Hennepin County Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47264 Based on interview and document review, the facility failed to ensure a patient’s right to be free from physical abuse when security staff used law enforcement weapons to restrain 2 of 10 patients (P10, P9) reviewed for patient rights. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. A condition level deficiency was issued at A-0115. See A-0154 for additional information.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 47264 Based on interview and document review, the facility failed to ensure a patient’s right to be free from physical abuse when security staff used law enforcement weapons to restrain 2 of 10 patients (P10, P9) reviewed for patient rights. Findings Include: P10’s emergency department (ED) visit note dated 4/13/26 at 9:32 p.m. indicated P10 was a 21-year-old male who presented to the ED on via self with family for evaluation of suicidality. P10’s relevant medical history included major depressive disorder, oppositional defiant disorder, polysubstance abuse, and suicide attempts. An acute psychiatric services note dated 4/13/26 at 11:18 p.m. indicated P10 had attempted to shoot himself in the head with a loaded gun. P10 did not have a history of harming others, was cooperative and engaged in the assessment. Impression was noted to indicate P10 was experiencing suicidal ideation while under the influence of illicit substances and alcohol. A progress note dated 4/13/26 at 11:18 p.m. indicated P10 had initially been in the ED on a voluntary basis, however, became acutely agitated. “[P10] was in restraints, he was maced, and he was fighting ...and not able to settle down.” Nursing and security staff roomed P10 on a gurney. Intramuscular (IM) medications were administered for agitation, and P10 was placed on 1:1 observation for monitoring. A violent restraint note dated 4/14/26 at 4:32 a.m. indicated P10 continued to resist his restraints. However, P10 was downgraded from 4-point restraints to 2-point restraints for comfort. A violent restraint note dated 4/14/26 at 8:11 a.m. indicated P10 was resting, and restraints were discontinued. On 4/14/26 at 4:21 p.m., P10 was transferred to inpatient psychiatry for further treatment. A psychiatric discharge summary dated 5/5/26 at 1:15 p.m. indicated P10 was discharged to a residential detox facility. A document titled “Event Review Assessment Program” dated 4/28/26 indicated the use of Repuls (water-based irritant made up of water, ammonium propionate, propionic acid, ammonium citrate, and a surfactant) on P10 by SG-B was reviewed by security manager-A and security manager-B. The audio, video, reports, and use of force were reviewed. The report indicated the consequences of the event were “Repuls used, physical restraint.” It was determined most security staff would have responded to this event in a similar manner. No action was required because of the use of force review. An unfinished document titled “Use of Force Review,” dated 4/21/26 indicated the events of 4/13/26 were reviewed. The document indicated nursing staff had requested security staff place restraints on P10 so P10 could be transferred and receive care in a secure patient care area. Because P10 continued to actively resist security staff, he was told he would be “sprayed,” and was sprayed with Repuls by SG-B. The document indicated suggestions were not made because facility policies were followed. No further action was recommended. Body camera video footage from 5/30/26 at 8:52 a.m. was reviewed on 7/20/26 at 2:55 p.m. with the security manager. The footage was comprised of four body worn cameras situated in the center of security guards’ ballistic vests; the footage played in sync. In the footage, P10 was exiting a triage space when security attempted to stop him. Security and P10 fell to the ground, and visuals were limited as P10 began screaming and actively resisting staff as they initiated a manual hold. Multiple staff gave directives for P10 to drop items and stop fighting, however P10 continued to struggle. Security began applying restraints to P10’s wrists and ankles while P10 actively attempted to kick and punch staff while shouting. Once violent bilateral wrist and ankle restraints were applied, staff informed P10 they were going to transfer him from the floor to a gurney. P10 continued to resist and was told if he did not stop fighting staff, he would be “sprayed.” Throughout the struggle, security was seen with their hands on P10’s face and ears, in addition to a forearm across P10’s neck and chest. Security attempted to lift P10 onto the gurney as he continued to struggle. SG-B stated, “Stop fighting or I’m going to spray you.” While lifted off the ground and actively resisting, SG-B sprayed P10 with Repuls. P10 was then placed on the gurney face down and the violent restraints were attached to the gurney. Security continued to also hold P10’s limbs to the bed as he continued to thrash. A security guard could be seen using the palm of his hand to press the side of P10’s face into the mattress of the gurney, covering P10’s cheek and ear. P10 was then transported from the acute psychiatric services lobby and triage area to the secured patient care area. Once in a private patient room, P10 was informed they intended to transfer him to a ligature resistant bed secured to the floor. A nursing staff member administered an IM medication, and staff completed transferring P10 onto the bed face up. While on the bed, nursing staff continued to attempt de-escalation as the violent restraints were secured. Throughout the incident, P10 was screaming and thrashing, requiring intermittent manual restraint in addition to the use of violent 4-point restraints. P9’s ED visit note dated 5/26/26 at 10:30 a.m. indicated P9 was an 18-year-old male who presented to the ED via ambulance for evaluation of safety following suicidal ideations of jumping from bridges. P9 was on a provisional discharge from civil commitment at the time he presented to the ED. P9’s relevant medical history included suicide attempt in 2024, schizoaffective disorder bipolar type, autism, intellectual disability, traumatic brain injury (TBI), antisocial personality disorder, and fetal alcohol syndrome. A provider note dated 5/27/26 at 9:55 a.m. indicated P9 had been to multiple hospitals for evaluation within the last few days. Upon the most recent discharge, P9 called police while walking on a bridge. Law enforcement officers who responded had to pull P9 off the bridge railing to safety. Clinical findings indicated P9 reported symptoms with psychosis. P9 was placed on a 72-hour hold, and county case management indicated they would petition for his provisional discharge to be revoked. The plan was to admit P9 for further stabilization and treatment. P9 was transferred to the inpatient psychiatric unit on 5/28/26 at 5:27 p.m. A certification note dated 5/29/26 at 7:26 a.m. indicated inpatient psychiatric care was medically necessary to decrease P9’s symptoms and improve his overall condition. A progress note dated 5/29/26 at 3:19 p.m. indicated P9 was increasingly irritated and agitated and demanded to be discharged. Upon education regarding his legal status, P9 indicated he would “beat people up” to be discharged. Oral as needed (prn) medications were administered for behavioral concerns. A violent restraint note dated 5/30/26 at 1:41 p.m. indicated P9 began pounding on the nursing station plexiglass with various demands. Staff activated the panic alarm, and a behavioral response team was initiated. Nursing and security staff successfully deescalated P9 and brought him to seclusion, where he agreed to multiple oral PRN medications. While in seclusion, P9 began pounding the glass of the door while requesting to be taken to jail. Staff attempted to deescalate the situation, however, P9 threatened to assault nursing staff to be arrested and taken to jail. Deescalation by nursing and security staff was unsuccessful. When P9 started to strike the door again, security staff informed him he would be tased. P9 postured and refused to sit in bed. When staff opened the door to enter the seclusion room, P9 lunged out of the room and security staff used their taser on P9. P9 was then placed on his bed in five-point restraints for safety. A violent restraint note dated 5/30/26 at 3:42 p.m. indicated P9 was transitioned from five-point restraints to seclusion at 12:45 p.m. A violent restraint note dated 5/30/26 at 3:49 p.m. indicated P9’s seclusion was discontinued at 1:10 p.m. A discharge summary dated 6/1/26 at 2:45 p.m. indicated P9 was discharged to the community in a psychiatrically stable condition. A security incident report titled “CR05302026-393888_1” dated 5/30/26 at 11:43 a.m. indicated security guard (SG)-A responded to inpatient psychiatry unit for P9’s behavioral disturbance. While in seclusion, P9 stated he would punch SG-A in the face. “Due to [P9’s] very agitated behavior and threats of violence,” verbalized they would potentially need to use their taser, and nursing staff said this was okay. The established plan was to open the seclusion room door and hold P9 at taser-point. When the door was unlocked, P9 pushed the door open, but then retreated away in a “fighting stance”. P9 then charged at security and the door, and SG-A deployed their taser and achieved neuromuscular incapacitation (NMI) and fell to the ground. Security and nursing staff then placed P9 in violent restraints. The taser prongs were removed from P9’s body, and P9 was moved from the ground to the bed where the violent restraints were secured. During a debrief meeting, staff met and agreed this was the best outcome and actions were appropriate due to P9’s agitation and threats of violence. A body worn camera was active. A security incident report titled “CR05302026-393888” dated 5/30/26 at 5:26 p.m. indicated SG-B accompanied SG-A, nursing staff, and additional security staff to the psychiatric unit for P9’s behavioral disturbance. Deescalation was attempted, however P9 continued to punch the door and threaten staff. Security “ordered” P9 to lay on the bed, and P9 refused and stated he wanted to be taken to jail and would assault staff. Security then deemed entering the seclusion room would be unsafe and decided to proceed with use of a taser. SG-A drew her taser and informed P9 he would be tased if he continued to refuse directions. Upon entering the room, security had the taser drawn, activated, and was then deployed. Security then applied four-point restraints while P9 was lying on the ground and then moved to the bed where medical staff applied the fifth restraint, a waist belt. Local county sheriffs were notified of the incident. A body worn camera was active. A document titled “Event Review Assessment Program” dated 6/3/26 indicated the use of a taser on P9 by SG-A was reviewed by security manager-A and security manager-B. The video, audio, report, and the use of force were reviewed. The report indicated SG-A deployed their taser in response to P9’s threats and charging security. It was determined most security staff would have responded to this event in a similar manner. No action was required because of the use of force review. An unfinished document titled “Use of Force Review,” dated 7/20/26 indicated the events of 5/30/26 were reviewed on 6/4/26. The document indicated suggestions were not made because facility policies were followed. No further action was recommended. Body camera video footage from 5/30/26 at 8:52 a.m. was reviewed on 7/20/26 at 2:28 p.m. with the security manager. The footage was comprised of four body worn cameras situated in the center of security guards’ ballistic vests; the footage played in sync. In the footage, P9 was seen inside the seclusion room slamming his fists against the glass while nursing staff attempt to deescalate him. Registered nurse (RN)-A approached the group of security guards and discussed the situation. RN-A stated P9 was not actively psychotic, had a history of assaulting staff, and indicated nursing staff needed to place P9 into restraints because he was hurting his fists on the glass. For several minutes, nursing staff attempted to deescalate P9 and were unsuccessful. They then allow security to approach the door, and P9 threatens to assault SG-A. Multiple security staff could be seen holding violent restraints while speaking with P9. Security staff attempt to deescalate by asking P9 to sit on the bed so they can enter and apply the restraints. P9 refused. SG-A told P9 to lie on the bed or they would taser him. After several minutes of failed de-escalation, security staff state they are going to enter the room despite P9 refusing their directives. A security guard indicated they wanted to “go hands on” as soon as they enter the room, but SG-A stated, “I don’t think that’s a good idea,” to which the other guard asked “Why?” SG-A stated, “It’s not hands on right now.” SG-A then spoke to nursing staff and stated security may need to deploy the taser, and P9 may be tased if he did not comply. Nursing staff did not object. Under security’s direction, a nursing staff member unlocked the seclusion room door. P9 pushed the door open hard, security staff rushed in, and P9 responded by backing up. The taser guiding lights were immediately seen on P9’s torso, indicating SG-A had drawn her taser and turned it on. SG-A told P9 to lay down on the bed. P9 then ran towards security and the door. The taser was deployed as P9 collided with SG-A’s left shoulder, and P9 fell to the ground. Security staff immediately began applying restraints to P9’s bilateral wrists and ankles. P9 did not actively resist at this time and allowed security staff to apply the violent restraints. Together, staff lifted P9 onto the medical bed and secured the restraints to the bed. Nursing staff then applied a fifth point of restraint in the form of a waist band. During an interview on 7/20/26 at 9:24 a.m., registered nurse (RN)-A stated she had been P9’s primary nurse on 5/30/26. On the morning of 5/30/26, P9 jumped over the counter into the nursing station, triggering a call for a behavioral emergency response team. When security arrived, they were initially able to work together to walk P9 into the seclusion room and take oral PRN medications without an issue. However, while in seclusion, P9 began banging his fists on the door and walls to the point his hands were bloody. Nursing staff worked for about half an hour to attempt to deescalate P9, however he was intent on assaulting staff to go to jail and continued to injure himself by striking the door and walls. When additional security arrived, RN-A informed them of the situation and the need to place P9 into violent restraints. Three or four security guards approached the seclusion room and attempted their own de-escalation, and P9 specifically threatened SG-A. Security staff spoke about going hands on versus using the taser, and the decision was made to enter with the taser drawn. When nursing staff opened the door, P9 postured and charged the door, but backed away when he saw the taser. RN-A stated P9 did not have access to weapons or anything to use as a weapon while in seclusion and was wearing hospital scrubs. SG-A told him to get on the bed, and when P9 refused and charged staff, SG-A deployed the taser. Immediately, security began applying violent restraints while nursing staff supervised. RN-A stated she felt there were no other steps that could have been taken to prevent P9 from being tased. During an interview on 7/30/26 at 9:37 a.m., the nursing manager stated it is the responsibility of nursing staff to work with security and avoid the use of law enforcement tools whenever possible. If there is a situation where a patient continues to be violent, security will take the lead. Nursing staff are to intervene when medically necessary and continue to deescalate whenever possible. In the past, the nurse manager had seen tasers and Repuls presented to patients over verbal threats. During an interview on 7/30/26 at 10:40 a.m., RN-B stated she worked with P10 after security had sprayed him in the face with Repuls. RN-B stated if she saw security using law enforcement weapons on a patient to place them into restraints, she would notify the provider and then immediately notify nursing leadership. During an interview on 7/30/26 at 12:42 p.m., SG-B stated restraints are only applied at the direction of medical or nursing staff. The facility provides law enforcement weapons of Repuls and a taser. Repuls can be used if staff have given instruction to the patient and they do not cease aggressive behaviors. Tasers are only used if there is concern for great bodily harm. SG-B stated their weapons can be used in “any situation you can justify for using the tool,” such as “if [the patient] is being extremely aggressive and they need to gain control,” or “if they don’t have enough [security staff] and they are having a hard time controlling the situation.” SG-B stated they are smaller and “fighting a really big guy,” they can “justify when [they used] a taser.” When security is experiencing bodily harm and patients are not listening to directives, they are allowed to use whichever weapon is most appropriate. SG-B stated these law enforcement tools cannot be used to gain patient compliance to be placed into medical restraints. Security staff should use a manual hold if a patient is resisting restraint placement. SG-B stated on 4/13/26 she assisted with trying to place P10 into restraints. Security had P10 on the ground as he continued to actively resist. There were at least eight security staff at that time, including a security supervisor. P10 was given multiple directives to stop resisting, and as they were lifting him onto the gurney, he continued to be aggressive. Because of this continued behavior, SG-B sprayed P10 in the face with Repuls. The Repuls spray was minimally effective, and he continued to struggle against staff. P10 was then placed on the gurney, restrained, and brought back to the secured patient care area. SG-B stated they chose to deploy their Repuls spray because P10 was “actively trying to put people in danger.” During an interview on 7/20/26 at 1:08 p.m., SG-A stated either Repuls or tasers can be used on patients “if there is an act or threat of violence towards security or staff.” SG-A stated if a patient is actively resisting, security must act in the protection of “staff and self and may use weapons to get [patients] into restraints.” On 5/30/26, SG-A stated she was working with other security staff to try and place P9 into restraints. While in the seclusion room, P9 was punching the door’s glass, threatening to assault nursing staff, and threatening to hurt SG-A. After P9 threatened SG-A, SG-A asked nursing staff “if a taser incident was okay,” and “they were okay with that.” Security discussed amongst themselves on using hands-on tactics or a taser, and it was decided they would draw and point the taser as soon as they opened to door to see if they could get P9 to cooperate with being placed in restraints. When the door was opened, P9 charged forward and pushed the door. SG-A immediately drew her taser, and P9 backpedaled into the seclusion room. SG-A gave P9 directives to lay on the bed, and he charged at her. SG-A deployed the taser at the same time P9 ran into her left shoulder. The deployment resulted in neuromuscular incapacitation, and he fell to the floor. Security staff immediately placed P9 into restraints. She informed nursing staff where the taser probes were and they were removed. P9 was then lifted onto the seclusion room bed, and the restraints were attached to the bed. County sheriffs were notified of the use of the taser, and they elected not to arrest him. P9 remained on the unit as a patient. During an interview on 7/21/26 at 8:40 a.m., security manager-A stated all security staff are provided with handcuffs, Repuls, and tasers. Handcuffs are only used if a person who is not a patient has committed a crime and staff are completing a citizen’s arrest. Repuls may be used if patients are threatening to fight, or they are starting to “come at [staff].” Tasers may be used on patients exhibiting active aggression, attempting to assault staff, or actively assaulting someone. Security manager-A stated staff may not use [Repuls or tasers] to place a patient into restraints. Use of force reviews are conducted whenever there is a staff or patient injury, or the use of a law enforcement tool occurs. The review will consist of security managers or supervisors reviewing the security guard’s report, supplemental reports, and any video footage from hallways or body cameras. Reviews were conducted on incidents regarding P9 and P10 and found they were within the facility’s policies. During an interview on 7/21/26 at 9:48 a.m., the chief nursing officer (CNO) stated all nursing staff are aware security cannot use their weapons to gain compliance with restraint placement. If nursing staff were to witness this, they would need to intervene, report it, and ensure the patient is safe. It is the responsibility of the clinical team to determine how patients are placed into restraints. During an interview on 7/21/26 at 10:03 a.m., the director of security stated Repuls may be used when de-escalation fails, and the patient begins clenching their fists or making verbal threats. Tasers may be used if there is active resistance, aggressive body language, or verbal threats. The director stated the taser cannot be used to point at a patient and tell them to get onto the bed. Tasers may only be used to prevent assaults. The director of security stated law enforcement weapons may not be used as a means to force a patient to comply with restraint placement. A training titled “Repuls Instructor Course,” dated 2022 indicated Repuls can be deployed when security staff encounter passive resistance, and tasers may be deployed when encountering active resistance, not assaultive behavior. A facility policy titled “Use of Force,” dated April 2024 indicated the use of any law enforcement weapon must be in accordance with CMS guidelines. The policy indicated law enforcement weapons may not be used to place a patient in restraint or seclusion. Facility security may display their provided law enforcement weapons as a threat of force. Active resistance was defined as evasive movements, pushing or pulling away from security, and bracing or tensing. When a patient or subject exhibited active resistance, security is authorized to use their taser, Repuls, and non-deadly force. Active aggression was defined as attacks “with or without a weapon with the intent and apparent ability to cause death or Great Bodily Harm.” When a patient or subject exhibited active aggression, security staff are authorized to use their taser, Repuls, non-deadly force, and deadly force. The use of intermediate weapons, taser and Repuls, were not to be used as a tool to gain control of a patient for application of restraints. A facility policy titled “Use of Force” dated August 27, 2024, indicated security’s responsibility is to use the least amount of force necessary when handling patients. It indicated the use of Repuls or taser by security staff may not be used as a tool to gain control of a patient for placement of medical restraints. A document titled “New Hire Defensive Tactics” dated January 2025 indicated all new hires were educated on the mechanics of escort holds, rear-clinch takedowns, ground control, and ground defense, “weapon retention,” and choke defense. The training did not include indications for use of these maneuvers. The Lesson Plan and Class Transcripts” dated indicated training for use of manual restraint holds, handcuffs, grappling, and weapon retention were discussed and completed over a period of 5 days. The training did not include any explanation for when law enforcement weapons were appropriate.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40945 Based on interview and document review, the hospital failed to ensure patient rights were protected when the facility failed to thoroughly investigate and prevent abuse for 1 of 10 patients (P1) reviewed for abuse when a patient spit in a staff’s face and called the staff a racial slur, the staff reacted by slapping the patient in the face. The patient or patient representative and staff were not interviewed, and staff were not reeducated following the incident. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. A condition level deficiency was issued at A-0145. See A-0145 for additional information.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40945 Based on interview and document review, the hospital failed to ensure patient rights were protected when the facility failed to thoroughly investigate and prevent abuse for 1 of 10 patients (P1) reviewed for abuse when a patient spit in a staff’s face and called the staff a racial slur, the staff reacted by slapping the patient in the face. The patient or patient representative and staff were not interviewed, and staff were not reeducated following the incident. Findings include: P1’s medical record was reviewed. P1 was admitted to the medical unit on 3/16/26, for altered mental status. P1’s diagnosis included acute toxic metabolic encephalopathy, severe agitation, delirium, amphetamine intoxication, and opioid withdrawal. A hospital report dated 3/24/26 indicated on 3/23/26, at around 2:30 pm, P1 began to hit the side rail with his restrained arm hand. RN-A was concerned that he might injure himself. RN-A placed his hand on P1’s arm and when he did that, P1 spit into RN-A’s face and called him a racial slur. RN-A reacted instinctively and slapped P1’s cheek. RN-A self-reported the event and notified nursing leadership present at the time. RN-A was placed on administrative leave, and the HR process was being followed. Vulnerable adult protocols were being followed including leadership interviews of witnesses and discussion with P1 although he currently had limited understanding of the situation. P1 was examined by a provider, and no injuries were noted. A nursing note dated 3/23/26, at 3:32 p.m., indicated P1 alternated between being sleepy and being agitated. P1 spit on staff and called staff the “n-word”. P1 was unable to be reoriented or fully understand plan of care despite attempts to educate. P1’s registered nurse (RN) neurological/cognitive assessment at that time indicated P1 displayed poor judgement/safety awareness, poor attention/concentration, agitation, restlessness, and was tearful. During an interview on 4/22/26, at 10:94 a.m., RN-B stated he was the interim RN manager for the medical ICU unit which P1 was on while hospitalized. He stated after the incident RN-C immediately came to him and reported what she had heard. RN-C reported while RN-A was in the room providing care for P1 she heard a slap and entered P1’s room. P1 was yelling and said RN-A had hit him. RN-A also came to RN-B and reported that while providing care for P1, P1 spit into RN-A’s face and RN-A instinctively slapped P1 across the face. RN-A was immediately suspended pending the investigation and received three days of unpaid suspension for the incident. No other patients or family members were interviewed as part of the investigation. No other staff members were interviewed as part of the investigation. RN-A was allowed to return to providing care on the medical ICU unit after the three-day suspension without any formal education, training, or coaching sessions. This was required to be reported to the Minnesota Board of Nursing; however, it was not reported until 4/22/26. During an interview on 4/23/26, at 8:25 a.m., RN-A stated P1 had spit on his face while he was administering medications. P1 assaulted me first by spitting in my face. He instinctively struck P1 across his face. P1 was in bilateral arm restraints at this time. After the incident he reported this to the unit manager and was placed on leave. He received a written letter explaining the findings of the hospital investigation which included the Vulnerable Adult policy and the consequences of his actions, and a three-day suspension without pay. He was not required to complete any additional education, in person coaching or training. During an interview on 4/23/26, at 10:28 a.m. Chief Nursing Officer (CNO) stated after an allegation or incident involving patient abuse the hospital must complete an investigation. A complete investigation would include interviewing other patients on the units, talking to family members if applicable and interviewing other staff members. The concern for her would be is this is an isolated incident or has abuse occurred prior and we need to have all the details to develop an action plan. This is critical to ensure patient care is being provided in a safe setting. Prior to RN-A being allowed to return and provide patient care there should have been education and training. RN-A should have had education related to the following areas, Nurses Practice Act, VA abuse prevention, assigned education courses online and meeting with unit leaders. Education should have been provided to ensure this would not happen again. In addition, this event should have been reported immediately to the Minnesota Bard of Nursing, however it was not until 4/22/26. The hospital policy titled Vulnerable Adult dated 4/26/2021, indicated the purpose of the policy is to ensure identification and protection of vulnerable adults, to minimize the risk, or prevent maltreatment of vulnerable adults, and to detect/report/prevent maltreatment or potential maltreatment when such maltreatment is suspected. The policy defines abuse as any act which violates Minnesota criminal laws in the areas of assault, mistreatment of confined persons, use of drugs to intentionally injure another or facilitate a crime; or the solicitation, inducement or promotion of prostitution or criminal sexual misconduct; or the intentional or non-therapeutic infliction of pain or injury; or any persistent course of conduct intended to produce mental or emotional distress, including the unauthorized use of aversive and deprivation procedures. This includes hitting, slapping, kicking, pinching, biting or corporal punishment. The policy further indicated the manager of the unit will Investigate the event to discover what happened, if maltreatment is suspected, individual patient assessments are completed by licensed professionals during the healthcare encounter. Specific care plans and interventions shall be documented in the electronic health record (EHR) when suspected maltreatment is identified and put corrective measure into place to prevent recurrence. The hospital policy titled Investigating Employment Misconduct Workplace Concerns dated 4/9/2024, indicated in the event that an employee’s performance and/or behavior does not meet expectations, corrective action may be appropriate. The types of corrective action may include, but are not limited to, coaching, verbal reprimand, written reprimand, suspension, demotion, and termination.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48300 Based on observation, interview, and document review, the facility failed to discontinue restraints at the earliest possible time on the pediatric unit for 1 of 10 patients (P1) reviewed for restraints. This resulted in P1 remaining in locked 2-point restraints for 9 days despite documented times of calm and cooperative behavior. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.12. A condition-level deficiency was issued. Please see A-0174.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 48300 Based on observation, interview, and document review, the facility failed to discontinue restraints at the earliest possible time on the pediatric unit for 1 of 10 patients (P1) reviewed for restraints. This resulted in P1 remaining in locked 2-point restraints for 9 days. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.12. This failure resulted in an Immediate Jeopardy (IJ). The IJ began on 3/12/24 when facility staff failed to remove locked restraints from P1 despite documented times of calm and cooperative behavior. The Chief Executive Officer (CEO), Chief Nurse Executive (CNE), Vice President of Performance Improvement and Safety, Accreditation Program Manager, Service Line Critical Care Senior Director, Accreditation Program Specialist, Pediatrics Manager, Pediatric Medical Director, and Pediatrics Physician Chair were notified of the IJ findings on 3/22/24 at 10:23 a.m. The IJ was removed on 3/25/24 at 1:15 p.m. after verification of an acceptable removal plan, but a condition level deficiency was issued. Findings include: P1’s admission record indicated P1 was admitted to the hospital on 2/15/24 with diagnoses that included autism spectrum disorder, fetal alcohol syndrome, major depressive disorder, and schizophrenia. P1’s medical record indicated on 3/12/24, P1 was placed in 4-point locking restraints after punching a staff member and breaking a window with his foot. P1’s risk assessment by psychologist on 3/13/24 at 4:50 p.m. indicated P1 stated he would not hurt anyone if taken off restraints. The assessment indicated the patient did not appear or show any indication of being in imminent risk to himself or other people. This assessment was shared with the pediatric physician, who is responsible for the overall care of P1 and declined to release P1 from restraints. 3/14/24 1:38 p.m. pediatrician (MD-A) note indicated P1 contracted to not harm property or others. The note also indicated the facility could not ensure the safety of the infants and children on this medical unit where P1 resided. without additional staffing resources (a mental health worker as a 1:1 and a security guard). The above information was reviewed in staff care conference with care coordinator, social worker, nursing, child life, ethics and peds medical team. 3/15/24 7:02 a.m. MD-A note indicated P1 continued in 2-point restraints due to high risk of destruction, harm to self, and harm to others. 3/15/24 9:30 a.m. nursing note indicated patient was understanding, apologetic, laughing and singing. 3/15/24 2:09 p.m. psychologist note indicated P1 denied any interest or plan to hurt another person, denied hallucinations and was calm. 3/17/24 5:06 p.m. MD-A note indicated P1 complained of left arm pain from the restraints. 3/18/24 12:30 p.m. nursing note indicated P1 was hearing voices that were frightening and requested as needed antianxiety medication. P1 was redirectable with conversation and music. 3/18/24 5:33 p.m. physical therapy note indicated restraints were removed with 2 security guards present in the therapy gym. The patient was in good mood and cooperative with therapy. Restraints were reapplied following therapy. 3/19/24 Psychologist note indicated P1 was pleasant, engaged and calm. “Violent restraints incur risk of traumatizing an individual, especially if those individuals are a vulnerable person and people with a trauma history, such as this patient”. P1’s Restraint Flow Sheets indicated he was in either 4-point or 2-point restraints continuously from 3/12/24 through 3/21/24. P1 was released from continuous restraints only to toilet, to ambulate or to attend therapy. On 3/19/24 at 3:15 p.m., P1 was observed lying on his back in his bed with locked restraints on his left wrist and right ankle. P1 was interviewed and stated the reason the restraints had been applied. He did not know what he needed to do to have the restraints removed. He stated he hadn’t “done anything bad lately”. On 3/20/24 at 2:00 p.m., psychologist was interviewed and stated he was present with P1 when the restraint order was renewed on 3/13/24. P1 was calm and denied intent to hurt self or others, but the restraints were renewed and continued. P1 repeatedly asked to have restraints removed. Psychologist does not have ordering/discontinuing privileges. Psychologist has provided de-escalation techniques and offered to remain on the unit while P1 restraints were removed. P1 remained in restraints. On 3/20/24 at 2:38 p.m., MD-A stated P1 needs to be compliant with instruction and demonstrate safety for the restraints to be removed. P1 is largely doing those requirements. The facility does not have the resources to keep him and others safe after removal. “I don’t want him in violent restraints, but I can’t think of another way to keep him safe. We are not the right place for his healing.” On 3/21/24 at 8:33 a.m., social worker (SW)-A stated she is working on placement an inpatient pediatric psych unit. P1 has been denied due to aggression and acuity and identified P1 is calm and appropriate during the visits. On 3/21/24 at 10:23 a.m., nurse manager (NM) of the pediatric unit stated the pediatric department had asked for additional resources to assist with the safety on the unit during the initial 48 hours following the discontinuation of restraints for P1. Requests included but not limited to security present on the pediatric unit, 1 to 1 mental health workers, or moving the patient to a different secure unit. The requests were declined citing limited resources. The Hennepin Healthcare System Restraint and Seclusion policy dated 3/9/2021 instructs discontinuation of restraint and seclusion should occur as soon as possible, based on an individualized patient assessment and reevaluation, when the observed behaviors have decreased in severity or no longer present and the patient has met the discontinuation criteria regardless of the scheduled expiration of the order. The IJ was removed on 3/25/24 at 1:15 p.m. after the following actions were completed: current restraint and Seclusion policy was reviewed with no revisions needed. A new supporting document, Violent Restraint Process in Pediatrics was added to the Restraint and Seclusion policy. The new supporting document outlined the purpose of ensuring the least restrictive interventions for the least amount of time and is specific to the pediatric’ unit’s restraint use. Online education on the new supporting document, violent restraints, ensuring the least restrictive restraint use for the least amount of time and utilization of the chain of command when inappropriate use of behavioral restraints id identified was provided to pediatric unit nurses, physicians, and health care workers. Each team member will complete this education during their first shift working on the pediatric unit. The Violent Restraint Patient Flow Meeting Standard work was created to provide oversight to patient in violent restraints. The standard work form will be filled out daily and presented at the daily patient flow meeting for each patient in violent restraints. All patients in violent restraints will be reviewed for validation of patient behaviors warranting continued use of violent restraints, reduction strategies attempted, and any resources needed. This was verified through staff interview and document review.”