Huntsville Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47295 Based on review of video footage, Medical Records (MR), restraint logs, hospital policy and procedure, and staff interview, it was determined the facility failed to ensure all restraints were documented in the MR. This deficient practice affected Patient Identifier (PI) # 1, in one of four psychiatric unit MRs reviewed and had the potential to negatively affect all patients requiring restraints. Refer to A 115, A 159, A 168, A 170, and A 179 for findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(A) Definitions. (i) A restraint is- (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or This Standard is not met as evidenced by: 47295 Based on review of video footage, Medical Records (MR), restraint logs, hospital policy and procedure, the Behavioral Health Geriatric Agitated Behavior Scale Downtime Form, and staff interview, it was determined the facility failed to ensure all restraints were documented in the MR. This deficient practice affected Patient Identifier (PI) # 1, in one of four psychiatric (psych) unit MRs reviewed and had the potential to negatively affect all patients requiring restraints. Findings include: Hospital Policy: Caring for the Patient in Restraints and Seclusion Reference Number: PCI.082.19 Date Last Revised/Reviewed: 03/03/2026 1. Purpose A. To provide information and guidelines on the use of Non-Violent, non-self-destructive and Violent self-destructive restraint or seclusion that promotes the patient’s rights, dignity, and wellbeing ... II. Definitions A. A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs or head freely; or a (chemical) drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment, route of administration or dosage for the patient’s condition ... 2. Forcefully holding a patient to administer medication in an emergent situation for violent self-destructive behavior to prevent the patient from harming themselves or others is a physical restraint ... III. Guidelines D. The hospital uses the least restrictive form of restraint...that protects the physical safety of the patient, staff, or others... G. Violent Self-Destructive Restraint and Seclusion is only used in an emergent situation to prevent the patient from harming themselves or others... H. The hospital discontinues restraint or seclusion at the earliest possible time... L. Restraint or seclusion is only used when less restrictive interventions are ineffective unless it is an emergency situation to prevent patients from harming themselves or others. Less restrictive interventions include but are not limited to: ... 12. Medication/Agitation Protocol... N. Initiation of restraint or seclusion requires an order from the patient’s provider. 1. Provider or registered nurse (RN) assesses the patient to determine whether the patient meets the specific criteria for restraints and whether less restrictive alternatives were attempted and ineffective. 2. In the event of an unanticipated change in the patient’s condition, when a RN initiates use of restraint or seclusion for the safety of the patient, the RN notifies the provider and obtains an order for the restraint immediately. 3. The attending/on call provider is notified as soon as possible (ASAP) (within a few minutes or when it is safe to leave the patient’s bedside) if that provider did not order the restraint. Document provider notification in the MR... VIII. Procedure for Violent self-destructive or Seclusion Episode... C. Security can be called to assist nursing with the application of restraints for Violent Self-Destructive Behavior... I. A specially trained RN can conduct the in person face to face assessment within one hour of initiation of restraint or seclusion in the absence of a provider, and consults with the attending provider... responsible for the care of the patient ASAP after the evaluation to discuss the findings... J. If a provider does not perform the initial evaluation; the provider sees the patient face-to-face within 24 hours after initiation of each restraint... episode... N. The Plan of Care (POC) is modified as needed to include initiation, continuation and termination of behavioral restraint... IX. Documentation for Violent Self-Destructive Behavior or Seclusion ...E. Initiation of Violent restraint ... episode including: ...2. Behavioral reason requiring restraint... initiation. 3. Description of Behavior of patient. 4. Notification of dedicated support person ... 5. Type of restraint and extremities restrained ... Findings: 1. PI # 1 was admitted to the psych unit on 4/28/26 with a primary diagnosis of Mood Disorder due to Known Physiological Condition with Manic Features. MR review revealed PI # 1 had been out on the unit in the common area on 4/29/26 since 7:00 PM, when he/she began showing paranoia symptoms while on the phone with a family member. She/he became loud and increasingly agitated, kicking and hitting staff. Staff were unable to redirect her/him. Further MR review revealed the total Agitated Behavioral Score was documented by the RN on 4/29/26 at 8:55 PM as 18. Review of the Behavioral Health Geriatric Agitated Behavior Scale Downtime Form revealed a score of 12 or greater is considered “severe.” PI # 1 was given Haldol 2 milligrams (mg) intramuscular (IM) injection by the RN. Video footage was provided of PI # 1 on 4/29/26 at 8:55 PM. Review of the video footage revealed PI # 1 sitting in the common area. Two staff members were present on either side of him/her. At the 10:50 mark, the staff members held PI # 1’s arms while the RN administered an IM injection. The hold lasted 18 seconds. Further MR review revealed on 5/2/26 at 12:20 PM, PI # 1 became extremely anxious and agitated with paranoid delusions and was crying, hyperventilating, shaking and hitting herself in the head. The total Agitated Behavioral Score was documented by the RN as 13 (severe). PI # 1 was given Zyprexa 10 mg IM by the RN. Video footage was provided of PI # 1 on 5/2/26 at 12:20 PM. Review of the video footage revealed PI # 1 in the common area on the phone. At the 2:25 mark, a security officer was seen lifting PI # 1 and carrying him/her down the hall to the patient’s room. The video ends at the 2:37 mark with the security officer and PI # 1 no longer visible on camera. Further MR review revealed on 5/3/26 at 11:50 AM, PI # 1 was yelling, spitting at staff, and grabbing at staff member’s faces. The total Agitated Behavioral Score was documented by the RN as 24 (severe). Video footage was provided of PI # 1 on 5/3/26 at 11:50 AM. Review of the video footage revealed PI # 1 in the common area eating lunch. At the 4:21 mark, several staff members were seen surrounding PI # 1, holding his/her arms and legs for Zyprexa 10 mg IM injection to be administered by the RN. PI # 1 was released at the 5:03 mark after a total of a 42 second hold. Further review of the video footage revealed a security officer approaching PI # 1 at the 8:51 mark and bringing him/her from a seated position to a standing position by holding one arm. At the 9:30 mark another security officer arrived and they each were observed holding an arm and escorting PI # 1 off the geriatric psych unit and out of the view of the camera at the 9:34 mark. Further MR review revealed PI # 1 was escorted to the acute care or “crisis” unit for monitoring due to aggressive behavior. Review of the Restraint Log for the past six months revealed no documented restraints for PI # 1. An interview conducted on 5/12/26 at 10:30 AM with Employee Identifier (EI) # 1, Behavioral Health Unit Director, revealed the staff do not document holds for medication administration as restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 47295 Based on Medical Record (MR) review, hospital policy and procedure review, review of video footage, and staff interview, it was determined staff failed to obtain physician’s orders for the use of restraints. This deficient practice affected Patient Identifier (PI) # 1, in one of four psychiatric (psych) unit MRs reviewed and had the potential to negatively affect all patients requiring the use of restraints. Findings include: Hospital Policy: Caring for the Patient in Restraints and Seclusion Reference Number: PCI.082.19 Date Last Revised/Reviewed: 03/03/2026 ...N. Initiation of restraint or seclusion requires an order from the patient’s provider. 1. Provider or registered nurse (RN) assesses the patient to determine whether the patient meets the specific criteria for restraints and whether less restrictive alternatives were attempted and ineffective. 2. In the event of an unanticipated change in the patient’s condition, when a RN initiates use of restraint or seclusion for the safety of the patient, the RN notifies the provider and obtains an order for the restraint immediately. 3. The attending/on call provider is notified as soon as possible (within a few minutes or when it is safe to leave the patient’s bedside) if that provider did not order the restraint. Document provider notification in the MR... Findings: 1. PI # 1 was admitted to the psych unit on 4/28/26 with a primary diagnosis of Mood Disorder due to Known Physiological Condition with Manic Features. Video footage was provided of PI # 1 on 4/29/26 at 8:55 PM. Review of the video footage revealed PI # 1 sitting in the common area. Two staff members were present on either side of him/her. At the 10:50 mark, the staff members held PI # 1’s arms while the RN administered an intramuscular (IM) injection. The hold lasted 18 seconds. Video footage was provided of PI # 1 on 5/2/26 at 12:20 PM. Review of the video footage revealed PI # 1 in the common area on the phone. At the 2:25 mark, a security officer was seen lifting PI # 1 and carrying him/her to the patient’s room. The video ends at the 2:37 mark with security and PI # 1 no longer visible on camera. Video footage was provided of PI # 1 on 5/3/26 at 11:50 AM. Review of the video footage revealed PI # 1 in the common area eating lunch. At the 4:21 mark, several staff members were seen surrounding PI # 1, holding his/her arms and legs for an IM injection to be administered by the RN. PI # 1 was released at the 5:03 mark after a total of a 42 second hold. Further review of the video footage revealed a security officer approached PI # 1 at the 8:51 mark and brought him/her from a seated position to a standing position by holding one arm.. At the 9:30 mark, a second security officer arrived and they each were observed holding an arm and escorting PI # 1 off the unit and out of the view of the camera at the 9:34 mark. MR review revealed no orders for a provider for restraints on 4/29/26, 5/2/26, or 5/3/26. An interview was conducted on 5/14/26 at 2:11 PM with Employee Identifier (EI) # 1, Behavioral Health Unit Director, who confirmed no physician’s order was obtained prior to applying restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(7) The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. This Standard is not met as evidenced by: 47295 Based on Medical Record (MR) review, hospital policy and procedure review, review of video footage, and staff interview, it was determined staff failed to consult the attending physician as soon as possible after the initiation of restraints not ordered by the physician. This deficient practice affected Patient Identifier (PI) # 1, in one of four psychiatric (psych) unit MRs reviewed and had the potential to negatively affect all patients requiring the use of restraints. Findings include: Hospital Policy: Caring for the Patient in Restraints and Seclusion Reference Number: PCI.082.19 Date Last Revised/Reviewed: 03/03/2026 ...N. Initiation of restraint or seclusion requires an order from the patient’s provider. 1. Provider or registered nurse (RN) assesses the patient to determine whether the patient meets the specific criteria for restraints and whether less restrictive alternatives were attempted and ineffective. 2. In the event of an unanticipated change in the patient’s condition, when a RN initiates use of restraint or seclusion for the safety of the patient, the RN notifies the provider and obtains an order for the restraint immediately. 3. The attending/on call provider is notified as soon as possible (within a few minutes or when it is safe to leave the patient’s bedside) if that provider did not order the restraint. Document provider notification in the MR... Findings: 1. PI # 1 was admitted to the psych unit on 4/28/26 with a primary diagnosis of Mood Disorder due to Known Physiological Condition with Manic Features. Video footage was provided of PI # 1 on 4/29/26 at 8:55 PM. Review of the video footage revealed PI # 1 sitting in the common area. Two staff members were present on either side of him/her. At the 10:50 mark, the staff members held PI # 1’s arms while the RN administered an IM injection. The hold lasted 18 seconds. Video footage was provided of PI # 1 on 5/2/26 at 12:20 PM. Review of the video footage revealed PI # 1 in the common area on the phone. At the 2:25 mark, a security officer was seen lifting PI # 1 and carrying him/her down the hall to the patient’s room. The video ends at the 2:37 mark with the security officer and PI # 1 no longer visible on camera. Video footage was provided of PI # 1 on 5/3/26 at 11:50 AM. Review of the video footage revealed PI # 1 in the common area eating lunch. At the 4:21 mark, several staff members were seen surrounding PI # 1, holding his/her arms and legs for Zyprexa 10 mg IM injection to be administered by the RN. PI # 1 was released at the 5:03 mark after a total of a 42 second hold. Further review of the video footage revealed a security officer approaching PI # 1 at the 8:51 mark and bringing him/her from a seated position to a standing position by holding one arm.. At the 9:30 mark, another security officer arrived and they each were observed holding an arm and escorting PI # 1 off the geriatric psych unit and out of the view of the camera at the 9:34 mark. MR review revealed no documentation the physician was notified as soon as possible after the use of restraints was initiated by the RN. An interview conducted on 5/14/26 at 2:11 PM with Employee Identifier (EI) # 1, Behavioral Health Unit Director, revealed the physician was not notified as soon as possible of restraints being initiated on 4/29/26, 5/2/26 or 5/3/26.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 47295 Based on Medical Record (MR) review, hospital policy and procedure review, review of video footage, and staff interview, it was determined staff failed to perform a face-to-face evaluation one hour after the initiation of restraints to evaluate the patient’s immediate situation, the patient’s reaction to the intervention, and the patient’s medical and behavioral condition. This deficient practice affected Patient Identifier (PI) # 1, in one of four psychiatric (psych) unit MRs reviewed and had the potential to negatively affect all patients requiring the use of restraints. Findings include: Hospital Policy: Caring for the Patient in Restraints and Seclusion Reference Number: PCI.082.19 Date Last Revised/Reviewed: 03/03/2026 VIII. Procedure for Violent self-destructive or Seclusion Episode... I. A specially trained RN can conduct the in person face to face assessment within one hour of initiation of restraint or seclusion in the absence of a provider, and consults with the attending provider... responsible for the care of the patient ASAP after the evaluation to discuss the findings... Findings: 1. PI # 1 was admitted to the psych unit on 4/28/26 with a primary diagnosis of Mood Disorder due to Known Physiological Condition with Manic Features. Video footage was provided of PI # 1 on 4/29/26 at 8:55 PM. Review of the video footage revealed PI # 1 sitting in the common area. Two staff members were present on either side of him/her. At the 10:50 mark, the staff members held PI # 1’s arms while the RN administered an IM injection. The hold lasted 18 seconds. Video footage was provided of PI # 1 on 5/2/26 at 12:20 PM. Review of the video footage revealed PI # 1 in the common area on the phone. At the 2:25 mark, a security officer was seen lifting PI # 1 and carrying him/her down the hall to the patient’s room. The video ends at the 2:37 mark with the security officer and PI # 1 no longer visible on camera. Video footage was provided of PI # 1 on 5/3/26 at 11:50 AM. Review of the video footage revealed PI # 1 in the common area eating lunch. At the 4:21 mark, several staff members were seen surrounding PI # 1, holding his/her arms and legs for Zyprexa 10 mg IM injection to be administered by the RN. PI # 1 was released at the 5:03 mark after a total of a 42 second hold. Further review of the video footage revealed a security officer approaching PI # 1 at the 8:51 mark and bringing him/her from a seated position to a standing position by holding one arm.. At the 9:30 mark, another security officer arrived and they each were observed holding an arm and escorting PI # 1 off the geriatric psych unit and out of the view of the camera at the 9:34 mark. MR review revealed no documentation a face-to-face evaluation was completed within an hour after the initiation of restraints to evaluate the patient’s immediate situation, reaction to the intervention, and the patient’s medical and behavioral condition. An interview conducted on 5/14/26 at 2:11 PM with Employee Identifier (EI) # 1, Behavioral Health Unit Director, revealed no face-to-face evaluation was completed within an hour on 4/29/26, 5/2/26 or 5/3/26.”

“Neurological Examination CFR(s): When indicated, a complete neurological examination must be recorded at the time of the admission physical examination. This Standard is not met as evidenced by: 46293 47295 Based on Medical Record (MR) reviews and staff interviews, it was determined the facility failed to ensure a complete neurological examination (neuro exam) was completed upon admission. This deficient practice affected Patient Identifier (PI) # 1, # 2, # 3, and # 4 in four of four MRs reviewed and had the potential to negatively affect all patients admitted to the psychiatric (psych) unit. Findings: 1. PI # 1 was admitted to the psych unit on 4/28/26 with a primary diagnosis of Mood Disorder due to Known Physiological Condition with Manic Features. Review of the History and Physical Reports revealed neuro exam documentation by the physician on 4/29/26 at 8:10 AM stated “Oriented x 3.” An interview was conducted on 5/14/26 at 12:10 PM with Employee Identifier (EI) # 1, Behavioral Health Unit Director, who confirmed “oriented x 3” did not constitute a complete neuro exam. 2. PI # 3 was admitted to the psych unit on 3/25/26 with diagnoses including Bipolar Disorder and Acute Psychosis. Review of the History and Physical Reports revealed neuro exam documentation by the physician on 3/25/26 at 4:47 PM stated “Oriented x 3.” An interview was conducted on 5/14/26 at 12:47 PM with EI # 1, who confirmed “oriented x 3” did not constitute a complete neuro exam. 3. PI # 2 was admitted to the psych unit on 12/15/25 with a primary diagnosis of Delirium due to Known Physiological Condition. Review of the History and Physical Reports revealed incomplete documentation was provided to the surveyor. There was no documentation of a complete neuro exam signed and dated by the physician. An interview was conducted on 5/14/26 at 12:18 PM with EI # 1, who confirmed there was no documentation of a complete neuro exam. 4. PI # 4 was admitted to the psych unit on 2/19/26 with a primary diagnosis of Bipolar Disorder. Review of the History and Physical Reports dated 2/20/26 at 1:00 PM revealed neuro exam documentation per the physician stated “no findings.” An interview was conducted on 5/14/26 at 1:02 PM with EI # 1, who confirmed “no findings” did not constitute a complete neuro exam.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 40119 Based on review of hospital medical record and hospital policy, it was determined the hospital failed to include an appropriate summary of the risks and benefits specific to the patient upon which the Physician Certification is based. This affected Patient Identifier # 1, one of two patients who presented to the Emergency Department with post operative bleeding and were transferred from the facility. This had the potential to negatively affect all patients who require emergency services. Findings include: Refer to A 2409 for findings.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 40119 Based on review of hospital medical record (MR) and hospital policy, it was determined the hospital failed to include the specific reason for the request for an appropriate summary of the risks and benefits specific to the patient upon which the Physician Certification is based. This affected Patient Identifier (PI) # 1, one of two patients who presented to the Emergency Department (ED) with post operative bleeding and were transferred from the facility. This had the potential to negatively affect all patients who require emergency services. Findings include: Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act)-General Requirements and Definitions Policy Number: ADM.069.02 Revised Date: 11/25/24 1. Purpose A. The purpose of this policy is to set forth general requirements necessary for complying with the federal EMTALA. 2. Policy It is the policy of The Health Care Authority of the City of Huntsville for all Huntsville Hospital Health System acute-care or specialty hospitals to comply with the Medicare Conditions of Participation...EMTALA... 3. Overview of EMTALA... D. Definitions... 20. Physician Certification - i. Refers to the written certification by the treating physician prior to the patient’s transfer that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility, outweigh the increased risks to the individual... ii. The certification includes a summary of the risks and benefits upon which the certification is based and the reason(s) for the transfer... IV. Additional EMTALA Requirements... D. Appropriate Transfer Obligations: 1. The Hospital may only arrange an appropriate transfer of an individual whose EMC (Emergency Medical Condition) has not been stabilized for the following two (2) reasons: ...ii. The physician has certified the expected benefits of the transfer outweigh the increased risks. 1. PI # 1 presented to the ED on 5/22/25 at 6:04 PM with a chief complaint of bleeding to surgical site for two days following a spinal fusion on 5/8/25. Review of the ED Physician note dated 5/22/25 at 6:15 PM revealed the patient was diagnosed with Bleeding, Post Op (Operative) Infection, Post-op Bleeding and Drainage, and Seroma ( a collection of clear, yellow tinged fluid (serum) that builds up under the skin) of Musculoskeletal Structure After Musculoskeletal System Procedure. Further review revealed the patient understood he/she would be transferred to Hospital B (Receiving Hospital) for reevaluation by his/her surgeon. Review of the Patient Transfer (Physician Certification) form dated 5/23/25 revealed documentation of “...to be seen by surgeon...” for the risk of transfer and “...quick travel...” for the benefits of the transfer signed by the ED Physician. There was no documentation of the risk of the transfer to the patient or patient specific benefits of surgical evaluation and source control of the post-op infection. The Physician Certification failed to included an appropriate summary of the risks and benefits specific to the patient upon which the certification is based and the reason(s) for the transfer.”