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 observation, interview and record review, the facility failed to ensure that the seclusion room bed was a safe surface for physical management for one (#1) of 8 patients reviewed for physical management (restraint or seclusion) out of a total sample of 18, resulting in two broken upper front incisors (front teeth), and the potential for skull and facial injuries to all patients receiving physical management on the seclusion room bed, with the potential to effect all 181 patients in the facility. Findings include:

On 11/17/16 at 1000, review of hospital emergency room (ER) records for Patient #1 revealed the following. Patient #1 was an [AGE] year old male who was transferred to the ER from the facility on 11/14/16 for evaluation of broken teeth allegedly received during physical management at the facility. The ER Physician's note, dated 11/14/16 at 14:00 noted "The Patient states one of the staff members 'pushed him on his bed' resulting in him hitting his face on the backboard of the bed, cracking his front teeth. ...teeth #8 and #9 (upper front teeth) there is partial avulsion (tearing away of a body part) of the distal aspect (front side of the teeth).

On 11/17/16 at 1120, Patient #1 was interviewed on the unit. Patient #1's two upper front teeth were broken off and jagged. When asked, Patient #1 said, "It happened on my first day here. Two people pushed me down on the bed in the quiet room, with no mattress on the bed and I smashed my teeth on the bed frame."

On 11/17/16 at 1210, the Co-Charge Nurse, Staff F, who was one of the two staff members who performed the physical management of Patient #1 when his teeth were broken, was interviewed. Staff F said, "(Staff J) and I took him (Patient #1) to the Quiet Room (seclusion room). He got mad and threw the mattress at us, so we took it out of the room. He was out of control and we couldn't get him to settle down, so (Co-Charge Nurse, Staff L) called the doctor, who wanted him to have a shot (injection) to calm him down. When (Nurse, Staff K) came in with the shot, he went out of control and started hitting and kicking us and trying to get away. (Patient Care Specialist, Staff J) and I each took him by the arm and had him in control position (physically restrained) in front of the bed. We were trying to lay him down on the bed so (Staff K) could give him the injection safely, when he suddenly went down and hit his face on the edge of the bed. When we let him up after the shot, I saw two little teeth, and he said, "look what you did to my teeth."

On 11/17/16 at 1400, the Director of Risk and Quality, Staff B was interviewed, and Patient #1's clinical record and the facility Grievance and Incident Investigation into Patient #1's injury during physical management on 11/13/16 were reviewed, and revealed the following:

A face sheet documented that Patient #1 was an [AGE] year old male with diagnoses of Bipolar Disorder and Behavior and Mood Disorder, who was admitted into the facility on [DATE]. A Grievance and Accident Investigation dated 11/13/16, and Nursing Note dated 11/13/14 at 1743, documented that on 11/13/16 at 1743, "patient had to be physically held; during the physical restraint, patient was injured, AEB (as evidenced by) patient chipped his front teeth."

On 11/17/16 at 1630, security camera footage of Patient #1's physical restraint in the Quiet Room on 11/13/16 at 14:43 was observed. There was no mattress or padding on the bed in the room. Patient #1 was trying to escape staff and attempting to hit them when Staff F and Staff J restrained him at the foot of the bed by holding his arms. Patient #1 struggled and suddenly propelled himself forward, landing face first on the bed in a slightly diagonal position.

On 11/17/16 at 1650, the Quiet room where Patient #1's incident occurred was observed with the Director of Nursing, Staff A. The Quiet room bed was observed to be a hard plastic/vinyl polymer frame with a concave center and hard raised edges. There was an exercise/camping type mattress placed over the top of the bed frame. The mattress was not contoured to fit shape of the bed, and the slid off the bed when touched. Staff A reported that the facility added the mattress for patient comfort, and said, "It's not required." When asked whether she would like to be rapidly restrained down onto, or to fall face down onto the hard surface of the Quiet room bed, Staff A stated, "No."

Manufacturer's guidelines and recommendations for the Quiet Room bed were requested but not provided by exit.

On 11/18/16 at 0800, review of the facility safety training program manual entitled, "Nonviolent Crisis Intervention Foundation Course", dated 2015, revealed no guidance on how to safely restrain a patient from a standing position to a prone position (face down) onto a hard surface.

On 11/18/16 at 0900, review of the facility policy entitled, "Restraint/Seclusion, use of", dated 10/22/15 revealed the following statement,"A prone position (face down) is to be avoided." There was no guidance on how to safely restrain a patient from a standing position to a prone position onto a hard surface.