HospitalInspections.org

Based on policy review, record review, and interview, the Hospital failed to ensure it met the requirements for Patient Rights Condition of Participation when the hospital failed to protect and promote each patient's rights.

Findings Include:

1. The hospital failed to ensure the monitoring for 1 of 2 patient in restraints as required per hospital policy. (Refer to Tag A0175)

2. The hospital failed to ensure that a physician or other licensed practitioner performed a face-to-face evaluation within one hour after the initiation of restraint when used for the management of violent behavior for 2 of 2 sampled patient in restraints. (Refer to Tag A0178)

Based on policy review, record review, and interview, the Hospital failed to ensure the condition of a patient in restraints was monitored at intervals required by hospital policy for 1 of 2 (Patient 1) patients reviewed with restraints. This deficient practice places any patient in restraints at risk for injury and harm.

Findings Include:

Review of a policy titled, "Safety Needs: Fall Prevention and Restraint Use," revised 08/2024 showed, " ...To guide the staff in using alternative / non-physical interventions to restraints to prevent or minimize the use of restraints. To guide the staff in decision making about least-restrictive methods of restraint use. To establish guidelines to validate and ensure the safe application and removal of restraints by competent staff. To establish guidelines to protect the patient's health and safety and preserve their dignity, rights and well-being when restraints are in use. To establish guidelines for assessing/collecting data on the patient's needs for the use or continued use of restraints to facilitate discontinuation as soon as possible. To establish guidelines for monitoring the patient during the use of restraints and meeting their safety and personal needs, including vulnerable patient populations, such as pediatric, emergency, and cognitively or physically limited patients. To establish guidelines for the appropriate ordering of restraints. To establish guidelines for the medical record documentation when restraints are used ... Soft Limb Restraint(s): a. At least every 2 hours, and as needed, the restraint(s) will be loosened/removed to: i. Perform ROM exercise. ii. Monitor skin temperature and color; and to massage skin under restraint. iii. Monitor neurovascular status (cap refill, pulse(s) and movement). b. At least every 2 hours, and as needed: i. Monitor the clinical justification for continued use of the restraint, and for patient readiness from release from restraint. ii. Re-enforce patient and/or family restraint education as needed iii. Monitor effectiveness of restraint and document the type of restraint in use. iv. Attend to the patient's needs, i.e. toileting, nutrition and hydration, and positioning. v. Monitor the patient's level of consciousness / mental status. vi. Assure that restraints are applied correctly. vii. Assure the patient call-light is in reach and that patient rights and dignity are maintained viii. Due to the risk associated with restraint use in vulnerable patient populations such as pediatric, and cognitively or physically impaired patients, additional monitoring may be required ..."


Patient 1

Review of Patient 1's 08/14/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 12:24 PM by EMS and police. Chief complaint " ...Patient arrives from [home] with c/o aggression. Per EMS, patient became aggressive towards staff and PD [police department] had to be notified. Upon arrival to the ED, patient was extremely aggressive and attempting to hit staff. Patient is screaming "no" repeatedly. Patient has abrasions noted to his nose. Per staff, patient was hitting his head on a van." Past medical history includes: Intellectual Disability Diagnosis (IDD) (learning disability); Edentulous (toothless); Xerostomia (dry mouth); Obsessive Compulsive Disorder (pattern of unwanted thoughts and fears known as obsessions); Hypertension (elevated blood pressure); and Diabetes (increased blood sugar).

Review of a document titled, "Emergency Department Physician Documentation" dated 08/15/24 at 11:10 AM showed, "Chief complaint: Altered Mental Status Time Seen by Provider: 08/14/24 13:40 [1:40 PM] ... male who lives in supervised group home facility ...brought to emergency department by EMS and police department because of acute change of mental status and aggressive behavior according to EMS and facility patient has aggressive behavior towards staff. He was very agitated and loud on arrival required both chemical and physical restraint. Patient given Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] 5 mg IM [intramuscular]. Patient has history of similar behavior in the past and he had multiple visits to emergency department for aggressive behavior. No fall or trauma reported by facility. Patient has history of manic depressive disorder. ..."

Review of a document titled "Patient Order Summary" dated 08/14/24 at 2:14 PM, showed, "Order Restraints: Initiate/Renewal ...Start 08/14/24 14:22 [2:22 PM]. Complete 08/14/24 15:11 [3:11 PM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Care Assessments" dated 08/14/24 showed, "Restraints: Initiate/Monitor 08/14/24 12:20 [12:20 PM] ... -Date Initiated 08/14/24 -Time Initiated 12:20 ... -Date Restraint Removed 08/14/24 -Time Restraint Removed 15:10 [3:10 PM] ..."

Documentation showed restraints were initiated approximately two hours prior to restraint order.

Review of a document titled "Patient Order Summary" dated 08/14/24 at 5:32 PM, showed, "Order Restraints: Initiate/Renewal ...Start 08/14/24 17:32 [5:32 PM]. Complete 08/14/24 23:28 [11:28 PM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Care Assessments" dated 08/14/24 showed, "Restraints: Initiate/Monitor 08/14/24 17:32 [5:32 PM] ... -Date Initiated 08/14/24 -Time Initiated 17:32 [5:32 PM] ...08/14/24 19:00 [7:00 PM] -Patient Response to Restraints remains agitated and restless ..."

From 08/14/24 at 7:00 PM through 08/14/24 at 11:28 PM when patient discharged, Patient 1's medical record failed to show documentation of every two hour restraint monitoring as required per policy.


Review of Patient 1's 08/19/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 12:50 PM by private vehicle. Chief complaint " ...[Staff] His behavior has been getting worse, He is hitting and scratching people. He was trying to wrap the seatbelt around his neck today. We want to get him evaluated ..."

Review of a document titled, "Emergency Department Physician Documentation" dated 08/19/24 at 3:53 PM showed, "Chief complaint: Mental Health Emergency Time Seen by Provider: 08/19/24 13:15 [1:15 PM] ...male with history of intellectual deficiency and behavior disorder brought to emergency department severe agitation screaming and yelling emergency department. Patient require physical and chemical restraint ...Patient agitation become under control with total 10 mg Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] IM [intramuscular] ...I requested screening with Healthsource and patient signed out to night shift physician on shift change apparently patient apparently screen and discharge ..."

Review of a document titled "ED Notes" dated 08/19/24 at 1:19 PM showed, "Pt [sic] assisted in to bed with by x5 asst. [sic] Soft wrist restraints applied per [Staff I] and Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] 5 mg IM [intramuscular] given in left: deltoid. Pt [sic] continues to holler out. Lights dimmed to try to help the patient rest."

Review of a document titled "Patient Order Summary" dated 08/19/24 at 2:19 PM, showed, "Order Restraints: Initiate/Renewal ...Start 08/19/24 13:00 [1:00 PM]. Complete 08/20/24 02:49 [2:49 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints risk of falling cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Care Assessments" dated 08/19/24 showed, "Restraints: Initiate/Monitor 08/19/24 13:19 [1:19 PM] ... -Date Initiated 08/19/24 -Time Initiated 13:19 [1:19 PM] ... -Date Restraint Removed 08/20/24 -Time Restraint Removed 02:50 [2:50 AM] ..."

From 08/19/24 at 1:19 PM through 08/19/24 at 7:00 PM Patient 1's medical record failed to show documentation of every two hour restraint monitoring as required per policy.


Review of Patient 1's 08/28/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 5:46 PM by EMS. Chief complaint [community housing] staff brought patient in to for aggression. Patient has a history of these episode [community housing]wishes to have a mental health evaluation. ..."

Review of a document titled, "Emergency Department Physician Documentation" dated 08/29/24 at 2:56 AM showed, "Chief complaint: Mental Health Emergency Time Seen by Provider: 08/28/24 18:26 [6:26 PM] ... 57-year-old male with past medical history inclusive of intellectual disability, type 2 diabetes BPH, seizure disorder intermittent explosive disorder urinary incontinence hypertension recurrent behavioral disturbance who presents from [community housing]facility with request for behavioral health evaluation in the setting of increasingly aggressive behavior with patient attempting to assault staff both at his facility and on arrival in the emergency department. Patient without medical complaint but is found to be uncooperative with evaluation. By report patient has history of these violent outbursts ..."

Review of a document titled "Patient Order Summary" dated 08/28/24 at 6:15 PM, showed, "Order Restraints: Initiate/Renewal ...Start 08/28/24 18:15 [6:15 PM]. Complete 08/29/24 03:22 [3:22 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Care Assessments" dated 08/28/24 showed, "Restraints: Initiate/Monitor 08/28/24 18:15 [6:15 PM] ... -Date Initiated 08/28/24 -Time Initiated 18:15 [6:15 PM] ... -Date Restraint Removed 08/29/24 -Time Restraint Removed 03:22 [3:22 AM]

Patient 1's medical record failed to show documentation of every two hour restraint monitoring as required per policy from 08/28/24 at 6:15 PM through 08/28/24 at 11:00 PM.

During an interview on 09/10/24 at 11:48 AM Staff B, CNO stated, " ...we use paper charting on the floor so that there is no time stamp..."

During an interview on 09/10/24 at 11:15 AM Staff B, CNO, Staff A, RN, and Staff D, RN acknowledged Patient 1's medical record was missing every two-hour documentation.

During an interview on 09/10/24 at 11:15 AM Staff B, CNO, Staff E, RN, and Staff D, RN acknowledged facility policy does not differentiate violent verse non-violent restraints.

During an interview on 09/11/24 at 9:30 AM Patient Representative (PR) 1 stated, "I had my staff verify that they did not take the restraints off at all at any point when he was there so they just left him in the bed and kept giving [Patient 1] medication to sedate [Patient 1] ..."

Based on document review, policy review, and security video review, the Hospital failed to ensure a patient in restraints received a face-to-face assessment within one hour of initiating the restraints physician or other licensed practitioner as required for 2 of 2 (Patient 1 and 21) patient reviewed with restraints. This deficient practice places any patient receiving services at this hospital at risk for serious injury and harm.

Findings Include:

Review of a policy titled, "Safety Needs: Fall Prevention and Restraint Use," revised 08/2024 failed to address one hour face to face by a physician or other licensed practitioner after the initiation of restraints as required by Centers for Medicare and Medicaid Services (CMS).

Patient 1

Review of Patient 1's 08/14/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 12:24 PM by EMS and police. Chief complaint " ...Patient arrives from [home] with c/o aggression. Per EMS, patient became aggressive towards staff and PD [police department] had to be notified. Upon arrival to the ED, patient was extremely aggressive and attempting to hit staff. Patient is screaming "no" repeatedly. Patient has abrasions noted to his nose. Per staff, patient was hitting his head on a van." Past medical history includes: Intellectual Disability Diagnosis (IDD) (learning disability); Edentulous (toothless); Xerostomia (dry mouth); Obsessive Compulsive Disorder (pattern of unwanted thoughts and fears known as obsessions); Hypertension (elevated blood pressure); and Diabetes (increased blood sugar).

Review of a document titled, "Emergency Department Physician Documentation" dated 08/15/24 at 11:10 AM showed, "Chief complaint: Altered Mental Status Time Seen by Provider: 08/14/24 13:40 [1:40 PM] ... male who lives in supervised group home facility ...brought to emergency department by EMS and police department because of acute change of mental status and aggressive behavior according to EMS and facility patient has aggressive behavior towards staff. He was very agitated and loud on arrival required both chemical and physical restraint. Patient given Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] 5 mg IM [intramuscular]. Patient has history of similar behavior in the past and he had multiple visits to emergency department for aggressive behavior. No fall or trauma reported by facility. Patient has history of manic depressive disorder. ..."

Review of a document titled "Patient Order Summary" dated 08/14/24 at 2:14 PM, showed, "Order Restraints: Initiate/Renewal ...Start 08/14/24 14:22 [2:22 PM]. Complete 08/14/24 15:11 [3:11 PM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Care Assessments" dated 08/14/24 showed, "Restraints: Initiate/Monitor 08/14/24 12:20 [12:20 PM] ... -Date Initiated 08/14/24 -Time Initiated 12:20 ... -Date Restraint Removed 08/14/24 -Time Restraint Removed 15:10 [3:10 PM] ..."

Documentation showed restraints were initiated approximately two hours prior to restraint order.

Review of a document titled "Patient Order Summary" dated 08/14/24 at 5:32 PM, showed, "Order Restraints: Initiate/Renewal ...Start 08/14/24 17:32 [5:32 PM]. Complete 08/14/24 23:28 [11:28 PM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Care Assessments" dated 08/14/24 showed, "Restraints: Initiate/Monitor 08/14/24 17:32 [5:32 PM] ... -Date Initiated 08/14/24 -Time Initiated 17:32 [5:32 PM] ...08/14/24 19:00 [7:00 PM] -Patient Response to Restraints remains agitated and restless ..." Patient 1 was in restraints from 08/14/24 at 7:00 PM through 08/14/24 at 11:28 PM when patient discharged.

The medical record failed to show Patient 1 received a one hour face to face assessment by the physician or licensed practitioner on 08/14/24.

Review of Patient 1's 08/19/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 12:50 PM by private vehicle. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found. Usually, rather move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2). Chief complaint " ...[Staff] His behavior has been getting worse, He is hitting and scratching people. He was trying to wrap the seatbelt around his neck today. We want to get him evaluated ..."

Review of a document titled, "Emergency Department Physician Documentation" dated 08/19/24 at 3:53 PM showed, "Chief complaint: Mental Health Emergency Time Seen by Provider: 08/19/24 13:15 [1:15 PM] ...male with history of intellectual deficiency and behavior disorder brought to emergency department severe agitation screaming and yelling emergency department. Patient require physical and chemical restraint ...Patient agitation become under control with total 10 mg Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] IM [intramuscular] ...I requested screening with Healthsource and patient signed out to night shift physician on shift change apparently patient apparently screen and discharge ..."

Review of a document titled "ED Notes" dated 08/19/24 at 1:19 PM showed, "Pt [sic] assisted in to bed with (sic) by x5 asst. [sic] Soft wrist restraints applied per [Staff I]..."

Review of a document titled "Patient Order Summary" dated 08/19/24 at 2:19 PM, showed, "Order Restraints: Initiate/Renewal ...Start 08/19/24 13:00 [1:00 PM]. Complete 08/20/24 02:49 [2:49 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints risk of falling cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Care Assessments" dated 08/19/24 showed, "Restraints: Initiate/Monitor 08/19/24 13:19 [1:19 PM] ... -Date Initiated 08/19/24 -Time Initiated 13:19 [1:19 PM] ... -Date Restraint Removed 08/20/24 -Time Restraint Removed 02:50 [2:50 AM] ..." Patient 1 was in restraints from 08/19/24 at 1:19 PM through 08/19/24 at 7:00 PM when patient discharged.

The medical record failed to show Patient 1 received a one hour face to face assessment by the physician or licensed practitioner on 08/19/24.


Review of Patient 1's 08/28/24 medical record showed, a 57-year-old, presented to the Emergency Department (ED) at 5:46 PM by EMS. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found. Usually, rather move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2). Chief complaint [community housing] staff brought patient in to for aggression. Patient has a history of these episode [community housing] wishes to have a mental health evaluation. ..."

Review of a document titled, "Emergency Department Physician Documentation" dated 08/29/24 at 2:56 AM showed, "Chief complaint: Mental Health Emergency Time Seen by Provider: 08/28/24 18:26 [6:26 PM] ... 57-year-old male with past medical history inclusive of intellectual disability, type 2 diabetes BPH, seizure disorder intermittent explosive disorder urinary incontinence hypertension recurrent behavioral disturbance who presents from [community housing] facility with request for behavioral health evaluation in the setting of increasingly aggressive behavior with patient attempting to assault staff both at his facility and on arrival in the emergency department. Patient without medical complaint but is found to be uncooperative with evaluation. By report patient has history of these violent outbursts ..."

Review of a document titled "Patient Order Summary" dated 08/28/24 at 6:15 PM, showed, "Order Restraints: Initiate/Renewal ...Start 08/28/24 18:15 [6:15 PM]. Complete 08/29/24 03:22 [3:22 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Care Assessments" dated 08/28/24 showed, "Restraints: Initiate/Monitor 08/28/24 18:15 [6:15 PM] ... -Date Initiated 08/28/24 -Time Initiated 18:15 [6:15 PM] ... -Date Restraint Removed 08/29/24 -Time Restraint Removed 03:22 [3:22 AM]. Patient 1 was in restraints from 08/28/24 at 6:15 PM through 08/28/24 at 6:15 PM when patient discharged.

The medical record failed to show Patient 1 received a one hour face to face assessment by the physician or licensed practitioner on 08/28/24.


Patient 21

Review of Patient 21's medical record showed, a 26-year old, presented to the ED on 07/06/24 at 7:38 PM via Emergency Medical Services. Patient 21 presented with a chief complaint " ...Seizures x 2 then combative ..." Past medical history includes: Seizures.

Review of a document titled, "Emergency Department Physician Documentation" dated 07/06/24 at 7:47 PM showed, "Chief complaint: Seizure ...Patient arrived after having a seizure via EMS Patient was combative with EMS and the police had to help with transfer per. Patient is unable answer questions. Patient did move to the gurney from the EMS cot. Patient is sane letter words without making since ..."

Review of a document titled "Patient Order Summary" dated 07/06/24 at 8:48 PM, showed, "Order Restraints: Initiate/Renewal ...Start 07/06/24 20:48 [8:48 PM]. Stop Request 07/07/24 00:14 [12:14 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Patient Order Summary" dated 07/06/24 at 10:46 PM, showed, "Order Restraints: Initiate/Renewal ...Start 07/06/24 22:46 [10:46 PM]. Complete 07/08/24 10:15 [10:15 AM] ... Intervention Text *Reassesses patient every 2 hours ... Behavior requiring non-violent restraints cognitive disorder Non-violent restraint type foam/soft limb ..."

Review of a document titled "Physician Order for Restraint" dated 07/07/24 at 00:00 [12:00 AM], showed, "Clinical Justification for use of Restraint To Promote Safety/Healing ...To Prevent Patient Injury ...Type of Restraint Soft Limb Restraint-Right Wrist Soft Limb Restraint- Left Wrist Soft Limb Restraint - Right Ankle Soft Limb Restraint - Left Ankle 3. Patient to be Restraint for 24 hours ..." Electronically signed by physician 08/01/24 at 2:31 PM 25 days, 14 hours, 31 minutes after restraints applied.

Review of a document titled "Physician Order for Restraint" dated 07/08/24 at 00:00 [12:00 AM], showed, "Clinical Justification for use of Restraint To Promote Safety/Healing ...To Prevent Patient Injury ...Type of Restraint Soft Limb Restraint-Right Wrist Soft Limb Restraint- Left Wrist 3. Patient to be Restraint for 24 hours ..." Electronically signed by physician 08/01/24 at 2:31 PM 24 days, 14 hours, 31 minutes after restraints applied.

Review of the medical record failed to show a one-hour face to face was completed for Patient 21.

During an interview on 09/10/24 at 11:48 AM Staff B, CNO stated, " ...we use paper charting on the floor so that there is no time stamp..."

During an interview on 09/10/24 at 11:15 AM Staff B, CNO, Staff E, RN, and Staff D, RN acknowledged missing one hour face-to-face in facility policy.