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This condition is not met as evidenced by:

Based upon a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain emotional health and safety of a patient by permitting a transportation company to place the patient in forensic restraints in order to transfer to another facility (A-0144) and failed to adhere to policy requirements for violent restraints (A-0167).


Cross reference
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(e)(4)(ii) Patient Rights: Restraint or Seclusion

Based upon a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain emotional health and safety of a patient by permitting a transportation company to place the patient in forensic restraints in order to transfer to another facility for one of one medical records reviewed (MR1).


Findings include:


On March 24, 2025, a review of the policy "Restraints and Seclusion" (Last Approved: 12/2024; Last Revised: 12/2024) was completed and revealed the following: "Definitions: ...4. Exceptions to Restraints- The following situations are not considered restraint interventions: ...3. The use of handcuffs or other restrictive devices applied by law enforcement for custody, detention, and criminal activity effecting public safety. Interventions and Procedures: 1. Restraint Initiation: The decision to use restraint or seclusion is not specific to any treatment setting or diagnosis but rather to the situation or behavior the restraint is being used to address. 1. Restraint can only be used when less restrictive interventions/alternatives have been determined to be ineffective to protect the patient or others from harm. These must be documented. ..."


On March 24, 2025, a review of the policy "Patient Rights and Responsibilities, F-03" (Last Approved: 03/2024; Last Revised 04/2018) was completed and revealed the following: "... You have the right to good quality care and high professional standards that are continually maintained and reviewed. ... You have the right to be free from restraints and seclusion of any form that are not medically necessary or are used as means of coercion, discipline, convenience or retaliation by staff."



On March 24, 2025, a review of MR1 revealed that the patient presented to the Emergency Department on March 12, 2025, with depression and voluntarily sought admittance for psychiatric care. On March 12, 2025, MR1 was to be transported to another facility for psychiatric care and was placed in handcuffs and a waist chain for transport. MR1 was not under the control of law enforcement: thus, this intervention did not meet the requirement of a restraint exception.



During an interview on March 24, 2025, at 12:05 PM, EMP6, the employee responsible for the handoff of MR1 to the transport company was interviewed and asked to explain what occurred at the time of the incident. EMP6 explained that voluntary commitment forms and paperwork were provided to, and report was given to EMP8 that MR1 was not a behavioral problem. EMP6 explained that EMP8 began to handcuff and shackle MR1. EMP6 intervened and explained that MR1 is voluntarily committed and that restraints were not appropriate. EMP6 recalled that EMP8 responded, "We signed a contract- ride in our cars, you are going to wear cuffs."



On March 24, 2025, at 11:52 AM, the above findings were confirmed by EMP4.

Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to adhere to policy requirements for violent restraints (extremities locked) for three of four restraint records reviewed (MR1, MR2 and MR3).


Findings include:


On March 24, 2025, a review of the policy "Restraints and Seclusion" (Last Approved: 12/2024; Last Revised: 12/2024) was completed and revealed the following: "Definitions: ...4. Exceptions to Restraints- The following situations are not considered restraint interventions: ...3. The use of handcuffs or other restrictive devices applied by law enforcement for custody, detention, and criminal activity effecting public safety. Interventions and Procedures: 1. Restraint Initiation: The decision to use restraint or seclusion is not specific to any treatment setting or diagnosis but rather to the situation or behavior the restraint is being used to address. 1. Restraint can only be used when less restrictive interventions/alternatives have been determined to be ineffective to protect the patient or others from harm. These must be documented. Violent Behavioral Restraints: A. Patients in violent behavioral mechanical extremity restraint/seclusion are placed in Special Constant Observation (SCO) until assessed by a Licensed Practitioner whom at the time, may order an alternate observation status. G. Assessment and Monitoring: 1. The patient is assessed by an RN at the time of restraint/seclusion and not to exceed every two hours thereafter, with the exclusion of chemical and physical hold restraints, and attends to their personal needs to prevent or reduce the potential physical and emotional complications of restraint use and to determine the continuing need for restraint to facilitate release at the earliest possible time. I. The restraint order is not to exceed 4 hours for adults ...K. A licensed practitioner is required to perform a face to face assessment within ONE hour of the initiation of the restrain/seclusion intervention. If the patient is released from seclusion, restraint, or physical hold within one hour, the one hour face to face must still be performed. Q. If a patient remains in restraint or seclusion for the management of violent or self-destructive behavior 24 hours after the original order, a licensed practitioner must examine the patient and conduct a face to face reevaluation before writing a new order for continued use ...".



On March 24, 2025, a review of MR1 revealed that the patient presented to the Emergency Department on March 12, 2025, with depression and voluntarily sought admittance for psychiatric care. On March 12, 2025, MR1 was to be transported to another facility for psychiatric care and was placed in handcuffs and a waist chain for transport. MR1 was not under the control of law enforcement: thus, this intervention did not meet the requirement of a restraint exception.


On March 24, 2025, a review of MR2 was completed and revealed the patient presented to the Emergency Department on 03/19/2025 at 21:31 after a fall. On 03/20/2025, MR2 was placed in violent restraints ("extremities locked") at 21:00. A physician face to face was completed on 03/20/2025 at 21:33. On March 20, 2025, at 1300, the patient was, again, placed in violent restraint (extremities locked). A physician face to face was completed on 03/20/2025 at 13:45. On 03/20/2025, an order was written, at 17:10 for the continuation of violent restraints. This order exceeds the 4 hour time limited policy for violent restraint as outlined by the facility. Further review of MR2 revealed that on March 20, 2025, at 21:38, an order was entered for the continuation of violent restraints. This order exceeds the 4 hour time limited policy for violent restraint as outlined by the facility. A face to face was completed by the practitioner. On March 21, 2025, violent restraint was reduced to 2 point restraint at 03:00 and discontinued on 03/21/2025, at 05:47, exceeding the 4 hour time limit without an additional order. On 3/21/2025 at 07:04, MR2 was again ordered violent restraints. Violent restraint was discontinued at 23:59. There are no orders for violent restraint at 11:04, 15:04, and 19:04. All documentation for the use of violent restraints ceases on 03/21/2025 at 17:00.


On March 24, 2025, at 11:52 AM, the above findings were confirmed by EMP4.


A review of MR3 revealed that on March 15, 2025, violent restraints (extremities locked) were initiated at 19:47 and discontinued at 22:46. MR3 was also placed in Special Constant Observation (SCO). There was no documented evidence of a face to face assessment by the physician for this 3 hour time period. On March 15, 2025, a second order was written for violent restraints at 20:04 and discontinued on March 16, 2025 at 00:49. MR3 was also placed in Special Constant Observation (SCO). There was no documented evidence of a face to face assessment by the physician for this approximately 3 hour period. Further review of MR3 revealed that on March 16, 2025, at 06:25, violent restraints were again initiated with a practitioner face to face occurring at 06:27. On March 16, 2025, MR3 remained in 2 point violent restraints at 10:30. The order was written at 11:07. This order exceeds the 4 hour time limited policy for violent restraint as outlined by the facility. The violent restraints were discontinued at 12:38. On March 17, 2025, at 00:00, an order was placed for the continuation of violent restraint that was initiated on March 16, 2025 at 10:30. The discontinuation time for restraint was documented in the MR3 as March 19, 2025 at 13:59. There was no documentation or entries in the chart regarding monitoring/assessment of restraint or additional 4 hours orders by the licensed practitioner after March 16, 2025 at 12:34.


On March 24, 2025 at 12:34 PM, EMP4 confirmed the above findings.