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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS was out of compliance.

A0154- USE OF RESTRAINT OR SECLUSION Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only 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. Based on observations, document review, and interviews, the facility failed to ensure staff protected patient rights. Specifically, the facility failed to have a process in place to ensure patients left the facility safely upon discharge in one of one patients reviewed who was physically carried out of the building upon discharge. (Patient #3)

Based on observations, document review, and interviews, the facility failed to ensure staff protected patient rights. Specifically, the facility failed to have a process in place to ensure patients left the facility safely upon discharge in one of one patients reviewed who was physically carried out of the building upon discharge. (Patient #3)

Findings include:

Facility policies:

The Seclusion and Physical Restraint Hold policy read, each patient has the right to be free from restraint or seclusion, or any form, used as a means of coercion, discipline, convenience, or retaliation. Restraint or seclusion is used only when non-physical interventions are not effective or not viable and when there is an imminent risk of a patient physically harming himself or herself, staff or others. Any use of restraint and/or seclusion requires clinical justification by a qualified registered nurse and must have a physician's order. Restraint is a method, physical or mechanical device, material, or equipment which immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.

The 2023 Security Management Plan, Non-Violent Crisis Prevention- Handle with Care policy read, the nonviolent crisis intervention program is a safe, non-harmful behavior management system designed to help human service professionals provide the best possible care, welfare, safety, and security to disruptive, assaultive, and out-of-control individuals- even during their most violent moments. Nonviolent physical crisis intervention and team intervention demonstrates physical control and restraint positions to be implemented when physical control is necessary as a last resort due to an individual's dangerous behavior.

1. Facility staff utilized restraint to remove a patient from the building without any indication the patient met criteria for the use of restraint and without an order from a physician.

a. On 4/3/23 at 8:49 a.m., observations of video surveillance footage from 3/28/23 were conducted. Video marker 35:01 revealed Patient #3 sitting quietly in a chair in the lobby. At video marker 47:44, Therapist #1 approached Patient #3 and sat in a chair beside her. At video marker 51:42, Patient #3 was observed speaking to Therapist #1 with no appearance of agitation. Therapist #1 stood up and walked away from Patient #3 and returned to the chair beside Patient #3 at video marker 52:02. At video marker 1:04:38, mental health technician (MHT) #3 was observed to hold Patient #3's left arm. MHT #5 was observed to hold Patient #3's right arm. MHT #3 and MHT #5 attempted to stand Patient #3 out of the chair. Patient #3 went limp with her legs and sat on the floor. MHT #3 and MHT #5 released Patient #3's arms. Patient #3 remained still and without signs of agitation.

At video marker 1:05:17, MHT #3 picked Patient #3 up from behind, under both arms. MHT #5 picked up Patient #3's right leg, and the director of admissions (Director) #6 picked up Patient #3's left leg. Chief nursing officer (CNO) #4 assisted. MHT #3, MHT #5, and Director #6 carried Patient #3 out of the lobby, through the main entrance doors, and down the sidewalk toward the parking lot. CNO #4 and milieu manager (Manager) #7 were present. Patient #3 remained still and without signs of agitation.

This was in contrast to the Seclusion and Physical Restraint Hold Policy which read, restraint or seclusion was used only when non-physical interventions were not effective or not viable and when there was an imminent risk of a patient physically harming himself or herself, staff or others.

This was also in contrast to the 2023 Security Management Plan, Non-Violent Crisis Prevention- Handle with Care policy which read, nonviolent physical crisis intervention and team intervention demonstrated physical control and restraint positions to be implemented when physical control was necessary as a last resort due to an individual's dangerous behavior.

b. Medical record review for Patient #3 revealed she was admitted on 3/19/23 for suicidal ideation with the intent to overdose. Record review also revealed no physician order for restraint was documented on 3/28/23. Further review revealed no documentation of the incident of Patient #3 being carried out of the facility.

c. On 4/3/23 at 2:53 p.m., an interview with MHT #5 was conducted. MHT #5 stated Patient #3 refused to walk out of the building. MHT #5 stated the usual practice was to call the police for patients who refused to leave, however, staff were recently told the practice changed because the police department issued trespassing warrants that would result in patients not being able to seek treatment at the facility in the future.

d. On 4/3/23 at 3:37 p.m., an interview with Therapist #1 was conducted. Therapist #1 confirmed the patient in the video surveillance was Patient #3. Therapist #1 stated she talked to Patient #3 while in the lobby as a way to help Patient #3 feel heard. Therapist #1 stated her intent was to help Patient #3 understand the patient's desire to discharge to another patient's house was not a safe discharge plan. Therapist #1 stated she attempted to assist Patient #3 to understand the discussed discharge plan of placement at a shelter was in her best interest. Therapist #1 stated Patient #3 laid down on the floor when she was asked to go. Therapist #1 stated Patient #3 said nothing on the way out the door and was carried out by staff and put in the car.

e. On 4/4/23 at 10:56 a.m., an interview with MHT #3 was conducted. MHT #3 stated the facility used a program called Handle with Care for their restraint program. The hold technique utilized from the program was referred to as physical restraint technique (PRT). MHT #3 explained PRT was used when patients were a harm to self, others, or property and at times required two to five people to hold patients after they failed at verbal de-escalation techniques. MHT #3 stated a provider order was necessary for the medication and physical hold in a restraint situation. MHT #3 stated in the past, the process was to use verbal de-escalation for patients refusing to leave the premises. MHT #3 stated patients who were aggressive were escorted off the property and police were called on patients who became assaultive.

MHT #3 stated she and another tech were instructed by their supervisors to escort Patient #3 from the lobby to the car. MHT #3 stated patient #3 did not want to stand and MHT #3 was unsure how to navigate the situation. MHT #3 stated CNO #4 instructed them to pick up Patient #3 and carry her to the car. MHT #3 stated the patient was not saying anything, but her facial expressions showed she was upset and mad. When shown a picture of staff holding Patient #3 from video surveillance, MHT #3 stated the way the patient was being carried was not consistent with the way Handle with Care techniques were taught to staff.

f. On 4/4/23 at 1:35 p.m., an interview with RN #8 was conducted. RN #8 stated Patient #3 was carried out of the building by staff because Patient #3 refused to walk to the car. RN #8 stated CNO #4 told staff to escort Patient #3 out of the building because Patient #3 was discharged and needed to get out and the police assistance could not be used. RN #8 stated once Patient #3 was in the car and the seat belt was on, Patient #3 attempted to get out of the car. RN #8 stated at that time, CNO #4 held the car door to prevent Patient #3 from leaving the car and asked the driver to put on the child safety locks for the door. RN #8 stated she believed staff should not have placed hands on the patient while discharging the patient to the car. RN #8 stated the patient should have been reassessed by staff prior to initiating hands on the patient because utilizing hands on the patient was a restraint without a provider order.

g. On 4/4/23 at 2:22 p.m., an interview with Manager #7 was conducted. Manager #7 stated Patient #3 went limp when staff attempted to escort her from the building. Manager #7 stated carrying Patient #3 out of the building was not considered as a restraint because Patient #3 was not resisting staff.

This was in contrast with the Seclusion and Physical Restraint Hold policy which defined restraint as a method, physical or mechanical device, material, or equipment which immobilized or reduced the ability of a patient to move his or her arms, legs, body or head freely.

h. On 4/4/23 at 2:51 p.m., an interview with Director #6 was conducted. Director #6 stated a physical restraint was used when a patient became a danger to self or others which required staff intervention. Director #6 stated a physical hold involved a staff member assigned to hold each limb of the patient and the patient's head. Director #6 stated a physical restraint was used to prevent a patient from engaging in self-harm or harm toward others. Director #6 stated a physician order was always required when staff restrained a patient and if an order was not given the restraint violated the patient's rights.

Director #6 stated Patient #3 was not combative or resistive toward staff, and remained calm while she refused to walk out of the building. Director #6 stated Patient #3 went limp and dropped to her knees when staff attempted to escort her out of the building. Director #6 stated Patient #3 was not held by staff in a restraining manner, but was escorted out of the building assisted by staff carrying her because she would not walk on her own.

This was in contrast with the Seclusion and Physical Restraint Hold policy which defined restraint as a method, physical or mechanical device, material, or equipment which immobilized or reduced the ability of a patient to move his or her arms, legs, body or head freely.

i. On 4/4/23 at 3:50 p.m., an interview with CNO #4 was conducted. CNO #4 stated a physical restraint was used when a patient was out of control or was engaging in self-harm behavior. CNO #4 stated the difference between an escort and a restraint was whether the patient resisted the hold by staff. CNO #4 further stated at the moment the patient resisted or pushed back from staff during an escort, that became a restraint. CNO #4 also stated when a PRT was used it was considered a restraint. CNO #4 stated a physician order was required when a patient was restrained. CNO #4 stated when a restraint occurred the risk of harm to staff and or the patient was always a possibility.

CNO #4 stated Patient #3 was considered a visitor while in the lobby of the building and if police were called for assistance to remove the patient from the facility, the patient would have been issued a trespassing charge and not be able to receive services by the facility in the future. CNO #4 stated she was not sure who decided from the facility to carry Patient #3 outside the building to a car outside in the parking lot.

j. On 4/4/23 at 4:22 p.m. an interview with Director #9 was conducted. Director #9 stated Patient #3 displayed a flat affect (showed no emotion) and it was difficult to tell if Patient #3 escalated from the video footage. Director #9 stated after she looked at the video footage, there were areas the facility could improve on. Director #9 stated the physical hold was a gray area and Patient #3 did not resist the staff and had the freedom to move. Director #9 stated police guidance given to the facility was to not make it a practice for the facility to call police to remove patients from the building. Director #9 further stated the facility was told by police when they were called to the facility to remove a patient, a trespass charge was filed and the person removed from the facility was not allowed back on the property. Director #9 then stated no incident report was necessary related to video footage involving Patient #3 as Patient #3 was discharged at the time of being carried out of the facility.