HospitalInspections.org

Based on interview and record review, it was determined that for 1 of 10 patients, the hospital did not obtain a physician order for a restraint when force was needed by the staff to administer a feeding through a feeding tube. (Patient identifier: 1)

Findings include:

1. A review of patient 1's medical record was completed on June 3, 2025, and revealed the following:

Patient 1 was admitted to the hospital on December 18, 2024, and discharged on January 11, 2025, with diagnoses that included unspecified psychosis, Gastrostomy tube (G tube) feedings due to a history of intentional self-harm with lye ingestion, failure to thrive, and anorexia.

At admission, Patient 1 weighed 39 kilograms (86 pounds) with a low body mass index (BMI) of 15.47 (according to the Centers for Disease Control and Prevention and the National Heart, Lung, and Blood Institute, the normal range for a female in her 20s is between 18.5 and 24.9).

On December 24, 2024, at 9:16 AM, a physician wrote the following order: "If she does not complete each tube feed within 1 hour of scheduled mealtimes, staff will administer tube feed."

Note: Court documents showed that on April 5, 2022, the state of Wyoming granted legal guardianship to Patient 1's parents and deemed her incompetent. Per an interview with Patient 1's parents, they were aware and consented to the use of force to administer prescribed feedings if necessary.

On December 24, 2024, at 11:50 PM, a registered nurse (RN 1) documented that after the one-hour time limit, the patient had not self-administered any of the ordered feeding. Per the physician's order, the nurse attempted to initiate feeding, but staff had to "gently" hold Patient 1's arms while the nurse administered the feeding to prevent the patient from grabbing the tubing or swinging arms to interfere with the feeding.

On December 24, 2024, at 12:36 PM, a psychiatric technician (Psych Tech 1) documented that Patient 1 was given a specific amount of time to finish her feeding. Psych Tech 1 further stated that Patient 1 injected more water than formula into her G tube, and the staff needed to go "hands-on" to assist with the patient's feeding. Patient 1 appeared to struggle and stated, "That is very traumatizing for them to do that to me."

2. On June 2, 2025, at 7:07 AM, the surveyor interviewed RN 1. When RN 1 was asked about the nursing note she wrote on December 24, 2024, at 11:50 PM, she stated, "From what I remember, she never fought me or the team. We would hold her hands very softly. She was more vocal about issues with staff feeding her, but never abusive with staff."

On June 2, 2025, at 11:02 AM, the surveyor completed a second interview with Psych Tech 1. When asked to explain "hands on", she stated that three staff members went in to finish administering Patient 1's feeding, two staff members held the patient's arms while the nurse fed the patient through her G-tube.

The surveyor found no documented evidence that restraints had been ordered for Patient 1 at any time during her admission.
On June 2, 2025, at 10:36 AM, an interview was conducted with Patient 1's attending physician. He stated that Patient 1 had never been restrained during her admission.

On June 3, 2025, at 2:15 PM, the surveyor interviewed the Chief Quality Medical Officer and the Accreditation Manager. Both stated that holding Patient 1's arm to complete her feeding would not be considered a restraint. They both stated that restraining a patient to complete a medical procedure would not be considered a restraint. The Accreditation Manager used the example of a papoose board, a medical device that temporarily immobilizes an infant or child to facilitate completion of medical procedures, and it was not considered a restraint.

3. The hospital's policy for Violent and Non-Violent Restraint or Seclusion of Patients was reviewed. Hospital policy describes restraints as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

Centers for Medicare & Medicaid Services' standardized interpretation of "Physical Holding" is as follows: Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint. This includes holds that some members of the medical community may term 'therapeutic holds'. "Physical Holding for Forced Medications" is the application of force to physically hold a patient, in order to administer a medication against the patient's wishes, and is considered a restraint. The use of force in order to medicate a patient, as with other restraints, must have a physician's order.