HospitalInspections.org

Based on observation, staff interview, review of facility video surveillance from 04/01/25, medical record review (Patient (P)1), and review of facility documents, it was determined that the facility failed to ensure that: 1.) the patients outcome behaviors and medications administered as an alternative to restraints, are documented in accordance with facility policy (A0186); 2.) Behavioral Health and security staff received recertification training and utilized de-escalation techniques in accordance with the facility's "Handle with Care " de-escalation training, and restraint policy (A0200); and 3.) visitors who have been restricted from the facility, are denied access as per facility policy and procedure (A0215). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.

On 04/09/25 at 2:21 PM, an IJ was identified for the facility's failure to ensure Behavioral Health and security staff received recertification training and utilized de-escalation techniques in accordance with the facility's "Handle with Care " de-escalation training, and restraint policy (A0200). At 4:08 PM, the IJ template was provided to Staff (S)1 (Senior Director of Clinical Transformation) and a removal plan was requested. An acceptable removal plan was received on 4/10/25 at 10:08 AM. The facility provided education to all nursing and security staff on verbal de-escalation prior to their next shift, a handout document summarizing de-escalation techniques, and an attestation signed by the staff members stating that he/she will maintain current with the complete de-escalation course requirement. The IJ was removed on 04/11/25 at 11:00 AM, after the State Survey Agency verified the full implementation of the removal plan, and Condition Level non-compliance remains (A0115).

Cross Reference:
482.13(e)(16)(iii) Patient Rights: Restraint or Seclusion
482.13(f)(2)(ii) Patient Rights: Restraint or Seclusion: Staff Training Requirements
482.13(f)(h) Patient Rights: Patient Visitation Rights

Based on medical record review, staff interview, review of facility documents, and review of facility video surveillance from 04/01/25, it was determined that the facility failed to ensure the patients outcome behaviors and medications administered as an alternative to restraints, are documented in accordance with facility policy.

Findings include:

Facility policy titled, "Restraint Policy," last revised date February 2023, stated, "... Documentation: ... Documentation must clearly reflect patient risk, associated behaviors and all alternatives attempted. ..."

On 04/08/25, review of Patient (P)1's EMR (electronic medical record) was conducted with Staff (S)2 (Registered Nurse [RN] Clinical Coordinator, Behavioral Health Unit). A progress note from 04/01/25 at 20:00 [8:00 PM], from S41 [Advanced Practice Nurse] revealed that P1 had been placed in 4-point restraints for safety. Upon request to view the restraint documentation, S2 stated that the orders for restraint and restraint charting are on paper, which is currently on the Behavioral Health Unit with P1. A request was made for copies of the paper restraint documentation.

At 2:03 PM, a review of security video surveillance from 04/01/25 at 19:32 [7:32 PM] on the Behavioral Health Unit, was conducted with S4 (Safety Manager) and S5 (Director of Risk). A person, identified by S4, as S6 (Clinical Coordinator) was observed standing and speaking to P1, who was sitting in a wheelchair in the visiting room beside a visitor, identified by S4 as the patient's mother. Another camera view showed four people watching and listening while S6 and P1 were speaking to each other. S6 was observed leaving the waiting area through one door, then returning through the farther door from the patient. When S6 returned through the farther door, he/she was observed pointing his/her finger at P1, and P1 was observed pointing back. At 19:34 [7:34 PM], P1 threw a full fountain soda cup in the direction of S6, and it struck the wall beside him/her. Staff members then entered the room and surrounded the patient, wheeling P1 out of the waiting area and towards his/her room. At 19:43 [7:43 PM], P1 required restraints and seclusion.

On 04/09/25 at 11:35 AM, a review was conducted of P1's medical record with S3 (RN Quality Control). The paper restraint documentation included a "Restraint or Seclusion Debriefing" checklist, that stated the following: "Manager or Supervisor will conduct and document the debriefing as soon as patient and staff are safe and stabilized." The form includes a series of "Debriefing Topic" questions requiring a "yes" or "no" response and an area for comment is provided.

Question: "All appropriate alternatives to restraint were attempted and documented, including patient outcomes behaviors." Comment: "Appropriate alternatives were offered, meds and negotiation." Question: "Any other alternatives available that should have been attempted before restraint" Comment: "All other appropriate alternatives were exhausted such as meds and limit setting that wasn't effective."

A review of P1's electronic medical record with S3 revealed that at 20:00 [8:00 PM], 17 minutes after restraint, P1 received Benadryl 50 mg (milligrams) IM (intramuscular) and Thorazine (schizophrenia and bipolar symptom medication) 50 mg IM. S3 confirmed that no PRN (as needed) meds were documented as administered, prior to P1 being placed in restraints. S3 confirmed that the last psychiatric medications that P1 received, prior to the Benadryl and Thorazine given after restraint, were scheduled medications at 5:14 PM, 5:16 PM, and 5:26 PM. The medical record lacked documentation of which medications were given as an alternative to restraint, and the patient's outcome behaviors from the medication. These findings were reviewed with S3 and S1.

On 04/09/25 at 3:03 PM, a telephone interview was conducted with S40 (RN). S40 confirmed that he/she was P1's nurse on 04/01/25. S40 stated that before taking his/her meal break, P1 was "responding, talking to [himself/herself], usual baseline." S40 stated that while on break, he/she heard a noise, and when he/she returned "[Named S6, Clinical Coordinator], was medicating [P1] when I took over in the seclusion room." S40 was unable to confirm that any medications were administered to P1 as an alternative to restraints, as documented in the "Restraint or Seclusion Debriefing" document.

Based on observation, staff interview, review of facility video surveillance from 04/01/25, medical record review (Patient (P)1), and review of facility documents, it was determined that the facility failed to ensure Behavioral Health and security staff received recertification training and utilized de-escalation techniques in accordance with the facility's "Handle with Care " de-escalation training, and restraint policy.

Findings include:

Facility policy titled, "Restraint Policy," last revised February 2023, stated, "... IV. Procedure: ... 2. Attempt to de-escalate the situation: Use non-physical de-escalation techniques to help patient regain control of behavior. Be supportive, firm, and empathetic. ... Be aware of personal space, body position, and language. Keep all non-verbal cues non-threatening. ..."

Facility document titled, "Handle With Care Behavior Management System Verbal Intervention Manual for Participants" stated, "Support: ...1. Listen: Allow the client to ventilate verbally without your becoming defensive or reactive. This is difficult when you or other staff are subjects of the complaint ... Be aware that your body language - nonverbal communication (facial expressions, hand gestures, pointing etc) reveals your true affect. ..."

On 04/08/25 at 11:13 AM, during a tour of the Behavioral Health involuntary unit, Patient (P)1 stated that he/she "was assaulted, me and my Mom." Staff (S)7 (Nurse Manager) stated to the patient from behind survey staff, "You were assaulted? You did the assaulting." The staff member failed to allow the client to ventilate verbally in accordance with facility "Handle with Care" de-escalation training.

At 2:03 PM, a review of security video surveillance from 04/01/25 at 19:32 [7:32 PM] on the Behavioral Health Unit, was conducted with S4 (Safety Manager) and S5 (Director of Risk). A person, identified by S4, as S6 (Clinical Coordinator) was observed standing and speaking to P1, who was sitting in a wheelchair in the visiting room beside a visitor, identified by S4 as the patient's mother. Another camera view showed four people watching and listening while S6 and P1 were speaking to each other. S6 was observed leaving the waiting area through one door, then returning through the farther door from the patient. When S6 returned through the farther door, he/she was observed pointing his/her finger at P1, and P1 was observed pointing back. At 19:34 [7:34 PM], P1 threw a full fountain soda cup in the direction of S6, and it struck the wall beside him/her. Staff members then entered the room and surrounded the patient, wheeling P1 out of the waiting area and towards his/her room. At 19:43 [7:43 PM], P1 required restraints and seclusion.

At 3:25 PM, an interview was conducted with S6 regarding P1. During the interview, S6 stated that during the time observed on video, P1 was yelling and threatening staff. S6 stated that he/she completes de-escalation training at the facility every year, and that during interactions with P1 "I set limits, boundaries, before it gets physical." On 04/10/25 at 3:08 PM, during a second interview with S6, he/she confirmed pointing at the patient in order to direct the patient to move.

On 04/09/25 at 10:46 AM, a video review was conducted with S6. The video surveillance was from 04/01/25 at 19:43 [7:43 PM] on the Behavioral Health involuntary unit, of Seclusion Room 2. P1 was observed being placed in 4-point restraints with 11 staff members present. As staff were exiting the room, a person, identified by S4, as S12 (Registered Nurse [RN]) was observed approaching the patient, who was in restraints, pointing his/her finger and speaking to the patient while posturing forward towards the patient prior to exiting the room.

On 04/10/25 at 1:31 PM, a telephone interview was conducted with S12. S12 stated that when a patient is restrained, "someone has to stay back and make sure [he/she] is ok. I rechecked the wrists and ankles. [He/she] was cursing me out. I think [he/she] spat at me or something like that. I was just making sure [he/she] was comfortable." P12 further stated, "I really cannot recall specifically pointing fingers." For non-verbal communication skills taught in Handle with Care, S12 confirmed, learning about non-verbal cues, non-verbal stances, and not to assume a stance that looks ready to be aggressive, or offensive towards [him/her]." S12 stated that when P1 was restrained, "I made sure [he/she] as a patient was very safe. No one was putting hands on [him/her]. I made sure [he/she] didn't spit on everybody. It was a safe de-escalation."

At 11:46 AM, an interview was conducted with S20, the manager responsible for the Handle With Care de-escalation training. S20 stated that education is provided for staff on handling a patient escalating in behavior and making threats. S20 stated that staff are taught "limit setting" which includes "keeping your voice low, almost whispering," "not yelling back," and "not pointing. You're giving attitude. It's not going to calm the patient down." S20 confirmed that all staff are required to receive Handle With Care Training upon hire and are recertified annually.

On 04/09/25 at 12:03 PM, S1 (Senior Director of Clinical Transformation) provided a list of the last time all security officers and staff members from the in-patient behavioral health unit completed the Handle With Care training. Twenty-two out of 64 staff members from the behavioral health unit and 21 out of 37 security officers had not received the Handle with Care recertification within the past year.

At 2:21 PM, S1 confirmed that the security officers and behavioral health staff were not up to date with their annual re-certification of Handle with Care. S6 (Clinical Coordinator), S22 (Mental Health Aide), S17 (Security Officer), S18 (Security Officer), S16 (Security Officer), and S25 (Security Officer) were identified on the provided lists as staff members who have not received Handle With Care within the past year. These staff members were identified on video as assisting when P1 was restrained on 04/01/25.

Based on staff interview and review of facility documents, it was determined that the facility failed to ensure that visitors who have been restricted due to staff safety are denied entrance to the facility.

Findings include:

Facility policy titled, "Visitation Policy," reviewed April 2025, stated, "... IV. Procedure: ... 4. Visitor Limitations... B. Visitors who display behavior that is aggressive, offensive, belligerent, or disrespectful to other people within the hospital will not be tolerated and may be requested to leave. ... C. ... ii. Visitor's visitation privileges will be reinstated pending review by administration. ..."

On 04/08/25 at 3:44 PM, during an interview with Staff (S)6 (Clinical Coordinator, behavioral health unit) and S12 (Registered Nurse, behavioral health unit), S12 stated that a patient's visitor (V) had punched him/her during visiting hours on 04/01/25. S12 stated that the visitor (V2), who had arrived with another visitor (V1), had been removed from the unit by staff and security. After the visitor was removed, S6 stated that the behavioral health unit began receiving threatening phone calls from another family member (V3) of the patient. S12 stated that he/she called the police. S12 further stated that V1, V2, and V3 had been placed on the facility's visitor restriction list; however, S12 stated that over the weekend, he/she saw V1 and another visitor in the elevator on the way to the unit.

On 04/09/25 at 2:27 PM, S1 (Senior Director of Clinical Transformation) and S4 (Safety Manager) provided copies of the lists of patients who were restricted from visitation at the facility from 04/01/25 until present. Two lists were provided, dated 04/01/25 and 04/07/25. S4 confirmed that the list from 04/01/25 remained in effect until 04/07/25, when there was a change. On the list dated 04/01/25, there were three names listed under "visitors not allowed: V1, V2, and V3."

A review of the listing of all visitors who had logged in at the front desk from 04/01/25 until 04/07/25 revealed that on 04/06/25, V1 and V3 had logged in as visitors. S4 stated that on 04/06/25, "there was a miss because the hostess went on break. She was relieved, and the visitors got up to the floor but did not get on the unit." S4 stated that the hostess was relieved by a security guard, who allowed the visitors to enter the facility despite being on the restricted list. When asked if any action had taken place as a result of this miss, S4 stated that he/she "spoke to the hostess." S4 was unable to confirm that the security officer had been educated on the miss. S4 stated that when P1's family arrived on the unit, they were informed of the visitor restriction and not allowed to enter.

Based on observation, staff interview, and facility document review, it was determined that the facility failed to ensure: 1.) portable space heating devices are not used in patient care areas; and 2.) Items located in the corridor are limited to the following: equipment carts in use, medical emergency carts, and/or patient lifting and transport equipment.

Findings include:

1. Reference: National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, stated, "...19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met: (1) Such devices are used only in non-sleeping staff and employee areas. (2) The heating elements of such devices do not exceed 212 degrees Fahrenheit (F)."

On 04/08/25 at 11:33 AM, in the presence of Staff (S)1 (Director of Quality) an electrical powered portable space heating device was in use on the fourth floor inpatient Voluntary Behavioral Health Unit. The heating device was a Dayton Salamander Heater, Model 1RKT9C.

This portable heating unit was located in the corridor outside the Nurses' Station and was plugged into an electrical outlet on the wall. A staff member was noted to be sitting beside the heater. On 4/9/2025 at 10:51 AM, during a tour of the Voluntary Behavioral Health Unit, S7 (Nurse Manager) stated that temperatures fluctuate on the North side (voluntary unit), and the heater is used to keep patients warm. S7 confirmed that the heater is monitored by a nurse or technician, and they are assigned to sit there every shift.

On 04/08/25 at 11:33 AM, in the presence of S1, patients were observed walking up and down the corridor near the heater.

A label affixed to the top of the heater read, "Caution: Hot Surface. The front surface temperature could reach above 150 degrees Fahrenheit."

During an interview on 04/10/25 at 10:15 AM, S24 (Director of Plant Operations), confirmed the portable heating units were used on the unit during brief periods of extreme cold weather.

2. Reference: NFPA 101 Life Safety Code 2012 Edition, "...19.2.3.4(4) Projections into the required width shall be permitted for the wheeled equipment, provided that all of the following conditions are met . . . (c) The wheeled equipment is limited to the following: i. Equipment in use, ii. Medical emergency equipment not in use, iii. Patient lift and transport equipment."

On 04/08/25 and 04/09/25, the portable heating unit, which measured approximately 28 inches wide, was located in the patient care corridor reducing the overall width of the corridor to approximately 68 inches.