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.

ST. VINCENT'S MEDICAL CENTER 2800 MAIN ST BRIDGEPORT, CT 06606 May 15, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record reviews, review of facility documentation, review of facility policies, review of facility video surveillance monitoring, and interviews for one of eleven patients who exhibited uncooperative/combative behaviors (Patient #2), the facility failed to ensure that the patient was free from physical abuse and that abuse and restraint policies were followed.

The CoP for Patient Rights has not been met.

Refer to A 145, A 164, A 167 A 175 and A 188.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on medical record reviews, review of facility policies, review of facility documentation, review of facility video surveillance monitoring, and interviews for one of eleven patients who exhibited uncooperative/combative behaviors (Patient #2), the facility failed to ensure that the patient remained free from physical abuse. The finding includes:

Patient (P) #2 was admitted to the Emergency Department (ED) on 3/3/19 at 4:00 PM via ambulance from home on a PEER (police emergency evaluation request) with delusional and combative behavior. The ED record identified that P#2 was cleared medically at 7:38 PM and transitioned to the BHU (behavioral health unit) in the ED.

Video surveillance monitoring (no audio) viewed on 4/26/19 at 11:03 AM and dated 3/3/19 at 7:39 PM and/or 7:40 PM noted P#2 in the BHU of the ED with three SO (security officers), ERT (emergency room Technician) #1, and Registered Nurse (RN) #1. RN#1 subsequently exited the area via a door to enter the nursing station while P#2 remained in the general area of the BHU and had not yet entered his/her room.

The video monitoring further identified the following:
1.) P#2 was pacing in a circular motion and four SO's and ERT#1 closely encircled P#2.

2.) Four SO's and ERT#1 placed hands on P#2, SO#1 held P#2 around the back of the neck at the same time SO#1 pushed/corralled P#2 to room #6 when the patient was not observed to demonstrate any self-harm or harm to others.

3.) P#2 was brought to the floor by the 4 SO's and ERT#1. ERT#1 was in a kneeling-like position and SO#1 had his arm around P#2's posterior neck and the video showed SO#1 punch P#2 in the head/face 8 to 9 times while the patient's hands/arms were held by the other SO's present although the patient was not observed to demonstrate any self-harm or harm to others.

4.) P#2 was face down on the floor and subsequently the patient was moved onto the bed by the SO's and ERT#1.

5.) P#2 was placed in the prone position (face down) on the bed and was held in this position with ERT#1's knee placed on P#2's upper back in an attempt to help restrain P#2. Although the video did not show that the patient was moving/resisting, four or five SO's were observed holding the patient's arms and legs down on the bed for 3 minutes. In the video monitoring a pool of blood was observed on the floor where P#2's face had been positioned.

6.) Bilateral wrist restraints were applied to P#2 by SO#1 and ERT#1, after P#2 was lifted, turned and placed in a supine position. Bright red blood was noted on the bedding that had been beneath the right side of P#2's face. P#2 remained in restraints for 25 minutes.

P#2's ED record dated 3/3/19 indicated that P#2 sustained a 2 centimeter left periorbital facial laceration that required 7 sutures, a subconjunctival hemorrhage of the left eye, and a large displaced left inferior orbital wall fracture that would require surgical intervention. The ED record further identified P#2 was evaluated by trauma surgery and determined the patient did not need acute intervention and would require follow up with trauma, opthomolgy and plastic surgery after discharge.

SO#1 was requested to leave the facility immediately following the event. SO#1 was no longer employed by the facility and was not available for interview during the investigation.

ERT#1 did not work for the facility following the incident beginning 3/8/19 and ERT#1's employment with the facility was terminated on 3/12/19. ERT#1 was not available for interview during the investigation.

Interviews with SO#3, #4 and #5 on 5/14, 5/15 and 5/16 respectively, identified that they did not see SO#1 punch P#2 and questioned if P#2 may have sustained the injury from facial contact with the floor.

Interview with SO#4 on 5/15/19 at 8:39 AM identified that SO#4 asked P#2 to go to room #6 repeatedly and informed P#2 that if P#2 did not go to the room, then staff would assist P#2 to the room. SO#4 further indicated that he believed P#2's body language to be aggressive and told P#2 "don't do that or we will have to go hands on".

Interview with Manager #2 (Security) on 4/26/19 at 11:03 AM indicated that when the patient was moved to room #6 the escort hold should have been used which is a mild hold on the patient's arm. In addition Manager #2 indicated that after video review she did not identify that P#2 exhibited behaviors that would have warranted "hands on". She further noted that, in accordance with facility training, when dealing with an agitated patient, the patient should be given space and should not be cornered. Manager #2 identified that there was "no such thing as too long" when having a discussion with a patient in an attempt to deescalate a situation.

Interview with Manager #1 on 4/26/19 at 12:47 PM noted that ERT#1 was not MOAB (management of aggressive behavior) trained and used an inappropriate hold/restraint technique and excessive force when subduing P#2 on 3/3/19.

Interview with Director #2 on 5/14/19 at 8:20 AM indicated that SO#1 used excessive force with P#2 on 3/3/19 and would consider this behavior abusive in accordance with the facility Abuse policy.

The facility failed to ensure that the patient was restrained appropriately and he/she remained free from physical abuse.

The facility Patient Rights policy identified that the patient should expect considerate and respectful care at all times.

The facility Abuse policy identified, in part, that abuse is the willful infliction of injury to include an act such as rough handling, pushing, shoving, and/or corporal punishment (beating, thrashing pounding) which causes pain and temporary or permanent disfigurement. The policy further identified that patients have a right to be free from abuse and all hospital employees have an obligation to protect patients and prevent abuse.

Subsequent to the event, the facility submitted a CAP (corrective action plan) to include disciplinary action, revision of training requirements and education/reeducation for the behavioral health and ED staff. The facility was found to be compliant with the CAP as submitted.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on medical record review, review of facility policies, review of facility documentation, review of facility video surveillance monitoring, and interviews for two of eleven patients who exhibited uncooperative/combative behaviors (Patient #2), the facility failed to ensure that restraints (physical holds) were utilized safely and/or that an enclosure bed was used in accordance with facility policy/practice. The finding includes:

Patient (P) #2 was admitted to the Emergency Department (ED) on 3/3/19 at 4:00 PM via ambulance from home on a PEER (police emergency evaluation request) with delusional and combative behavior. The ED record identified that P#2 was cleared medically at 7:38 PM and transitioned to the BHU (behavioral health unit) in the ED.

Video surveillance monitoring (no audio) viewed on 4/26/19 at 11:03 AM and dated 3/3/19 at 7:39 PM and/or 7:40 PM noted P#2 in the BHU of the ED with three SO (security officers), ERT (emergency room Technician) #1, and Registered Nurse (RN) #1. RN#1 subsequently exited the area via a door to enter the nursing station while P#2 remained in the general area of the BHU and had not yet entered his/her room.

The video monitoring further identified the following

1.) P#2 was pacing in a circular motion and four SO's and ERT#1 closely encircled P#2.

2.) Four SO's and ERT#1 placed hands on P#2, SO#1 held P#2 around the back of the neck at the same time SO#1 pushed/corralled P#2 to room #6 when the patient was not observed to demonstrate any self-harm or harm to others. SO #1 failed to escort P#2 according to MOAB (management of aggressive behavior) training.

3.) P#2 was brought to the floor by the 4 SO's and ERT#1. ERT#1 was in a kneeling- like position and SO#1 had his arm around P#2's posterior neck and the video showed SO#1 punch P#2 in the head/face 8 to 9 times while the patient's hands/arms were held by the other SO's present although the patient was not observed to demonstrate any self-harm or harm to others.

4.) P#2 was face down on the floor and subsequently the patient was moved onto the bed by the SO's and ERT#1.

5.) P#2 was placed in the prone position (face down) on the bed and was held in this position with ERT#1's knee placed on P#2's upper back in an attempt to help restrain P#2. Although the video did not show that the patient was moving/resisting, four or five SO's were observed holding the patient's arms and legs down on the bed for 3 minutes. In the video monitoring a pool of blood was observed on the floor where P#2's face had been positioned.

6.) Bilateral wrist restraints were applied to P#2 by SO#1 and ERT#1, after P#2 was lifted, turned and placed in a supine position. Bright red blood was noted on the bedding that had been beneath the right side of P#2's face. P#2 remained in restraints for 25 minutes.

P#2's ED record dated 3/3/19 indicated that P#2 sustained a 2 centimeter left periorbital facial laceration that required 7 sutures, a subconjunctival hemorrhage of the left eye, and a large displaced left inferior orbital wall fracture that would require surgical intervention. The ED record further identified P#2 was evaluated by trauma surgery and determined the patient did not need acute intervention and would require follow up with trauma, opthomolgy and plastic surgery after discharge.

SO#1 was requested to leave the facility immediately following the event. SO#1 was no longer employed by the facility and was not available for interview during the investigation.

ERT#1 did not work for the facility following the incident beginning 3/8/19 and ERT#1's employment with the facility was terminated on 3/12/19. ERT#1 was not available for interview during the investigation.

Interview with Manager #1 on 4/26/19 at 12:47 PM noted that ERT#1 used an inappropriate hold/restraint technique and excessive force with P#2 on 3/3/19 and did not act within his scope of practice.

Interview with Manager #2 (Security) on 4/26/19 at 11:03 AM indicated that when the patient was moved to room #6 the escort hold should have been used which is a mild hold on the patient's arm.

The facility training for MOAB (management of aggressive behavior) identified to use the basic escort that includes lightly touching the patient's upper arm with both hands, sliding the front hand down to the patient's wrist and standing at a 45 degree angle to the patient. The MOAB training manual did not include a neck hold as an escort hold. The facility restraint policy identified physical hold as a restraint. The MOAB training manual directed different types of arm holds and did not direct a neck hold as a form of hold or escort technique.


b. Patient (P) #14 was brought to the ED by ambulance on 5/6/19 after being found on the street by the mobile crisis unit. The patient had a diagnosis of Schizophrenia with medication noncompliance. P#14's conservator indicated the patient had been acting erratic, paranoid, delusional and irritable. A chest x-ray dated 5/6/19 identified a possible tuberculosis lesion and the plan was for P#14 to be admitted to a negative pressure room on a medical unit with a patient sitter. Although alternatives were tried in the ED such as de-escalation, diversion, medication, and a sitter to help control the patient's physically aggressive behavior, P#14 continued to be physically aggressive, tried to leave the ED, and was placed in an enclosure bed at 5:17 AM on 5/7/19 per the MD (Medical Doctor) order.

P#14 was subsequently admitted via a PEC (Physician's Emergency Evaluation) on 5/7/19 at 1:39 PM and placed in a regular bed, in a negative pressure room on the medical unit (10 South) and with a sitter in attendance.

Nursing flow records dated 5/9/19 at 12:03 AM, 1:04 AM, 3:41 AM, 5:23 AM and 6:02 AM identified that P#14 was physically abusive (not specifically described) towards staff. A nursing flow record dated 5/9/19 at 7:49 AM identified that a enclosure (SOMA) bed was needed. A physician order dated 5/9/19 at 7:49 AM directed P#14 was to be placed in an enclosure bed because the patient was an imminent risk to self and/or others.

Physician progress notes dated 5/9/19 at 9:30 AM and subsequent MD order at 11:16 AM identified that P#14 was intermittently agitated, posed an increased threat to staff and instructed to continue the enclosure bed and sitter.

Nursing, MD#1's and/or facility documentation dated 5/10/19 identified that P#14 went for a bronchoscopy at 10:09 AM, returned at 2:18 PM and was somnolent/calm in the enclosure bed.

Nursing, MD#1's, facility documentation and/or the security report dated 5/10/19 indicated at 3:15 PM, P#14 got out of the enclosure bed via an unzipped side at the foot of the bed. P#14 was agitated, refused to go back to bed, attempted to hit staff and security (Security Officer #6) was called to assist. A physician progress note dated 5/10/19 at 4:51 PM identified that the MD emphasized the need for the enclosure bed to be completely zipped.

The facility staff failed to secure the zippers on the enclosure bed in accordance with facility policy.

Interview with CNA#1 (Sitter) on 5/21/19 at 10:30 AM noted that she did not check to ensure that the enclosure bed was totally zipped after she assisted P#14 to the enclosure bed after a bronchoscopy because she would not have expected the foot of the bed to be unzipped. She further identified that the all zippers should be checked when a patient is in an enclosure bed.

Interview with Director #4 on 5/20/19 at 2:20 PM indicated that if the enclosure bed had been completely zipped, P#14 would not have been able to exit the enclosure bed. Had the enclosure bed restraint been properly applied, the security event with subsequent patient injury may have been avoided.

The facility policy for safe use of an enclosure (SOMA) bed identified that the patient will be placed in the enclosure bed by staff and staff will secure the zippers on all 4 sides of the enclosure bed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on medical record review, review of facility policy, review of a facility video surveillance monitoring, and interview for two of eight patients who were restrained (Patient #2 and Patient #14), the facility failed to ensure that the patient was monitored as per policy during the use of a restraint. The finding includes:

Patient (P) #2 was admitted to the Emergency Department (ED) on 3/3/19 at 4:00 PM via ambulance from home on a PEER (police emergency evaluation request) with delusional and combative behavior. The ED record identified that P#2 was cleared medically at 7:38 PM and transitioned to the BHU (behavioral health unit) in the ED.

Nursing narratives dated 3/3/19 by RN#1 indicated that P#2 was agitated in what he/she called the "man trap", became aggressive (posturing) and was unable to be redirected therefore security was called to assist with restraining P#2.

A physician's order dated 3/3/19 at 7:50 PM signed by MD#1 at 9:53 PM noted that P#2 was an imminent risk to harm self or others and directed the use of 4 point restraints.

Review of video surveillance monitoring on 4/26/19, dated 3/3/19 at 7:50 PM, indicated that bilateral locked, keyed wrist restraints were brought to the room by the Social Worker. The restraints were applied by SO#1 and ERT#1.

Nursing restraint documentation identified that the restraints were initiated on 3/3/19 at 7:50 PM although the video did not show that the patient was moving/resisting, as four or five SO's were observed holding the patient's arms and legs down on the bed for 3 minutes. At 8:15 PM violent release criteria was completed and identified that the patient was no longer exhibiting behaviors that were threatening harm to self or others.

Review of the Patient's EMR (electronic medical record) and interview with RN#2 on 5/14/19 at 12:00 PM identified that P#2 was restrained for approximately 25 minutes according to the nursing documentation timed 8:15 PM however the actual time for discontinuation of the restraints was not documented. RN#2 further indicated the medical record lacked documentation that the every 15 minute monitoring had been completed by RN#1 as per facility policy.

The facility restraint policy identified that continuous monitoring of patients in restraints included every 15 minute monitoring safety observation checks and assessment documentation by the RN (circulation, mental status, respiratory and restraint evaluation). The policy further directed that documentation should include the time the restraint was implemented and discontinued.

b. Patient (P) #14 was brought to the ED by ambulance on 5/6/19 after being found on the street by the mobile crisis unit. The patient had a diagnosis of Schizophrenia with medication noncompliance. P#14's conservator indicated the patient had been acting erratic, paranoid, delusional and irritable. A chest x-ray dated 5/6/19 identified a possible tuberculosis lesion and the plan was for P#14 to be admitted to a negative pressure room on a medical unit with a patient sitter in attendance.

Nursing narratives, security reports and MD progress notes dated 5/8/19 indicated that at 7:49 AM, P#14 attempted to leave the unit via the 8th floor stairwell and security was immediately called. Medications were administered per MD orders and P#14 returned to the unit with a patient sitter in place.

A physician's order dated 5/9/19 at 7:24 AM directed a non-violent restraint enclosure bed for interfering with medical devices. A physician's order dated 5/10/19 at 11:16 AM directed a violent restraint enclosure bed for imminent risk for harm to self or others.

Nursing restraint documentation identified that Patient #14 was in the enclosure bed from 9:12 AM on 5/9/18 until the time Patient #14 went for a bronchoscopy at 10:09 AM on 5/10/19. Although the non-violent restraint order had expired at 7:24 AM on 5/10/19 and was changed to a violent restraint order, the medical record lacked documentation that every 15 minute behavioral monitoring had been completed during the violent restraint use.

Interview with Manager #1 on 4/26/19 at 12:47 PM indicated that patient behaviors should be monitored every 15 minutes when a violent restraint is used.

The facility physical restraint and seclusion policy identified that violent or self-destructive behavioral restraints required patient monitoring and documentation every 15 minutes.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
Based on medical record review, review of facility policies, review of facility documentation, and interviews for one of eleven patients who exhibited uncooperative/combative behaviors (Patient #14), the facility failed to document patient behaviors that warranted the use of as needed (PRN) psychoactive medication. The finding includes:

Patient (P) #14 was brought to the ED by ambulance on 5/6/19 after being found on the street by the mobile crisis unit. The patient had a diagnosis of Schizophrenia with medication noncompliance. P#14's conservator indicated the patient had been acting erratic, paranoid, delusional and irritable. In addition P#14 had not been taking his/her medications. A chest x-ray dated 5/6/19 identified a possible tuberculosis lesion and P#14 was subsequently admitted via a PEC (Physician's Emergency Evaluation) on 5/7/19 at 1:39 PM and placed in a regular bed, in a negative pressure room on the medical unit (10 South) with a sitter in attendance.

Nursing narratives and/or security reports and/or MD progress notes dated 5/8/19 indicated that at 7:49 AM, P#14 left the unit and exited via the stairwell to the 8th floor. Security was immediately called as the Patient left the unit. Medications were administered per MD orders and P#14 returned to the unit with sitter in place.

The MD psychiatric consult dated 5/8/19 at 1:02 PM directed to administer Haldol, Ativan and Benadryl orally for severe agitation as needed (PRN) and to please give the medications IM (intramuscularly) if the patient refused the medication, was agitated and/or was a danger to self or others.

Nursing narratives and/or medication records noted that PRN Ativan 2 milligrams (mg), Haldol 5 mg., and Benadryl 50 mg. was administered IM at 9:00 PM on 5/8/19 however the behaviors exhibited requiring the administration of the medications were not documented in the medical record.

Interview with the Chief Nursing Officer on 5/21/19 at 2:12 PM noted that she could not identify what behaviors prompted the use of the psychoactive medication as the patient's exhibited behaviors were not documented.

The facility physical restraint and seclusion policy identified, in part, that 1.) Medications used in addition to or replacement of the patient's regular drug regimen to control behavior or restrict freedom of movement is a chemical restraint. 2.) A comprehensive assessment by an RN or LIP (licensed independent practitioner) should include a description of the patient's behaviors or potential for harmful behavior.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
Based on medical record review, review of facility policies, review of facility documentation, review of a facility video surveillance monitoring and interviews for two of eleven patients who exhibited uncooperative behaviors (Patient #2 and Patient #14), the facility failed to ensure that alternatives were tried prior to restraint use. The finding includes:

a. Patient (P) #2 was admitted to the Emergency Department (ED) on 3/3/19 at 4:00 PM via ambulance from home on a PEER (police emergency evaluation request) with delusional and combative behavior. The ED record identified that P#2 was cleared medically at 7:38 PM and transitioned to the BHU (behavioral health unit) in the ED.

Video surveillance monitoring (no audio) viewed on 4/26/19 at 11:03 AM and dated 3/3/19 at 7:39 PM and/or 7:40 PM noted P#2 in the BHU of the ED with three SO's (security officers), ERT (emergency room Technician) #1, and Registered Nurse (RN) #1. R #1 subsequently exited the area via a door to enter the nursing station while P#2 remained in the general area of the BHU and had not yet entered his/her room.

The video monitoring further identified the following:

1.) P#2 was pacing in a circular motion and four SO's and ERT#1 closely encircled P#2.

2.) Four SO's and ERT#1 placed hands on P#2, SO#1 held P#2 around the back of the neck at the same time SO#1 pushed/corralled P#2 to room #6 when the patient was not observed to demonstrate any self-harm or harm to others.

3.) P#2 was brought to the floor by the 4 SO's and ERT#1. ERT#1 was in a kneeling- like position and SO#1 had his arm around P#2's posterior neck and the video showed SO#1 punch P#2 in the head/face 8 to 9 times while the patient's hands/arms were held by the other SO's present although the patient was not observed to demonstrate any self-harm or harm to others.

4.) P#2 was face down on the floor and subsequently the patient was moved onto the bed by the SO's and ERT#1.

5.) P#2 was placed in the prone (face down) position on the bed and was held in this position face down with ERT#1's knee placed on P#2's upper back in an attempt to help restrain P#2. Although the video did not show that the patient was moving/resisting, four or five SO's were observed holding the patient's arms and legs down on the bed for 3 minutes. In the video monitoring a pool of blood was observed on the floor where P#2's face had been positioned.

6.) Bilateral locked/keyed wrist restraints were applied to P#2 by SO#1 and ERT#1, after P#2 was lifted, turned and placed in a supine position. Bright red blood was noted on the bedding that had been beneath the right side of P#2's face. P#2 remained in restraints for 25 minutes.

7.) The video identified that P#2 received an intramuscular injection (deltoid) by RN #1. Review of the clinical record indicated that RN #1 administered IM Haldol 5 mg. and Ativan 2 mg. at 7:56 PM. The corresponding nursing note indicated that the IM was administered for posturing and aggressive behavior (not described), although the patient was not observed on the video to demonstrate any self-harm or harm to others during the restraint application.

Interview with SO#4 on 5/15/19 at 8:39 AM identified that SO#4 asked P#2 to go to room #6 repeatedly and informed P#2 that if P#2 did not go to the room, then staff would assist P#2 to the room. SO#4 further indicated that he believed P#2's body language to be aggressive and told P#2 "don't do that or we will have to go hands on".

Interview with SO#3 on 4/15/19 at 9:10 AM identified that following the restraining episode of P#2 on 3/3/19, he believed he would have tried harder to deescalate P#2 prior to restraining and would not "corner" the Patient.

Interview with Manager #2 (Security) on 4/26/19 at 11:03 AM indicated that after video review he did not identify that P#2 exhibited behaviors that would have warranted "hands on". She further noted that, in accordance with facility training, when dealing with an agitated patient, the patient should be given space and should not be cornered. Manager #2 identified that there was "no such thing as too long" when having a discussion with a patient in an attempt to deescalate a situation.

The facility physical restraint and seclusion policy identified, in part, that restraints included physical holds and wrist restraints and utilize least restrictive alternatives prior to the application of restraints. The policy further identified to set limits, intervene verbally to redirect the patient and/or de-escalate the behavior. The facility training for MOAB (management of aggressive behavior) identified that the importance of personal space cannot be stressed enough and without recognizing the importance of personal zones there is a risk of increasing the other person's anxiety.


b. Patient (P) #14 was brought to the ED by ambulance on 5/6/19 after being found on the street by the mobile crisis unit. The patient had a diagnosis of Schizophrenia with medication noncompliance. P#14's conservator indicated the patient had been acting erratic, paranoid, delusional and irritable. A chest x-ray dated 5/6/19 identified a possible tuberculosis lesion and the plan was for P#14 to be admitted to a negative pressure room on a medical unit with a patient sitter. Although alternatives were tried in the ED such as de-escalation, diversion, medication, and a sitter to help control the patient's physically aggressive behavior, P#14 continued to be physically aggressive, tried to leave the ED and was placed in an enclosure bed at 5:17 AM on 5/7/19 per the MD (Medical Doctor) order.

P#14 was subsequently admitted via a PEC (Physician's Emergency Evaluation) on 5/7/19 at 1:39 PM and placed in a regular bed, in a negative pressure room on the medical unit (10 South) and with a sitter in attendance.

Nursing documentation, security reports and/or MD progress notes dated 5/8/19 indicated that P#14 attempted to leave the unit at 7:49 AM via the stairwell to the 8th floor and security was immediately called as the patient tried to leave the unit. Medications were administered per MD orders and P#14 returned to the unit with a sitter in place.

A psychiatric consult dated 5/8/19 at 1:02 PM directed to administer Haldol, Ativan and Benadryl orally for severe agitation and to please give the medications IM (intramuscularly) if patient refused, was agitated and/or a endanger to self or others.

Nursing narratives and/or medication records noted that PRN Ativan, Haldol and Benadryl medications were administered IM at 9:00 PM on 5/8/19 to P#14. The medical record lacked documentation of alternatives tried prior to medication use.

Nursing documentation identified that P#14 had a sitter in attendance on 5/8/19 into 5/9/19.

Nursing flow records by RN#7 dated 5/9/19 identified that P#14 was physically abusive towards others at 12:03 AM, 1:04 AM, 3:41 AM, 5:23 AM and 6:02 AM.

A call placed to RN #7 and returned on 5/23/19 at 11:20 AM identified the nursing flow records dated 5/9/19 identified that P#14 was physically abusive towards others at 12:03 AM, 1:04 AM, 3:41 AM, 5:23 AM and 6:02 AM, however, RN#7 indicated the medical record was inaccurate and Patient #14 was cooperative during the shift from 5/8/19 into 5/9/19 and had a male sitter in attendance throughout the shift.

Although a physician's order dated 5/9/19 at 7:24 AM directed a non-violent restraint enclosure bed with a rationale to prevent interfering with medical devices, no applicable medical devices were identified in the medical record. RN#7 stated during interview that P#14 was placed in the enclosure bed for the safety of the sitter when it was learned that a female sitter would be monitoring P#14. The medical record lacked documentation of alternatives tried prior to the initiation of the enclosure bed.

The facility physical restraint and seclusion policy directed to limit the use of restraints and seclusion by utilizing least restrictive alternatives prior to application of restraints (violent/non- violent).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, review of a facility monitoring video surveillance, review of facility policy, and interview for two of seven patients who were restrained (Patient #2 and Patient #7), the facility failed to ensure that the patient was debriefed following the discontinuation of the restraint. The finding includes:

a. Patient (P) #2 was admitted to the Emergency Department (ED) on 3/3/19 at 4:00 PM via ambulance from home on a PEER (police emergency evaluation request) with delusional and combative behavior. The ED record identified that P#2 was cleared medically at 7:38 PM and transitioned to the BHU (behavioral health unit) in the ED.

Nursing narratives dated 3/3/19 by RN #1 indicated that P#2 was agitated in the "man trap", became aggressive, and he/she was unable to be redirected therefore security was called and became involved in restraining the patient.

A physician's order dated 3/3/19 at 7:50 PM signed by MD #1 at 9:53 PM noted that P#2 was an imminent risk to harm self or others and directed the use of 4 point restraints.

Review of the monitoring video surveillance dated 3/3/19 on 4/26/19 indicated that bilateral locked/keyed wrist restraints were applied to P#2.

Nursing restraint documentation identified that the restraints were initiated at 7:50 PM on 3/3/19 and violent release criteria documentation timed 8:15 PM identified that the patient no longer was exhibiting behaviors that were threatening harm to self or others.

Review of the Patient's EMR (electronic medical record) with RN#2 on 5/14/19 at 12:00 PM identified that P#2 was restrained for approximately 25 minutes according to the nursing documentation and the patient debriefing was not documented by RN#1 as per policy.

b. Patient #7 was admitted on [DATE] for psychiatric evaluation and suicidal ideation. Nursing documentation dated 3/16/19 identified that the patient was agitated, swinging at staff and was unable to be redirected. The documentation further indicated that restraints were applied at 6:56 PM and Physician orders dated 3/16/19 at 7:00 PM directed the use of four point restraints for risk of self-injury. Nursing documentation dated 3/16/19 identified that the restraints were discontinued at 7:34 PM and the P#7 was quiet. Review of the patient's EMR with RN#2 on 5/15/19 at 9:45 AM indicated that the medical record lacked documentation P#7 had been debriefed by RN #1 as per policy.

The facility restraint policy identified that post restraint debriefing should occur immediately after or as soon as the patient is willing to participate.