HospitalInspections.org

Based on review of video footage, facility policies, medical records (MR), and employee interviews (EMP), it was determined the facility failed to provide a safe environment for a patient during a physical hold.
A discussion took place with the survey team and the facility's administrative staff (EMP1) regarding the survey team's concerns related to Patient Rights on January 8, 2025, at 1:18 PM.
On January 8, 2025, the survey team reviewed facility documents, education logs, audit logs, conducted observations and interviewed staff to determine compliance for the removal of the Immediate Jeopardy.
The survey team verified these immediate interventions were implemented and confirmed the facility's Immediate Jeopardy was removed.

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

Based on review of video footage, facility policies, medical records (MR), and employee interviews (EMP), it was determined the facility failed to provide a safe environment for a
Findings include:
Review of facility video footage of the Crisis Lobby dated Decemebr 22, 2024 revealed, PT1 was in physical hold in prone position from 1:20:46 PM until 1:27:04 PM. Afterwards, PT1 was placed in the supine position, appeared unconscious and subseqeuntly suffered a medical emergency.

Review of facility policy on January 8, 2025 "Seclusion and Restraint Policy", dated 3/25/22 revealed, "Purpose: The purpose of this policy is to identify and guide staff in the approved utilization of seclusion and/or restraints ... Holding for the purpose of safety during the following medical interventions is considered a restraint: IM or PO refusal of medication in an emergency situation ... B. Initiation of Seclusion and/or Restraint ... 11 ... "Patients should never be restrained face down."

Review of MR1 on January 8, 2025 revealed, PT1 arrived to facility at 11:00 AM on December 22, 2024. Further review reveals PT1 was placed in a physical hold due to aggressive behavior and need to administer intramuscular medication (IM). PT1 was held in prone position while in a physical hold for several minutes. After PT1 was placed in supine positon, PT1 was noted to be unresponsive and not breathing. Emergency Medical Technician (EMT) administered intranasal Narcan to PT1 without result, staff initiated CPR, 911 called. PT1 was transported to hospital via ambulance and ultimately expired.

Interview with EMP3 at 11:53 AM on January 8, 2025, after viewing video footage of patient placed in the prone position during physical hold confirmed PT1 was restrained in the prone position and that patients should not be restrained in the prone position.

Interview with EMP5 at 1:30 PM on January 8, 2025, confirmed, staff was called to the crisis area because of a patient (PT1) was being uncooperative. PT1 was placed in a physical hold to administer IM medication. PT1 was held in a prone position for a period of time. Once we flipped PT1 in supine position, PT1 was unconscious and wasn't breathing. CPR was started and an ambulance transported PT1 to the hospital.

Interview with EMP6 at 1:50 PM on January 8, 2025 confirmed, PT1 refused vital signs and medication, IM medication ordered, PT1 was placed in a physical hold in a prone position. When we turned PT1 to supine position, PT1 was breathing but "not normal breaths".


Cross reference:
482.13 Patient Rights