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Based on document review, medical record review, and staff interviews, the CAH failed to ensure compliance with state law governing the involuntary detention of individuals with suspected mental illness. Specifically, for 1 of 27 patients reviewed (Patient #6), the facility failed to document evidence of grave disability or imminent danger, failed to obtain a court order or initiate a legal mental health hold, and improperly detained and restrained Patient #6. This had the potential to put all patients at risk seeking treatment in the CAH emergency department.

"IDAHO STATUTES TITLE 66 STATE CHARITABLE INSTITUTIONS 3 HOSPITALIZATION OF MENTALLY ILL," updated 7/01/22, stated "66-326. Detention without hearing. (1) No person shall be taken into custody or detained as an alleged emergency patient for observation, diagnosis, evaluation, care or treatment of mental illness unless and until the court has ordered such apprehension and custody under the provisions outlined in section 66-329, Idaho Code; provided, however, that a person may be taken into custody by a peace officer and placed in a facility, or the person may be detained at a hospital at which the person presented or was brought to receive medical or mental health care, if the peace officer or a physician medical staff member of such hospital or a physician's assistant or advanced practice registered nurse practicing in such hospital has reason to believe that the person is gravely disabled due to mental illness or the person's continued liberty poses an imminent danger to that person or others, as evidenced by a threat of substantial physical harm; provided, under no circumstances shall the proposed patient be detained in a nonmedical unit used for the detention of individuals charged with or convicted of penal offenses. For purposes of this section, the term "peace officer" shall include state probation and parole officers exercising their authority to supervise probationers and parolees. Whenever a person is taken into custody or detained under this section without court order, the evidence supporting the claim of grave disability due to mental illness or imminent danger must be presented to a duly authorized court within twenty-four (24) hours from the time the individual was placed in custody or detained." This Statute was not followed. An example includes:

Patient #6 was a 41 year old female who was transported to the hospital via ambulance with chief complaint of altered mental status. She was transported after being approached by police officers in a parking lot and refusing to answer questions for police officers and EMS personnel.

Patient #6's medical record included the EMS report. The EMS report noted the following, "Upon arrival adult F is found standing in the parking lot of the carl jr's [sic] with LE at patient side. Patient is noted to be breathing normally, refuses to answer questions. Patient refuses to be touched. Skin is noted to be cool and dry to the touch with feces noted to patients [sic] hands, down her legs and in her shoes." In a section titled "Neurological Exam" the following is noted: "Level of Consciousness: Alert, Chemically Paralyzed: No, Neuro Comments: Patient is alert but refuses to answer questions. When willing to speak to EMS patient is alert but unable to recall current event's [sic]. When attempted to [sic], Neurological Present: Speech Normal, Strength-Normal, Mental Present: Uncooperative." Pupils are noted to both be normal and reactive. Sensory and motor is noted to be normal in all extremities. Glasgow coma scale is noted to be a total of 15. In a section titled "Airway" the following is noted: "Status: Patent, Comments: Patient airway is open and patent, breathing normally, able to speak in complete sentences when willing to answer questions." On the EMS report there is a note timed, "01:55 Patient is transferred to hospital bed in room 6 using the slide method. SBAR report given to ED RN. SLJ assumes all patient care at this time." The EMS report documented that Patient #6 was alert but chose not to answer questions.

Patient #6's medical record included an RN assessment note dated 11/17/24 with a time of 2:11 AM, "Patient in ed via found at the carls jr parking lot and will not answer questions. Patient on arrival keeps not answering. Patient with soiled pants myself and Maria RN attempted to clean patient up and patient remains not answering questions. Security and other RNs responded as patient started to get agitated and aggressive and wanted to leave. Patient was educated on we are there to help her and continually tried to deescalate verbally. Patient placed in restraints as she began to kick security guard multiple times, hit, scratch, and bite at other staff members ...."

It was unclear through documentation why multiple persons were in the room with Patient #6 while staff were trying to deescalate Patient #6. There was no documentation of attempted nonverbal de-escalation techniques utilized. It was unclear through documentation how Patient #6 refusing to answer questions put her in imminent danger or had grave disability.

Patient #6's medical record included the following ED provider note dated 11/17/24 with a time of 2:29 AM, "Patient is a 123 y.o. female presenting to the ED with altered mental status. Patient was apparently found in a parking lot by law enforcement. She was unresponsive. They called EMS and EMS brought the patient here to the ER. Once arrival here she went violent on staff and thus law enforcement was called and they put her in restraints. Patient is still not giving us meaningful responses. She told the story to the nursing staff that she was at a hotel with some unknown man. She is unsure if she was given something by this man. She has no complaints. Patient is in restraints. She has been incontinent of stool and urine. She does not give me any complaints. She does not really give me any history. Patient assaulted medical staff and thus will need to get lab work from her for HIV and hepatitis .....She was scratching and biting and grabbing and kicking and swinging and punching and trying to elope ....."

There was no documentation of specific evidence of grave disability or imminent danger due to mental illness. Additionally, there was no documentation the Physician was seeking an evaluation for a mental health condition.

The Nurse Manager was interviewed on 3/25/25 beginning at 12:35 PM and Patient #6's medical record was reviewed in her presence. She stated that staff put the patient in restraints because patient was "getting agitated and aggressive and assaulted staff so she was not allowed to leave". When asked why the patient was not allowed to leave, she stated, "Because she physically assaulted a healthcare worker."

The COO/CNO was interviewed on 3/26/25 beginning at 1:20 PM. He stated that patient was not allowed to leave the ED because the doctor had determined that she was not of sound mind as she was not willing to answer questions. He was asked if the patient had been placed on a mental health hold and he said she was not. He was asked if she had the capacity to make decisions for herself and he stated, "I do not think she had capacity to make decisions." He was asked if there was any paperwork filed for the patient being detained and not allowed to leave the hospital and he stated there was not.

The CAH failed to comply with Idaho Code §66-326 by detaining Patient #6 without obtaining a court order or documenting evidence of grave disability or imminent danger due to mental illness, as required by law for emergency mental health holds. Additionally, the facility failed to document that a physician was actively seeking or initiating a mental health evaluation or legal hold, resulting in the patient being improperly held and restrained against her will.

Based on hospital policy review, record review, EMS report review, and staff interview, it was determined the hospital failed to ensure restraints were utilized appropriately per hospital policy for 1of 1 patient (Patient #6) who's record was reviewed and had restraints applied for violent behaviors. This had the potential for unsafe conditions for all patients receiving care at the hospital. Findings include:

A hospital policy titled, "Restraints & Seclusion", dated 05/23/24, stated: "II. LESS RESTRICTIVE MEASURES/ALTERNATIVES TO RESTRAINTS/SECLUSION

A. Prior to the use of any restraint/seclusion, the patient care provider must attempt and/or consider less restrictive measures to protect the patient, staff members, or other from harm.

B. Document the implementation of less restrictive measures or the reason less restrictive measures were not an option prior to restrain/seclusion application/use.

C. The following are examples of less restrictive measures or the reason less restrictive alternatives to restraints/seclusion:

1. Address physical and medical needs (e.g., offer regular toileting, keep personal items within reach).
2. Treatment of symptoms of illness causing behaviors e.g., olanzapine for hallucinations due to delirium.
3. Provide patient with diversion activities (e.g., magazine, television, and music).
4. Move patient closer to the nurse's station.
5. Use of medical equipment (e.g., splints, arm boards, positioning equipment).
6. Employ verbal de-escalation techniques.
7. Increase activity as tolerated.
8. Use Patient Safety Attendant/family member to stay with the patient.
9. Offer medication for restlessness or anxiety if the medication and dose are currently part of the patient's treatment plan.
10. Implement fall precautions. "
This policy was not followed.

Patient #6 was a 41 year old female who was transported to the hospital via ambulance with chief complaint of altered mental status. She was transported after being approached by police officers in a parking lot and refusing to answer questions for police officers and EMS personnel.

Patient #6's medical record included the EMS report. The EMS report noted the following, "Upon arrival adult F is found standing in the parking lot of the carl jr's [sic] with LE at patient side. Patient is noted to be breathing normally, refuses to answer questions. Patient refuses to be touched. Skin is noted to be cool and dry to the touch with feces noted to patients [sic] hands, down her legs and in her shoes." In a section titled "Neurological Exam" the following is noted: "Level of Consciousness: Alert, Chemically Paralyzed: No, Neuro Comments: Patient is alert but refuses to answer questions. When willing to speak to EMS patient is alert but unable to recall current event's [sic]. When attempted to [sic], Neurological Present: Speech Normal, Strength-Normal, Mental Present: Uncooperative." Pupils are noted to both be normal and reactive. Sensory and motor is noted to be normal in all extremities. Glasgow coma scale is noted to be a total of 15. In a section titled "Airway" the following is noted: "Status: Patent, Comments: Patient airway is open and patent, breathing normally, able to speak in complete sentences when willing to answer questions." On the EMS report there is a note timed, "01:55 Patient is transferred to hospital bed in room 6 using the slide method. SBAR report given to ED RN. SLJ assumes all patient care at this time." The EMS report documented that Patient #6 was alert but chose not to answer questions.

Patient #6's medical record included an RN assessment note dated 11/17/24 with a time of 2:11 AM, "Patient in ed via found at the carls jr parking lot and will not answer questions. Patient on arrival keeps not answering. Patient with soiled pants myself and Maria RN attempted to clean patient up and patient remains not answering questions. Security and other RNs responded as patient started to get agitated and aggressive and wanted to leave. Patient was educated on we are there to help her and continually tried to deescalate verbally. Patient placed in restraints as she began to kick security guard multiple times, hit, scratch, and bite at other staff members ...." It was unclear through documentation why multiple persons were in the room with Patient #6 while staff were trying to deescalate Patient #6. There was no documentation of attempted nonverbal de-escalation techniques utilized.

Patient #6's medical record included the following ED provider note dated 11/17/24 with a time of 2:29 AM, "Patient is a 123 y.o. female presenting to the ED with altered mental status. Patient was apparently found in a parking lot by law enforcement. She was unresponsive. They called EMS and EMS brought the patient here to the ER. Once arrival here she went violent on staff and thus law enforcement was called and they put her in restraints. Patient is still not giving us meaningful responses. She told the story to the nursing staff that she was at a hotel with some unknown man. She is unsure if she was given something by this man. She has no complaints. Patient is in restraints. She has been incontinent of stool and urine. She does not give me any complaints. She does not really give me any history. Patient assaulted medical staff and thus will need to get lab work from her for HIV and hepatitis .....She was scratching and biting and grabbing and kicking and swinging and punching and trying to elope ....."

It is unclear what less restrictive measures were implemented prior to the use of restraints.
It is unclear how the hospital addressed her physical and medical needs prior to placing patient in restraints.
It is unclear how the hospital treated any of Patient #6's symptoms prior to placing her in restraints.
It is unclear how the hospital provided diversion activities before placing her in restraints.
It is unclear what verbal de-escalation techniques were used prior to placing Patient #6 in restraints.

The Nurse Manager was interviewed on 3/25/25 beginning at 12:35 PM and Patient #6's medical record was reviewed in her presence. She stated that staff put the patient in restraints because patient was "getting agitated and aggressive and assaulted staff so she was not allowed to leave". When asked why the patient was not allowed to leave, she stated, "Because she physically assaulted a healthcare worker."

The COO/CNO was interviewed on 3/26/25 beginning at 1:20 PM and Patient #6's medical record was reviewed in his presence. He stated that patient was not allowed to leave the ED because the doctor had determined that she was not of sound mind as she was not willing to answer questions. He was asked if the patient had been placed on a mental health hold and he said she was not. He was asked if she had the capacity to make decisions for herself and he stated, "I do not think she had capacity to make decisions." He was asked if there was any paperwork filed for the patient being detained and not allowed to leave the hospital and he stated there was not.

The hospital failed to ensure restraints were used appropriately.

Based on medical record review and staff interviews, it was determined that the hospital failed to ensure that patient care plans were complete for 5 of 5 swing bed patients (Patient #9, #10, #11, #12, #13) and assessments were comprehensive to ensure activity assessments were completed for 4 of 5 swing bed patients (Patient #9, #10, #11, #12) whose records were reviewed. This lack of comprehensive care plans and activity assessments created the potential for unmet patient needs.
1. Patient care plans were not complete to include necessary mental health interventions and goals.
Patient #13 was a 76 year old female who was admitted to the hospital on 10/02/24. She was later transferred to swing bed admission on 10/17/24. Both her inpatient and swing bed records were reviewed.
Patient #13's medical record from her inpatient admission included a psychiatric consultation conducted on 10/08/24 by a psychiatrist. The assessment noted that she had experienced suicidal ideation within the last 48 hours. Additionally, the assessment indicated Patient #13 had adjustment disorder with depression and anxiety.
Patient #13's medical record included a history and physical admission note by her swing bed admitting provider on 10/17/24. The note stated that Patient #13 had "adjustment disorder with mixed anxiety and depressed mood."
Patient #13's medical record included assessments of emotional well-being and mood. Patient #13 was assessed several times for mood as follows:
· On 10/17/24, Patient #13 exhibited "flat affect" and "inappropriate/delusional-like conversation.
· On 10/20/24, Patient #13 "avoids eye contact", exhibited "flat affect", and appeared "agitated."
· On 10/21/24, Patient #13 exhibited "flat affect", declined care, and appeared "agitated".

Patient #13's care plan for her swing bed admission was reviewed. The care plan lacked interventions and goals for her identified mental health needs.

On 03/25/24, beginning at 10:00 AM, the hospital's Assistant Nursing Manager was interviewed, and Patient #13's record was reviewed in her presence. She confirmed that the care plan did not include goals and interventions for Patient #13's assessed mental health issues.

The CAH failed to ensure that swing bed admission care plans were complete, including necessary mental health interventions and goals.

2. Patient comprehensive assessments were not complete to include activities assessment, and patient care plans did not include activity's integrated into their care plans.

Pt # 9 was a 57 year old male who was admitted to swing bed on 3/13/25 for ambulatory dysfunction, his medical record was reviewed.

Pt #9's medical record included: "What Kind of Activities Do You Enjoy?" No activities were documented for this patient for his length of stay as a swing bed pt. Additionally, no documented activity preferences were included on patient #9's care plan.

Pt #10 was a 93 year old female who was admitted to swing bed on 3/26/25 for ambulatory dysfunction, her medical record was reviewed.

Pt #10's medical record included: "What Kind of Activities Do You Enjoy?" No activities were documented for this patient for her length of stay as a swing bed pt. Additionally, no documented activity preferences were included on patient #10's care plan.

Pt # 11 was a 68 year old female who was admitted to swing bed on 3/7/25 for ambulatory dysfunction, her medical record was reviewed.

Pt #11's medical record included: "What Kind of Activities Do You Enjoy?" No activities were documented for this patient for her length of stay as a swing bed pt. Additionally, no documented activity preferences were included on patient #11's care plan.

Pt # 12 was a 65 year old female who was admitted to swing bed on 3/20/25 for ambulatory dysfunction, her medical record was reviewed.

Pt #12's medical record included: "What Kind of Activities Do You Enjoy?" No activities were documented for this patient for her length of stay as a swing bed pt. Additionally, no documented activity preferences were included on patient #12's care plan.

The CAH's Nursing Manager and Assistant Nursing Manager were interviewed on 3/26/25 beginning at 9:30 AM, and Pt's #9, #10, #11, and #12's records were reviewed in their presence. The Nursing Manager stated they assess activities for swing bed pt's, but she confirmed there was no documentation for all 4 pt's records.

The hospital failed to ensure swing bed patients activity assessments were part of the patient comprehensive assessment, and that activities were integrated into their care plans.