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420 S 5TH AVENUE

WEST READING, PA 19611

PATIENT RIGHTS

Tag No.: A0115

A hospital must protect and promote each patient's rights.

This CONDITION is not met as evidenced based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that the facility failed to utilize the least restrictive measure in the application of restraints (482.13 Tag A-0165) and failed to ensure that staff were properly trained on the use of physical restraints or received training annually in accordance with facility policy (482.13 Tag A-0196).


Cross Reference:
482.13 (e)(3) Patient Rights: Restraint or Seclusion
482.13(f)(1) Patient Rights: Restraint or Seclusion

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0165

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the type of restraint used was the least restrictive device that will be effective in four of five patients restrained with Posey Twice-As-Tough Cuffs (MR1, MR5, MR7, MR8).

Findings include:
Review of facility policy titled "Use of Force by Reading Hospital Security Officers" with a revision date of December 2022, revealed "... Purpose: To provide guidance on the use of any force against another individual. Policy: ... 5. Use of Force may only be exercised by trained security officers who will make every effort to protect the dignity, rights, and well-being of all individuals. ... Procedure: 1. ... The process here is to apply the least intrusive intervention first. ..."

Review of facility policy, "Restraint" with a last revision date of February 2022, revealed " ... Definitions: Physical Restraint: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Devices implemented for physical restraint include, but are not limited to, Bed Side Rails, Geri Chair/Tabletop Chair, Hand Mitt, Soft Limb Restraint or Locked Cuff Restraint. ... Procedure ... C. Restraint (nonviolent/non-self-destructive versus violent/self-destructive) is not specific to any treatment setting or device type but is determined by the specific situation/behavior. ... III. Violent/Self-Destructive Restraint A. Restraint used in a crisis or emergency when an unanticipated outburst of severely aggressive, combative, or destructive behavior poses immediate, danger to the patient, other patients, staff, or others. B. Used only when less restrictive interventions have been determined to be ineffective ..."

Review of manufacturer information for the double locking wrist and ankle restraints called Posey Twice-As-Tough Cuffs revealed "Description: Locking Twice-as-Tough Cuffs ... these locking cuffs have the added safety and security that locks provide. ... Restraint Cuff comes with a lock on both the cuff and the connecting strap ... and come with two Universal Posey Keys."

Review of MR1 on March 9, 2023, revealed patient was admitted to the Emergency Room via ambulance on January 16, 2023, at 10:54 PM with history of epilepsy. Patient was taken to the hospital for multiple seizers. Other diagnosis included Anxiety, Hypertension, Depression, and Obesity. Patient was admitted and monitored; status epilepticus was excluded with testing. Further review of MR1 showed that patient was "agitated" on January 18, 2023, at 6:00 PM and found out of bed. Doctor notified and ordered Zyprexa. While waiting for the order the patient started to become more aggressive. Patient removed monitoring equipment and IV, left his room and was wandering on the floor. Nursing attempted to redirect. Security was called. Patient appeared to be hallucinating, charging towards staff, and behaving unusually, trying to grab things in the air. Security placed patient in 4-point, double lock cuff restrains from 7:32 PM on January 18, 2023, to 12:40 AM on January 19, 2023. The MR had no documentation to support the use of the twice-as Tough Cuffs (double locking requiring a key) for wrist and ankles as a 4-point physical restraint was the least restrictive physical restraint to keep the patient and others safe. There was no documentation that the facility considered or attempted the use of less restrictive devices such as Velcro restraints without locks or other devices.

Review of MR5 on March 9, 2023, revealed patient arrived in the Emergency Room via ambulance on January 9, 2023, for blast injury of right hand, delusions, and paranoia. Further review of MR5 revealed that on January 15, 2023, patient began refusing medications and becoming aggressive. Staff was unable to redirect. Security was called. When security arrived, patient became combative with security guards. Security initiated and applied Twice -As-Tough Cuffs (double locking, requiring a key) for wrist and ankles as a 4-point physical restraint with a total of 8 locks. Locked cuff restraints were applied to this patient from 8:46 AM to 11:11 AM on January 15, 2023. The MR had no documentation to support the use of the twice-as Tough Cuffs (double locking requiring a key) for wrist and ankles as a 4-point physical restraint was the least restrictive physical restraint to keep the patient and others safe. There was no documentation that the facility considered or attempted the use of less restrictive devices such as Velcro restraints without locks or other devices.

Review of MR7 on March 9, 2023, revealed patient walked into the Emergency Department on February 14, 2023, and was admitted with a diagnosis of Hallucinations and Parkinson disease. Further review of the MR documented on February 18, 2023, patient became combative with staff and was hitting and kicking. Staff was unable to redirect and called security. Security applied 4-point locked cuffs. Locked cuff restraints were applied to this patient from 10:00 PM on February 18, 2023, to 4:59 AM on February 19, 2023. The MR had no documentation to support the use of the twice-as Tough Cuffs (double locking requiring a key) for wrist and ankles as a 4-point physical restraint was the least restrictive physical restraint to keep the patient and others safe. There was no documentation that the facility considered or attempted the use of less restrictive devices such as Velcro restraints without locks or other devices.

Review of MR8 on March 9, 2023, revealed patient was brought into the Emergency Department (ED) on January 8, 2023, on a voluntary commitment for psychiatric care. While in the ED the patient became agitated, aggressive, and threatening. Security was called. Security applied 4-point locked cuff restraints to this patient from 6:15 PM to 10:15 PM on January 9, 2023. The MR had no documentation to support the use of the twice-as Tough Cuffs (double locking requiring a key) for wrist and ankles as a 4-point physical restraint was the least restrictive physical restraint to keep the patient and others safe. There was no documentation that the facility considered or attempted the use of less restrictive devices such as Velcro restraints without locks or other devices.

Interview with EMP1 on March 9, 2023, at approximately 6:00 PM, confirmed the facility failed to determine and document less restrictive measures were attempted prior to security applying the double locked cuffs.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0196

Based on review of facility documents, staff interview (EMP) and personnel files, it was determined that the facility failed to provide training for 16 of 16 security personnel in need of annual restraint training ( PF1, PF7, PF8, PF9, PF10, PF11, PF12, PF13, PF14, PF15, PF16, PF17, PF18, PF19, PF20, PF21).

Findings include:

On March 9, 2023, a review of the facility policy "Restraint" with revision date of February 2022, revealed "Policy: I. Reading Hospital is committed to the prevention, reduction, and elimination of the use of restraint. A. Through the use of education, training leaders and direct care staff will work to prevent situations that have the potential to lead to the use of restraint .... Education and Training: II. Staff will be trained and able to demonstrate competency prior to providing care for a patient in restraint, as part of orientation and subsequently on an annual basis ...."


Review of PF1 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF7 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF8 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF9 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF10 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022 .

Review of PF11 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF12 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF13 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF14 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF15 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF16 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF17 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF18 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF19 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF20 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.

Review of PF21 (Security personnel) on March 9, 2023, revealed no documentation of restraint training annually. The last documented training for restraints was on September 28, 2021, prior to policy revision on February 2022.


Interview with EMP1 (Director of Regulatory Affairs) on March 9, 2023, at approximately 5:20 PM confirmed that the above 16 PF did not complete restraint training in the past year and no annual restraint training had been provided. EMP1 confirmed the most recent annual restraint training occurred on September 28, 2021 prior to the Restraint policy updates dated February 2022.