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Based on a review of clinical records, facility documentation, policies, and staff interviews, it was determined that the hospital failed to meet the Conditions of Participation for Patient Rights by failing to:


1. Ensure staff activated the fire alarm when a flame was observed coming from a patient's mattress in accordance with facility policy and/or ensure one patient's rights were protected. Refer to A-144

2. Ensure restraint policies were followed for two of six sampled patient's. Refer to A-160, A-164, A-166, A-174, A-179, A-185, and A-196.

1. Based on a review of the clinical record, facility documentation, facility policies, and interviews, the facility failed to ensure that the fire alarm was activated when one patient (#31), lit his/her mattresss on fire. The finding includes the following:

Patient #31 was brought to the satellite ED by ambulance on 1/8/18 at 1:05 PM after being involved in a motor vehicle accident with rollover. The patient was triaged at 1:10 PM and evaluated by the Physician Assistant (PA) at 1:12 PM. The PA's note indicated that the patient was alert and oriented to person, place and situation. The patient was noted to have a 1 cm laceration on his/her left ear and a superficial laceration to the right eyelid. The PA note further identified that the patient's mental status had improved and his/her grandfather was called to get the patient, however while waiting, the patient had concealed a lighter that s/he had on his/her person and apparently activated the lighter while s/he was on the stretcher causing a burn to either the stretcher, or the mattress, or the sheet on the mattress. Review of the RN note dated 1/8/18 at 2:41 PM identified that the patient was found going through the cabinets. Security at bedside. Then found by staff with a lighter when s/he tried to light the stretcher mattress and linen on fire. Scorch marks were observed to linen and mattress.

Interview with Paramedic #1 on 1/12/18 at 9:50 AM indicated that he was standing across from the entrance to the patient's cubicle on 1/8/18 and heard the patient ripping the sheet. The Paramedic told the patient to stop and the patient did, however shortly thereafter the paramedic observed flames coming from the stretcher. The paramedic stated he entered the room, folded the sheet onto itself, and the flames went out. The paramedic stated that the fire alarm was not activated secondary to the fire being extinguished immediately. The State police were notified and the patient was placed in custody.

Interview with RN #80 on 1/16/18 at 1:30 PM stated that she was the RN assigned to care for Patient #31 on 1/8/18. RN #80 stated that there were no flames and no smoke and knew that the police would call the fire department. RN #80 further identified that the smoke detectors are very sensitive and didn't activate during this event.

Interview with the Director of the ED on 1/11/18 at 1:40 PM indicated that the staff should follow facility policy related to activation of fire alarm. Review of the policy with the Director indicated that "RACE" should be followed, R- remove or rescue, A-activate the alarm, C- Contain and E- evacuate.

Observation of the stretcher on 1/12/18 at 5PM noted a 1 centimeter area of charring on the lower aspect of the mattress. The mattress was subsequently discarded by staff .

Review of the Paramedic's personnel record identified that Paramedic #1 had fire and safety education completed on 10/9/17 including but not limited to the RACE policy.


2. Based on clinical record review and interviews for 2 of 10 patients reviewed for patient rights, the hospital failed to ensure patient rights were protected. The findings include:

P#3 with diagnoses that included depression, post-traumatic stress disorder (PTDS), anxiety and substance use disorder. He/she was evaluated in the CIU for increased distress, anxiety, withdrawal symptoms and suicidal ideation (SI).

P#27 with diagnoses that included schizophrenia, bipolar disorder, depression and PTSD. He/she was evaluated in the CIU for crisis evaluation of SI and homicidal ideation (HI). P#27 had no previous history of inappropriate sexual behavior.

A review of hospital documentation, including video observation, was conducted with the Regulatory Compliance Manager and Director of the Emergency Department (ED) on 1/17/18.

The incident review identified on 12/7/17 P#3 entered his/her room following a shower and found P#27, unsupervised, in the corner of his/her room performing a sexual act on his/her self. P#3 immediately proceeded to the nurse's station and informed staff of the incident. Subsequently while P#3 was standing at the nurse's station, P#27 walked by P#3 and touched his/her buttocks. P#27 was immediately removed from the crisis intervention unit (CIU) and brought to the main ED under constant observation and local law enforcement was notified.

P#27 was subsequently arrested by local law enforcement for fourth degree sexual assault and indecent exposure.

P#3 was evaluated and although he/she had been assessed initially as stable for discharge, P#3 was admitted to the inpatient behavioral health unit (BHU) due to possible emotional implications related to the event.

Patient rights policy indicated patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation.

Based on a clinical record review, staff interviews and a review of the hospital policies and procedures for one of six sampled patients (Patient #23), the hospital failed to indicate the rationale for the use emergency medications in accordance with the hospital's policies and procedures. The findings included:

Review of the clinical record identified Patient #23 was admitted to the Emergency Department (ED) on 3/7/16 at 7:12 PM with complaints of abdominal pain. Patient #23's diagnosis included chronic pancreatitis, diabetes mellitus, fibromyalgia and gastroesophageal reflux disease. Laboratory work was completed and an ultrasound was conducted, both were unremarkable. Patient #23 also complained of chest discomfort while in the ED. The physician was notified, an electrocardiogram (EKG) was ordered. The findings were normal and did not require treatment or further testing. Medications were administered for nausea and pain. As the patient was being prepared for discharge he/she verbalized suicidal statements, therefore, Patient #23 was not discharged. The patient was medically cleared and transferred to the behavioral health unit of the ED. On 3/8/16 at approximately 1:58 AM Patient #23 become agitated, was placed in a physical hold, and administered Haldol 5 milligrams (mg) and Ativan 2 mg intramuscular (IM). Patient #23 was evaluated by psychiatry in the morning on 3/8/16 and subsequently discharged to home at 10:45 AM.

Interview and review of the clinical record with MD #15 on 1/16/18 at 2:08 PM identified an order that directed an emergent use of Haldol 5 milligrams (mg) and Ativan 2 mg intramuscular (IM), was written for Patient #23 on 3/8/16 at 1:58 PM. The order failed to identify an indication for the administration of Haldol or Ativan. Interview with the Director of the Emergency Department on 1/16/18 at 3:30 PM indicated an indication for use of emergency medication was required in accordance with the hospital policy. The hospital policy entitled Administration of Involuntary Medication for the treatment of Psychiatric Disabilities directed in part emergency mediation treatment may be administered without consent if obtaining consent would cause a harmful delay to a patient whose condition is critical in nature as determined by the physician. In such emergency situations, medication orders must specify that medications can be administered without patient consent and the reason why.

Based on a clinical record review, staff interviews and a review of the hospital policies and procedures for one of six sampled patients (Patient #23), the hospital failed to document alternate interventions prior to the restraint. The findings included:


Review of the clinical record identified Patient #23 was admitted to the Emergency Department (ED) on 3/7/16 at 7:12 PM with complaints of abdominal pain. Patient #23's diagnosis included chronic pancreatitis, diabetes mellitus, fibromyalgia and gastroesophageal reflux disease. Laboratory work was completed and an ultrasound was conducted, both were unremarkable. Patient #23 also complained of chest discomfort while in the ED. The physician was notified, an electrocardiogram (EKG) was ordered. The findings were normal and did not require treatment or further testing. Medications were administered for nausea and pain. As the patient was being prepared for discharge he/she verbalized suicidal statements, therefore, Patient #23 was not discharged. The patient was medically cleared and transferred to the behavioral health unit of the ED. On 3/8/16 at approximately 1:58 AM Patient #23 become agitated, was placed in a physical hold, and administered Haldol 5 milligrams (mg) and Ativan 2 mg intramuscular (IM). Patient #23 was evaluated by psychiatry in the morning on 3/8/16 and subsequently discharged to home at 10:45 AM.

Interview and review of the clinical record with the Director of the ED on 1/16/18 at 3:15 PM failed to identify that several alternate interventions were utilized and/or documented prior to the physical hold and use of medications in an emergent situation and should have been. Interview with RN #8 on 1/16/18 at 1:52 PM identified she conducts ongoing restraint training that directs involuntary medication should only be administered if alternative measures have been attempted prior, and have failed. Including and not limited to verbal de-escalation, oral medications, diversional activities, verbal limits and re-direction and decreased stimulation.

Based on a clinical record review, staff interviews and a review of the hospital policies and procedures for one of six sampled patients (Patient #23), the hospital failed to obtain a physician's order for a restraint in accordance with the hospital's policies and procedures. The findings included:

Review of the clinical record identified Patient #23 was admitted to the Emergency Department (ED) on 3/7/16 at 7:12 PM with complaints of abdominal pain. Patient #23's diagnosis included chronic pancreatitis, diabetes mellitus, fibromyalgia and gastroesophageal reflux disease. Laboratory work was completed and an ultrasound was conducted, both were unremarkable. Patient #23 also complained of chest discomfort while in the ED. The physician was notified, an electrocardiogram (EKG) was ordered. The findings were normal and did not require treatment or further testing. Medications were administered for nausea and pain. As the patient was being prepared for discharge he/she verbalized suicidal statements, therefore, Patient #23 was not discharged. The patient was medically cleared and transferred to the behavioral health unit of the ED. On 3/8/16 at approximately 1:58 AM Patient #23 become agitated, was placed in a physical hold, and administered Haldol 5 milligrams (mg) and Ativan 2 mg intramuscular (IM). Patient #23 was evaluated by psychiatry in the morning on 3/8/16 and subsequently discharged to home at 10:45 AM.

Interview and review of the clinical record with MD #15 on 1/16/18 at 2:00 PM identified she failed to write an order for a physical hold on 3/8/16 at 1:58 AM when Patient #23 had received emergency medication against his/her will. MD #15 indicated she was unaware that a physical hold was a type of restraint. Interview with the Director of the Emergency Department on 1/16/18 at 2:10 PM identified a physical hold was a restraint that required a physician's order in accordance with the hospital policy. The hospital policy entitled Use of Restraint directed in part that the use of a physical hold for forced medications is a type of restraint.

Based on a review of clinical records, policies, and interview, for one of six patient's reviewed for the utilization of restraints (P#31), the facility failed to ensure that restraints were removed at the earliest possible time and/or that behaviors that posed a risk to self or others were identified. The finding includes the following:

a. Review of Patient #31's clinical record dated 1/8/18 at 4:08 PM identified that the patient was seen a matter of a few hours ago following a MVA and was discharged into police custody. While in custody, the patient stated s/he would like to kill him/herself and was returned to the satellite ED on a PEER with concern for suicidality and placed on constant observation. A nurse's note dated 1/8/18 at 5:12 PM reflected that the patient was offered Haldol to help with agitation, patient feeling disquiet, however the medication was declined. The patient continued to make statements of self-harm with a plan to be evaluated for behavioral health concerns.

Review of a nurse's note on 1/11/18 with the Nurse Manager dated 1/8/18 at 5:16 PM indicated that the patient was placed in four point restraints for trying to leave the ED and getting out of bed multiple times. The patient was "non-cooperative and exhibited belligerent behaviors" toward staff and police. Haldol 5 mg IM was administered at that time in accordance with the physician's order.

A physician's order dated 1/8/18 at 5:44 PM directed bilateral ankle and wrist restraints, violent/self-destructive adult. A nurse's note dated 1/8/18 at 6:40 PM indicated that the patient's restraints were removed for CT scan, CNS intact, wrists red but blanchable. The patient was noted to be resting with his/her eyes closed. The clinical record indicated that the patient was verbally aggressive with 4-point restraints reapplied at 6:42 PM. Although the restraint monitoring flow sheet indicated that at 6:30 PM the patient was lying quietly, the nurse's note dated 1/8/18 at 6:50 PM indicated an error in the previous note and that the patient continues to be verbally aggressive, restraints replaced after CT scan. The facility failed to ensure that behaviors that warranted the use of restraints were identified.

Review of the restraint flow sheet during the period of 6:30 PM through 8:00 PM, documentation identified that the patient continued to lie quietly, however, remained in four point restraints until 8:19 PM when bilateral wrist restraints were removed, with subsequent removal of leg restraints at 8:27 PM. The facility failed to ensure that restraints were discontinued at the earliest possible time.

Review of the facility policy indicated, in part, that restraints must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

Based on a clinical record review, staff interviews and a review of the hospital policies and procedures for one of six sampled patients (Patient #23), the hospital failed to document a face to face evaluation within one hour of the restraint in accordance with the hospital policy. The finding included:

Review of the clinical record identified Patient #23 was admitted to the Emergency Department (ED) on 3/7/16 at 7:12 PM with complaints of abdominal pain. Patient #23's diagnosis included chronic pancreatitis, diabetes mellitus, fibromyalgia and gastroesophageal reflux disease. Laboratory work was completed and an ultrasound was conducted, both were unremarkable. Patient #23 also complained of chest discomfort while in the ED. The physician was notified, an electrocardiogram (EKG) was ordered. The findings were normal and did not require treatment or further testing. Medications were administered for nausea and pain. As the patient was being prepared for discharge he/she verbalized suicidal statements, therefore, Patient #23 was not discharged. The patient was medically cleared and transferred to the behavioral health unit of the ED. On 3/8/16 at approximately 1:58 AM Patient #23 become agitated, was placed in a physical hold, and administered Haldol 5 milligrams (mg) and Ativan 2 mg intramuscular (IM). Patient #23 was evaluated by psychiatry in the morning on 3/8/16 and subsequently discharged to home at 10:45 AM.

Interview and review of the clinical record with MD #15 on 1/16/18 at 2:05 PM identified she failed to document a face to face evaluation within one hour of the restraint in accordance with the hospital policy and should have. The hospital policy entitled Use of Restraints directed in part that a Licensed Practitioner complete an order for a restraint, complete a face to face evaluation within one hour of application and document the evaluation. The face to face evaluation would be completed even if the patient was released from restraints before the Licensed Practitioner arrived to see the patient.

Based on a clinical record review, staff interviews and a review of the hospital procedures and documentation for one of six sampled patients (Patient #23), the hospital failed to document the behaviors that required a restraint in accordance with the hospital's procedures. The findings included:

Review of the clinical record identified Patient #23 was admitted to the Emergency Department (ED) on 3/7/16 at 7:12 PM with complaints of abdominal pain. Patient #23's diagnosis included chronic pancreatitis, diabetes mellitus, fibromyalgia and gastroesophageal reflux disease. Laboratory work was completed and an ultrasound was conducted, both were unremarkable. Patient #23 also complained of chest discomfort while in the ED. The physician was notified, an electrocardiogram (EKG) was ordered. The findings were normal and did not require treatment or further testing. Medications were administered for nausea and pain. As the patient was being prepared for discharge he/she verbalized suicidal statements, therefore, Patient #23 was not discharged. The patient was medically cleared and transferred to the behavioral health unit of the ED. On 3/8/16 at approximately 1:58 AM Patient #23 become agitated, was placed in a physical hold, and administered Haldol 5 milligrams (mg) and Ativan 2 mg intramuscular (IM). Patient #23 was evaluated by psychiatry in the morning on 3/8/16 and subsequently discharged to home at 10:45 AM.

Interview and review of the clinical record with the Director of the ED on 1/16/18 at 2:55 PM identified agitation was the behavior that required the physical hold and the indication for the administration of medications in an emergent situation. Interview with RN #7 and MD #15 on 1/16/18 indicated they failed to document that Patient #23 was spitting, anxious and threatening to harm staff. Further interview with the Director of the ED identified that RN #7 and MD #15 failed to document the behaviors that required the use of a physical hold or medication against the patient's will. The hospital documentation entitled Involuntary Medication Administration that was utilized to train ED staff in part identified that all patients have the right to refuse medication and that agitation is not a sufficient cause to administer mediations against the patient's will.

Based on a clinical record review, staff interviews and a review of the hospital policies and procedures for one of six sampled patients (Patient #23), the hospital failed to develop a process/protocol and/or provide staff training for the implementation of a physical hold when emergent medications were administered in accordance with the hospital policy. The findings included:

Review of the clinical record identified Patient #23 was admitted to the Emergency Department (ED) on 3/7/16 at 7:12 PM with complaints of abdominal pain. Patient #23's diagnosis included chronic pancreatitis, diabetes mellitus, fibromyalgia and gastroesophageal reflux disease. Laboratory work was completed and an ultrasound was conducted, both were unremarkable. Patient #23 also complained of chest discomfort while in the ED. The physician was notified, an electrocardiogram (EKG) was ordered. The findings were normal and did not require treatment or further testing. Medications were administered for nausea and pain. As the patient was being prepared for discharge he/she verbalized suicidal statements, therefore, Patient #23 was not discharged. The patient was medically cleared and transferred to the behavioral health unit of the ED. On 3/8/16 at approximately 1:58 AM Patient #23 become agitated, was placed in a physical hold, and administered Haldol 5 milligrams (mg) and Ativan 2 mg intramuscular (IM). Patient #23 was evaluated by psychiatry in the morning on 3/8/16 and subsequently discharged to home at 10:45 AM.

The clinical record identified on 3/8/16 at 1:56 AM Patient #23 was agitated, MD #15 was notified and ordered Haldol 5 mg and Ativan 2 mg IM. Interview with RN #7 on 1/16/18 at 3:00 PM identified she was the nurse responsible for the care of Patient #23 in the ED on 3/8/16. RN #7 indicated security was notified when the patient became agitated. RN #7 identified Patient #23 was placed in a supine position and held by two security officers and two ED technician's each holding one limb while she injected the medication into the patient's right arm. Further interview with RN #7 indicated although she had Management of Aggressive Behavior Training (MOAB), the training did not include a physical hold in a supine position to administer medications in an emergent situation. Interview with RN #8, who was the emergency room educator on 1/16/18 at 1:50 PM indicated MOAB training included the application of a desensitizing touch that directed the light placement of hands on both sides of the patient's elbows however, did not include placing a patient in a supine position and holding each limb for the purpose of medication administration. Interview with the Director of the ED on 1/16/18 at 2:55 PM indicated the hospital failed to have a protocol for physical holds and should have. The hospital policy entitled Use of Restraints directed in part that initial and ongoing training for all staff with direct patient care responsibilities must include restraint techniques and holds.