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Based on a review of 10 open and 3 closed medical records, it was determined that the hospital failed to provide either the initial or the secondary Important Message from Medicare (IMM) as required in 4 of 13 records reviewed.

Patient #2 (Pt# 2) presented to the Emergency Department (ED) via ambulance after a fall and was admitted. The initial IMM for Pt# 2 was dated the 16th day of admission. Review of Pt# 2's medical record revealed the hospital failed to provide the initial IMM within the required timeframe.

Patient #4 (Pt# 4) was was a current patient. When reviewed on day nine, no evidence was found in Pt# 4's record the hospital provided the required initial IMM.

Patient #12 (Pt# 12) had a nine day admission. No evidence was found of the second required IMM in Pt# 12's medical record.

A review of Patient #13 (Pt# 13) closed medical record revealed no evidence that a secondary IMM was provided by the hospital as required prior to discharge.

Based on interview, a review of the Armed Officer job description, and a request for the hospital Use of Force policy, it was determined that the hospital 1) failed to train armed officers in restraint techniques which were subject to clinical oversight; and 2) failed to define use of force for all security and armed officers related to the safe use of forensic weapons and when and how to obtain clinical oversight.

Interview with a security officer on August 13, 2018 at approximately 0930 revealed that security officers receive the same restraint training as that received by clinicians, and that security staff do not carry weapons of any kind.

Further interview revealed that the hospital employs part-time Armed Officers (AO) who are off-duty police officers hired part-time for weekends. A review of the AO job description revealed in part, under "Decision-making Authority" that the AO is to make decisions within the scope of responsibilities and use independent judgement in most cases consulting with appropriate resources as applicable.

While the AO job descriptors under "Role Specific Competencies" stated in part, "Assisting with restraining as needed," the director of security stated that AOs did not receive any training on the safe and appropriate use of restraint devices or manual restraint in the therapeutic environment. Therefore, forensic methods of restraint may be utilized for which clinicians are not trained, and could not give oversight.

Additionally, the hospital had no Use of Force policy because employed security personnel do not carry weapons. However, AO employees do carry weapons inclusive of hand-cuffs, guns, tasers, pepper-spray, and batons.

Based on all information, the hospital had no policy or procedure for clinical oversight for AO restraint processes, and no expectation of oversight for the use of AO weapons.

Based on a review of 2 violent restraint records, it was determined that patient #12 (P12) and patient #13 (P13) were restrained past they point at which they had ceased to be dangerous or violent.

P12 was an adult who presented to the emergency department (ED) at 1757 via ambulance in March 2018 following a motor vehicle accident. Shortly after presentation, P12 became disoriented, and aggressive while also attempting to leave the emergency department. Patient #12 was placed into 4-point restraints at 1814.

P12 was noted to be asleep at 2045. At 2100, documentation revealed that P12 was still asleep when P12 was taken to CT (Computed Tomography) and the restraints were removed. At 2115, P12 was back in the room. At 2230, documentation noted that range of motion was done, indicating that restraints were reapplied following return from CT, though by falling asleep, P12 no longer represented a danger to self or other. At 2330, all restraints were removed.

While standards allow for removal of restraints to give care, meeting behavioral criterion for a lack of dangerousness was the indication for termination of restraints. P12 clearly met criterion when P12 fell asleep. Nursing failed to discontinue restraint at that time. P12 was documented as asleep from 2214 through 2330 yet the restraints were not removed. Based on this, the hospital failed to discontinue restraint at the earliest possible time

P13 was a developmentally disabled young adult who was brought to the emergency department via ambulance in May 2018 after becoming agitated in the community and self-harming. On entry to care, P13 continued self-harming and combative behaviors and was placed into 4-point restraints at 2251.

Fifteen minute monitoring revealed P13 was noted as "Quiet Asleep" by 0020 through 0541, yet remained in restraints. P13 was kept in restraint without documented behavioral justification for more than 5 hours.