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Based on document review and interviews, it was determined that the Hospital failed to protect and promote patient rights to ensure the patient's emotional health and safety as well as his/her physical safety. Therefore, the Condition of Participation 42 CFR 482.13, Patient Rights was NOT met, as evidenced by:

Findings Include:



1. The Hospital failed to ensure that medications and dosages used as a restriction to manage the patient's behavior were clarified to ensure the safety of the patient. See A-0160

2. The Hospital failed to ensure the attending physician was consulted as soon as possible if the attending physician did not order the restraint. See A-0170


3. The Hospital failed to ensure adequate and proper vital sign monitoring of a chemically restrained patient was performed to prevent the potential for reoccurrence, deterioration of patient status, and/or patient demise. See A-0175 A

4. The Hospital failed to ensure staff training on chemical restraints and staff training of what constitutes a restraint, including Geri chairs. See A-0205


An immediate jeopardy (IJ) was identified due to the hospital's failure to ensure that medications and dosages used as a restriction to manage the patient's behavior were clarified; failed to ensure the attending physician was consulted as soon as possible if the attending physician did not order the restraint; failed to ensure adequate and proper vital sign monitoring of a chemically restrained patient was performed; and failed to ensure staff training on chemical restraints and staff training of what constitutes a restraint, including Geri chairs. Subsequently, a restrained patient (Pt #1), patient expired. The IJ was identified on 2/27/2020 at 42 CFR 482.13, Patient Rights. The IJ for tags A-0160, A-0175, and A-0205 was announced on 2/27/2020 at 4:45 PM, during a meeting with the Hospital Administrator (E #1) and was not removed by the survey exit date of 2/28/2020. The IJ for tag A-0170 was identified on 2/28/20. The IJ for tag A-0170 was announced on 2/28/2020 at 10:40 AM, during a meeting with the Hospital Administrator (E #1) and was not removed by the survey exit date of 2/28/2020 as evidenced by:

Based on document review and interview, it was determined for 2 of 9 (Pt #2, Pt #9) restrained/secluded patients, the Hospital failed to ensure that restraint/seclusion were implemented safely and without the fear of coercion or discipline.

Findings include:

1. On 2/26/20, the Hospital's policy titled, "Restraints, Use of" (revised by the hospital, 4/19) was reviewed and indicated "...Restraint shall not be used to punish or discipline an individual or as a convenience to staff..."

2. On 2/26/20, Pt #2's clinical record was reviewed. Pt #2 was admitted to the ED on 2/4/20 with the diagnosis of "Social Problem." Pt #2's clinical record dated 2/4/20 indicated Pt #2 has mild MR (mental retardation) and is manic. Pt #2's clinical record indicated, Daily Focus Assessment Report dated 2/4/20 indicated: on 2/24/20 at 8:00 PM, "Pt #2 yelling and screaming at staff, wanted to be taken to another Facility instead of here, not happy, "Pt #2 walked off EMS cot and was pacing in room, then slammed the safety door, (which is a seclusion room.). Pt #2 slammed door herself, kept door closed for staff safety...Pt #2 has mild MR (mental retardation) and is manic." On 2/4/20 at 8:15 PM, "Remains agitated - seclusion room." On 2/4/20 at 8:30 PM, "Pt #2 starting to calm down, sat down on floor, crying, (staff) talking to Pt #2 through window, (staff)agreed to open door if Pt #2 willing to change and use restroom. Walked Pt #2 to restroom, where she continued to yell and swear...walking back to room, Pt #2 became very agitated again..."

3. On 2/26/20, Pt #9's clinical record was reviewed. Pt #9 was admitted to the Hospital on 11/8/19 with the diagnosis of acute alcohol intoxication. Pt #9's clinical record in the Intensive Care Unit dated 11/10/19 at 1:25 AM indicated: (Advance Practice Nurse -APN #2) was called due to Pt #9's continued agitation and attempts to crawl out of bed despite the use of bilateral wrist restraints, regular Ativan (antianxiety medication) doses and Precedex (sedative medication) drip. It was ordered to give (Pt #9) 5 mg (milligrams) of Haldol (antipsychotic medication) IM. After administration of Haldol, Pt #9 began attempting to crawl off the end of the bed again demanding to be able to call 911...Pt #9 began to get verbally aggressive and refused to lay back in the bed. Pt #9 finally scooted back, and began starting to rear back to kick. Bilateral soft ankle restraints were placed and at 1:15 AM, Pt #9 was placed in Trendelenberg position (Head of bed lower than the foot) for some time to prevent getting out of bed. Pt #9 has sat up a few times since, but has not attempted to crawl out of bed..."

3. On 2/26/20 at 3:15 PM, an interview was conducted with the Chief Nursing Officer (E #2). E #2 stated that it would not be condoned to coerce a patient with seclusion and would not be condoned to place a patient in Trendelenberg position to keep a patient in bed or used as a restraint.

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient death in a restraint, the Hospital failed to ensure that medications and dosages used as a restriction to manage the patient's behavior were clarified to ensure the safety of the patient. This has the potential to affect all inpatient and outpatients who require the use of chemical restraint(s) by the Hospital.

Findings include:

1. The Hospital restraint log for November 2019 to January 2020 was reviewed on 2/25/2020. The log indicated the use of violent restraints for approximately 5 patients monthly. The log lacked whether chemical restraints were used.

2. On 2/25/2020 through 2/27/2020, Pt #1's medical record was reviewed. Pt #1 (70 years old) was admitted to the Hospital, under observation status on 2/15/2020, with the diagnosis of aggressive behavior. Pt #2 was awaiting for nursing home placement. APN#1's history and physical indicated Pt #1's past medical history included advanced dementia, myocardial infarction, chronic kidney disease, congestive heart failure, type 2 diabetes mellitus, and dyslipidemia.
According to Pt #1's record: on 2/15/2020 at at 10:00 PM, Pt #1 started wandering the halls; tried to go into other patient rooms, was getting agitated and demanding, given Haldol 5 mg IM and placed in Geri-chair for becoming combative; on 2/15/2020 at 10:44 PM, continued to be combative and non-cooperative; in Geri- chair, given Benadryl 50 mg IM and Ativan 2 mg (Lorazepam) IM, broke Geri- chair tray and new one on. Code White called on patient; and on 2/15/2020 at 11:19 PM to 2/16/2020 at 6:55 AM, Pt #1 was sleeping in the Geri-chair. The use of the Geri-chair as a violent restraint was not discontinued at the earliest possible time, after the behavior subsided. According to Pt #1's record, on 2/16/2020 at 7:36 AM, Pt #1 was "lying in Geri-chair, white face, no breathing, and no pulse." According to Pt #1's record: on 2/16/2020, a physician's addendum to the APN's history and physical indicated, "Patient seen at around 8:45 AM ...Pt admitted with aggressive (spelling in quote), delusional behavior likely due to advanced dementia ... Patient likely cause of death is respiratory demise."

3. The Haldol and Ativan manufacturer recommendations were reviewed on 2/26/2020 at approximately 1:45 PM. They indicated the following: Haldol manufacturer recommendations: "Warning ... Increased Mortality in Elderly Patients with Dementia-Related Psychosis ... at increased risk of death ... Warnings ... Haldol injection is not approved for the treatment of patients with dementia-related psychosis ..." Lorazepam manufacturer recommendations: "Warnings ... Lorazepam, both used alone and in combination with other CNS (central nervous system) depressants, may lead to potentially fatal respiratory depression ..."

4. On 2/25/2020 at approximately 8:15 AM, an interview was conducted with Pharmacist (E#4) . E#4 reviewed Pt #1's record and stated, "The Haldol may not have taken full effect yet (when the Ativan and Benadryl were given). Yes, the Haldol and Ativan were both higher than usual for this patient being (Pt #1) was elderly (70 years old) and had a history of kidney and heart disease."


5. On 2/26/2020 approximately 12:00 PM, an interview was conducted the on-call Hospitalist providing oversight of APN#1, on 2/15/2020 and 2/16/2020 (MD #1). MD#1 stated, "I do not use these medications for patients, especially the elderly and I do feel the doses were higher than they should have been."

6. On 2/26/2020 at approximately 3:10 PM, an interview was conducted with The Nurse Practitioner ( APN#1). APN #1 stated that, having experience with using these drugs, at these dosages, for other patients with similar diagnoses without any negative outcomes previously.

Based on document review and interview, it was determined that for 1 of 1 (Pt #2) patient records reviewed for seclusion, the Hospital failed to implement seclusion only for the management of violent or self-destructive behavior.

Findings include:

1. On 2/26/20, the Hospital's policy titled, "Restraints, Use of" (revised by the Hospital, 4/19) was reviewed and indicated "...Restraint shall not be used to punish or discipline an individual or as a convenience to staff..."

2. On 2/26/20, Pt #2's clinical record was reviewed. Pt #2 was admitted to the ED on 2/4/20 with the diagnosis of "Social Problem." Pt #2's clinical record dated 2/4/20 indicated Pt #2 has mild MR (mental retardation) and is manic. Pt #2's clinical record indicated, Daily Focus Assessment Report dated 2/4/20 indicated: on 2/24/20 at 8:00 PM, "Pt #2 yelling and screaming at staff, wanted to be taken to another Facility instead of here, not happy, "Pt #2 walked off EMS cot and was pacing in room, then slammed the safety door, (which is a seclusion room.). Pt #2 slammed door herself, kept door closed for staff safety...Pt #2 has mild MR (mental retardation) and is manic." On 2/4/20 at 8:15 PM, "Remains agitated - seclusion room." On 2/4/20 at 8:30 PM - "Pt #2 starting to calm down, sat down on floor, crying, (staff) talking to Pt #2 through window, (staff)agreed to open door if Pt #2 willing to change and use restroom. Walked Pt #2 to restroom, where she continued to yell and swear...walking back to room, Pt #2 became very agitated again..." Pt #2 records lacked documentation an order for seclusion or that seclusion was warranted.

3. On 2/26/20 at 1:00 PM, an interview was conducted with the Clinical Informatics & Educator (E#7). E#7 stated that if a patient put themselves in seclusion, the appropriate intervention would be to go in the room and assess the patient.

4. On 2/26/20 at 2:00 PM, an interview was conducted with the ED Supervisor (E #8). E #8 stated that Pt #2 was monitored by video camera while in seclusion.

Based on document review and interview, it was determined for 1 of 9 (Pt #1) patients, who required the use of restraints, the Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner, authorized to order restraints. This has the potential to affect all inpatients and outpatients serviced by the Hospital.

Findings include:

1. The Policy titled, "Restraints, Use of" (revised by the Hospital 4/2019) was reviewed on 2/25/2020 at approximately 2:00 PM. On page 1, the policy indicated, "Policy... Therefore, use of restraints of any kind must be applied only upon the order of a physician... b) The order must specify the type of restraint, the duration, and the circumstances under which the restraints are to be used. No "Restraint PRN (as needed) orders are allowed except for Geri chairs. Geri chair. If patient requires the use of a Geri chair with the tray locked in place in order for the patient to safely be out of bed, a standing or PRN order is permitted. Given that a patient may be out of bed in a Geri chair several times a day, it is not necessary to obtain a new order each time."

2. On 2/25/2020 through 2/27/2020, Pt #1's medical record was reviewed. Pt #1 was admitted to the Hospital, under observation status on 2/15/2020 with the diagnosis of aggressive behavior. Nursing and Advance Practice Nurse (APN#1) documentation indicated the following: on 2/15/2020 at 5:30 PM, Pt #1 arrived on the medical/surgical floor; nursing documentation indicated no aggressive behaviors until 10:00 PM that night; on 2/15/2020 at 9:00 PM, APN#1's history and physical for Pt #1 indicated, " ... sitting up in bed watching TV, mildly agitated this time ..."; at 10:00 PM, Pt #1 started wandering the halls; tried to go into other patient rooms, was getting agitated and demanding, given Haldol 5 mg IM and placed in Geri-chair for becoming combative; at 10:44 PM, continued to be combative and non-cooperative; in Geri- chair; given Benadryl 50 mg IM and Ativan 2 mg IM, broke Geri- chair tray and new one on; and on on 2/15/2020 at 12:37 PM, there was an Advance Practice Nurse (APN#1) order for "Geri chair PRN (as needed)".

3. On 2/26/2020 at approximately 3:10 PM, and interview was conducted with APN#1. APN#1 stated recollection of Pt #1 and, "Yes, we did use the Geri chair because (Pt #1) was getting so combative. I did write and order (the PRN order). I didn't think of it at the time, but it was being used for combative behavior (violent behavior). I'll have to think of that next time.

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient death in a restraint, the Hospital failed to ensure the attending physician was consulted as soon as possible if the attending physician did not order the restraint. This has the potential to affect all inpatients who require the use of restraint/seclusion by the Hospital.

Findings include:


1. On 2/25/2020 through 2/27/2020, Pt #1's medical record was reviewed. Pt #1 (70 years old) was admitted to the Hospital, under observation status on 2/15/2020 with the diagnosis of aggressive behavior, while awaiting nursing home placement. The following is a timeline of events: on 2/15/2020 at 10:00 PM, Pt #1 started wandering the halls; tried to go into other patient rooms; was getting agitated and demanding, given Haldol 5 mg IM and placed in Geri-chair for becoming combative. Pt #1 was unable to release self from Geri-chair.; at 10:44 PM, continued to be combative and non-cooperative, in Geri- chair; given Benadryl 50 mg IM and Ativan 2 mg IM, broke Geri- chair tray and new one on, Code White called on patient; and from 2/15/2020 at 11:19 PM to 2/16/2020 at 6:55 AM, Pt #1 was sleeping in the Geri-chair.

2. According to Pt #1's record on 2/16/20 at 7:36 AM, Pt #1 was lying in Geri-chair, white face, no breathing, and no pulse. Pt #1's record lacked documentation to indicate that MD#1, as the attending physician, was consulted as soon as possible concerning the orders for the use of Haldol, Ativan, and Benadryl as chemical restraints and for the use of the Geri-chair as a violent restraint. According to Pt #1's record, on 2/16/2020, a physician's addendum to the history and physical per MD#1, indicated, "Patient seen at around 8:45 AM, nurse called and stated patient passed (spelling in quote) away ... Patient likely cause of death is respiratory demise." Pt #1's record stated that the Discharge Summary dated 2/16/20 and completed per MD#1, indicated, "The patient was seen by the nurse practitioner overnight. Due to the patient's aggressive behavior, the patient was given Haldol 5 mg IM, Benadryl 50 mg, Ativan 2 mg IV, and Seroquel. The nurse practitioner did not consult me nor call me prior to giving any of these medications. In the morning, nurse called me and stated that the patient has expired."

3. An interview was conducted on 2/26/2020 at approximately 12:00 PM with MD#1. MD#1 stated, "I don't use these medications like this on my patients and not at these doses (IM Haldol, IM Ativan, and IM Benadryl). If you need to use these three meds (medications) on a patient, especially an elderly one, I should be called, no matter what the time. Then, I could have given my own orders as to what I wanted done to the nurse on the floor..."

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient death in a restraint, the Hospital failed to ensure restraints were discontinued at the earliest possible time. This has the potential to affect all inpatients and outpatients who require the use of restraint/seclusion serviced by the Hospital.

Findings include:

1. The Hospital's policy titled "Restraints, Use of" indicated " ...An RN will determine if improvement of the patient's mental status, functional abilities, and overall cessation of symptoms, and/or behavior warranting the use of restraints have resolved to allow discontinuation of the restraint ..."

2. On 2/25/2020 through 2/27/2020, Pt #1's medical record was reviewed. Pt #1 was admitted to the Hospital, under observation status on 2/15/2020 with the diagnosis of aggressive behavior. Nursing and Advance Practice Nurse (APN#1) documentation indicated the following: on 2/15/2020 at 10:00 PM, Pt #1 started wandering the halls, tried to go into other patient rooms, was getting agitated and demanding, patient was given Haldol 5 mg IM and placed in Geri-chair for becoming combative; at 10:44 PM, patient continued to be combative and non-cooperative; in Geri- chair; given Benadryl 50 mg IM and Ativan 2 mg IM, broke Geri- chair tray and new one on, Code White called on patient; and from 2/15/2020 at 11:19 PM to 2/16/2020 at 6:55 AM, Pt #1 was sleeping in the Geri-chair. The use of the Geri-chair as a violent restraint was not discontinued at the earliest possible time, after the behavior subsided. On 2/16/20 at 7:36 AM, Pt #1 was lying in Geri-chair, white face, no breathing, and no pulse.

3. An interview was conducted with the Chief Nursing Officer (E#2) on 2/26/2020 at approximately 11:00 AM. E#2 reviewed Pt #1's record and stated, "I don't know why they wouldn't have put (Pt#1) into bed once (Pt #1) calmed down. I was surprised when I saw that."

A. Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient who died in restraints, the Hospital failed to ensure adequate and proper vital sign monitoring of a chemically restrained patients was performed to prevent the potential for reoccurrence, deterioration of patient status, and/or patient demise. This has the potential to affect all patients who require the use of chemical restraints by the Hospital.

Findings include:

1. The Policy titled, "Restraints, Use of" (revised by the Hospital, 4/2019) was reviewed on 2/25/2020 at approximately 2:00 PM. The policy does not address chemical restraints and required monitoring of vital signs and respiratory status.

2. On 2/25/2020 through 2/27/2020, Pt #1's medical record was reviewed. Pt #1 was admitted to the Hospital, under observation status on 2/15/2020 with the diagnosis of aggressive behavior, while awaiting nursing home placement. Nursing documentation indicated the following: on 2/15/2020 at 10:00 PM, Pt #1 was given Haldol 5 mg (milligrams) IM (intramuscular); at 10:44 PM, Pt #1 was given Benadryl 50 mg IM and Ativan 2 mg IM.

3. Pt #1's record indicated respirations were as follows (No other vital signs or oxygen levels (Pox) were assessed, unless otherwise noted below): on 2/15/2020: 3:58 PM: BP (blood pressure)- 122/71, P (pulse)- 70, R (respirations)- 16, Pox (pulse oximetry)- 100 % on room air; 5:59 PM: BP-124/70, P -64, R- 18, Pox - 100% on room air; 11:19 PM and 11:50 PM: respirations 14; on 2/16/2020: 12:12 AM: no BP, P- 56, R- 14, Pox- 97% room air; Between 12:38 AM and 5:31 AM, respirations -12, with one time 14; 6:06 AM. respirations- 10; 6:31 AM, respirations- 12; and on 2/16/2020 at 7:36 AM, Pt #1 was found lying in the Geri-chair, white face, no breathing, and no pulse.

4. According to Pt #1's record, Advance Practice Nurse (APN#1) documentation indicated the following: 2/15/2020 at 11:45 PM, "Stopping by patient's room, resting quietly, respiration 14."; 2/16/2020 at 1:00 AM and 6:00 AM, "called RN regarding patient status and respirations 12 at 3:15 AM, and stopped by patient's room, still sleeping with regular respirations." There was no documentation of any follow up related to the decreasing respirations and lack of vital sign monitoring. According to Pt #1's record, on 2/16/2020, a physician' addendum to APN'#1's history and physical indicated, "Patient likely cause of death is respiratory demise."

5. The Haldol and Ativan manufacturer recommendations were reviewed on 2/26/2020 at approximately 1:45 PM. They indicated the following: Haldol manufacturer recommendations: "Warning ... Increased Mortality in Elderly Patients with Dementia-Related Psychosis ... at increased risk of death ... Warnings ... Haldol injection is not approved for the treatment of patients with dementia-related psychosis ..." Lorazepam manufacturer recommendations: "Warnings ... Lorazepam, both used alone and in combination with other CNS (central nervous system) depressants, may lead to potentially fatal respiratory depression ..."

6. During an interview conducted with APN#1 on 2/26/2020 at approximately 3:10 PM, stated verbally instructing the LPN (Licensed Practical Nurse- E#15) who was caring for Pt #1 to monitor vitals and respiratory status hourly. "I didn't write it as an order though."

7. During an interview conducted with the Licensed Practical Nurse ( E #15) on 2/27/2020 at approximately 8:55 AM, E#15 stated, "I would definitely check their respirations and oxygen. With this patient (Pt#1), I didn't do full vital signs. I didn't check on (Pt #1) every 15 minutes, but I did check him at least every 30 minutes or so."

8. An interview was conducted with the Chief Nursing Officer (E#2) on 2/26/2020 at approximately 10:00 AM. E#2 verbally agreed the Hospital restraint policy does not include guidance on the use of chemical restraints and the required monitoring of the patient.


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B. Based on document review and interview, it was determined that for 1 of 1 patient (Pt #2) reviewed for seclusion, it was determined that the Hospital failed to ensure that Pt #2 was monitored by a licensed practitioner or trained staff while Pt #2 was in seclusion.

Findings include:

1. On 2/26/20, the Hospital's policy titled, "Restraints, Use of" (revised by the Hospital, on 4/19) was reviewed. The policy lacked documentation regarding monitoring patients while in seclusion.

2. On 2/26/20, Pt #2's clinical record was reviewed. Pt #2 was admitted to the ED on 2/4/20 with the diagnosis of "Social Problem." Pt #2's clinical record dated 2/4/20 indicated Pt #2 has mild MR (mental retardation) and is manic. Pt #2's clinical record indicated, Daily Focus Assessment Report dated 2/4/20 indicated: on 2/24/20 at 8:00 PM, "Pt #2 yelling and screaming at staff, wanted to be taken to another Facility instead of here, not happy, "Pt #2 walked off EMS cot and was pacing in room, then slammed the safety door, (which is a seclusion room.). Pt #2 slammed door herself, kept door closed for staff safety...Pt #2 has mild MR (mental retardation) and is manic." On 2/4/20 at 8:15 PM, "Remains agitated - seclusion room." . On 2/4/20 at 8:30 PM - "Pt #2 starting to calm down, sat down on floor, crying, (staff) talking to Pt #2 through window, (staff)agreed to open door if Pt #2 willing to change and use restroom. Walked Pt #2 to restroom, where she continued to yell and swear...walking back to room, Pt #2 became very agitated again..." There is no documentation that a staff member was in the seclusion room with Pt #2. Pt #2's record lacked documentation that less restrictive interventions were implemented, an order for seclusion or documentation of any monitoring by a physician other licensed practitioner

3. On 2/26/20 at 1:00 PM, an interview was conducted with the Clinical Informatics & Educator (E#7). E#7 stated that if a patient put themselves in seclusion, the appropriate intervention would be to go in the room and assess the patient.

4. On 2/26/20 at 2:00 PM, an interview was conducted with the ED Supervisor (E #8). E #8 stated that Pt #2 was monitored by video camera while in seclusion. E #8 stated that the video camera does not have auditory capability. E #8 stated that the unit secretary watches the camera if they are at the desk.

Based on document review and interview, it was determined that for 1 of 10 patient (Pt #2) clinical records reviewed for restraints and seclusion, the Hospital failed to ensure that less restrictive interventions were attempted prior to 4 point locked restraints application.

Findings include:

On 2/26/20, the Hospital's policy titled, "Restraints, Use of" (revised by the facility, 4/19) was reviewed and indicated "...Restraint shall not be used to punish or discipline an individual or as a convenience to staff..."

2. On 2/26/20, Pt #2's clinical record was reviewed. Pt #2 was admitted to the ED on 2/4/20 with the diagnosis of "Social Problem." Pt #2's clinical record dated 2/4/20 indicated Pt #2 has mild MR (mental retardation) and is manic. Pt #2's clinical record indicated: Daily Focus Assessment Report dated 2/4/20 indicated: on 2/24/20 at 8:00 PM, "Pt #2 yelling and screaming at staff, wanted to be taken to another Facility instead of here, not happy, "Pt #2 walked off EMS cot and was pacing in room, then slammed the safety door, (which is a seclusion room.). Pt #2 slammed door herself, kept door closed for staff safety...Pt #2 has mild MR (mental retardation) and is manic." On 2/4/20 at 8:15 PM, "Remains agitated - seclusion room." On 2/4/20 at 8:30 PM - "Pt #2 starting to calm down, sat down on floor, crying, (staff) talking to Pt #2 through window, (staff)agreed to open door if Pt #2 willing to change and use restroom. Walked Pt #2 to restroom, where she continued to yell and swear...walking back to room, Pt #2 became very agitated again..." On 2/4/20 at 8:41 PM - "Pt #2 yelling in room banging and kicking on seclusion door"
On 2/4/20 at 8:42 PM, "Pt #2 began punching window in safety room - Code White called - Police walked into ER for a different manner, helped restrain Pt #2...Restraint applied - left wrist, right wrist, left ankle and right ankle, Pt #2 remains agitated." There is no documentation that less restrictive interventions were implemented prior to 4 point locked restraint application.


3. On 2/26/20 at 2:00 PM, an interview was conducted with the ED Supervisor (E #8). E #8 stated that the emergency room nurses talked to Pt #2 before putting her into 4 point locked restraints.

Based on document review and interview, it was determined that for 5 of 5 Registered Nurses (E #9, E#10, E#11, E #13, E#14), 1 of 1 Licensed Practical Nurse (E#15) and 1 of 1 Certified Nursing Assistant (E #12) personnel files reviewed for training, the Hospital failed to ensure staff training on chemical restraints and staff training of what constitutes a restraint, including Geri chairs.

Findings include:

1. On 2/27/20, the Hospital's policy titled, "Restraints, Use of" (revised by the facility, 4/2019), was reviewed and required "...All direct patient care employees receive annual education on the restraint policy, use of alternatives, and patient's rights..." There is no documentation that direct patient care employees received training on monitoring patients on chemical restraints.

2. On 2/26/20, the Registered Nurses' (E#9, E#10, E #11, E #13, E #14), the Licensed Practical Nurse's (E #15) and the Certified Nursing Assistant's (E#12) personnel files were reviewed. The files lacked documentation of chemical restraint training.

3. On 2/27/20 at 9:15 AM, an interview was conducted with the Licensed Practical Nurse (E#15). E#15 stated that, "has not received training for chemical restraints."

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient death in a restraint patient, the Hospital failed to ensure death in restraint was reported by close of business the next business day. This has the potential to affect all death in restraint patients serviced by the Hospital.

Findings include:

1. On 2/25/2020 through 2/27/2020, Pt #1's medical record was reviewed. Pt #1 was admitted to the Hospital, under observation status on 2/15/2020 with the diagnosis of aggressive behavior, while awaiting nursing home placement. According to Pt #1;s record: on 2/15/2020 at 10:00 PM, Pt #1 was given Haldol 5 mg (milligrams) IM (intramuscular) and was placed in a Geri chair with a locked tray for combative behavior. At 10:44 PM, Pt #1 was given Benadryl 50 mg IM and Ativan 2 mg IM. On 2/16/2020 at 7:36 AM, Pt #1 was found lying in the Geri chair, white face, no breathing, and no pulse.

2. The Centers for Medicare and Medicaid (CMS) form 10455 "Report of a Hospital Death Associated With Restraint or Seclusion" completed by the Quality Manager (E#3), indicated CMS was notified on 2/18/2020 at 4:33 PM, one day beyond the required timeframe.

3. An interview was conducted with E#3 on 2/25/2020 at approximately 11:00 AM. E#3 stated, "I realized that I sent it in late, but I did get it there."