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.

STRONG MEMORIAL HOSPITAL 601 ELMWOOD AVE ROCHESTER, NY 14642 April 30, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on medical record review, policy review and interview, the facility did not ensure that a face-to-face evaluation was completed in accordance with facility policy in 5 of 16 patients restrained for violent/self destructive behaviors. Not completing a face to face evaluation could compromise patient and staff safety.

Findings Include:

Review on 4/26/18 of policy "10.02.01 Restraint and Seclusion for Violent/Self Destructive Behaviors Policy" last revision 11/01/15 revealed that a physician is to evaluate the patient within 60 minutes of the initiation of restraint or seclusion. Face-to-face evaluation includes evaluation of immediate situation, reaction to intervention, medical or behavioral condition.

Medical record review on 4/24/18 revealed no documentation to indicate that a physician conducted a face to face evaluation within one hour of application of 4-point restraints for Patient #1 on 5/16/18, Patient #15 for second restraint episode on 1/6/18 at 3:40AM, Patient #16 for second restraint episode on 1/9/18 at 3:40AM, Patient #17 for second restraint episode on 1/2/18 at 6:43PM and Patient #18 for second restraint episode on 1/19/18 at 11:15PM.

Interview on 4/24/18 at 12:00 PM with Staff (I), Nursing Quality and Staff (J), Nursing Quality, confirmed the above noted findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
Based on policy review, personnel file review and interview the facility did not ensure that all security personnel involved in restraint situations completed training on the prevention and management of crisis situation, including the appropriate and safe use of restraints/seclusion in 5 out of 5 records reviewed. Lack of documented education could result in harm to patients and staff in a crisis situation.

Findings include:

Review of the Department of Public Safety policy entitled "Training, General Order #600" last issued 1/26/18 revealed the training manager is to ensure class attendance by members and retain inservice training logs for annual inservice training.

Review of personnel files revealed no documentation to indicate completion of de-escalation training or the safe application of restraints/seclusion for Staff (X), (W), (Y) Peace Officers and Staff (U), (V) Public Safety Officers.

Interview on 04/26/18 at 8:50AM with staff (JJ) Training Coordinator and staff (I) Director of Nursing Quality Safety and Patient Outcomes verified the lack of documentation related to de-escalation training and the safe application of restraints/seclusion for Staff (X), (W), (Y) Peace Officers and Staff (U), (V) Public Safety Officers.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, document review and interview, facility security staff employed the use of law enforcement techniques, including the use of metal handcuffs, pepper gel, batons and body strikes and holds as a means of subduing a patient and restraining a patient in 20 of 20 cases reviewed. The use of law enforcement techniques in the healthcare setting could result in harm to patients.

Findings include:

Review of Policy #2.9 Department of Public Safety (DPS) Interface in the Care of Psychiatric Patients revealed that when collaborating with the Charge Nurse or designee (CND), a patient becomes a danger to themselves or others AND the CND relinquishes communication with/direction of the patient to DPS staff, officers will assume control of the situation in the manner in which they are trained. This requires clear and concise communication from the CND handing over authority to DPS by saying, "I'm going to let Public Safety speak with you now" which communicates that it is clear the DPS has assumed charge of the situation. Even when handing over authority of an unsafe situation to DPS, a nurse must remain present at all times with the patient and DPS.

Interview with Staff (U) and (V) Public Safety Officers and (W), (X) and (Y) Peace Officers on 4/23/18 revealed handcuffs may be applied as a temporary restraint at times prior to the application of 4-point restraints. The length of time is variable based on availability of a 4-point restraint bed. Use of handcuffs is not always documented. At times, an email reporting the use of handcuffs is sent to the Commander or a SRR (Subject Resistance Report) is completed. In addition, they are trained in the use of pepper gel spray, defensive tactic "holds" and batons which are used on patients within the limits of their security training. Some officers carry firearms while on duty, but firearms are not allowed on locked units.

Review of Patient #1's medical record revealed the patient was admitted on [DATE]. On 5/16/17 the patient began to verbally threaten staff and refuse medication. Security staff were called to assist.

Review of SRR reports for Patient #1 dated 5/16/17 revealed pepper gel was deployed, along with knee strikes and use of batons. The patient was handcuffed and placed in a restraint bed, following which 4-point restraints were applied.

Review of Patient #2's medical record revealed the patient was evaluated in the Comprehensive Psychiatric Emergency Program (CPEP) on 12/4/17. The patient was agitated and security was called to assist.

Review of SRR reports for Patient #2 dated 12/4/17 revealed two knee strikes to the patient's left thigh, along with a hypoglossal hold (application of pressure under the jaw) were deployed, following which 4-point restraints were applied. Review of the patient's medical record revealed no documentation of the security interventions utilized.

Review of Patient #3's medical record revealed the patient was evaluated in the CPEP on 1/27/18. The patient was informed she was being discharged and became very agitated. Security was called to intervene and officers used "hands on" techniques. A "pop" was heard and the patient complained of left arm pain. She was transported to the pediatric Emergency Department (ED) and diagnosed with a left humerus fracture.

Review of SRR reports for Patient #3 dated 1/27/18 revealed the patient was observed to be banging her head against the wall. Two officers put her in a "bent arm bar" and waited to escort the patient to a restraint bed. Once the patient saw the restraint bed, she began to thrash and attempted to break free. While another officer was attempting to secure the patients legs, a "pop" was heard. The two officers stopped struggling with the patient and the patient was escorted to the ED as she could not move her arm.

Review of Patient #29's medical record revealed the patient was admitted on [DATE]. After being placed in 4-point restraints, the patient removed the restraints and security was called to assist.

Review of SRR reports for Patient #29 dated 3/1/18 revealed three security officers responded and handcuffs were applied, following which an attempt was made to return the patient to the restraint bed. The patient continued to resist by kicking, thrashing and refusing to follow commands. The patient's legs were secured. Additional security officers presented and a device fastening the patient's legs together (hobble) was applied. The patient was placed in the restraint bed. During the removal of the handcuffs, the patient began to thrash and a mandibular angle pressure point (pressure near the ear and lower jaw) was applied. Review of the patient's medical record revealed no documentation of the use of the hobble and pressure point holds.

Review on 4/26/18 of Handcuff Tracking Report dated 1/1/18 to 4/26/18 revealed 16 patients (Patient #'s 3, 14, 24, and 29-41) were handcuffed.

Review of medical records revealed no documentation of the handcuff use or the reason why they were applied in 12 of the 16 patients prior to the patient being placed in 4 or 5 point restraints. (Patient #'s 3, 24, 30-32, 34-35, and 40-41)
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, medical record review and interview, the facility failed to protect and promote each patient's rights by permitting the use of law enforcement techniques, consisting of metal handcuffs, pepper gel, batons and body strikes as a means of subduing and restraining patients. The use of law enforcement techniques in the healthcare setting could result in harm to patients.

See findings under Tag # 154,178, 194 and 273.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review, medical record review and interview, the facility did not utilize data collected to ensure the appropriate and safe application of patient restraints. Lack of complete data analysis could result in a failure to identify opportunities for improvement.

Findings include:

Review of Nursing Practice Quality and Safety Steering Council meeting minutes dated 1/10/17 and 7/11/17 revealed a graph that listed a total of 4 restraints for the 1/10/17 meeting and 6 restraints for the 7/11/17 meeting. No further information, including the type of restraint or reason for use was identified.

Review of 2018 QA Restraint Summary dated 1/18 revealed quantitative data (why restraint ordered, restraint type, day of week restraint applied, hour of day restraint applied, restraint use by unit and alternatives attempted prior to restraint) related to restraint use. There is no evidence the data collected was reviewed and analyzed. In addition, the use of law enforcement techniques was not noted.

Review on 4/26/18 of Handcuff Tracking Report dated 1/1/18 to 4/26/18 revealed 16 patients (Patient #'s 3, 14, 24, and 29-41) were handcuffed.

Review of medical records revealed no documentation of the handcuff use or the reason why they were applied in 12 of the 16 patients prior to the patient being placed in 4 or 5 point restraints. (Patient #'s 3, 24, 30-32, 34-35, and 40-41)

Interview with Staff I, Nursing Quality on 4/26/18 verified the lack of review related to the use of law enforcement techniques employed by facility security staff for patient restraint.