HospitalInspections.org

Based on a review of facility documents, medical records (MR), employee interviews (EMP), it was determined that the facility failed to follow hospital policy in the implementation of least-restrictive restraints and renewal of the violent/self destructive restraint order, in one of eleven medical records reviewed (MR1).



Findings include:

On November 7, 2024, a review of facility policy titled "Violent/Self Destructive Restraints (Behavioral)", last reviewed February 2022, revealed "... These may be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. ... Violent, self-destructive restraint(s) will be implemented only after all other less restrictive, non-physical preventative strategies, interventions, or appropriate alternatives have failed. ... Restraints are never to be used for the purpose of coercion, discipline, retaliation by staff, or for the convenience of staff members, or in response to behaviors or circumstances that do not constitute danger of injury to self or others (i.e., verbally abusive behavior). ... The use of physical restraint(s) will be discontinued as soon as possible in all cases. ... The need for restraints will be assessed by the nurse and by the physician caring for the patient in consultation with the healthcare team. ... Restraint order is valid for a maximum of: 4 hours - adults age 18 and older ... Follow-up Evaluation (Re-evaluation): ... If the need for restraint(s) continues, the physician conducts a re-evaluation within 24 hours of the application of restraints and prior to order renewal. ..."


On November 7, 2024, a review of facility policy "WVU Medicine Uniontown Hospital Police Policy and Procedures: 520 Taser Use Guidelines", last revised June of 2023, revealed "POLICY: ... The TASER may be deployed when using reasonable force with the intent to temporarily incapacitate and permit the officer(s) to control the subject. At NO time should an Officer deploy the TASER device for patient compliance in a medical or non-criminal situation. ..."


On November 7, 2024, a review of the medical record and facility documents provided the following chronological summary of the events that occurred regarding MR1 on October 8, 2024:
· 02:20:00 Uniontown Hospital Police Department (EMP13, EMP14) notified of an incoming patient via EMS who was intoxicated. Police officers traveled to Emergency Department.
· 02:22:00 MR1 arrived in the Uniontown Hospital Emergency Department
· 02:27:10 EMP25 assigned as attending provider of MR1, initial patient evaluation performed
· 02:28:42 EMP25 removed as attending provider of MR1
· 02:29:00 Heart rate, respiratory rate, blood pressure, and pulse oximetry measured via automated monitor
· 02:31:36 EMP13 activated taser
· 02:31:46 EMP13 applied taser to MR1 for approximately two seconds
· 02:32:04 EMP13 de-activated taser
· 02:34:00 Chief Complaint documented as "Alcohol intoxication"
· 02:36:51 EMP10 assigned as attending provider of MR1
· 02:37:00 Nursing Note: "Pt arrived via [EMS], pt heavily intoxicated and lethargic"
· 02:40:00 EMP10 ordered Violent/Self-destructive Restraints for MR1
· 02:40:00 Officer EMP13 left ED scene, notified EMP4 taser was used on MR1
· 02:50:00 One-to-one observer handoff completed (EMP15, EMP27)
· 02:50:00 "Suicide Risk Screening deferred by social worker because 'Patient lacks capacity'"
· 02:50:00 Officer EMP14 left emergency department
· 03:00:00 Ligature risks removed from MR1's room
· 03:42:00 MR1 to CT
· 04:45:00 Psychological Status/Behavior documented as "restless; mumbling; and/or inappropriate laughing", continued through 07:00:00.
· 06:40:00 The 4-hour violent/self-destructive restraint order expires
· 06:45:00 Restraints documented as "CONTINUED". MR1 behavior noted as "restless, mumbling, and/or inappropriate laughing"
· 06:45:00 Nursing Note: "Spoke to [EMP11] for violent restrain orders, pt restless and grinning"
· 06:45:12 EMP11 placed order: "Restraints - Violent/Self-Destructive Restraints (Behavioral)"
· 07:07:00 Change of shift completed (EMP15, EMP17)
· 07:15:00 Right wrist restraint removed
· 07:30:00 Left wrist restraint removed
· 08:00:00 Bilateral ankle restraints removed
· 09:13:00 MR1 assessed by Social Services
· 09:17:00 Provider Note: Patient seen by previous attending please see [EMP10]'s note. ..."
· 09:49:00 MR1 discharged to family


On November 7, 2024, a review of facility document "Use of Force Report" dated October 8, 2024, regarding MR1 revealed "... Date/Time of Occurrence: 10/8/2024 0231 hours ... Subject Injury: Injured; Welts at Taser Contact Points ... Summary of Incident: Patient began flexing muscles, clenching fists, and growling. [MR1] then began ripping medical equipment off. [EMP14, EMP12] began to take control of patient's actions. They were not able to control patient. I drew my taser and gave verbal commands to comply, patient refused. Patient was drive stunned to gain compliance. Patient was then put in medical restraints."


On November 7, 2024, at 10:30 AM, an interview was conducted with EMP13, in which they attested to tasing the patient prior to using mechanical restraints. When asked if police officers are required to follow hospital policy, as hospital employees, EMP13 replied, "Yes".



During an interview with EMP3 at 1:30 PM on November 7, 2024, it was confirmed that the facility failed to exhaust all other less restrictive, non-physical preventative strategies, interventions, and alternatives, before tasing the patient to gain compliance and initiating violent/self-destructive restraints. A 'Behavioral Assist Alert' was not utilized to attempt de-escalation techniques by specially trained staff. The facility was unable to provide evidence that a bedside re-evaluation was completed by the attending provider prior to the renewal order of violent restraints.