Parkview Regional Medical Center

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 32952 Based on document review and interview, the facility failed to ensure a patient was free from the use of restraints/handcuffs by staff for 1 of 10 medical records reviewed. (Patient #1). Findings include: 1. Review of facility policy titled “Restraint and Seclusion” PolicyStat ID 17906704 last revised 4/2025 indicated the following: “I. Policy Statement: A. The purpose of this policy is to identify patient’s basic rights to remain restraint and seclusion free, ensure safety, and eliminate the inappropriate use of restraint and seclusion. ...D. The decision to use a restraint is not driven by diagnosis, procedure, or convenience, but by a documented, comprehensive individual assessment of the patient’s actions, behaviors, cognitive ability and risk of harm. ...F. Types of Restraint: 1. Less restrictive measures should be attempted before utilization of restraint or seclusion...2. b. Handcuffs, shackles, or other restrictive devices applied by law enforcement to maintain custody, detention, or in other situations where the safety of patients, staff, or the public is in jeopardy. 2. Review of a facility policy titled “Law Enforcement use of Restraint and Handcuffing Procedure, last approved on 1/1/2023 indicated the following: I. PURPOSE: A. The purpose of this procedure is to identify the types of restraints available to (Police Department #1) Officers and under what conditions restraints are authorized. B. Use of handcuffs for...Law Enforcement intervention, and unsafe or potentially combative or violent patient transport. II. Definition of terms: D. Handcuffs: Law enforcement restraint device to secure an individual’s wrist in proximity to each other by lockable linked metal rings. III. Procedure: C. Handcuffs should be used when making an on-site arrest...Handcuffs may be used for forensic purposes when a criminal act has occurred in the presence of the officer, if officer has probable cause to believe a crime has been or is being committed, and immediate detention of the person must take place to protect staff, patients, visitors or officers from immediate harm, even if it is determined after the fact that criminal charges will not be pursued. Handcuffs may also be used to transport patients who are actively aggressive, threatened to harm self, staff, or officers or pass on information from local law enforcement warns of officer safety concerns. 3. Review of Medical Record for Patient #1 indicated the following: (a) Nurse note by N1 (Registered Nurse) dated 7/9/25 indicated: (On 7/10/25 at 12:30 to 12:48 a.m.): Patient came out of (his/her) room again, took BHT’s (Behavioral Health Technician’s) seat, and continued limit-testing, making noise and refusing to follow direction. (He/She) continues to refuse medications. Patient encouraged to go to (his/her) room or walk in hallway. (He/She) got up and barricaded (himself/herself) in (his/her) room and slammed door on staff attempting to open (his/her) room door. Security assisted staff to get into patient’s room and hands on started at (12:55 a.m.); emergent IM injections given per provider orders for agitation. (On 7/10/25 at 12:55 a.m.): IM (Intramuscular) Haldol 5 milligrams and IM Valium 5 milligrams given for emergent violent behavior. Patient was immediately released after injections. Patient sitting on (his/her) bed. Patient encouraged to rest. (On 7/10/25 at 12:57 a.m.): Patient lunged at public safety officer as officer was leaving the patient’s room, striking (him/her) in the face with a closed fist. Public safety officer’s glasses were sent across the room from the strike. (On 7/10/25 at 12:58 a.m.): Public safety officer and staff still present in the room went hands-on again for safety, patient violently attacking staff. Alarm was sounded, more staff arrived, and patient was escorted to locked seclusion; order obtained from MD2 (Doctor of Medicine/Psychiatry). (On 7/10/25 at 1:00 a.m.): Locked seclusion initiated. (b) Progress note by N3 (Behavioral Health Specialist) dated 7/10/25 at 1:00 a.m. indicated the following: Writer was sitting on North hall when hearing a bang come from West hall. Writer went to West hall to see if they needed assistance. Writer seen two nursing staff, nursing graduate, a patient care technician and Officer with patient holding patient to provide injections. Writer stood at the doorway to observe if more assistance was needed. All staff began walking out of the room with backs towards patient. Patient stood and walked toward staff calmly when writer noticed patient look at the officer, pulled (his/her) hand up and writer yelled “behind you”. Patient lifted hand with closed fist and hit the officer. Patient hit the officer toward the backside of the head, writer heard the hit from the hallway, the officer’s glasses were knocked off (his/her) face due to the assault. Officer turned with other staff who restrained patient on the bed. Writer assisted holding arm of patient when patient was placed in handcuffs due to patient not calming or complying with commands, resisting against staff. (c). Progress note by N4 (Patient Care Technician) dated 7/10/25 at 1:53 a.m. indicated the following: Patient was redirected multiple times due to other patients trying to sleep. Patient then said, “What if I won’t, what are you going to do about it?” Security got called because RN (Registered Nurse) is about to medicate the patient. Staff and officer tried to talk to patient to take medication willingly, but patient still refused. When RN was getting ready for IM, patient was doing push-ups in front of the nurse station and trying to intimidate staff. When patient saw RN with medication, patient walked back to (his/her) room and blocked the door so staff couldn’t go in. (PO8, Police Officer/Police Department #1) then opened the door forcefully and staff and officer restrained patient for medication. After medication was given and staff and officer was walking out of patient’s room, N3 (Behavioral Health Specialist) yelled from the hall at (PO8) because the patient was about to swing at (PO8). (PO8) got hit at the back of (his/her) head. Officer and writer then ran back and restrained patient on (his/her) bed. Patient was resisting until patient was dragged down to the floor where patient was handcuffed. (d). Nurse note by N1 dated 7/10/25 at 5:05 a.m. indicated the following: Updated (Family Member #2) on the situation of what led up to patient being placed in locked seclusion and also the pending charges patient will have pressed against (him/her) for assaulting an officer. 4. Review of incident report related to Patient #1 dated 7/10/25 at 9:37 a.m. indicated handcuff usage and restraint was deemed a police action. 5. Review of a facility job description titled “Police Officer” Job Code 2429, no date, indicated the following: Summary: Enhances the patient experience by taking proactive steps to ensure our customers receive services in a safe and secure environment. Performs general safety and security duties with an emphasis on the protection of life and property while providing enforcement of (Health System #1) policies and procedures, and when necessary, in order to protect the safety and security of others, enforces Indiana state law as directed under IC 16-18-4. Licensure/Certification: Nonviolent Crisis Intervention (CPI) within six (6) months of hire. Indiana Law Enforcement Academy within 1 year of hire. Key Outcomes: Safety and Quality: Responds to calls of aggressive persons, patient, visitor, and handles these situations with the least invasive techniques possible. 6. A review of (Police Department #1) “USE OF FORCE AFTER ACTION REVIEW” for event date of 7/10/25 indicated the following: Shift: Nights. Time of Event: (12:56 a.m.). Panel Members Present: (PO12, Captain/Supervisor), (PO14, Training Representative) and (PO15, Captain) and Officer involved: (PO8). Type of Force: 1.) Soft Empty Hand Techniques: Holding or Grasping of Suspect. Physically Moving Suspect. EOAM Techniques were not marked as being used during the event. 2.) Handcuff. 3.) Hard Empty Hand Techniques: Strikes. Reason for Use of Force: Medical. (PO14) Training Representative Summary: (PO8) was sucker punched by the patient (Patient #1). After the punch, efforts to control the patient were made and handcuffs were used. (PO8) was asked why (he/she) used handcuffs, and (he/she) said that (his/her) understanding to use handcuffs is because (he/she) was just battered. Upon further talking with (PO8), (he/she) made the decision to handcuff because the patient had just acted out violently without any warning and (he/she) was worried about staff safety. Take Away: (PO8) did use handcuffs as a PSO (Public Safety Officer) without Police guidance, but that has not been established in Policy yet. 7. During observation on 9/18/25 at 1:20 p.m. with A8 of video camera footage from inside of Patient #1’s room on 7/10/25 beginning at 12:55 a.m. the following was observed: Patient #1 was observed holding the door to (his/her) room from the inside of (his/her) room to prevent staff from entering the room. Staff members were able to get into the patient’s room, the patient backed up and PO8 walked Patient #1 to the bed to sit. Patient #1 appeared calm and not fighting the staff related to the administration of medication via injections in each arm, one administered by N1 and the other by N2. After the injections were administered staff began walking out of Patient #1’s room with PO8 being the last one and had (his/her) back toward Patient #1, as PO8 got near the doorway to Patient #1’s room, Patient #1 got off the bed, walked toward PO8 and hit (him/her) in the head. PO8 immediately turned and rushed Patient #1 as the patient was backing up from PO8 and did not continue to attack/fight PO8 at that time. PO8 rushed/tackled/taken down Patient #1 as the patient was getting on the bed. PO8’s feet came off the floor as Patient #1 was taken down on (his/her) bed. Other staff members, N4 and N6 rushed into the patient’s room and assisted PO8 with trying to gain control of Patient #1. Patient #1 was fighting against the staff. Writer was unable to observe the technique of the elbow strike and/or where it landed on Patient #1 as staff were trying to hold the patient and it was not a clear observation. Writer was able to observe that Patient #1 did have a hold of PO8’s collar up by (his/her) neck. Patient #1 was then moved from the bed to the floor to gain control of the patient and both wrists were observed to be handcuffed by PO8. Once PO8 had Patient #1 handcuffed and sitting up PO9 (Police Officer/Police Department #1) and P10 (Police Officer/Police Department #1) arrived to assist in taking Patient #1 to seclusion as PO8 stepped away. 8. During an interview with A7 (Captain/Supervisor of Public Safety) on 9/17/25 at approximately 12:35 p.m., A7 verified that Patient #1 was placed in handcuffs while inpatient. 9. During a phone interview with (PO8) on 9/18/25 at 12:48 p.m. (PO8) indicated that (he/she) was walking out of (Patient #1’s) door and that was when (Patient #1) hit (him/her). (PO8) indicated that after getting hit in the head by (Patient #1), (he/she) turned around and kind of rushed (Patient #1) a little bit, got the patient on the bed, tried to get control of the patient and the patient started fighting at that time. (PO8) indicated that (Patient #1) grabbed (his/her) shirt, microphone to their radio, badge holder with one arm, so (PO8) hit the patient’s arm one time to get the patient off (his/her) neck and get more control of the patient. (PO8) indicated that (Patient #1) was still fighting, so we got the patient on the ground to get better control of (him/her). (PO8) indicated that (he/she) handcuffed (Patient #1) for the safety of (himself/herself) and the staff, as the way (Patient #1) hit (him/her) and being unprovoked. (PO8) indicated that the patient was being detained at the time (he/she) was handcuffed, but not under arrest. (PO8) indicated that the handcuffs came off (Patient #1) once (he/she) was placed in the seclusion room. 10. During an interview with PO14 (Lieutenant/Trainer Police Department #1) on 9/19/25 beginning at 10:52 a.m., PO14 indicated that (he/she) instructs all staff across the healthcare system on “Essentials of Aggression Management”. PO14 indicated that they push situational awareness and knowing your patient. PO14 verified a forearm strike, rushing/tackling/taking down a patient and handcuffing a patient is not part of the “Essentials of Aggression Management” PO14 indicated that if a patient was to hit a staff member in the head, backed up and did not continue to attack, staff would try to distant themselves from the situation. PO14 indicated but unless you are the person attacked, you wouldn’t know how that person would react. PO14 indicated that just because a person who attacked a staff member backed up does not mean they are not thinking of their next move. PO14 indicated that they are taught to use handcuffs in defensive tactics training. PO14 indicated that they do not place handcuffs on a patient unless their intent was to arrest them. We teach them to continue to talk to the patient what their intent is, instructions in a calm manner to get the patient to respond to the team and continue de-escalating the situation. 11. During an interview with A5 (Director of Nursing Behavioral Health) on 9/19/25 at 3:00 p.m., A5 verified the medical record information for Patient #1.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 32952 Based on document review and interview, the facility failed to ensure a Registered Nurse followed facility policy related to medication storage for 1 of 10 patients (Patient #1). Findings include: 1. Facility policy titled “Medication Administration - Bar Code Med Scanning”, PolicyStat ID 17595117, last revised on 3/2025 indicated the following: III. Procedure: 3. Do not remove medications for more than one patient at a time. 4. Take medication to the patient and administer immediately, do not store them in other locations. 2. During a phone interview with N6 on 6/26/25 at 2:40 p.m., N6 (Registered Nurse/Assistant Nurse Manager) indicated that in the early afternoon on 6/4/25, A5 (Director of Nursing Services/Facility #2’s Heart Institute) had informed (him/her) that (Patient #1’s) family had come to (him/her) about nitroglycerin being at (Patient #1’s) bedside. N6 indicated that (he/she) had gone into (Patient #1’s) room and looked around the patient’s room for the bottle of nitroglycerin. N6 indicated that (he/she) had found a bottle of nitroglycerin located on the counter tucked beneath the sharps container, which was a difficult place to see the medication. N6 indicated that nurses usually prep medications on the counter near the sink in the patients’ room. N6 indicated that medication should be put back in the patient specific medication box and/or locked in secure area in the medication room.”

“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: 32952 Based on document review and interview, the facility failed to follow their policy to ensure an appropriate transfer was completed for 1 of 20 patients’ medical records reviewed. (Patient #1) Findings include; 1. Facility policy titled “COBRA EMTALA - Emergency Medical Treatment and Active Labor Act”, PolicyStat 14791143, last revised 12/2023 indicated the following: “I. D. Patient Transfer: 1. Transfer of a Patient with an Emergency Medical Condition. c. The transfer must be an appropriate transfer. 3. Appropriate Transfer: For a Transfer to be appropriate, the Hospital must: a. Provide medical treatment within the Hospital’s Capability and Capacity that minimize the risks to the individual’s health. b. Obtain agreement from a receiving facility that the receiving facility has the Capability and Capacity to treat the individual and that it will accept the Transfer and provide appropriate medical treatment. c. Use qualified personnel and transportation equipment as required to effect the Transfer safely. d. Send to the receiving facility copies of all available medical records related to the Emergency Medical Condition. If the patient is being transferred to a facility that does not have access to EMR (Electronic Medical Records), the Transfer Documentation/EMTALA form shall be printed from the EMR and sent with the patient. In the alternative, Form #766 may be used. As soon as practicable after the Transfer, send by facsimile copies of any records not available at time of Transfer. Records to be sent include any available history, observations of signs or symptoms, preliminary diagnosis, result of diagnostic tests or telephone reports of test results, and treatment provided.” 2. Review of Patient #1’s medical record from Facility #1 indicated the following: The ED Care Timeline for Patient #1 indicated the following: Transfer Disposition Selected on 4/17/25 at 2:42 p.m. by (MD1, Doctor of Medicine/Emergency Medicine). Transfer Documentation/EMTALA Form: Completed by MD1 on 4/17/25 at 2:43 p.m., Section 1: Physician Certification: MD Certification: Patient examined, and risks explained. Patient Condition: Benefit outweighs risk. Reason for Transfer: Consult physician request. Benefits of Transfer: Capacity; Necessities available at receiving facility. Risks of Transfer: Time delay; Deterioration; Loss of IV (intravenous); Discomfort; Accidents or delays; Worsening condition. Accepting Physician: (MD5, Emergency Department Physician at Facility #2). Primary Specialty Needed for Transfer: Ophthalmology. Patient Status Update on 4/17/25 at 2:55 p.m. indicated EMS req (required), paperwork filled out and handed to N2, who is taking over care at this time, aware to call report to (Facility #2). 4/17/25 at 6:21 p.m. by (N2, Registered Nurse/Emergency Department) indicated report attempted to (Facility #2, Acute Care Facility) times 2. No answer on line provided. Patient discharged on 4/17/25 at 6:22 p.m. An ED provider note by MD1 dated 4/17/25 at 10:38 a.m. indicated the following: Chief Complaint: (Patient #1) presents with eye problem. Sent by (Facility #3, Ophthalmology facility). (Patient #1) has no vision in right eye, sent to our emergency department for transfer to Facility #2. Needs evaluation for penetrating keratoplasty. Attempting to transfer to (Facility #2). Spoke with MD5, ED to ED transfer to (Facility #2). Disposition: Transfer to Another Facility. Final Impression: 1. Corneal ulcer of right eye. A scanned in Certificate of Transfer for Patient #1 signed by Family Member #2 on 4/17/25 at 3:14 p.m. indicated the following: This is to certify the following information concerning the transfer of (Patient #1) from (Facility #1) on 4/17/25 at 2:55 p.m. to (MD5) (accepting physician). Patient Condition: Stabilized patient: I certify that the below named patient had an emergency medical condition but was stabilized at the time of transfer. Summary of Benefits and Risks: Principle potential benefits of transfer: Specialized care/equipment/monitoring available at the receiving hospital, capacity, necessities available at the receiving facility. Principle Potential risks of transfer: Deterioration of medical condition. Time delay, deterioration, loss of IV (intravenous), discomfort, worsening condition. Transferring Physician Certification: I certify that I have explained the risks and benefit of transfer to the patient/representative. Based upon information available to me at the time of transfer, the medical benefits reasonably expected from the provisions of appropriate medical treatment at another medical facility outweigh the increased risk to the individual. Receiving Hospital and Physician: Accepting Physician (MD5), Time: 2:42 p.m. Accepting Facility: (Facility #2). Accepting facility has capacity to treat patient. Accepting facility agrees to receive the transfer. Mode of Transportation: Ground Ambulance. Transfer Requested By: MD1. Instructions: Send Copy with patient. Keep Original with Medical Record. 3. Patient #1’s medical record lacked documentation, a nurse to nurse report, medical records including the certificate of transfer, Form #766, being sent to Facility #2, and/or an appropriate transfer from Facility #1. 4. During a phone interview with A20 (Chief Risk, Regulatory and Patient Safety Officer/Facility #1) on 5/16/25 at 10:24 a.m., A20 indicated that they had received Patient #1 with no accepting physician and when they tried to get the medical records from Facility #1, but they would not provide them to us as they did not have a signed release of information from Patient #1, so to provide any continuity of care to the patient was very difficult for us. A20 indicated that (he/she) had received an email that indicated that they had received a call from an ambulance that they were 10 (minutes) out with an ophthalmology transfer that we were not expecting. They arrived with no transfer paperwork, just a printout of what they did at their facility. There was no accepting physician, no transfer paperwork, and no nurse to nurse report called. 5. During a phone interview with Patient #1 and Family Member #2 on 5/27/25 at 11:22 a.m., they indicated that they were in (Facility #1’s) ED for several hours, because (Facility #2) said they did not have a room for Patient #1, but something happened and (Facility #2) ended up taking (Patient #1). (Family Member #2) indicated that they had got down to (Facility #2) and no one knew what was going on. (Family Member #2) thought that all the physicians were communicating with each other, like a big communicating circle, but no one was communicating with each other. No one knew what was going on. (Family Member #2) indicated that when they got to (Facility #2), the receptionist/nurse at the front desk of the ED asked (Facility #1’s) EMS staff where the paperwork was and the EMS driver said this is all we have. They did not have anything. They took us to (Facility #2) and dropped us off. 6. During an interview with A5 on 5/29/25 at 1:45 p.m., A5 verified the medical record information for Patient #1. 7. During a phone interview with N2 (Registered Nurse/Emergency Department) on 5/29/25 at 3:15 p.m., N2 indicated that they did not know that (he/she) needed to fill out the “RN Transfer Checklist” documentation. N2 indicated that (he/she) attempted to call the phone number provided to them for (Facility #2) two times but would receive a general message to call back. N2 indicated that (he/she) then google searched the general phone number for (Facility #2’s) ED. N2 indicated that (he/she) had spoken with a receptionist in the ED at (Facility #2), informed them that (he/she) needed to give report to a nurse in the ED, gave (his/her) name, call back number, and was on hold for an extended period of time. N2 indicated that (he/she) had to continue patient care and hung up the call. N2 indicated that (he/she) never received a call back from (Facility #2’s) ED to give report on (Patient #1).”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 44532 Based on document review and interview, the facility failed to have documentation of nurse training for continuous fetal heart monitoring for 2 of 2 Emergency Department (ED) nursing personnel files reviewed. [N1 (Registered Nurse-RN) and N2 (RN)] Findings included: 1. The facility policy, “Fetal Heart Monitoring on Non-OB Units”, PolicyStat ID: 12422958, last revised 5/2022, Indicated under A. In a situation where patients are being cared for in non-OB units and require continuous fetal monitoring, an L&D RN will remain at the bedside to manage fetal monitor and respond to tracing as needed. 2. MR review on 09/28/2025 at 1010 hours indicated N3 (Obstetric Nurse) was at P8 bedside placing on patient provider ordered fetal heart tone (FHT) monitor. N3 indicated he/she advised ED nurse to call with any concerns or issues since he/she was instructed to return to the OB (obstetrics) department. 3. N1 and N2 were assigned to care for P8 in the ED on 09/28/2024, patient required a FHT monitor placed. 4. Review of personnel files indicated of N1 (Register Nurse, Emergency Department) and N2 (Registered Nurse, Emergency Department), lacked training/education/competency in fetal heart tone monitor and/or placement. 5. In interview with A10 (Registered Nurse, Emergency Department) on 2/19/2025 at approximately 1000 hours, he/she indicated when a patient requires a fetal heart tone (FHT) monitor, this would not be within the ED nurse scope of practice.”