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ASSURANCE HEALTH PSYCHIATRIC HOSPITAL
USE OF RESTRAINT OR SECLUSION
Tag No.: A0154
Based on document review, observation, and interview, the facility failed to ensure the patient the right to be from restraint for 1 of 10 (Patient 8) patient medical records reviewed.
Findings include:
1. Facility policy titled, "Psychiatric Patient Rights", Policy No. RE16, last reviewed 03/2023, indicated Under Procedure, 10. Be free from restraint or seclusion unless there is imminent risk of physical harm to self or others.
2. Review of Patient 8's medical record indicated the provider ordered 1:1 observation on 06/18/2024 due to patient's high risk of fall.
3. Review of video surveillance on 06/26/2024 indicated at approximately at 2:43 p.m., S1 (Certified Nursing Assistant) was caring for Patient 8. Video surveillance confirmed S1 held patient 8 down in chair, by placing their hands on the shoulders of the patient. Video confirmed S1 repeatedly forced the patient to stay seated in the chair. S1 then placed the patient in the chair and pinned the patient between the wall and the table where the patient was unable to stand, restraining the patient to the chair.
4. Review of photo from video surveillance on 06/26/2024 indicated at approximately 6:30 p.m., patient 8 was seated in a chair that was pushed up against the edge of a table, placing the patient between the chair and table. A separate chair had been placed up against the back of the chair, back-to-back, to patient 8's chair patient 8. S2 (Certified Nursing Assistant) sat in the chair that was to the back of patient 8's chair restraining the patient from getting up from their chair.
5. Review of S6 (Licensed Practical Nurse) investigation written statement dated 06/29/2024, confirmed restraint incident of patient 8 by S2 as indicated above.
6. Review of S3 (CNA) investigation written statement dated 06/28/2024, confirmed restraint incident of patient 8 by S1 as indicated above.
7. Interview with A2 (Regional Quality Manager) on 07/10/2024 at approximately 2:25 p.m., confirmed the incidents above occurred through video surveillance and written witness statements.