Based on observations, interviews, and record reviews during the course of the complaint investigation, the Condition of Participation: Emergency Services was not met as evidenced by the failure of the hospital to ensure there was sufficiently trained staff to address behavioral management as evidenced by the periodic use of law enforcement presence for standby for potentially violent and/or self-destructive patients; and use of police presence during involuntary medication administration for 2 of 10 applicable patients (Patient #1, Patient #3). Findings include: 1. Per review of nursing progress notes from 8/1/18 at 4:55 PM, Patient #1 tried to leave his/her ED room. Security had asked the patient to return to the room and the patient had refused. The patient started to push past the security officer and the officer stepped in front of the patient. The patient grabbed a keyboard from the computer outside his/her door and struck the screen of the computer several times, and then struck the keyboard on the wall. Security grabbed the patient and they wrestled around in the room with the security officer hitting his/her head on the wall during the interaction. Eventually, the security officer was able to get the patient on to the hospital bed and the patient calmed. The local police and crisis were called. At 5:00 PM the police were at the patient's bedside. At 5:40 PM, crisis was in the room evaluating the patient. At 6:00 PM, the police remained at the patient's bed side. At 8:00 PM, the police informed the staff that they were short staffed, "administration contacted to have officers on standby, pt calm at this time ....awaiting call back from administration for further plan of security support". At 8:45 PM, "sleeping. awaiting local law enforcement sign on for bedside standby". At 9:30 PM, "security updated on patient care plan to call PD immediately if patient awakens". At 11:30 PM, "pd arrived briefly for assessment of pt. pt awoke momentarily. pt fell back to sleep". Per interview on 9/10/18 at approximately 1:23 PM with the Chief Nursing Officer (CNO) and Manager of Regulatory Affairs, they stated that police were only called when the staff was feeling unsafe. The police were not utilized to manage patients; the police were there to support the staff. On 9/11/18 at approximately 4:00 PM during an interview with the ED Nurse Manager, s/he stated that when police show their presence, it was comforting to visitors and other patients. S/he stated that when the situation goes beyond the security guards' capacity the police were called; and that generally when the police walk into the department, patients' tend to change their actions. Per nursing notes on 8/2/18 at 12:15 AM, "2 security officers continue at bedside for standby, PD and sheriffs unable to have officer standby due to staffing. pt sleeping". On 8/2/18 at 8:30 AM, "Pt (patient) sitting on floor pushing buttons on the bed, pt then unlocked the bed. This RN told pt to stop pushing the buttons on the bed and leave the bed locked in place. This RN went around to the right side of the bed and locked the bed. Pt grabbed the lower left safety rail and began shaking the rail. Security officers x 2 went into room pt then grabbed the side rail and shoved the bed across the room. Security officers wrestled pt to the ground and pinned down pt down on the ground. RN called the police for assistance". Upon further review of the nursing progress notes, at 8:40 AM, 4 police officers and 3 security guards were at the patient's bed side and the crisis clinician was called to evaluate the patient. At least one police officer and two security guards remained at the patient's bed side until approximately 11:30 AM. Per interview on 9/12/18 at 8:47 AM with ED RN #1, s/he stated that Patient #1 had episodes in which s/he had escalated quickly and became violent. S/he stated that the patient had assaulted security guards at least 2 times prior to this incident and that the police had been called for staff and other patients' safety. 2. Patient #3 was admitted on [DATE] with a psychiatric diagnosis of bipolar and a history of noncompliance with prescribed medication and treatment. It was determined after a crisis screening Patient #3 required psychiatric hospitalization . While awaiting involuntary placement, Patient #3 was held in the Emergency Department (ED) for 10 days and experienced episodes of agitation, mania, delusions, resisting care and refusing medication. During this period of time, Patient #1 was subjected to staff coercion regarding the use of police presence. On 9/8/18 at 17:00 Nursing Mental Health Documentation states one of the ED physicians informed Patient #3 that because s/he was "...acting angry and aggressive" staff will need to administer an injection. The note further states "...s/he can either sit on the bed and take the injection or s/he needs to be restrained to the bed and then given the injection. Pt stated s/he would not hurt anyone and would be compliant". Meanwhile during the time of the discussion between ED nursing staff and Patient #3, at the door entrance stood 3 St. Alban's Police Officers and 2 county Sheriffs. The patient was then administered the involuntary medication of Zyprexa (antipsychotic) 10 mg. IM On 09/09/18 at 23:00 Nursing Mental Health Documentation states:" Pt. continues to be agitated. Walking around room-punching his/her fist in his/her hand. Discussed with MD. Decision to medicate--St. Alban's police called stand by assistance" At 09/09/18 at 23:31 a follow-up note states: "Two St. Alban's PD and two NMC security guards at bedside for medication administration by two RNs-patient cooperative with the RN and team for medication." The patient was administered Zyprexa 20 mg. IM. Per interview on 9/12/18 at 10:40 AM, Security guard #1 confirmed that at times with past events in the ED the St. Alban's police would be utilized to assist staff to hold down a patient in an emergent behavioral situation. During the events on 9/8/18 and 9/9/18 involving Patient #3, the police remained " a show of presence". Per interview on 9/12/18 at 11:20 AM, ED RN #2 confirmed s/he has called police "...as a back-up to our security" and further stated staff would call police "...to be present and once they are present patients will react...patient will calm down and listen." In addition, per ED Physician Documentation in regards to ED staffing and the use of restraints for Patient #3; On 9/9/18 at 06:53 s/he states: "May be worth trying him/her off restraints during the day if adequate security is present to manage him/her if s/he tried to leave". Per interview on 9/11/18 at 3:02 PM with the Director of Facilities and the Manager of Security, they stated that all of the security officers take the MANDT training which was a type of training that focuses on preventing, deescalating and if necessary intervening when the behavior of an individual poses a threat of harm to themselves and/or others. The Manager of Security stated that security's role was to maintain one to one observation, patrol the facility, check parking lots, check other buildings that that hospital owns, and help to maintain outside community relations. Per the Director of Facilities, s/he stated that security would coordinate with the local police department when necessary; however, the police would only be called with acts that were possibly criminal in nature; and that it was not very often that police were called. Per review of the hospital education transcripts for the security guards, there was evidence that only 2 of 6 staff members had MANDT training. Per interview on 9/12/18 at 2:28 PM with the Manager of Regulatory affairs, s/he confirmed that only 2 of the 6 security officers had MANDT training. S/he stated that it was the hospital's goal to have everyone trained within the year.