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Based on medical record review, document review and interview, in three (3) of 10 medical records reviewed, it was determined the facility failed to (a) involve a patient in their treatment plan, (b) protect a patient's right to be free from physical restraints for several consecutive hours as per its policy, (c) order physical restraints according to its policy and, (d) release restraints at the earliest possible time. This was evident for Medical Records (MR) #s 1, 2, and 3.

These failures may have placed patients at risk for serious psychological harm.

Findings include:

Review of MR #1 identified the patient was unresponsive upon arrival to the Emergency Department (ED) on 2/24/2022 and was admitted to the hospital. The patient was evaluated, treated, and was cleared for discharge home on 2/26/2022 at approximately 7:14 PM. The facility failed to involve the patient in the formulation of the treatment plan and disposition when there was a change in the patient's condition and failed to allow the patient to refuse care.

See findings at A 0131.

Review of MR#1 identified the facility failed to protect a patient's right to be free from restraints. Patient was placed in restraints for 13 consecutive hours, was on constant observation and concurrently administered medications to restrict their movement (chemical restraints), when the patient became agitated and wanted to be discharged from the hospital.

See findings at A 0154.


The facility failed to follow its policy when orders for physical restraints were written as standing orders. This was evident in medical record #s 1, 2 and 3.

See findings at A 169


The facility failed to ensure that the medical staff wrote orders for violent physical restraints that were consistent with its policy. This was evident in MR #s 1, 2 and 3.

See findings at A 0171.


Review of MR #2 identified the facility failed to renew orders for non-violent restraints that were consistent with its policy and this requirement, to ensure the safety of non-violent patients.

See findings at A 0173.

Review of MR #1 identified the facility failed to ensure that patient restraint was released at the earliest possible time regardless of the length of time identified in the order.

See findings at A 0174.

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, revealed the facility failed to involve the patient in the formulation of their treatment plan and disposition when there was a change in the patient's condition, and failed to allow the patient to refuse care. This was evident for MR #1.

Findings include:

The document titled "Restraint and Seclusion Policy" which was last revised 03/2022 states, "A patient with capacity has sufficient understanding to comprehend the purpose and consequence(s) of their situation and any responsibility held; and has the right to refuse restraint and seclusion. These patients should be educated on the purpose of the device, as well as the alternative measures that have been attempted and failed. Involve family as appropriate."

Review of MR #1 identified a 37-year-old patient who was admitted to the facility on 2/24/2022 at 10:50 AM. Upon arrival to the Emergency Department, patient was unresponsive except to deep sternal rub. By 11:26 AM that morning, the patient was awake, alert and spoke clearly. The nurse documented "patient speaks up clearly, states, I took my medicines last night before 5 PM, 1 mg of Klonopin (medication for panic disorder), Flexeril (medication for muscle pain) 10 mg & 200 mg of Neurontin (anti-seizure medication)."

A psychiatrist evaluation at 2/24/2022 at 5:02 PM, was done to rule out drug overdose and documented that the patient was alert and oriented to person, place and time and followed all commands. The psychiatric assessment was "negative for confusion." The patient's treatment plan and recommendation was, observation.
There was documented evidence in these notes that the findings were "viewed by the patient."

A doctor documented on 2/26/22 at 2:34 PM that the medicine and neurology medical staff cleared the patient at 2:34 PM as evidenced by the following, "patient medically stable to transfer to BHU (Behavioral Health Unit) or discharge home once cleared by psychiatry."

There was documented evidence in these notes that the findings were "shared with the patient."

The psychiatrist documented on 2/26/2022 at 7:14 PM; patient was reliable and the "patient through this hospitalization has denied overdosing on her prescribed Klonopin and Flexeril. The patient told me she has found 'salvation in Christ' and her new belief system is a deterrent to attempt to end her life. She reported past suicidal ideations. The psychiatrist signed off the patient's care and noted "Patient is psychiatrically cleared." The psychiatrist documented for the "disposition" that the "patient does not meet criteria for inpatient psychiatric admission." The psychiatrist also documented "patient will continue outpatient care with her treating psychiatrist upon discharge."

There was documented evidence that these findings were "viewed by the patient."

A discharge order was not written and 1:1 observation continued despite the psychiatrist recommendation, the psychiatrist signing off her care and recommendation for continued outpatient therapy.

On 2/27/2022 at 5:20 PM a psychiatric nurse practitioner (NP) was called to see the patient for insomnia. The NP documented the patient reported not sleeping well in the hospital but sleeps well at home. "Today patient assigned RN reports that the patient has been behaving erratically, screaming at staff when patient thinks [patient's] wishes are not met, and acting chaotic. The patient tried to justify a dislike with being on 1:1."

The RN and NP failed to specify the patient's chaotic and erratic behavior.
The NP documented on 2/27/2022 at 5:20 PM that patient was not psychiatrically cleared.

There was no documentation that this assessment and treatment plan was viewed and/or shared with the patient.
There was no evidence that the NP discussed with any psychiatrist the decision to rescind the patient's clearance from the psychiatrist.

A supervisor wrote a Verge (incident) report at 4:30 AM on 2/28/2022. Based on this Verge (Incident) report of 2/28/2022 at 4:30 AM, the patient became agitated on 2/27/2022 because patient wanted to be discharged from the hospital.

There was no documentation Staff A, Hospitalist who saw the patient on 2/28/22, RNs, or a supervisor shared the NP assessment of 2/27/2022 at 5:20 PM to justify why the patient was being kept in the hospital against the patient's will. In addition, there was no documentation that the patient was allowed to refuse care.

The patient was given medication: Ativan (sedative) 1 mg intravenously (IV) at 11:04 PM on 2/27/2022 and at 4:41 AM on 2/28/2022 as well as Haldol (causes sedation) 5 mg IM (intramuscularly) at 4:46 AM and placed in wrists restraints at 4:00 AM on 2/28/2022 because the patient was agitated, combative and verbalized she wanted to go home.

The patient was discharged home on 3/1/2022 at 2:07 PM, less than 24 hours after patient was released from restraints.

These findings were shared with Staff C, Compliance and Privacy Officer on 7/11/2022 at 4:15 PM.

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, it was determined the facility failed to ensure a patient's right to be free from the use of physical restraints. Specifically, a patient was cleared for discharge and became agitated after not being discharged, was placed in physical restraints, and kept on constant observation. This was evident in MR#1.

Findings include:

The document titled "Restraint and Seclusion Policy" which was last revised 3/2022 states, the definition of a Medical Non-Violent/Non Self-Destructive restraint is "The restriction of patient movement to prevent disruption of medical healing and treatment and/or to promote medical-surgical healing. The policy also states "Non-violent/Non Self-Destructive Restraint is utilized for soft wrist (left and/or right)."

The policy also states Behavioral Violent/Self-Destructive restraint is the "restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff members, or others. It is intended for emergency situations when a patient's behavior becomes aggressive or violent, presenting an immediate danger to his/her safety or that of others."

Review of MR #1 identified a 37-year-old patient who was admitted to the facility on 2/24/2022 at 10:52 AM. As per triage assessment, patient was unresponsive upon arrival except to deep sternal rub. The initial diagnosis documented at 8:06 PM, was Acute Transient Neurological Disturbance (disorder of the brain and nerves), unclear etiology. Patient also had a history of episodic weakness. The patient's previous medical history included Asthma, Chronic low back pain, a history of Laminectomy (spinal surgery) and Spinal Stimulator Implant, Anxiety, Depression, Bipolar Disorder, Borderline Personality Disorder and suicide attempt.

On 2/24/2022 at 10:44 AM and 2/25/2022 at 10:07 AM, the patient was seen by psychiatry to rule out drug overdose. The psychiatrist recommended enhanced observation.

On 2/26/2022 at 2:34 PM, a doctor documented that the medicine and neurology medical staff cleared the patient at 2:34 PM as evidenced by the following, "patient medically stable to transfer to BHU (Behavioral Health Unit) or discharge home once cleared by psychiatry."

On 2/26/22 at 7:14 PM the psychiatrist documented disposition that "patient does not meet criteria for inpatient psychiatric admission." The psychiatrist did not renew or recommend continued constant observation.

There was no evidence of a communication between the doctors of their decisions to discharge the patient.

On 2/27/22 at 1:45 PM the hospitalist documented "Today's subjective: upset since psychiatrist didn't come." The last vital signs were reviewed which were all normal. The physical examination revealed the general assessment, the patient "appears in no distress. Laying in bed. Lungs: Bilateral clear to auscultation. Heart: heart regular rate & rhythm, (-) murmurs. MSE (+) alert, awake, oriented X3." All systemic assessments (GI, musculoskeletal neuro and skin) were normal. Assessment and Plan: #Encephalopathy-resolved, EEG WNL, -no evidence of TIA or CVA, -neuro signed off case. #Chronic pain, -Gabapentin, -may have CRPS, work-up as outpatient. #Possible anxiety attacks: psychiatric consultation. Echo report WNL. Patient is medically stable to transfer to BHU or discharge home once cleared by psychiatrist. Patient remains on one-to-one watch, as suggested by psychiatrist.

On 2/27/2022 at 2:25 PM a Verge report noted the patient was agitated and was attempting to leave her room. A Code Grey was called and the patient was advised that she needed to stay in her room. The patient stated she would stay in her room.

On 2/27/22 at 4:05 PM a nurse documented that the patient had personal trauma which was discussed with a Behavioral Health NP (Nurse Practitioner-Psychiatry) and that the patient should be cared for by females due to constant accusatory comments directed towards men.

The hospital has one (1) psychiatric team which includes the Psychiatric NP who was on call on 2/27/2022 for the Psychiatry service.

On 2/27/2022 at 5:20 PM the psychiatric nurse practitioner (NP) was called to see the patient for insomnia. The patient reported that she does not sleep well in the hospital, but she sleeps well at home. "Today her assigned RN reports that the patient has been behaving erratically, screaming at staff when she thinks her wishes are not met and acting chaotic. The patient tried to justify her dislike with being on 1:1."

There was no documentation of a 2 Physician Certification (2 PC) for an involuntary admission of a psychiatric patient.

On 2/27/2022 at 11:04 PM the patient was given Ativan (sedative) 1 mg intravenously (IV) for agitation.

Staff A, Hospitalist, order at 4:43 AM on 2/28/2022, noted, nonviolent left and right wrists restraints and the indication for the restraint was "to prevent interference with medical treatment."
The "Standing Order Information" section in the order noted "restraint until discontinued reviewed daily. Expires 3/4/22."

A Verge (Incident) report for 2/28/2022 at 4:30 AM noted a Code Grey was called because the "patient wanted to be discharged."

On 2/28/2022 at 4:40 AM, Staff A, Hospitalist, documented in the medical record "patient agitated and combative - 2 doses Ativan 1 mg IV given. Placed in wrists restraints. Has female 1:1. Requested I leave room as I am male."

During an interview conducted on 7/8/22 at approximately 2:30 PM, Staff A, Hospitalist, stated, he was called to see the patient on 2/28/2022 at approximately 4:30 AM because the patient was trying to leave the unit and was agitated. He also stated the patient was given IV (intravenous) Ativan (sedative) x 2 and Haldol (causes sedation) 5 mgs IM (intramuscularly) at 4:46 AM that night and placed in wrists restraints because patient was agitated and wanted to leave the unit.

There was no documented evidence that the patient was receiving medical treatment that required inpatient hospitalization and bilateral wrists restraints up to 2/28/2022 at 4:00 AM when the restraints were applied.

The restraints were ordered for the patient's attempt to leave hospital, which according to the facility's policy, would be for violent behavior.

These findings were confirmed during another interview with Staff A, Hospitalist on 7/11/2022 at 11:15 AM.

Documentation in the flow sheets for 2/28/2022 revealed at 4:00 AM the patient was placed in bilateral wrists restraints. Patient was also on 1:1 constant observation as required by the facility's policy titled "Restraint and Seclusion Policy."

On 2/28/2022 at 9:13 AM the hospitalist documented "last night events reviewed, sleeping. The "General" assessment was "sleeping." "HEENT, lungs, heart, GI, musculoskeletal, and skin" assessments were normal. Cannot do neuro exam. Assessment and Plan: #Encephalopathy-resolved, EEG WNL, -no evidence of TIA or CVA, -neuro signed off case. #Chronic pain, -Gabapentin, -may have CRPS, work-up as outpatient. #Possible anxiety attacks: psychiatric consultation. Echo report WNL. Patient is medically stable to transfer to BHU or discharge home once cleared by psychiatrist. Patient remains on one-to-one watch, as suggested by psychiatrist.

On 2/28/2022 at 12:16 PM a psychiatrist documented that the "patient was agitated and apparently was aggressive toward staff early this morning, speech highly pressured and tangential, making bizarre and false accusations.... Seems delusional about our intentions and wishes to do harm to her. Still refuses to allow me to speak with her parents, with whom she lives, to ascertain their impression of what may have happened and what may have led to her very altered mental state leading to admission. The degree of agitation and disorganization are profound. I think her behavior at this juncture is so disorganized and dysfunctional as to require a brief inpatient psychiatric stay to stabilize her. I do not believe she is able to care for herself adequately in her current mental state."

The wrists restraints were removed on 2/8/2022 at 5:00 PM, 13 hours after they were applied.

The patient was discharged home in stable condition the following day on 3/1/2022 at 2:07 PM, less than 24 hours after the restraints were discontinued.

These findings were shared with Staff A, Hospitalist on 7/11/2022 at 11:50 AM, who acknowledged that he should have written an order for behavioral restraints for a two (2) hour duration.

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, it was determined the staff wrote orders for physical restraints as standing orders. This was evident in medical record #s 1.

Findings include:

The document titled "Restraint and Seclusion Policy" which was last revised 03/2022 states, the restraint orders for Violent/Self-Destructive restraint or seclusion is the "maximum duration of time restraint and seclusion may not exceed 2 hours for patients 17 years old and above." The policy also "Standing orders and orders written on an as needed basis, or PRN, are not permitted." The order requirement for "Non-Violent/Non Self-Destructive Restraint is daily."

Review of MR #1 identified a 37-year-old patient who was alert and oriented to person, place and time and had been cleared by all evaluating physicians for discharge home on 2/26/2022. The patient became agitated and attempted to leave the hospital on 2/27/2022 at approximately 10:00 PM.

Staff A, Hospitalist's, order on 2/28/2022 at 4:43 AM, noted, left and right wrists restraints and the indication for the restraint was "to prevent interference with medical treatment."
The "Standing Order Information" section in the order noted "restraint until discontinued reviewed daily. Expires 3/4/22."

This order was for non-violent behavior.

This order would expire four (4) days after the order was written.

This order did not meet the two (2) hour or 24-hour timeframes required for violent and
non-violent restraints.

This standing order was discussed with Staff A, Hospitalist on 7/11/2022 at 11:50 AM, who responded the duration of this order should have been for two (2) hours, which is the timeframe for orders for violent restraint and the orders should not be written as a standing order.

These findings were shared with Staff C, Compliance and Privacy Officer on 7/11/2022 at 4:15 PM.

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, it was determined the staff wrote orders for physical restraints for violent behavior that were not consistent with its policy and this requirement. This was evident in Medical Record # 3.

Findings include:

The document titled "Restraint and Seclusion Policy" which was last revised 03/2022 states, the restraint orders for Violent/Self-Destructive restraint or seclusion is the "maximum duration of time restraint and seclusion may not exceed 2 hours for patients 17 years old and above." The policy also states "Standing orders and orders written on an as needed basis, or PRN, are not permitted."

MR #3 is a 24-year-old patient who on 6/13/2022 arrived at the Emergency Department in acute psychosis (mental illness) and agitation, and was admitted to the BHU. The patient had a previous medical history of Schizoaffective Disorder.
On 6/13/2022 at 6:35 PM, a doctor wrote an order for a four (4) point restraint for interference with medical treatment. Restraint until discontinued reviewed daily. Expires 6/17/2022."

This order was written for violent behavior.

The order expired four (4) days after the order was written.

These findings were shared with Staff C, Compliance and Privacy Officer on 7/11/2022 at 4:20 PM.

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, it was determined the facility failed to renew orders for non-violent restraints that were consistent with its policy and this requirement to ensure the safety of non-violent patients. This was evident in Medical Record # 2.

Findings include:

The document titled "Restraint and Seclusion Policy" which was last revised 03/2022 states, the order requirement for "Non-Violent/Non Self-Destructive Restraint is daily." The policy also states "Continued use of restraint beyond the authorized time frame requires a new order. The restraint must be clinically justified."

MR #2 is a 62-year-old patient who was brought into the hospital for a psychiatric evaluation on 3/11/2022, and was admitted with diagnoses of Psychosis (mental illness) and anxiety.
On 6/5/2022 a doctor ordered application of "left mitt, right mitt for interference with medical treatment. Restraint until discontinued reviewed daily. Expires 6/10/22."

This order was for non-violent behavior.

The order expired five (5) days after the order was written.
This order did not meet the 24-hour timeframes required for non-violent restraints.

These findings were shared with Staff C, Compliance and Privacy Officer on 7/11/2022 at 4:20 PM.

Based on medical record review, document review and interview in one (1) of 10 medical records reviewed, it was determined the restraint was not released at the earliest possible time for a patient who was kept in restraint for an extended period of time. This was evident in MR #1.


Findings include:

The document titled "Restraint and Seclusion Policy" which was last revised 03/2022 states, for "Violent/Self-Destructive restraint or seclusion the maximum duration of time restraint and seclusion may not exceed 2 hours for patients 17 years old and above." The policy also states "Restraint and seclusion is discontinued when the RN or LIP/psychiatrist assesses that the behavior or condition, that was the basis for the order is resolved, even if less than the time limits set by the order. If the same behavior becomes evident again, a new order must be obtained. If the patient falls asleep during the restraint or seclusion, the restraint or seclusion is discontinued."


Review of MR #1 identified a 37-year-old patient who was alert and oriented to person, place and time and had been cleared by all evaluating physicians for discharge home on 2/26/2022. The patient became agitated and attempted to leave the hospital on 2/27/2022 at approximately 10:00 PM.

A Verge (Incident) Report for MR#1, noted on 2/28/2022 at 4:30 AM, a Code Grey was called because the "patient wanted to be discharged."

Review of MR #1 revealed the nursing staff applied bilateral wrist restraints to the patient on 2/28/2022 at 4:00 AM, as per documentation on the Flowsheet.

Staff A's Hospitalist, order at 4:43 AM on 2/28/2022, noted, left and right wrists restraints and the indication for the restraint was "to prevent interference with medical treatment."
The "Standing Order Information" section in the order noted "restraint until discontinued reviewed daily. Expires 3/4/22."

Documentation on the Flowsheet revealed the patient was asleep at 5:15 AM, 1 ½ hour after application of the restraint and asleep at 6:30 AM on 2/28/2022, two and a half (2 ½) hours after the wrists' restraints were applied.
The restraints were not removed until 5:00 PM that day, 13 hours after they were applied.

The staff failed to follow its policy to remove the patient's restraints when the patient was no longer agitated or trying to leave the hospital and when patient had fallen asleep at 5:15 AM and at 6:30 AM that morning, (2 ½) hours after the wrists' restraints were applied.

These findings were shared with Staff C, Compliance and Privacy Officer on 7/11/2022 at 4:30 PM.

Based on medical record review, document review and interview, it was determined the facility failed to investigate a patient's allegation of sexual assault. This was evident for MR #1.

Findings include:

Review of MR #1 revealed Staff B, Licensed Medical Social Worker (LMSW) documented on 2/28/2022 at 11:54 AM that the patient made allegation of being sexually assaulted while in the hospital that morning after the night nurse gave the patient's medication
Documentation in the medical record noted during this timeframe patient was administered Ativan (sedative) IV 1 mg x 2 at 11:04 PM (2/27/2022) and at 4:41 AM on 2/28/2022 and Haldol (medication for calming and agitation) 5mg IM at 4:46 AM on 2/28/2022.

A Verge (Incident) report was documented and investigated for the Code Grey (alert for a behavioral emergency) activated at 4:30 AM on 2/28/2022 because the "patient wanted to be discharged."

Review of incidents in the hospital Incident Reporting System (VERGE), revealed there was no documentation that the patient had made an allegation of sexual assault nor documentation of an investigation.

Review of Quality Assessment and Performance improvement document titled "Department of Quality Management Quality Review," which was not dated, revealed, the Manager of Security was made aware of Patient # 1's complaint that a male, possibly a patient, was allowed into her room sometime around 0200 hr on 2/27/2022. The patient claims that a male sexually assaulted her in her bed while a female staff member (Patient Care Associate) was watching. The Orangetown Police were called and filed a report. A SANE (sexual assault nurse examiner) had responded and examined the patient.

The document lists notes from the patient's medical record but there was no documentation of an investigation or analysis of the alleged incident.

These findings were shared with Staff C, Compliance and Privacy Officer on 7/11/2022 at 4:25 PM.