HospitalInspections.org

482.13 Tag A-0115

The information reviewed during the unannounced survey on June 23, 2022, provided evidence the facility failed to provide a safe environment for a patient during a mechanical restraint on June 16, 2022, as evidenced by: Video surveillance clearly showing staff member hovering/laying on top of a patient's upper body area (head and neck region). Frame by frame viewing of the surveillance video revealed the patient being pushed down on to the bed via their forehead with the hand of a staff member. Further frame by frame viewing revealed questionable staff hand placement near/on the neck and head of the patient. Five interviews with staff involved with the restraint confirmed they saw the staff member's hands and/or arms on/near the patient's head/neck region in a manner not consistent with safe restraint practices. The facility did not complete any refresher or retraining of the staff prior to unannounced survey on June 23, 2022.

A discussion took place with the survey team and the facility's administrative staff (EMP9) and (EMP10), regarding the survey team's concerns related to Patient's Rights on June 23, 2022 at 4:24 PM.



Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting

Based on video review, policy review, and interviews with staff (EMP) it was determined the facility failed to ensure care was provided in a safe setting, as evidenced by using unsafe methods to restrain a patient physically and mechanically in one out one patient record reviewed (MR1).
Review on June 23, 2022, of facility video footage "EH Restraint 061622.ave" dated June 16, 2022 revealed, at 11:10:07.556 AM staff member (EMP1) tackled a patient who is posturing in the doorway onto the restraint bed. Six other staff members follow EMP1 into the room. 11:10:13.556 AM EMP1 appears to have his left hand on patient's forehead while pushing the patient back on to the bed with the same hand. 11:10:14.556 AM through 11:10:15.056 AM it appears that EMP1's hand is in the neck area of the patient, before EMP1's body gets in the way of the camera. At 11:10:15.356 AM through 11:10:15.756 AM there is another view of what appears to be EMP1's left hand in the patient's neck area. 11:10:16.256 AM through 11:13:04056 AM it appears that EMP1 is laying/hovering on or around the neck/head area of the patient. At 11:13:04.556 AM through 11:13:06.156 it appears, as EMP1 pulls away from the patient, EMP1's right forearm is on the head of the patient and the left hand slides out from the neck area of the patient underneath EMP1's right forearm. At 11:13:06.756 AM through 11:13:14.956 AM the staff removed themselves off the patient and patient has a grip on EMP1's shirt until EMP1 goes out of the view of the camera to the right. 11:13:14. 956 AM through 11:14:03.987 AM patient was sitting at the foot of the bed rocking back and forth. His lower extremities were in restraints. At 11:14:03.987 AM patient laid back on his own and allowed staff to place upper extremity restraints on. From 11:14:03.987 AM through 11:25:04.601 AM patient was restrained with staff present along the perimeter of the bed. 11:25:04.601 AM it appears staff are discontinuing the 4 point restraints.
Review on June 23, 2022 of facility policy and procedure Seclusion and Restraint, revised February 2021revealed "...PHILOSPHY: The hospital's philosophy is communicated to all members of the organization who have direct care responsibility and the individuals served. This philosophy includes: A. The prohibition of: *Any procedures that deny any basic needs, such as nutrition, food, water, shelter[,] and essential and safe clothing *Corporal punishment *Fear-eliciting procedures * The use of intimidation, force or threat ...H. Preserving the safety and dignity of the individual when restraint or seclusion is used ...L. The use of restraint techniques that restrict the flow of air into the patient's lungs are prohibited ...PURPOSE: To establish guidelines for the safe, effective use of restraints or seclusion in accordance with State, Center for Medicare and Medicaid Services (CMS), The Joint Commission (TJC) and Administration on Aging (AOA) regulations as well as education and training in methods to use to avoid the use of restraint and seclusion. To ensure the protection of the rights, dignity, physical and psychological well-being of individuals requiring restraint or seclusion ...The use of restraint or seclusion was implemented using safe techniques ...Training ...Staff education, training and demonstration include the following ...*Safe application and use of all type of restraint or seclusion used, including how to recognize and respond to signs of physical or psychological distress ..."
Interview with EMP2 on June 23, 2022 at 12:26 PM revealed they heard the patient say "He is choking me." EMP2 confirmed witnessing foam around the patient's mouth. EMP2 reported that EMP1 did not follow CPI (Crisis Prevention Institute) methods during the restraint.
Interview with EMP3 on June 23, 2022 at 12:54 PM revealed EMP1's forearm was in the neck region of the patient during the restraint.
Interview with EMP4 on June 23, 2022 at 1:03 PM revealed "I saw the patient foaming at the mouth and saw [name redacted] [EMP1's] arm around the neck area of the patient. I don't think it was on purpose, but it could have been bad ... This was the worst restraint I have ever seen in my life." Interview with EMP4 further confirmed the patient began to shake and that is when EMP4 yelled "Everyone off."
Interview with EMP5 on June 23, 2022 at 1:29 PM confirmed "I saw [name redacted] [EMP1] with a forearm on the side of his [patient's] head and one hand on his [patient's] neck ...he kept saying to get off my neck." EMP5 also reported there was a "huge miscommunication" during this restraint and "[regarding initiating the physical/mechanical restraint] [name redacted] went gung ho and just went for it."
Interview with EMP6 on June 23, 2022 at 1:58 PM confirmed "[name redacted] [EMP1] was choking him [patient]. He [EMP1] had his right forearm on his [patient's] face and his [EMP1] left hand was around his [patient's] neck." Interview with EMP6 further confirmed EMP6 saw the patient foaming at the mouth. EMP6 confirmed this was not part of CPI training.
Interview with EMP8 on June 23, 2022 at 3:08 PM revealed "I didn't see him [patient] being choked, but I saw him [EMP1] removing his forearm from the patients facial area."
Interview with EMP9 on June 23, 2022 at 4:31 PM confirmed the restraint was not performed appropriately.