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Based on document review, video review and interview, the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The Hospital failed to ensure healthcare approved restraint interventions were used during restraint application. See deficiency at A-154.

2. The Hospital failed to ensure the use of restraint was implemented in accordance with safe and appropriate restraint techniques. See deficiency at A-167.


Two Immediate Jeopardies were identified on 10/2/2025 due to the Hospital's failure to ensure healthcare approved restraint interventions were used during restraint interventions for 2 psychiatric patients (Pt #3 and Pt #13); and the Hospital's failure to ensure the use of restraint was implemented in accordance with safe and appropriate restraint techniques during physical holds for 2 patients (Pt #3 and Pt #6). The IJs were identified at 42 CFR 482.13, Patient Rights. The IJs were announced on 10/2/2025 at 3:00 PM during a meeting with the President, Accreditation Manager, Manager of Security, Director of Security, Director of ED (emergency department), CMO (Chief Medical Officer), Chief Nursing Officer, Director of Behavior Health Services, Assistant CMO, System VP Quality, VP Operations, System VP Security Services. The IJs were not removed by the survey exit date of 10/2/2025.

Based on document review and interview, for 1 of 1 behavioral health unit, the Hospital failed to ensure that the behavioral rounding sheets included the patient's ordered precautions to ensure patients were monitored for the appropriate precautions.

Findings include:

1. A Hospital's policy regarding documentation/completion of patient observation rounding sheets was requested. The Hospital was unable to provide a policy.

2. On 9/29/2025 at 12:28 PM, an observational tour of the Inpatient Behavioral Health unit was conducted. During the tour, the "Observation Flow Sheet" (behavior observation/precautions rounding tool), was reviewed. The rounding sheets lacked the individually ordered precaution types (e.g. susicide, elopement, assault), for each patient to indicate special precautions to observe for while rounding. The clipboard that was actively being used for rounding did not have the patient's census that would indicate the patient's precaution types/levels.

3. On 9/29/2025 at 1:10 PM, an interview was conducted with the Behavioral Health Program Director (E #16). E #16 stated that the ordered precautions used to be on the rounding sheets in the past. E #16 stated that the precautions were removed from the sheets, in order to keep the sheet "clean" if there are order changes. E #16 stated that the rounding Behavioral Health Counselor (BHC) should know what precautions that the patients are on. E #16 stated that the BHC could go off memory from the daily report or come to the nurse's station to look at the census sheet. E #16 acknowledged that the census sheet was not on the clipboard that had the rounding sheets attached.

Based on document review, video surveillance review, and interview, the hospital failed to ensure healthcare approved restraint interventions were used during restraint interventions for 2 of 2 (Pt #3 and Pt #13) psychiatric patients who were placed in forensic restraints (handcuffs) by hospital staff. Hospital staff engaged in law enforcement action by placing the patients in handcuffs without charges being filed or the patient being taken into legal custody, which resulted in Pt. #3 requiring medical treatment following restraint. The use of handcuffs by hospital staff is likely to result in serious harm, injury, or death to any current or future patients requiring restraints.

Findings include:

1. The hospital's policy titled, "Use of Force & Restraint" (7/20/2023) was reviewed on 9/30/2025 and included, "handcuffs cannot be used by hospital security staff as a healthcare intervention. Hospital security staff may use handcuffs on individuals in criminal situations, with the expectation that the individual will be charged with a crime."

2. The security forensic restraint log for 2025 was reviewed on 9/30/2025 and included Pt. #3 and Pt. #13, as patients who were placed in handcuffs.

3. The clinical record of Pt. #3 was reviewed on 9/29/2025. Pt. #3 presented to the emergency room on 8/19/1025 at 7:57 AM with complaint of being depressed and wanting to see a counselor. Pt. #3 does have a history of motorcycle accident where has bilateral AKA [above knee amputation].

- Hourly continuous video monitoring documentation of Pt #3 indicated that Pt. #3 remained calm and cooperative from admission until 8/20/2025 at 10:00 AM, around which time Pt #3 was informed they would be transferred to the inpatient BH (behavioral health) unit. At 10:00 AM, Pt. #3 became agitated and uncooperative.

- A charge nurse (E#5) note dated 8/20/2025 at 10:30 AM included that at around 10:00 AM, Pt. #3 was informed that Pt. #3 was being admitted to the hospital's inpatient behavioral health [BH] unit. Pt. #3 was resistant. "On my arrival to [Pt. #3's] room, Crisis [worker] was at the bedside attempting to talk with [Pt. #3] when I saw the door closing. Crisis thought [Pt. #3] was self-transferring into the wheelchair that was at the bedside. Patient was not transferring self and placed the wheelchair in front of the door blocking access to the room. Security was able to gain access to the room through the safety door (small door inside the main door with separate key to gain access). Security and this nurse then attempted to get the patient to agree to transfer to the BH unit ... When getting [Pt. #3] to the wheelchair [Pt. #3] went limp and wouldn't sit up. [Pt. #3] then sat up quickly and appeared to lunge forward. Security then grabbed on to [Pt. #3] not wanting [Pt. #3] to fall and [Pt. #3] started fighting. [Pt. #3] was able to be medicated and was able to be placed in the wheelchair shortly after. [Pt. #3] was yelling the entire interaction. [Pt. #3] was continuously visually monitored for respirations and ease of breathing by this nurse. [Pt. #3's] breathing not compromised during the interaction."

- The inpatient psychiatrist's (MD#1) admission note, dated 8/20/2025 at 11:03 AM included, "With two ED visits in two days for suicidal ideation, hallucination, hyper religious focus, and spending time out in the woods with bizarre behavior. ... This author witnessed [Pt. #3] in the ED coming out of physical holds by security officers who placed [Pt. #3] in handcuffs during holds. ... [Pt. #3] stated was sorry for behavior in the ED. ... Will obtain CT [computerized tomography] scan head, spine, chest, abdomen and pelvis to assess for injury due to physical holds by officers in ED."

- The CT scans were completed on 8/20/2025 at 9:37 PM with an indication: "During restraints multiple people on top of [Pt. #3]." There was no evidence of acute fractures or injuries on CTs.

4. The video surveillance of the event related to Pt. #3 from 8/20/2025 was reviewed on 9/30/2025 at 10:40 AM with the manager of security (E#13). The recording of Pt. #3's room started at 10:03 AM and continued as follows:

- 10:04 AM - Pt. #3 watching TV and nurse talking to patient from behind a wheelchair (w/c).
Crisis worker entered room. Pt. #3 appears to be refusing to get in w/c.
- 10:06 AM - security officer (E#10) seen in doorway. E#10 walks away from doorway. No staff visible.
- 10:07 AM - Pt. #3 closes door and places w/c in front of door.
- 10:08 AM - security (E#8) enters room through safety door (small door within larger door) and moves w/c to side.
- 10:09 AM - three security officers (E#8, E#10 and E#11) enter room. Continue to talk with Pt. #3.
- 10:11 AM - Nurse (E#5) enters room talking with Pt. #3.
- 10:13 AM - E#8 assists Pt. #3 to sitting position and places arms under Pt. #3's arms and lifts into w/c. 4 officers in room (E#7, E#8, E#10 and E#11).
- 10:14 AM - Pt. #3 reaches for bed to return to bed and Pt. #3 grabs onto E#8's leg appearing to stop Pt #3 from falling to floor. Pt. #3 ends up on floor, face down (prone). E#8 seen with arm around Pt. #3's neck.
- 10:15 AM - Pt. #3 fighting with officers and trying to get off of stomach. Four security officers in room holding Pt. #3 on the floor. E#8 with arm still around Pt #3's neck. E#7 laying across Pt. #3's back. The security officers attempted to release the physical hold and Pt. #3 began fighting again.
- 10:17 AM - Officers unable to release hold to move Pt. #3 into wheelchair.
- 10:20 AM - Pt. #3 remained on floor with the 4 security officers around Pt. #3. E#7 remained lying on Pt. #3's back.
- 10:21 AM - E#10 gets handcuffs from waist belt and attempts to place on Pt. #3's arms.
- 10:22 AM - MD#1 enters room. MD #1 places hands on E#10's shoulders and pulls back. Some movement from Pt. #3 seen to attempt to get up. E#8 no longer with arm around Pt. #3's neck. MD#1 trying to get close to Pt. #3 to talk. Handcuffs (2 pairs of handcuffs connected - to increase length because of Pt. #'s size) in place and Pt. #3's arms were behind their back.
- 10:23 AM - MD#1 pulls at security officers' shoulder again to release hold.
- 10:24 AM - All officers let go and move away.
- 10:26 AM - Handcuffs remain in place. Pt. #3 lifted into w/c.
- 10:27 AM - Handcuffs removed by E#10.
- 10:29 AM -Pt. #3 taken out of room to be taken to inpatient unit.

5. MD#1 (psychiatrist) was interviewed via telephone on 9/29/2025. MD#1 felt that security using handcuffs is not within psychiatric standard of care.

6. A security officer (E#7), involved in the incident with Pt. #3 was interviewed on 9/30/2025 at 10:00 AM. ... E#7 stated that 3 officers were injured during the encounter, and everybody was in danger, so it was decided to use handcuffs. The police were called. E#7 stated, "We are able to use handcuffs because we have them."

7. Security officer (E#8), involved in the incident with Pt. #3 was interviewed on 9/30/2025 at 10:20 AM. ... E#8 stated, "Since we could not use restraints because we could not get [Pt. #3] off the floor, we decided to use handcuffs." E#8 stated that whenever someone commits a crime, security is allowed to legally detain that person. E#8 stated, "[Pt. #3] hurt 3 officers and would not stop fighting. It is an Illinois state law for a citizen's arrest to detain the person. The police were called, and a report was filed. The handcuffs were removed before the police arrived because the patient calmed down."

8. The security director (E#12) was interviewed on 9/30/2025 at 12:15 PM. E#12 stated, "I reviewed the video and determined that [Pt. #3] had a lower center of gravity because of being an amputee and regular restraints could not be utilized. This was definitely an outlier. Forensic restraints (handcuffs) were applied because the patient committed a crime."

9. The manager of security (E#13) was interviewed on 9/30/2025 at 12:25 PM. E#13 stated that handcuffs are not supposed to be used on a patient. E#13 stated, "After watching the video and observing the officers CPI technique - I didn't love it, but there really was no other means to restrain this patient." E#13 stated that no change in policy or practice has been implemented since this incident.

10. Pt. #13 was also included on the forensic restraint log.
The Hospital's incident report (dated 7/26/2025) regarding Pt. #13 noted, "On 7/26/2025 at approximately 7:00 PM, security officer (E #19) was coming out of the doctor's entrance door in the ambulance bay when E #19 observed Pt. #13 from ER #13 start to run from the ambulance bay ER doors with ER nurse right behind him. E #19 knows that Pt. #13 is to be a 1:1 watch for homicidal ideation and was awaiting placement, so E #19 began to pursue Pt. #13. During this taking place, ED nurse called local police to report the elopement. E #19 then dispatched Security Officer (E #20), Security Officer (E #21), and Security Officer (E #22) to assist the fleeing patient (Pt. #13). E #19 pursued Pt. #13 through the ER parking lot and into same day surgery parking lot where we ended up in the field next to the childcare building. E #19 then instructed Security Officer (E #21) to grab the security vehicle while Security Officer (E #20), Security Officer (E #22) and E #19 stayed in pursuit of Pt. #13. Pt. #13 was able to make it to Route 31 where Pt. #13 almost caused multiple accidents when crossing. When it was safe to cross Route 31 security caught up with Pt. #13 in the parking lot of Starbucks where Pt. #13 then was apprehended. After going hands on (take patient by arm to escort), Pt. #13 tried multiple times to elope from E #20 and E #22 by flailing Pt. #13's bloody arms/hands and kicking, trying to inflict serious damages or injuries to security officers. With this manic behavior, Pt. #13 was displaying and for the safety of the public, my security officers and Pt. #13 himself, E #19 instructed E #20 to apply forensic restraints until we arrived back in the ER room at approximately 7:09 PM. Outcome of event included, "No harm to patient."

11. The security officer (E#19), involved with Pt. #13 was interviewed via telephone on 10/2/2025 at 10:10 AM. E#19 stated Pt. #13 had exited the ED, and E#19 knew that Pt. #13 was a psychiatric patient. E#19 yelled for the charge nurse to call the local police and began pursuit after Pt. #13. E#19 stated, "[Pt. #13] ran through a field and obtained cuts from the trees and was also bleeding from an IV site that had been pulled out." E#19 stated that Pt. #13 was followed across a busy street, and Pt. #13 almost caused two separate car accidents. Pt. #13 was able to be caught at the Starbucks parking lot. E#19 stated, "I called for assistance from other officers who arrived by vehicle. We took ahold of [Pt. #13's] arms to escort back to the hospital. When [Pt. #13] tried to run into traffic again, I decided to use handcuffs for [Pt. #13's] safety and ours because of the blood. We were able to bring [Pt. #13] back to the hospital safely, and the handcuffs were removed." E#19 stated that the police did stop as they were returning to the hospital because they had been notified and saw Pt. #13 in handcuffs. But since E#19 stated that everything was ok, the police left. Pt. #19 stated that handcuffs can be used if a law is broken or for patient/staff/public safety. E#19 stated, "I felt handcuffs were the best option to keep everyone safe."

12. The patient safety program manager (E#29) was interviewed via telephone on 10/2/2025 at 9:30 AM. E#29 stated that after any investigation is complete and categorized with a severity level, E#29 ensures that any action plans to prevent reoccurrence are completed. E#29 stated, "The event related to [Pt. #3] was classified as 'appropriate care' because the staff did their due diligence to keep the patient safe, even though several security officers were injured during the encounter. We did notice that the actions taken by the security officers did not support our policies for handcuff usage. Our policies also do not align with CMS conditions of participation." E#29 stated that they have 3 - 6 months to complete the policy review/revision and that is being worked on now (not completed).

13. The security director (E#12) was interviewed on 10/2/2025 at 10:45 AM. E#12 stated, "The security officer for [Pt. #13] should have asked for assistance from the police to escort the patient back to the hospital. Placing the handcuffs on in the first place is part of the Illinois citizen's arrest process for safety. The security officer had the right to handcuff the patient. Obviously, handcuffs are only used in emergent situations." E#12 stated that the organization is working on future education to align/standardize training. The policies are being looked at to see if changes need to be made to align with CMS requirements. E#12 stated that no immediate actions were taken. The staff are all still employed, and no disciplinary actions were needed.

Based on document review, video surveillance review, and interview for 2 of 2 psychiatric patients (Pt. #3 and Pt. #6) requiring behavioral physical restraints, the hospital failed to ensure that the use of restraint was implemented in accordance with safe and appropriate restraint techniques by failing to ensure an emergency safety intervention/crisis prevention (CPI) hold was correctly and safely performed. This failure to ensure the appropriate technique for emergency safety interventions led to Pt. #3 being in a prone position for approximately 5 minutes with staff on Pt. #3's back causing distress to Pt. #3 and requiring medical testing/intervention; Pt. #6 had Pt. #6's legs tied together for over 5 minutes and a knee placed on Pt. #6's groin during physical hold; and is likely to cause serious physical and psychological harm, injury, or death to any patients requiring crisis prevention interventions.

Findings include:

1. The Hospital's policy titled, "Restraints and Seclusion (11/10/2021)" was reviewed on 9/30/2025 and required, "The least restrictive for of restraint must be considered to protect the physical safety of the patient, staff or others."

2. The crisis prevention institute (CPI) booklet (dated 2020) was reviewed and indicated, "In any emergency where an individual is held on the floor, a supine (face up) position should be used ...Restrictive intervention should be reasonable, proportionate, and least restrictive to maximize safety and minimum harm. A restrictive intervention can generally be described as any physical, chemical, environmental, or mechanical intervention used to restrict a person's liberty of movement ...Restrictive interventions should never be used as a punishment, to force control, gain compliance, or enforce rules ...Only staff who have received training should use restrictive intervention skills. Restrictive interventions should be used only for the minimum amount of time, using the minimum amount of restriction on the basis of prevailing risk that staff are attempting to manage."

3. The clinical record of Pt. #3 was reviewed on 9/29/2025. Pt. #3 presented to the emergency room on 8/19/1025 at 7:57 AM with complaint of being depressed and wanting to see a counselor.

- A charge nurse (E#5) note dated 8/20/2025 at 10:30 AM included that around 10:00 AM Pt. #3 was informed that Pt. #3 was being admitted to the hospital's inpatient behavioral health [BH] unit. Pt. #3 was resistant. ... "Crisis thought Pt. #3 was self-transferring into the wheelchair that was at bedside. Patient was not transferring self and then the wheelchair was blocking access to the room. Security was able to gain access to the room through the safety door [small door inside the main door with separate key to gain access]. Security and this nurse then attempted to get the patient to agree to transfer to the BH unit [Pt. #3] then moved to negotiating with us. ... [Pt. #3] then was compliant with security assisting [Pt. #3] to the wheelchair. When getting [Pt. #3] to the wheelchair [Pt. #3] went limp and wouldn't sit up. [Pt. #3] then sat up quickly and appeared to lunge forward. Security then grabbed on to [Pt. #3] not wanting [Pt. #3] to fall and [Pt. #3] started fighting. ... [Pt. #3] was yelling the entire interaction. [Pt. #3] was continuously visually monitored for respirations and ease of breathing by this nurse. [Pt. #3's] breathing not compromised during the interaction."

- The inpatient psychiatrist (MD#1) admission note dated 8/20/2025 at 11:03 AM included, " ... Report of [Pt. #3] aggression the ED. Multiple security officers on top of [Pt. #3] in ED in form of physical hold restraints. ... This author witnessed [Pt. #3] in the ED coming out of physical holds by security officers who placed [Pt. #3] in handcuffs during holds. This author met with patient on the inpatient psychiatry unit. ... Will obtain CT [computerized tomography] scan head, spine, chest, abdomen and pelvis to assess for injury due to physical holds by officers in ED."

- The CT scans were completed on 8/20/2025 at 9:37 PM with an indication: "During restraints multiple people on top of [Pt. #3]." There was no evidence of acute fractures or injuries on CTs.

4. A security officer (E#7), involved in the incident with Pt. #3 was interviewed on 9/30/2025 at 10:00 AM. E#7 stated that Pt. #3 was 'out of control'. It took 4 security officers to subdue Pt. #3 and every time they tried to release their hold Pt. #3 would start fighting again. Pt. #3 was face down and because [Pt. #3] had no legs it was very difficult to get a good hold. E#7 stated, "I don't remember ever being on the patient back, I believe I was on the upper leg and lower torso."

5. Security officer (E#8), involved in the incident with Pt. #3 was interviewed on 9/30/2025 at 10:20 AM. E#8 stated that after Pt. #3 was delaying a transfer, security was instructed to just lift Pt. #3 into the wheelchair. A security assist was called overhead to get more assistance. E#8 stated, "I was on one side and another officer on the other, we lifted [Pt. #3] into the chair and [Pt. #3] went limp. [Pt. #3] lunged forward and grabbed my leg. I was injured and had to be seen in the ED after the event." E#8 stated that Pt. #3 continued to fight with the security officers and 2 other officers were injured. E#8 stated, "[Pt. #3] ended up on the floor and continued to fight. [Pt. #3] was rolling on the floor and we needed to make [Pt. #3] stop for safety. I believe once we were able to subdue [Pt. #3], [Pt #3] was in the prone position [on stomach]. We were in a tight space, and we were unable to use the normal hold [arms and legs] because [Pt. #3] did not have legs. We ended up laying/holding [Pt. #3] down by the lower torso/shoulder blade area." E#8 stated that E#8 did hear Pt. #3 state that [Pt. #3's] 'heart was going to explode.' E#8 stated that E #8 did not notice any distress.

6. The video of the event related to Pt. #3 from 8/20/2025 was reviewed on 9/30/2025 at 10:40 AM with the manager of security (E#13). The recording of Pt. #3's room started at 10:03 AM and continued as follows:

- 10:13 AM - E#8 assists Pt. #3 to sitting position, places arms under Pt. #3's arms and lifts into w/c (wheelchair). Four officers were in the room (E#7, E#8, E#10 and E#11).
- 10:14 AM - Pt. #3 reaches for bed to return to bed and security tries to stop Pt. #3. Pt. #3 grabs onto E#8's leg appearing to stop Pt #3 from falling to floor. Pt. #3 ends up on floor, face down (prone). E#8 seen with arm around Pt. #3's neck.
- 10:15 AM - Pt. #3 fighting (trying to get free from arms being held by using body to push against officers) with officers and trying to get off stomach. Four security officers were in the room, holding Pt. #3 on the floor. E#8 with arm still around Pt #3's neck. E#7 laying across Pt. #3's back. The security officers attempted to release the physical hold on Pt. #3, but Pt. #3 began fighting again.
- 10:20 AM - Pt. #3 remained on floor with the 4 security officers around Pt. #3. Unable to see where E#8's arm was. E#7 remained lying on Pt. #3's back.
- 10:22 AM - MD#1 enters room. Places hands on E#10's shoulders and pulls back. Some movement from Pt. #3 appearing to attempt to get up. E#8 no longer with arm around Pt. #3's neck. MD#1 trying to get close to Pt. #3 to talk. Handcuffs (2 sets of handcuffs linked together - to increase length because of Pt. #3's size) were applied by E #10 to Pt. #3's arms behind their back while Pt. #3 remained prone on the floor.
- 10:26 AM - Physical hold stopped. Pt. #3 lifted into w/c.

7. The security director (E#12) was interviewed on 9/30/2025 at 12:15 PM. E#12 reviewed the incident. E#12 stated, "I reviewed the video when a report of abuse was filed on 8/21/2025. It was determined that [Pt. #3] had a lower center of gravity because of being an amputee. This was definitely an outlier." E#12 stated that the officers did not follow CPI protocol and 'We could have done better'.

8. Pt. #6's clinical record was reviewed on 10/1/2025. Pt #6 was admitted to Hospital's Inpatient Behavioral Health unit on 6/16/2025 with a diagnosis of bipolar disease (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and psychosis (not based in reality).

9. On 10/1/2025, Pt. #6's grievance report (dated 6/17/2025) was reviewed and noted, "Pt. #6 reported to patient relations department at Hospital B that security officers circled Pt. #6, took Pt. #6 down and one officer (unknown) put his knee on Pt. #6's neck which was punishment for being in a psych ward

10. On 10/1/2025 at 10:55 AM, a video surveillance review of Hospital B's Acute Behavioral Health hallway, was conducted with the Security Manager (E #13). The video footage began on 6/17/2025 at 12:58 PM and the following was observed:

- 12:58 PM: Pt #6 seen in the hallway interacting with a staff member at the nurse's station
- From 12:59:00-12:59:39, Pt #6 remained in the hallway
- 12:59:39 PM: Pt #6 walked back into Pt #6's bedroom. At 12:59:53, Pt #6 walked back out of room and into the hallway. Pt #6 remains pacing in the hallway with 5 security officers present.
- 1:06 PM: Pt #6 was pacing and surrounded by the 5 security officers. Pt #6 was seen making hand gestures and posturing backwards. Two other staff members, RNs were in the hallway, totaling 7 staff members facing/encircling Pt #6.
- 1:12:36 PM: 1 security officer (E #27), 2 ED RN (E #24 and #25) and 1 psychiatric counselor (E #26) made physical contact in attempt to restrain Pt #6, and Pt #6 was lowered to the ground.
- 1:12:50 PM, Pt #6 on the floor lying on Pt. #6's back. The security officer (E #23) was seen with knee on Pt #6's thigh. The ED RN's (E#24)'s knee was pressing near Pt #6's groin area. [Pt #6 remained restrained on the floor until 1:23:15 PM.]
- 1:13:40 PM: A RN was observed giving an intramuscular injection to Pt #6
- 1:16:20 PM: An Environmental Facilities staff (E #28) was observed assisting with restraining/holding Pt #6's leg.
- 1:17:19 PM: An ED RN (E #25), was observed tying a bedsheet around Pt #6's lower legs. [Remained with sheets tied around legs until 1:22:11 PM]
-1:18:38 PM - E #24 was observed with E #24's knee still on Pt. #6's groin area.
- 1:18:53 PM: Pt #6 received an additional IM injection. Not resisting at the time of injection
- 1:23:15 PM: Pt #6 gets up from the floor, with assistance from the staff
- 1:23:46 PM: Pt #6 escorted into quiet room

11. After the video review on 10/1/2025, E#13 stated that incorrect CPI was utilized during the hold of Pt. #6. E #13 stated that using a sheet to tie Pt. #6's legs together is not a CPI technique.

12. The security director (E#12) was interviewed on 10/2/2025 at 10:45 AM. E#12 stated that debriefings are held after each unusual occurrence. The situation is discussed and opportunities for improvement are brought forward. E#12 stated that CPI does not include tying a patient with anything; an arm around the neck should never happen; a patient can only be prone for a short period of time; and laying on top of a patient is prohibited. E#12 stated, "These circumstances were unusual. Communication between departments could have been clearer so everyone has defined roles". E#12 stated that the organization is working on future education to align/standardize training." E#12 stated that no actions have been taken since these incidents. The staff are to continue taking their CPI training as scheduled annually.

Based on document review and interview for 1 of 5 (Pt. #3) patients' clinical records reviewed for restraints, the hospital failed to ensure restraints were in accordance with the order of a physician, as required.

Finding included:

1. The hospital's policy titled, "Restraints and Seclusion (12/6/2023)" was reviewed on 9/30/2025 and required, "Restraints/seclusion is used upon the order of a physician that is responsible for the care of the patient. ... In the event of an emergent situation ... within an hour of restraint initiation."

2. The clinical record of Pt. #3 was reviewed on 9/29/2025. Pt. #3 presented to the emergency room on 8/19/1025 at 7:57 AM with complaint of being depressed and wanting to see a counselor.

- The inpatient psychiatry (MD#1) admission note, dated 8/20/2025 at 11:03 AM included, " ... Report of [Pt. #3] aggression the ED. Multiple security officers on top of [Pt. #3] in ED in form of physical hold restraints. ... This author witnessed [Pt. #3] in the ED coming out of physical holds by security officers who placed [Pt. #3] in handcuffs during holds."

- The clinical record did not include an order for physical hold or handcuffs.

3. The charge nurse (E#5), who was in charge on 8/20/2025 and assisted with Pt. (#3) was interviewed on 9/30/2025 at 9:40 AM. E#5 stated, "Handcuffs would be considered a restraint, and an order should have been obtained for the handcuffs and the physical hold."