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Based on document review and interview, the facility failed to ensure; (a) patients' rights to safe, and appropriate health care restraint intervention, (b) ongoing training of all security officers who applies and monitor patients in restraints, in accordance with the required regulatory training.

These findings may have placed all patients at risk for harm.

Findings include:

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Based on medical record (MR) review, document review, and interview, in 2 of 5 medical records reviewed, the facility failed to furnish patients with the "Important Message from Medicare (IM)" within forty-eight hours of admission as required for patients who receive Medicare covered services.

Findings include:

Patient #1 is a 79-year-old Medicare beneficiary who was admitted to the facility on 10/18/15. A blank copy of the IM form was found in the patient's MR on 10/21/15
at 12:20 PM, three days after admission.

Patient #2, an 87-year-old admitted on 10/18/15. The patient's IM form reviewed on 10/22/15 at 12:30 PM, was blank and had not been furnished to patient or her representative.

The facility policy and procedure titled, "Patients' Rights/Responsibilities/Important Message from Medicare (IM)," last revised on 4/2014 notes, "IM is provided to the patient or their agent/surrogate) in their primary language or via an interpreter within 48 hours of admission date."

During interview with Staff A on 10/21/15 at 1:10 PM, she acknowledged that the IM notice was not provided to Patient #1 and #2 or their representatives. Staff A stated that whenever IM is not furnished by the admission staff due to the patient's mental status, nurses are required to provide the IM within 48 hours of admission to either the patient or their representative.

Based on interview and review of document, it was determined the facility failed to ensure patient's rights to care in a safe setting. Specifically, the facility permitted the use of handcuffs, a law enforcement restraint device that are unsafe to be used by hospital personnel for the restraint of patients. This finding was noted in 4 of 20 security incident reports reviewed

Findings include:


Incident #1 dated 9/17/15 notes, Security Staff B was called to 8 Bernstein (Psych unit) because Patient #3 refused to hang up the phone. Security Staff #B and Staff C escorted the patient to the seclusion room but the patient refused to go into the room. The patient was restrained by the wrist by the two security staff while the registered nurse administered medication. Security Staff B notes, "patient continued to struggle. He had to be handcuff."


Incident #2 dated 6/21/15 and authored by Security Staff D notes, "I had to use my handcuffs as well as Staff E's to keep Patient #4 restrained to the wheelchair during his transport to 8 Bernstein. Staff D reported the patient was handcuffed because he was very unruly and very combative with the nursing staff and security guards on the scene.


Incident #3 dated 4/30/15, Security Staff F reported Patient #5 had assaulted a doctor in the Emergency Department and threatened other staff members. The patient was handcuffed with the help of several other security staff pending the arrival of police officers who arrested the patient.


Incident #4 dated 4/1/15, Security Staff G notes Patient #6 was disruptive in the Ambulance triage area because he could not visit his friend in the Emergency Department and he began to trash the nurse's station. Staff G notes, "Patient #6 was placed in handcuffs until New York Police Department officers arrived."

The review of facility's policy (Policy #241) titled, "Use of Force", last revised in 2010 notes, "Handcuffs cannot be used as a form of restraints. Handcuffs can be used to prevent criminal behavior, including but not limited to assault, in persons who are considered a danger to themselves and others." The policy indicates security officers may arrest another person for any offense when the offense was committed in their presence.
The policy further notes, "Handcuffs are hospital property provided for officers protection, and are part of Security uniform."

At interview with Security officers regarding the use of handcuffs, Staff H, on 10/21/15 at 2:30 PM stated, handcuff is used as a last resort to apprehend patients who are disruptive and combative and who are deemed a danger to self and others.

Security Staff I on 10/21/15 at 2:27 PM, stated handcuff is used temporary to restrain a patient who is unruly, and a threat to staff, until the patient is moved to a location where hospital restraints can be safely applied by clinical staff.

Security Staff J on 10/21/15 at 2:35 PM, stated that a patient who has committed a crime in the hospital could be handcuffed pending the arrival of the New York Police Department.

At interview on 10/21/15 at 12:45 PM, Staff K (Director of Security), acknowledged the use of handcuffs by security staff and reported handcuffs are used only in immediate life threatening situations. He added that security staff members are not peace officers and can only make a citizen arrest.

Based on medical record review, document review, and interview, in 2 of 10 patients with restraints, nursing staff failed to ensure patients were restrained in accordance with the order of a physician or other licensed independent practitioner .

Findings include:
(a) Patient #7 is a 31 year- old with no known medical history who was triaged on 6/30/15 at 8:36 AM with a chief complaint of face pain and irritation/ itching of the eyes. Triage nurse notes, the patient had positive redness, irritation, and itching of eyes and face. On 6/30/32015 08:42, the nurse noted patient is combative, repetitive speech, threatening, throwing equipment in the air and screaming that someone sprayed something in his eyes and face. The nurse notes that five Security Officers escorted the patient to the treatment area where he received Haldol 5 milligram (mg) and Ativan 2mg. The patient was placed on security hold and four point restraints. The patient ' s eyes were irrigated by the Emergency Department resident.

Review of the Restraint Monitoring Flowsheet, dated 6/30/2015, noted that the patent was placed on four-point restraints on 6/30/2015 at 8:42 AM and the restraints were released on 6/30/2015 10:30 AM.

Security Incident Report, dated 6/30/2014 0940, confirmed the patient was placed in four-point restraint by security personnel.

Review of patient's record revealed there were no physician orders for the restraints applied to Patient #7 on 6/30/15.

(b) Patient #8 is a 22- year- old who arrived in the ED by ambulance on 7/11/2015 at 5:21 AM with chief complaint of alcohol intoxication and altered mental status. On 7/11/2015 at 6:24 AM, the nurse noted the patient was agitated with unsteady gait, and he attempted to leave the ED. The patient received medication for agitation. On 7/11/2015 at 7:13 AM, the nurse noted the patient was alert and oriented, but lethargic and combative and was placed in restraints.
The physician's orders written on 7/11/2015 8:00 AM, notes, "Restraints". The type of restraints and time frames for renewal of the restraint order was not indicated in the physician order.

There was inconsistent documentation of the type of restraint applied on Patient#8. The nurse noted on 7/11/14 at 8:03 AM, that two-point wrist restraint was applied to the patient; however, security incident report, dated 7/11/2015 0630, indicated that the patient was physically restrained and placed on four- point soft limp restraints.

During interview with Staff L on 10/23/15 at 2:30 PM, she acknowledged there was no restraint order for Patient #7 and she acknowledged the lack of proper restraints order for Patient #8.

Based on medical record review and document review, it was determined that in 1 of 10 medical records, nursing staff failed to discontinue restraints at the earliest possible time.


Findings include:

Patient #8 is a 22- year- old patient who was evaluated in the ED on 7/11/15 at 5:21 AM, with a chief complaint of alcohol intoxication and altered mental status.
On 7/11/2015 at 07:13 AM, the nurse noted that the patient was combative and was placed in restraints for safety.
It was noted that on 7/11/2015 from 8:39 AM to approximately 10:12 AM, Patient #8 was asleep; however, the restraint was maintained until 10:00 AM for a patient that was no longer a danger to self or others. Documentation entered by the RN on 7/11/2015 at 8:39 AM, noted the patient was asleep, continue restraints, circulatory assessment unchanged; at 9:43 AM, the physician notes, the patient is still sleeping.
On 7/11/15 at 10:12 AM, the nurse noted restraints discontinued as per MD at 10:00 AM.

The facility's policy and procedure; Policy NO: - R-3, titled "Restraints," last revised 8/15, notes that patients are not maintained in restraints longer than is necessary.

Based on medical record review, document review, observation, and interview, it was determined that in 3 of 6 medical records reviewed, nursing staff failed to ensure patients in restraint are consistently monitored for safety.

Findings include:

The facility's policy titled, "Restraints and Seclusion", last revised 8/2015, notes "Observe, assess and document (on Restraint Monitoring form) patients placed in restraints every thirty minutes for extremity restraint, and every two hours for Lap restraint when the Non Behavioral standard (Acute Medical Surgical Standards) are in place or at least once every fifteen minutes when the Behavior Management Standard are in place." The policy notes "provide safety and comfort measures every 2 hours or more frequently as the patient's condition indicates." In addition, "Patient response to restraint use is documented in the medical record and/or on the restraint flowsheet."


Patient #1: a 79-year-old who was admitted to the facility on 10/18/15 with changes in mental status. The patient was placed in bilateral wrist restraints on 10/18/15 at 12:30 PM, to prevent the removal of lines, tubes, and equipment.

The document titled "Restraint Monitoring Flowsheet," dated 10/20/15, revealed lack of documentation of patient monitoring on 10/20/15 from 7:30 AM to 10:00 AM; 11:00 AM to 11:30 AM; 12:00 PM to 12:30 PM and 1:00 PM to 2:00 PM. The restraint was discontinued on 10/20/15 at 2:00 PM.


Patient #9: a 54-year-old who was observed in bilateral wrist restraints, during tour of an inpatient unit (4 Linsky) on 6/21/15 at 12:25 PM.

The "Restraint Monitoring Flowsheet" for 10/20/15, did not indicate every two hours nursing intervention that was provided to the patient from 7:30 AM to 12:00 PM.
Review of the "Restraint Monitoring Flowsheet," dated 10/21/15, lacked indication of nursing care provided to the patient every thirty minutes and comfort measures every two hours, from 7:00 AM to 12:00 PM.


Patient #7: a 31- year- old was triaged in the ED on 6/30/15 at 8:36 AM, and was treated for irritation to the face and eyes. The nurse noted that the patient was combative and threatening and was placed in 4-point restraints.
The "Restraint Monitoring Flowsheet," dated 6/30/15, notes the patient was placed in restraints because he exhibited behavior that puts him and others at risk for harm. There is no documentation to indicate that the patient was monitored every fifteen minutes, in accordance with facility's policy for the management of patients who are violent or self-destructive.


At interview with Staff A, RN, on 10/21/15 at 12:45 PM, she stated that Patient #1 was out of the unit for a diagnostic test from 7:30 AM to 10:00 AM. She confirmed the patient was not monitored for the two hours and thirty minutes he was out of the unit in restraints.

During interview with Staff M, staff nurse for Patient #9, on 10/21/15 at approximately 12:25 PM, she stated she had been busy and did not have the time to document the assessment and interventions provided to the patient since 7:00 AM.



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Based on interviews and the review of 10 of 10 Security staff personnel files, it was determined the facility failed to ensure that staff members who apply and monitor patients in restraints, are trained in the safe implementation of restraints. (Staff N through W).

Findings include:

Security Staff N's file, lacked evidence of training and competencies in the implementation of restraints.
Similar findings regarding the lack of training and competencies in restraint implementation was found in the remaining staff files reviewed.

Review of document titled, "Responsibilities," notes, Security Officer Duties includes but are not limited to "Assists medical staff with psychiatric hold patients to prevent patient from harming self, staff, and others." Other duties of the security officers include assistance with restraint application and manual hold of patient under the direction of clinical staff.

Interview with Security Staff P, on 10/21/15 at 2:15 PM, he stated that he once applied four point restraint on a combative patient under the direction of a Registered Nurse.

Security Staff R, on 10/21/15 at 2:30 PM, stated that most times, he assist with restraint application but occasionally, he had applied restraints with the assistance of clinical staff.

At interview with Staff K, on 10/21/15 at 12:45 PM, he confirmed that security officers perform manual hold and assist in the application of mechanical restraints. He stated security officers have had no training in restraint implementation.

Based on interviews and the review of 10 of 10 Security staff personnel files, it was determined the facility failed to ensure that staff members who apply restraints are trained in nonphysical intervention skills, based on specific needs of their patient population.
(Staff N through W).

Findings include:

Security Staff N's file, lacked evidence of training and competencies in nonphysical intervention skills prior to the implementation of restraints.
Similar findings regarding the lack of training and competencies in crisis intervention for behavioral health patients were noted in the remaining staff files reviewed.

At interview with Staff K, on 10/24/15 at 2:40 PM, he confirmed that security officers were not certified in crisis prevention intervention.

Based on interviews and the review of 10 of 10 Security staff personnel files, it was determined the facility failed to ensure that security staff who assist in take downs, application and monitoring of patients in restraints, are trained in the use of first aid techniques and cardiopulmonary resuscitation. (Staff N through W).

Findings include:

Security Staff N's file, lacked evidence of training in First Aid and cardiopulmonary resuscitation.
Similar findings regarding the lack of training and competencies in first aid and cardiopulmonary resuscitation were found in the remaining staff files reviewed.

During interview on 10/21/15 at 12:45 PM, Staff K stated there is no mandatory First Aid and cardiopulmonary resuscitation training for Security Officers.