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Based on document review and interview, it was determined, for 2 of 10 patients sampled (Pts. 1 & 5), the Hospital failed to ensure psychiatric patients were adequately monitored for safety, effectively restrained without injury,and injury reported when known.

As a result, it was determined the Condition of Participation, 42 CFR 482.13, Patient Rights, was not met.

Findings include:

1. The Hospital failed to ensure an incident report was completed after a patient injury during restraint (A-144A).

2. The Hospital failed to ensure close monitoring observations were documented every 15 minutes, as required (A-144B).

3. The Hospital failed to ensure patients were not injured during the restraint process (A-167A).

4. The Hospital failed to ensure leather wrist restraints fit properly to safely secure patients (A-167B).

A. Based on document review and interview, it was determined for 1 of 1 patient (Pt. #1) injured during restraint application, the Hospital failed to ensure an incident report was completed.

Findings included:

1. Hospital policy No. I-1000-12, titled, "Incident Occurrences", revised 5/2013, was reviewed on 11/25/15 at 9:30 AM. The policy included, "Procedure: 1. A report of occurrence form shall be completed and submitted by every employee who observes or who is directly aware of a reportable occurrence or hazardous condition... Types of Incidents to report... equipment/device problems... falls... injury... Upon completion of the occurrence report, the Unit Manager or House Coordinator will review the report.. The completed report will be forwarded to Risk Management for additional follow up..."

2. The clinical record of Pt. #1 was reviewed on 11/23/15 at 9:30 AM. Pt. #1 was a 29 year old female, who presented to the Emergency Department (ED) on 10/22/15 at 1:43 AM, for a psychiatric evaluation. Pt. #1's medical screening exam dated 10/22/15 at 2:04 AM, included, "...Shortly after I saw her in triage, she changed her mind about being seen and attempted to abscond and when security tried to stop her, she became violent and combative requiring restraints... "

3. On 11/23/15 at 11:35 AM, an interview was conducted with a security officer (E #5) who was involved in Pt. #1's restraint process. E #5 stated, Pt. #1 became combative and tried to "get out of the door." When the nurse told security Pt. #1 needed to be restrained, Pt. #1 "lost control". Security had to "get her [Pt. #1] down on the bed and tie her down". Pt. #1 and and another Security Guard (E #7) were "wrestling". During the struggle both Pt. #1 and E #7 fell to the floor. Pt. #1 fell backwards and hit her head. Pt. #1 told E #5 her tooth was knocked out. A doctor (MD #1) examined Pt. #1 and said it was a rotten tooth and would have come out anyway. E #5 stated, Pt. #1 kept getting out of the wrist restraints because her arms were small.

4. On 11/24/15 at 9:35 AM, an interview was conducted with the Security Supervisor (E #15). E #15 stated he was called to assist in restraining Pt. #1 because she was combative, fighting, and spitting. "She was like Houdini " getting out of restraints 4 to 6 times. When E #15 reported the incident to the Director of Security (E #1), she told him she had been called by someone from the mental health hospital, where Pt. #1 was transferred to, regarding the incident.

5. On 11/24/15 at 10:20 AM, an interview was conducted with the Security Director (E #1). E #1 stated she received a call from the mental health hospital and was told Pt. #1's tooth was " knocked out " during restraint. E #1 reported it to her Supervisor (E #17) and to Risk Management (E # 18). E #1 stated she did not initiate an incident report.

6. On 11/24/15 at 10:35 AM, an interview was conducted with E #1 ' s Supervisor (E #17), the Vice President of Ancillary and Support Services. E #17 stated he did not recall any incident being reported by E #1 regarding Pt. #1. E #17 stated E #1 " should have put it in writing. "

7. On 11/24/15 at 11:30 AM, an interview was conducted with the Risk Manager (E #18). E #18 stated she did not receive any documents regarding Pt. #1 from the Security Director (E #1). E #18 stated an incident report should have been generated because a tooth extraction was an " untoward event " and an " unintended effect " of Pt. #1 ' s restraint procedure.

8. On 11/24/15 at 7:55 AM, an interview was conducted with a House Supervisor (E #12). E #12 stated the Emergency Department Charge Nurse (E #10) called her about Pt. #1 ' s tooth coming out during a restraint procedure and she instructed E #10 to write an incident report. E #12 stated an incident report was not done.


B. Based on document review and interview, it was determined for 2 of 5 (Pt.s #1 & 5) patients in the triage II area (psychiatric area in the emergency department - ED), the Hospital failed to ensure close monitoring observations were documented every 15 minutes as required.

Findings include:

1. Hospital policy titled, "Close Observation", revised 4/2013, was reviewed on 11/24/15 at 2:30 PM. The policy required, "On Close Observation he/she will be directly observed by staff every 15 minutes".

2. The clinical record of Pt. #1 was reviewed on 11/23/15 at 9:30 AM. Pt. #1 was a 29 year old female who presented to the Emergency Department (ED) on 10/22/15 at 1:43 AM and was placed in the triage II area for a psychiatric evaluation. Pt. #1 remained in the triage II area until 10/23/15 at 12:00 AM. The clinical record lacked documentation of every 15 minutes checks for the entire stay in triage II.

3. The clinical record of Pt. #5 was reviewed on 11/23/15 at approximately 11:30 AM. Pt. #5 was a 51 year old female who presented to the ED on 11/7/15 at 4:38 AM and was placed in the triage II area with the complaint of being extremely agitated. Pt. #5 remained in the triage II area until 11/8/15 at 5:45 PM. The clinical record lacked documentation of every 15 minute checks on 11/7/15 from 10:00 AM to 11/8/15 at 12:00 AM and 11/8/15 from 7:00 AM to 3:00 PM.

4. During an interview on 11/23/15 at 2:25 PM, the Vice President of Nursing Services (E#6) stated, "All patients in the triage II area are considered to be on close observation and require every 15 minute checks documented".


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A. Based on document review and interview, it was determined, for 1 of 1 patient (Pt. #1) injured during restraint application, the Hospital failed to ensure the patient was not injured during the restraint process.

Findings included:

1. Hospital policy, titled, "Use of Force", dated 12/30/14, was reviewed on 12/16/15 at 11:40 AM. The policy included, "...The use of excessive force, unwarranted physical force... will not be tolerated..."

2. The clinical record of Pt. #1 was reviewed on 11/23/15. at 9:30 AM. Pt. #1 was a 29 year old female, who presented to the ED on 10/22/15 at 1:43 AM, for a psychiatric evaluation. Pt. #1's triage note dated 10/22/15 at 1:49 AM, included Pt. #1 had suicidal thoughts. Pt. #1's medical screening exam dated 10/22/15 at 2:04 AM, indicated Pt. #1 was "homeless and feeling hopeless" and considered hanging herself. "...When seen, she is quiet, withdrawn, angry, and very hostile. Shortly after I saw her in triage, she changed her mind about being seen and attempted to abscond and when security tried to stop her, she became violent and combative requiring restraints..."

3. On 11/23/15 at 1:00 PM, a security department report (#15-1407) dated 10/22/15, was reviewed. The report indicated 2 security officers (E #5 & 7) were involved in restraining Pt. #1 on 10/22/15 at approximately 2:23 AM. The report did not include information regarding the restraint process or injuries, except, "The patient became combative during the restraint and my [E #5] shirt was torn."

4. On 11/24/15 at approximately 2:00 PM, E #5 & 7's personnel files were reviewed. E #7's file included a written reprimand dated 9/5/15 for "failed to follow established protocols after escort to triage 2..."

5. On 11/23/15 at 11:35 AM, an interview was conducted with a security officer (E #5) who was involved in Pt. #1's restraint process. E #5 stated Pt. #1 was doing fine for 30 to 40 minutes when she arrived in the ED, but then became impatient and tried to leave the ED. E #5 had to stop Pt. #1 from leaving and another Security Officer (E #7) arrived to assist. "They had to get her down on the bed and tie her down." Pt. #1 and E #7 were "wrestling". During the struggle both Pt. #1 and E #7 fell to the floor. Pt. #1 fell backwards and hit her head. Pt. #1 told E #5 her tooth was knocked out. The doctor (MD #1) said it was a rotten tooth and would have come out anyway.

B. Based on document review and interview, it was determined for 1 of 7 patients (Pt. #1) in restraints, the Hospital failed to ensure leather wrist restraints fit properly to safely secure patients.

Findings included:

1. Hospital policy No. I-1000-49, titled, "Hospital-Patient Mutual Rights and Responsibilities", revised 5/2000, was reviewed on 11/24/15 at 1:55 PM. The policy included, "The patient has the right to... personal safety..."

2. Hospital policy No. 6-1000-145, titled, "Utilization of Human Restraints", revised 5/2013, was reviewed on 11/24/15 at 2:46 PM. The policy included, "It is the policy of... that physical restraint shall be employed... to prevent a recipient from causing physical harm to himself / herself or physical abuse to others..."

3. The clinical record of Pt. #1 was reviewed on 11/23/15 at 9:30 AM. Pt. #1 was a 29 year old female, who presented to the ED on 10/22/15 at 1:43 AM, for a psychiatric evaluation. Pt. #1's medical screening exam dated 10/22/15 at 2:04 AM, included, "...Shortly after I saw her in triage, she changed her mind about being seen and attempted to abscond and when security tried to stop her, she became violent and combative requiring restraints ..."

4. On 11/23/15 at 3:30 PM, an interview was conducted with a security officer (E #7) who was involved in restraining Pt. #1. E #7 stated Pt. #1 kept getting her arms out of the restraints because her hands were small. Pt. #1 fell asleep and no longer required restraints. E #7 stated there have been other occasions where patients have been able to escape restraints.

5. On 11/24/15 at 9:35 AM, an interview was conducted with the Security Supervisor (E #15). E #15 stated he was called to assist in restraining Pt. #1 because she was combative, fighting, and spitting. "She was like Houdini" getting out of the wrist restraints 4 to 6 times.