HospitalInspections.org

Based on observation of facility video surveillance, review of facility policy, record reviews, and interviews, the facility failed to ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital's restraint policy, training program and in accordance with State law during the implementation of a physical restraint for one of eight patients reviewed (Patient #A).

Findings included:

Review of the facility policy Restraint Process (Policy Number 2.26, effective 04/01/2022), under Initiation of Personal/Physical Hold Restraint, it stated "staff member will utilize approved SAMA technique to restrict the patient's movement for safety."

Video review of 06/28/2025 incident involving Patient #A who was having an emergency behavioral incident
06:23 PM Staff #6 places Patient #A's arms behind her back and forces her towards seclusion room
06:25 PM Patient #A placed in seclusion
06:50 PM Patient #A released from seclusion

Video review of 06/30/2025 incident involving Patient #A who was having an emergency behavioral incident that required seclusion
11:04 PM Staff # 8 who stands over Patient #A face to face (dialogue inaudible)
11:05 PM Staff # 8 pushes against Patient #A onto Staff #7
11:05 PM Staff # 7 pulls Patient #A by the arm towards the seclusion room
11:05 PM Patient #A hits Staff #7
11:06 PM Patient #A is on the floor behind the seclusion room with indistinguishable staff above her trying to force her into seclusion room
11:09 PM seclusion doors closed and locked
11:15 PM Patient #A attempts to push the seclusion door open
07/01/2025
01:24 AM seclusion doors unlocked, but staff is blocking the exit
02:10 AM patient is released from seclusion

Review of Patient #A's chart revealed a restraint hold were ordered for the above incidents.

Review of the facility training for techniques for effective aggression management (SAMA) did NOT include physical holds like the ones observed in the video for both incidents.

An interview with Staff #1 on 07/08/25 at 11:20 AM in the conference room confirmed the above findings.

Based on review of facility policy, review of medical records and confirmed in interview, the facility failed to ensure each restraint used for the management of violent or self-destructive behavior was in accordance with the 2 hour time limit for adolescents in one of five patients with restraints reviewed (Patient #A).

Findings included:

Review of the facility policy Seclusion Process (Policy Number 2.28, effective 11-2024), it stated "Each and every Seclusion episode requires a separate physician's order in an emergency situation, the RN may authorize the use of seclusion. In those circumstances, however, a physician's order (written/verbal) for seclusion must be obtained immediately following or no later than one hour following the initiation of seclusion/restraint. As part of obtaining that order, the RN consults with the physician regarding the patient's physical/ psychological condition and release criteria.

Seclusion orders are time-limited as follows:
Ages (18 and up) - 4 hours
Ages 9 to 17 - 2 hours
Ages under 9 - 1 hour
Orders include:
Reason for seclusion/restraint
Type of Restraint
Release criteria

If the original order is about to expire, and a clinically competent RN has evaluated the individual face-to-face and determined the continuing existence of an emergency, he/she must contact the physician to obtain a new order to continue the process.
The physician must sign all telephone orders for seclusion, to include the time of the order, within 48 hours of the time that the order was originally issued"

Review of Patient #A's medical chart revealed she is a 16 year old female with a history of ADHD, DMDD, and GAD who was admitted to the facility for their program.

Further review of her chart revealed personal and seclusion restraints were used on 06/30/2025. Staff #8's nursing notes included:

"Patient was observed filling cups with hand sanitizer and pouring it onto the floor, then proceeded to throw
milk cartons into the nurses' station and at staff. When staff attempted to retrieve the items, patient became
physically aggressive, striking staff in the face. Due to continued combative behavior-including punching, kicking,
hair-pulling staff, and refusing to release grip-staff initiated personal restraints from 23:05
to 23:08. Special Teams was called, and patient was placed in seclusion at 23:09. While in seclusion, patient
was noted to be yelling, crying, and cursing at staff. Patient removed her clothing and attempted to strangle herself.
Staff immediately intervened to remove the clothing for patient safety; however, patient remained combative
toward staff. The House Officer was notified of the patient's status. An order was received for Thorazine 25 mg IM
STAT, which was administered to the right ventrogluteal site. Medication was tolerated well, with no adverse
reactions noted. Patient was released from seclusion at 01:09 after demonstrating decreased agitation and
aggressive behaviors. No injuries were observed. An attempt was made to notify the patient's caseworker; however,
there was no answer. Patient was able to return to her room without further behavioral concerns"

Review of Patient #A's medical chart revealed the following orders for restraints:

11:13 PM Personal Restraints, Restraints adolescent seclusion
with reason as "To prevent imminent physical or emotional harm to others because of threats, attempts or other acts the patient overtly or continually makes or commits"

Video review of 06/30/2025 incident involving Patient #A who was having an emergency behavioral incident that required seclusion
11:04 PM Staff # 8 who stands over Patient #A face to face (dialogue inaudible)
11:05 PM Staff # 8 pushes against Patient #A onto Staff #7
11:05 PM Staff # 7 pulls Patient #A by the arm towards the seclusion room
11:05 PM Patient #A hits Staff #7
11:06 PM Patient #A is on the floor behind the seclusion room with indistinguishable staff above her trying to force her into seclusion room
11:09 PM seclusion doors closed and locked
11:15 PM Patient #A attempts to push the seclusion door open
07/01/2025
01:24 AM seclusion doors unlocked, but staff is blocking the exit
02:10 AM patient is released from seclusion

Restraints were kept on for over 2 hours (2 hours 15 minutes) with no documentation of a new order to continue.

In an email received 07/23/2025 with Staff #2, she acknowledged that the restraints were kept on longer than the 2 hour limit for patient's age.