HospitalInspections.org

Based on observation, record review, and interview, the facility's Governing Body failed to carry out responsibilities, monitoring, and oversight to ensure facility policies and procedures were followed; and that the Hospital's Condition of Participation was met for Patient Rights.

Findings included:

The facility's Governing Body failed to ensure specific patient rights were protected and promoted by providing monitoring and oversight to ensure the facility's written restraint policies and procedures, and training program are followed during the implementation of physical restraints used for the management of behaviors for 5 of 5 patients reviewed (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5) with patient rights violations.

Specifically, the facility's Governing Body failed to:

1.) Ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital's restraint policy, training program; and in accordance with State law during the implementation of a physical restraint for Patient #1.

On 4/9/24 Patient #1

a.)Was restrained in an unsafe physical hold by the facility's contracted security personnel without a physician's order or authorized restraint initiation with clinical personnel witnessing, and

b.)Was physically restrained on a hospital gurney for a total of 17 minutes, with all extremities held in a personal hold restraint. For approximately 14 of those minutes, the patient was placed in a prohibited prone position, which was intermittently observed by various clinical staff. Afterward, the patient was repositioned into a supine position and secured using "Security/Rigid" restraints (Posey 2700Q, Twice-As-Tough Cuff), despite these restraints being contraindicated for aggressive, combative, or self-destructive behaviors. This was done instead of using the Physician-ordered Soft (Quick Release Quilted) restraints.

Patient #1 became unresponsive, with a decrease in oxygen saturation, and pulseless while in physical restraint requiring the initiation of Cardiopulmonary resuscitation (CPR). Resuscitative efforts were unsuccessful.

Interview on 2/3/25 at 4:30 PM with Administrative Staff #2 stated nursing staff do not conduct "physical holds" and that physical holds is not covered in nursing clinicals; as it is "not a nursing function." Administrative Staff #2 said a Patient Care Tech (PCT) or security officers (SO's) will conduct the physical holds on patients if needed and the nursing staff will apply the soft restraints (2 or 4 point). Administrative Staff #2 said that nursing are taught the application of soft restraints.

Refer to deficiency A 0167 for evidence of specific findings.

2.) Ensure the use of physical restraints was in accordance with an order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order a restraint in accordance with hospital policy and State law for Patient's #1 and #2.

a.) Patient #1 was inappropriately restrained in an unsafe personal physical hold by the facility's contracted security personnel without a physician's order on a hospital gurney by all extremities continuously for 17 minutes that included a prohibited prone position for an approximate 14 minutes and,

b.) Patient #2 was placed in violent restraints by nursing staff without a physician's order for one hour and 35 minutes.

Interview on 2/5/25 at 10:08 AM with Administrative Staff #2 stated that restraint logs are maintained and that every shift the charge nurse audits the restraint documentation on a local department level to determine if the required documentation is completed and will follow up immediately with the specific staff for issues or incomplete documentation that is identified. Administrative Staff #2 stated she was not aware if any further data was being collected and reviewed further for patient restraints.

Refer to deficiency A 0168 for evidence of specific findings.

3.) Ensure physical restraints were discontinued at the earliest possible time according to the physician orders and facility's policy and procedures for restraint Patient #2, #3, and #5 who had continued violent physical restraints after the patient's behavior(s) had resolved.

a.) Patient #2 remained in violent 4-point (all extremities) soft restraints while patient was sleeping for at least 1 hour and 45 minutes.
b.) Patient #3 remained in violent 4-point soft restraints while patient was calm and cooperative for 2 hours.
c.) Patient #5 remained in violent 2-point soft restraints while patient was sleeping for 30 minutes.

Refer to deficiency A 0174 for evidence of specific findings.

4.) Ensure the condition of patients who were physically restrained were monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by the hospital's restraint policy for Patient #1 and Patient #4.

a.) Patient #1's condition was not monitored or assessed according to the facility's restraint policy when was she was inappropriately restrained on the hospital gurney in an unsafe prohibited physical hold by the facility's contracted security personnel, and was subsequently held in a personal hold restraint by all extremities continuously for 17 minutes that included a prohibited prone position, which is prohibited and not in accordance with the facility's restraint policy or training program for an approximate 14 minutes that was witnessed periodically by clinical personnel; and then was placed in a supine position with "Security/Rigid" [Posey 2700Q, Twice-As-Tough Cuff] restraints that are contraindicated for aggressive/combative/self-destructive behaviors, and not Soft [Quick Release Quilted] restraints as ordered by the Physician.

Patient #1 became unresponsive, with a decrease in oxygen saturation, and pulseless while in physical restraint requiring the initiation of Cardiopulmonary resuscitation (CPR). Resuscitative efforts were unsuccessful.

b.) Patient #4 was restrained in a 4-point restraint all extremities for the management of behaviors without evidence of monitoring for safety at least every 15 minutes in accordance with the facility's policy.

Refer to deficiency A 0175 for evidence of specific findings.

Interview on 2/10/25 at 12:15 PM with Administrative Staff #3 stated that Administrative staff can see the alerts (task alert reminders) provided by the facility's electronic health record (EHR) platform from patient records when specific requirements that are built into the EHR platform are not completed. Administrative Staff #3 was asked if this data or information is monitored, collected, or trended for restraints to use for quality review or performance improvement projects, and he reported not at this time, but it was being developed.

The identified deficient practices were determined to constitute an Immediate Jeopardy to patient health and safety, placing all patients at significant risk of harm, serious injury, or potential death.

Refer to Condition of Participation for Patient Rights at: A0115

The cumulative effects of these deficient practices and the Condition of Participation was not met for Patient Rights resulted in the facility's inability to meet the Condition of Participation for Governing Body.

Based on observation of facility video surveillance, record reviews and interviews, it was determined the facility failed to ensure specific patient rights were protected and promoted in accordance with the facility's restraint policies and procedures, training program; and in accordance with State law during the implementation of physical restraints used for the management of behaviors for 5 of 5 patients reviewed (Patient #1, Patient #2, Patient #3, Patient #4 and Patient #5) resulting in patient rights violations. Specifically,

1.) Patient #1:
a.) Was restrained in an unsafe physical hold by the facility's contracted security personnel without a physician's order or authorized restraint initiation with clinical personnel witnessing, and
b.) Was physically restrained on a hospital gurney for a total of 17 minutes, with all extremities held in a personal hold restraint. For approximately 14 of those minutes, the patient was placed in a prohibited prone position, which was intermittently observed by various clinical staff. Afterward, the patient was repositioned into a supine position and secured using "Security/Rigid" restraints (Posey 2700Q, Twice-As-Tough Cuff), despite these restraints being contraindicated for aggressive, combative, or self-destructive behaviors. This was done instead of using the Physician-ordered Soft (Quick Release Quilted) restraints.

Patient #1 became unresponsive, with a decrease in oxygen saturation, and pulseless while in physical restraint requiring the initiation of Cardiopulmonary resuscitation (CPR). Resuscitative efforts were unsuccessful.

2.) Patient #2:
a.) Was placed in violent restraints by nursing staff without a physician's order for one hour and 35 minutes, and
b.) Remained in violent 4-point (all extremities) soft restraints while patient was sleeping for at least 1 hour and 45 minutes.

3.) Patient #3 remained in violent 4-point soft restraints while patient was calm and cooperative for 2 hours.

4.) Patient #4 was restrained in a 4-point restraint all extremities for the management of behaviors without evidence of monitoring for safety at least every 15 minutes in accordance with the facility's policy.

5.) Patient #5 remained in violent 2-point soft restraints while patient was sleeping for 30 minutes.

These deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety, placing all patients at at significant risk of harm, serious injury, or potential death.

Prohibited positional restraints [prone] can result in asphyxia (which occurs when a person's body position prevents them from breathing normally) and; prolonged restraints increase the risk of restraint-related deaths.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Refer to deficiencies; A 0167, 0168, 0174, and 0175 for evidence of specific findings.

Based on observation of facility video surveillance, record reviews, and interviews, it was determined the facility failed to ensure physical restraints were implemented in accordance with safe and appropriate restraint techniques as determined by the hospital's restraint policy, training program and in accordance with State law during the implementation of a physical restraint for 1 of 1 Patient reviewed (Patient #1).

Specifically, on 4/9/24 Patient #1

a.) Was restrained in an unsafe physical hold by the facility's contracted security personnel without a physician's order or authorized restraint initiation with clinical personnel witnessing, and

b.) Was physically restrained on a hospital gurney for a total of 17 minutes, with all extremities held in a personal hold restraint. For approximately 14 of those minutes, the patient was placed in a prohibited prone position, which was intermittently observed by various clinical staff. Afterward, the patient was repositioned into a supine position and secured using "Security/Rigid" restraints (Posey 2700Q, Twice-As-Tough Cuff), despite these restraints being contraindicated for aggressive, combative, or self-destructive behaviors. This was done instead of using the Physician-ordered Soft (Quick Release Quilted) restraints.

Patient #1 became unresponsive, with a decrease in oxygen saturation, and pulseless while in physical restraint requiring the initiation of Cardiopulmonary resuscitation (CPR). Resuscitative efforts were unsuccessful.

The identified deficient practices were determined to constitute an Immediate Jeopardy to patient health and safety, placing all patients at significant risk of harm, serious injury, or potential death.

Findings included:

Review of the Emergency Medical Services (EMS) run report dated 4/9/24, documented EMS arrived on scene at 7:21 PM for assault. Patient was sitting on the ground in care of the local police department and other emergency personnel. Patient #1 sustained an elevated heart rate throughout the run. Vital signs included heart rate (HR) documentation, in part; HR 158 bpm (normal is 60 to 100 beats per minute) at 7:07 PM, HR 129 at 07:14 PM, HR 148 at 7:34 PM and HR 127 at 7:44 PM. The last vital signs documented on the EMS run report were at 7:44 PM: HR 127, Blood Pressure 127/86, and Respiratory rate was 55 (normal respiratory rate is between 12 and 20 breaths per minute). Arrival to destination/hospital at 7:50 PM.

Review of the Emergency Provider Report, Triage Adult dated 4/9/24 at 08:07 PM documented by Physician #8 revealed the initial greet time was 8:07 PM. Patient brought in under ED (Emergency Detention) for "high heart rate" and bizarre behavior, has history of schizophrenia.

Review of Patient #1's Emergency Patient Record dated 4/9/24 indicated the following documentation:

Patient was determined to be an ESI/Priority 2. Patient was 5 feet 2 inches with a weight of 100 kilograms.
At 8:10 PM, Registered Nurse (RN) # 3 documented patient is refusing to wear a gown, patient is refusing all care. Security and Charge Nurse (RN #2) is aware.
At 8:12 PM, RN #3 documented patient yelling at nurses station, "that security guard is trying to rape me, I am not staying here, you can't hold me. I need my rights read to me, this is crazy. I'm not staying here." Physician #8 and Charge RN #2 aware.
At 8:12 RN #3 documented labs and meds delayed due to patient not letting staff touch her. Security having to hold patient down.
At 8:28 PM Charge RN #2 documented patient slammed head on metal cabinet in hallway 05; security/ERP informed.
At 8:35 PM, RN #2 administered diphenhydramine HCL (Benadryl 50 milligram Vial) Intramuscular (IM) as documented in the "Medication Information" to the "bilateral gluteal." Patient #1's position during administration was not documented. There was not any further documentation by RN #2 in Patient #1's record regarding her behaviors during or after the administration of Benadryl IM at 8:35 PM by RN #2.
At 8:36 PM, RN #2 administered Haloperidol Lactate (Haldol 5 mg) IM as documented in the "Medication Information" to the "left ventrogluteal." Patient #1's position during administration was not documented. There was not any further documentation by RN #2 in Patient #1's record regarding her behaviors during or after the administration of Haldol IM at 8:36 PM by RN #2.
At 8:40 PM, RN #3 documented, "patient not being compliant, security guards holding patient down at bedside."
At 8:50 PM, RN #3 documented that she was notified by PCT #9 "that patient was acting different, she was less responsive and slurring her words."
At 8:54 PM, RN #3 documented, Physician #8 was notified that patient was less responsive, a pulse was not found. CPR was started at 8:54.

Review of Patient #1's Resuscitation Form dated 4/9/24 documented the time of Code Team Arrival at 8:50 PM. Resuscitation began at 8:54 PM and resuscitation efforts terminated at 10:26 PM. Patient expired.

Review of the Emergency Provider Report for Patient #1 dated 4/9/24 at 8:39 PM documented by Physician #8 indicated the following, in part; "25-year-old female with reported history of schizophrenia (per EMS/EDW) here under EDW [Emergency Detention Warrant] for homicidal ideation and possible mental decompensation. Reportedly has not been on her medications for some time. Per the EDW, the pt reported that she was hearing voices to kill her tattoo artist. EMS reported pt was tachycardic and EDW reported that she had hit her face on a tree. The patient stated that someone hit her but could not provide details. She states that she also hurt her left hand and right knee. States she is not hurt anywhere else. The patient's shirt is wet and she is covered in leaves/grass; she states that she poured water all over herself as well. She denies SI [suicidal ideations], HI [homicidal ideations], AVH [auditory/visual hallucinations] to me, but then later yelled in the hallway that she was homicidal. History otherwise difficult to obtain as the patient is not forthcoming and is agitated. No medications reported prior to arrival."

"Stated Complaint: Elevated HR [Heart Rate], Psych."

Physical Exam noted findings, in part : "Agitated. Contusion to the left brow. Right knee tenderness. Abrasion to the left hand."

Laboratory Urine test 4/9/24 at 8:45 PM, Positive for Urine Opiates Screen, Moderate urine Protein, Large Urine Blood, Small Urine Leukocyte Esterase. Urine White Blood Count, 42 (High), Urine Red Blood Count, 218 (High). Urine Color, Dark Yellow.

Further review of the Re-Evaluation & MDM [Medical Decision Making] notes indicated, in part; "Pt evaluated in hallway bed 5, she is awake, alert, not forthcoming with information/poor historian, agitated but does not appear to be responding to internal stimuli at this time. Pt stated someone hit her on the head/face, but the EDW states that she hit her head on a tree. Pt (and bed) is covered in vegetation and her clothes are wet."

"Pt agitated so it was difficult to get detailed exam at this time for safety concerns, but she does have contusion to the left brow region, abrasions to the left hand, and tenderness to right knee however her pant leg was too tight to lift up to evaluate the skin, so plan to re-evaluate once pt is less agitated and in paper scrubs for more detailed exam to determine further workup/imaging. She did appear to be neurologically intact without any obvious focal weakness."

Physician #8 ordered basic labs, CK, UA, EKG, CT of the head/face/neck given head injury, X-rays of the left hand and right knee- in order to evaluate metabolic causes of agitation, (such as electrolyte imbalance, rhabdo) or traumatic injury. IVF fluids were ordered due to reported tachycardia per EMS.

"Radiology came to bedside to attempt imaging, but pt was agitated and had been declining tests so they will try later."

"Pt was declining care and blood draw, but did provide urine sample initially, with UDS [urine drug screen] later returning + [positive] for opiates."

"The patient was agitated in the hallway, initially just verbally by yelling profanities at staff, calling staff names, vulgarity, making racially charged statements, etc. Staff attempting to deescalate patient."
"Placed IM [Intramuscular] sedation meds for severe agitation/patient/staff safety should the pt not be able to be de-escalated."

"Pt later reportedly spat at staff and threw a punch. Pt also reportedly hit her head against the metal box on the wall twice and dented it in 2 spots. At some point during this time, security team attempted to restrain patient for her safety and staff safety while nursing was getting a room ready to move patient into. Nursing asked for restraints due to agitation, self-harm, and harm of staff."

"Near immediately after the pt was brought into a room, alerted by an ER tech that the patient was altered, was slurring her speech and had a faint pulse. She had just received IM sedation meds (5 mg of Haldol and 25 milligrams of Benadryl), however, I doubt this to be a medication reaction as pt had been appropriately dosed and possibly even underdosed meds, given pt's body weight; [100 kg/220 pounds]; it also was intramuscular and unlikely to have fully absorbed by that time. Did not see signs of anaphylaxis such as facial/oropharyngeal swelling or hives."

Physician #8 evaluated Patient #1 in the room, "and the patient was unresponsive, could not confidently palpate a pulse, and a code blue was called. We began bagging the patient with BVM with NP airway and CPR started and ACLS was followed."

"After a prolonged resuscitation and despite our best efforts, TOD [Time of Death] was called at 22:26 [10:26 PM] without reservation to all those present."

Review of Patient #1's Physician Orders (PO) dated 4/9/24 revealed the following emergency medication and restraint orders by Physician #8:
20:22 (8:22) PM, Haldol 5 milligrams (mg) AMP Intramuscular (IM)
8:22 PM, Benadryl 50 mg vial IM.
At 20:45 (8:45 PM) Physician #8 ordered a violent/self-destructive restraint due to Patient #1's combative and physical aggressive behaviors. Violent restraint device ordered, "Soft all extremities" with a time limit of 4 hours.

Further review of Patient #1's PO's revealed there was not a PO for the personal hold/physical hold restraint implemented at 08:28 PM by SO #1.

Observation conducted by surveyors on 2/3/25 at 2:30 PM of the "Security Footage Clip 4.mp4" of Patient #1's 4/9/24 at 7:51 PM revealed the following, in part:
The length of the video clip is 15 minutes and 41 seconds (15:41) and there is no audio. The camera angle is at the crossing of Hallway 5 and Hallway 6. At the beginning of the video, Patient #1 is seen walking with security officer (SO) #3 behind her to a gurney/stretcher in the Emergency Department's hallway 5, that is against the wall next to room #6, and directly across from the nurses station. Patient #1 sits on the gurney/stretcher sideways in the middle with her feet dangling towards the floor, not touching, and wearing a face mask over her mouth. SO#3 leaves the area of camera.

At 1:00 [minute mark] of the 15:41 video, (1:00/15:41) Patient #1 is sitting sideways on the gurney that is against the wall. SO #3 comes back towards Patient #1 and begins to talk with her. SO #3 is standing adjacent to Patient #1 with his hands crossed across his abdomen in a non-threatening manner, and Patient #1 is talking to SO #3. SO #3 is conversing back.
At 1:33/15:41, RN #2 approaches where they are both seen communicating with Patient #1. Armed Police Officer (APO) #5 is standing towards the wall down the hallway on the other side of room #6 observing the interactions (at the ambulance bay entrance). Throughout the continuation of the video, Patient #1 is seen talking to staff in the area, attempting to engage anyone in the area. She is seen pulling her face mask down to talk out.
At 8:40/15:41 another security officer (SO) #2 is seen approaching Patient #1 and engage in conversation while SO #3 is seen in the area at a distance.
At 9:10/15:41, Patient Care Tech (PCT) #9 is seen to walk up to Patient #1 places his hand on her shoulder, solicits a hand shake and begins to communicate with Patient #1 while SO #2 and SO #3 remain at a distance.
At 9:56/15:41, PCT #9 walks away and SO#2 and SO #3 remain.
At 10:16/15:41, the Lead SO #1 is seen walking down the hallway and stands in proximity of Patient #1 near the nurses station. SO#1 puts on gloves, stands next to APO#5 and they are seen talking and monitoring Patient #1 from a distance.
At 11:23/15:41 Patient #1 is seen talking to APO #5 and SO #1. She is shrugging her shoulders, shaking her leg, pointing her finger towards others, and using expressive gestures with her hands while talking to those in the vicinity of the nurses station.
At 11:36/15:41 SO #1 walks closer to Patient #1 and remains at a distance standing at the nurses station while Patient #1 continues to talk and engage anyone in the vicinity.
At 12:14/15:41 Patient #1 re positions herself up onto the stretcher sitting in the middle with her back and head against the wall, and legs crossed in front of her. She continues to attempt to talk to others to engage those in the vicinity. There is a metal lock box that is mounted on the wall behind her.
At 13:48/15:41 SO #1 walks away from the nurses station and approaches next to APO #5 at the end of the hallway. Patient #1 continues to talk to those in the vicinity. RN #2 is seen placing sheets on an empty stretcher that is next to Patient #1's stretcher in the hallway.
At 14:01/15:41 Patient #1 is seen to hit the back of her head once or possibly two times against the wall and the metal cabinet that is secured on the wall. RN #2 observes this behavior and Lead SO #1 then immediately walks over to Patient #1. RN #3 walks over towards Patient #1 also. When SO #1 arrives in front of Patient #1 (at 14:04/15:41) she is sitting on the stretcher, not engaged in hitting the back of her head or any other self-harm.
At 14:04/15:41 SO #1 uses his right hand to grab around Patient #1's waist and uses his left hand to grab her neck. SO #1 pushes Patient #1's head down into a lateral position on the stretcher. Once in a lateral position, he lowers the head of the bed down with his right hand and then uses his right hand to hold Patient #1's head down while RN #2 and RN#3 observe. RN #3 then walks by Patient #1 being physically restrained by SO #1, and walks into room #6 with a student nurse. RN #2 turns back around towards the empty stretcher that is next to Patient #1, continues to adjust the sheets, and places the rails down. The Unit Secretary #1 is at the nurses station sitting at a computer monitor and begins to look over at the direction of SO #1 and Patient 1. APO #5 walks over and holds down Patient #1's feet. SO #2 hurriedly walks over to the head of the bed, goes to place both hands on Patient #1, then immediately holds both of his hands up, looks up at the gloves on the wall that appear empty and walks away.
At 14:24/15:41 Patient #1 is seen continuing to move her upper body and head around and towards the wall, while SO #1 continues the physical hold on Patient #1. The patient is also seen with her mask on her mouth.
At 14:26/15:41 SO #1 then lifts his left leg and knee onto the stretcher followed by his right leg and knee. SO #1 then begins to straddle onto Patient #1's torso area while she is positioned in a partial lateral and partial supine position.
At 14:31/15:41 Patient #1 is seen using her left hand in attempt to grab SO #1's weapon (taser) while SO #1 has his right forearm pressured onto her neck and head area. APO #5 continues to hold Patient #1's feet. SO #1 then grabs Patient #1's left wrist with his right hand and places her arm across her neck area while holding her wrist onto her neck area. SO #1 has a hold of Patient #1's right arm with his left hand. Patient #1 continues to struggle and move around.
At 14:36/15:41 SO #1 appears to lose balance and then repositions himself back into a straddle position holding Patient #1's left arm out and above her head on the stretcher while he maintains hold of her right arm.
At 14:38/15:41 SO #2 and SO #3 are seen returning and remain standing next to the stretcher while SO #1 continues to hold Patient #1.
At 14:42/15:41 SO #2 and SO #3 lift the right-side rail of the stretcher. RN #2 is seen walking by observing the physical restraint and enters Room #6.
At 14:45/15:41 SO#1 places Patient #1's left arm back across her neck while he continues to hold her wrist.
At 14:50/15:41 SO #1 begins to reposition Patient #1's right arm across her chest, then holds both of Patient #1's arms at the wrist area with his right hand and then places his left hand onto Patient #1's head while he continues to straddle her.
At 14:57/15:41 SO #3 goes to the head of the stretcher and begins to move it away from the wall and SO #2 is standing to the right side of the stretcher.
At 15:00/15:41 the stretcher is moved away from the wall with SO #2 on the right side, SO #3 moves from the front to the left side, APO #5 at the rear holding Patient #1's feet and SO #1 straddled onto Patient #1 holding down her arms across her chest with his right hand and head with his left hand (opened). Patient #1 continues to struggle and move around. SO #3 raises up the left side rail of the stretcher.
At 15:02/15:41 SO #1 uses his left hand to grab Patient #1's hair/braids and physically moves her head and neck into a partial side/partial face down position. Immediately after that, Patient #1 frees her right hand from SO #1's right hand hold and uses her forearm and elbow to hit SO #1's face. Patient #1 continues to struggle.
At 15:08/15:41 Physician #8 is seen walking out of an office adjacent to the nurses station and stands at the nurses station observing the physical restraint. Further note, Physician #8 remains at the nurses station observing the remainder of the physical hold restraint until the end of the video at 15:41.
At 15:12/15:41 SO#3 is holding one of Patient's ankles/leg, APO#5 is holding the other and SO #2 is assisting SO #1 at the head of the bed to maintain the physical hold of Patient #1.
At 15:21/15:41 Emergency Management personnel and RN # 3 are seen moving another patient on a stretcher out of Room #6. SO #1 is seen holding each of Patient #1's wrists with her arms crossed in front of her chest, with each of his hands, straddled on top of her on the stretcher while SO #3 and APO#5 are holding her legs. She is in a lateral position at this point and her face mask is still over her mouth.
At 15:291/15:41, SO #2 moves Patient #1's stretcher into room #6 while SO #1 remains straddled on Patient #1, on the stretcher; holding her wrists with each of his hands; arms across her chest, with APO#5 holding one leg and SO #3 holding the other leg. Her face mask remains over her mouth. Patient #1 appeared to be exhibiting less struggle than previously observed.
At 15:39/15:41 Patient #1's stretcher is in Room #6 with SO #1, SO#2, SO#3 and APO#5. There are EMS personnel standing at the doorway. There are no further observations for Patient #1 on video.

Review of the security incident form dated 4/9/24 at 10:40 PM completed by Lead Security Officer (SO) #1 documented the following, in part;

"On April 9th, 2024 at approximately 20:24, [08:24 PM] I [SO#1] responded to ER (Emergency Room) Hallway Bed 5 due to reports of ED (Emergency Detention) patient's [#1's] behavior escalating and her refusing to cooperate with behavioral health protocols. I arrived, and the patient was already screaming at me, calling me a "faggot" while also hurling verbal insults at SO [#2] and APO (Armed Police Officer) [facility staff #5]. I was notified that attempts at de-escalating the patient had failed, so the decision was made to wait for the patient to be moved into a room before starting anything. I remained on standby with [SO #2, SO #3, and APO-staff #5] while the patient continued to hurl insults at the security team and emergency personnel. As the patient continued to scream and cuss, at approximately 20:28 [8:28 PM], she slammed the back of her head on the lock box directly above her bed in ER Hallway, Bed 5. There was a huge indention on the lock box as a result of the patient slamming the back of her head against it. The patient continued to threaten to slam her head as she continued to scream. I approached the patient, grabbed a hold of the back of her head, and pushed her head down into the bed. This was done because the patient continued to threaten to slam her head, and the fear that she could hurt herself even more if she continued to do so. Once on the bed, I laid the bed flat and held her down while talking to the patient. APO [staff #5] arrived and held down the patient's feet to prevent her from kicking. [SO #2] arrived but stood by at my request. I kept my hand at the back of the patient's head as she kept trying to slam the back of her head on the railing beside her bed. Due to the patient's large size, and the current location that we were at, it was difficult to maintain control of the patient." I got onto the bed with the patient and put pressure her arms as we struggled to maintain control of her. The patient kept trying to slam her head into the wall, I put both of her hands against her chest and held them down with my right hand while holding her head with my left hand so prevent her from slamming her head around. The patient was moved to ER Bed 6, where the patient was restrained on the bed. I got off of the bed where [SO #2, SO #3, APO staff #5] and I continued to restrain the patient. The patient continued to struggle in a wild manner making it extremely difficult to maintain control of the patient. C/N (Charge Nurse) [Registered Nurse (RN) #2] was the first to standby in the room but had to switch out with PCT (Patient Care Tech) [Staff #1, unit secretary] so that she could go retrieve medication for the patient. As the patient continued to thrash around the bed, attempting to break free, she found herself stomach down [prone position] on the bed. The patient had flipped herself over onto her stomach during the struggle. I maintained control of the patient's head by having it pushed off to the side, the patient was able to breath easily while continuing to yell insults at those in the room. I also maintained a grip on the patient's right arm, [SO #3] maintained a grip on the patient's left arm, [SO #2] maintained a grip on the patient's left leg, and APO [ staff #5] maintained a grip on the patient's right leg. C/N [RN #2] returned and proceeded to administer medications to the patient. PCT [staff #9] arrived and proceeded to take over in restraining the patient's left arm while [SO #3] retrieved the "Security" Restraint at the request of the medical staff (unknown who approved the restraints). [SO #3] returned with the "Security" Restraints, and PCT [#9] took over in restraining both the patient's left arm and left leg. [SO #2] and [SO #3] prepped the restraints around the bed first. Once the restraints were ready, the five of us needed to assist the patient in flipping over. As we turned the patient over, she freed one of her arms and punched me in the face. The patient also managed to claw at my face, leaving a minor cut on it. Once on her back, the patient nearly fell down which led to us needing to support all the patient's weight as she continued to scream. The patient, during this time, spat in the face of [SO #2]. PCT [#9] draped a towel over the patient's face to prevent her from spitting. The towel was not held down, just draped over and left loose. The patient continued to wildly struggle, a paramedic with [ the local Fire Department] entered the room and assisted with restraining the patient. The paramedic, [SO #2, SO #3 and APO #5] assisted with placing the patient's leg restraints while PCT [#9] restrained the patient's arms. The leg restraints were placed but not tight, but enough to prevent the patient from kicking as it remained difficult to properly put them on. Next were attempts at the arm restraints, I was more focused on the patient as she was breaking loose from me, but the arm restraint on the right arm was placed. As we now attempted to put the restraint on the left arm, the patient suddenly stopped moving. PCT [#9] directed everyone to back away from the patient as he checked for a pulse, which was something we had already done beforehand. All the security team stepped outside of the room, while the medical staff took over as a Code Blue (Cardiac/Pulmonary Arrest) was initiated. [SO #3, APO #5], and I cleared from the scene at approximately 21:00 [9:00 PM] while [SO #2] remained on the Code Blue."

Patient #1's record did not include "Restraint Documentation" or assessment by an RN of the required restraint assessment documentation to include; "Respiratory, circulation, skin integrity and cardiac status," during the 26 minute physical restraint.

Further review of Patient #1's emergency record revealed no documentation of vital signs (blood pressure, heart rate, oxygen saturation rate, or respiratory rate) until after CPR resuscitation began.

Interview with RN Staff #2 on 2/4/25 at 7:00 AM stated the following: on 4/9/24 she was the charge RN and she remembered Patient #1 well. She was very vocal and began escalating quickly after her arrival to the ER. She did not seem to respond to her in a favorable manner, so RN #2 stepped back and allowed other staff to engage Patient #1 while she was in the area. When the restraint started in the hallway, RN #2 was surprised in how aggressive the security officer (#1) was and that he got onto the stretcher with Patient #1. When security moved Patient #1's stretcher into the room (#6) RN #2 went to retrieve the psychiatric medications that Physician #8 ordered. When RN #2 returned, Patient #1 was struggling with the four security personnel that had her in a physical hold, one on each limb with Patient #1 in a prone position on the stretcher. RN #2 administered the medications by injection into the hip muscle. RN #2 then told them, "Once she settles down, let's get her on a machine" to monitor her pulse and o2 stats (blood oxygenation saturation). RN #2 said she later heard the "button go off" for a code and then a group of clinical staff entered the room. RN #2 said that it was reported that Patient #1 was "acting weird" and that her SPO2 (blood oxygen saturation) was dropping and was in the 70's (normal is 95 to 100%); she was going into respiratory distress. There was a portable pulse oximeter being used at this time to monitor her. RN #2 said they ran the code for more than an hour to an hour and half. Physician #8 was adamant about resuscitating Patient #1. There was concerns in regard to the harm she may have caused to herself and with security; "how they took her down." RN #2 said she talked to the security officers that were involved in Patient #1's restraint about the aggressiveness that was witnessed. RN #2 also stated there was a debrief after the incident and she talked to Physician #8 and the House Supervisor/RN Staff #4 about security's role in the restraint. She did not like how "security handled" Patient #1; how she was "taken down in the hall, held in a prone position by security." RN #2 said "I verbalized, that's excessive." RN #2 said she would not have taken Patient #1 down like security did; she would have only changed her positioning first. "It was excessive." RN #2 said she had never seen that occur before, although there had been "hearsay" where others had concerns with security. She said security will be called to assist on standby, to be around and you will see them "gloving up and ready to go in" they will physically "puff up" with their "egos" when sometimes all you have to do is calm the patient by feeding them, giving them warm blankets, etc. RN #2 said sometimes psychiatric patients will see security as "intimidating."

Interview with RN #3 on 2/4/24 at 9:24 PM stated the following: on 4/9/24 she remembered Patient #1 being hostile, saying a lot of racial things and yelling. She would not let anyone access her, obtain labs or vital signs. RN #3 said that Patient #1 did report that her "heart was racing," and that may have been the reason she came in. RN #3 said Patient #1 was saying that she was "raped, and someone was coming after her." Patient #1 continued to escalate even more and hit her head on metal box behind her and then "security put hands on her." Patient #1 said she was "pinned down," by security. RN #2 then gave Patient #1 emergency meds. There were several security officers trying to get "rigid restraints" secured. Then a "Code Blue" was called due to the patient not breathing and RN #3 started to be the recorder for the code and the team ran the code under staff #8 direction. RN #3 said in the ER, the nurses do the restraints, but security does the physical and personal restraints (hands on). RN #3 said she does not tell security when to do physical hold restraints, they initiate it on their own. But the Nurses do the post restraint evaluation and record that in the treatment plan.

Interview on 2/5/25 at 5:39 PM with Physician #8 stated the following: On 4/9/24 she was the attending physician for Patient #1. She received information that the patient was on an ED for mental decompensation; with reports of HI and increased heart rate. Physician #8 triaged the patient and placed orders. Patient #1 was refusing care, refusing blood work and radiology but did provide a urine sample. Physician #8 said Patient #1 was too agitated and refusing care, so she put in orders for Haldol 5mg and Benadryl at 8:21 PM and went about to see other patients. She then saw a nursing note that Patient #1 hit her head on a metal box in the hallway after becoming more and more verbally agitated. Security was present and an APO at the EMS bay. Patient #1 received medications, Haldol and Benadryl at 8:35 PM. At 8:40 PM Patient #1 was still agitated and at 8:45 PM, Physician #8 put in a "restraint order" for soft restraints all 4 extremities. Physician #8 walked up and saw several people restraining Patient #1 physically. She was being held by each limb, the bed was against the wall, and someone was on the bed; a security officer, not a nurse. Patient #1 was on her stomach. Patient #1 received sedation meds in the room. Physician #8 said the PCT #9 came out and said Patient #1's mental status changed, she was slurring her speech, and her heart rate was dropping on the monitor. A code was called and CPR with resuscitation continued for approximately 1.5 hours. Attempted labs, ABG; but do not believe results were accurate. Physician #8 said she met with Patient #1's family and reported to them to the best of her ability what she knew. Physician #8 reported to the family that her urine sample was positive for opioids, but this situation was not consistent with an opioid overdose.

Further interview with Physician #8 confirmed she did not place an order for a physical hold restraint for Patient #1 and had not ever ordered a personal physical hold restraint because she was not aware that a physical hold was a restraint or an option in the record. Physician #8 said her hierarchy for treatment for mental health emergencies is emergency medications usually at a lower dose, because she can always add more, and then two or four-point soft restraints. Physician #8 said security (SO's) usually will help by holding down the patient's while the 2- or 4-point restraints are applied because security (SO's) are trained to hold and restrain patients, and she tries not interfere.

Interview on 2/5/25 at 3:10 PM with Security Staff #7, the Director of Security and training instructor for the Security Officers for CPI. Staff #7 said their SO's receive CPI training every two years, until recently in 2025 where they now receive annual CPI training. Staff #7 further stated the security officers are trained in non-violent crises intervention, verbal de-escalation, personal holds, disengagement skills, and some physical holds. There is an online portion of learning and a practical portion in accordance with CPI guidelines. In the practical instruction is where the personal and physical holds are taught and demonstrated with a return demonstration required.

Interview on 2/5/25 at 7:45 PM with Unit Secretary -Staff #1 said she was called into Patient #1's room (#6) on 4/9/24 to be a female "chaperone" in t

Based on observation of facility video surveillance, record reviews, and interviews, it was determined the facility failed to ensure the use of physical restraints was in accordance with an order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order a restraint in accordance with hospital policy and State law for 2 of 5 Patient's (Patient's #1 and #2) reviewed for restraints.

Specifically,

1.) Patient #1 was inappropriately restrained in an unsafe personal physical hold by the facility's contracted security personnel without a physician's order on a hospital gurney by all extremities continuously for 17 minutes that included a prohibited prone position for an approximate 14 minutes and,

2.) Patient #2 was placed in violent restraints by nursing staff without a physician's order for one hour and 35 minutes.

This deficient practice affected Patient #1 and Patient #2's rights.

Findings included:

1.) Observation conducted by surveyors on 2/3/25 at 2:30 PM of the "Security Footage Clip 4.mp4" of Patient #1's 4/9/24 at 7:51 PM revealed the following, in part:

The length of the video clip is 15 minutes and 41 seconds (15:41) and there is no audio. The camera angle is at the crossing of Hallway 5 and Hallway 6. At the beginning of the video, Patient #1 is seen walking with security officer (SO) #3 behind her to a gurney/stretcher in the Emergency Department's hallway 5, that is against the wall next to room #6, and directly across from the nurses station. Patient #1 sits on the gurney/stretcher sideways in the middle with her feet dangling towards the floor, not touching, and wearing a face mask over her mouth. SO#3 leaves the area of camera.

At 1:00 [minute mark] of the 15:41 video, (1:00/15:41) Patient #1 is sitting sideways on the gurney that is against the wall. SO #3 comes back towards Patient #1 and begins to talk with her. SO #3 is standing adjacent to Patient #1 with his hands crossed across his abdomen in a non-threatening manner, and Patient #1 is talking to SO #3. SO #3 is conversing back.
At 1:33/15:41, RN #2 approaches where they are both seen communicating with Patient #1. Armed Police Officer (APO) #5 is standing towards the wall down the hallway on the other side of room #6 observing the interactions (at the ambulance bay entrance). Throughout the continuation of the video, Patient #1 is seen talking to staff in the area, attempting to engage anyone in the area. She is seen pulling her face mask down to talk out.
At 8:40/15:41 another security officer (SO) #2 is seen approaching Patient #1 and engage in conversation while SO #3 is seen in the area at a distance.
At 9:10/15:41, Patient Care Tech (PCT) #9 is seen to walk up to Patient #1 places his hand on her shoulder, solicits a hand shake and begins to communicate with Patient #1 while SO #2 and SO #3 remain at a distance.
At 9:56/15:41, PCT #9 walks away and SO#2 and SO #3 remain.
At 10:16/15:41, the Lead SO #1 is seen walking down the hallway and stands in proximity of Patient #1 near the nurses station. SO#1 puts on gloves, stands next to APO#5 and they are seen talking and monitoring Patient #1 from a distance.
At 11:23/15:41 Patient #1 is seen talking to APO #5 and SO #1. She is shrugging her shoulders, shaking her leg, pointing her finger towards others, and using expressive gestures with her hands while talking to those in the vicinity of the nurses station.
At 11:36/15:41 SO #1 walks closer to Patient #1 and remains at a distance standing at the nurses station while Patient #1 continues to talk and engage anyone in the vicinity.
At 12:14/15:41 Patient #1 re positions herself up onto the stretcher sitting in the middle with her back and head against the wall, and legs crossed in front of her. She continues to attempt to talk to others to engage those in the vicinity. There is a metal lock box that is mounted on the wall behind her.
At 13:48/15:41 SO #1 walks away from the nurses station and approaches next to APO #5 at the end of the hallway. Patient #1 continues to talk to those in the vicinity. RN #2 is seen placing sheets on an empty stretcher that is next to Patient #1's stretcher in the hallway.
At 14:01/15:41 Patient #1 is seen to hit the back of her head once or possibly two times against the wall and the metal cabinet that is secured on the wall. RN #2 observes this behavior and Lead SO #1 then immediately walks over to Patient #1. RN #3 walks over towards Patient #1 also. When SO #1 arrives in front of Patient #1 (at 14:04/15:41) she is sitting on the stretcher, not engaged in hitting the back of her head or any other self-harm.
At 14:04/15:41 SO #1 uses his right hand to grab around Patient #1's waist and uses his left hand to grab her neck. SO #1 pushes Patient #1's head down into a lateral position on the stretcher. Once in a lateral position, he lowers the head of the bed down with his right hand and then uses his right hand to hold Patient #1's head down while RN #2 and RN#3 observe. RN #3 then walks by Patient #1 being physically restrained by SO #1, and walks into room #6 with a student nurse. RN #2 turns back around towards the empty stretcher that is next to Patient #1, continues to adjust the sheets, and places the rails down. The Unit Secretary #1 is at the nurses station sitting at a computer monitor and begins to look over at the direction of SO #1 and Patient 1. APO #5 walks over and holds down Patient #1's feet. SO #2 hurriedly walks over to the head of the bed, goes to place both hands on Patient #1, then immediately holds both of his hands up, looks up at the gloves on the wall that appear empty and walks away.
At 14:24/15:41 Patient #1 is seen continuing to move her upper body and head around and towards the wall, while SO #1 continues the physical hold on Patient #1. The patient is also seen with her mask on her mouth.
At 14:26/15:41 SO #1 then lifts his left leg and knee onto the stretcher followed by his right leg and knee. SO #1 then begins to straddle onto Patient #1's torso area while she is positioned in a partial lateral and partial supine position.
At 14:31/15:41 Patient #1 is seen using her left hand in attempt to grab SO #1's weapon (taser) while SO #1 has his right forearm pressured onto her neck and head area. APO #5 continues to hold Patient #1's feet. SO #1 then grabs Patient #1's left wrist with his right hand and places her arm across her neck area while holding her wrist onto her neck area. SO #1 has a hold of Patient #1's right arm with his left hand. Patient #1 continues to struggle and move around.
At 14:36/15:41 SO #1 appears to lose balance and then repositions himself back into a straddle position holding Patient #1's left arm out and above her head on the stretcher while he maintains hold of her right arm.
At 14:38/15:41 SO #2 and SO #3 are seen returning and remain standing next to the stretcher while SO #1 continues to hold Patient #1.
At 14:42/15:41 SO #2 and SO #3 lift the right-side rail of the stretcher. RN #2 is seen walking by observing the physical restraint and enters Room #6.
At 14:45/15:41 SO#1 places Patient #1's left arm back across her neck while he continues to hold her wrist.
At 14:50/15:41 SO #1 begins to reposition Patient #1's right arm across her chest, then holds both of Patient #1's arms at the wrist area with his right hand and then places his left hand onto Patient #1's head while he continues to straddle her.
At 14:57/15:41 SO #3 goes to the head of the stretcher and begins to move it away from the wall and SO #2 is standing to the right side of the stretcher.
At 15:00/15:41 the stretcher is moved away from the wall with SO #2 on the right side, SO #3 moves from the front to the left side, APO #5 at the rear holding Patient #1's feet and SO #1 straddled onto Patient #1 holding down her arms across her chest with his right hand and head with his left hand (opened). Patient #1 continues to struggle and move around. SO #3 raises up the left side rail of the stretcher.
At 15:02/15:41 SO #1 uses his left hand to grab Patient #1's hair/braids and physically moves her head and neck into a partial side/partial face down position. Immediately after that, Patient #1 frees her right hand from SO #1's right hand hold and uses her forearm and elbow to hit SO #1's face. Patient #1 continues to struggle.
At 15:08/15:41 Physician #8 is seen walking out of an office adjacent to the nurses station and stands at the nurses station observing the physical restraint. Further note, Physician #8 remains at the nurses station observing the remainder of the physical hold restraint until the end of the video at 15:41.
At 15:12/15:41 SO#3 is holding one of Patient's ankles/leg, APO#5 is holding the other and SO #2 is assisting SO #1 at the head of the bed to maintain the physical hold of Patient #1.
At 15:21/15:41 Emergency Management personnel and RN # 3 are seen moving another patient on a stretcher out of Room #6. SO #1 is seen holding each of Patient #1's wrists with her arms crossed in front of her chest, with each of his hands, straddled on top of her on the stretcher while SO #3 and APO#5 are holding her legs. She is in a lateral position at this point and her face mask is still over her mouth.
At 15:291/15:41, SO #2 moves Patient #1's stretcher into room #6 while SO #1 remains straddled on Patient #1, on the stretcher; holding her wrists with each of his hands; arms across her chest, with APO#5 holding one leg and SO #3 holding the other leg. Her face mask remains over her mouth. Patient #1 appeared to be exhibiting less struggle than previously observed.
At 15:39/15:41 Patient #1's stretcher is in Room #6 with SO #1, SO#2, SO#3 and APO#5. There are EMS personnel standing at the doorway. There are no further observations for Patient #1 on video.

Review of the security incident form dated 4/9/24 at 10:40 PM completed by Lead Security Officer (SO) #1 documented the following, in part;

"On April 9th, 2024 at approximately 20:24, [08:24 PM] I [SO#1] responded to ER (Emergency Room) Hallway Bed 5 due to reports of ED (Emergency Detention) patient's [#1's] behavior escalating and her refusing to cooperate with behavioral health protocols. I arrived, and the patient was already screaming at me, calling me a "faggot" while also hurling verbal insults at SO [#2] and APO (Armed Police Officer) [facility staff #5]. I was notified that attempts at de-escalating the patient had failed, so the decision was made to wait for the patient to be moved into a room before starting anything. I remained on standby with [SO #2, SO #3, and APO-staff #5] while the patient continued to hurl insults at the security team and emergency personnel. As the patient continued to scream and cuss, at approximately 20:28 [8:28 PM], she slammed the back of her head on the lock box directly above her bed in ER Hallway, Bed 5. There was a huge indention on the lock box as a result of the patient slamming the back of her head against it. The patient continued to threaten to slam her head as she continued to scream. I approached the patient, grabbed a hold of the back of her head, and pushed her head down into the bed. This was done because the patient continued to threaten to slam her head, and the fear that she could hurt herself even more if she continued to do so. Once on the bed, I laid the bed flat and held her down while talking to the patient. APO [staff #5] arrived and held down the patient's feet to prevent her from kicking. [SO #2] arrived but stood by at my request. I kept my hand at the back of the patient's head as she kept trying to slam the back of her head on the railing beside her bed. Due to the patient's large size, and the current location that we were at, it was difficult to maintain control of the patient." I got onto the bed with the patient and put pressure her arms as we struggled to maintain control of her. The patient kept trying to slam her head into the wall, I put both of her hands against her chest and held them down with my right hand while holding her head with my left hand so prevent her from slamming her head around. The patient was moved to ER Bed 6, where the patient was restrained on the bed. I got off of the bed where [SO #2, SO #3, APO staff #5] and I continued to restrain the patient. The patient continued to struggle in a wild manner making it extremely difficult to maintain control of the patient. C/N (Charge Nurse) [Registered Nurse (RN) #2] was the first to standby in the room but had to switch out with PCT (Patient Care Tech) [Staff #1, unit secretary] so that she could go retrieve medication for the patient. As the patient continued to thrash around the bed, attempting to break free, she found herself stomach down [prone position] on the bed. The patient had flipped herself over onto her stomach during the struggle. I maintained control of the patient's head by having it pushed off to the side, the patient was able to breath easily while continuing to yell insults at those in the room. I also maintained a grip on the patient's right arm, [SO #3] maintained a grip on the patient's left arm, [SO #2] maintained a grip on the patient's left leg, and APO [ staff #5] maintained a grip on the patient's right leg. C/N [RN #2] returned and proceeded to administer medications to the patient. PCT [staff #9] arrived and proceeded to take over in restraining the patient's left arm while [SO #3] retrieved the "Security" Restraint at the request of the medical staff (unknown who approved the restraints). [SO #3] returned with the "Security" Restraints, and PCT [#9] took over in restraining both the patient's left arm and left leg. [SO #2] and [SO #3] prepped the restraints around the bed first. Once the restraints were ready, the five of us needed to assist the patient in flipping over. As we turned the patient over, she freed one of her arms and punched me in the face. The patient also managed to claw at my face, leaving a minor cut on it. Once on her back, the patient nearly fell down which led to us needing to support all the patient's weight as she continued to scream. The patient, during this time, spat in the face of [SO #2]. PCT [#9] draped a towel over the patient's face to prevent her from spitting. The towel was not held down, just draped over and left loose. The patient continued to wildly struggle, a paramedic with [ the local Fire Department] entered the room and assisted with restraining the patient. The paramedic, [SO #2, SO #3 and APO #5] assisted with placing the patient's leg restraints while PCT [#9] restrained the patient's arms. The leg restraints were placed but not tight, but enough to prevent the patient from kicking as it remained difficult to properly put them on. Next were attempts at the arm restraints, I was more focused on the patient as she was breaking loose from me, but the arm restraint on the right arm was placed. As we now attempted to put the restraint on the left arm, the patient suddenly stopped moving. PCT [#9] directed everyone to back away from the patient as he checked for a pulse, which was something we had already done beforehand. All the security team stepped outside of the room, while the medical staff took over as a Code Blue (Cardiac/Pulmonary Arrest) was initiated. [SO #3, APO #5], and I cleared from the scene at approximately 21:00 [9:00 PM] while [SO #2] remained on the Code Blue."

Review of Patient #1's Physician Orders (PO) dated 4/9/24 revealed there was not a PO for the personal hold/physical hold restraint implemented at 08:28 PM by SO #1. Further review revealed at 20:45 (8:45 PM) Physician #8 ordered a violent/self-destructive level of restraint due to Patient #1's combative and physical aggressive behaviors. Violent restraint device ordered, "Soft all extremities" with a time limit of 4 hours.

Interview with RN Staff #2 on 2/4/25 at 7:00 AM stated the following: on 4/9/25 she was the charge RN and she remembered Patient #1 well. She was very vocal and began escalating quickly after her arrival to the ER. She did not seem to respond to me in a favorable manner, so RN #2 stepped back and allowed other staff to engage Patient #1 while she was in the area. When the restraint started in the hallway, RN #2 was surprised in how aggressive the security officer (#1) was and that he got onto the stretcher with Patient #1. When security moved Patient #1's stretcher into the room (#6) RN #2 went to retrieve the psychiatric medications that Physician #8 ordered. When RN #2 returned, Patient #1 was struggling with the four security personnel that had her in a physical hold, one on each limb with Patient #1 in a prone position on the stretcher. RN #2 said she talked to the security officers that were involved in Patient #1's restraint about the aggressiveness that was witnessed. RN #2 also stated there was a debrief after the incident and she talked to Physician #8 and the House Supervisor/RN Staff #4 about security's role in the restraint. She did not like how "security handled" Patient #1; how she was "taken down in the hall, held in a prone position by security." RN #2 said "I verbalized, that's excessive." RN #4 said she would not have taken Patient #1 down like security did; she would have only changed her positioning first. "It was excessive." RN #2 said she had never seen that occur before, although there had been "hearsay" where others had concerns with security. She said security will be called to assist on standby, to be around and you will see them "gloving up and ready to go in" they will physically "puff up" with their "egos" when sometimes all you have to do is calm the patient by feeding them, giving them warm blankets, etc. RN #2 said sometimes psychiatric patients will see security as "intimidating."

Interview on 2/5/25 at 5:39 PM with Physician #8 stated on 4/9/24 she was the attending physician for Patient #1 and confirmed she did not place an order for a personal physical hold restraint for Patient #1.

2.) Patient #2

Review of Patient #2's Emergency Patient Record dated 11/3/24 documented Patient #2 was placed in violent restraints at 10:00 AM using soft BUE (bilateral upper extremities).

Review of Patient #2's Physician orders revealed an order for Violent restraints was not ordered until 11:35 AM, (One hour and 35 minutes later).

During a review of Patient #2's records on 2/10/25 at 11:45 AM with the administrative staff; including Administration staff #3 and the Director of Patient Safety #1, confirmed the findings for Patient #2.

Review of the facility's Restraint/Seclusion policy last revised 07/2023 indicated the following, in part;

Policy: The facility will comply with state laws when initiating restraints to,
D. Protect the rights and well-being of individuals during the use of restraint.

Procedure:
5. Order for Restraint
a. An order for restraint must be obtained from a physician who is responsible for the care of the patient prior to the application of restraint.
d. When a physician is not available to issue a restraint or seclusion order, an RN with specialized training may initiate restraint or seclusion use based on face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated.
6. Application of Restraints
e. Only a physician, registered nurse, or LIP in accordance with a physician's delegated authority, may initiate restraint or seclusion.

Review of State law, Texas Administrative Code, Title 25 Chapter 415, Subchapter F, §415.254 General Requirements for the use of Restraint and §415.260 Initiation of Restraint in a Behavioral Emergency [transferred on 12/12/24 to Title 26 TAC, Part 1, Chapter 320, Subchapter C, §320.107 and §320.119]

1.) General Requirements for the use of Restraint, §320.107(b)(3), and §320.107(b)(6)
(b) Use of personal or mechanical restraint` or seclusion. The use of personal or mechanical restraint or seclusion is permissible on the facility's premises, and personal or mechanical restraint is permissible for transportation of an individual only if implemented:
(3) in accordance with, and using only those safe and appropriate techniques as determined by the facility's written policies or procedures and training program as specified in subsection (e) of this section;
(6) in accordance with the applicable initiation and physician order requirements specified in §415.260 of this title (relating to Initiation of Restraint or Seclusion in a Behavioral Emergency);

2.) Initiation of Restraint in a Behavioral Emergency, §320.119(b)
(b) Physician's order. Only a physician member of the facility's medical staff may order restraint.

Based on record review and interview, the facility failed to ensure physical restraints were discontinued at the earliest possible time according to the physician orders and facility's policy and procedures for restraint for 3 of 3 patients reviewed (Patient #2, #3, and #5) who had continued violent physical restraints after the patient's behavior(s) had resolved.

Specifically,

Patient #2 remained in violent 4-point (all extremities) soft restraints while patient was sleeping for at least 1 hour and 45 minutes.
Patient #3 remained in violent 4-point soft restraints while patient was calm and cooperative for 2 hours.
Patient #5 remained in violent 2-point soft restraints while patient was sleeping for 30 minutes.

This deficient practice violated patients' rights to be free from unnecessary restraint.

Findings included:

1.) Patient #2

Review of Patient #2's Emergency Patient Record dated 11/03/24 documented on page 4, "Restraint Documentation" by RN #10 at 4:07 AM: Violent restraints initiated at 04:07 AM based on the clinical justification of combative and physical aggression. Violent restraint device used: Bedrails, Quick release synthetic all extremities.

Review of the Emergency notes 11/3/24 at 05:20 AM by RN #10 documented Patient is asleep. Visible rise and fall of chest. Restraints in place. (1 hour and 13 minutes after the initiation of restraint).

At 7:30 AM, RN #11 documented report received from RN #10. Patient in 4-point violent restraints. Resting. No complaints at this time.
At 8:00 AM, RN#11 documented no order for BLE restraints. Removed at this time.

Further review of the "restraint documentation" in the Emergency Patient Record for 11/3/24 documented the following:
At 06:15 AM, RN #10 documented Patient #2's Level of consciousness: "sleeping."
At 06:30 AM RN #10 documented Patient #2's Level of consciousness: "sleeping" (2 hours and 23 minutes after restraint initiation). Meets criteria for release: "No."
At 06:45 AM RN #10 documented Patient #2's Level of consciousness: "sleeping." Meets criteria for release: "No."
At 07:16 AM RN #10 documented Patient #2's Level of consciousness: "sleeping." Meets criteria for release: "No."
At 07:20 AM RN #10 documented Patient #2's Level of consciousness: "sleeping." Meets criteria for release: "No."
At 07:35 AM RN #11 documented Patient #2's Level of consciousness: "sleeping." Meets criteria for release: "No."
At 08:00 AM RN #11 documented restraint status: Discontinue. Criteria for restraint release met: yes. Restraint discontinued 11/3/24 at 08:00 AM.

2.) Patient #3

Review of Patient #3's Emergency Patient record dated 1/25/25 record revealed the following:
At 05:10 AM Patient #3 was placed in violent restraint, soft all extremities for combative, destructive, and physical aggression behaviors.

Review of the 1:1 sitter documentation for Patient #3 dated 1/25/25 revealed the sitter documented that the patient was calm and cooperative from 7:00 AM to 09:00 AM on the observation flow sheet. Further review of Patient #3's records revealed the violent restraints were not discontinued or removed during this period when Patient #3 was calm and cooperative.

3.) Patient #5

Review of Patient #5's Emergency Patient Record dated 10/25/24, "Restraint Documentation" documented the following:

At 09:10 PM RN #12 documented the initiation of violent restraint based on the clinical justification; combative, OOB (out of bed) is extreme injury, (inj) risk, physical aggression, violent. Level of restraint; Violent restraint device. Device used: soft BUE. Factors affecting behavior: Agitation, Altered consciousness, Confused, Environmental discomfort, Unable to comprehend.

At 9:45 PM RN #12 documented that violent restraints were initiated at 9:10 PM. RN #12 documented that the clinical justification for violent restraints was Combative, OOB is extreme Inj risk, physical aggression, violent. The documentation indicated that the level of consciousness for Patient # 5 was confused, disoriented, drowsy, non responsive, not following commands.

At 10:00 PM RN #12 documented the violent restraints remained in use. Device use BUE. Clinical Justification: Combative, violent OOB is extreme Inj risk, physical aggression. Level of consciousness: disoriented, drowsy, not responsive.

At 10:15 PM RN #12 documented; the violent restraints remained in use. Device use BUE. Clinical Justification: Combative, violent OOB is extreme Inj risk, physical aggression. Level of consciousness: disoriented, drowsy, not responsive.

At 10:30 PM RN #12 documented; the violent restraints remained in use. Device use BUE. Clinical Justification: Combative, violent OOB is extreme Inj risk, physical aggression. Level of consciousness: disoriented, drowsy, not responsive.

At 10:45 PM RN #12 documented; the violent restraints remained in use. Device use BUE. Clinical Justification: Combative, violent OOB is extreme Inj risk, physical aggression. Level of consciousness: disoriented, drowsy, not responsive.

At 11:00 PM RN #12 documented; the violent restraints remained in use. Device use BUE. Clinical Justification: Combative, violent OOB is extreme Inj risk, physical aggression. Level of consciousness: disoriented, drowsy, not following commands, not responsive, "Sleeping".

At 11:15 PM RN #12 documented; the violent restraints remained in use. Device use BUE. Clinical Justification: Combative, violent OOB is extreme Inj risk, physical aggression. Level of consciousness: "Sleeping", Not responsive, Not following commands.

At 11:30 PM RN #12 documented; the violent restraints discontinued. Restraints discontinued at 11:30 PM.

Review of Patient #5's Physician Orders dated 10/25/24 at 11:01 PM, Physician #13 ordered Violent restraints for physical aggression and combative. The violent restraint device ordered was, freedom splints all extremities. Time limit: 4 hours. Criteria for release of restraints is met when patient stops: violent, physical aggression and combative.

During a collaborate review of Patient #2, #3 and #5's records on 2/10/25 between 11:30 AM and 2:00 PM with administrative staff; which included Administration Staff #1 and Administrative Staff #3; Administrative Staff #3 confirmed the findings for Patient's #2, #3 and #5 that had continued violent physical restraints after the patient's behavior(s) had resolved and/or documentation of the patient's sleeping while in restraint. There was no explanation provided upon review and the surveyor was asked by Administrative Staff #3 which regulation was being referenced during the review. It was explained to Administrative Staff #3 that the sampled Patient's records that included physical restraints were being reviewed to determine the facility's overall compliance with the facility's policy on Restraints; which coincides with the governing Federal regulations and State Laws for patient restraints.

Review of the facility's Restraint/Seclusion policy last revised 07/2023 indicated the following, in part;
Procedure:
7. Monitoring the Patient in Restraints
g. Any change in physical or psychological response will be reported to the RN. The RN will determine if medical intervention is required or if criteria for release have been met.
11. Discontinuation of Restraint:
a. The patient in restraint is evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period.
12. Actions to be Taken when an Individual Falls Asleep in Violent Restraint
a. If the individual is determined to be asleep, the RN will ensure the individual is immediately released from restraint.
Further review of Page 5, Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met.

Based on observation of facility video surveillance, record reviews, and interviews, it was determined the facility failed to ensure the condition of patients who were physically restrained were monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by the hospital's restraint policy for 2 of 5 patients reviewed (Patient #1 and Patient #4) for restraints.

Specifically,

Patient #1's condition was not monitored or assessed according to the facility's restraint policy when was she was inappropriately restrained on the hospital gurney in an unsafe prohibited physical hold by the facility's contracted security personnel, and was subsequently held in a personal hold restraint by all extremities continuously for 17 minutes that included a prone position, which is prohibited and not in accordance with the facility's restraint policy or training program for an approximate 14 minutes that was witnessed periodically by clinical personnel; and then was placed in a supine position with "Security/Rigid" [Posey 2700Q, Twice-As-Tough Cuff] restraints that are contraindicated for aggressive/combative/self-destructive behaviors, and not Soft [Quick Release Quilted] restraints as ordered by the Physician.

Patient #1 became unresponsive, with a decrease in oxygen saturation, and pulseless while in physical restraint requiring the initiation of Cardiopulmonary resuscitation (CPR). Resuscitative efforts were unsuccessful.

And,

2.) Patient #4 was restrained in a 4-point restraint all extremities for the management of behaviors without evidence of monitoring for safety at least every 15 minutes in accordance with the facility's policy.

The identified deficient practices were determined to constitute an Immediate Jeopardy to patient health and safety, placing all patients at significant risk of harm, serious injury, or potential death.

Prohibited positional restraints [prone] can result in asphyxia (which occurs when a person's body position prevents them from breathing normally) and; prolonged restraints increase the risk of restraint-related deaths.

Findings included:

Review of the facility's Restraint/Seclusion policy last revised 07/2023 indicated the following, in part;
Procedure:
6. Application of Restraints
e. Only a physician, registered nurse, or LIP in accordance with a physician's delegated authority, may initiate restraint or seclusion.
g. The following practices are prohibited:
1. A hold or restraint that obstructs a patient's airway, impairs the patient's breathing, restricts circulation, secures a patient to a stationary object while the patient is in a standing position, causes pain to restrict a patient's movement (pressure points or joint locks), or hinders the patient's ability to communicate.
7. Monitoring the Patient in Restraints
a. Patients are assessed by an Registered Nurse (RN) immediately after restraints are initiated to assure safe application/initiation of the restraint.
b. The assessment will include where appropriate:
1. Signs of injury associated with restraint, including circulation of affected extremities.
2. Respiratory, circulation, skin integrity and cardiac status
3. Psychological status including level of distress or agitation, mental status and cognitive functioning.
d. A trained staff member monitors each patient in restraint at least every 15 minutes for safety and to confirm the patient's rights and dignity are maintained.
f. Monitoring is based on the individual needs of the patient. Variables of the patient's condition, cognitive status, risks associated with the chosen intervention may require more frequent evaluations.
h. Staff members will:
3. Ensure undue physical discomfort, harm or pain to the individual does not occur when initiating or using restraint.
4. Use only the amount of physical force that is reasonable and necessary to implement a particular restraint.
14. Documentation Requirements:
The medical record contains documentation of:
a. Assessment for risk for restraint
b. Restraint or seclusion alternatives employed
d. Second tier review of need for restraint
j. Assessment of the patient in restraint
k. Monitoring of the patient in restraint

Further review of Appendix D: Definitions, E. Physical Holds: in part; Holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint. This included holds that some members of the medical community may term "therapeutic holds." Many deaths have occurred while employing these practices. If the patient is in a physical hold, a second staff person is assigned to observe the patient to ensure safety and the patient's airway is not compromised.

1.) Patient #1

Review of the Emergency Medical Services (EMS) run report dated 4/9/24, documented EMS arrived on scene at 7:21 PM for assault. Patient was sitting on the ground in care of the local police department and other emergency personnel. Patient #1 sustained an elevated heart rate throughout the run. Vital signs included heart rate (HR) documentation, in part; HR 158 bpm (normal is 60 to 100 beats per minute) at 7:07 PM, HR 129 at 07:14 PM, HR 148 at 7:34 PM and HR 127 at 7:44 PM. The last vital signs documented on the EMS run report were at 7:44 PM: HR 127, Blood Pressure 127/86, and Respiratory rate was 55 (normal respiratory rate is between 12 and 20 breaths per minute). Arrival to destination/hospital at 7:50 PM.

Review of the Emergency Provider Report, Triage Adult dated 4/9/24 at 08:07 PM documented by Physician #8 revealed the initial greet time was 8:07 PM. Patient brought in under ED (Emergency Detention) for "high heart rate" and bizarre behavior, has history of schizophrenia.

Review of Patient #1's Emergency Patient Record dated 4/9/24 indicated the following documentation:
At 8:28 PM Charge RN #2 documented patient slammed head on metal cabinet in hallway 05; security/ERP informed.
At 8:40 PM, RN #3 documented, "patient not being compliant, security guards holding patient down at bedside."
At 8:50 PM, RN #3 documented that she was notified by PCT #9 "that patient was acting different, she was less responsive and slurring her words."
At 8:54 PM, RN #3 documented, Physician #8 was notified that patient was less responsive, a pulse was not found. CPR was started at 8:54.

Review of Patient #1's Resuscitation Form dated 4/9/24 documented the time of Code Team Arrival at 8:50 PM. Resuscitation began at 8:54 PM and resuscitation efforts terminated at 10:26 PM. Patient expired.

Patient #1's record did not include "Restraint Documentation" or assessment by an RN of the required restraint assessment documentation to include; "Respiratory, circulation, skin integrity and cardiac status," during the 26 minute physical restraint.

Further review of Patient #1's complete Emergency Patient record including the Emergency Provider Report on 4/9/24 reveals there is not any documentation of any type of vitals signs for Patient #1 from the time patient is received by EMS at 7:56 PM until after patient is in CPR resuscitation beginning at 8:54 PM. There is not any documentation for Patient #1 of a blood pressure, heart rate, oxygen saturation rate, or respiratory rate prior to CPR.

Review of the Report of Hospital Death Associated with the Use of Restraint submitted on 4/11/24 documented the following: Patient Death Occurred: "Within 24 hours of removal of Restraint, Seclusion, or Both" was circled in. The area for "While in Restraint, Seclusion, or Both" was not chosen or circled. "Type" was filled in for "Physical Restraint." "Type" was filled in for "Other" and documented, "4 Point Physical Hold."
Circumstances Surrounding Death: "Patient in prone position, exhibiting violent, aggressive behavior spitting, punching, scratching staff members, continuing to verbalize threats to staff at which time staff released physical hold to roll patient to supine position. Once patient in supine position, she continued to be verbally aggressive, slurred speech and change in clinical condition noted. Pulse check completed. Weak, thready pulse noted. Decrease in oxygen saturation noted. Bag Mask Ventilation initiated, resuscitation efforts proceeded, CPR initiated. Resuscitative efforts continued for 1 hour 30 minutes without success."
Date Restraint Applied: 4/9/24. Time Restraint Applied: "20:30" [8:30 PM]. Date Patient Last Monitored: 4/9/24. Time Patient Last Monitored: "20:56" [8:56 PM]. Total Length of time in Restraint, for the most recent restraint episode: "26 minutes." Was restraint used to manage violent or self-destructive behavior? "Yes" was circled/filled in.

Observation conducted by surveyors on 2/3/25 at 2:30 PM of the "Security Footage Clip 4.mp4" of Patient #1's 4/9/24 at 7:51 PM revealed the following, in part:
The length of the video clip is 15 minutes and 41 seconds (15:41) and there is no audio. The camera angle is at the crossing of Hallway 5 and Hallway 6. At the beginning of the video, Patient #1 is seen walking with security officer (SO) #3 behind her to a gurney/stretcher in the Emergency Department's hallway 5, that is against the wall next to room #6, and directly across from the nurses station. Patient #1 sits on the gurney/stretcher sideways in the middle with her feet dangling towards the floor, not touching, and wearing a face mask over her mouth. SO#3 leaves the area of camera.

At 1:00 [minute mark] of the 15:41 video, (1:00/15:41) Patient #1 is sitting sideways on the gurney that is against the wall. SO #3 comes back towards Patient #1 and begins to talk with her. SO #3 is standing adjacent to Patient #1 with his hands crossed across his abdomen in a non-threatening manner, and Patient #1 is talking to SO #3. SO #3 is conversing back.
At 1:33/15:41, RN #2 approaches where they are both seen communicating with Patient #1. Armed Police Officer (APO) #5 is standing towards the wall down the hallway on the other side of room #6 observing the interactions (at the ambulance bay entrance). Throughout the continuation of the video, Patient #1 is seen talking to staff in the area, attempting to engage anyone in the area. She is seen pulling her face mask down to talk out.
At 8:40/15:41 another security officer (SO) #2 is seen approaching Patient #1 and engage in conversation while SO #3 is seen in the area at a distance.
At 9:10/15:41, Patient Care Tech (PCT) #9 is seen to walk up to Patient #1 places his hand on her shoulder, solicits a hand shake and begins to communicate with Patient #1 while SO #2 and SO #3 remain at a distance.
At 9:56/15:41, PCT #9 walks away and SO#2 and SO #3 remain.
At 10:16/15:41, the Lead SO #1 is seen walking down the hallway and stands in proximity of Patient #1 near the nurses station. SO#1 puts on gloves, stands next to APO#5 and they are seen talking and monitoring Patient #1 from a distance.
At 11:23/15:41 Patient #1 is seen talking to APO #5 and SO #1. She is shrugging her shoulders, shaking her leg, pointing her finger towards others, and using expressive gestures with her hands while talking to those in the vicinity of the nurses station.
At 11:36/15:41 SO #1 walks closer to Patient #1 and remains at a distance standing at the nurses station while Patient #1 continues to talk and engage anyone in the vicinity.
At 12:14/15:41 Patient #1 re positions herself up onto the stretcher sitting in the middle with her back and head against the wall, and legs crossed in front of her. She continues to attempt to talk to others to engage those in the vicinity. There is a metal lock box that is mounted on the wall behind her.
At 13:48/15:41 SO #1 walks away from the nurses station and approaches next to APO #5 at the end of the hallway. Patient #1 continues to talk to those in the vicinity. RN #2 is seen placing sheets on an empty stretcher that is next to Patient #1's stretcher in the hallway.
At 14:01/15:41 Patient #1 is seen to hit the back of her head once or possibly two times against the wall and the metal cabinet that is secured on the wall. RN #2 observes this behavior and Lead SO #1 then immediately walks over to Patient #1. RN #3 walks over towards Patient #1 also. When SO #1 arrives in front of Patient #1 (at 14:04/15:41) she is sitting on the stretcher, not engaged in hitting the back of her head or any other self-harm.
At 14:04/15:41 SO #1 uses his right hand to grab around Patient #1's waist and uses his left hand to grab her neck. SO #1 pushes Patient #1's head down into a lateral position on the stretcher. Once in a lateral position, he lowers the head of the bed down with his right hand and then uses his right hand to hold Patient #1's head down while RN #2 and RN#3 observe. RN #3 then walks by Patient #1 being physically restrained by SO #1, and walks into room #6 with a student nurse. RN #2 turns back around towards the empty stretcher that is next to Patient #1, continues to adjust the sheets, and places the rails down. The Unit Secretary #1 is at the nurses station sitting at a computer monitor and begins to look over at the direction of SO #1 and Patient 1. APO #5 walks over and holds down Patient #1's feet. SO #2 hurriedly walks over to the head of the bed, goes to place both hands on Patient #1, then immediately holds both of his hands up, looks up at the gloves on the wall that appear empty and walks away.
At 14:24/15:41 Patient #1 is seen continuing to move her upper body and head around and towards the wall, while SO #1 continues the physical hold on Patient #1. The patient is also seen with her mask on her mouth.
At 14:26/15:41 SO #1 then lifts his left leg and knee onto the stretcher followed by his right leg and knee. SO #1 then begins to straddle onto Patient #1's torso area while she is positioned in a partial lateral and partial supine position.
At 14:31/15:41 Patient #1 is seen using her left hand in attempt to grab SO #1's weapon (taser) while SO #1 has his right forearm pressured onto her neck and head area. APO #5 continues to hold Patient #1's feet. SO #1 then grabs Patient #1's left wrist with his right hand and places her arm across her neck area while holding her wrist onto her neck area. SO #1 has a hold of Patient #1's right arm with his left hand. Patient #1 continues to struggle and move around.
At 14:36/15:41 SO #1 appears to lose balance and then repositions himself back into a straddle position holding Patient #1's left arm out and above her head on the stretcher while he maintains hold of her right arm.
At 14:38/15:41 SO #2 and SO #3 are seen returning and remain standing next to the stretcher while SO #1 continues to hold Patient #1.
At 14:42/15:41 SO #2 and SO #3 lift the right-side rail of the stretcher. RN #2 is seen walking by observing the physical restraint and enters Room #6.
At 14:45/15:41 SO#1 places Patient #1's left arm back across her neck while he continues to hold her wrist.
At 14:50/15:41 SO #1 begins to reposition Patient #1's right arm across her chest, then holds both of Patient #1's arms at the wrist area with his right hand and then places his left hand onto Patient #1's head while he continues to straddle her.
At 14:57/15:41 SO #3 goes to the head of the stretcher and begins to move it away from the wall and SO #2 is standing to the right side of the stretcher.
At 15:00/15:41 the stretcher is moved away from the wall with SO #2 on the right side, SO #3 moves from the front to the left side, APO #5 at the rear holding Patient #1's feet and SO #1 straddled onto Patient #1 holding down her arms across her chest with his right hand and head with his left hand (opened). Patient #1 continues to struggle and move around. SO #3 raises up the left side rail of the stretcher.
At 15:02/15:41 SO #1 uses his left hand to grab Patient #1's hair/braids and physically moves her head and neck into a partial side/partial face down position. Immediately after that, Patient #1 frees her right hand from SO #1's right hand hold and uses her forearm and elbow to hit SO #1's face. Patient #1 continues to struggle.
At 15:08/15:41 Physician #8 is seen walking out of an office adjacent to the nurses station and stands at the nurses station observing the physical restraint. Further note, Physician #8 remains at the nurses station observing the remainder of the physical hold restraint until the end of the video at 15:41.
At 15:12/15:41 SO#3 is holding one of Patient's ankles/leg, APO#5 is holding the other and SO #2 is assisting SO #1 at the head of the bed to maintain the physical hold of Patient #1.
At 15:21/15:41 Emergency Management personnel and RN # 3 are seen moving another patient on a stretcher out of Room #6. SO #1 is seen holding each of Patient #1's wrists with her arms crossed in front of her chest, with each of his hands, straddled on top of her on the stretcher while SO #3 and APO#5 are holding her legs. She is in a lateral position at this point and her face mask is still over her mouth.
At 15:291/15:41, SO #2 moves Patient #1's stretcher into room #6 while SO #1 remains straddled on Patient #1, on the stretcher; holding her wrists with each of his hands; arms across her chest, with APO#5 holding one leg and SO #3 holding the other leg. Her face mask remains over her mouth. Patient #1 appeared to be exhibiting less struggle than previously observed.
At 15:39/15:41 Patient #1's stretcher is in Room #6 with SO #1, SO#2, SO#3 and APO#5. There are EMS personnel standing at the doorway. There are no further observations for Patient #1 on video.

Review of the security incident form dated 4/9/24 at 10:40 PM completed by Lead Security Officer (SO) #1 documented the following, in part;

"On April 9th, 2024 at approximately 20:24, [08:24 PM] I [SO#1] responded to ER (Emergency Room) Hallway Bed 5 due to reports of ED (Emergency Detention) patient's [#1's] behavior escalating and her refusing to cooperate with behavioral health protocols. I arrived, and the patient was already screaming at me, calling me a "faggot" while also hurling verbal insults at SO [#2] and APO (Armed Police Officer) [facility staff #5]. I was notified that attempts at de-escalating the patient had failed, so the decision was made to wait for the patient to be moved into a room before starting anything. I remained on standby with [SO #2, SO #3, and APO-staff #5] while the patient continued to hurl insults at the security team and emergency personnel. As the patient continued to scream and cuss, at approximately 20:28 [8:28 PM], she slammed the back of her head on the lock box directly above her bed in ER Hallway, Bed 5. There was a huge indention on the lock box as a result of the patient slamming the back of her head against it. The patient continued to threaten to slam her head as she continued to scream. I approached the patient, grabbed a hold of the back of her head, and pushed her head down into the bed. This was done because the patient continued to threaten to slam her head, and the fear that she could hurt herself even more if she continued to do so. Once on the bed, I laid the bed flat and held her down while talking to the patient. APO [staff #5] arrived and held down the patient's feet to prevent her from kicking. [SO #2] arrived but stood by at my request. I kept my hand at the back of the patient's head as she kept trying to slam the back of her head on the railing beside her bed. Due to the patient's large size, and the current location that we were at, it was difficult to maintain control of the patient." I got onto the bed with the patient and put pressure her arms as we struggled to maintain control of her. The patient kept trying to slam her head into the wall, I put both of her hands against her chest and held them down with my right hand while holding her head with my left hand so prevent her from slamming her head around. The patient was moved to ER Bed 6, where the patient was restrained on the bed. I got off of the bed where [SO #2, SO #3, APO staff #5] and I continued to restrain the patient. The patient continued to struggle in a wild manner making it extremely difficult to maintain control of the patient. C/N (Charge Nurse) [Registered Nurse (RN) #2] was the first to standby in the room but had to switch out with PCT (Patient Care Tech) [Staff #1, unit secretary] so that she could go retrieve medication for the patient. As the patient continued to thrash around the bed, attempting to break free, she found herself stomach down [prone position] on the bed. The patient had flipped herself over onto her stomach during the struggle. I maintained control of the patient's head by having it pushed off to the side, the patient was able to breath easily while continuing to yell insults at those in the room. I also maintained a grip on the patient's right arm, [SO #3] maintained a grip on the patient's left arm, [SO #2] maintained a grip on the patient's left leg, and APO [ staff #5] maintained a grip on the patient's right leg. C/N [RN #2] returned and proceeded to administer medications to the patient. PCT [staff #9] arrived and proceeded to take over in restraining the patient's left arm while [SO #3] retrieved the "Security" Restraint at the request of the medical staff (unknown who approved the restraints). [SO #3] returned with the "Security" Restraints, and PCT [#9] took over in restraining both the patient's left arm and left leg. [SO #2] and [SO #3] prepped the restraints around the bed first. Once the restraints were ready, the five of us needed to assist the patient in flipping over. As we turned the patient over, she freed one of her arms and punched me in the face. The patient also managed to claw at my face, leaving a minor cut on it. Once on her back, the patient nearly fell down which led to us needing to support all the patient's weight as she continued to scream. The patient, during this time, spat in the face of [SO #2]. PCT [#9] draped a towel over the patient's face to prevent her from spitting. The towel was not held down, just draped over and left loose. The patient continued to wildly struggle, a paramedic with [ the local Fire Department] entered the room and assisted with restraining the patient. The paramedic, [SO #2, SO #3 and APO #5] assisted with placing the patient's leg restraints while PCT [#9] restrained the patient's arms. The leg restraints were placed but not tight, but enough to prevent the patient from kicking as it remained difficult to properly put them on. Next were attempts at the arm restraints, I was more focused on the patient as she was breaking loose from me, but the arm restraint on the right arm was placed. As we now attempted to put the restraint on the left arm, the patient suddenly stopped moving. PCT [#9] directed everyone to back away from the patient as he checked for a pulse, which was something we had already done beforehand. All the security team stepped outside of the room, while the medical staff took over as a Code Blue (Cardiac/Pulmonary Arrest) was initiated. [SO #3, APO #5], and I cleared from the scene at approximately 21:00 [9:00 PM] while [SO #2] remained on the Code Blue."

Review of Patient #1's Physician Orders (PO) dated 4/9/24 revealed there was not a PO for the personal hold/physical hold restraint implemented at 08:28 PM by SO #1. Further review revealed at 20:45 (8:45 PM) Physician #8 ordered a violent/self-destructive level of restraint due to Patient #1's combative and physical aggressive behaviors. Violent restraint device ordered, "Soft all extremities" with a time limit of 4 hours.

Interview with RN Staff #2 on 2/4/25 at 7:00 AM stated the following: on 4/9/25 she was the charge RN and she remembered Patient #1 well. She was very vocal and began escalating quickly after her arrival to the ER. She did not seem to respond to me in a favorable manner, so RN #2 stepped back and allowed other staff to engage Patient #1 while she was in the area. When the restraint started in the hallway, RN #2 was surprised in how aggressive the security officer (#1) was and that he got onto the stretcher with Patient #1. When security moved Patient #1's stretcher into the room (#6) RN #2 went to retrieve the psychiatric medications that Physician #8 ordered. When RN #2 returned, Patient #1 was struggling with the four security personnel that had her in a physical hold, one on each limb with Patient #1 in a prone position on the stretcher. RN #2 said she talked to the security officers that were involved in Patient #1's restraint about the aggressiveness that was witnessed. RN #2 also stated there was a debrief after the incident and she talked to Physician #8 and the House Supervisor/RN Staff #4 about security's role in the restraint. She did not like how "security handled" Patient #1; how she was "taken down in the hall, held in a prone position by security." RN #2 said "I verbalized, that's excessive." RN #4 said she would not have taken Patient #1 down like security did; she would have only changed her positioning first. "It was excessive." RN #2 said she had never seen that occur before, although there had been "hearsay" where others had concerns with security. She said security will be called to assist on standby, to be around and you will see them "gloving up and ready to go in" they will physically "puff up" with their "egos" when sometimes all you have to do is calm the patient by feeding them, giving them warm blankets, etc. RN #2 said sometimes psychiatric patients will see security as "intimidating."

Interview with RN #3 on 2/4/24 at 9:24 PM stated the following: She was Patient #1's assigned nurse on 4/9/24 and she remembered Patient #1 being hostile, saying a lot of racial things and yelling. She would not let anyone access her, obtain labs or vital signs. RN #3 said that Patient #1 did report that her "heart was racing," and that may have been the reason she came in. RN #3 said Patient #1 was saying that she was "raped, and someone was coming after her." Patient #1 continued to escalate even more and hit her head on metal box behind her and then "security put hands on her." Patient #1 said she was "pinned down," by security. RN #2 then gave Patient #1 emergency meds. There were several security officers trying to get "rigid restraints" secured. Then a "Code Blue" was called due to the patient not breathing and RN #3 started to be the recorder for the code and the team ran the code under staff #8 direction. RN #3 said in the ER, the nurses do the restraints, but security does the physical and personal restraints (hands on). RN #3 said she does not tell security when to do physical hold restraints, they initiate it on their own. But the Nurses do the post restraint evaluation and record that in the treatment plan. RN #3 she had received CPI (Crisis Prevention Institute) training and in addition, receives an annual "ER blitz, hands on training" for the application of soft restraints.

Interview on 2/5/25 at 5:39 PM with Physician #8 stated on 4/9/24 she was the attending physician for Patient #1 and she received information that the patient was on an Emergency Detention for mental decompensation; with reports of HI and increased heart rate. Physician #8 triaged the patient and placed orders. Patient #1 was refusing care, refusing blood work and radiology but did provide a urine sample. Physician #8 said Patient #1 was too agitated and refusing care, so she put in orders for Haldol 5mg and Benadryl at 8:21 PM and went about to see other patients. She then saw a nursing note that Patient #1 hit her head on a metal box in the hallway after becoming more and more verbally agitated. Security was present and an APO at the EMS bay. Patient #1 received medications, Haldol and Benadryl at 8:35 PM. At 8:40 PM Patient #1 was still agitated and at 8:45 PM, Physician #8 put in a "restraint order" for soft restraints all 4 extremities. Physician #8 walked up and saw several people restraining Patient #1 physically. She was being held by each limb, the bed was against the wall, and someone was on the bed; a security officer, not a nurse. Patient #1 was on her stomach. Patient #1 received sedation meds in the room. Physician #8 said the PCT #9 came out and said Patient #1's mental status changed, she was slurring her speech, and her heart rate was dropping on the monitor. A code was called and CPR with resuscitation continued for approximately 1.5 hours.

Further interview with Physician #8 confirmed she did not place an order for a physical hold restraint for Patient #1 and had not ever ordered a personal physical hold restraint because she was not aware that a physical hold was a restraint or an option in the record. Physician #8 said her hierarchy for treatment for mental health emergencies is emergency medications usually at a lower dose, because she can always add more, and then two or four-point soft restraints. Physician #8 said security (SO's) usually will help by holding down the patient's while the 2- or 4-point restraints are applied because security (SO's) are trained to hold and restrain patients, and she tries not interfere. Physician further indicated that she has not had restraint training.

Review of the Posey Twice-As-Tough Cuffs 2700Q, 2700QL [known as the "security/rigid" restraints] Application instructions for wrist and ankle padded limb restraints, Rev B 2022-09-30, indicated the following:
Contraindications: Do not use this device with someone who has continued highly aggressive or combative behavior, self-destructive behavior, or deemed to be an immediate risk to others or to self.

2.) Patient #4

Review of Patient #4's Emergency Patient Record dated 12/04/24 at 12:25 PM by RN# 11 documented, Restraint Documentation; Initiation of violent restraint, soft all extremities, for combative, OOB (out of bed) is extreme injury (inj) risk, and physical aggression. Restraints initiated at 12:25 PM.
The next Restraint Documentation after 12:25 PM is not until 1:22 PM, when RN# 11 documented, restraint status: discontinue. Patient #4's Emergency Patient Record did not have any further restraint assessment documentation for the restraint implemented at 12:25 PM and discontinued at 1:22 PM.

During a collaborate review of Patient #4's records on 2/10/25 between 11:30 AM and 2:00 PM with administrative staff; which included Administration Staff #1 and Administrative Staff #3; Administrative Staff #3 confirmed the findings for Patient #4's record that failed to document monitoring at least every 15 minutes to ensure patient safety. Administrative Staff #3 asked the Director of Informatics #15 to navigate Patient #4's record to look for this documentation and none was found.

Review of the Crisis Prevention Institute (CPI) training manual, Participant Workbook, 2nd Edition, 2020, Appendix, Understanding the Risks of Physical Restraints on page 67 indicated the following, in part: Restraint-Related Deaths - A Multi-Factorial Event. Most Vulnerable Individuals included, in part; people with serious mental illness, people from minority ethnic groups, people with a high body mass index and people who are held for prolonged periods of time*. [*Some researchers, O'Halloran, et al. (2000) and Miller (2004) provide case-study evidence to suggest collapse can occur between 2 and 12 minutes, others such as Parkes (2000) argue that restraints involving prolonged, severe struggle are of greatest concern.] Contributing/Situational Factors included in part;
1. People who have a pre-existing health condition that is compromised by physical restraint: Respiratory disease, cardiovascular disease, epilepsy, obesity.
2. Stress-related cardiomyopathy: A weakening of the heart muscle triggered by high levels of emotional stress or anxiety resulting in high circulating levels of catecholamines (adrenaline and epinephrine).
3. External respiratory restriction as a result of the restrain position: Positional asphyxia associated with prone, hog-tie, and flexed-seated restraint.
5. Excited delirium: A combination of acute behavioral disturbance, agitation, severe anxiety, disorientation, and elevated body temperature; associated with severe mental illness and/or drug intoxication.
8. Use of prescribed psychotropic medication: Prescribed medication which may have an adverse effect on the person's physiology resulting in hypotension, respiratory compromise, and in extreme cases, neuroleptic malignant syndrome.

Further review on page 68, Positional Asphyxia and Restraint Position indicated; Although there are a relatively s