HospitalInspections.org

Tag A-0115 CFR 482.13 Condition of Participation: Patient Rights. A hospital must protect and promote each patient's rights.

Based on review of facility policies, facility documents, medical records (MR), and interview with staff (EMP), it was determined that Conemaugh Health System Memorial Medical Center failed to protect and promote each patients rights by failing to ensure that all patients have the right to be free from physical or mental abuse, and corporal punishment (A-0154), failed to determine whether the facility's policies and procedures employ a definition or description of what constitutes a restraint that is consistent with the regulation, failed to attempt least restrictive interventions (A-0164), failed to obtain physician order (A-0168), and failed to provide a face to face within one hour of the intervention (A-0178) for 10 of 10 patients (MR1, MR2, MR3, MR4, MR5, MR6, MR11, MR12, MR13, MR14).

Findings include:

Review of facility policy "Conemaugh Health System Memorial Medical Center Organizational Policy Manual Patient Rights dated December 2010, revealed, " ... 15. You have the right to be free from any form of restraints-both physical and drug-that is not medically necessary. ... ."

Review of facility policy "Conemaugh Health System Memorial Medical Center Organizational Policy Manual Title: Restraint and Seclusion Policy" revised November 2009, revealed, " ... The purpose of this policy is to provide guidelines for the use of restraint and seclusion. Memorial Medical Center is committed to preventing and reducing restraint and seclusion use, as well as striving to eliminate use. Non-physical interventions should be considered before restraint or seclusion is used. Interventions will be instituted to prevent emergency situations that may lead to restraint and seclusion use. Restraint and seclusion will only be used if less restrictive interventions have been ineffective. Patients have the right to be free from restraint in any form that is used for coercion, discipline, convenience or retaliation by staff. Therefore, restraint and seclusion will only be used with an order from a physician and will be limited to situations in which there is an assessed need for its use. During the use of restraint and seclusion, the patient's rights, dignity and well being will protected and respected. ... Physical restraint-any method, physical, or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his arms, legs, body or head freely. Physical force may be human, mechanical or a combination of thereof attached to the patient's body that he/she cannot easily remove. Holding a patient in a manner that restricts his/her movement constitutes restraint for that patient. ... Exceptions The following are not governed by this policy: 1. The use of handcuffs and other restrictive devices applied by law enforcement officials. These are considered forensic restrictions. ... Physician's Orders 1. Orders for restraints and seclusion must be either written or verbally given by a licensed independent practitioner. * Only a physician or resident can write these orders. ... 9. When applying a Self-Destructive-Emergency Restraint, the physician or Registered Nurse or Physicians assistant (has completed Secure Training) must see the patient face to face and evaluate the need for restraint/seclusion within one hour after initiation of the intervention. ... ."

Review of facility policy "Restraint and Seclusion Department: Behavioral Medicine" dated March 2011, revealed, " ... 1.0 Policy The purpose of this policy is to provide guidelines for the use of restraint and seclusion. We are committed to preventing and reducing restraint and seclusion use, as well as striving to eliminate use. Non-physical interventions should be considered before restraint or seclusion is used. Interventions will be instituted to prevent emergency situations that may lead to restraint and seclusion use. Restraint and seclusion will only be used if less restrictive interventions have been ineffective. We believe that patients have the right to be free from restraint in any form that is used for coercion, discipline, convenience, or retaliation by staff. Therefore, restraint and seclusion will only be used with an order from a physician and will be limited to situations in which there is an assessed need for its use. During the use of restraint and seclusion, the patient's rights, dignity, and well-being will be protected and respected. There are two types of restraints: 1. Non-Emergency Restraints (Acute Medical/Surgical Restraint) 2. Emergency Restraints (Behavior Management Restraint) The type of restraint is not specific to the setting the patient is in, but to the situation, the restraint is being used to address. *All restraints, which occur on the Behavioral Medicine Units, are governed by the Emergency Restraint Standards only. 2.0 Definitions Physical Restraint- The direct application of physical force to a patient, with or without the patient's permission, to restrict freedom of movement. Physical force may be human, mechanical, or a combination thereof attached to the patient's body that he/she cannot easily remove. Holding a patient in a manner that restricts his/her movement constitutes restraint for that patient. ... 3.0 Exceptions The following are not governed by this policy: 1. The use of handcuffs and other restrictive devices applied by law enforcement officials. These are considered forensic restrictions and are utilized only by members of the police force or corrections officers. ... 7.0 Physician Orders 1. Orders for restraint and seclusion must either be written or verbally given by a physician. 9.0 Restraint Assessment (One-Hour Rule) 1. ... If the patient recovers quickly and is released from restraint/seclusion within the first hour of use, the RN/physician/physician assistant must still complete one hour face-to-face evaluation. 2. One-hour-face-to-face assessment: The physician, physician assistant, or a qualified RN shall perform a face-to-face assessment of the patient's physical an psychological status within 1 hour of the initiation of the restraint. This assessment shall include and be documented in the medical record: The patient's immediate situation, The patient's reaction to the intervention, The patient's medical and behavioral condition, The need to continue or terminate the restraint or seclusion, Provide guidance in ways to help patient gain control. ... 14.0 Staff Training and Competency 1. ... Training takes place during departmental or medical staff orientation and shall be repeated at least annually in the department's educational plan. The education plan shall include; de-escalation and non-physical techniques and alternatives to avoid use of restraint and seclusion, training on identifying early warning signs of physical and psychological distress, safe application and release of restraints, and return demonstrations or post training tests required by nationally recognized course or program. ... ."

Review of facility policy "Handcuff Policy" revised October 16, 2010, revealed, "Policy: Security Department personnel are not authorized to use handcuffs, until they complete departmental training on handcuff usage. ... If an antagonist is in danger of harming himself, others and/or causing property damage and no other restraint method is feasible, handcuffs are to be used only as a last resort. They are not to be considered normal hospital restraints. ... The Security Director shall be notified when the use of handcuffs are necessary. A Security Incident Report shall be completed prior to the end of the officer's shift. ... ."

Review of facility policy "Use of Force" revised June 17, 2010, revealed, " ... Purpose: To clearly define the circumstances under which the force by a Security Officer is justified. The use of force necessary to control a situation or individual will be justified: Whenever the clear and present danger of bodily injury to the Security Officer or another person is immediately present, when making an arrest, when attempting to control a violent patient. ... Policy: Use of Nondeadly Force: A Security Officer is authorized to use nondeadly force to protect himself/herself or another person from physical harm; to restrain or subject a person resisting a lawful arrest; or to bring an unlawful or unsafe situation under control in the following manner. Assess the Situation: When faced with an incident that may require the use of force, a Security Officer must immediately assess the situation and determine which techniques and/or weapons will effectively de-escalate the situation and bring it under control at the least risk of injury to the officer and others. ... Reporting Procedures: Whenever a Security Officer uses force in any form, other than routine application of handcuffs or patient restraint under medical supervision, the Nursing Supervisor will immediately notify the Security Director. Every Security Officer involved will complete a detailed written report prior to the end of his/her watch, which will be forwarded to the Security Director. ... ."

1) Conemaugh Health System Job Description Job Title: Security Officer was reviewed. The job description stated, " ... Job Summary The Security Officer is responsible for assets ranging from human lives to personal property including the premises and contents for all employees and customers of Memorial Medical Center. Typical services include ... violent patient assistance ... . Job Qualifications ... Certification/Licensure/Registration Required ... Annual Secure Care training ... Preferred: Crisis Intervention Training . ... ."

2) Review of "Incident File Full Report" Security documentation dated October 2010 to present revealed 70 data reports in which Security was called for assistance in the emergency department, adult, child and geri behavioral health units.

Review of "Incident File Full Report" Security documentation dated February 23, 2011, 13:49 was reviewed. The report stated, "On the above date and time [EMP4] and [EMP5], [EMP5] was dispatched to 10-10 (Adult Psych) to assist staff with a patient. Officers arrived shortly after, [EMP2] advised Officers that the patient standing at the nurses [sic] station (Later identified as [MR1]) needed to have medications and to go back to room. [EMP5] then directed [MR1] to cooperate with staff and walk back to [MR1] room. [MR1] replied "I'm not taking any meds." [MR1] then walked back the hall towards [MR1] room (GS7706) and prior to entering [MR1] stated to [EMP4] and [EMP5] 'I'm not going in their [sic] I don't care.' [EMP5] then advised [MR1] that we would then have to physically take [MR1] in the room. [MR1] replied 'I'm not going in.' [EMP4] and [EMP5], each taking control of a [sic] arm then began to walk [MR1] into the room. [MR1] then attempted to punch [EMP4] with [MR1] left fist. Both Officers then physically move [sic] [MR1] from the hallway and into the room. While [MR1] was combatively resisting (attempting to punch) Officers [MR1] did strike the left side of [MR1] face off of the bathroom door, which was open approximately two feet. Officers then physically moved [MR1] to the bed where [MR1] continued to resist by attempting to punch, elbow and kick Officers and staff member [EMP6]. [EMP4] then handcuffed [MR1] and while holding [MR1] on the bed [EMP2] administer [sic] on injection of medication. [EMP5] was then instructed by [EMP2] to remove the handcuffs after [MR1] agreed to cooperate with all staff directions. [EMP5] then removed the handcuffs without incident. [EMP2] then checked [MR1] for injuries and reported no injuries to [EMP5] at that time and also no staff were injured. Both Officers then stood by on the unit and were cleared to depart by [EMP2] approximately five minutes after [MR1] was released from the handcuffs."

Review of "Incident File Full Report" Security documentation [MR2] dated October 5, 2010, revealed, " ... Sublocation: Emergency Room ... Myself and Badge 4 gained control of the resisting subject and proned [MR2] against the wall, I grabbed the knife and secured it, then cuffed the subject. The subject continued to resist and was reaching for [MR2] back pocket for I felt [MR2] was attempting to obtain another weapon. ... I took the detained subject into the lot upon police presence and JPD did take [MR2] into custody. ... ."

Review of "Incident File Full Report" Security documentation [MR3] dated March 23, 2011 revealed, " ... Sublocation: Emergency Medicine ... After [MR3] was physically restrained with the handcuffs, [MR3] was placed on a bed and wheeled to cubicle #26. [MR3] attempted many times to get off the bed and had to be physically held down and placed into "twice as tough" four point restraints. [MR3] continued with the verbal and physical attempts to get free for some time, even after two IM's were given to [MR3] by DEM staff. At one point, [MR3] was able to get free [MR3] left wrist from a restraint, and was attempting to flip [MR3] bed onto its side. Officer ... arrived and did assist me to restrain this wrist a second time. No injuries to staff or patient were reported. Officers were cleared to leave ... ."

Review of "Incident File Full Report" Security documentation [MR4] dated December 1, 2010, revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On 12/1/2010 at 1130 hours, security dispatched available officers to responds to the Adult Psych Unit to assist with a patient who is refusing to shower .... [EMP7] and [EMP8] continued to try and explain to the patient why [MR4] needs to shower and that is policy for patient to have a shower every day or every other day. ... Every attempt was made by the unit staff to convince the patient to shower, but [MR4] continued refusing. So [EMP9], [EMP5] and I [EMP10] tried to escort the patient back to the room for patient showering ... but the patient became combative and had to be place in handcuffs, then taken to the shower room where staff members [EMP7] and [EMP8] washed the patient while Security officers assisted holding the patient still. After the showering process, the patient was dressed in hospital gown and pants ... cuffs were removed ... ."

Further review of "Incident File Full Report" Security documentation [MR5] dated November 1, 2010, 10:56 revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On the above date and time [EMP10], [EMP17] and [EMP5] were dispatched to 10-10 (Adult Psych) to assist with a patient. When all Officers arrived shortly after [EMP1] advised Officers that staff needed to medicate patient [MR5] and change into hospital clothing (gown and hospital pants). [MR5] who was standing at the nurses station then began to yell at [EMP10] "I am leaving this place your all corrupt I'm not crazy." [EMP1] then advised [MR5] that [MR5] needed to walk back to [MR5] room. [MR5] did comply and walked back to [MR5] room without incident other than repeating the same phrases as written above. When at [MR5] room ... [EMP1] advised [MR5] that [MR5] will need to take some medications and change into that so I look crazy" [MR5] then removed a pen from [MR5] pants pocket and threaten to stab Officers and Staff stating "Anyone of you come near me I'm going to stab you, I'll stab all of you, I want out of here' This Officer then remove my pepper spray and held it at my side. [MR5] did view this Officer remove the spray and when [EMP1] asked [MR5] to lay the pen down [MR5] then threw it on the floor in front of [EMP10]. ... [EMP1] then advised [MR5] that [MR5] needed to now change into hospital clothing. [MR5] then became combative and began swinging [MR5] arms at Officers. Officers [EMP10], [EMP17] and I then Physically moved [MR5] from a standing position to a prone position on the floor. Officers then Held [MR5] as [EMP18] change [MR5] into Hospital clothing. [EMP1] then instructed Officers to pick [MR5] up and asked [MR5] if [MR5] is going to keep [MR5] under control, listen to staff and stay in [MR5] room. [MR5] replied "yea". EMP1 then instructed Officers to let go of [MR5] (Officers were holding both arms). Immediately after releasing [MR5] then sat down on the bed and began to state that everyone was corrupt. ... ."

Review of "Incident File Full Report" Security documentation sheet [MR5] dated November 1, 2010, 5:12 revealed, " On the above date and time these officers [EMP11] and [EMP12] responded to the adult psych unit to assist with medications. ... Subject was holding the door shut in the restroom and refusing to exit. This officer [EMP11] positioned to the side with O.C. spray in position. [EMP12] informed the subject that if [MR5] did not come out and comply with staff, [MR5] would be sprayed. The subjects tone changed instantly, [MR5] stated that [MR5] was sprayed twice before and did not want to be sprayed again. Subject exited the restroom without incident and allowed staff to administer I.M. medication. ... ."

Review of "Incident File Full Report" Security documentation dated March 16, 2011, " ... [MR6] was being held to the floor ... . At this time the patient was then taken control of and placed on the floor. The patient was then lifted while maintaining control by security and DEM staff and placed on the cart in cubical in #29. ... ."

Review of "Incident File Full Report" Security documentation dated October 30, 2010, " ... he was then physically controlled and put down on the bed, while restraints were retrieved from the storage room, as Officers held the patient [MR11] on the bed he continued to resist and try to strike Officers. ... ."

Review of "Incident File Full Report" Security documentation dated April 2, 2011, " ... I at this time grabbed the patient [MR12] and did take pt down. ... ."

Review of "Incident File Full Report" security documentation dated February 14, 2011, " ... that occurred while using force to control [MR13] prior to the four point restraints be applied. ... ."

Review of "Incident File Full Report" Security documentation dated November 19, 2010, " ... All officers closed at this point in order to gain control of [MR14] limbs and body. ... Officers [EMP10], [EMP5], and [EMP4], were attempting to gain upper body control and move [MR14] to the floor. This officer took hold of [MR14] legs assisting in taking [the patient] to the floor. ... ."

3) Review of [MR1], [MR3], [MR4], [MR5], [MR6], [MR7], [MR8], [MR12], and [MR14], revealed no documented evidence of the one or more of the following medical record requirements: completion of physician order for use of force or handcuffs, nursing flowsheet restraint documentation related to use of force or handcuffs, least restrictive alternatives/attempted interventions prior to use of force or handcuff placement, and face to face documentation following the use of force or handcuff placement.

4) An interview was conducted with [EMP3] on March 16, 2011, at 14:30 PM. [EMP3] stated, "It's not standard that we go. We go up [to the Behavioral Health Unit] when we're called, when patients are out of control if nothing else can be done. We track all of our interaction. We would use handcuffs as a last resort and take them off as soon as we can. My officers are familiar with de-escalation and have CIT training." [EMP3] stated that it was not policy for security to respond to the Behavioral Health Unit when a patient refuses medications.

5) An interview was conducted with [EMP3] on April 4, 2011, at 11:30 AM. [EMP3] was queried in regard to the Security Department considering itself law enforcement. [EMP3] stated, "There is a fine line there. We are not a police department. Patients may be discharged into the custody of law enforcement. It is common practice for us to be called by Behavioral Health to assist and a report is filed. Handcuffs are a last resort used to protect themselves and the staff."

6) An interview with [EMP3] was conducted on April 15, 2011, at approximately 1:30 PM. [EMP3] stated, "Every officer is trained on handcuffs. Nursing is aware that handcuffs are an option. After the order is obtained from the doctor, security does assist nursing with the application of restraints." [EMP3] stated that the security policies are approved by self and not the medical staff.

7) An interview was conducted with [EMP5] on May 5, 2011, at 11:25 AM. [EMP5] stated, "It is clearly our judgment to use handcuffs. The staff does not direct us. We are called upstairs to psych frequently for disturbances there. Handcuffs are rare; it's a last resort for us. It is for safety for property damage, staff and us. They are removed as soon as restraints and adequate staff is present."

8) An interview was conducted with [EMP16] on May 5, 2011, at 10:30 AM. [EMP16] was asked about the usage of handcuffs by the Security personnel. [EMP16] revealed, " ... I personally review every report of security. Ninety-nine percent was from staff that was scared and called security. Things like handcuffs require clinical direction. Handcuffs are treated like any other restraint. The clinician who directs the nurse of physician directs Security to use the handcuffs. We will only use handcuffs as directed to. The officers do not make the call for use of handcuffs. ... I am certain that the CEO is aware of usage of handcuffs. I occasionally forward the I track reports to the VP of Nursing and CEO. The strongest weapon is pepper spray. I have not reviewed an I track report that pepper spray has been used in the two years I have been in this position."

9) An interview was conducted with [EMP9] on May 5, 2011, at 10:55 AM. [EMP9] was asked ift they ever used handcuffs. EMP9 revealed, "Yes, I cuffed a patient. Recently I had CIT training. I have not had to handcuff since training three weeks ago. It's verbalization to the patient now." The question was asked of who directs you to handcuff a patient. [EMP9] stated, "If we feel we are in jeopardy of being hurt or staff or visitors, if we feel safety is an issue, we utilize handcuffs. No one directs me to use a handcuff, that's a pretty last resort. Handcuffs are used as a tool until the four points twice as tough are applied. We have had training on applying restraints. ... I have never had to use pepper spray myself. Let me add, I feel with this day and age, we need the handcuffs."

10) An interview was conducted with [EMP5] on May 5, 2011, at 11:25 AM, an interview was held with [EMP5]. [EMP5] was asked who directs Security to use handcuffs. [EMP5] stated, "Directed by us only officers. It is clearly our judgment to use handcuffs. The staff does not direct us. We are called upstairs to psych frequently for disturbances there. Handcuffs are rare; it's a last resort for us. It is for safety for property damage, staff and us. They are removed as soon as restraints and adequate staff is present." When asked about pepper spray, [EMP5] revealed, "I used pepper spray one time last year. It was for an adolescent, for a barricaded patient, for staff to gain access to the room. Pt was throwing two by two drywall at us. ... ."

Based on review of facility policies, facility documentation, and interview with staff (EMP), it was determined that Conemaugh Health System Memorial Medical Center failed to ensure that patients were free from coercion (threat of pepper spray) and/or handcuffs used as a means of restraint for 10 of 10 patients. (MR1, MR2, MR3, MR4, MR5, MR6, MR11, MR12, MR13, MR14).

Findings include:

Review of facility policy "Conemaugh Health System Memorial Medical Center Organizational Policy Manual Patient Rights dated December 2010, revealed, " ... 15. You have the right to be free from any form of restraints-both physical and drug-that is not medically necessary. ... ."

Review of facility policy "Conemaugh Health System Memorial Medical Center Organizational Policy Manual Title: Restraint and Seclusion Policy" revised November 2009, revealed, " ... The purpose of this policy is to provide guidelines for the use of restraint and seclusion. Memorial Medical Center is committed to preventing and reducing restraint and seclusion use, as well as striving to eliminate use. Non-physical interventions should be considered before restraint or seclusion is used. Interventions will be instituted to prevent emergency situations that may lead to restraint and seclusion use. Restraint and seclusion will only be used if less restrictive interventions have been ineffective. Patients have the right to be free from restraint in any form that is used for coercion, discipline, convenience or retaliation by staff. Therefore, restraint and seclusion will only be used with an order from a physician and will be limited to situations in which there is an assessed need for its use. During the use of restraint and seclusion, the patient's rights, dignity and well being will protected and respected. ... Physical restraint-any method, physical, or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his arms, legs, body or head freely. Physical force may be human, mechanical or a combination of thereof attached to the patient's body that he/she cannot easily remove. Holding a patient in a manner that restricts his/her movement constitutes restraint for that patient. ... Exceptions The following are not governed by this policy: 1. The use of handcuffs and other restrictive devices applied by law enforcement officials. These are considered forensic restrictions. ... Physician's Orders 1. Orders for restraints and seclusion must be either written or verbally given by a licensed independent practitioner. * Only a physician or resident can write these orders. ... 9. When applying a Self-Destructive-Emergency Restraint, the physician or Registered Nurse or Physicians assistant (has completed Secure Training) must see the patient face to face and evaluate the need for restraint/seclusion within one hour after initiation of the intervention. ... ."

Review of facility policy "Restraint and Seclusion Department: Behavioral Medicine" dated March 2011, revealed, " ... 1.0 Policy The purpose of this policy is to provide guidelines for the use of restraint and seclusion. We are committed to preventing and reducing restraint and seclusion use, as well as striving to eliminate use. Non-physical interventions should be considered before restraint or seclusion is used. Interventions will be instituted to prevent emergency situations that may lead to restraint and seclusion use. Restraint and seclusion will only be used if less restrictive interventions have been ineffective. We believe that patients have the right to be free from restraint in any form that is used for coercion, discipline, convenience, or retaliation by staff. Therefore, restraint and seclusion will only be used with an order from a physician and will be limited to situations in which there is an assessed need for its use. During the use of restraint and seclusion, the patient's rights, dignity, and well-being will be protected and respected. There are two types of restraints: 1. Non-Emergency Restraints (Acute Medical/Surgical Restraint) 2. Emergency Restraints (Behavior Management Restraint) The type of restraint is not specific to the setting the patient is in, but to the situation, the restraint is being used to address. *All restraints, which occur on the Behavioral Medicine Units, are governed by the Emergency Restraint Standards only. 2.0 Definitions Physical Restraint- The direct application of physical force to a patient, with or without the patient's permission, to restrict freedom of movement. Physical force may be human, mechanical, or a combination thereof attached to the patient's body that he/she cannot easily remove. Holding a patient in a manner that restricts his/her movement constitutes restraint for that patient. ... 3.0 Exceptions The following are not governed by this policy: 1. The use of handcuffs and other restrictive devices applied by law enforcement officials. These are considered forensic restrictions and are utilized only by members of the police force or corrections officers. ... 7.0 Physician Orders 1. Orders for restraint and seclusion must either be written or verbally given by a physician. 9.0 Restraint Assessment (One-Hour Rule) 1. ... If the patient recovers quickly and is released from restraint/seclusion within the first hour of use, the RN/physician/physician assistant must still completethe one hour face-to-face evaluation. 2. One-hour-face-to-face assessment: The physician, physician assistant, or a qualified RN shall perform a face-to-face assessment of the patient's physical an psychological status within 1 hour of the initiation of the restraint. This assessment shall include and be documented in the medical record: The patient's immediate situation, The patient's reaction to the intervention, The patient's medical and behavioral condition, The need to continue or terminate the restraint or seclusion, Provide guidance in ways to help patient gain control. ... 14.0 Staff Training and Competency 1. ... Training takes place during departmental or medical staff orientation and shall be repeated at least annually in the department's educational plan. The education plan shall include; de-escalation and non-physical techniques and alternatives to avoid use of restraint and seclusion, training on identifying early warning signs of physical and psychological distress, safe application and release of restraints, and return demonstrations or post training tests required by nationally recognized course or program. ... ."

Review of facility policy "Handcuff Policy" revised October 16, 2010, revealed, "Policy: Security Department personnel are not authorized to use handcuffs, until they complete departmental training on handcuff usage. ... If an antagonist is in danger of harming himself, others and/or causing property damage and no other restraint method is feasible, handcuffs are to be used only as a last resort. They are not to be considered normal hospital restraints. ... The Security Director shall be notified when the use of handcuffs are necessary. A Security Incident Report shall be completed prior to the end of the officer's shift. ... ."


Review of facility policy "Use of Force" revised June 17, 2010, revealed, " ... Purpose: To clearly define the circumstances under which the force by a Security Officer is justified. The use of force necessary to control a situation or individual will be justified: Whenever the clear and present danger of bodily injury to the Security Officer or another person is immediately present, when making an arrest, when attempting to control a violent patient. ... Policy: Use of Nondeadly Force: A Security Officer is authorized to use nondeadly force to protect himself/herself or another person from physical harm; to restrain or subject a person resisting a lawful arrest; or to bring an unlawful or unsafe situation under control in the following manner. Assess the Situation: When faced with an incident that may require the use of force, a Security Officer must immediately assess the situation and determine which techniques and/or weapons will effectively de-escalate the situation and bring it under control at the least risk of injury to the officer and others. ... Reporting Procedures: Whenever a Security Officer uses force in any form, other than routine application of handcuffs or patient restraint under medical supervision, the Nursing Supervisor will immediately notify the Security Director. Every Security Officer involved will complete a detailed written report prior to the end of his/her watch, which will be forwarded to the Security Director. ... ."

1) Conemaugh Health System Job Description Job Title: Security Officer was reviewed. The job description stated, " ... Job Summary The Security Officer is responsible for assets ranging from human lives to personal property including the premises and contents for all employees and customers of Memorial Medical Center. Typical services include ... violent patient assistance ... . Job Qualifications ... Certification/Licensure/Registration Required ... Annual Secure Care training ... Preferred: Crisis Intervention Training . ... ."

2) Review of "Incident File Full Report" Security documentation dated October 2010 to present revealed 70 data reports in which Security was called for assistance in the emergency department, adult, child and geri behavioral health units.

Review of "Incident File Full Report" Security documentation dated February 23, 2011, 13:49 was reviewed. The report stated, "On the above date and time [EMP4] and [EMP5], [EMP5] was dispatched to 10-10 (Adult Psych) to assist staff with a patient. Officers arrived shortly after, [EMP2] advised Officers that the patient standing at the nurses [sic] station (Later identified as [MR1]) needed to have medications and to go back to his room. [EMP5] then directed [MR1] to cooperate with staff and walk back to [MR1] room. [MR1] replied "I'm not taking any meds." [MR1] then walked back the hall towards [MR1] room (GS7706) and prior to entering [MR1] stated to [EMP4] and [EMP5] 'I'm not going in their [sic] I don't care.' [EMP5] then advised [MR1] that we would then have to physically take [MR1] in the room. [MR1] replied 'I'm not going in.' [EMP4] and [EMP5], each taking control of a [sic] arm then began to walk [MR1] into the room. [MR1] then attempted to punch [EMP4] with [MR1] left fist. Both Officers then physically move [sic] [MR1] from the hallway and into the room. While [MR1] was combatively resisting (attempting to punch) Officers [MR1] did strike the left side of [MR1] face off of the bathroom door, which was open approximately two feet. Officers then physically moved [MR1] to the bed where [MR1] continued to resist by attempting to punch, elbow and kick Officers and staff member [EMP6]. [EMP4] then handcuffed [MR1] and while holding [MR1] on the bed [EMP2] administer [sic] on injection of medication. [EMP5] was then instructed by [EMP2] to remove the handcuffs after [MR1] agreed to cooperate with all staff directions. [EMP5] then removed the handcuffs without incident. [EMP2] then checked [MR1] for injuries and reported no injuries to [EMP5] at that time and also no staff were injured. Both Officers then stood by on the unit and were cleared to depart by [EMP2] approximately five minutes after [MR1] was released from the handcuffs."

Review of "Incident File Full Report" Security documentation [MR2] dated October 5, 2010, revealed, " ... Sublocation: Emergency Room ... Myself and Badge 4 gained control of the resisting subject and proned [MR2] against the wall, I grabbed the knife and secured it, then cuffed the subject. The subject continued to resist and was reaching for [MR2] back pocket for I felt [MR2] was attempting to obtain another weapon. ... I took the detained subject into the lot upon police presence and JPD did take [MR2] into custody. ... ."

Review of "Incident File Full Report" Security documentation [MR3] dated March 23, 2011 revealed, " ... Sublocation: Emergency Medicine ... After [MR3] was physically restrained with the handcuffs, [MR3] was placed on a bed and wheeled to cubicle #26. [MR3] attempted many times to get off the bed and had to be physically held down and placed into "twice as tough" four point restraints. [MR3] continued with the verbal and physical attempts to get free for some time, even after two IM's were given to [MR3] by DEM staff. At one point, [MR3] was able to get free [MR3] left wrist from a restraint, and was attempting to flip [MR3] bed onto its side. Officer ... arrived and did assist me to restrain this wrist a second time. No injuries to staff or patient were reported. Officers were cleared to leave ... ."

Review of "Incident File Full Report" Security documentation [MR4] dated December 1, 2010, revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On 12/1/2010 at 1130 hours, security dispatched available officers to responds to the Adult Psych Unit to assist with a patient who is refusing to shower .... [EMP7] and [EMP8] continued to try and explain to the patient why [MR4] needs to shower and that is policy for patient to have a shower every day or every other day. ... Every attempt was made by the unit staff to convince the patient to shower, but [MR4] continued refusing. So [EMP9], [EMP5] and I [EMP10] tried to escort the patient back to the room for patient showering ... but the patient became combative and had to be place in handcuffs, then taken to the shower room where staff members [EMP7] and [EMP8] washed the patient while security officers assisted holding the patient still. After the showering process, the patient was dressed in hospital gown and pants ... cuffs were removed ... ."

Further review of "Incident File Full Report" Security documentation [MR5] dated November 1, 2010, 10:56 revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On the above date and time [EMP10], [EMP17] and [EMP5] were dispatched to 10-10 (Adult Psych) to assist with a patient. When all Officers arrived shortly after [EMP1] advised Officers that staff needed to medicate patient [MR5] and change into hospital clothing (gown and hospital pants). [MR5] who was standing at the nurses station then began to yell at [EMP10] "I am leaving this place your all corrupt I'm not crazy." [EMP1] then advised [MR5] that [MR5] needed to walk back to [MR5] room. [MR5] did comply and walked back to [MR5] room without incident other than repeating the same phrases as written above. When at [MR5] room ... [EMP1] advised [MR5] that [MR5] will need to take some medications and change into that so I look crazy" [MR5] then removed a pen from [MR5] pants pocket and threaten to stab Officers and Staff stating "Anyone of you come near me I'm going to stab you, I'll stab all of you, I want out of here' This Officer then remove my pepper spray and held it at my side. [MR5] did view this Officer remove the spray and when [EMP1] asked [MR5] to lay the pen down [MR5] then threw it on the floor in front of [EMP10]. ... [EMP1] then advised [MR5] that [MR5] needed to now change into hospital clothing. [MR5] then became combative and began swinging [MR5] arms at Officers. Officers [EMP10], [EMP17] and I then Physically moved [MR5] from a standing position to a prone position on the floor. Officers then Held [MR5] as [EMP18] change [MR5] into Hospital clothing. [EMP1] then instructed Officers to pick [MR5] up and asked [MR5] if [MR5] is going to keep [MR5] under control, listen to staff and stay in [MR5] room. [MR5] replied "yea". EMP1 then instructed Officers to let go of [MR5] (Officers were holding both arms). Immediately after releasing [MR5] then sat down on the bed and began to state that everyone was corrupt. ... ."

Review of "Incident File Full Report" Security documentation sheet [MR5] dated November 1, 2010, 5:12 revealed, " On the above date and time these officers [EMP11] and [EMP12] responded to the adult psych unit to assist with medications. ... Subject was holding the door shut in the restroom and refusing to exit. This officer [EMP11] positioned to the side with O.C. spray in position. [EMP12] informed the subject that if [MR5] did not come out and comply with staff, [MR5] would be sprayed. The subjects tone changed instantly, [MR5] stated that [MR5] was sprayed twice before and did not want to be sprayed again. Subject exited the restroom without incident and allowed staff to administer I.M. medication. ... ."

Review of "Incident File Full Report" Security documentation dated March 16, 2011, " ... [MR6] was being held to the floor ... . At this time the patient was then taken control of and placed on the floor. The patient was then lifted while maintaining control by security and DEM staff and placed on the cart in cubical in #29. ... ."

Review of "Incident File Full Report" Security documentation dated October 30, 2010, " ... pt was then physically controlled and put down on the bed, while restraints were retrieved from the storage room, as Officers held the patient [MR11] on the bed pt continued to resist and try to strike Officers. ... ."

Review of "Incident File Full Report" Security documentation dated April 2, 2011, " ... I at this time grabbed the patient [MR12] and did take pt down. ... ."

Review of "Incident File Full Report" Security documentation dated February 14, 2011, " ... that occurred while using force to control [MR13] prior to the four point restraints be applied. ... ."

Review of "Incident File Full Report" Security documentation dated November 19, 2010, " ... All officers closed at this point in order to gain control of [MR14] limbs and body. ... Officers [EMP10], [EMP5], and [EMP4], were attempting to gain upper body control and move [MR14] to the floor. This officer took hold of [MR14] legs assisting in taking [the patient] to the floor. ... ."

3)An interview was conducted with [EMP3] on March 16, 2011, at 14:30 PM. [EMP3] stated, "It's not standard that we go. We go up [to the Behavioral Health Unit] when we're called, when patients are out of control if nothing else can be done. We track all of our interaction. We would use handcuffs as a last resort and take them off as soon as we can. My officers are familiar with de-escalation and have CIT training." [EMP3] stated that it was not policy for security to respond to the Behavioral Health Unit when a patient refuses medications.

4) An interview was conducted with [EMP3] on April 4, 2011, at 11:30 AM. [EMP3] was queried in regard to the Security Department considering itself law enforcement. [EMP3] stated, "There is a fine line there. We are not a police department. Patients may be discharged into the custody of law enforcement. It is common practice for us to be called by Behavioral Health to assist and a report is filed. Handcuffs are a last resort used to protect themselves and the staff."

5) An interview with [EMP3] was conducted on April 15, 2011, at approximately 1:30 PM. [EMP3] stated, "Every officer is trained on handcuffs. Nursing is aware that handcuffs are an option. After the order is obtained from the doctor, Security does assist nursing with the application of restraints." [EMP3] stated that the Security policies are approved by self and not the medical staff.

6) An interview was conducted with [EMP5] on May 5, 2011, at 11:25 AM. [EMP5] stated, "It is clearly our judgment to use handcuffs. The staff does not direct us. We are called upstairs to psych frequently for disturbances there. Handcuffs are rare; it's a last resort for us. It is for safety for property damage, staff and us. They are removed as soon as restraints and adequate staff is present."

7) An interview was conducted with [EMP16] on May 5, 2011, at 10:30 AM. [EMP16] was asked about the usage of handcuffs by the security personnel. [EMP16], " ... I personally review every report of Security. Ninety-nine percent was from staff that was scared and called Security. Things like handcuffs require clinical direction. Handcuffs are treated like any other restraint. The clinician who directs the nurse of physician directs security to use the handcuffs. We will only use handcuffs as directed to. The officers do not make the call for use of handcuffs. ... I am certain that the CEO is aware of usage of handcuffs. I occasionally forward the I track reports to the VP of Nursing and CEO. The strongest weapon is pepper spray. I have not reviewed an I track report that pepper spray has been used in the two years I have been in this position."

8) An interview was conducted with [EMP9] on May 5, 2011, at 10:55 AM. [EMP9] was asked if they ever used handcuffs. [EMP9] revealed, "Yes, I cuffed a patient. Recently I had CIT training. I have not had to handcuff since training three weeks ago. It's verbalization to the patient now." The question was asked of who directs you to handcuff a patient. [EMP9] stated, "If we feel we are in jeopardy of being hurt or staff or visitors, if we feel safety is an issue, we utilize handcuffs. No one directs me to use a handcuff, that's a pretty last resort. Handcuffs are used as a tool until the four points twice as tough are applied. We have had training on applying restraints. ... I have never had to use pepper spray myself. Let me add, I feel with this day and age, we need the handcuffs."

9) An interview was conducted with [EMP5] on May 5, 2011, at 11:25 AM. [EMP5] was asked who directs Security to use handcuffs. [EMP5] stated, "Directed by us, only officers. It is clearly our judgment to use handcuffs. The staff does not direct us. We are called upstairs to psych frequently for disturbances there. Handcuffs are rare; it's a last resort for us. It is for safety for property damage, staff and us. They are removed as soon as restraints and adequate staff is present." When asked about pepper spray, [EMP5] revealed, "I used pepper spray one time last year. It was for an adolescent, for a barricaded patient, for staff to gain access to the room. Pt was throwing two by two drywall at us. ... ."

Based on review of facility policies, facility documentation, and interview with staff (EMP), it was determined that Conemaugh Health System Memorial Medical Center failed to ensure that less restrictive interventions/alternatives were attempted prior to the use of restraints ( i.e. handcuffs and physical force) for 10 of 10 patients (MR1, MR2, MR3, MR4, MR5, MR6, MR11, MR12, MR13, MR14).

Findings include:

Review of facility policy "Conemaugh Health System Memorial Medical Center Organizational Policy Manual Patient Rights dated December 2010, revealed, " ... 15. You have the right to be free from any form of restraints-both physical and drug-that is not medically necessary. ... ."

Review of facility policy "Conemaugh Health System Memorial Medical Center Organizational Policy Manual Title: Restraint and Seclusion Policy" revised November 2009, revealed, " ... The purpose of this policy is to provide guidelines for the use of restraint and seclusion. Memorial Medical Center is committed to preventing and reducing restraint and seclusion use, as well as striving to eliminate use. Non-physical interventions should be considered before restraint or seclusion is used. Interventions will be instituted to prevent emergency situations that may lead to restraint and seclusion use. Restraint and seclusion will only be used if less restrictive interventions have been ineffective. Patients have the right to be free from restraint in any form that is used for coercion, discipline, convenience or retaliation by staff. Therefore, restraint and seclusion will only be used with an order from a physician and will be limited to situations in which there is an assessed need for its use. During the use of restraint and seclusion, the patient's rights, dignity and well being will protected and respected. ... Physical restraint-any method, physical, or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his arms, legs, body or head freely. Physical force may be human, mechanical or a combination of thereof attached to the patient's body that he/she cannot easily remove. Holding a patient in a manner that restricts his/her movement constitutes restraint for that patient. ... Exceptions The following are not governed by this policy: 1. The use of handcuffs and other restrictive devices applied by law enforcement officials. These are considered forensic restrictions. ... ."

Review of facility policy "Restraint and Seclusion Department: Behavioral Medicine" dated March 2011, revealed, " ... 1.0 Policy The purpose of this policy is to provide guidelines for the use of restraint and seclusion. We are committed to preventing and reducing restraint and seclusion use, as well as striving to eliminate use. Non-physical interventions should be considered before restraint or seclusion is used. Interventions will be instituted to prevent emergency situations that may lead to restraint and seclusion use. Restraint and seclusion will only be used if less restrictive interventions have been ineffective. We believe that patients have the right to be free from restraint in any form that is used for coercion, discipline, convenience, or retaliation by staff. Therefore, restraint and seclusion will only be used with an order from a physician and will be limited to situations in which there is an assessed need for its use. During the use of restraint and seclusion, the patient's rights, dignity, and well-being will be protected and respected. There are two types of restraints: 1. Non-Emergency Restraints (Acute Medical/Surgical Restraint) 2. Emergency Restraints (Behavior Management Restraint) The type of restraint is not specific to the setting the patient is in, but to the situation, the restraint is being used to address. *All restraints, which occur on the Behavioral Medicine Units, are governed by the Emergency Restraint Standards only. 2.0 Definitions Physical Restraint- The direct application of physical force to a patient, with or without the patient's permission, to restrict freedom of movement. Physical force may be human, mechanical, or a combination thereof attached to the patient's body that he/she cannot easily remove. Holding a patient in a manner that restricts his/her movement constitutes restraint for that patient. ... 3.0 Exceptions The following are not governed by this policy: 1. The use of handcuffs and other restrictive devices applied by law enforcement officials. These are considered forensic restrictions and are utilized only by members of the police force or corrections officers. ... ."

Review of facility policy "Handcuff Policy" revised October 16, 2010, revealed, "Policy: Security Department personnel are not authorized to use handcuffs, until they complete departmental training on handcuff usage. ... If an antagonist is in danger of harming himself, others and/or causing property damage and no other restraint method is feasible, handcuffs are to be used only as a last resort. They are not to be considered normal hospital restraints. ... The Security Director shall be notified when the use of handcuffs are necessary. A Security Incident Report shall be completed prior to the end of the officer's shift. ... ."

Review of facility policy "Use of Force" revised June 17, 2010, revealed, " ... Purpose: To clearly define the circumstances under which the force by a Security Officer is justified. The use of force necessary to control a situation or individual will be justified: Whenever the clear and present danger of bodily injury to the Security Officer or another person is immediately present, when making an arrest, when attempting to control a violent patient. ... Policy: Use of Nondeadly Force: A Security Officer is authorized to use nondeadly force to protect himself/herself or another person from physical harm; to restrain or subject a person resisting a lawful arrest; or to bring an unlawful or unsafe situation under control in the following manner. Assess the Situation: When faced with an incident that may require the use of force, a Security Officer must immediately assess the situation and determine which techniques and/or weapons will effectively de-escalate the situation and bring it under control at the least risk of injury to the officer and others. ... Reporting Procedures: Whenever a Security Officer uses force in any form, other than routine application of handcuffs or patient restraint under medical supervision, the Nursing Supervisor will immediately notify the Security Director. Every Security Officer involved will complete a detailed written report prior to the end of his/her watch, which will be forwarded to the Security Director. ... ."

1) Conemaugh Health System Job Description Job Title: Security Officer was reviewed. The job description stated, " ... Job Summary The Security Officer is responsible for assets ranging from human lives to personal property including the premises and contents for all employees and customers of Memorial Medical Center. Typical services include ... violent patient assistance ... . Job Qualifications ... Certification/Licensure/Registration Required ... Annual Secure Care training ... Preferred: Crisis Intervention Training . ... ."

2) Review of "Incident File Full Report" Security documentation dated October 2010 to present revealed 70 data reports in which Security was called for assistance in the emergency department, adult, child and geri behavioral health units.

Review of "Incident File Full Report" Security documentation dated February 23, 2011, 13:49 was reviewed. The report stated, "On the above date and time [EMP4] and [EMP5], [EMP5] was dispatched to 10-10 (Adult Psych) to assist staff with a patient. Officers arrived shortly after, [EMP2] advised Officers that the patient standing at the nurses [sic] station (Later identified as [MR1]) needed to have medications and to go back to room. [EMP5] then directed [MR1] to cooperate with staff and walk back to [MR1] room. [MR1] replied "I'm not taking any meds." [MR1] then walked back the hall towards [MR1] room (GS7706) and prior to entering [MR1] stated to [EMP4] and [EMP5] 'I'm not going in their [sic] I don't care.' [EMP5] then advised [MR1] that we would then have to physically take [MR1] in the room. [MR1] replied 'I'm not going in.' [EMP4] and [EMP5], each taking control of a [sic] arm then began to walk [MR1] into the room. [MR1] then attempted to punch [EMP4] with [MR1] left fist. Both Officers then physically move [sic] [MR1] from the hallway and into the room. While [MR1] was combatively resisting (attempting to punch) Officers [MR1] did strike the left side of [MR1] face off of the bathroom door, which was open approximately two feet. Officers then physically moved [MR1] to the bed where [MR1] continued to resist by attempting to punch, elbow and kick Officers and staff member [EMP6]. [EMP4] then handcuffed [MR1] and while holding [MR1] on the bed [EMP2] administer [sic] on injection of medication. [EMP5] was then instructed by [EMP2] to remove the handcuffs after [MR1] agreed to cooperate with all staff directions. [EMP5] then removed the handcuffs without incident. [EMP2] then checked [MR1] for injuries and reported no injuries to [EMP5] at that time and also no staff were injured. Both Officers then stood by on the unit and were cleared to depart by [EMP2] approximately five minutes after [MR1] was released from the handcuffs."


Review of "Incident File Full Report" Security documentation [MR2] dated October 5, 2010, revealed, " ... Sublocation: Emergency Room ... Myself and Badge 4 gained control of the resisting subject and proned [MR2] against the wall, I grabbed the knife and secured it, then cuffed the subject. The subject continued to resist and was reaching for [MR2] back pocket for I felt [MR2] was attempting to obtain another weapon. ... I took the detained subject into the lot upon police presence and JPD did take [MR2] into custody. ... ."

Review of "Incident File Full Report" Security documentation [MR3] dated March 23, 2011 revealed, " ... Sublocation: Emergency Medicine ... After [MR3] was physically restrained with the handcuffs, [MR3] was placed on a bed and wheeled to cubicle #26. [MR3] attempted many times to get off the bed and had to be physically held down and placed into "twice as tough" four point restraints. [MR3] continued with the verbal and physical attempts to get free for some time, even after two IM's were given to [MR3] by DEM staff. At one point, [MR3] was able to get free [MR3] left wrist from a restraint, and was attempting to flip [MR3] bed onto its side. Officer ... arrived and did assist me to restrain this wrist a second time. No injuries to staff or patient were reported. Officers were cleared to leave ... ."

Review of "Incident File Full Report" Security documentation [MR4] dated December 1, 2010, revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On 12/1/2010 at 1130 hours, security dispatched available officers to responds to the Adult Psych Unit to assist with a patient who is refusing to shower .... [EMP7] and [EMP8] continued to try and explain to the patient why [MR4] needs to shower and that is policy for patient to have a shower every day or every other day. ... Every attempt was made by the unit staff to convince the patient to shower, but [MR4] continued refusing. So [EMP9], [EMP5] and I [EMP10] tried to escort the patient back to the room for patient showering ... but the patient became combative and had to be place in handcuffs, then taken to the shower room where staff members [EMP7] and [EMP8] washed the patient while security officers assisted holding the patient still. After the showering process, the patient was dressed in hospital gown and pants ... cuffs were removed ... ."

Further review of "Incident File Full Report" Security documentation [MR5] dated November 1, 2010, 10:56 revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On the above date and time [EMP10], [EMP17] and [EMP5] were dispatched to 10-10 (Adult Psych) to assist with a patient. When all Officers arrived shortly after [EMP1] advised Officers that staff needed to medicate patient [MR5] and change into hospital clothing (gown and hospital pants). [MR5] who was standing at the nurses station then began to yell at [EMP10] "I am leaving this place your all corrupt I'm not crazy." [EMP1] then advised [MR5] that [MR5] needed to walk back to [MR5] room. [MR5] did comply and walked back to [MR5] room without incident other than repeating the same phrases as written above. When at [MR5] room ... [EMP1] advised [MR5] that [MR5] will need to take some medications and change into that so I look crazy" [MR5] then removed a pen from [MR5] pants pocket and threaten to stab Officers and Staff stating "Anyone of you come near me I'm going to stab you, I'll stab all of you, I want out of here' This Officer then remove my pepper spray and held it at my side. [MR5] did view this Officer remove the spray and when [EMP1] asked [MR5] to lay the pen down [MR5] then threw it on the floor in front of [EMP10]. ... [EMP1] then advised [MR5] that [MR5] needed to now change into hospital clothing. [MR5] then became combative and began swinging [MR5] arms at Officers. Officers [EMP10], [EMP17] and I then Physically moved [MR5] from a standing position to a prone position on the floor. Officers then Held [MR5] as [EMP18] change [MR5] into Hospital clothing. [EMP1] then instructed Officers to pick [MR5] up and asked [MR5] if [MR5] is going to keep [MR5] under control, listen to staff and stay in [MR5] room. [MR5] replied "yea". EMP1 then instructed Officers to let go of [MR5] (Officers were holding both arms). Immediately after releasing [MR5] then sat down on the bed and began to state that everyone was corrupt. ... ."

Review of "Incident File Full Report" Security documentation sheet [MR5] dated November 1, 2010, 5:12 revealed, " On the above date and time these officers [EMP11] and [EMP12] responded to the adult psych unit to assist with medications. ... Subject was holding the door shut in the restroom and refusing to exit. This officer [EMP11] positioned to the side with O.C. spray in position. [EMP12] informed the subject that if [MR5] did not come out and comply with staff, [MR5] would be sprayed. The subjects tone changed instantly, [MR5] stated that [MR5] was sprayed twice before and did not want to be sprayed again. Subject exited the restroom without incident and allowed staff to administer I.M. medication. ... ."

Review of "Incident File Full Report" Security documentation dated March 16, 2011, " ... [MR6] was being held to the floor ... . At this time the patient was then taken control of and placed on the floor. The patient was then lifted while maintaining control by security and DEM staff and placed on the cart in cubical in #29. ... ."

Review of "Incident File Full Report" Security documentation dated October 30, 2010, " ... pt was then physically controlled and put down on the bed, while restraints were retrieved from the storage room, as Officers held the patient [MR11] on the bed pt continued to resist and try to strike Officers. ... ."

Review of "Incident File Full Report" Security documentation dated April 2, 2011, " ... I at this time grabbed the patient [MR12] and did take pt down. ... ."

Review of "Incident File Full Report" Security documentation dated February 14, 2011, " ... that occurred while using force to control [MR13] prior to the four point restraints be applied. ... ."

Review of "Incident File Full Report" Security documentation dated November 19, 2010, " ... All officers closed at this point in order to gain control of [MR14] limbs and body. ... Officers [EMP10], [EMP5], and [EMP4], were attempting to gain upper body control and move [MR14] to the floor. This officer took hold of [MR14] legs assisting in taking [the patient] to the floor. ... ."

3) Review of [MR1], [MR3], [MR4], [MR5], [MR6], [MR7], [MR8], [MR12], and [MR14], revealed no documented evidence of the one or more of the following medical record requirements: completion of physician order for use of force or handcuffs, nursing flowsheet restraint documentation related to use of force or handcuffs, least restrictive alternatives/attempted interventions prior to use of force or handcuff placement, and face to face documentation following the use of force or handcuff placement.

4) An interview was conducted with [EMP3] on March 16, 2011, at 14:30 PM. [EMP3] stated, "It's not standard that we go. We go up [to the Behavioral Health Unit] when we're called, when patients are out of control if nothing else can be done. We track all of our interaction. We would use handcuffs as a last resort and take them off as soon as we can. My officers are familiar with de-escalation and have CIT training." [EMP3] stated that it was not policy for security to respond to the Behavioral Health Unit when a patient refuses medications.

5) An interview was conducted with [EMP3] on April 4, 2011, at 11:30 AM. [EMP3] was queried in regard to the Security Department considering itself law enforcement. [EMP3] stated, "There is a fine line there. We are not a police department. Patients may be discharged into the custody of law enforcement. It is common practice for us to be called by Behavioral Health to assist and a report is filed. Handcuffs are a last resort used to protect themselves and the staff."

6) An interview with [EMP3] was conducted on April 15, 2011, at approximately 1:30 PM. [EMP3] stated, "Every officer is trained on handcuffs. Nursing is aware that handcuffs are an option. After the order is obtained from the doctor, security does assist nursing with the application of restraints." [EMP3] stated that the security policies are approved by himself and not the medical staff.

7) An interview was conducted with [EMP5] on May 5, 2011, at 11:25 AM. [EMP5] stated, "It is clearly our judgment to use handcuffs. The staff does not direct us. We are called upstairs to psych frequently for disturbances there. Handcuffs are rare; it's a last resort for us. It is for safety for property damage, staff and us. They are removed as soon as restraints and adequate staff is present."

8) An interview was conducted with [EMP16] on May 5, 2011, at 10:30 AM. [EMP16] was asked about the usage of handcuffs by the security personnel. [EMP16] revealed, " ... I personally review every report of security. Ninety-nine percent was from staff that was scared and called security. Things like handcuffs require clinical direction. Handcuffs are treated like any other restraint. The clinician who directs the nurse of physician directs security to use the handcuffs. We will only use handcuffs as directed to. The officers do not make the call for use of handcuffs. ... I am certain that the CEO is aware of usage of handcuffs. I occasionally forward the I track reports to the VP of Nursing and CEO. The strongest weapon is pepper spray. I have not reviewed an I track report that pepper spray has been used in the two years I have been in this position."

9) An interview was conducted with [EMP9] on May 5, 2011, at 10:55 AM. [EMP9] was asked if they ever used handcuffs. [EMP9] revealed, "Yes, I cuffed a patient. Recently I had CIT training. I have not had to handcuff since training three weeks ago. It's verbalization to the patient now." The question was asked of who directs you to handcuff a patient. [EMP9] stated, "If we feel we are in jeopardy of being hurt or staff or visitors, if we feel safety is an issue, we utilize handcuffs. No one directs me to use a handcuff, that's a pretty last resort. Handcuffs are used as a tool until the four points twice as tough are applied. We have had training on applying restraints. ... I have never had to use pepper spray myself. Let me add, I feel with this day and age, we need the handcuffs."

10) An interview was conducted with [EMP5] on May 5, 2011, at 11:25 AM. [EMP5] was asked who directs Security to use handcuffs. [EMP5] stated, "Directed by us, only officers. It is clearly our judgment to use handcuffs. The staff does not direct us. We are called upstairs to psych frequently for disturbances there. Handcuffs are rare; it's a last resort for us. It is for safety for property damage, staff and us. They are removed as soon as restraints and adequate staff is present." When asked about pepper spray, [EMP5] revealed, "I used pepper spray one time last year. It was for an adolescent, for a barricaded patient, for staff to gain access to the room. Pt was throwing two by two drywall at us. ... ."

Based on review of facility policies, facility documentation, and interview with facility staff (EMP), it was determined that the facility failed to obtain a physician order for restraints for 10 of 10 patients (MR1, MR2, MR3, MR4, MR5, MR6, MR11, MR12, MR13, MR14).

Findings include:

Review of facility policy "Conemaugh Health System Memorial Medical Center Organizational Policy Manual Title: Restraint and Seclusion Policy" revised November 2009, revealed, " ... The purpose of this policy is to provide guidelines for the use of restraint and seclusion. Memorial Medical Center is committed to preventing and reducing restraint and seclusion use, as well as striving to eliminate use. ... Physician's Orders 1. Orders for restraints and seclusion must be either written or verbally given by a licensed independent practitioner. * Only a physician or resident can write these orders. ... ."

Review of facility policy "Restraint and Seclusion Department: Behavioral Medicine" dated March 2011, revealed, " ... 1.0 Policy The purpose of this policy is to provide guidelines for the use of restraint and seclusion. ... 7.0 Physician Orders 1. Orders for restraint and seclusion must either be written or verbally given by a physician.


1) Review of "Incident File Full Report" Security documentation dated October 2010 to the present revealed 70 data reports in which Security was called for assistance in the emergency department, adult, child and geri behavioral health units.

Review of "Incident File Full Report" Security documentation dated February 23, 2011, 13:49 was reviewed. The report stated, "On the above date and time [EMP4] and [EMP5], [EMP5] was dispatched to 10-10 (Adult Psych) to assist staff with a patient. Officers arrived shortly after, [EMP2] advised Officers that the patient standing at the nurses [sic] station (Later identified as [MR1]) needed to have medications and to go back to room. [EMP5] then directed [MR1] to cooperate with staff and walk back to [MR1] room. [MR1] replied "I'm not taking any meds." [MR1] then walked back the hall towards [MR1] room (GS7706) and prior to entering [MR1] stated to [EMP4] and [EMP5] 'I'm not going in their [sic] I don't care.' [EMP5] then advised [MR1] that we would then have to physically take [MR1] in the room. [MR1] replied 'I'm not going in.' [EMP4] and [EMP5], each taking control of a [sic] arm then began to walk [MR1] into the room. [MR1] then attempted to punch [EMP4] with [MR1] left fist. Both Officers then physically move [sic] [MR1] from the hallway and into the room. While [MR1] was combatively resisting (attempting to punch) Officers [MR1] did strike the left side of [MR1] face off of the bathroom door, which was open approximately two feet. Officers then physically moved [MR1] to the bed where [MR1] continued to resist by attempting to punch, elbow and kick Officers and staff member [EMP6]. [EMP4] then handcuffed [MR1] and while holding [MR1] on the bed [EMP2] administer [sic] on injection of medication. [EMP5] was then instructed by [EMP2] to remove the handcuffs after [MR1] agreed to cooperate with all staff directions. [EMP5] then removed the handcuffs without incident. [EMP2] then checked [MR1] for injuries and reported no injuries to [EMP5] at that time and also no staff were injured. Both Officers then stood by on the unit and were cleared to depart by [EMP2] approximately five minutes after [MR1] was released from the handcuffs."


Review of "Incident File Full Report" Security documentation [MR2] dated October 5, 2010, revealed, " ... Sublocation: Emergency Room ... Myself and Badge 4 gained control of the resisting subject and proned [MR2] against the wall, I grabbed the knife and secured it, then cuffed the subject. The subject continued to resist and was reaching for [MR2] back pocket for I felt [MR2] was attempting to obtain another weapon. ... I took the detained subject into the lot upon police presence and JPD did take [MR2] into custody. ... ."

Review of "Incident File Full Report" Security documentation [MR3] dated March 23, 2011 revealed, " ... Sublocation: Emergency Medicine ... After [MR3] was physically restrained with the handcuffs, [MR3] was placed on a bed and wheeled to cubicle #26. [MR3] attempted many times to get off the bed and had to be physically held down and placed into "twice as tough" four point restraints. [MR3] continued with the verbal and physical attempts to get free for some time, even after two IM's were given to [MR3] by DEM staff. At one point, [MR3] was able to get free [MR3] left wrist from a restraint, and was attempting to flip [MR3] bed onto its side. Officer ... arrived and did assist me to restrain this wrist a second time. No injuries to staff or patient were reported. Officers were cleared to leave ... ."

Review of "Incident File Full Report" Security documentation [MR4] dated December 1, 2010, revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On 12/1/2010 at 1130 hours, security dispatched available officers to responds to the Adult Psych Unit to assist with a patient who is refusing to shower .... [EMP7] and [EMP8] continued to try and explain to the patient why [MR4] needs to shower and that is policy for patient to have a shower every day or every other day. ... Every attempt was made by the unit staff to convince the patient to shower, but [MR4] continued refusing. So [EMP9], [EMP5] and I [EMP10] tried to escort the patient back to the room for patient showering ... but the patient became combative and had to be place in handcuffs, then taken to the shower room where staff members [EMP7] and [EMP8] washed the patient while security officers assisted holding the patient still. After the showering process, the patient was dressed in hospital gown and pants ... cuffs were removed ... ."

Further review of "Incident File Full Report" Security documentation [MR5] dated November 1, 2010, 10:56 revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On the above date and time [EMP10], [EMP17] and [EMP5] were dispatched to 10-10 (Adult Psych) to assist with a patient. When all Officers arrived shortly after [EMP1] advised Officers that staff needed to medicate patient [MR5] and change into hospital clothing (gown and hospital pants). [MR5] who was standing at the nurses station then began to yell at [EMP10] "I am leaving this place your all corrupt I'm not crazy." [EMP1] then advised [MR5] that [MR5] needed to walk back to [MR5] room. [MR5] did comply and walked back to [MR5] room without incident other than repeating the same phrases as written above. When at [MR5] room ... [EMP1] advised [MR5] that [MR5] will need to take some medications and change into that so I look crazy" [MR5] then removed a pen from [MR5] pants pocket and threaten to stab Officers and Staff stating "Anyone of you come near me I'm going to stab you, I'll stab all of you, I want out of here' This Officer then remove my pepper spray and held it at my side. [MR5] did view this Officer remove the spray and when [EMP1] asked [MR5] to lay the pen down [MR5] then threw it on the floor in front of [EMP10]. ... [EMP1] then advised [MR5] that [MR5] needed to now change into hospital clothing. [MR5] then became combative and began swinging [MR5] arms at Officers. Officers [EMP10], [EMP17] and I then Physically moved [MR5] from a standing position to a prone position on the floor. Officers then Held [MR5] as [EMP18] change [MR5] into Hospital clothing. [EMP1] then instructed Officers to pick [MR5] up and asked [MR5] if [MR5] is going to keep [MR5] under control, listen to staff and stay in [MR5] room. [MR5] replied "yea". EMP1 then instructed Officers to let go of [MR5] (Officers were holding both arms). Immediately after releasing [MR5] then sat down on the bed and began to state that everyone was corrupt. ... ."

Review of "Incident File Full Report" Security documentation sheet [MR5] dated November 1, 2010, 5:12 revealed, " On the above date and time these officers [EMP11] and [EMP12] responded to the adult psych unit to assist with medications. ... Subject was holding the door shut in the restroom and refusing to exit. This officer [EMP11] positioned to the side with O.C. spray in position. [EMP12] informed the subject that if [MR5] did not come out and comply with staff, [MR5] would be sprayed. The subjects tone changed instantly, [MR5] stated that [MR5] was sprayed twice before and did not want to be sprayed again. Subject exited the restroom without incident and allowed staff to administer I.M. medication. ... ."

Review of "Incident File Full Report" Security documentation dated March 16, 2011, " ... [MR6] was being held to the floor ... . At this time the patient was then taken control of and placed on the floor. The patient was then lifted while maintaining control by security and DEM staff and placed on the cart in cubical in #29. ... ."

Review of "Incident File Full Report" Security documentation dated October 30, 2010, " ... pt was then physically controlled and put down on the bed, while restraints were retrieved from the storage room, as Officers held the patient [MR11] on the bed pt continued to resist and try to strike Officers. ... ."

Review of "Incident File Full Report" Security documentation dated April 2, 2011, " ... I at this time grabbed the patient [MR12] and did take pt down. ... ."

Review of "Incident File Full Report" Security documentation dated February 14, 2011, " ... that occurred while using force to control [MR13] prior to the four point restraints be applied. ... ."

Review of "Incident File Full Report" Security documentation dated November 19, 2010, " ... All officers closed at this point in order to gain control of [MR14] limbs and body. ... Officers [EMP10], [EMP5], and [EMP4], were attempting to gain upper body control and move [MR14] to the floor. This officer took hold of [MR14] legs assisting in taking [the patient] to the floor. ... ."

2) Review of [MR1], [MR3], [MR4], [MR5], [MR6], [MR7], [MR8], [MR12], and [MR14], revealed no documented evidence of the one or more of the following medical record requirements: completion of physician order for use of force or handcuffs, nursing flowsheet restraint documentation related to use of force or handcuffs, least restrictive alternatives/attempted interventions prior to use of force or handcuff placement, and face to face documentation following the use of force or handcuff placement.

Based on review of facility policies, facility documentation, and interview with staff (EMP), it was determined that Conemaugh Health System Memorial Medical Center failed to ensure that a one hour face to face evaluation occurred and/or was documented following the use of force or handcuff placement for 10 of 10 patients. (MR1, MR2, MR3, MR4, MR5, MR6, MR11, MR12, MR13, MR14).

Findings include:

Review of facility policy "Conemaugh Health System Memorial Medical Center Organizational Policy Manual Title: Restraint and Seclusion Policy" revised November 2009, revealed, " ... 9. When applying a Self-Destructive-Emergency Restraint, the physician or Registered Nurse or Physicians assistant (has completed Secure Training) must see the patient face to face and evaluate the need for restraint/seclusion within one hour after initiation of the intervention. ... ."

Review of facility policy "Restraint and Seclusion Department: Behavioral Medicine" dated March 2011, revealed, " ... 9.0 Restraint Assessment (One-Hour Rule) 1. ... If the patient recovers quickly and is released from restraint/seclusion within the first hour of use, the RN/physician/physician assistant must still complete the one hour face-to-face evaluation. 2. One-hour-face-to-face assessment: The physician, physician assistant, or a qualified RN shall perform a face-to-face assessment of the patient's physical an psychological status within 1 hour of the initiation of the restraint. This assessment shall include and be documented in the medical record: The patient's immediate situation, The patient's reaction to the intervention, The patient's medical and behavioral condition, The need to continue or terminate the restraint or seclusion, Provide guidance in ways to help patient gain control. ... 14.0 Staff Training and Competency 1. ... Training takes place during departmental or medical staff orientation and shall be repeated at least annually in the department's educational plan. The education plan shall include; de-escalation and non-physical techniques and alternatives to avoid use of restraint and seclusion, training on identifying early warning signs of physical and psychological distress, safe application and release of restraints, and return demonstrations or post training tests required by nationally recognized course or program. ... ."


1)Review of "Incident File Full Report" Security documentation dated October 2010 to the present revealed 70 data reports in which Security was called for assistance in the emergency department, adult, child and geri behavioral health units.

Review of "Incident File Full Report" Security documentation dated February 23, 2011, 13:49 was reviewed. The report stated, "On the above date and time [EMP4] and [EMP5], [EMP5] was dispatched to 10-10 (Adult Psych) to assist staff with a patient. Officers arrived shortly after, [EMP2] advised Officers that the patient standing at the nurses [sic] station (Later identified as [MR1]) needed to have medications and to go back to room. [EMP5] then directed [MR1] to cooperate with staff and walk back to [MR1] room. [MR1] replied "I'm not taking any meds." [MR1] then walked back the hall towards [MR1] room (GS7706) and prior to entering [MR1] stated to [EMP4] and [EMP5] 'I'm not going in their [sic] I don't care.' [EMP5] then advised [MR1] that we would then have to physically take [MR1] in the room. [MR1] replied 'I'm not going in.' [EMP4] and [EMP5], each taking control of a [sic] arm then began to walk [MR1] into the room. [MR1] then attempted to punch [EMP4] with [MR1] left fist. Both Officers then physically move [sic] [MR1] from the hallway and into the room. While [MR1] was combatively resisting (attempting to punch) Officers [MR1] did strike the left side of [MR1] face off of the bathroom door, which was open approximately two feet. Officers then physically moved [MR1] to the bed where [MR1] continued to resist by attempting to punch, elbow and kick Officers and staff member [EMP6]. [EMP4] then handcuffed [MR1] and while holding [MR1] on the bed [EMP2] administer [sic] on injection of medication. [EMP5] was then instructed by [EMP2] to remove the handcuffs after [MR1] agreed to cooperate with all staff directions. [EMP5] then removed the handcuffs without incident. [EMP2] then checked [MR1] for injuries and reported no injuries to [EMP5] at that time and also no staff were injured. Both Officers then stood by on the unit and were cleared to depart by [EMP2] approximately five minutes after [MR1] was released from the handcuffs."

Review of "Incident File Full Report" Security documentation [MR2] dated October 5, 2010, revealed, " ... Sublocation: Emergency Room ... Myself and Badge 4 gained control of the resisting subject and proned [MR2] against the wall, I grabbed the knife and secured it, then cuffed the subject. The subject continued to resist and was reaching for [MR2] back pocket for I felt [MR2] was attempting to obtain another weapon. ... I took the detained subject into the lot upon police presence and JPD did take [MR2] into custody. ... ."

Review of "Incident File Full Report" Security documentation [MR3] dated March 23, 2011 revealed, " ... Sublocation: Emergency Medicine ... After [MR3] was physically restrained with the handcuffs, [MR3] was placed on a bed and wheeled to cubicle #26. [MR3] attempted many times to get off the bed and had to be physically held down and placed into "twice as tough" four point restraints. [MR3] continued with the verbal and physical attempts to get free for some time, even after two IM's were given to [MR3] by DEM staff. At one point, [MR3] was able to get free [MR3] left wrist from a restraint, and was attempting to flip [MR3] bed onto its side. Officer ... arrived and did assist me to restrain this wrist a second time. No injuries to staff or patient were reported. Officers were cleared to leave ... ."

Review of "Incident File Full Report" Security documentation [MR4] dated December 1, 2010, revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On 12/1/2010 at 1130 hours, security dispatched available officers to responds to the Adult Psych Unit to assist with a patient who is refusing to shower .... [EMP7] and [EMP8] continued to try and explain to the patient why [MR4] needs to shower and that is policy for patient to have a shower every day or every other day. ... Every attempt was made by the unit staff to convince the patient to shower, but [MR4] continued refusing. So [EMP9], [EMP5] and I [EMP10] tried to escort the patient back to the room for patient showering ... but the patient became combative and had to be place in handcuffs, then taken to the shower room where staff members [EMP7] and [EMP8] washed the patient while Security officers assisted holding the patient still. After the showering process, the patient was dressed in hospital gown and pants ... cuffs were removed ... ."

Further review of "Incident File Full Report" Security documentation [MR5] dated November 1, 2010, 10:56 revealed, " ... Sublocation: Adult Inpatient Psychiatric Unit ... On the above date and time [EMP10], [EMP17] and [EMP5] were dispatched to 10-10 (Adult Psych) to assist with a patient. When all Officers arrived shortly after [EMP1] advised Officers that staff needed to medicate patient [MR5] and change into hospital clothing (gown and hospital pants). [MR5] who was standing at the nurses station then began to yell at [EMP10] "I am leaving this place your all corrupt I'm not crazy." [EMP1] then advised [MR5] that [MR5] needed to walk back to [MR5] room. [MR5] did comply and walked back to [MR5] room without incident other than repeating the same phrases as written above. When at [MR5] room ... [EMP1] advised [MR5] that [MR5] will need to take some medications and change into that so I look crazy" [MR5] then removed a pen from [MR5] pants pocket and threaten to stab Officers and Staff stating "Anyone of you come near me I'm going to stab you, I'll stab all of you, I want out of here' This Officer then remove my pepper spray and held it at my side. [MR5] did view this Officer remove the spray and when [EMP1] asked [MR5] to lay the pen down [MR5] then threw it on the floor in front of [EMP10]. ... [EMP1] then advised [MR5] that [MR5] needed to now change into hospital clothing. [MR5] then became combative and began swinging [MR5] arms at Officers. Officers [EMP10], [EMP17] and I then Physically moved [MR5] from a standing position to a prone position on the floor. Officers then Held [MR5] as [EMP18] change [MR5] into Hospital clothing. [EMP1] then instructed Officers to pick [MR5] up and asked [MR5] if [MR5] is going to keep [MR5] under control, listen to staff and stay in [MR5] room. [MR5] replied "yea". EMP1 then instructed Officers to let go of [MR5] (Officers were holding both arms). Immediately after releasing [MR5] then sat down on the bed and began to state that everyone was corrupt. ... ."

Review of "Incident File Full Report" Security documentation sheet [MR5] dated November 1, 2010, 5:12 revealed, " On the above date and time these officers [EMP11] and [EMP12] responded to the adult psych unit to assist with medications. ... Subject was holding the door shut in the restroom and refusing to exit. This officer [EMP11] positioned to the side with O.C. spray in position. [EMP12] informed the subject that if [MR5] did not come out and comply with staff, [MR5] would be sprayed. The subjects tone changed instantly, [MR5] stated that [MR5] was sprayed twice before and did not want to be sprayed again. Subject exited the restroom without incident and allowed staff to administer I.M. medication. ... ."

Review of "Incident File Full Report" Security documentation dated March 16, 2011, " ... [MR6] was being held to the floor ... . At this time the patient was then taken control of and placed on the floor. The patient was then lifted while maintaining control by Security and DEM staff and placed on the cart in cubical in #29. ... ."

Review of "Incident File Full Report" Security documentation dated October 30, 2010, " ... pt was then physically controlled and put down on the bed, while restraints were retrieved from the storage room, as Officers held the patient [MR11] on the bed pt continued to resist and try to strike Officers. ... ."

Review of "Incident File Full Report" Security documentation dated April 2, 2011, " ... I at this time grabbed the patient [MR12] and did take pt down. ... ."

Review of "Incident File Full Report" Security documentation dated February 14, 2011, " ... that occurred while using force to control [MR13] prior to the four point restraints be applied. ... ."

Review of "Incident File Full Report" Security documentation dated November 19, 2010, " ... All officers closed at this point in order to gain control of [MR14] limbs and body. ... Officers [EMP10], [EMP5], and [EMP4], were attempting to gain upper body control and move [MR14] to the floor. This officer took hold of [MR14] legs assisting in taking [the patient] to the floor. ... ."

2) Review of [MR1], [MR3], [MR4], [MR5], [MR6], [MR7], [MR8], [MR12], and [MR14], revealed no documented evidence of the one or more of the following medical record requirements: completion of physician order for use of force or handcuffs, nursing flowsheet restraint documentation related to use of force or handcuffs, least restrictive alternatives/attempted interventions prior to use of force or handcuff placement, and face to face documentation following the use of force or handcuff placement

3) A second interview was conducted with EMP13 on May 27, 2011, at approximately 2:00 PM. EMP13 was queried regarding patient face-to-face documentation following placement of restraints. EMP13 confirmed that there is a section on the physician order sheet for behavioral restraints that included the physician or licensed independent practitioner face-to-face documentation.
The physician order revealed, " ... I have examined this patient and restraints are necessary. Reason: Danger to self, Danger to others, Other/Annotate Physician or Licensed Independent Practitioner Signature Date and Time."
EMP 13 confirmed that it was difficult to ascertain whether physician signature, date and time, was for the actual behavioral restraint order or for the face-to-face documentation.