February 24, 2009 | | Comments 13
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Do you know CMS’ stance on weapon use in healthcare?

It’s Scott Wallask filling in a bit for Steve Mac this week — as Mac put it to me,  “I”m up to my eyeballs in alligators this week.” Knowing Mac’s sense of humor, that comment could probably mean one of many things.

Moving on, one thing I’ve noticed is that security topics get a fair amount of hits on the blog, which prompted me to dig up this reference about CMS’s views on weapon use:

“The use of weapons by security staff is considered a law enforcement action, not a healthcare intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion,” according to CMS’ interpretive guidelines to section 482.13(e) of the State Operations Manual. “If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.”

Weapons include pepper spray, mace, nightsticks, Tasers, cattle prods, stun guns, pistols, and other similar equipment, according to the interpretive guidelines. Further, handcuffs, manacles, shackles, and other chain-type restraints are considered law enforcement items and aren’t appropriate healthcare measures to help staff members to restrain patients.

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Scott Wallask About the Author: Scott Wallask is senior managing editor for HCPro's Hospital Safety Center (www.hospitalsafetycenter.com) and the award-winning newsletters, Briefings on Hospital Safety and Healthcare Life Safety Compliance. He has written about healthcare for HCPro since 1998, with a focus on occupational and building safety, emergency management, fire protection, and infection control. Prior to joining HCPro, he worked as a reporter for several newspapers in eastern Massachusetts. He holds a BA in print journalism, magna cum laude, from Northeastern University in Boston. Contact Scott at swallask@hcpro.com.

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  1. What is their stance on forensic patients (i.e. prisoners who are receiveing inpatient care). Should they be shackled to the bed? If they were not in the hospital they would be behind bars in jail. A custody officer should accompany the prisoner to the hospital and remain with the patient until discharged.

  2. Scott Wallask

    Hi Mike —

    Here’s more detail from the CMS interpretive guidelines that I think will answer your question:

    “The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate healthcare restraint interventions for use by hospital staff to restrain patients. The law enforcement officers who maintain custody and direct supervision of their prisoner (the hospital’s patient) are responsible for the use, application, and monitoring of these restrictive devices in accordance with federal and state law. However, the hospital is still responsible for an appropriate patient assessment and the provision of safe, appropriate care to its patient (the law enforcement officer’s prisoner).”

  3. I can answer this for you: once the police drop the patient off at the mental health facility, staff are not allowed to use weapons and are discouraged to use any form of coercion/seclusion/restraint. The use of such jeopardizes their reimbursement from Medicare/Medicaid. Prisoners, who are a danger to armed officers and sometimes need multiple officers as escort, are treated as patients/clients on the mental health wards–most wards are co-ed and patients/clients can move freely throughout the ward–rooms always unlocked.

    Truth is stranger than fiction

  4. By the way, if you do feel the need to put a patient in seclusion/restraint, you will be required to fill out enough paperwork to render you useless on your ward for the rest of your shift–thus inspiring you to overlook patient-patient violence and self-inflicted violence. But the up-side to this is it will pad the numbers for HCPro’s bit of feel-good social propaganda, ie. Restraint and Seclusion, by Bloom and Bennington-Davis.

  5. Linda —

    You watered down your points about paperwork and prisoner patients with your parting shot in the second post. The restraint and seclusion book by Bennington-Davis has been off of our online store for quite a while, so it’s likely no one is making money off it any more…Scott Wallask, Senior Managing Editor

  6. Linda, I feel your “pain”…but having come from a Law Enforcement background, I have been on both sides now.

    It is more a matter of training for your Security Officers to keep them up-to-date of what ALL the agencies are saying (CMS, TJC, state/federal law) and yes, it does restrict them in various ways. Fortunately, we have not had a serious incident at my facility, as we only carry keys and radios, but they have been trained in verbal descalation techniques and proper restraint usage, hospital policy, and state/federal laws. We are allowed to use force when used in the protection of self, others, or property. Unfortunately, that use of force can result in injury…not only to the patient, but to the employee as well. I try not to look at the “lack” of weapons as a hinderance of the job performed, but as a challenge to keep my officers well. Sure, having tasers, handcuffs, batons, etc would be a “presence” in the use of force, and when properly trained, they may never have to be used. I can remember being “sized up” by the subject on a daily basis, to include my appearance, stance, posture, and yes…my “bat belt”. A “dancing red dot” can be very effective in calming someone down…
    Just my 2 cents.

  7. I would like to know who in CMS has defined handcuffs as not being “appropriate” for use by hospital staff, specifically trained Security Officers. What is CMS’ training, education and basis for this definition? Do the CMS decision-makers in this process have first-hand knowledge/experience dealing with assaultive patients/visitors? Yes, verbal de-escalation is the preferred method – everyone knows that. It does not always work. OSHA stipulates that we provide a safe, secure environment for our employees/visitors. How can we do that when one agency defines an item of EQUIPMENT as a weapon?! Ask any personnel who regularly and responsibly utilize handcuffs – not a one would define them as weapons. Hmmmm, I’ve seen Heparine, when used improperly, hurt/kill patients. Maybe CMS should outlaw the use of Heparin! In today’s economy, relying on a large staff response to control a combative patient is not realistic. Slashes to nursing and security staff often have hospitals getting by with a skeleton crew. In my opinion, if CMS decision-makers were the ones getting chairs thrown at them, punched, kicked, spit on, etc., the definitions would be much different.

  8. Our proprietary Security Department has enjoyed TASER technology in keeping our Level 1 Trauma center staff as free from assaultive injuries as possible for over the last 6 years. Under the guidelines of CMS, we treat every deployment of our TASER device (X26) as a law enforcement action – one that would justify arrest by a Law Enforcement agency. If we are forced to deploy on an assaultive/combative individual to protect self or 3rd party, we do so under strict deployment guidelines set forth in our training and meeting CA Penal Codes. After each deployment, we notify our Police Department of the tasing and the basic elements that met that deployment. It is then up to the Police agency to disposition that incident as they deem necessary and appropriate. We do not deploy to merely control an individual or to place in seclusion or restraint. All attempts to deescalate an adverse event through verbal and PMAB techniques are utlized unless violence is in progress requiring immediate deployment for stopping potential serious injury. We are not now, or ever have been, looked at like ‘cowboys or gunslingers’ by any medical staff or senior administrators. We document every mention of the TASER when used to stop potential or active violence whether it be through ‘presence’, ‘display’, or ‘deployment’. Over 6 years, we’ve documented 28 actual deployments out of 62 violent events that were in progress or on the verge of violence. By the mere presence of the device (on every Officer on duty), those who are considering (or cease using active violence) when we arrive on scene with TASER technology holstered, it is amazing at how many recognize what the TASER is capable of and that they meet the criteria of being tased. Our program allows anyone acting out time to recognize their error and make their decisions to deescalate prior to any deployment we may deem necessary for everyone’s safety. It has been a win-win program for our non-sworn proprietary Security Officers, one that is transparent, supported, and very accountable with only the intent of safety and security in the minds of every Officer who interacts in those unfortunate adverse events. We’ve never had an injury or fatality using the TASER, nor have we ever had a person that met the criteria to be tased bring suit against the organization. Medical staff have now come to rely on our presence with TASER technology for consistent support and protection – especially with those in mental crises who are violent. Our Security Department actually replaced Police presence as security for our Medical Center, as we have agencies within 3-4 minutes response times, yet during those 3-4 minutes, we’ve never had an incident that our Officers couldn’t handle with the verbal, hands-on, or TASER technology that required Police back-up. Our Security Department is 31 staff strong with a 3-Officer response to all violent incidents on each Watch. This has seemed to be a winning combination for us and continues today. I wish the same success for every Security entity out there who faces daily the potential for (and in-progress) violence and considers employing TASER technology for everyone’s benefit.

  9. To Greg Lawritson – I recognize this post as very dated, but wanted to ask if you’re still out there. If you are please contact me at stephen.garner@hcamidwest.com. Your hospital sounds like a copy of ours. Level I Trauma Center, Security Dept of about 31. One difference seems to be that we are commissioned with arrest authority, a distinction without a difference for CMS purposes since we are in-house security. Oh, and though we are armed, we do not carry tasers. I would be very interested in comparing notes.

  10. Greg Lawritson. We are trying to get approval to look at the Taser. We have about 24 officers, with no items to defend against aggressive patient, visitors, or others on the property. Some of us are Reserve Police officer and use the Taser at other jobs. Hos is your policy written. I do agree that they would only be used in a manner requiring Law Enforcement assistance for arrest in some events. Any info would be very helpful.

  11. CMS guidelines specifically mention tazers aka Conducted Electrical Weapons (CEW). Related guidelines state that use of such a device on patients violates a patient’s right to a safe environment per 42 CFR 482.13(f). Although specific to hospitals, the guidelines should be considered applicable to all healthcare settings. This does not mean they cannot be used; only that specific guidelines must be followed. http://cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf

    CMS considers any weapon (including CEWs) used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement. “CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.

    The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. The law enforcement officers who maintain custody and direct supervision of their prisoner (the hospital’s patient) are responsible for the use, application, and monitoring of these restrictive devices in accordance with Federal and State law. However, the hospital is still responsible for an appropriate patient assessment and the provision of safe, appropriate care to its patient (the law enforcement officer’s prisoner).”

    Suggested Safety Program (Required Training Elements on Use of CEW and Clinical Treatment of tazed victims not included in this list)
    CEW Program Guidelines
    1. Program Development
    a. Must be in accordance with state-specific statutes and regulations.
    b. Should follow CMS guidelines (even if the facility is not Medicare certified).
    c. Develop in-house written deployment and limits on firing criteria.
    d. Staff is required to agree (in writing) to operate the CEW under strict written deployment guidelines.
    e. CEW is only be deployed to protect self or third-party.
    f. CEW is NOT deployed to control an individual or to place the individual in seclusion or restraint.
    2. Deployment Process
    a. First attempts at deescalating an adverse event should be through verbal and Prevention and Management of Aggressive Behavior (PMAB) techniques, unless violence is in progress requiring immediate deployment for stopping potential serious injury.
    b. Provide the person to be shocked time to recognize their error and make their decision to deescalate prior to any deployment.
    c. If possible, announce the firing of the weapon by informing the individual to be shocked:
    i. of the presence of the CEW
    ii. what the CEW is capable of, and
    iii. that they meet the criteria of being shocked.
    d. CEWs should not be deployed near flammable chemicals or gases because there can be an electrical spark as the current arcs across the two wires.
    e. Attempt to clear the area of other individuals to prevent accidental shocking of individuals
    3. Documentation of use.
    a. Document every mention of the CEW between staff and the person to be shocked.
    b. Document showing the CEW to the person to be shocked.
    c. Document who warned the patient they are about to be shocked.
    d. Videotape as much of the event as possible, including the warning, CEW deployments, and effects.
    e. Document who deployed the CEW.
    f. Document the time CEW was deployed.
    g. Report deployment of CEW (except in training scenarios) as incident and conduct evaluation of event.
    4. Law Enforcement
    a. Treat every deployment of a CEW as a law enforcement action
    b. Deploy the CEW only when the subject’s actions would justify arrest by an enforcement agency.
    c. Notify the local law enforcement agency immediately following the deployment of the CEW and the basic elements that required the deployment.

  12. I wish a similar accomplishment for each Security substance out there who faces day by day the potential for viciousness and considers utilizing TASER innovation for everybody’s advantage.

  13. I am new to the administrative part of Hospital Security. I have been an officer for several years but was recently made a training officer. However, our training program was lack luster and I am playing catch up. Where can I find the CMS Standards for Security Training? We carry Tasers and are phasing in Armed officers after the removal of the local police department. I just want to make sure I train the department to be functional but still meet the requirements.

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