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Based on observation, interview, and review of the patient pamphlet, it was determined that the hospital failed 1) to notify patients in the behavioral health area of the emergency department of 24/7 video monitoring; and 2) failed to provide privacy to a non-behavioral health patient who was video monitored continuously with no clinical rationale.

Observations of the emergency department behavioral health (BH) pod included room 14 (across the hall from the main BH area) which according to staff was used for behavioral health and non-behavioral patients. Observation of video monitors revealed that two occupied behavioral health pod rooms, and room 14 across the hall, occupied by a non-behavioral health patient were actively video monitored.

Interview with the behavioral health RN on June 12, 2018 at approximately 1030 revealed that all behavioral health patients are video monitored 24 hours a day, every day in the emergency department. Inquiry as to how patients are made aware of continuous monitoring revealed the RN statement of, "I don't know how other nurses inform patients, but I tell patients and try to put it in my progress note." However, the RN could state no consistent way in which behavioral patients are made aware that they were continuously video monitored.

Further inquiry as to why a non-behavioral patient was being continuously video monitored in room 14 revealed that no one had turned off that monitor. The video attendant stated not knowing how to turn off the monitor for room 14.
Review of the "Patient Guide to Services" pamphlet revealed the Rights statement in part, "Right to Privacy: The patient can expect ...to know why any observers are present ..." Based on this, behavioral health patients had a right to know that they were continuously being monitored by observers on video, and why. Additionally, the hospital failed to identify the need for, and provide privacy for a non-behavioral patient for whom no clinical rationale for video observation was indicated.

Based on a review of two restraint records for patients #10 and #11, it was determined that face to face assessments were not timed and so might not have been done within one hour from the start of restraint.

Patient #10 was a 60+ year old, restrained in February 2018 following increasing agitation resulting in aggression. Review of the record revealed a face to face with no indicated time by which to determine compliance with regulation.

Patient #1 was a 60+ year old, restrained in May following intoxication resulting in aggression. Review of the record revealed a face to face with no indicated time by which to determine compliance with regulation. Therefore, the hospital failed to meet regulatory requirements for a face to face within one hour.

Based on interviews and a review of staff restraint training, it was revealed that 1) Advanced Restraint training instructed staff to conduct a manual hold ending in prone positioning which was known to have a high risk of asphyxia; and 2) No training provision instructed staff on how to recognize when a patient was in distress.

Interview with a hospital Risk Manager on June 12, 2018 at approximately 0930 revealed that the hospital had developed its own method for manual restraint holds. Review of hospital restraint holds revealed multiple safe holds, but also a manual hold called "Forward Take with Lowering." Pictures of the hold demonstrated staff lowering a patient to the floor in a prone position.

Prone positioning had been demonstrated to be an inherently dangerous restraint practice with a high incidence of asphyxia, injury and death. Interview with the security manager on 6/13 at approximately 0930 revealed in part, that once a patient is prone on the floor, staff are verbally trained to turn a patient into a supine position. While this may be so, no written restraint education, illustration or policy was found to support any other instruction after a patient had been placed in a prone position. Additionally, while struggles with patients in a health care setting may unintentionally and momentarily result in prone positioning, instruction to intentionally place a patient in prone positioning is an unsafe and non-standard form of manual restraint.

Further review of training revealed no education and training of staff on how to determine when a patient is in distress. This lack of education increased the risk to any restrained/secluded patient.

In summary, hospital staff failed to show a safe implementation of restraint and seclusion when it trained staff in prone positioning and failed to teach how to identify when a patient is in distress.