The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on document review and interview, the facility failed to ensure that the facility Policy clearly identifies which staff received training and can apply restraints.

This failure results in being unclear which staff are appropriate to apply restraints.


The facility's Policy titled "Public Safety Department Policy and Procedure" Section 4.27 "Securities role when restraining a patient", last updated 05/15, documents that it is the responsibility of the Clinical Staff to place the restraints on the patients' wrists and ankles during a physical restraint.

Per interview with Staff T on 11/10/16 at 10:30AM, the Security Guards do not apply restraints. They work under the guidance of the Clinical Staff in assisting to hold the patient if necessary. However, this staff member is the Supervisor and does not have training in the use of restraints.

During an interview with Staff S on 11/10/16 at 10:30PM, the staff member stated that he personally does participate with the application of both wrist and ankle restraints. He advises he does work with the Clinical Staff when he performs this action.

During an interview with Staff R on 11/10/16 at 1:30PM, the staff member advised that he follows the Nurses' lead when a patient needs to be restrained. He advised that if there is no Patient Care Associate available, or if there is one and they are new and do not know how to apply them, he will apply the restraints to the wrists and ankles if a 4 Point Restraint is ordered by the Doctor.

He stated "We will also assist in applying 4 Point Restraints in the Emergency Department when someone comes in for detox or drugs and they are agitated."

The Lesson Plan Training Materials titled "Restraint and Seclusion" dated 01/16 documents that "only qualified staff with validated competency may apply restraints as per manufacturer's directions".

A review of Staff Members R and S Personnel Files revealed that CPR, First Aid, verbal de-escalation techniques and training of the application / use of restraints was current. This was confirmed during an interview with Staff T.
Based on Medical Record review, document review and interview, the facility did not have an updated Investigation Policy and Procedure for the Psychiatry Department reflecting the investigative process currently in place for incident investigations. This was evident in two (2) of two (2) Psychiatric Medical Records.

This lapse in current Policy resulted in inconsistent and potentially untimely internal investigations conducted by the Department of Psychiatry.


The facility' Policy & Procedure titled "Incident / Patient Safety Event Reporting" last approved 05/07/2015 stated " Incident Reports can be completed from any computer desktop through the Verge [Incident Reporting] application ... Additional paper forms are: OMH-147 (Office of Mental Health). This form is used to report all incidents involving a patient in the Department of Psychiatry / Psychology ..."

The Psychiatric Department's Policy & Procedure titled "Incident Management" last revised 02/2015 directed staff reporting all incidents involving patients to use "the OMH-147 form, and the Verge Solutions System [for incident reporting]". This Policy also states that a Physician initiates the investigation, and Unit Investigators can request special investigations through the Special Review Committee (SRC) by contacting the Chair of the SRC, where an Ad Hoc Meeting will be convened to plan and implement a special investigation.

Review of Patient #12's Medical Record revealed an allegation of abuse incident occurred on 10/29/16 at 8:22AM, which the patient reported to staff on 11/02/16.

Incident Reports Review for 10/2016 and 11/2016 revealed that no Incident Reports had been initiated for this incident.

Interview with Staff B on 11/14/16 at 2:00PM revealed that an investigation was initiated on 11/02/16 by the Risk Manager, but an "Incident Report was not initiated".

Review of Patient #1's Medical Record revealed that an allegation of abuse incident occurred on 10/14/16 at 3:50AM, which, after a Nursing observation, the patient reported to the staff on 10/17/16. The investigation was initiated and investigated by the Department Risk Manager, not a Physician as stated in the "Incident Management" Policy.

An interview with Staff A on 11/10/16 at 2:30PM revealed that the paper OMH form is no longer being utilized and the Psychiatric Department's investigative process outlined in the "Incident Management Policy" is not the investigative process currently in practice. She stated some that Nursing Staff may still use the paper form for their personal information gathering, but all are required to enter the information electronically into the Verge Application. Staff A indicated that the Policy directing staff to utilize the paper OMH form for Incident Reporting is not accurate.

Interview with Staff Members A and B on 11/10/16 at 10:50AM revealed that the current investigation process delivers email notifications to both the Director or Risk Management and the Psychiatric Risk Manager upon initiation of the Verge Incident Report.

As per interview with Staff A on 11/10/16 at 2:30PM, the staff member explained that the investigative process is initiated by the Psychiatric Department's Risk Manager from the initial email notifications, where then patient interviews, external reporting, patient / staff safety actions, as well as the collection of staff statements, photos, and other investigative actions will be initiated. Appropriate actions, such as staff re-education, counseling, etc., will also be identified and initiated. Completed incident investigations are all reviewed, tracked and trended by the Incident Review Committee for Psychiatry, then reported hospital-wide.

Staff A noted that the current Policy does not reflect the current investigative process utilized for incident investigations.
Based on Medical Record review, document review and interview, Psychiatric Nursing Staff did not accurately document skin reassessments for a patient with evidence of skin alterations. This failure in inconsistent assessment documentation may affect other providers' ability to monitor patients' condition or provide appropriate care.


Review of Patient #1's Medical Record identified that this patient presented to the Psychiatric Emergency Department (ED) on 10/14/16 at 3:02AM with erratic, anxious and paranoid behavior. Skin assessments performed in the Psychiatric ED revealed no evidence of skin breakdown or bruising. Patient #1 was later admitted to the Inpatient Unit, PSY01A, on 10/15/06 at 7:15PM.

The Initial Psychiatric Nursing Admission Form dated 10/15/16 at 7:35PM revealed that the patient denied a full skin assessment, but identified that Patient #1 had "Ecchymosis" (bruising) to the bilateral anterior upper extremities and a facial abrasion on the anatomical figure diagram.

The Skin Reassessments on 10/15/16 at 10:07PM, 10/16/16 at 1:48AM, 10/16/16 at 11:51AM and 10/17/16 at 1:58AM did not identify upper extremity bruising or a facial abrasion as noted on the initial skin assessment. Documentation revealed that patient had "no rash" and skin was "dry and intact". No other skin alterations were documented.

The Incident Report dated 10/17/16 at 1:28PM identified that Nursing Staff "observed black and blue bruising on patient's extremities ... patient [did] have bruising on arms and thigh ... and photographs [of the bruising on the upper extremities and thigh] were taken and sent to the Psychiatric Quality Management Department".

The Skin Reassessments dated 10/17/16 at 4:00PM through 11/01/16 at 12:15PM revealed thirty (30) skin reassessment entries, none of which documented the previously identified bruising. All skin reassessment documentation stated that the patient had "no rash" and skin was "dry and intact". No other skin alterations were identified or documented.

During an interview with Staff Members C and D on 11/10/16 at 11:00AM, Staff D explained that bruising would not be included in the skin reassessment if the patient was not being treated for it like an open wound.

The facility's Policy and Procedure titled "Daily Skin Reassessment" last revised 01/19/2012 stated "The Daily Skin Reassessment shall provide a record indicating ... the presence of any skin alterations ..."

During an interview with Staff A on 11/10/16 at 2:30PM, the staff member acknowledged these findings. Staff A indicated that although the Policy exempts Psychiatry Units from completing daily skin reassessments every shift, she would have expected that Patient #1's bruising, once identified, to have been reflected in the daily skin reassessments that followed. Staff A stated the new bruising in this case should have been considered a skin alteration.