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Based on medical record review, policy review, security report review, and staff interview, the facility failed to ensure care was provided in a safe setting (A144). The facility failed to ensure patients were free from chemical and physical restraints that were not imposed to ensure the immediate physical safety of the patient, a staff member, or others (A154). The facility failed to ensure restraints were only used when less restrictive interventions were determined to be ineffective to protect the patient or others from harm (A164). The facility failed to ensure restraints were only used when ordered by a physician (A168).

Based on medical record review, policy review, and staff interview, the facility failed to ensure care was provided in a safe setting for one of 13 medical records reviewed (Patient #1). The facility census was 181.

Findings include:

Review of the medical record for Patient #1 revealed an admission date of 08/16/21. On 08/16/21 at 9:50 PM, Patient #1 was brought to the emergency room (ER) by ambulance with police for suicidal ideation. Patient #1 had diagnoses of thrombocytopenia, Schizophrenia, severe mixed Bipolar disorder, adrenal insufficiency, drug abuse, and a history of hepatitis C and ITP (Immune Thrombocytopenia - when the immune system mistakenly attacks a person's platelets). Patient #1 was pink slipped (Involuntary Emergency Admission for mental illness) on 08/16/21 at 10:19 PM for a substantial risk of physical harm to self and would benefit from treatment in a hospital for mental illness. Patient #1 was suicidal with no plan and had not been taking her medications. Patient #1's drug screen was positive for Cannabinoid, Amphetamines, and Cocaine Metabolite. Patient #1's platelets were low at 37 (normal count was 150-400 x 10/Liters) and was admitted to confirm her platelets were stable. Once medically stable, Patient #1 would be transferred to a psychiatric facility for treatment. Patient #1 was admitted to 4 North (a medical surgical unit) on 08/17/21 at 5:26 AM. Patient #1's psychiatric consult resulted in orders for suicide precautions, sitter at all times, Carbamezapine 200 milligrams (antiseizure medication but can be used to treat bipolar disorder) twice a day, and to transfer to a psychiatric inpatient unit on an involuntary basis once medically stable. In addition, an order was written to give Benadryl 50 milligrams (antihistamine) intravenously and Haldol 5 milligrams (antipsychotic) intramuscularly and Ativan 2 milligrams (sedative) intramuscularly every six hours as needed for agitation. Activity was ordered as up as tolerated. Patient #1 was five foot six and weighed 176 pounds.

On 08/17/21 at 11:22 AM the nurse documented Patient #1 was verbally abusive towards the sitter and nurse. Patient #1 wanted to leave but was pink slipped. The nurse made a decision to give the Haldol, Benadryl, and Ativan. Three nurses and security held the patient down to administer the medications.

Patient #1's medical record did not document attempts of deescalation prior to medication. The medical record lacked documentation of orders to force medicate or to hold down for medication administration. This was verified on 08/24/21 at 4:15 PM by Staff B and F.

On 08/18/21 at 11:19 AM, the nurse documented that Patient #1 was agitated, yelling, screaming, and cursing at staff. A Code Violet (when a person demonstrates hostile or disruptive behavior and/or presents a threat of danger to himself/herself or others) was called. The medical record showed the patient was given the as needed medication for agitation.

On 08/19/21, the physician documented Patient #1 was seen early that morning and was medically stable. Arrange placement in a psychiatric facility on an involuntary basis.

On 08/19/21 at 10:36 AM, the nurse documented Patient #1 was seen running from the room, the panic button was hit, and the operator was called for a Code Brown (for patient elopement). Patient #1 was seen exiting the next unit (4E) by the stairwell. Staff followed at a safe distance, but lost track of Patient #1. Two nurses were following Patient #1. Security responded and the police were called.

Review of the security report dated 08/19/21 at 10:36 AM revealed security was called to 4 North when Patient #1 ran out of her room and headed towards 4 East. Security officers responded throughout the property trying to locate Patient #1. The security officer who responded to 4 North was immediately redirected to 4 East and proceeded down the stairwell while informing other officers by radio that Patient #1 had gone down the stairs. The security officer monitoring the cameras advised Patient #1 was last seen running out the physician exit. All officers responded to the back side of the hospital property where Patient #1 was last seen. On officer heard an unknown individual calling for help, which was Patient #1. Patient #1 appeared to have fallen off a steep embankment, estimated to be close to 40 feet high. Patient #1 was lying next to a railroad track and appeared to be in a lot of pain. Facility staff on scene assisted with keeping Patient #1 calm until medical assistance could arrive. Police and Fire and Rescue arrived at approximately 11:15 AM and took command of the scene.

Review of the police report dated 08/19/21 at 11:01 AM revealed police were dispatched to the hospital on report of a suicidal patient who had run from the hospital. The patient had an active pink slip and was combative. Patient #1 was reported to have run north from the rear of the hospital into the woods. An officer was flagged down by hospital security who stated they had a security guard with the patient. The officer made his way west of her location and was able to get across the tracks and follow them down to the patient who was later identified as Patient #1. Patient #1 was in severe pain and unable to move her legs. Patient #1 was laying at the bottom of a cliff that was approximately 40 foot high. Patient #1 made comments that she was pushed off the ledge and also that she had fallen. Shortly after arriving, the medics and other officers arrived. They were able to get Patient #1 into a squad with the help of railroad staff.

The ambulance run sheet documented receiving the call at 11:05 AM on 08/19/21. The medics arrived on scene at 11:12 AM. Patient #1 was unable to move or feel her feet. The medics requested an air-medical transport service be called. Patient #1 complained of severe pain to hips and lower back. Cervical spine control was taken manually. Access for equipment and personnel was delayed slightly due to area and distance. Additional medics arrived with back board, Cervical Immobilization Device and cervical collar, and stokes basket. Cervical collar was applied with Cervical Spine precaution. Patient #1 was moved via back board to stokes basket and to railway maintenance truck. Patient #1 was moved via truck to staging area and then to the ambulance. The ER was notified at this time of trauma alert. The medics were advised that the air-medical transport service could not fly and that a Mobile Intensive Care Unit was dispatched. Patient #1 transported to the ER.

Review of the medical record for Patient #1 revealed on 08/19/21 at 11:43 AM, a bed was held for Patient #1 in the ER. At 11:50 AM, Patient #1 arrived in the ER by ambulance due to trauma. Patient #1 fell from 40 feet onto railroad tracks with back pain, transient hypotension, and complaints of pain and inability to move her legs. A pelvic x-ray was negative. Patient #1 was intubated as a precaution to ensure her airway was not compromised. A chest x-ray confirmed placement of the airway. At 2:09 PM, Patient #1 was transferred to a trauma facility by mobile intensive care unit in critical condition.

Review of the medical record from the trauma facility revealed Patient #1's injuries included spinal fractures at L1 and T12, spinal cord injury with paraplegia (loss of muscle function on the lower half of the body) two rib fractures (without pneumothorax - collapsed lung) as well as 2.0 centimeter (cm) thick paraspinal hematoma (collection of blood that compresses the spinal cord). Chest x-ray on 08/19/21 revealed left seventh and ninth rib fractures without pneumothorax. Pelvic x-ray on 08/19/21 revealed no fractures. A computed tomography (CT) of head without contrast on 08/19/21 revealed small right frontal scalp hematoma without fracture, nondisplaced acute fractures of the bilateral nasal bones, and no acute intracranial abnormality or hemorrhage. A CT of the maxillofacial and sinus without contrast on 08/19/21 revealed nondisplaced acute fractures of the bilateral nasal bones with associated soft tissue swelling and no other acute facial fracture.

A CT of the chest, abdomen, and pelvis with contrast on 08/19/21 revealed: "Chest: 1. Horizontally oriented fracture through the facets, lamina, and spinous process at T12 related to the L1 chance fracture (unstable spine fracture). 2. Acute superior endplate compression fractures of T7 and T8 with 10% to 15% superior endplate height loss, respectively. 3. No other evidence of acute trauma to the chest. 4. Mild bibasilar dependent atelectasis (partial collapse of the lungs), but the lungs are otherwise clear. 5. Endotracheal tube is appropriately positioned. Abdomen/pelvis: 1. L1 chance fracture with associated burst fracture (injury in which the vertebra, the primary bone of the spine, breaks in multiple directions) of the L1 vertebral body. Associated bony retropulsion (when pieces of vertebrae are displaced into the spinal canal) results in severe spinal canal stenosis. Spinal cord transection cannot be excluded. 2. There is surrounding paraspinal hematoma measuring up to 2.0 cm thick. There is no associated contrast blush on delayed imaging to suggest active bleeding. 3. Approximately 3 mm grade 1 retrolisthesis (parts of the spine slip backward on one another) of L1 on L2, likely posttraumatic in nature and concerning for associated ligamentous injury. 4. Mildly offset obliquely oriented fracture through the S5 vertebral body. 5. No other evidence of acute trauma to the abdomen and pelvis. 6. Appropriately positioned orogastric tube, terminating in the gastric body."

CT of the cervical spine without contrast on 08/19/21 revealed no evidence of acute fracture. CT reformation thoracic spine and lumbar spine on 08/19/21 revealed "THORACIC SPINE: Horizontally oriented fracture through the facets, lamina, and spinous process at T12 related to the L1 chance fracture, described below. Acute superior endplate compression fractures of T7 and T8 with 10% to 15% superior endplate height loss, respectively. LUMBAR SPINE: L1 chance fracture with associated burst fracture of the L1 vertebral body. Associated bony retropulsion results in severe spinal canal stenosis. Spinal cord transection cannot be excluded. There is surrounding paraspinal hematoma measuring up to 2.0 cm thick. There is no associated contrast blush on delayed imaging to suggest active bleeding. Approximately 3 mm grade 1 retrolisthesis of L1 on L2, likely posttraumatic in nature and concerning for associated ligamentous injury."

A Focused Assessment Sonography for Trauma (FAST - a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart or abdominal organs after trauma) Exam procedure on 08/19/21 was negative. Magnetic Resonance Imaging (MRI) of the cervical spine without contrast on 08/19/21 revealed no acute abnormality of cervical spine. MRI of the thoracic spine without contrast on 08/19/21 revealed "Acute vertebral body compression fractures of T7 and T8 with approximately 10% loss of vertebral body height at these levels. Fracture of the posterior elements at T12 involving the lamina, inferior articular facets, and posterior spinous process." MRI of the lumbar spine on 08/19/21 revealed "Unstable chance fracture of the L1 level with severe central stenosis and lower cord myelomalacia extending from T11/T12 to L1/L2."

On 08/20/21, Patient #1 had a Lumbar-1 open reduction internal fixation, Thoracic 11-L3 spine posterior instrumented fusion, and Lumbar 1 and 2 laminectomy. On 08/20/21 at 6:25 AM, the physician progress note documented spinal cord injury with paraplegia and no sensation or motor function from the waist down.

On 08/23/21 at 3:25 PM, Staff H stated there was no psychiatric unit at the hospital so care staff were not trained to do hands on intervention. The security staff were trained in deescalation techniques and hands on interventions to stop and restrain patients. Staff G stated nursing staff got some deescalation training, but not the full training. Patient #1 had Code Violets called on 08/17/21 and 08/18/21. Staff H stated it took three security officers to hold Patient #1 for medication administration the first day. On the second day the security officers did not have to hold the patient. On the third day, Patient #1 eloped.

On 08/24/21 at 9:37 AM, Staff L, who was assigned to care for Patient #1 on 08/19/21, was interviewed. Staff L stated this was the first and only day she was assigned to Patient #1. Staff L had been on the unit the previous day and she had overheard Patient #1 yelling at staff but was not involved in her care. Patient #1 was not cooperative that day and had requested to leave. The nurse tried to calm Patient #1 down. Patient #1 wanted to smoke and wanted her cigarettes. The hospitalist had seen Patient #1 that morning with the nurse present. Staff L knew Patient #1 was pink slipped so she could not leave. Patient #1 was getting loud again and wanted to shower. Patient #1 was allowed to shower. After her shower, Patient #1 was getting restless again. Staff L offered Ativan and Patient #1 said "no thanks." Staff L spoke to the charge nurse and another nurse regarding Patient #1 . They felt Patient #1 was going to need medicated because she was getting loud. Staff L went to get the medications with another nurse as the plan was to medicate Patient #1. When the nurses were leaving the medication room, everyone said Patient #1 was running down the hall. To Staff L's knowledge, the only person in the room with Patient #1 had been the sitter. Patient #1 was up walking around the room, pacing, and not staying in the bed. The nurse heard Patient #1 ran pretty fast. Patient #1 was having blood work monitored. Patient #1 had refused to allow the lab technician to draw blood that morning. The nurse talked to Patient #1 and eventually Patient #1 allowed the blood draw. Patient #1 was there for monitoring until medically cleared to go to a psychiatric facility. Staff L had eight patients that day including Patient #1 and two scheduled discharges. Staff L stated that they typically have six patients. Staff L did not follow Patient #1 as she was already gone and others were following her. Patient #1 was out of sight when Staff L exited the medication room. A Code Violet and a Code Brown were called. Staff L stated verbal direction was the only way to control patient actions and they did not have an order to restrain Patient #1 for any reason. Staff L stated she had not had any deescalation training here. They were given a protocol for psychiatric patients in orientation and had it on hand for reference. They were not given any training from the hospital on how to deal with psychiatric patients. For psychiatric patients, the staff only had constant monitoring, as needed medications, and calling Code Violet or Code Brown available. There were no orders or training for hands on intervention, so if a patient tried to elope they could just try not to lose sight of patient and verbally direct them to stop. Staff L stated she worked in long term care for years and received lots of deescalation training there.

On 08/24/21 at 10:06 AM, Staff M was interviewed. Staff M was assigned to observe Patient #1 on 08/19/21 and stated this was the only day she was assigned to Patient #1. Staff M stated she was talking to Patient #1 and they were getting along okay. Patient #1 wanted to shower, and the nurse said it was okay. Patient #1 took her shower. The nurse offered medication to Patient #1 and Patient #1 refused. After her shower, the lab technician came in and Patient #1 got agitated with them. Patient #1 yelled at staff to "get the F out" swearing at them. The lab technician left and informed the nurse. The nurse talked to Patient #1. Patient #1 calmed down enough for the blood draw but was still cussing at the lab technician as the blood was drawn. The nurse came in to tell Patient #1 she was going to get a shot, maybe 10-15 minutes after the blood draw. Patient #1 refused, and after the nurse left Patient #1 jumped up and took off. Staff M was sitting at the computer between the door and the bed. When Patient #1 took off, she passed Staff M . Staff M followed Patient #1 at a safe distance until the charge nurse stopped Staff M . Staff M stated verbal direction and observation were the only options the sitters had. Patient #1 would not listen and did not follow directions. Patient #1 was focused on getting a cigarette. Patient #1 had tried to leave the room prior and had listened to staff and remained in the room. Patient #1 had resumed their conversation earlier in the day. Patient #1 was the only patient that actually left the room. Staff M was stopped from following before Patient #1 was off the unit. Patient #1 then started running and ran fast. Two nurses followed Patient #1 off the unit, but Staff M could not remember who. Staff M stated she received deescalation training one on one in the classroom for interacting with psychiatric patients and a workday learning class. When Staff M received report at the beginning of her shift, she was told there was a Code Violet the day before, to be careful, and Patient #1 was easily agitated. Patient #1 was sleeping at the beginning of the shift.

On 08/24/21 at 11:09 AM, Staff O was interviewed. Staff O stated on 08/17/21 Patient #1 was very agitated, yelling and threatening staff. Staff requested the security officers hang back at first. Patient #1 was cursing a lot and threatening physical harm to staff. The nurses got the medications ready and requested assistance to hold Patient #1 for medication administration. One officer had Patient #1's legs, a nurse and a security officer were on each side of the bed. Staff O held an arm. Patient #1 did not fight as much as others had. Patient #1 was not compliant but not swinging at staff. It took a few minutes to give medications, so they held Patient #1 for maybe 25 -30 seconds. They stopped holding her and then stepped back and left with nurses in the room still. Patient #1 was still yelling threats, and security headed back to their posts. They knew she was pink slipped but that was all the information they had. Staff O stated he had training for holds. He was a former police officer. Here he received Welle (Behavioral Safety Management for Healthcare) training and NAPPI (Non-Abusive Psychological and Physical Intervention) training, and he was an instructor for Welle training, which is very much like NAPPI training.

On 08/25/21 at 8:15 AM, Staff M was interviewed again. Staff M stated Patient #1 was sitting on the side of the bed. Patient #1 just jumped up and took off without saying anything. Patient #1 had been yelling at the lab people and cussing at her while drawing the blood prior to that. The nurse came and talked to Patient #1 about a shot to calm down. This upset Patient #1 who was cussing at the nurse as the nurse left. Patient #1 used the "F" word frequently. Patient #1 just jumped up and darted out of the room without a word. Earlier when Patient #1 was talking about leaving, she was saying she just wanted to get a cigarette. When Staff M said she could no't leave and they could get her a Nicotine patch, Patient #1 said I don't want an F-ing nicotine patch and sat back down. There were no visitors that morning.

On 08/25/21 at 9:17 AM, Staff S was interviewed. Staff S stated on 08/17/21 the floor had called and requested help with a combative patient. He went to the room. The patient was yelling. They had tried to deescalate, but it was not working. They talked to Patient #1, who was cussing at security. Patient #1 didn't want anyone "dicking her down while she was on medication". They knew the patient was pink slipped, but were not aware of her medical condition. Patient #1 was swinging at and pushing at staff prior to security arrival. There were two other security officers up there as well. Patient #1 did not make contact with any staff to his knowledge. The nurse had medication to give Patient #1. Patient #1 was yelling "no no". The nurse told Patient #1 she had to take the medication. Security helped hold Patient #1 down and the nurse gave the medication. Security stepped out into the hall for a few minutes and then left. Staff S stated a report is written for restraint or medication help. Then on 08/18/21, Staff S and two other security officers went up to assist with medication administration for Patient #1 for the same type of circumstances. They assisted with holding her down for medication administration a second time. Patient #1 did not put up as much of a fight the second time, not as resistive. On 08/19/21, the Security Team Lead was in the dispatch office when the call for a mental health patient leaving 4 North to 4 East came in. The Security Team Lead took the elevator to the fourth floor, and was immediately re-directed to 4 East. He followed Patient #1 and ran down the stairs to the physician entrance. He went to the left and started searching. Staff S called the Code Brown while going down the stairs. Everyone was looking for Patient #1. Someone was assigned to review the cameras, but did not see anything. He ran behind the hospital and heard someone calling for help. Staff T was stating "over here." He radioed to call 911. Staff T and another security officer climbed down to the patient. Staff S went down as well to Patient #1. Patient #1 was in the ditch next to the tracks. There was no break in the fence. The ambulance staff arrived maybe 20 minutes later. Staff S was giving directions over his radio to dispatch to relay to the medics how to get there. They stayed with Patient #1 until she was loaded up and transported to the ambulance. The police arrived ten to 15 minutes before the medics arrived.

Review of the "Code Violet - Violent Patient/Combative" policy, approved 05/03/21, revealed a "Code Violet is called when a person demonstrates hostile or disruptive behavior and/or presents a threat of danger to himself/herself or others. The Code Violet Team should be composed of persons who have completed a non-violent crisis intervention training program." The Charge Nurse or another staff member from the unit will lead the Code Violet response. Physical restraint, including holds, forced escort, etc. will be carried out as instructed in non-violent crisis intervention training.

Review of the "Physical Restraint - Use of Restraints for Violent, Self-Destructive Patient Situations" policy, approved 04/21/21, revealed restraints are used when other less restrictive interventions have been attempted but found ineffective for providing a safe and therapeutic environment. Restraints require a physician order. Chemical restraints are medications administered to control behavior or restrict a patient's freedom of movement. Physically restraining or holding a patient for forced medication administration is a restraint.

This substantiates Substantial Allegation OH00125127.

Based on interview and medical record review, and security case report review, the facility failed to ensure patients were free from chemical and physical restraints that were not imposed to ensure the immediate physical safety of the patient, a staff member, or others for three of 13 medical records reviewed (Patient #8, #9, and #10). The facility census was 181.

Findings include:

1.The medical record review for Patient #8 was completed on 08/31/21. The medical record review revealed the 87-year-old was admitted on 07/01/21 through the emergency department with diagnoses of multiple falls, hypothyroidism, dementia, lactic acidemia, and coronary artery disease.

The medical record review revealed an emergency department physician note dated 07/01/21 at 6:37 PM that stated the patient fell sometime during the day on the way to the bathroom. The note stated she fell again after trying to get up, then crawled to the living room to wait for family to return home.

The history and physical dated 07/02/21 at 12:05 AM described the patient as alert and oriented to person, place, and time with an appropriate affect. The note stated the author believed the patient was being overmedicated with antihypertensives and noted if elderly patients were having recurrent falls, "permissive hypertension is allowed."

The physician's activity order dated 07/02/21 at 12:05 AM revealed the patient could be up with assist.

A security case report, dated 07/02/21 at 8:35 PM revealed security was dispatched to the patient's room at approximately 8:35 PM. The report stated the elderly patient "was a fall risk" and climbed out of bed and "stumbled" onto the couch. The report stated she "refused to get into bed." The report stated the officer convinced her to get back into bed. The report stated when the nurse flushed the patient's intravenous access port, the patient threw a punch. The report stated "at that time" one officer secured her left arm and leg while another secured her right arm and leg. The report concluded, "Staff applied restraints and medicated the patient."

The medical record review revealed on 07/02/21 at 8:45 PM the patient was medicated with 0.5 milligrams of Ativan.

The medical record review revealed a physician order dated 07/02/21 at 10:32 PM for soft bilateral wrist restraints for "involuntary movement to cause harm."

The medical record review revealed the patient remained in restraints until 07/03/21 at 8:00 AM.

On 08/26/21 at 2:55 PM in an interview, Staff C was unable to find a medical reason for the administration of Ativan or why the patient was restrained after agreeing to go back to bed.

2. The medical record review for Patient #9 was completed on 08/31/21. The medical record review revealed the patient was admitted to the facility on 06/05/21. The history and physical dated 06/05/21 at 10:17 AM revealed the patient was transferred from an outside facility and that he had presented to that facility's emergency department for a chief complaint of fatigue and increased weakness to right arm. The review revealed the patient was diagnosed with acute metabolic encephalopathy with unclear etiology. The patient had "poorly controlled" diabetes mellitus, coronary artery disease, and hypertension.

A security case report dated 06/05/21 at 3:30 AM revealed security officers escorted the ambulance crew and patient to the patient's room. The report said he was in two point soft restraints upon arrival. The report stated security assisted getting the patient into the hospital bed and the restraints were reapplied. The report stated the patient was attempting to get out of bed.

The review did not reveal where the patient was receiving intravenous fluids, had an indwelling urinary catheter, or any other type of medical device.

The review revealed conflicting activity orders. On 06/05/21 at 4:42 AM the patient was ordered both strict bed rest and to be ambulated.

The medical record review did not reveal why the patient needed to be in two point restraints.

On 08/30/21 at 1:33 PM in an interview, Staff C was unable to show in the medical record review why the patient needed restrained and put on bed rest.

3. The medical record review for Patient #10 was completed on 08/31/21. The medical record review revealed the 37-year-old patient presented to the emergency department on 01/14/21. The medical record review revealed an emergency department physician note dated 01/14/21 at 4:21 AM that stated she presented with emergency medical services and local police department for suspected psychosis. The note stated when the police arrived at the patient's home, she was holding a knife and threatening to kill herself. The note stated emergency medical services was able calm patient and transport the patient to the emergency department.

A review of a security case report dated 01/14/21 at 4:25 AM was completed on 08/31/21. The medical record review revealed the officers "assisted staff with medication, getting the patient into a green gown, and then restraints."

The medical record review did not reveal what kind of restraints were applied and for how long. The medical record review did not reveal what behaviors the patient was exhibiting at the facility to warrant physical restraints (whatever form that took) and what less restrictive measures were taken prior to their application.

The medical record review did reveal the physician progress note dated 01/14/21 at 4:21 AM (signed on 01/14/21 at 5:21 AM) that stated, "Patient restraints removed once patient was able to calm down."

On 08/30/21 at 2:33 PM in an interview, Staff C confirmed the medical record review did not reveal what the patient was doing while at the hospital to warrant physical restraints and what else was tried prior to their application.

Based on medical record review, policy review, security report review and staff interview, the facility failed to ensure restraints were only used when less restrictive interventions were determined to be ineffective to protect the patient or others from harm for three of 13 medical records reviewed (Patients #1, #6, and #11). The facility census was 181.

Findings include:

1. Review of the medical record for Patient #1 revealed an admission date of 08/16/21. On 08/16/21 at 9:50 PM, Patient #1 was brought to the emergency room (ER) by ambulance with police for suicidal ideation. Patient #1 had diagnoses of thrombocytopenia, Schizophrenia, severe mixed Bipolar disorder, adrenal insufficiency, drug abuse, and a history of hepatitis C and ITP (Immune Thrombocytopenia - when the immune system mistakenly attacks a person's platelets). Patient #1 was pink slipped (Involuntary Emergency Admission for mental illness) on 08/16/21 at 10:19 PM for a substantial risk of physical harm to self and would benefit from treatment in a hospital for mental illness. Patient #1 was suicidal with no plan and had not been taking her medications. Patient #1's psychiatric consult resulted in orders for suicide precautions, sitter at all times, Carbamezapine 200 milligrams (antiseizure medication but can be used to treat bipolar disorder) twice a day, and to transfer to a psychiatric inpatient unit on an involuntary basis once medically stable. In addition, an order was written to give Benadryl 50 milligrams (antihistamine) intravenously and Haldol 5 milligrams (antipsychotic) intramuscularly and Ativan 2 milligrams (sedative) intramuscularly every six hours as needed for agitation. Activity was ordered as up as tolerated.

On 08/17/21 at 11:22 AM the nurse documented Patient #1 was verbally abusive towards the sitter and nurse. Patient #1 wanted to leave but was pink slipped. The nurse made a decision to give the Haldol, Benadryl, and Ativan. Three nurses and security held the patient down to administer the medications.

Patient #1's medical record did not document attempts of deescalation prior to medication. The medical record lacked documentation of orders to force medicate or to hold down for medication administration. This was verified on 08/24/21 at 4:15 PM by Staff B and Staff F.

On 08/18/21 at 11:19 AM, the nurse documented that Patient #1 was agitated, yelling, screaming, and cursing at staff. A Code Violet (when a person demonstrates hostile or disruptive behavior and/or presents a threat of danger to himself/herself or others) was called. The medical record showed the patient was given the as needed medication for agitation.

On 08/23/21 at 3:25 PM, Staff H stated Patient #1 had Code Violets called on 08/17/21 and 08/18/21. Staff H stated it took three security officers to hold Patient #1 for medication administration the first day. On the second day the security officers did not have to hold the patient.

On 08/24/21 at 9:37 AM, Staff L stated they did not have an order to restrain Patient #1 for any reason. There were no orders for hands on intervention.

On 08/24/21 at 11:09 AM, Staff O was interviewed. Staff O stated on 08/17/21 Patient #1 was very agitated, yelling and threatening staff. Staff requested the security officers hang back at first. Patient #1 was cursing a lot and threatening physical harm to staff. The nurses got the medications ready and requested assistance to hold Patient #1 for medication administration. One officer had Patient #1's legs, a nurse and a security officer were on each side of the bed. Staff O held an arm. Patient #1 did not fight as much as others had. Patient #1 was not compliant but not swinging at staff. It took a few minutes to give medications, so they held Patient #1 for maybe 25 -30 seconds. They stopped holding her and then stepped back and left with nurses in the room still. Patient #1 was still yelling threats, and security headed back to their posts. They knew she was pink slipped but that was all the information they had.

On 08/25/21 at 9:17 AM, Staff S was interviewed. Staff S stated on 08/17/21 the floor had called and requested help with a combative patient. He went to the room. The patient was yelling. They had tried to deescalate, but it was not working. They talked to Patient #1, who was cussing at security. Patient #1 didn't want anyone "dicking her down while she was on medication". They knew the patient was pink slipped, but were not aware of her medical condition. Patient #1 was swinging at and pushing at staff prior to security arrival. There were two other security officers up there as well. Patient #1 did not make contact with any staff to his knowledge. The nurse had medication to give Patient #1. Patient #1 was yelling "no no". The nurse told Patient #1 she had to take the medication. Security helped hold Patient #1 down and the nurse gave the medication. Security stepped out into the hall for a few minutes and then left. Then on 08/18/21, Staff S and two other security officers went up to assist with medication administration for Patient #1 for the same type of circumstances. They assisted with holding her down for medication administration a second time. Patient #1 did not put up as much of a fight the second time, not as resistive.

Review of the "Code Violet - Violent Patient/Combative" policy, approved 05/03/21, revealed a "Code Violet is called when a person demonstrates hostile or disruptive behavior and/or presents a threat of danger to himself/herself or others. The Code Violet Team should be composed of persons who have completed a non-violent crisis intervention training program." The Charge Nurse or another staff member from the unit will lead the Code Violet response. Physical restraint, including holds, forced escort, etc. will be carried out as instructed in non-violent crisis intervention training.

Review of the "Physical Restraint - Use of Restraints for Violent, Self-Destructive Patient Situations" policy, approved 04/21/21, revealed restraints are used when other less restrictive interventions have been attempted but found ineffective for providing a safe and therapeutic environment. Restraints require a physician order. Chemical restraints are medications administered to control behavior or restrict a patient's freedom of movement. Physically restraining or holding a patient for forced medication administration is a restraint.

2. The medical record review for Patient #6 was completed on 08/31/21. The medical record review revealed the patient came from an assisted living facility and was admitted through the emergency department on 08/12/21. The medical record review revealed he presented to the emergency department on 08/11/21 with a fall and accompanying left rib pain.

The medical record review revealed an emergency department physician progress note dated 08/12/21 at 7:35 PM that stated the assisted living nurse described the patient as falling " 'nearly every day' " and has had a steady decline in mental status and energy. The note described the patient's past medical history as including deep vein thrombosis of the left leg, long term use of anticoagulation, hypertension, Parkinson's disease, abnormalities of gait and mobility, and benign prostatic hyperplasia with lower urinary tract symptoms. The note describes the patient as alert and oriented to person, place, and time, with normal cognition and appropriate affect.

The patient was admitted for bilateral deep vein thrombosis in both legs and a urinary tract infection.

The history and physical dated 08/13/21 at 12:44 AM revealed the patient was diagnosed with repeated falls, urinary tract infection, bilateral leg deep vein thrombosis, Parkinson's disease, and benign prostatic hyperplasia.

A nursing note dated 08/13/21 at 8:25 PM revealed the patient was getting combative with staff and pulling at his indwelling urinary catheter. The note stated staff attempted to calm the patient down, and he responded by saying they were trying to kill him. The note stated staff were unable to calm him, an order was obtained, and bilateral soft wrist restraints were applied.

The medical record review revealed a nursing note dated 08/14/21 at 3:55 AM that stated the patient became irate and agitated when the nurse entered the room and tried to hit, bite and kick.

Review of a security report dated 08/14/21 at 4:38 AM revealed officers arrived at the patient's room at approximately 4:00 AM. The note stated staff were holding down the patient's legs and "security relieved staff of that and also helped keep the patients (sic) arms restrained so that staff could medicate."

The medical record review revealed a physician order dated 08/14/21 at 4:13 AM to give 20 milligrams of Geodon(used to treat schizophrenia, acute mania, or mixed episodes of bipolar disorder, and for acute agitation in adults with schizophrenia) intramuscularly.

The medical record review confirmed 20 milligrams of Geodon was given intramuscularly on 08/14/21 at 4:13 AM.

The medical record review did not reveal a physician progress note explaining the reason for ordering the medication for the patient.

The medical record review did not reveal any interventions were performed after re-application of soft wrist restraints and before the administration of Geodon.

On 08/26/21 at 12:19 PM in an interview, Staff C confirmed the absence of any progress note and of interventions between when the patient was restrained and when the drug was given.

3. The medical record review for Patient #11 was completed on 08/31/21. A physician note dated 03/04/21 at 3:10 PM revealed the patient was brought to the emergency room with an application for emergency admission for a suicide attempt with insulin.

A nursing note dated 03/04/21 at 4:28 PM revealed the patient was pacing in the room and "refusing to cooperate." The note did not explain in what way the patient was uncooperative.

The review revealed a physician order dated 03/04/21 at 4:36 PM to place the patient in four point restraints for danger to self and others.

A nursing note dated 03/04/21 at 4:38 PM revealed the patient was restrained in four point restraints.

The medical record review did not reveal any least restrictive interventions were attempted prior to using the four point restraints.

On 08/30/21 at 4:13 PM in an interview, Staff C confirmed four point restraints had been applied and there was no documentation of less restrictive measures employed prior.

Further medical record review revealed a physician progress note dated 03/05/21 at 5:33 AM that stated the patient was agitated and attempting to leave against medical advice (AMA) while on an application for emergency admission. The note stated the patient was "walked" back into the room and was given Ativan, Haldol, Benadryl, a bolus of precedex (an intravenous anesthetic for sedation with analgesic effects, and is used for sedation of mechanically ventilated intensive care unit patients or for sedation of non-intubated patients) and a precedex drip. The note concluded, "At this time patient is sleeping and restrained."

There was no documentation any least restrictive interventions were attempted prior to administering the medication.

Based on medical record review, policy review, security case report review and staff interview, the facility failed to ensure restraints were only used when ordered by a physician for seven of 13 medical records reviewed (Patients #7, #9, #10, #1, #6, #8, and #4). The facility census was 181.

Findings include:

1. The medical record review for Patient #7 was completed on 08/31/21. An emergency department physician progress note dated 08/11/21 at 5:49 PM revealed the patient presented to the emergency department with a complaint of "mental health problem". The patient came with an application for emergency admission completed by the local police department.

Review of the application for emergency admission revealed the patient was damaging his home, cars, and tossing trash around the neighborhood. The patient also threatened to jump out of a second story window headfirst.

A physician progress note dated 08/11/21 at 5:49 PM revealed the patient had a medical history of acute respiratory failure, aspiration pneumonia, asthma, gunshot wound, and polysubstance abuse.

A nursing note dated 08/11/21 at 6:35 PM revealed the patient was yelling and attempting to leave. The note stated, "Patient tackled by security." The note stated the patient does have a skin "tear" to the right elbow.

Review of a security case report dated 08/11/21 at 6:45 PM revealed the patient attempted to leave and that the officer told him numerous times he could not. The report concluded with, "Office (sic) [Officer #1] and I physically restrained [the patient] and with the help of ED staff, place [Patient #7] onto a bed, while staff applied "hard" restraints and administered medications."

A psychiatry note dated 08/11/21 at 11:29 PM revealed the patient denied suicide or homicidal ideation and admitted to having a substance abuse problem. The note stated the patient was educated on treatment facilities. The note did not say when he was restrained, with what, and for how long.

A physician progress note dated 08/12/21 at 1:08 AM that stated the patient attempted to run out of the emergency department, that "security had to tackle patient", and that he did strike his right elbow on the ground during the incident and sustained a five centimeter laceration. The note stated the laceration was closed with three sutures. The note did not describe the application or duration of restraints.

Neither the medical record review nor the review of the case report revealed how many hard restraints were applied. Neither document revealed how long the patient was restrained. The medical record review did not reveal any order to restrain the patient with "hard" restraints or other means.


On 08/26/21 at 12:54 PM in an interview, Staff C confirmed the medical record review did not contain orders to restrain the patient with hard restraints or any other methods.

2. The medical record review for Patient #9 was completed on 08/31/21. The medical record review revealed the patient was admitted to the facility on 06/05/21. A history and physical dated 06/05/21 at 10:17 AM revealed he was transferred from an outside facility and had presented to that facility's emergency department for a chief complaint of fatigue and increased weakness to right arm. The review revealed the patient was diagnosed with acute metabolic encephalopathy with unclear etiology. The patient had "poorly controlled" diabetes mellitus, coronary artery disease, and hypertension.

Review of a security case report dated 06/05/21 at 3:30 AM revealed security officers escorted the ambulance crew and patient to the patient's room. The report said he was in two point soft restraints upon arrival. The report stated security assisted getting the patient into the hospital bed and the restraints were reapplied. The report stated the patient was attempting to get out of bed.

The review did not reveal where the patient was receiving intravenous fluids, had an indwelling urinary catheter, or any other type of medical device.

The review revealed conflicting activity orders. On 06/05/21 at 4:42 AM the patient was ordered both strict bed rest and to be ambulated.

The medical record review did not reveal why the patient needed to be in two point restraints.

On 08/30/21 at 1:33 PM in an interview, Staff C was unable to show in the medical record review why the patient needed restrained and put on bed rest.

The medical record review revealed a physician order for two point soft wrist restraints dated 06/05/21 at 4:29 AM, but there was no order to restrain the patient at the time of arrival on 06/05/21 at 3:15 AM.

3. The medical record review for Patient #10 was completed on 08/31/21. The patient presented to the emergency department on 01/14/21. An emergency department physician note dated 01/14/21 at 4:21 AM revealed the patient presented with emergency medical services and local police department for suspected psychosis. The note stated when the police arrived at the patient's home, she was holding a knife and threatening to kill herself. The note stated emergency medical services was able calm patient and transport the patient to the emergency department.

A security case report dated 01/14/21 at 4:25 AM revealed the officers "assisted staff with medication, getting the patient into a green gown, and then restraints."

The medical record review did not reveal what kind and/or number of physical restraints were applied and for how long.

The medical record review did not reveal a physician order for any kind of physical restraint.

On 08/30/21 at 2:33 PM in an interview, Staff C confirmed the clinical record did not have a physician order for physical restraints.


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4. Review of the medical record for Patient #1 revealed an admission date of 08/16/21. Patient #1 had diagnoses of thrombocytopenia, Schizophrenia, severe mixed Bipolar disorder, adrenal insufficiency, drug abuse, and a history of hepatitis C and ITP (Immune Thrombocytopenia - when the immune system mistakenly attacks a person's platelets). Patient #1 was pink slipped (Involuntary Emergency Admission for mental illness) on 08/16/21 at 10:19 PM for a substantial risk of physical harm to self and would benefit from treatment in a hospital for mental illness. Patient #1 was suicidal with no plan and had not been taking her medications. Patient #1's psychiatric consult resulted in orders for suicide precautions, sitter at all times, Carbamezapine 200 milligrams (antiseizure medication but can be used to treat bipolar disorder) twice a day, and to transfer to a psychiatric inpatient unit on an involuntary basis once medically stable. In addition, an order was written to give Benadryl 50 milligrams (antihistamine) intravenously and Haldol 5 milligrams (antipsychotic) intramuscularly and Ativan 2 milligrams (sedative) intramuscularly every six hours as needed for agitation. Activity was ordered as up as tolerated.

On 08/17/21 at 11:22 AM the nurse documented Patient #1 was verbally abusive towards the sitter and nurse. Patient #1 wanted to leave but was pink slipped. The nurse made a decision to give the Haldol, Benadryl, and Ativan. Three nurses and security held the patient down to administer the medications.

Patient #1's medical record did not document attempts of deescalation prior to medication. The medical record lacked documentation of orders to force medicate or to hold down for medication administration. This was verified on 08/24/21 at 4:15 PM by Staff B and Staff F.

On 08/18/21 at 11:19 AM, the nurse documented that Patient #1 was agitated, yelling, screaming, and cursing at staff. A Code Violet (when a person demonstrates hostile or disruptive behavior and/or presents a threat of danger to himself/herself or others) was called. The medical record showed the patient was given the as needed medication for agitation.

On 08/23/21 at 3:25 PM, Staff H stated Patient #1 had Code Violets called on 08/17/21 and 08/18/21. Staff H stated it took three security officers to hold Patient #1 for medication administration the first day. On the second day the security officers did not have to hold the patient.

On 08/24/21 at 9:37 AM, Staff L stated they did not have an order to restrain Patient #1 for any reason. There were no orders for hands on intervention.

On 08/24/21 at 11:09 AM, Staff O was interviewed. Staff O stated on 08/17/21 Patient #1 was very agitated, yelling and threatening staff. Staff requested the security officers hang back at first. Patient #1 was cursing a lot and threatening physical harm to staff. The nurses got the medications ready and requested assistance to hold Patient #1 for medication administration. One officer had Patient #1's legs, a nurse and a security officer were on each side of the bed. Staff O held an arm. Patient #1 did not fight as much as others had. Patient #1 was not compliant but not swinging at staff. It took a few minutes to give medications, so they held Patient #1 for maybe 25 -30 seconds. They stopped holding her and then stepped back and left with nurses in the room still. Patient #1 was still yelling threats, and security headed back to their posts. They knew she was pink slipped but that was all the information they had.

On 08/25/21 at 9:17 AM, Staff S was interviewed. Staff S stated on 08/17/21 the floor had called and requested help with a combative patient. He went to the room. The patient was yelling. They had tried to deescalate, but it was not working. They talked to Patient #1, who was cussing at security. Patient #1 didn't want anyone "dicking her down while she was on medication". They knew the patient was pink slipped, but were not aware of her medical condition. Patient #1 was swinging at and pushing at staff prior to security arrival. There were two other security officers up there as well. Patient #1 did not make contact with any staff to his knowledge. The nurse had medication to give Patient #1. Patient #1 was yelling "no no". The nurse told Patient #1 she had to take the medication. Security helped hold Patient #1 down and the nurse gave the medication. Security stepped out into the hall for a few minutes and then left. Then on 08/18/21, Staff S and two other security officers went up to assist with medication administration for Patient #1 for the same type of circumstances. They assisted with holding her down for medication administration a second time. Patient #1 did not put up as much of a fight the second time, not as resistive.

Review of the "Code Violet - Violent Patient/Combative" policy, approved 05/03/21, revealed a "Code Violet is called when a person demonstrates hostile or disruptive behavior and/or presents a threat of danger to himself/herself or others. The Code Violet Team should be composed of persons who have completed a non-violent crisis intervention training program." The Charge Nurse or another staff member from the unit will lead the Code Violet response. Physical restraint, including holds, forced escort, etc. will be carried out as instructed in non-violent crisis intervention training.

Review of the "Physical Restraint - Use of Restraints for Violent, Self-Destructive Patient Situations" policy, approved 04/21/21, revealed restraints are used when other less restrictive interventions have been attempted but found ineffective for providing a safe and therapeutic environment. Restraints require a physician order. Chemical restraints are medications administered to control behavior or restrict a patient's freedom of movement. Physically restraining or holding a patient for forced medication administration is a restraint.


5. The medical record review for Patient #6 was completed on 08/31/21. The patient came from an assisted living facility and was admitted through the emergency department on 08/12/21. The medical record review revealed he presented to the emergency department on 08/11/21 with a fall and accompanying left rib pain.

The medical record review revealed an emergency department physician progress note dated 08/12/21 at 7:35 PM that stated the assisted living nurse described the patient as falling " 'nearly every day' " and has had a steady decline in mental status and energy. The note described the patient's past medical history as including deep vein thrombosis of the left leg, long term use of anticoagulation, hypertension, Parkinson's disease, abnormalities of gait and mobility, and benign prostatic hyperplasia with lower urinary tract symptoms. The note described the patient as alert and oriented to person, place, and time, with normal cognition and appropriate affect.

The patient was admitted for bilateral deep vein thrombosis in both legs and a urinary tract infection.
A history and physical dated 08/13/21 at 12:44 AM revealed the patient was diagnosed with repeated falls, urinary tract infection, bilateral leg deep vein thrombosis, Parkinson's disease, and benign prostatic hyperplasia.

A nursing note dated 08/13/21 at 8:25 PM revealed the patient was getting combative with staff and pulling at his indwelling urinary catheter. The note stated staff attempted to calm the patient down, and he responded by saying they were trying to kill him. The note stated staff were unable to calm him, an order was obtained, and bilateral soft wrist restraints were applied.

The medical record review revealed a nursing note dated 08/14/21 at 3:55 AM that stated the patient became irate and agitated when the nurse entered the room and tried to hit, bite and kick.

Review of a security report dated 08/14/21 at 4:38 AM revealed officers arrived at the patient's room at approximately 4:00 AM. The note stated staff were holding down the patient's legs and "security relieved staff of that and also helped keep the patients (sic) arms restrained so that staff could medicate."

A physician order dated 08/14/21 at 4:13 AM ordered 20 milligrams of Geodon (antipsychotic) intramuscularly.

The medical record review confirmed 20 milligrams of Geodon was given intramuscularly on 08/14/21 at 4:13 AM.

The medical record review did not reveal a physician order to force hold the patient to force medicate him.

On 08/26/21 at 12:21 PM in an interview, Staff C confirmed the clinical record did not include an order to force hold the patient to force medicate.

6. The medical record review for Patient #8 was completed on 08/31/21. The medical record review revealed the patient was admitted on 07/01/21 through the emergency department with diagnoses of multiple falls, hypothyroidism, dementia, lactic acidemia, and coronary artery disease.

An emergency department physician note dated 07/01/21 at 6:37 PM revealed the patient fell sometime during the day on the way to the bathroom. The note stated she fell again after trying to get up, then crawled to the living room to wait for family to return home.

A history and physical dated 07/02/21 at 12:05 AM revealed the patient was alert and oriented to person, place, and time with an appropriate affect. The note stated the author believed the patient was being overmedicated with antihypertensives and noted if elderly patients were having recurrent falls, "permissive hypertension is allowed."

A physician activity order dated 07/02/21 at 12:05 AM stated the patient could be up with assist.

A security case report dated 07/02/21 at 8:35 PM revealed security was dispatched to the patient's room at approximately 8:35 PM. The report stated the elderly patient "was a fall risk" and climbed out of bed and "stumbled" onto the couch. The report stated she "refused to get into bed." The officer convinced her to get back into bed. The report stated when the nurse flushed the patient's intravenous access port, the patient threw a punch. "At that time" one officer secured her left arm and leg while another secured her right arm and leg. The report concluded, "Staff applied restraints and medicated the patient."

On 07/02/21 at 8:45 PM the patient was medicated with 0.5 milligrams of Ativan (sedative).

The medical record review did not reveal a physician's order to force hold to medicate the patient.

On 08/26/21 at 2:55 PM in an interview, Staff C confirmed the findings.

7. The medical record review for Patient #4 was completed on 08/31/21. The patient presented to the emergency department on 03/02/21 at 12:09 AM. A physician progress note dated 03/02/21 at 12:09 AM revealed after a "presumed" overdose and acute alcohol intoxication, the patient was "dropped off" in front of the hospital. The note concluded with diagnoses of diabetic ketoacidosis without coma associated with type two diabetes mellitus and acute alcoholic intoxication with complication. The note stated she presented "agitated, screaming, and combative. She was noted to be tachycardic into the low 130s and 140s." The note stated the patient was noncompliant with care and "seemed to lack capacity of how sick she was." The note said for that reason, an application for emergency admission was made.

A physician order dated 03/02/21 at 12:35 AM to restrain the patient with bilateral soft wrist restraints for the patient being a danger to self and others.

A nursing note dated 03/02/21 at 1:00 AM revealed the patient was found exiting the room and into the hallway, naked, and pulled out intravenous access. "Patient presumed to removed self from restraints," it said. The note said the patient deescalated with nursing intervention, allowed intravenous access sites to be bandaged and returned to her room. The note said intravenous access was reestablished and fluids resumed.

Review of a security case report dated 03/02/21 at 12:03 AM revealed they went to the patient's room, and she tried to push past them to gain exit. They then assisted staff to restrain her physically "while staff restrained her medically."

A nursing note of 03/02/21 at 2:00 AM revealed the patient had removed her intravenous access, was ambulating into the corridor, then escorted back to bed by security. The note said ketamine was given intramuscularly and the patient was restrained.

The medical record review did not reveal any physician order to force hold the patient to medicate her.

On 08/31/21 at 2:45 PM in an interview, Staff C confirmed the absence of an order to force hold the patient to medicate her.