require immediate action, must be reported immediately to the Chief Executive Officer or, in his absence, the House Supervisor. EC.9.20 ...an evaluation of the security ' s management plan objectives, scope, performance, and effectiveness will occur ...The Security Management Plan and Program is evaluated annually. This evaluation includes a review of the objective, scope, performance, and effectiveness of the program. EC.9.30 ...improves the environment of care ...Ongoing monitoring of performance regarding actual or potential security risks for performance improvements are established by the Security Officer and Safety/Systems/LSU consultant and presented to the Environment of Care Committee. Performance Improvement are established by the Security Officer and the Environment of Care Consultant during the annual evaluation. The actual or potential risks are chosen from the following: 2. The level of staff participation in security management activities; 3. Monitoring and inspecting activities; 4. Emergency and incident reporting procedures that specify when and to whom reports are communicated; "

The policy titled, " Unusual Occurrence/Incident Reporting of " , Policy Number: 31-06-15, Origin date of 01/96, Revision Date: 06/10, with no Reviewed Date presented as current " UOR " policy on 8/17/10 at 2:25pm read in part, " Policy- to ensure that all security incidents are investigated and reported that involves any patient, visitor. Purpose- B. to provide a mechanism for tracking and trending. C. To establish a basis for improving performance. Procedure- A. Unusual occurrences/incidents will be documented and reported to shift supervisor who will submit all reports to the Security Officer at the end of the shift during which the situation occurred. C. The Security Officer 4. Tracks and trends all occurrences/incidents and submits reports to Environment of Care Committee.

Review of the policy titled, "Occurrence Reporting", Department: Administration, Policy Number: 01-01-0030, Effective Date: 11/03/05, Revision Date: 11/03/05, Reference: DHH 9353, CMS 482.25, JCAHO MM.6.20, with no origin or reviewed dates, pages 1 to 6, presented as the hospital ' s current "Occurrence Reporting" policy on 8/18/10 at 8:50 am revealed in part,
" Policy-A. All known occurrences, which are not consistent with the routine operation of the facility or the implementation of the medical plan of care, are to be reported to the Safety Officer within 24 hours or the next business day using the "Confidential Occurrence Report".