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.

The hospital violated the patients rights by verbally threatening to administer a shot to patients as form of corporal punishment, imposed as a means of coercion, discipline, convenience or retaliation by staf. Restraint or seclusion may only be imposed to insure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Findings Include:

Through interview, observation and record review, Hospital Staff # 10 verbally threatened hospital patients by threatening to administer Emergent Medication as a result to control behavior.

Through interview, observation and record review, the hospital did terminate Staff #10 for verbally threatening patients.

Through interview, obersvation and record review, the hospital did not follow its own policies by making verbal threats to patients/


The hospital Nursing Services Policy dated 10/22/2019 reflected, "It is the policy of Perimeter Healthcare to provide a safe treatment environment for all patients and to utilize interventions that are the least restrictive when confronted with potentially dangerous patient behaviors. A physical hold is a therapeutic emergency behavioral intervention used when a patient is in imminent danger or harming him/herself or others and less restrictive interventions have been ineffective. The use of physical holds will be monitored as part of the performance/quality improvement activities of Perimeter.

The hospital Policy of Perimeter Healthcare to create an environment that protects the patient's health and safety and preserves his or her dignity, rights and well-being. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety or the patient, a staff member or others."

The hospital Nursing Services Policy dated 07/17/2019 reflected, "The Seclusion/Restraint event is documented in each case of patient seclusion and/or restraint ...A Registered Nurse (RN) who has been trained and tested to be competent in restraint/seclusion is responsible for initiating and reviewing the Seclusion/Restraint documentation records. The RN shall be responsible for nursing assessments at a minimum of every 2 hours, for ensuring that the physician has been contacted in the appropriate time frame to obtain a renewal order if the criteria for seclusion and/or restraint continue to be met, and for supervising the observation and care provided by other assigned staff. The documentation is used to ensure the patient's rights are respected, that the patient's privacy and care needs are met, and to provide means for monitoring the use of seclusion and/or restraint at Perimeter Healthcare."