Trinity Health Livingston 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: 36887 Based on observation, interview and record review, the facility failed to 1) provide privacy for 14 (P-11, P-12, P-13, P-14, P-15, P-16, P-17, P-18, P-19, P-20, P-21, P-22, P-23, P-24) of 16 patients on the 2 South unit and 2) failed to properly restrain 3 (P-1, 2, 3) of 4 patients reviewed for restraint resulting in the loss of patient rights and the potential for poor patient outcomes. Findings include: See Specific Tags: A-143 Failure to provide privacy to patients A-171 Failure to renew the restraint order every 4 hours while in restraint A-175 Failure to assess the restrained patient A-179 Failure to conduct a face to face assessment within 1 hour of restraint application”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 36887 Based on observation and interview, the facility failed to provide privacy for 14 (P-11, P-12, P-13, P-14, P-15, P-16, P-17, P-18, P-19, P-20, P-21, P-22, P-23, P-24) of 16 patients on the 2 South unit resulting in the loss of patient rights. Findings include: During the initial tour on 9/2/2025 at 0952, the 2 South hallway was entered and a monitor was noted to be on the wall near the ceiling showing heart rhythms for patients. On the top left hand of the rhythm box was the first and last name of each patient whose heart rhythm was present and could be easily read by anyone who walked by and looked at the monitor. Additionally, when standing in front or at the left side of the nurse’s station, another monitor was present on the counter at the back of the nurse’s station to the far left which also had first and last patient names present with heart rhythms. The names could be easily read from the front or side of the nurse’s station counter where other patients or visitors could be standing. On 9/2/2025 at 1002, after the monitors with patients’ first and last names being present were discussed with Staff A, Staff A stated, “It’s a process issue we need to work out.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to renew a violent restraint order every four hours while the patient was in restraint for 1 (P-3) of 4 patients reviewed for restraint resulting in the loss of patient rights and the potential for poor patient outcomes. Findings include: Review of the medical record for P-3 revealed he was a 25-year-old male who presented to the Emergency Department 5/29/2025 with psychosis. On 5/30/2025 at 1343, an order was given for four-point locked restraints and they were applied at 1344. P-3 remained in four-point locked restraint until a new order was given on 5/30/2025 at 1907, 5 hours and 24 minutes, for the left wrist and right ankle to remain in locked restraint. The order for renewal was on 5/31/2025 at 0107, 5 hours later, for the left wrist and right ankle to remain in locked restraint. Facility policy “Restraint (Non-violent and Violent)” last revised 2/2025 states, “A physician/LIP [license independent practitioner] restraint order to manage a patient’s violent or self-destructive behavior must be renewed on the following scheduled [sic]: i. Adults 18 and older: every four (4) hours...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to assess 1 (P-1) of 3 patients reviewed for violent/behavioral restraint resulting in the potential for unidentified, unmet patient needs and poor patient outcomes. Findings include: Review of the medical record for P-1 revealed she was a 52-year-old female who presented to the Emergency Department (ED) 7/28/2025 for a mental health evaluation. Due to her agitation, verbal aggression and repeated attempts to elope, P-1 was placed into violent/behavioral restraints on 7/28/2025 at 0900. Review of the ED timeline, flowsheet, and the “Patient Monitoring” form revealed a lack of documentation regarding monitoring and assessment of the patient every 15 minutes while restrained. On 9/2/2025 at 1334, Staff C stated, “There’s no 15 minute checks on this. I think they grabbed the wrong form.” On 9/3/2025 at 1015, Staff E stated the “Patient Monitoring” form was for use by the patient observers and was not meant for restraint documentation. Facility policy “Restraint (Non-violent and Violent)” last revised 2/2025 states, “For violent or self-destructive behavior, patients need to be monitored continuously. This is required regardless of the number of limbs restrained (2, 3 or 4), the type of limb restraint (soft or locked*) or the patient ’ s location (inpatient versus ED). All elements on the Restraints (violent) Flow Sheet must be completed when the restraints are initiation and for all subsequent reassessments until discontinuation.” The policy did not address what the assessments should include.”

“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: 36887 Based on interview and record review, the facility failed to conduct a face-to-face assessment within one hour of initiation of violent/behavioral restraint for 3 (P-1, P-2, P-3) of 4 patients reviewed for restraint resulting in the potential for unidentified patient needs and poor patient outcomes. Findings include: Review of the medical record for P-1 revealed she was a 52-year-old female who presented to the Emergency Department (ED) 7/28/2025 for a mental health evaluation. P-1 was petitioned (legal request by a lay person for mental health evaluation) and a clinical certificate (legal document by physician certifying the need for mental health services) was given. P-1 became agitated, verbally aggressive, and was attempting to elope. An order for restraint was given for four-point violent restraint on 7/28/2025 at 0901 and restraint was initiated at 0900. The face-to-face assessment was conducted 7/28/2025 at 0900. Review of the medical record for P-2 revealed he was a 38-year-old male who presented to the ED on 3/30/2025 with alcohol withdrawal syndrome with delirium. The order for violent restraint was given on 3/30/2025 at 0344 and restraint was initiated at 0345. The face to face assessment was conducted at 0344. This was confirmed by Staff A 9/2/2025 at 1425. Review of the medical record for P-3 revealed he was a 25-year-old male who presented to the ED on 5/29/2025. Orders for violent restraint were given 5/30/2025 at 0620 and restraints were applied at 0600. The face-to-face assessment was conducted at 0600. This was confirmed by Staff A 9/2/2025 at 1450. Facility policy “Restraint (Non-violent and Violent) last revised 2/2025 states, “For violent of self-destructive behavior, a face-to-face evaluation between the physician/LIP [licensed independent practitioner] and the patient will need to occur within one hour of the initiation of the restraint. The physician/LIP conducting a required evaluation must include an assessment of the following issues and document the evaluation findings in the patient’s medical record: i. The patient’s immediate situation ii. The patient’s reaction to the intervention iii. The patient’s medical and behavioral condition iv. The need to continue or terminate the restraint or seclusion.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 15195 Based on interview and record review, the facility failed to document behavioral restraint application training and competency for 3 (B, X, Y) of 3 security staff files reviewed, resulting in the potential for less than optimal patient outcomes for all patients placed in behavioral restraints by security. Findings include: On 1/17/24 at approximately 1415, interview with Security Officer B revealed that he and other security officers had applied behavioral restraints on patients. Further discussion revealed that Security Officer B had Crisis Prevention Institute (CPI)) Nonviolent Intervention Training every one to two years, but application and competency of physical restraint training was unclear. On 1/18/24 at 1200, review of Security Staff files with Human Resource Staff R revealed that Security Officers B, X, and Y lacked documentation of training and competency of behavioral restraint application. Interview with Security Manager U, 1/18/24 at approximately 1215, revealed that he thought that physical restraint training was provided by the CPI Trainers V and W. Interview with the CPI Trainer V, on 1/18/24 at 1235 revealed that he did not go over physical restraint application with security staff, and that it was a separate competency. Also, interview with CPI Trainer W, on 1/18/24 at 1305, verified no physical restraint training or competency was demonstrated by security staff in recent security staff training sessions.”