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 a review of facility policy and medical records and staff interviews (EMP), it was determined that the facility failed to ensure patients have the right to be free from restraints or seclusion for one medical record reviewed (MR1).

Findings include:
A review of facility policy Rights and Responsibilities of Patients dated January 2017, revealed, "Purpose: To define the rights and responsibilities of patients ......You have the right to ... Receive care is a safe setting free from any form of abuse, harassment and neglect... ."

A review of facility policy Patient Restraint and Seclusion dated April 2017, 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 ... E. Reasons for Restraints for Patients that Exhibit Violent, Self-Destructive Behavior: Emergency or crisis management of situations where a patient's behavior becomes violent or self-destructive, presenting an immediate serious danger to his/her safety or that of others regardless of clinical setting. ... G. Emergency or Crisis Situation: An instance in which a rapid assessment indicates that a patient's behavior is violent or self-destructive and where the behavior presents an immediate and serious danger to the safety of the patient, other patients, staff or others. ... K. Locked / Mechanical Restraint: Any restraint utilized which contains a locking mechanism. ... The determining factor in applying the appropriate standards is the reason for use, not the type of setting where the intervention occurs ... D. Restraints for violent, self-destructive behavior: These standards apply to Emergency or crisis management situations where a patient's behavior becomes self-destructive-or violent, presenting an immediate serious danger to his/her safety or that of others regardless of clinical setting. Restraints may be physical, chemical and/or seclusion ... Exceptions: These standards do not apply when any of the following conditions are present. ... Forensic restrictions or restrictions imposed by correction authorities for security purposes. Includes handcuffs and shackles... ."

A review of facility policy Use of Force Policy and Devices, dated July 2016, revealed, ... "Level 4 a. Situational Characteristics-verbal commands are ignored, physical violence appears likely. b. Force Continuum - Physicals tactics and restraints are needed to counteract the treat. Physical tactics, handcuffs, and PRO V2 Response 2 may be used for this level or greater. Police should IMMEDIATELY be notified to press charges when handcuffs are used. ... If handcuffs are used on an actor, the Authorized Personnel should immediately 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 immediately request law enforcement to arrest the actor if handcuffs are deployed... ."

Review of Incident Review Meeting Notes, September 5, 2017, revealed, "... Guards assisted gaining control of patient and handcuffed him using proper technique on the ground, patient was place in the room. Police arrived approximately 3 mins after patient was handcuffed. Initial leather leg restraints were placed on patient. Patient was left in handcuffs while police determined if they could take him to jail. Once determined the patient had to stay due to his 302 status handcuffs were removed and replaced with leather restraints.

During a telephone interview on October 5, 2017, EMP10 stated, "I was in the monitor room, I saw the patient assaulting the guard. Went there quickly, the patient was on the guard. I applied the handcuffs. I am aware that handcuffs are not to be used on patients. I assumed the patient would be arrested, so I used the handcuffs. I am aware that my intent was to have the patient arrested."

During an interview on October 6, 2017, EMP8 stated, "I was working the 12 to 8 shift, I came in early to get an update. I was watching the monitors, I saw the patient come out of the bathroom and attack the security personnel. Me and [another security personnel] responded fast. Once there we got the patient off [the security personnel]. The patient was on top of him. The patient kept fighting and kicking me and [security personnel] did get control of the patient and [security personnel] got the handcuffs on the patient. The patient was moved to the bed and put in restraints."