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Based on policy review, medical record review, document review, and interview, the hospital failed to protect and promote the rights of all patients. The hospital failed to protect and promote patient rights by not ensuring Crisis Prevention Intervention (CPI) techniques were properly used prior to and during a restraint application for Patient #1; failed to obtain required physician orders for restraints for three paitnets (Patient #1, Patient #5, and Patient #8); failed to conduct mandatory physician face-to-face assessments within one hour of restraint initiation for four patients (Patient #1, Patient #4, Patient #5, and Patient #8); failed to complete and submit an incident report within 24-hour timeframe for Patient #2's elopement from the Emergency Department (ED); and failed to implement previously identified corrective actions related to Patient #2's elopement from the Emergency Department (ED) despite the patient being on an involuntary admission physician order. These systematic failures across restraint protocols, documentation requirements, incident reporting, and policy implementation demonstrate the facility's inability to maintain basic patient rights protections, resulting in an Immediate Jeopardy finding and a determination that the Condition of Participation for Patient Rights was NOT MET.

Reference:

482.13(c)(2): The patient has the right to receive care in a safe setting.
482.13(e)(5): Restraint and/or Seclusion: Physician order.
482.13(e)(12): Restraint and/or Seclusion: Face-to-face assessment.

Based on policy review, medical record review, document review, and interview, it was determined the hospital failed to protect and promote the rights of all patients by ensuring all patients receive care in a safe setting, specifically:
1. In 1 of 11 medical records reviewed, Emergency Department (ED) staff failed to follow approved Crisis Prevention Intervention (CPI) techniques prior to and during restraint application (Patient #1).
2. In one of two medical records reviewed, the hospital failed to ensure that an incident report was completed and submitted within 24 hours to the quality department (Patient #2).
3. In one of two medical records reviewed, the hospital failed to implement corrective actions related to Patient #2's eloping from the ED while on an involuntary admission physician order (Patient #2).

Findings #1:

Review of the policy "Restraints and Seclusion," dated February 2025, revealed that restraints are used only as a last resort, after all efforts to avoid use have failed, indicating that the treatment of the patient is not effective. Before resorting to the use of restraints, other interventions must be attempted to maintain safety. Safe, effective, and least restrictive interventions are determined by the patient's assessed needs and effective methods, if previously used for the patient. All behavioral health staff and security will be trained on Crisis Prevention Institute (CPI-an organization providing de-escalation and crisis prevention training programs) with written record of training and use CPI techniques.

Review of the document "NCI (Nonviolent Crisis Intervention) With Advanced Physical Skills Training Instructor's Guide," from the Crisis Prevention Institute, copyright 2023 indicated the program objectives include: use the philosophy of care, welfare, safety, and security with a person centered approach when responding to a person in distress, the interpret distress behaviors, de-escalate of the situation, assess risk of behavior, and identify preventive strategies to mitigate risk, identify and respond appropriately to various levels of crisis behaviors. Safety intervention strategies include as staff move close to the person in distress, they approach from the side rather than the front or behind. The staff keep their posture nonthreatening, balanced, and relaxed. Staff respect their personal space and only move as close as they need to show support or provide assistance. Advanced physical skills include floor transition of a patient from a standing to seated positions. Staff are to maintain a supportive stance (managing your position, posture, and proximity in relation to the person in distress) and the outside/inside principle (Placing something on the outside and something on the inside of the limbs and/or body) on the person's arms. With a staff member supporting the arms, as the person moves to the floor, step back with your foot nearest the person, and kneel. Once in a kneeling position, adjust your supportive stance, placing your knee, nearest the person, close to their hip. Adjust the position of your leg, furthest from the person, so you remain balanced and stable. Remain close in the supportive stance and apply the outside/inside principle to maintain your hold. With a staff member supporting the shoulders, begin with the supportive stance, approaching the person from behind. Stand close, adjusting your furthest leg so you remain balanced and stable. Place both hands behind the person's shoulders. As the person moves to the floor, kneel placing your knee nearest the person on the floor, with your thigh resting against their spine. Once in a kneeling position, remain close, adjusting the position of your leg furthest from the person, so you remain balanced and stable. Once everyone is stable, encourage the person to rest back towards you. Avoid leaning or bending their body forward. Remain close in the supportive stance and apply the outside principle (by placing the palm of your furthest hand at their elbow, limits the outward motion of their arm, thus protecting yourself) to help maintain a seated position. Safety tips include move in a coordinated way, avoid pulling, pushing, or leaning the person forward as this will impair breathing, once the person is seated, consider the option to let go. The goal is to use the safety intervention that is a last resort, reasonable, and proportionate. And most often, this means considering verbal and environmental non-restrictive interventions first.

Review of the medical record for Patient #1 revealed that on 04/02/25 at 04:56 PM, Patient #1 presented to the ED via ambulance with complaints of suicidal ideation with a plan. At 06:15 PM, Staff (L), Registered Nurse, documented that Patient #1 arrived voluntarily, was angry, non-compliant with staff requests, and threw objects, yelled, and swore at staff. At 05:12 PM, a rapid response was called. Patient #1 punched a security guard in the face twice and kicked the security guard. Patient #1 was medicated with Haldol 10 mg, Versed 2 mg, and Benadryl 50 mg (medications use to calm behavioral health patients). Patient #1 was placed in 4-point restraints. At 05:49 PM, the restraints were released.

Review of the video surveillance of "ED Behavioral Health (BH) Hall 1," dated 04/02/25, revealed:
-At 05:04:21 PM, Patient #1 was escorted into the BH ED by Staff (O), Behavioral Health Technician (BHT), and was seated in a chair in the patient common area (located in front of the glassed in nursing station).
-At 05:11:25 PM, Patient #1 removed a plastic water bottle from the right front pocket of the robe they were wearing and tossed it at the wall towards Staff (P), RN. Staff (L), RN, entered the common area.
-At 05:11:34 PM, Staff (O), ED BHT, pointed down the hallway (in the direction of the bathroom) and Patient #1 shook their head in a side-to-side motion. Staff (O), Staff (N), RN, Staff (L), RN, and Staff (P), RN, were all in the common area standing approximately six feet from Patient #1. Staff (L) was speaking to Patient #1 who was becoming animated with their response to what Staff (L) was saying.
-At 05:12:27 PM, Staff (L), RN, entered the nursing station and picking up a telephone receiver. Staff (P), RN, Staff (N), RN, and Staff (O) ED BHT exited the common area and entered the nursing station.
-At 05:12:48 PM, Patient #1 stood up from the chair and began pacing, while talking and make gestures with their arms.
-At 05:12:58 PM, Patient #1 approached a table in the common area, picked up clothes on the table, and tossed them in the air.
-At 05:13:05 PM, Patient #1 walked up to the table, picked up a specimen collection cup, and stepped away from the table. Staff (K), RN, opened the door from the nurse ' s station and spoke to Patient #1.
-At 05:13:15 PM, Staff (I), Security Officer, Staff (K), RN, and Staff (N), RN, entered the common area from the nursing station. Patient #1 took a few steps back away from the staff members. Staff (I), Security Officer, approached Patient #1.
-At 05:13:30 PM, Staff (I), Security Officer, was standing approximately three feet away from Patient #1 while putting on a pair of gloves and talking to Patient #1. Staff (K), RN, and Staff (N), RN were approximately nine feet away from Patient #1, in front of the nursing station door.
-At 05:13:35 PM, Patient #1 took a step towards Staff (I), Security Officer, and was within two feet, yelling and pointing their left index finger at Staff (I). Staff (I) took a step towards Patient #1 and stood face-to-face with them, while pointing down the hall and speaking.
-At 05:13:38 PM, Staff (I), Security Officer, took their left hand, placed it on Patient #1 ' s right shoulder, and shoved Patient #1 in the direction Staff (I) had been pointing. Patient #1 took one step in the direction Staff (I) had been pointing. Patient #1 turned back to face Staff (I) and struck out with their right fist, which appeared to contact the left side of Staff (I)'s neck/jaw. Staff (I) stepped into Patient #1, grabbed Patient #1 ' s right arm with their left hand, and grabbed Patient #1's robe around the right shoulder with their right hand. Staff (I) took a step away from Patient #1, pulled Patient #1 towards them, and swung Patient #1 around Staff (I) ' s body to the ground. Patient #1 landed on their right hip and was then in an upright seated position on the floor. Staff (I) advanced to stand over the seated Patient #1. Patient #1 struck out with their right fist hitting Staff (I) in the left upper thigh area. Staff (I) pushed Patient #1 backwards. While lying on their back, Patient #1 kicked out at Staff (I). Staff (I) caught both of Patient #1's feet as they contacted Staff (I) and threw them to the side. Staff (I) stepped in and laid their weight on Patient #1. Patient #1 was on the ground struggling with Staff (I) on top of them. Patient #1 struck Staff (I) two to three times in the face with their left fist. During the struggle, Staff (L), RN, and Staff (F), RN/Director Of Emergency Department, entered the common area from the nursing station.
-At 05:14:00 PM, Staff (I), Security Officer, with the assistance of Staff (L), RN, and Staff (F), RN/Director of the ED, physically restrained Patient #1 to the ground lying in a back down lying position. Staff (F) secured Patient #1 ' s legs while Staff (L) secured Patient #1 ' s left upper body. Staff (I) held their forearm across the right side of Patient #1 ' s neck and chest area, while forcing Patient #1 ' s face to the left.
-At 05:14:32 PM, Staff (N), RN, arrived in the common area with a four-point restraint stretcher. Staff (R), Security Officer, arrived, went to Patient #1 ' s legs and took over for Staff (F). Staff (I) and Staff (R), Security Officers were physically restraining Patient #1 on the floor. The other nursing staff were preparing the restraint stretcher.
-At 05:15:11 PM, Staff (I), Security Officer, grabbed the left upper extremity of Patient #1, Staff (L), RN, grabbed the right upper extremity of Patient #1, Staff (R), Security Officer, grabbed the lower left extremity of Patient #1, and Staff (N), RN, grabbed the right lower extremity of Patient #1. Together the four staff members lifted Patient #1 from the floor to the stretcher. Once on the stretcher, Patient #1 was held in place by Staff (I) and Staff (R), while Staff (F), RN/Director Of Emergency Department, Staff (K), RN, Staff (L), RN, and Staff (O), ED BHT, placed the four-point restraints on Patient #1.
-At 05:16:24 PM, Patient #1 was restrained lying with their back down on the stretcher with all four extremities strapped to the stretcher at the ankles and wrists. All staff members removed their hands from Patient #1. Patient #1 was thrashing around on the stretcher.

Interview on 05/02/25 at 11:55 AM with Staff (J), Crisis Prevention Intervention (CPI) Instructor, revealed that they were unaware of the incident involving Patient #1. After reviewing video surveillance footage of the ED Behavioral Health unit, dated 04/02/25 from 05:04 PM to 05:17:59 PM, from three different angles, Staff (J) stated that there were multiple instances where CPI techniques were not followed by staff. Staff (I), Security Officer, approached Patient #1 alone, which was inconsistent with CPI training. CPI training teaches that when approaching a potentially threatening patient, there should be a minimum of two staff members, and ideally at least three staff members. Unless there was an immediate safety issue, which was not seen in the video, Staff (I) should have waited until more staff members arrived to approach Patient #1. If only one staff member had to approach a potentially threatening patient for safety reasons, they should approach from the patient's side, placing their hands on the patient's upper arms to prevent the patient from striking out, and guide the patient in the direction staff wishes patient to go. In the video footage Staff (I) approached Patient #1 face-to-face, placing their right arm on Patient #1's right shoulder and left hand on Patient #1's back, shoving Patient #1 in the direction of the bathroom. This is inconsistent with CPI training. There is no training in the CPI curriculum for a single person to take a patient from a standing position to the ground. At least three staff members should be used, and the take-down should be completed in two steps. There should be a staff member on each side of the patient and one directly behind the patient. The staff members should take patient from a standing position to a seated position, then from a seated position to a laying position with the patient lying flat on their back on the floor. The actions of Staff (I), grabbing Patient #1 by the arms and swinging them around to the ground, was inconsistent with the CPI training. Per CPI training curriculum, when holding a patient in a laying position there should be four staff members utilized, two holding the upper body at the shoulders and one holding each of the patient's legs. There should never be a staff member holding down a patient by placing an arm across a patient's neck and chest, as was seen in the surveillance video. Staff (I) placed their arm across Patient #1's neck and chest area, forcing Patient #1's face to the left. This action by Staff (I) was inconsistent with CPI training. There were other staff members, seen on the video footage, who had current CPI certification that should have intervened when they witnessed Staff (I)'s inappropriate actions.

Interview on 05/02/25 at 12:00 PM with Staff (A), Vice President of Quality and Compliance, verified that ED staff did not follow CPI approved techniques when restraining Patient #1.

Findings #2:

Review of policy "Pursuit of Patient Leaving Without Permission (Elopement)," dated August 2023, revealed any patient elopement must be reported within 24 hours to the quality management department and an incident report will be completed in its entirety by the department manager. Documentation of the event must be entered in the incident reporting system and should include the time of the elopement, who was notified by whom, that a code grey was performed, areas searched, and the condition of the patient upon return and final patient disposition. The report should also include the names of those notified and time of notification.

Review of medical record for Patient #2 revealed on 01/24/25 at 03:57 PM, Patient #2 presented to the Emergency Department (ED) for a mental health exam. On 01/25/25 at 10:44 AM, Staff (G), ED Physician completed a 9.39 Mental Hygiene Law (New York State law allowing for an involuntary emergency admission of an individual who is believed to have a mental illness and are in immediate danger of harming themselves or others.) form and placed an order for an involuntary emergency admission of Patient #2 to the behavioral health inpatient unit for severe postpartum depression, violent behavior, and severe anxiety. On 01/25/25 at 04:44 PM, Staff (AA), Registered Nurse, documented Patient #2 eloped from two staff members during transport to the behavioral health inpatient unit. A code was called. The physician and house supervisor were made aware. On 01/26/25 at 07:10 AM, Patient #2 called the hospital and wanted to come get their belongings. Staff (K), Registered Nurse, called the house supervisor who indicated to release the belongings to Patient #2. Patient #2 was notified that their belongings were at the front desk with the security guard and that they needed to sign that they picked up their stuff. Security was notified that Patient #2 would be arriving in 20 minutes and needed to sign paperwork. The call was ended, and the physician was notified.

Review of incident report log, dated 01/01/25 to 04/30/25, revealed no evidence that an incident was found for the elopement of Patient #2.

Interview on 05/12/25 at 02:00 PM with Staff (C), Chief Nursing Officer, verified this finding.

Findings #3:

Review of policy "Pursuit of Patient Leaving Without Permission (Elopement)," dated August 2023, revealed when a patient is discovered missing from an inpatient care unit, a code gray (patient elopement) is called. The hospital operator will contact security, the administrative coordinator on duty, and the police. At least two staff members from the unit will begin the immediate search. Once outside the facility, if the patient returns to the hospital they must be reevaluated and admitted through the emergency department. If applicable, the unit charge nurse will notify the following parties if the patient returns: communications, security, administrative coordinator, the police, quality management, and the case manager.

Review of medical record for Patient #2 revealed on 01/24/25 at 03:57 PM, Patient #2 presented to the ED for a mental health exam. On 01/25/25 at 10:44 AM, Staff (G), ED Physician completed a 9.39 Mental Hygiene Law (New York State law allowing for an involuntary emergency admission of an individual who is believed to have a mental illness and are in immediate danger of harming themselves or others.) form and placed an order for an involuntary emergency admission of Patient #2 to the behavioral health inpatient unit for severe postpartum depression, violent behavior, and severe anxiety. On 01/25/25 at 04:44 PM, Staff (AA), Registered Nurse, documented Patient #2 eloped from two staff members during transport to the behavioral health inpatient unit. A code was called. The physician and house supervisor were made aware. On 01/26/25 at 07:10 AM, Patient #2 called the hospital and wanted to come get their belongings. Staff (K), Registered Nurse, called the house supervisor who indicated to release the belongings to Patient #2. Patient #2 was notified that their belongings were at the front desk with the security guard and that they needed to sign that they picked up their stuff. Security was notified that Patient #2 would be arriving in 20 minutes and needed to sign paperwork. The call was ended, and the physician was notified.

Review of Quality Assurance documents from February 2025 revealed the facility identified the need to revise elopement policies to include security will be present on all behavioral health transfers and that any patient who elopes and returns the facility will be reassessed by a provider. However, the polices have not been approved by administration and there was no evidence of any formal staff education on the new procedures.

Interview on 05/12/25 at 10:39 AM and 02:00 PM with Staff (C), Chief Nursing Officer, revealed they were the house supervisor on 01/26/25. Staff (C) spoke with Staff (K), Registered Nurse from the ED who asked if Patient #2 could come into the hospital to pick up their belongings. Staff (K) updated Staff (C) on what had occurred with Patient #2. Staff (C) asked if Patient #2 was on a hold. Staff (K) stated Patient #2 was not on a hold. Staff (C) gave the okay that Patient #2 could pick up their belongings. If Staff (C) knew Patient #2 was on an involuntary admission hold, Patient #2 would have been re-evaluated by a provider upon arrival to the facility.

Interview on 05/12/25 at 11:18 AM with Staff (K), Registered Nurse, revealed on 01/26/25, they told Staff (C), Chief Nursing Officer, that Patient #2 was not on any involuntary emergency admission papers. Patient #2 was a voluntary presentation to the ED. Staff (K) stated the 9.39 involuntary emergency admission paperwork was signed for Patient #2 but indicated it would only go into effect when the patient presented to the inpatient behavioral health unit. 9.39 paperwork is for admission purposes only. Staff (K) stated Patient #2 was an inpatient behavioral health patient at the time of absconding from the ED.

Based on policy review, medical record review, document review, and interview, in 3 of 11 medical records reviewed, it was determined that a physician order was not obtained for the use of restraints (Patient #1, Patient #5, and Patient #8)

Findings include:

Review of the policy "Restraints and Seclusion," dated February 2025, revealed all restraint use is initiated and continued for a specified, limited period pursuant to a written order. Only a licensed physician may order restraints and/or manage patients in restraints. Restraints may be initiated by a physician, or in an emergency by a registered nurse (RN) when the patient presents as an immediate danger to self or others. The RN shall call the physician as soon as it is safe to do so, recording the time of the call, and the physician who was contacted.

Review of the policy "Restraints," dated September 2023, revealed all restraint use is initiated and continued for a specified, limited period of time pursuant to a written order. When the patient is engaging in an activity that presents an immediate danger to the patient or others and a physician is not available on the unit, a restraint may be applied, or under the supervision and direction of, a RN who must document the circumstances requiring the use of a restraint. In such emergencies, the nurse must immediately request an assessment by a physician and obtain a telephone order. A written order must be obtained within one hour. A telephone order must be obtained within five minutes of the application of restraint. The order for restraint will include date and time, type of restraint, specific indications and reasons for use, and a specified limited period of time for use. If a patient who is restrained for aggressiveness or violence quickly recovers and is released before the physician arrives to perform the assessment, the physician must still perform a face-to-face assessment and write an order for the period of time that the patient was restrained.

Review of the medical records revealed no evidence a physician order was obtained for the implementation and utilization of restraints for the following patients: Patient #1 was placed in four-point restraints on 04/02/25 from 05:16 PM until 05:49 PM; Patient #5 was placed in 4-point restraints on 01/31/25 from 04:18 AM to 04:48 AM; and Patient #8 was placed in 4-point restraints on 10/26/24 from 06:14 PM to 06:25 PM.

Interview on 05/01/25 at 02:00 PM with Staff (F), Director of Emergency Department, verified the finding for Patient #1. Interview on 05/02/25 at 02:00 PM with Staff (V), Emergency Department Clinical Coordinator, verified the finding for Patient #5 and Patient #8.

Based on policy review, medical record review, and interview, in 4 of 11 medical records reviewed, it was determined that a physician's face-to-face assessment was not conducted within one hour of the initiation of restraints. (Patient #1, Patient #4, Patient #5, and Patient #8).

Findings include:

Review of the policy "Restraints and Seclusion," dated February 2025, revealed restraints may be initiated by a physician (MD), or by a registered nurse (RN) in an emergency when the patient presents as an immediate danger to self or others. The physician who arrives must be the same as the physician who gave the restraints order. This physician must arrive to the unit within 30 minutes of restraints application, perform a face-to-face evaluation of the patient, and document this encounter using the "MD Face-to-Face Assessment note." If a physician does not arrive within thirty minutes of being summoned, the senior staff member shall record any such delay in the patient's clinical record with a written description justifying the emergency restraint, the nature of the restraints, and any conditions for maintaining the restraints until the arrival of a physician. The physician shall place in the clinical record an explanation for any such delay.

Review of the policy "Restraints," dated September 2023, revealed the physician will perform a face-to-face evaluation of the patient and write an order for the restraint within one hour of notification by the nurse. If a patient who is restrained for aggressiveness or violence quickly recovers and is released before the physician arrives to perform the assessment, the physician must still perform a face-to-face assessment and write an order for the period of time that the patient was restrained. The fact that the patient's behavior warranted the use of a restraint indicated a serious medical or psychological need for prompt assessment of the incident/situation that led to the intervention, as well as the medical and psychological condition of the patient at the time of the assessment.

Review of the medical records revealed no evidence a physician face to face assessment was conducted within one hour of the initiation of restraints for the following patients: Patient #1 was placed in four-point restraints on 04/02/25 from 05:16 PM until 05:49 PM; Patient #4 was placed in 4-point restraints on 02/24/24 from 07:00 PM until 07:15 PM; Patient #5 was placed in 4-point restraints on 01/31/25 from 04:18 AM to 04:48 AM; and Patient #8 was placed in 4-point restraints on 10/26/24 from 06:14 PM to 06:25 PM.

Interview on 05/01/25 at 02:00 PM with Staff (F), Director of Emergency Department, verified the finding for Patient #1.

Interview on 05/02/25 at 02:00 PM with Staff (V), Emergency Department Clinical Coordinator, verified the findings for Patients #4, Patient #5, and Patient #8.

Based on policy review, medical record review, and interview, in 4 of 11 medical records reviewed, clinical staff failed to complete restraint documentation for Patients #1, Patient #2, Patient #4, and Patient #7.

Findings include:

Review of the policy "Restraints and Seclusion," dated February 2025, revealed that upon initiation of restraints, the registered nurse (RN) shall complete the "Behavioral Health Restraint/Seclusion Application using the corresponding nursing note template in the electronic medical record. This documentation must contain the restraint/seclusion start time, name of the provider who was contacted and the time they were contacted, and the time the physician arrived to see the patient face-to-face. The nurse must also document any de-escalation methods attempted and the patient's response to these interventions.

Review of the policy "Restraints," dated September 2023, revealed the order for restraint will include date and time, type of restraint, specific indications and reasons for use, and a specified limited period of time for use. The nurse must document behaviors of the patient, which required maintaining the restraint until arrival of the practitioner.

Review of the medical record for Patient #1 revealed no evidence of the start time of restraint, and the name and time of the contacted provider. Patient #1 was placed in 4-point restraints on 04/02/25.

Review of medical record for Patient #2 revealed an order for a side rail restraint but Patient #2 was placed in five-point restraints on 01/24/25 by clinical staff.

Review of medical record for Patient #4 revealed no evidence of the start time or the time of discontinuation of the four-point restraints implemented on 04/24/25.

Review of medical record for Patient #7 revealed an order for a side rail restraint but Patient #7 was placed in four-point restraints on 12/19/24 by clinical staff.

Interview on 05/01/25 at 02:00 PM with Staff (F), Director of Emergency Department, verified the lack of documentation for Patient #1.

Interview on 05/02/25 at 02:00 PM with Staff (V), Emergency Department Clinical Coordinator, verified the wrong restraint orders and use for Patients #2 and #7 and the lack of documentation for Patient #4.

Based on policy review, document review, and interview, in three of nine credential/personnel files reviewed, the hospital failed to ensure all staff are trained on Crisis Prevention Intervention (Staff (F), Staff (N), and Staff (O).

Findings include:

Review of the policy "Restraints and Seclusion," dated February 2025, revealed Crisis Prevention Intervention (CPI) techniques will be used at all times by the behavioral health staff while on duty. All behavioral health staff, security staff, and any staff who responds to behavioral crisis situations will be trained on CPI, with written record of the training.

Review of credential/personnel files for Staff (F), Director of Emergency Department, Staff (N), Registered Nurse, and Staff (O), Behavioral Health Technician, revealed no evidence of CPI training.

Interview on 05/02/25 at 05:28 PM with Staff (O), Behavioral Health Technician, revealed they were not CPI trained.

Interview on 05/02/25 at 08:30 PM with Staff (F), Director of Emergency Department, revealed they were not CPI trained.

Interview on 05/12/25 at 12:16 PM with Staff (A), Vice President Quality and Compliance, revealed Staff (N), Registered Nurse, was not CPI trained.