HospitalInspections.org

Based on hospital policy reviews, observations during tours, medical record reviews, video footage review, grievance/complaint reviews, restraint list/log reviews, company police report reviews, Law Enforcement Officer (LEO) interviews, hospital documentation review, employee file reviews, and staff and physician interviews, the hospital's leadership failed to provide oversight and have systems in place to ensure the protection and promotion of Patients' Rights, an effective Quality Assurance Performance Improvement (QAPI) program, and an organized Nursing Service.

The findings include:

1. The hospital staff failed to protect and promote patients' rights in the Behavioral Health Unit for patients who were restrained.

~cross refer to 482.13 Patient Rights Condition - Tag A-0115.

2. The hospital staff failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program for monitoring restraint in the Behavioral Health Unit.

~cross refer to 482.21 Quality Assessment and Performance Improvement (QAPI) Condition - Tag A-0263.

3. The hospital nursing staff failed to ensure nursing supervision of care per the hospital policy and procedure when the staff failed to provide ongoing assessment of the condition or symptoms that warranted restraint in the Behavioral Health Unit.

~cross refer to 482.23 Nursing Condition - Tag A-0385.

Based on hospital policy and procedure reviews, video footage reviews, medical record reviews, company police report documentation review, and Law Enforcement Officer (LEO) interviews, staff and physician interviews, the hospital staff failed to protect and promote patients' rights in the Behavioral Health Unit.

The findings include:

1. The hospital staff failed to provide a safe setting for patient care by the nursing staff failing to assess and document the patient's condition or symptom that warranted the use of the restraint and having qualified nursing and law enforcement staff restraining behavioral health patients for 2 of 5 reviewed (Patients #7 and #9).

~cross refer to 482.13(c)(2) Patient Rights Standard - Tag A-0144.

2. The nursing staff failed to accurately document the patient's condition or symptom that warranted the use of the restraint for 2 of 5 patients reviewed in the Behavioral Health Unit.

~cross refer to 482.13(e)(16) Patient Rights Standard - Tag A-0187.

3. The hospital staff failed to periodically train and ensure competency of staff and Law Enforcement Officers (LEO) that restrained Behavior Health patients.

~cross refer to 482.13(f)(1) Patient Rights Standard - Tag A-0196.

Based on reviews of hospital policy, medical record reviews, company police report documentation review, and staff interviews, the hospital staff failed to provide a safe setting for patient care by the nursing staff failing to assess and document the patient's condition or symptom that warranted the use of the restraint and having qualified nursing and law enforcement staff restraining behavioral health patients for 2 of 5 reviewed (Patients #7 and #9).

The findings include:

Review of the hospital's policy "Prevention and Management of Aggressive, Assaultive or Self Harm Behavior revised 10/14" revealed "It is the policy of Behavioral Health to utilize a system of behavioral management methods that are based on prevention, ensures the safety of patients, staff and visitors, promotes patient safety and self control, and begins from the least restrictive interventions ...Purpose: To ensure that the therapeutic milieu is safe for patient, staff, and visitors and that utilization of seclusion/restraint is used only when less restrictive measures have been exhausted or have been clinically determined to be inappropriate or insufficient to protect the patient ...Guidelines: 1. Patient's behavior which are assessed as aggressive or harmful to the patient or others that do not respond to Non - Violent Crisis Intervention....techniques which are less restrictive will be clinically assessed for the need for seclusion/restraints and an order shall be obtained from a physician prior to implementation, except in an acute behavioral emergency. The Charge Nurse will assess the patient's need for seclusion/restraint. This should be documented in the patient's medical record. In addition to the behaviors exhibited by the patient, which may necessitate seclusion/restraint, the RN must also document what less restrictive measures have been taken to assist in de-escalating the patient ...3. Hospital Police and/or Public Safety Officers may be contacted to provide additional rounding or assist with patient aggression. Whenever possible the clinical team needs to remain in control and be actively involved so the patient clearly sees actions as therapeutic and not punitive. (Hospital Police and Public Safety Officers are trained in patient de-escalation in addition to law enforcement training)."
Review of hospital policy titled " Event Response Protocol for Prevention and Management of Aggressive, Assaultive, Sexual or Self Harm Behavior" revised 10/14 revealed "d) Application and removal of seclusion/restraint is safe and is done by competent staff. All Behavioral Health staff of XXX (Name of Hospital) are trained annually in non-violent crisis intervention technique and restraint application".

1. Review of Video surveillance footage (Video #1) dated 05/14/2015 at 22:20 (time noted on video is of minutes from the initial start of video) revealed Patient #7 dressed in hospital gowns in the hallway walking freely with a staff member (#1) beside the patient or no more than 3 feet away from the patient. At 23:01 patient #7 was observed on the right side of the hallway standing behind a meal cart. The patient walks up the hallway to the nursing station and appears to have conversation with staff member #1. At 26:15 patient #7 is sitting on the floor on the right side of the hallway with staff member #1 standing by. At 33:01 the patient is walking up the hall towards the nursing station with staff member #1 in attendance. At 34:15 Patient #7 has walked back down the hall and she was observed picking up the phone receiver and returning the receiver back to the wall phone. At 35:36 she was observed sitting down onto the floor under the wall phone with staff member #1 beside her. Patient #7 can not be viewed while sitting due to the meal cart obstructing the view. Staff member #2 is observed walking down the hall to patient #7. At 39:39 patient #7 was observed standing up. At 42:25 Law Enforcement Officer (LEO) #2 was observed coming into camera view at the nursing station. At 44:05 LEO #2 walks down to location of patient #7, who is still at the wall phone along with 2 nursing staff (Staff member #1 and #2). A third staff member is also in the location of patient #7. At 44:20 four staff members and LEO #2 are observed standing around patient #7. At 44:39 a fifth staff member is at at the patient's location. At 45:26 a second LEO (#1) was observed coming into camera view from the opposite end of the hallway (away from the nursing station). At 47:45 LEO #1 grasped the patient's left arm, LEO #2 grasped the right arm and two staff are seen picking up the patient's lower extremities. Staff member #2 was observed to grasp one of the lower extremities. The patient was observed calm as the staff applied the physical restraint (hold). The staff and LEOs are observed walking while holding the patient in supine position out of camera view.
Review of Video Surveillance footage #2, dated 05/14/2014 from a second camera showing the view of the entrance of the door way into Acute unit. Review of video surveillance revealed the patient arriving to the acute unit at doorway The patient is observed being carried through the doorway by 2 LEOs and 2 staff members. LEO #2 was observed holding the patient by the right wrist. LEO #1 is holding the patient by the left arm. Two staff were observed holding the legs. The patient was observed with no support to her neck and head and her neck and head bouncing as she was carried into the acute unit. The patient is placed on the floor and assisted by LEO to a sitting position. The patient is observed calm. The patient is moved into a room out of camera view. Observation of both videos did not reveal any physical aggressive behavior, violent behavior, or any behavior that was threatening to the staff or herself.
Review of hospital documentation of the actual times which coincided closely to the videos recording events on 05/14/2014 of Patient #7 being restrained revealed the following:
11:55:34 First police officer arrives on unit.
11:56:23 First police officer approaches patient in hallway.
11:56:35 Second police officer arrives on the scene.
11:59:16 Patient sits down on the floor.
12:00:55 Officers and staff touch patient.
12:01:32 Patient arrives in the acute unit.

Medical record review for Patient #7 revealed a 23 year old admitted to the Behavioral Health unit (Adult) on 05/04/2014 with a diagnosis of Bipolar Disorder. Review of physician's orders revealed on 05/14/2014 at 0925 a time limited (4 hours) order to restrain the patient for extreme agitation and using 4 point key lock restraints. At 1209 the physician ordered "Hospital Police may assist in moving patient to acute". At 1214 the physician ordered "Hospital Police may physically assist in moving patient to acute unit". Review of nursing documentation "Behavioral Health Services Rounding sheet" (BHRS) revealed on 05/14/2014 the staff documented every 15 minutes the location and behavior of the patient. Review of the BHRS revealed starting at 0115 on 05/14/2014 staff documented the patient was in the bedroom and was "Sleeping" or "Calm/Quiet" on each 15 minute check. Documentation review revealed from 0700 to 0730 the patient was in the hall with staff. At 0730 through 0915 the patient was off the unit and starting at 0930 the patient was in the bedroom with staff or was in the bedroom Calm/Quiet until 1130. At 1145 the patient was documented at the phone and Calm/Quiet. Review of the BHRS at 1200 staff documented the patient was on Acute unit. Medical record review did not reveal any documentation the patient had aggressive or violent behavior 11 hours 45 minutes prior to the transfer to the acute unit on 05/14/2014 at 1200.

Interview with staff member #1 on 07/15/2015 at 1030 revealed he was a charge nurse for the Behavioral Health Unit. The interview revealed he was with patient #7 on 05/14/2014. The interview revealed he assisted with the restraint when the patient was moved to the Acute unit. The interview revealed it is the "standard" to call the Police Officers when a patient exhibits aggressive behavior. The interview revealed based on patient #7's history, previous actions and self injurious behavior, as the charge nurse he made the decision to call for Police assistance. The interview revealed he did not remember what the patient was saying prior to restraining the patient. The interview revealed another RN told the patient she was going to be transferred to another unit. The interview revealed the patient was told she would have to move on her own and if she did not then they would assist her. The interview revealed during the restraint event he did not see any aggressive behavior by the patient. The interview revealed if a patient is aggressive the staff would secure the hallway. The interview revealed based on the video the hallway was not secured. The interview revealed the patient exhibited "Attention Seeking" behavior and did not exhibit aggressive behavior so securing the hallway was not an issue. The interview revealed he placed hands on the patient for the 4 point transport restraint.

Telephone interview with staff member #2 on 07/15/2015 at 1338 revealed she was a unit secretary on the Behavioral Health unit. The interview revealed she would assist with monitoring a patient such as 1:1 observation. The interview revealed she was providing close monitoring for patient #7 on 05/14/2014. The interview revealed she did not remember any aggressive behavior exhibited by the patient on 05/14/2015 while she was with her. The interview revealed she remembered the patient talking about "out of body" experiences as she was sitting on the floor by the phone. The interview revealed aggressive behavior could be physical or verbal. The interview revealed calling staff names would be aggressive behavior. The interview revealed "I am secretary" I do not put hands on the patient, because it is not her job. The interview revealed she could not member if she was assigned to patient #7.

Interview with LEO #1 on 07/15/2015 at 1120 revealed he was the second officer "dispatched for back up" for the transport of patient #7 on 05/14/2014. The interview revealed when he arrived on the unit the patient was calling staff ugly names and was refusing to move. The interview revealed he did not remember hearing the patient threatening the staff, only calling staff ugly names The interview revealed the patient sat down on the floor. The interview revealed when "we helped her up" she went "dead". The interview revealed he and LEO #2 and other nursing staff carried the patient down the hall to the acute unit. The interview revealed when they arrived at the acute unit the patient was lowered to the floor. The patient was given the option to walk to room and she refused. The interview revealed LEO #1 and LEO #2 held the patient and assisted her to the room. They stopped at the doorway and once the patient was in the room she calmed down. The interview revealed the patient did not have any aggressive behavior while being carried to the acute unit. The interview revealed he was dispatched to the Behavioral Health units for violent, aggressive behavior patients and for "stand by" for medication administration. The interview revealed he had training at the hospital in 2013 for non violent restraints. The interview revealed he had taken computer modules in 2014 in de-escalation techniques.

Interview with LEO #1 on 07/15/2015 at 1135 revealed he was called to the unit to assist with a patient transport and he was the first officer on the "scene" on 05/14/2014 regarding the restraint and transport of patient #7. The interview revealed the patient was she was verbally abusive using "foul" language. The interview revealed the patient had the phone in her hand and he did not remember how the phone was placed back on the wall. The interview revealed he did not remember who, whether Police officer or staff said to place hands on the patient. The interview revealed after placing hands on the patient they carried the patient to the acute unit. The interview revealed he had training in 2013 for non-violent interventions given by the hospital. The interview revealed he had not had any further training at the hospital regarding restraining a patient The interview revealed he had web based training in 2014 and had taken a 40 hour course also of how to work with mental health patients. The interview revealed this course was "use of force" training when the officer may use force. The interview revealed he did not remember any specific techniques for holding a patient.

2. Closed medical record review for Patient # 9 revealed a 57 year old female admitted 05/23/2015 and discharged 06/18/2015. Review revealed the admission diagnosis was suicidal ideation and altered level of consciousness. Record review revealed an order entered 05/30/2015 at 1559 by MD #1, which stated "police and RN teams may therapeutically lay hands on patient for purpose of administering PRN (as needed) medications for agitation" as a one-time occurrence. Review further revealed a Registered Nurse progress note entered on 05/30/2015 at 1626 by Staff Member #1, stating, "Police presence was required when administering scheduled IM (intramuscular) Ativan (for anxiety). Pt did not verbalize understanding of need for medication, but was not combative at time of administration." Review failed to reveal symptoms or condition that warranted restraint.
Review of a police report dated 05/30/2015 at 1600 revealed "on 5/30/15 at approximately 1600 hr I, Officer (LEO #3), received a call from Communications to assist nursing staff at Behavioral Health with administration of medication to patient (#9) in room BH 443. I met with (Staff Member #4) and was escorted to (patient #9) room and assisted nursing staff with chemical restraints by restraining (patient #9) left hand with my left hand and her right arm with my right hand while she was prone on the bed. (Staff Member #4) administered medication." Review failed to reveal symptoms or condition that warranted restraint.
Interview with the Behavioral Health Manager on 07/16/2015 at 0845 revealed the patient's symptoms or condition that warranted the use of restraint was not documented.
Interview on 7/15/15 with Staff Member #5 at 1400 revealed that the patient ' s symptoms or condition that warranted the use of restraint was not documented.
Interview on 07/16/2015 at 0900 with CPI (Crisis Prevention Intervention) instructor #1 revealed the hospital uses the non-violent crisis prevention intervention education in the training of staff and Law Enforcement Officers (LEO) in the hospital approved techniques in restraining patients. The interview revealed a 4 point transfer restraint is not a hospital approved method for restraining a patient. The interview revealed she was not aware of staff using this type of method to restrain a patient until she saw it on video on 07/15/2015 of an event occurring on 05/14/2014 with patient #7. The interview revealed there was no training for the staff to perform a 4 point restraint with transport of a patient. The interview revealed the hospital training for restraints "only" teaches restraining a patient in the standing position with two staff. The interview revealed no training is done for a patient in a sitting or laying position. The interview revealed it would be up to the Behavioral Health staff to get the patient from a standing or laying position. The interview revealed she is aware LEO restrain patients and the hospital does not train LEO how to restrain a patient. The interview revealed she did not know what a "wrist lock" transport was but it was not a method approved by the hospital to use on patients. The interview revealed the training for restraints does not include how to hold a patient therapeutically if needed.

Review of Hospital training education and materials during the interview revealed a booklet titled CPI Manual Nonviolent Crisis Intervention Training Program. Review of the manual revealed a picture of a two person and one person hold on a patient in the standing position.

Based on review of hospital policy, medical record reviews, video survielliance footage reviews, company police report reviews, and staff interviews, the nursing staff failed to document the patient's condition or symptom that warranted the use of the restraint for 2 of 5 patient reviewed (Patient #7 and #9).

The findings include:

Review of the hospital's policy "Prevention and Management of Aggressive, Assaultive or Self Harm Behavior revised 10/14" revealed "It is the policy of Behavioral Health to utilize a system of behavioral management methods that are based on prevention, ensures the safety of patients, staff and visitors, promotes patient safety and self control, and begins from the least restrictive interventions ...Purpose: To ensure that the therapeutic milieu is safe for patient, staff, and visitors and that utilization of seclusion/restraint is used only when less restrictive measures have been exhausted or have been clinically determined to be inappropriate or insufficient to protect the patient ...Guidelines: 1. Patient's behavior which are assessed as aggressive or harmful to the patient or others that do not respond to Non - Violent Crisis Intervention....techniques which are less restrictive will be clinically assessed for the need for seclusion/restraints and an order shall be obtained from a physician prior to implementation, except in an acute behavioral emergency. The Charge Nurse will assess the patient's need for seclusion/restraint. This should be documented in the patient's medical record. In addition to the behaviors exhibited by the patient, which may necessitate seclusion/restraint, the RN must also document what less restrictive measures have been taken to assist in de-escalating the patient ...3. Hospital Police and/or Public Safety Officers may be contacted to provide additional rounding or assist with patient aggression. Whenever possible the clinical team needs to remain in control and be actively involved so the patient clearly sees actions as therapeutic and not punitive. (Hospital Police and Public Safety Officers are trained in patient de-escalation in addition to law enforcement training)."
1. Review of Video surveillance footage (Video #1) dated 05/14/2015 at 22:20 (time noted on video is of minutes from the initial start of video) revealed Patient #7 dressed in hospital gowns in the hallway walking freely with a staff member (#1) beside the patient or no more than 3 feet away from the patient. At 23:01 patient #7 was observed on the right side of the hallway standing behind a meal cart. The patient walks up the hallway to the nursing station and appears to have conversation with staff member #1. At 26:15 patient #7 is sitting on the floor on the right side of the hallway with staff member #1 standing by. At 33:01 the patient is walking up the hall towards the nursing station with staff member #1 in attendance. At 34:15 Patient #7 has walked back down the hall and she was observed picking up the phone receiver and returning the receiver back to the wall phone. At 35:36 she was observed sitting down onto the floor under the wall phone with staff member #1 beside her. Patient #7 can not be viewed while sitting due to the meal cart obstructing the view. Staff member #2 is observed walking down the hall to patient #7. At 39:39 patient #7 was observed standing up. At 42:25 Law Enforcement Officer (LEO) #2 was observed coming into camera view at the nursing station. At 44:05 LEO #2 walks down to location of patient #7, who is still at the wall phone along with 2 nursing staff (Staff member #1 and #2). A third staff member is also in the location of patient #7. At 44:20 four staff members and LEO #2 are observed standing around patient #7. At 44:39 a fifth staff member is at at the patient's location. At 45:26 a second LEO (#1) was observed coming into camera view from the opposite end of the hallway (away from the nursing station). At 47:45 LEO #1 grasped the patient's left arm, LEO #2 grasped the right arm and two staff are seen picking up the patient's lower extremities. Staff member #2 was observed to grasp one of the lower extremities. The patient was observed calm as the staff applied the physical restraint (hold). The staff and LEOs are observed walking while holding the patient in supine position out of camera view.
Review of Video Surveillance footage #2, dated 05/14/2014 from a second camera showing the view of the entance of the door way into Acute unit. Review of video surveilance revealed the patient arriving to the acute unit at doorway The patient is observed being carried through the doorway by 2 LEOs and 2 staff members. LEO #2 was observed holding the patient by the right wrist. LEO #1 is holding the patient by the left arm. Two staff were observed holding the legs. The patient was observed with no support to her neck and head and her neck and head bouncing as she was carried into the acute unit. The patient is placed on the floor and assisted by LEO to a sitting position. The patient is observed calm. The patient is moved into a room out of camera view. Observation of both videos did not reveal any physical aggressive behavior, violent behavior, or any behavior that was threatening to the staff or herself.
Review of hospital documentation of the actual times which coincided closely to the videos recording events on 05/14/2014 of Patient #7 being restrained revealed the following:
11:55:34 First police officer arrives on unit.
11:56:23 First police officer approaches patient in hallway.
11:56:35 Second police officer arrives on the scene.
11:59:16 Patient sits down on the floor.
12:00:55 Officers and staff touch patient.
12:01:32 Patient arrives in the acute unit.

Medical record review for Patient #7 revealed a 23 year old admitted to the Behavioral Health unit (Adult) on 05/04/2014 with a diagnosis of Bipolar Disorder. Review of physician's orders revealed on 05/14/2014 at 0925 a time limited (4 hours) order to restrain the patient for extreme agitation and using 4 point key lock restraints. At 1209 the physician ordered "Hospital Police may assist in moving patient to acute". At 1214 the physician ordered "Hospital Police may physically assist in moving patient to acute unit". Review of nursing documentation "Behavioral Health Services Rounding sheet" (BHRS) revealed on 05/14/2014 the staff documented every 15 minutes the location and behavior of the patient. Review of the BHRS revealed starting at 0115 on 05/14/2014 staff documented the patient was in the bedroom and was "Sleeping" or "Calm/Quiet" on each 15 minute check. Documentation review revealed from 0700 to 0730 the patient was in the hall with staff. At 0730 through 0915 the patient was off the unit and starting at 0930 the patient was in the bedroom with staff or was in the bedroom Calm/Quiet until 1130. At 1145 the patient was documented at the phone and Calm/Quiet. Review of the BHRS at 1200 staff documented the patient was on Acute unit. Medical record review did not reveal any documentation the patient had aggressive or violent behavior 11 hours 45 minutes prior to the transfer to the acute unit on 05/14/2014 at 1200.

Interview with staff member #1 on 07/15/2015 at 1030 revealed he was a charge nurse for the Behavioral Health Unit. The interview revealed he was with patient #7 on 05/14/2014. The interview revealed he assisted with the restraint when the patient was moved to the Acute unit. The interview revealed it is the "standard" to call the Police Officers when a patient exhibits aggressive behavior. The interview revealed based on patient #7's history, previous actions and self injurious behavior, as the charge nurse he made the decision to call for Police assistance. The interview revealed he did not remember what the patient was saying prior to restraining the patient. The interview revealed another RN told the patient she was going to be transferred to another unit. The interview revealed the patient was told she would have to move on her own and if she did not then they would assist her. The interview revealed during the restraint event he did not see any aggressive behavior by the patient. The interview revealed if a patient is aggressive the staff would secure the hallway. The interview revealed based on the video the hallway was not secured. The interview revealed the patient exhibited "Attention Seeking" behavior and did not exhibit aggressive behavior so securing the hallway was not an issue. The interview revealed he placed hands on the patient for the 4 point transport restraint.

Telephone interview with staff member #2 on 07/15/2015 at 1338 revealed she was a unit secretary on the Behavioral Health unit. The interview revealed she would assist with monitoring a patient such as 1:1 observation. The interview revealed she was providing close monitoring for patient #7 on 05/14/2014. The interview revealed she did not remember any aggressive behavior exhibited by the patient on 05/14/2015 while she was with her. The interview revealed she remembered the patient talking about "out of body" experiences as she was sitting on the floor by the phone. The interview revealed aggressive behavior could be physical or verbal. The interview revealed calling staff names would be aggressive behavior. The interview revealed "I am secretary" I do not put hands on the patient, because it is not her job. The interview revealed she could not member if she was assigned to patient #7.

Interview with LEO #1 on 07/15/2015 at 1120 revealed he was the second officer "dispatched for back up" for the transport of patient #7 on 05/14/2014. The interview revealed when he arrived on the unit the patient was calling staff ugly names and was refusing to move. The interview revealed he did not remember hearing the patient threatening the staff, only calling staff ugly names The interview revealed the patient sat down on the floor. The interview revealed when "we helped her up" she went "dead". The interview revealed he and LEO #2 and other nursing staff carried the patient down the hall to the acute unit. The interview revealed when they arrived at the acute unit the patient was lowered to the floor. The patient was given the option to walk to room and she refused. The interview revealed LEO #1 and LEO #2 held the patient and assisted her to the room. They stopped at the doorway and once the patient was in the room she calmed down. The interview revealed the patient did not have any aggressive behavior while being carried to the acute unit. The interview revealed he was dispatched to the Behavioral Health units for violent, aggressive behavior patients and for "stand by" for medication administration. The interview revealed he had training at the hospital in 2013 for non violent restraints. The interview revealed he had taken computer modules in 2014 in de-escalation techniques.

Interview with LEO #1 on 07/15/2015 at 1135 revealed he was called to the unit to assist with a patient transport and he was the first officer on the "scene" on 05/14/2014 regarding the restraint and transport of patient #7. The interview revealed the patient was she was verbally abusive using "foul" language. The interview revealed the patient had the phone in her hand and he did not remember how the phone was placed back on the wall. The interview revealed he did not remember who, whether Police officer or staff said to place hands on the patient. The interview revealed after placing hands on the patient they carried the patient to the acute unit. The interview revealed he had training in 2013 for non-violent interventions given by the hospital. The interview revealed he had not had any further training at the hospital regarding restraining a patient The interview revealed he had web based training in 2014 and had taken a 40 hour course also of how to work with mental health patients. The interview revealed this course was "use of force" training when the officer may use force. The interview revealed he did not remember any specific techniques for holding a patient.

2. Closed medical record review for Patient # 9 revealed a 57 year old female admitted 05/23/2015 and discharged 06/18/2015. Review revealed the admission diagnosis was suicidal ideation and altered level of consciousness. Record review revealed an order entered 05/30/2015 at 1559 by MD #1, which stated "police and RN teams may therapeutically lay hands on patient for purpose of administering PRN (as needed) medications for agitation" as a one-time occurrence. Review further revealed a Registered Nurse progress note entered on 05/30/2015 at 1626 by Staff Member #1, stating, "Police presence was required when administering scheduled IM (intramuscular) Ativan (for anxiety). Pt did not verbalize understanding of need for medication, but was not combative at time of administration." Review failed to reveal symptoms or condition that warranted restraint.
Review of a police report dated 05/30/2015 at 1600 revealed "on 5/30/15 at approximately 1600 hr I, Officer (LEO #3), received a call from Communications to assist nursing staff at Behavioral Health with administration of medication to patient (#9) in room BH 443. I met with (Staff Member #4) and was escorted to (patient #9) room and assisted nursing staff with chemical restraints by restraining (patient #9) left hand with my left hand and her right arm with my right hand while she was prone on the bed. (Staff Member #4) administered medication." Review failed to reveal symptoms or condition that warranted restraint.
Interview with the Behavioral Health Manager on 07/16/2015 at 0845 revealed the patient's symptoms or condition that warranted the use of restraint was not documented.

Based on policy and procedure review, hospital company police report reviews, staff interviews, review of hospital approved training, video surveillance reviews and physician interviews the hospital staff failed to periodically train and ensure competency of staff and Law Enforcement Officers (LEO) that restrained Behavior Health patients.

The findings include:

Review of hospital policy titled " Event Response Protocol for Prevention and Management of Aggressive, Assaultive, Sexual or Self Harm Behavior" revised 10/14 revealed "d) Application and removal of seclusion/restraint is safe and is done by competent staff. All Behavioral Health staff of XXX (Name of Hospital) are trained annually in non-violent crisis intervention technique and restraint application".

1. Review of Police Report #1 revealed on 05/28/2014 at 0743 "at appox (approximately) 0744, PSO (Public Safety Officer) and Officer's (name of officer) responded to the BH (Behavioral Health) Adult in reference to a force medication order. The patient Z (initials of patient) was located in the court yard and refusing all requests from staff. I asked Z to walk to the Seclusion room and Z waved his T-Shirt at officers and began to speak some sort of unrecognizable jargon in some sort of attempt to tell officers to go away. I attempted to guide Z towards the Seclusion room when Z began pulling away from me. I took subject down to the floor in an effort to gain compliance as Z refused to comply with officer demands as well as attempting to pull away from me. Officer and PSO assisted in holding Z while staff administered medication. I then escorted Z to the Seclusion room using transport wrist Lock. All units clear without further incident".

2. Review of a police report dated 05/30/2015 at 1600 revealed "on 5/30/15 at approximately 1600 hr I, Officer (LEO #3), received a call from Communications to assist nursing staff at Behavioral Health with administration of medication to patient (#9) in room BH 443. I met with (Staff Member #4) and was escorted to (patient #9) room and assisted nursing staff with chemical restraints by restraining (patient #9) left hand with my left hand and her right arm with my right hand while she was prone on the bed. (Staff Member #4) administered medication."

3. Review of a police report dated 05/29/2015 at 1356 revealed "at approximately 1356 hours I, Officer (LEO #3) received a call from Communications for assistance with medications in the Behavioral Health Unit. I met with (Staff Member #3) and escorted her to the seclusion room on the Adult Side of BH (Behavioral Health). Patient (#9, DOB 1/22/58) was refusing to receive her medications and I assisted staff by restraining (patient #9's) arms as medications were given."

Interview with the Assistant Nurse Manager of the Behavioral Health unit on 07/15/2014 at 1050 revealed the police officers will hold the patients while the staff applies a restraint device. The interview revealed the police officers do not apply the restraint device.

Interview on 07/16/2015 at 0900 with CPI (Crisis Prevention Intervention) instructor #1 revealed the hospital uses the non-violent crisis prevention intervention education in the training of staff and Law Enforcement Officers (LEO) in the hospital approved techniques in restraining patients. The interview revealed a 4 point transfer restraint is not a hospital approved method for restraining a patient. The interview revealed she was not aware of staff using this type of method to restrain a patient until she saw it on video on 07/15/2015 of an event occurring on 05/14/2014 with patient #7. The interview revealed there was no training for the staff to perform a 4 point restraint with transport of a patient. The interview revealed the hospital training for restraints "only" teaches restraining a patient in the standing position with two staff. The interview revealed no training is done for a patient in a sitting or laying position. The interview revealed it would be up to the Behavioral Health staff to get the patient from a standing or laying position. The interview revealed she is aware LEO restrain patients and the hospital does not train LEO how to restrain a patient. The interview revealed she did not know what a "wrist lock" transport was but it was not a method approved by the hospital to use on patients. The interview revealed the training for restraints does not include how to hold a patient therapeutically if needed.

Review of Hospital training education and materials during the interview revealed a booklet titled CPI Manual Nonviolent Crisis Intervention Training Program. Review of the manual revealed a picture of a two person and one person hold on a patient in the standing position.

Review of Video surveillance footage (Video #1) dated 05/14/2015 at 22:20 (time noted on video is of minutes from the initial start of video) revealed Patient #7 dressed in hospital gowns in the hallway walking freely with a staff member (#1) beside the patient or no more than 3 feet away from the patient. At 23:01 patient #7 was observed on the right side of the hallway standing behind a meal cart. The patient walks up the hallway to the nursing station and appears to have conversation with staff member #1. At 26:15 patient #7 is sitting on the floor on the right side of the hallway with staff member #1 standing by. At 33:01 the patient is walking up the hall towards the nursing station with staff member #1 in attendance. At 34:15 Patient #7 has walked back down the hall and she was observed picking up the phone receiver and returning the receiver back to the wall phone. At 35:36 she was observed sitting down onto the floor under the wall phone with staff member #1 beside her. Patient #7 can not be viewed while sitting due to the meal cart obstructing the view. Staff member #2 is observed walking down the hall to patient #7. At 39:39 patient #7 was observed standing up. At 42:25 Law Enforcement Officer (LEO) #2 was observed coming into camera view at the nursing station. At 44:05 LEO #2 walks down to location of patient #7, who is still at the wall phone along with 2 nursing staff (Staff member #1 and #2). A third staff member is also in the location of patient #7. At 44:20 four staff members and LEO #2 are observed standing around patient #7. At 44:39 a fifth staff member is at at the patient's location. At 45:26 a second LEO (#1) was observed coming into camera view from the opposite end of the hallway (away from the nursing station). At 47:45 LEO #1 grasped the patient's left arm, LEO #2 grasped the right arm and two staff are seen picking up the patient's lower extremities. Staff member #2 was observed to grasp one of the lower extremities. The patient was observed calm as the staff applied the physical restraint (hold). The staff and LEOs are observed walking while holding the patient in supine position out of camera view.
Review of Video Surveillance footage #2, dated 05/14/2014 from a second camera showing the view of the entrance of the door way into Acute unit. Review of video surveillance revealed the patient arriving to the acute unit at doorway The patient is observed being carried through the doorway by 2 LEOs and 2 staff members. LEO #2 was observed holding the patient by the right wrist. LEO #1 is holding the patient by the left arm. Two staff were observed holding the legs. The patient was observed with no support to her neck and head and her neck and head bouncing as she was carried into the acute unit. The patient is placed on the floor and assisted by LEO to a sitting position. The patient is observed calm. The patient is moved into a room out of camera view. Observation of both videos did not reveal any physical aggressive behavior, violent behavior, or any behavior that was threatening to the staff or herself.
Interview with the Chief Nursing Officer on 07/16/2015 at 1610 revealed in 2013 training for an aggressive/violent behavior patient was stopped. The interview revealed she was not aware the training had been stopped. The interview revealed the only training taught is for a 2 person hold with a standing patient. The interview revealed a wrist lock hold was not an approved hold for a patient. The interview revealed a wrist lock hold is a law enforcement maneuver used with subjects under law enforcement custody.

Interview on 07/16/2015 at 1058 with the Behavioral Health Medical Director and the Chair of the Psychiatric Department revealed neither were aware of the training provided to the staff and LEO when restraining a behavioral health patient.

Based on review of Measure Rate Report and staff interviews the hospital failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program for monitoring restraint in the Behavioral Health Unit.


1. The hospital staff failed to have the Quality Assessment Performance Improvement (QAPI) program monitoring the effectiveness and safety of restraint use in the Behavioral Health Unit.

~Cross refer to 482.21 (b) Quality Assessment Performance Improvement, Standard Tag A-0273.

Based on review of Measure Rate Report and staff interviews, the hospital failed to have the Quality Assessment Performance Improvement (QAPI) program monitoring the effectiveness and safety of restraint usage in the Behavioral Health Unit.



The findings include:

Review on 07/16/2015 of the Measure Rate Report for first quarter of 2015 revealed data was collected on the number of hours a behavioral health patient was held in seclusion and number of hours a patient was maintained in restraints. Review of documentation did not reveal data or monitoring of the effectiveness and safety of restraint usage in the Behavioral Health Unit.

Interview on 07/16/2015 at 1005 with the Behavioral Health Manager and the Behavioral Health Director revealed there was no training for the four point transport restraint seen in the video; no training for restraint methods for the violent/aggressive behavior patient and no training for Law Enforcement Officers in restraining a patient. The interview revealed the staff are only taught nonviolent restraints. Interview revealed there was no further documentation of monitoring for the effectiveness and safety of restraint usage.

Interview with the Chief Nursing Officer on 07/16/2015 at 1610 revealed that training for an aggressive/violent behavior patient was stopped in 2013. The interview revealed administrative staff were not aware training for the aggressive/violent behavior patient had been stopped. The interview revealed there was no data available monitoring the use of restraints in the violent/aggressive behavior patient or the use of techniques/maneuvers used by Law Enforcement in restraining patients.

Based on Hospital policy/procedure review, administrative staff interviews, medical record reviews, Video footage review, company police report reviews, observations, staff/physician interviews and Law Enforcement Officer (LEO) interviews the hospital nursing staff failed to ensure nursing supervision of care per the hospital policy and procedure when the staff failed to provide ongoing assessment and evaluation of the patient's condition or symptoms that warranted the use of the restraint.

The findings include:

The nursing staff failed to document the patient's condition or symptoms that warranted the use of the restraint for 2 of 5 restrained patients reviewed (Patient #7 and #9).

~cross refer to 482.23(b)(3) Nursing Services Standard - Tag A-0395.

Based on review of hospital policy, video footage review, closed medical record reviews, company police report reviews, and physician and staff interviews, the nursing staff failed to document the patient's condition or symptoms that warranted the use of the restraint for 2 of 5 restrained patients reviewed (Patient #7 and #9).

The findings include:

Review of the hospital's policy "Prevention and Management of Aggressive, Assaultive or Self Harm Behavior revised 10/14" revealed "It is the policy of Behavioral Health to utilize a system of behavioral management methods that are based on prevention, ensures the safety of patients, staff and visitors, promotes patient safety and self control, and begins from the least restrictive interventions ...Purpose: To ensure that the therapeutic milieu is safe for patient, staff, and visitors and that utilization of seclusion/restraint is used only when less restrictive measures have been exhausted or have been clinically determined to be inappropriate or insufficient to protect the patient ...Guidelines: 1. Patient's behavior which are assessed as aggressive or harmful to the patient or others that do not respond to Non - Violent Crisis Intervention....techniques which are less restrictive will be clinically assessed for the need for seclusion/restraints and an order shall be obtained from a physician prior to implementation, except in an acute behavioral emergency. The Charge Nurse will assess the patient's need for seclusion/restraint. This should be documented in the patient's medical record. In addition to the behaviors exhibited by the patient, which may necessitate seclusion/restraint, the RN must also document what less restrictive measures have been taken to assist in de-escalating the patient ...3. Hospital Police and/or Public Safety Officers may be contacted to provide additional rounding or assist with patient aggression. Whenever possible the clinical team needs to remain in control and be actively involved so the patient clearly sees actions as therapeutic and not punitive. (Hospital Police and Public Safety Officers are trained in patient de-escalation in addition to law enforcement training)."
Review of hospital policy titled " Event Response Protocol for Prevention and Management of Aggressive, Assaultive, Sexual or Self Harm Behavior" revised 10/14 revealed "d) Application and removal of seclusion/restraint is safe and is done by competent staff. All Behavioral Health staff of XXX (Name of Hospital) are trained annually in non-violent crisis intervention technique and restraint application".

1. Review of Video surveillance footage (Video #1) dated 05/14/2015 at 22:20 (time noted on video is of minutes from the initial start of video) revealed Patient #7 dressed in hospital gowns in the hallway walking freely with a staff member (#1) beside the patient or no more than 3 feet away from the patient. At 23:01 patient #7 was observed on the right side of the hallway standing behind a meal cart. The patient walks up the hallway to the nursing station and appears to have conversation with staff member #1. At 26:15 patient #7 is sitting on the floor on the right side of the hallway with staff member #1 standing by. At 33:01 the patient is walking up the hall towards the nursing station with staff member #1 in attendance. At 34:15 Patient #7 has walked back down the hall and she was observed picking up the phone receiver and returning the receiver back to the wall phone. At 35:36 she was observed sitting down onto the floor under the wall phone with staff member #1 beside her. Patient #7 can not be viewed while sitting due to the meal cart obstructing the view. Staff member #2 is observed walking down the hall to patient #7. At 39:39 patient #7 was observed standing up. At 42:25 Law Enforcement Officer (LEO) #2 was observed coming into camera view at the nursing station. At 44:05 LEO #2 walks down to location of patient #7, who is still at the wall phone along with 2 nursing staff (Staff member #1 and #2). A third staff member is also in the location of patient #7. At 44:20 four staff members and LEO #2 are observed standing around patient #7. At 44:39 a fifth staff member is at at the patient's location. At 45:26 a second LEO (#1) was observed coming into camera view from the opposite end of the hallway (away from the nursing station). At 47:45 LEO #1 grasped the patient's left arm, LEO #2 grasped the right arm and two staff are seen picking up the patient's lower extremities. Staff member #2 was observed to grasp one of the lower extremities. The patient was observed calm as the staff applied the physical restraint (hold). The staff and LEOs are observed walking while holding the patient in supine position out of camera view.
Review of Video Surveillance footage #2, dated 05/14/2014 from a second camera showing the view of the entrance of the door way into Acute unit. Review of video surveillance revealed the patient arriving to the acute unit at doorway The patient is observed being carried through the doorway by 2 LEOs and 2 staff members. LEO #2 was observed holding the patient by the right wrist. LEO #1 is holding the patient by the left arm. Two staff were observed holding the legs. The patient was observed with no support to her neck and head and her neck and head bouncing as she was carried into the acute unit. The patient is placed on the floor and assisted by LEO to a sitting position. The patient is observed calm. The patient is moved into a room out of camera view. Observation of both videos did not reveal any physical aggressive behavior, violent behavior, or any behavior that was threatening to the staff or herself.
Review of hospital documentation of the actual times which coincided closely to the videos recording events on 05/14/2014 of Patient #7 being restrained revealed the following:
11:55:34 First police officer arrives on unit.
11:56:23 First police officer approaches patient in hallway.
11:56:35 Second police officer arrives on the scene.
11:59:16 Patient sits down on the floor.
12:00:55 Officers and staff touch patient.
12:01:32 Patient arrives in the acute unit.

Medical record review for Patient #7 revealed a 23 year old admitted to the Behavioral Health unit (Adult) on 05/04/2014 with a diagnosis of Bipolar Disorder. Review of physician's orders revealed on 05/14/2014 at 0925 a time limited (4 hours) order to restrain the patient for extreme agitation and using 4 point key lock restraints. At 1209 the physician ordered "Hospital Police may assist in moving patient to acute". At 1214 the physician ordered "Hospital Police may physically assist in moving patient to acute unit". Review of nursing documentation "Behavioral Health Services Rounding sheet" (BHRS) revealed on 05/14/2014 the staff documented every 15 minutes the location and behavior of the patient. Review of the BHRS revealed starting at 0115 on 05/14/2014 staff documented the patient was in the bedroom and was "Sleeping" or "Calm/Quiet" on each 15 minute check. Documentation review revealed from 0700 to 0730 the patient was in the hall with staff. At 0730 through 0915 the patient was off the unit and starting at 0930 the patient was in the bedroom with staff or was in the bedroom Calm/Quiet until 1130. At 1145 the patient was documented at the phone and Calm/Quiet. Review of the BHRS at 1200 staff documented the patient was on Acute unit. Medical record review did not reveal any documentation the patient had aggressive or violent behavior 11 hours 45 minutes prior to the transfer to the acute unit on 05/14/2014 at 1200.

Interview with staff member #1 on 07/15/2015 at 1030 revealed he was a charge nurse for the Behavioral Health Unit. The interview revealed he was with patient #7 on 05/14/2014. The interview revealed he assisted with the restraint when the patient was moved to the Acute unit. The interview revealed it is the "standard" to call the Police Officers when a patient exhibits aggressive behavior. The interview revealed based on patient #7's history, previous actions and self injurious behavior, as the charge nurse he made the decision to call for Police assistance. The interview revealed he did not remember what the patient was saying prior to restraining the patient. The interview revealed another RN told the patient she was going to be transferred to another unit. The interview revealed the patient was told she would have to move on her own and if she did not then they would assist her. The interview revealed during the restraint event he did not see any aggressive behavior by the patient. The interview revealed if a patient is aggressive the staff would secure the hallway. The interview revealed based on the video the hallway was not secured. The interview revealed the patient exhibited "Attention Seeking" behavior and did not exhibit aggressive behavior so securing the hallway was not an issue. The interview revealed he placed hands on the patient for the 4 point transport restraint.

Telephone interview with staff member #2 on 07/15/2015 at 1338 revealed she was a unit secretary on the Behavioral Health unit. The interview revealed she would assist with monitoring a patient such as 1:1 observation. The interview revealed she was providing close monitoring for patient #7 on 05/14/2014. The interview revealed she did not remember any aggressive behavior exhibited by the patient on 05/14/2015 while she was with her. The interview revealed she remembered the patient talking about "out of body" experiences as she was sitting on the floor by the phone. The interview revealed aggressive behavior could be physical or verbal. The interview revealed calling staff names would be aggressive behavior. The interview revealed "I am secretary" I do not put hands on the patient, because it is not her job. The interview revealed she could not member if she was assigned to patient #7.

Interview with LEO #1 on 07/15/2015 at 1120 revealed he was the second officer "dispatched for back up" for the transport of patient #7 on 05/14/2014. The interview revealed when he arrived on the unit the patient was calling staff ugly names and was refusing to move. The interview revealed he did not remember hearing the patient threatening the staff, only calling staff ugly names The interview revealed the patient sat down on the floor. The interview revealed when "we helped her up" she went "dead". The interview revealed he and LEO #2 and other nursing staff carried the patient down the hall to the acute unit. The interview revealed when they arrived at the acute unit the patient was lowered to the floor. The patient was given the option to walk to room and she refused. The interview revealed LEO #1 and LEO #2 held the patient and assisted her to the room. They stopped at the doorway and once the patient was in the room she calmed down. The interview revealed the patient did not have any aggressive behavior while being carried to the acute unit. The interview revealed he was dispatched to the Behavioral Health units for violent, aggressive behavior patients and for "stand by" for medication administration. The interview revealed he had training at the hospital in 2013 for non violent restraints. The interview revealed he had taken computer modules in 2014 in de-escalation techniques.

Interview with LEO #1 on 07/15/2015 at 1135 revealed he was called to the unit to assist with a patient transport and he was the first officer on the "scene" on 05/14/2014 regarding the restraint and transport of patient #7. The interview revealed the patient was she was verbally abusive using "foul" language. The interview revealed the patient had the phone in her hand and he did not remember how the phone was placed back on the wall. The interview revealed he did not remember who, whether Police officer or staff said to place hands on the patient. The interview revealed after placing hands on the patient they carried the patient to the acute unit. The interview revealed he had training in 2013 for non-violent interventions given by the hospital. The interview revealed he had not had any further training at the hospital regarding restraining a patient The interview revealed he had web based training in 2014 and had taken a 40 hour course also of how to work with mental health patients. The interview revealed this course was "use of force" training when the officer may use force. The interview revealed he did not remember any specific techniques for holding a patient.

2. Closed medical record review for Patient # 9 revealed a 57 year old female admitted 05/23/2015 and discharged 06/18/2015. Review revealed the admission diagnosis was suicidal ideation and altered level of consciousness. Record review revealed an order entered 05/30/2015 at 1559 by MD #1, which stated "police and RN teams may therapeutically lay hands on patient for purpose of administering PRN (as needed) medications for agitation" as a one-time occurrence. Review further revealed a Registered Nurse progress note entered on 05/30/2015 at 1626 by Staff Member #1, stating, "Police presence was required when administering scheduled IM (intramuscular) Ativan (for anxiety). Pt did not verbalize understanding of need for medication, but was not combative at time of administration." Review failed to reveal symptoms or condition that warranted restraint.
Review of a police report dated 05/30/2015 at 1600 revealed "on 5/30/15 at approximately 1600 hr I, Officer (LEO #3), received a call from Communications to assist nursing staff at Behavioral Health with administration of medication to patient (#9) in room BH 443. I met with (Staff Member #4) and was escorted to (patient #9) room and assisted nursing staff with chemical restraints by restraining (patient #9) left hand with my left hand and her right arm with my right hand while she was prone on the bed. (Staff Member #4) administered medication." Review failed to reveal symptoms or condition that warranted restraint.
Interview with the Behavioral Health Manager on 07/16/2015 at 0845 revealed the patient's symptoms or condition that warranted the use of restraint was not documented.
Interview on 7/15/15 with Staff Member #5 at 1400 revealed that the patient ' s symptoms or condition that warranted the use of restraint was not documented.
Interview on 07/16/2015 at 0900 with CPI (Crisis Prevention Intervention) instructor #1 revealed the hospital uses the non-violent crisis prevention intervention education in the training of staff and Law Enforcement Officers (LEO) in the hospital approved techniques in restraining patients. The interview revealed a 4 point transfer restraint is not a hospital approved method for restraining a patient. The interview revealed she was not aware of staff using this type of method to restrain a patient until she saw it on video on 07/15/2015 of an event occurring on 05/14/2014 with patient #7. The interview revealed there was no training for the staff to perform a 4 point restraint with transport of a patient. The interview revealed the hospital training for restraints "only" teaches restraining a patient in the standing position with two staff. The interview revealed no training is done for a patient in a sitting or laying position. The interview revealed it would be up to the Behavioral Health staff to get the patient from a standing or laying position. The interview revealed she is aware LEO restrain patients and the hospital does not train LEO how to restrain a patient. The interview revealed she did not know what a "wrist lock" transport was but it was not a method approved by the hospital to use on patients. The interview revealed the training for restraints does not include how to hold a patient therapeutically if needed.

Review of Hospital training education and materials during the interview revealed a booklet titled CPI Manual Nonviolent Crisis Intervention Training Program. Review of the manual revealed a picture of a two person and one person hold on a patient in the standing position.

NC00106870