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Based on document review, interview, and observation, it was determined for 2 of 5 (Pt. #1 and Pt #2) restraint records reviewed, the hospital failed to ensure that the patients' rights were protected. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.


Findings include:

1. The hospital failed to ensure that the use of restraint was implemented in accordance with safe and appropriate restraint techniques by failing to ensure an emergency safety interview/crisis prevention (CPI) hold was correctly and safely performed. See deficiency cited at A 167.

2. The hospital failed to ensure that a patient was monitored while in restraints, as required. See deficiency cited at A-175A

3. The hospital failed to ensure that the staff completed and documented the required assessments/reassessments while patients were in violent or non-violent restraints. See deficiency cited at A-175B.

Based on document review, observation, and interview, it was determined that for 1 of 10 (Pt #1) clinical records reviewed for restraints, the hospital failed to ensure a crisis prevention (CPI) hold was correctly and safely performed.

Findings include:

1. On 8/8/23, the policy titled, "Physical Holds (revised 12/13/22)" was reviewed. The policy stated,
"Procedures: ... 2. Physical hold can only be done by an employee who has successfully demonstrated competency in initial and annual training on CPI techniques (qualified staff member)... 6. Whenever physical hold is used, there shall be one staff person whose only responsibility is to observe the patient for duress throughout the use of physical hold."

2. On 8/9/23 Pt #1's record was reviewed. Pt. #1 was admitted to the hospital on 07/11/23 with diagnoses of "Primary: schizophrenia, Secondary: generalized anxiety disorder." Pt #1's record included a nursing note dated 7/14/23 6:35 PM which stated, "While staff was in the middle of another code red (aggressive/suicidal patient) with another patient, (Pt #1) took a chair and threw it against the fire door then proceeded to sit down in the restraint chair that was intended to be used by staff to restrain another aggressive patient. Limits were set with (Pt #1), and (Pt #1) was told to remove self from the chair. Pt #1 complied but then went to the fire door and started punching it. Another code red was called. Pt #1 was placed in a physical hold, and he started to hit, kick and spit at staff. Pt #1 was acutely psychotic, screaming nonsensical words and trying to hurt staff. During the struggle, pt #1 and staff ended up on the floor during the physical hold.... After a 3-minute physical hold pt was placed in the restraint chair at 6:41 PM..."

3. On 8/9/23 the video of Pt #1's restraint event was reviewed with the Manager of the Unit (E #3). The video showed at 6: 37 PM Pt #1, picked up and threw a chair. Pt #1 then starts to run down the hallway and turns around as MHT (E #5) is coming down the hall with a restraint chair. Thirteen seconds after Pt #1 threw the chair, E #5 puts a right hand on Pt #1's shoulder. E #5 pushes Pt #1 towards the wall. Pt #1 then pushes off the wall and sits in the restraint chair. RN (E #7) exits the other pt's room and speaks with Pt #1. Pt #1 gets out of the restraint chair and takes approximately 3 running steps towards the fire door. The fire doors open and E #5 grabs Pt #1. Pt #1 is seen with his right hand on the back of E #5's neck/shoulder. E #7 reached up and grabbed Pt #1 around the neck (in a choke hold), E #5 and another staff member (unidentified) are shown trying to brake Pt #1's grasp on E #5. The video then shows Pt #1 falling back towards E #7. Pt # 1, E #7 and E #5 fall to the floor. Then a total of 6 staff members are physically holding Pt #1. The pt is ultimately moved to the restraint chair at 6:41 PM. The video lacked a specific staff member observing the pt throughout the use of the physical hold.

4. An interview was conducted with the Unit Manager (E #3) during the video review. E #3 stated, "The choke hold is not a CPI technique and should not have been used. There is to be a staff member that is watching the pt. They are not to be hands on with the pt while observing. I do not see a staff member who is monitoring the pt in the video."

5. An interview was conducted with Quality Manager (E #1) on 08/10/23. E #1 stated, "(E #1), MHT (E #4) and (E #5) have been re-assigned to non-pt care areas pending OIG (Office of Inspector General) investigation. There is no disciplinary action. This is our protocol to remove individuals directly involved with any incident that goes to OIG while the investigation is on-going. There has been no re-education related to CPI. We have provided re-education related to the restraint chair."

A. Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed regarding use of restraints for violent, the hospital failed to ensure that a patient was monitored while in restraints, as required.

Findings include:

1. On 08/09/23, the Hospital's policy titled, "Use of Restraints and Seclusion (Containment) in Mental Health Facilities (Reviewed 12/13/22)" was reviewed. The policy stated, "... E. Continuous Observation. 1. An individual who is mechanically restrained or secluded must be continuously observed by 1:1 supervision from a qualified staff member whose only responsibility is to monitor the individual in mechanical restraint or seclusion...."

2. On 8/9/23 the clinical record of Pt. #1 was reviewed and included the following.
- Pt. #1 was admitted to the hospital on 07/11/23 with diagnoses of "Primary: schizophrenia, Secondary: generalized anxiety disorder."
- "Order for Physical Hold, Mechanical Restraint, or Seclusion" dated 7/14/23 at 6:39 PM, included, "Pt physically aggressive with staff. He threw a chair in the hall, sat in restraint chair then attacked staff. Placed staff at imminent risk of harm.... Type Ordered: Restraint Chair. Date/Time Seclusion or Restraint Began: 7/14/23 at 6:41 PM. Date/Time Seclusion or Restraint Ended 7/14/23 8:38 PM..."

3. On 9/9/23 the video of Pt #1's restraint event was reviewed with the Manager of the Unit (E #3). The video showed Mental Health Technician (E #4) pushed Pt #1, while in the restraint chair, from the hallway into the restraint room at 6:41 PM The video then showed E #4 exiting the restraint room at 6:43 PM. No staff enter the restraint room until MHT (E #5) is noted entering the restraint room at 6:56 PM. The video indicated Pt #1 was left restrained in the restraint room alone without continuous observation by 1:1 supervision between 6:43 PM and 6:56 PM (13 minutes).

4. An interview was conducted with E #3 during the review of the video recording. E #3 stated, "Anytime a patient is in restraints, there should be a 1:1 direct observation of the patient. The video shows that there isn't anybody in the room doing 1:1 supervision between 6:41 (PM) and when (E #) enters at 6:56 PM. The people standing in the hall are not completing the required 1:1 supervision. I'm not sure why they are standing out there."


B. Based on observation, document review and interview, it was determined that for 2 of 5 patients' (Pt. #1 and Pt. #2) clinical records reviewed regarding use of restraints, the Hospital failed to ensure that the staff documented the required assessments/reassessments while patients were in violent or non-violent restraints.

Findings include:

1. On 08/09/23, the Hospital's policy titled, "Use of Restraints and Seclusion (Containment) in Mental Health Facilities (Reviewed 12/13/22)" was reviewed. The policy stated, ".... Appendix Nursing Standards of Care for Individuals in Mechanical Restraint or Seclusion... III. Nursing Care Given During Mechanical Restraint or Seclusion:.. 2. The RN may delegate nursing care to qualified staff as appropriate... 3. Nursing care shall include: a. Direct observation at the bedside of a restrained individual.... b. summarization of individual's behavior at least every 15 minutes...

2. On 8/9/23, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 07/11/23 with diagnoses of "Primary: schizophrenia, Secondary: generalized anxiety disorder." Pt #1's record had an order for physical hold and mechanical restraint dated 7/14/23 at 6:39 PM. The order stated,"Pt physically aggressive with staff. He threw a chair in the hall, sat in restraint chair then attacked staff. Placed staff at imminent risk of harm.... Type Ordered: Restraint Chair. Date/Time Seclusion or Restraint Began: 7/14/23 at 6:41 PM. Date/Time Seclusion or Restraint Ended 7/14/23 8:38 PM..." Pt #1's "Restraint/Seclusion Flow Sheet" lacked signature of who completed the 6:56 PM and 7:11 PM observations.

3. On 8/9/23, the clinical record for Pt. #2 was reviewed. On 6/7/2023, Pt. #2 was admitted on 12/21/22 with a primary diagnosis of Borderline Personality Disorder. Pt #2 was placed on 1:1 observation on 7/15/23. Pt #2's "Special Observation Record" had documentation taped onto the form indicating Pt #2 was monitored. Underneath the taped documentation, the form had the initiation time of 7:42 PM and then nothing until 12:00 AM on 7/16/23.

4. An interview was conducted on 8/9/23 with the Manager of the Unit (E #3). E #3 reviewed Pt #2's record and stated, "I have no idea why they would do that. That is inappropriate. The observation record should be completed on the form." E #2 reviewed Pt #2's record and verbally stated, "The handwriting looks the same. The tech did not complete and sign the form and should have."

5. An interview was conducted on 8/10/23 with MHT ( E #6). E #6 reviewed the flow sheet and verbally agreed the handwriting at 6:56 PM, 7:11 PM, 7:26 PM and 7:41 PM was (E #6's) own writing. E #6 stated, "When I got in the room, the form was blank. I filled out the times and the other areas. I completed and signed the documentation for when I was observing the pt. I did not sign the other 2 areas (6:56 PM and 7:11 PM) as I was not in the room, but I did complete the boxes.