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Based on observation of video surveillance, document review and interview it was determined that the facility failed to protect and promote each patient's rights. Therefore, the Condition of Participation , 42 CFR 481.13 Patient Rights was not met, as evidenced by:


1. The Hospital failed to ensure that restraint/seclusion orders were obtained from a physician or mid-level practitioner. (see A-0168)

Based on observation of video surveillance, document review and interview, it was determined for 1 of 1 (Pt #1) behavioral health (BH) patient who required restraint-forced medication /seclusion in the Emergency Department (ED), the Hospital failed to ensure that restraint/seclusion orders were obtained from a physician or mid-level practitioner, as evidenced by:

Findings include:

1. On 5/25/22 at approximately 11:00 AM, the clinical record for Pt #1 was reviewed. Pt #1 was admitted to the ED on 4/21/22 at approximately 4:40 PM for complaint of "Anxiety". Pt #1 and diagnosed with Mania, Paranoia, and Bizarre Behavior. The ED physician's (MD #1) encounter note, dated 4/21/22: notes Pt #1 was experiencing "Mania, pressured speech, and paranoid thoughts." On 4/21/22 at 6:00 PM, it is noted "Pt has left the room several times. Talking about spaceship coming soon for patient." On 4/21/22 at 6:30 PM, it is noted, "Banging on room door yelling". An order was obtained on 4/21/22 at 6:30 PM, for Chemical Restraint. Pt #1 was then put into a physical hold at 6:37 PM, on 4/21/22 and given Lorazepam 2 milligrams (sedative), Haloperidol 5 milligrams (anti-psychotic) and then left alone in a locked seclusion room. The record lacked documentation of an order for a restraint/physical hold or seclusion.

2. On 5/26/22 at approximately 10:50 AM, the security footage of Pt #1 during the events of 4/21/2022 in the ED was reviewed with Director of Emergency Department (E #5). The video surveillance revealed:
4:46 PM-Patient in room with Uncle, and Uncle then leaves
4:50 PM-Patient in gown
4:55 PM---Patient in and out of room
5:05 PM---Patient drinking from cup
5:09 PM---MD #1 assessing patient
5:20 PM---Lab tech in room to do lab draw
5:25 PM---EKG tech in to do EKG
5:34 PM---Patient laying with blanket covering head
6:20 PM---X-ray tech in room to do patient chest x-ray (patient refused)
6:24 PM---Patient up and down from bed and in and out of room
6:27 PM---Patient trying to lift up door/wall
6:29 PM---Patient secluded/door shut by nurse
6:37 PM---3 nurses enter room, patient trying to leave room, restrained by 2 nurses (E #4 and E #6)
E #7 gave injection in right deltoid.
6:38 PM---E #6 holding patient head and all nurses release patient after med given (held approximately 15 seconds)
6:48 PM---Patient sitting on bed naked
7:14 PM---next shift RN to discuss with patient, patient cooperative
7:22 PM-door to room left open
7:26 PM---Patient out of room to use restroom with nurse

3. During an interview conducted on 5/26/22 at approximately 10:50 AM, E #5 stated, " We were not aware that holding someone to give medications required an order. However, they should have checked the seclusion box on the order form since she was in room 4.5." E #5 verbally agreed the record did not have a physician's order for the restraint/physical hold or seclusion.

4. During an interview conducted with MD #1 on 5/26/22 at 11:20 AM, MD #1 stated, "I couldn't keep Pt #1 in the room. The patient kept coming out of the room, looking into other patient's rooms and going up and down the hallway. We shut the door first because it locks and to keep Pt #1 in the room. The patient was banging on the door and yelling, so I then went to chemical restraint and ordered the medications for patient safety."

5. During an phone interview conducted on 5/26/22 at 1:30 PM, Registered Nurse (E #6) stated, "Family brought Pt #1 in, and patient was acting up in the room and pounding on the door and yelling. Pt #1 then walked down the ED hallway naked. The Doctor ordered the med's to get the patient back in the room." E #6 and two other nurses (E #4 and E #7) went to Pt #1's room to administer medications. E #6 stated, "Pt #1 did not do this willingly" E #6 and E #4 put patient into a physical hold and Pt #1 was administered forced medications by E #7. Then E #4, E #6, and E #7 left Pt #1 alone in the seclusion room and shut the locked door.