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.

EXCELA HEALTH WESTMORELAND HOSPITAL 532 WEST PITTSBURGH STREET GREENSBURG, PA 15601 June 10, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility documents and medical records (MR), and staff interviews (EMP) it was determined that the facility failed to protect and promote each patient rights by failing to protect patients from abuse and harassment (0145) failing to keep patients free from restraints and seclusion of any form imposed as a means of coersion, discipline, convenience or retaliation (154) failing to ensure that restraints and seclusion was the least restrictive method to protect the patient, staff member or other 0165) failing to follow the restraint policy 0167) failing to ensure the use of restraints in accordance with an order from a physician or licensed independent practitioner 0168) failing to ensure that physicians and licensed independent practitioners authorized to order restraints and seclusion by hospital policy, have a working knowledge of the hospital policy regarding the use of restraints and by (0176) failing to ensure that physicians and licensed independent practitioners authorized to order restraints and seclusion by hospital policyand have a working knowledge of the hospital policy regarding the use of restraints (0185).

The condition is NOT MET as evidenced by:

Based on review of medical records (MR), review of facility documents and staff interview (EMP) it was determined that the facility failed to protect patient's rights for two of two medical records, (MR1, MR12). (0145)
Based on review of facility documentation, medical records (MR) and staff interviews (EMP), it was determined the facility failed to ensure patients were free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff for one of one medical record reviewed (MR1). (0154)
Based on review of facility documentation and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure restraint or seclusion was the least restrictive intervention that was effective to protect the patient, a staff member, or others from harm, for one of one medical record reviewed (MR1). (0165)
Based on review of facility documentation and medical records (MR), and staff interview (EMP), it was determined the facility failed to follow their policy on restraint and seclusion for one of one medical record reviewed (MR1). (0167)
Based on review of facility documentation, medical records, and staff interview revealed the facility failed to use restraints in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient for four of four incident reports reviewed. (0168)
Based on review of facility documentation and staff interview (EMP), it was determined the facility failed to ensure the "Policy and Procedure for Patient Restraint and Seclusion" revised February 2016, specified the training requirements for physicians and other licensed independent practitioners authorized to order restraint or seclusion. (0176)
Based on review of facility documentation and staff interview (EMP), it was determined the facility failed to ensure the medical record included the patient's behavior and the intervention used for one of one medical record reviewed (MR1). (0185)
Cross reference with:
482.13(c)(3): The patient has the right to be free from all forms of abuse or harassment.
482.13(e): Restraint or seclusion
482.13(e)(2): Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff memeber, or others from harm.
482.(e)(4)(ii): The use of restraints or seclusion must be implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with state law
482.13(e)(5): The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with state law.
482.13(e)(ii): Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed independent practitioners authorized to order restraint or seclusion by hospital policy in accordance with state law must have a working knowledge of hospital policy regarding the use of restraint or seclusion.
482.13(e)(16)(ii): When restraint or seclusion is used, there must be documentation in the patient's medical record of the following: A description of the patient's behavior and the intervention used.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of medical records (MR), review of facility documents and staff interview (EMP) it was determined that the facility failed to protect patient's rights for two of two medical records, (MR1, MR12)

Findings include:

Review of facility policy. Rights and Responsibilities of Patients. Reviewed April, 2014. ... . Care Delivery: ... . You have a right to: ... . 2. Recieve care in a safe setting. free from and form of abuse, harassment and neglect. ... .
1) Review of MR12, May 13, 2016, "Addendum by [EMP8], May 11, 2016, 12:05 EDT. In seclusion room, when patient was combative with security, patient continued to be physically aggressive against security. When this RN arrived to administer IM, patient was in handcuffs. Security reported it was for the safety of patient and others due to assault. Once IM administered, handcuffs removed by security. Patient was calm and cooperative. Staff called security monitor room X2 during patient's combative behavior toward security in seclusion room to request additional security. Security arrived to assist after second phone call. Security called Greensburg police to file charges against patient after event. ... ."
2) Telephone interview May 13, 2016 with EMP9, "We were called to the second floor, when we got there the nursing staff was locked in the med room. The patient grabbed me with both hands, we did get him toward the seclusion room. When we got to the seclusion room the patient punched him [Security], he hit his head on the door frame. I did get the patient down and handcuffed him."
3) Interview with EMP4, May 13, 2016, "We do not use restraints on the [Behavioral Health] units. [Former Behavioral Health Director] got rid of them when he was here. He wanted a healing place. [Former Behavioral Health Director] also wanted to get rid of the seclusion room, but we talked him into keeping it. I was not aware of the handcuff use. Night shift here is scary. One nurse and one aide. That night however we did have an extra rn to work. The patient was agitated asking for more meds, he had been given all he had been ordered. The nurse got an order and was drawing up the medication when the assault occurred."
4) Interview with EMP1, May 13, 2016, "They [security] do not need an order for handcuffs."
5) EMP1 was asked if restraints and locked seclusion are used on the inpatient behavioral health units at Excela Westmoreland? EMP1 responded, "No"
6) Review of facility documentation dated April 26, 2016, revealed "Narrative ... Security gained control of the patient (MR1) and assisted her to her bed. The patient was ready for transport at this time. Behavioral Health requested that the patient be transported by the security transport van ... and ... placed the patient in handcuffs at 1615 hours so the patient would not harm any staff or patients during the transport."
7) Review of MR1 revealed "History and Physical ... April 26, 2016 20:43 ... History and physical is severely limited secondary to this patient required restraints for patient's safety upon arrival to the floor and is currently in seclusion."

8) Interview with EMP4 on May 13, 2016, at approximately 2:30 PM when asked what restraints the patient required revealed "That means the handcuffs"

Cross reference with: 482.13(e), 482.13(e)(5), 482.13(e)(2)
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on review of facility documentation, medical records (MR) and staff interviews (EMP), it was determined the facility failed to ensure patients were free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff for one of one medical record reviewed (MR1).
Findings include:
Review of "Rights and Responsibilities of Patients" reviewed April 2014, revealed, " You have the right: ... 2. Receive care in a safe setting free from any form of abuse, harassment, and neglect. ... 7. Receive care free from restraints or seclusion unless necessary to provide medical, surgical, or behavioral health care."
Review of "Policy and Procedure for Patient Restraint and Seclusion" revised February 2016, revealed "A. Restraint: Restraint or seclusion is utilized to promote medical/surgical healing and limited to emergencies in which there is an imminent risk of an individual physically harming himself or herself, staff or others, and when less restrictive interventions are ineffective. Use of restraint or seclusion is not based on an individual's restraint or seclusion history or on a history of dangerous behavior. 1. Physical Restraint: Any manual method or 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. ... D. Restraints For Violent, Self-Destructive Behavior ... Forensic restrictions or restrictions imposed by correction authorities for security purposes. includes handcuffs and shackles."
Review of facility policy and procedure "Use Of Force Policy And Devices review/revised dates: November 2015 ... Use of Force Continuum-sis a standard that indicates what degree of force or other methods of compliance method that may be used in a given situation. The continuum progresses from situations where no force is generally the appropriate response to those situations where a lethal response may be necessary. ... The use of force policy should be followed, so that the appropriate level of force is used, consistent with the level of threat presented, to provide safety for people and protection for property. The level of force should be no more than is required to control the situation. Authorized personnel may use that level of force necessary to restore order and avoid/or avoid potential harm. Force shall not be used to compel a person to participate in or comply with a clinical treatment. ... Level 3 a. Situational Characteristics-Combative, demonstrates signs of potential violence b. Force Continuum-verbal communication to include demands for actor to leave, visual deployment of non-lethal compliance devices, PRO-V2 Response 1 may be used for this level or greater, contact local law enforcement if necessary. ... E. Level 5 a. Situational Characteristics-Physical violence is inevitable or occurring b. Force Continuum-use of non-lethal compliance methods such as sprays and PRO V2 Response 3 may be used for this level or greater. Police should be notified to press charges. ... Situational Characteristics Force Continuum ... Level 3 Combative Demonstrates signs of potential violence ... Verbal commands to include demands to leave. Approved Device Use Scale Pro V2 Response 1(Audio, Video Recording, Laser) Notification to Law Enforcement When/Where Appropriate Level 4 Verbal commands are ignored, Physical violence is appears likely Physical tactics and/or restraint as needed to counteract threat Approved Device Use Scale Pro V2 Response 2 (Alert Siren, Strobe Light) Hand cuff use permitted for levels 4 or greater Police should be notified to press charges when handcuffs are used. ... 1. Handcuffing: (Approved) ... Handcuffs may be used for Level 4 or greater Situational Characteristic as defined on the Use of Force Continuum if the Authorized personnel deem it necessary to control an actor preventing potential harm to self/others/or substantial property damage. ... Authorized Personnel must stay with actor when handcuffed ... B. If handcuffs are used on an actor, the Authorized personnel should promptly contact the local law enforcement authorities to report the incident. The authorities should be advised that handcuffs were used to subdue the actor. Authorized personnel should request law enforcement to arrest the actor if handcuffs are deployed. ... 3. Pro V2 (Approved) Pro V2 is a multifunctional compliance device. It incorporates distraction devices and a chemical gel (Visual-laser and a strobe set at 2 flashes per cycle. Audible-siren. Defensive Spray-water based 10% OC pepper gel discharge) to be used for defensive purposes only, in accordance with policies"
1. Review of facility documentation dated April 26, 2016, revealed "Narrative ... Security gained control of the patient and assisted her to her bed. The patient was ready for transport at this time. Behavioral Health requested that the patient be transported by the security transport van ... and ... placed the patient in handcuffs at 1615 hours so the patient would not harm any staff or patients during the transport."
2. Interview with EMP1on May 13, 2016, at approximately 9:25 AM revealed "Once it(behavior) becomes a level 4 it is considered a criminal activity, assault, police are notified and the patient becomes the custody of the officer. We agree this should have never happened."

3. Review of MR1 revealed "History and Physical ... April 26, 2016 20:43 ... History and physical is severely limited secondary to this patient required restraints for patient's safety upon arrival to the floor and is currently in seclusion."

4. Interview with EMP4 on May 13, 2016, at approximately 2:30 PM when asked what restraints the patient required revealed "That means the handcuffs"


Cross reference with: 482.13(c)(3), 482.13(e), 482.13(e)(2), 482.13(e)(5), 482.13(e)(16)
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
Based on review of facility documentation and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure restraint or seclusion was the least restrictive intervention that was effective to protect the patient, a staff member, or others from harm, for one of one medical record reviewed (MR1).

Findings include:

Review of "Rights and Responsibilities of Patients" reviewed April 2014, revealed, " You have the right: ... 2. Receive care in a safe setting free from any form of abuse, harassment, and neglect. ... 7. Receive care free from restraints or seclusion unless necessary to provide medical, surgical, or behavioral health care."

Review of "Policy and Procedure for Patient Restraint and Seclusion" revised February 2016, revealed "1. Physical Restraint: Any manual method or physical or mechanical device, material or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely ... D. Alternative / Non-physical Interventions: Measures, which modify the environment, enhance interpersonal interactions or provide treatment so as to minimize or eliminate the issue of behavior, which places the patient at risk."

1. Review of MR1 revealed "ED Note-Nursing ... Note: Pt sleeping in bed. Resps(respirations) even and unlabored. Call bell is within reach. Security remains at the bedside. Will cont(continue) to monitor 04/26/2016 14:26 ... Disposition: (RN) admitted The patient was admitted to the Behavioral Health. The report was called to MH @ 04/26/2016 16:17. At admission, the patient's status was unchanged. The patient was felt to be in good condition. The patient was considered stable." Further review of MR1 revealed no documentation the patient had any behavioral issues.

2. Review of facility documentation dated April 26, 2016, revealed "Narrative ... The patient attempted to elope multiple times at from 1600 hours to 1615 hours. Security attempted to verbally de-escalate the patient without success. Security assisted the patient back into her room multiple times, when she tried to elope. The patient was also becoming combative at this time. ... Security gained control of the patient and assisted her to her bed. The patient was ready for transport at this time. Behavioral Health requested that the patient be transported by the security transport van ... and ... placed the patient in handcuffs at 1615 hours so the patient would not harm any staff or patients during the transport."

3. Review of MR1 revealed "History and Physical ... April 26, 2016 20:43 ... History and physical is severely limited secondary to this patient required restraints for patient's safety upon arrival to the floor and is currently in seclusion."

4. Interview with EMP4 on May 13, 2016, at approximately 2:30 PM when asked what restraints the patient required revealed "That means the handcuffs"

Cross reference with: 482,13(c)(3), 482.13(e), 482.13(3)(2), 482.13(e)(5), 482.13(e)(16),
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on review of facility documentation and medical records (MR), and staff interview (EMP), it was determined the facility failed to follow their policy on restraint and seclusion for one of one medical record reviewed (MR1).

Findings include:

Review of facility policy and procedure "Use Of Force Policy And Devices review/revised dates: November 2015 ... Use of Force Continuum-sis a standard that indicates what degree of force or other methods of compliance method that may be used in a given situation. The continuum progresses from situations where no force is generally the appropriate response to those situations where a lethal response may be necessary. ... The use of force policy should be followed, so that the appropriate level of force is used, consistent with the level of threat presented, to provide safety for people and protection for property. The level of force should be no more than is required to control the situation. Authorized personnel may use that level of force necessary to restore order and avoid/or avoid potential harm. Force shall not be used to compel a person to participate in or comply with a clinical treatment. ... Level 3 a. Situational Characteristics-Combative, demonstrates signs of potential violence b. Force Continuum-verbal communication to include demands for actor to leave, visual deployment of non-lethal compliance devices, PRO-V2 Response 1 may be used for this level or greater, contact local law enforcement if necessary. ... E. Level 5 a. Situational Characteristics-Physical violence is inevitable or occurring b. Force Continuum-use of non-lethal compliance methods such as sprays and PRO V2 Response 3 may be used for this level or greater. Police should be notified to press charges. ... Situational Characteristics Force Continuum ... Level 3 Combative Demonstrates signs of potential violence ... Verbal commands to include demands to leave. Approved Device Use Scale Pro V2 Response 1(Audio, Video Recording, Laser) Notification to Law Enforcement When/Where Appropriate Level 4 Verbal commands are ignored, Physical violence is appears likely Physical tactics and/or restraint as needed to counteract threat Approved Device Use Scale Pro V2 Response 2 (Alert Siren, Strobe Light) Hand cuff use permitted for levels 4 or greater Police should be notified to press charges when handcuffs are used. ... 1. Handcuffing: (Approved) ... Handcuffs may be used for Level 4 or greater Situational Characteristic as defined on the Use of Force Continuum if the Authorized personnel deem it necessary to control an actor preventing potential harm to self/others/or substantial property damage. ... Authorized Personnel must stay with actor when handcuffed ... B. If handcuffs are used on an actor, the Authorized personnel should promptly contact the local law enforcement authorities to report the incident. The authorities should be advised that handcuffs were used to subdue the actor. Authorized personnel should request law enforcement to arrest the actor if handcuffs are deployed."

2. Review of facility documentation dated April 26, 2016, revealed "Narrative ... The patient attempted to elope multiple times at from 1600 hours to 1615 hours. Security attempted to verbally de-escalate the patient without success. Security assisted the patient back into her room multiple times, when she tried to elope. The patient was also becoming combative at this time. ... Security gained control of the patient and assisted her to her bed. The patient was ready for transport at this time. Behavioral Health requested that the patient be transported by the security transport van ... and ... placed the patient in handcuffs at 1615 hours so the patient would not harm any staff or patients during the transport."

3. Review of facility documentation "Incident Report Greensburg Police Department ... Reported 04/26/2016 @ 19:13 ... hospital security supervisor called to report that he and another officer had to handcuff a combative mental health patient ... stated that hospital security recently began carrying handcuffs and it is part of their policy that any time handcuffs are used that they are to file a report with Greensburg Police." This was reported three hours after the incident. Authorized personnel did not promptly contact the local law enforcement authorities to report the incident or request law enforcement to arrest the actor after handcuffs were deployed as per policy.

Interview with EMP1 on May 13, 2016, at approximately 9:25 AM confirmed the above findings and revealed "Once it(behavior) becomes a level 4 it is considered a criminal activity, assault, police are notified and the patient becomes the custody of the officer."


Cross reference with: 482.13(c)(3), 482.13(e), 482.13(e)(2), 482.13(e)(5), (482.13(e)(16)
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of facility documentation, medical records, and staff interview revealed the facility failed to use restraints in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient for four of four incident reports reviewed.

Findings include:

Review of facility policy and procedure "Rights and Responsibilities of Patients" reviewed April 2014, revealed "F. Care Delivery ... 7. Receive care free from restraints or seclusion unless necessary to provide medical, surgical, or behavioral health care."

Review of "Policy and Procedure for Patient Restraint and Seclusion" revised February 2016, revealed "II. Definitions: ... 1. Physical Restraint: Any manual method or 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 ... The registered nurse may initiate restraints/seclusion. A telephone or verbal order must be obtained from a licensed independent practitioner as soon as possible. All orders for restraint/seclusion must include: Type of restraint utilized based upon patient's assessed needs and least restrictive modality Date and Time of order Clinical Justification for use."

1. Review of facility documentation "On 5-27-16 at 1525 hours, security was requested on the 2nd floor of the Behavioral Health inpatient unit for a medication assist. ... Security and staff controlled the patient on the bed while RN ... administered the medication via injection."

2. Review of facility documentation "At 1754 hours on 5/27/2016 ... Security and Nursing staff then controlled the patient while Nursing staff administered medication."

3. Review of facility documentation "At 1725 hours on 5/28/2016, ... Security escorted the patient to open seclusion and controlled the patient while nursing staff administered medication"

4. Review of facility documentation dated June 7, 2016, revealed "At 2140 hours, .... Security controlled the patient while Nursing staff administered medication."

5. Interview with EMP2 on June 10, 2016, at approximately 11:10 AM when asked what does it mean when someone says they control a patient revealed "We assist the patient to the floor and hold them while the nurse gives the injection"

6. Interview with EMP1 on June 10, 2016, at approximately 10:45 AM revealed "We do not get an order to physically hold a patient, we get the order for the outcome, the restraint, seclusion what ever it may be."


Cross reference with: 482.13(c)(3), 482.13(e), 482,13(e)(2), 482.13(e)(4)(i), 482.13(e)(16),
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0176
Based on review of facility documentation and staff interview (EMP), it was determined the facility failed to ensure the "Policy and Procedure for Patient Restraint and Seclusion" revised February 2016, specified the training requirements for physicians and other licensed independent practitioners authorized to order restraint or seclusion.

Findings include:

Review of facility "Policy and Procedure for Patient Restraint and Seclusion" revised February 2016, revealed "Education And Training Physician and LIP education 1. Physicians/LIP's who order restraint or seclusion are to have a working knowledge of this policy. 2. Education of physicians/LIP's will occur using any of the following means: policy distribution, electronic messaging, meetings, newsletters or educational forums." The practitioner training requirements were not specified in hospital policy.

Interview with EMP5 on May 13, 2016, at approximately 2:15 PM revealed "No it doesn't but it is part of their orientation." Further interview when asked what is the longest hire revealed "Maybe 35 years ago."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
Based on review of facility documentation and staff interview (EMP), it was determined the facility failed to ensure the medical record included the patient's behavior and the intervention used for one of one medical record reveiwed (MR1)

Findings include:

Review of facility "Policy and Procedure for Patient Restraint and Seclusion" Revised March 2016, revealed "Management Interventions for the Violent, Self-Destructive Patient 1. For patients who ultimately require either physical/chemical restraint or seclusion, documentation of the following is required: A. Early signs and symptoms of risk behavior B. Alternatives interventions attempted and their effectiveness C. Actions taken. D. Individual needs of the patient."

1. Review of MR1 revealed "ED Note-Nursing ... Note: Pt sleeping in bed. Resps(respirations) even and unlabored. Call bell is within reach. Security remains at the bedside. Will cont(continue) to monitor 04/26/2016 14:26 ... Disposition: (RN) admitted The patient was admitted to the Behavioral Health. The report was called to MH @ 04/26/2016 16:17. At admission, the patient's status was unchanged. The patient was felt to be in good condition. The patient was considered stable." Further review of MR1 revealed no documentation the patient had any behavioral issues.

2. Review of facility documentation dated April 26, 2016, revealed "Narrative ... The patient attempted to elope multiple times at from 1600 hours to 1615 hours. Security attempted to verbally de-escalate the patient without success. Security assisted the patient back into her room multiple times, when she tried to elope. The patient was also becoming combative at this time. ... Security gained control of the patient and assisted her to her bed. The patient was ready for transport at this time. Behavioral Health requested that the patient be transported by the security transport van ... and ... placed the patient in handcuffs at 1615 hours so the patient would not harm any staff or patients during the transport."

3. Review of MR1 revealed "History and Physical ... April 26, 2016 20:43 ... History and physical is severely limited secondary to this patient required restraints for patient's safety upon arrival to the floor and is currently in seclusion."

4. Interview with EMP4 on May 13, 2016, at approximately 2:30 PM when asked what restraints the patient required revealed "That means the handcuffs"