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Based on observation, medical record review, policy review, document review, and interview, in two of 13 medical records reviewed, it was determined the facility failed to protect and promote the rights of all patients related to the use of restraints as evidence by the facility's use of spit hoods (a mesh hood or spit guard is a restraint device intended to prevent a person from spitting or biting) on patients in the emergency department, lack of facility policy for the use of spit hoods, and the lack of staff training, education, and competency in the use of spit hoods (Patient #21 and Patient #22).

Reference:
482.13(e): Use of Restraint or Seclusion.

Based on observation, medical record review, policy review, document review, and interview, in two of 13 medical records reviewed, it was determined the facility used spit hoods/socks (a mesh hood or spit guard is a restraint device intended to prevent a person from spitting or biting) for emergency department patients. There is no clinical policy and/or training curriculum for the use of spit hoods/socks; there is lack of documentation for the initiation and discontinuation of spit hoods/socks; and there is lack of monitoring documentation.

Findings include:

Observation on 11/14/25 at 03:05 PM with Staff (O), Registered Nurse, revealed two single packaged spit hoods in a supply drawer under a desk in the nursing station.

Review on 11/15/24 of Patient # 21's emergency department medical record dated 10/30/24 revealed the following:
-At 12:38 AM, Patient #21 arrived at the emergency department on 9.41 papers (New York State Office of Mental Health Law that allows law enforcement to arrest an individual who appears mentally ill and transport them to a hospital for examination) with law enforcement.
-At 01:15 AM, Staff (G), Registered Nurse, documented Patient #21 was placed in four-point restraints for assaulting nurse and a law enforcement officer while in the emergency department.
-At 01:20 AM, Staff (F), Physician, ordered four-point leather behavioral restraints.
-At 01:25 AM, Staff (G), Registered Nurse, documented that a spit mask was applied to Patient #21's head.
-At 01:50 AM, the triage assessment by Staff (G), Registered Nurse, revealed Patient #21 was brought in by police for a mental health exam after getting into an altercation with the owner of a business next door to their house.
-At 05:20 AM, Staff (F), Physician, re-ordered four-point restraints due to Patient #21's continued display of violent behaviors.
-At 07:20 AM, Staff (M), Registered Nurse, documented all restraints were removed.
(There is no documentation of a provider order for a spit mask, assessment of spit mask placement, and/or when the spit hood was removed).

Review on 11/15/24 of Patient #22's emergency department medical record dated from 08/31/24 to 09/01/24 revealed the following:
-On 08/31/24 at 07:10 PM, Patient #22 was brought to the emergency department on 9.45 papers (New York State Office of Mental Health Law that allows law enforcement to arrest an individual who appears mentally ill and transport them to a hospital for examination) with law enforcement for acute psychosis.
-On 08/31/24 at 07:30 PM, triage note by Staff (T), Registered Nurse, revealed Patient #22 was brought in by law enforcement under 9.45 due to Patient #22 being inappropriate at an appointment and taking off their clothes. Patient #22 was uncooperative, spitting, and kicking.
-On 08/31/24 at 07:30 PM, Staff (T), Registered Nurse, documented a spit mask was placed on Patient #22. Patient #22 was placed in room #10 with a one-to-one monitor.
-On 08/31/24 at 07:30 PM, Patient #22 was placed in four-point restraints due to being hostile and harming self and others. Staff (U), Advanced Practice Practitioner, ordered behavioral restraints. There is no evidence of an order for a spit hood.
-On 08/31/24 at 07:34 PM, Staff (U), Advanced Practice Practitioner, documented Patient #22 was placed in restraints for their safety and the safety of others.
-On 09/01/24 at 12:00 AM, restraints were discontinued. At 12:25 AM, Patient #22 was admitted to the Behavioral Health in-patient unit.
(There is no documentation of a provider order for a spit mask, assessment of spit mask placement, and/or when the spit hood was removed).

Review of the product insert for the "The Hood TRANZPORT Protective Hood," (spit hood/mask) dated 2019, revealed on the front of the document has the following "WARNING: IMPROPER USE OF THE TRANSPORT HOOD MAY CAUSE INJURY OR DEATH." Improper use may result in serious injury or death due to asphyxiation, suffocation or drowning in one ' s own fluids. The wearer must be under constant visual supervision and should never be left unattended.

Review of the policy "Restraint-Use Of," last revised 08/2023, revealed a violent/self-destructive restraint is defined as "used for violent or self -destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others." Examples of violent restraints are four-point, chemical, and seclusion. Clinical support staff involved in caring for patient in restraints must complete restraint training during orientation and maintain annual competency thereafter. The provider is responsible for the patient's ongoing care must order the restraint after an initial evaluation is completed. Safety checks are done every 15 minutes and include restraints are applied by manufacturer's instructions, skin examination at restraint site, patient safe from injury, two fingers can be placed under restraint, skin under restraint is monitored for decreased sensation/color/mobility/warmth/integrity, and nutrition/hydration/hygiene/elimination needs are met. Every hour, restraints are assessed/reassessed for release, and to reposition patient. (The policy does not include the use of a spit mask/hood on patients, if a provider order is required for the use of a spit mask/hood, and what monitoring/safety check documentation are to be documented).

Review of the education for "Restraints," and "Restraint Competency," no date, revealed education and demonstrated competency for the use of restraints (soft limb, mitts, four-point in the emergency department only). The use of restraints requires a provider order, assessment of a patient while in restraints, provider face to face assessment requirements, documentation of restraint use, risks of restraint use, and indication for restraint use. (The education does not include use of spit masks/hoods).

Interview on 11/14/24 at 11:31 AM with Staff (L), Physician Assistant, at 11:35 AM with Staff (K), Emergency department Manager, and at 01:15 PM with Staff (D), Chief Nursing Officer, revealed that spit hoods are used on patient in the emergency department.

Interview on 11/14/24 at 02:00 PM with Staff (J), Nurse Educator and at 02:50 PM with Staff (A), Director of Quality and Risk, revealed the hospital does not have a policy regarding the use of spit hoods and staff do not have any training or education on the spit hoods.

Interview on 11/15/24 at 07:20 AM with Staff (G), Registered Nurse and at 09:30 AM with Staff (T), Registered Nurse, revealed that spit hoods are used in the emergency department when a patient is spitting. An order is not documented in the medical record. Staff (T) did not receive any training on the spit hood.