Cheshire Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 26364 Based on record review and interview, the hospital failed to implement policies and procedures to ensure safe and appropriate chemical and physical hold restraint usage (refer to A167 Patient Rights: Restraint or Seclusion); failed to have a physicians order for the use of restraints (refer to A168 Patient Rights: Restraint or Seclusion); failed to specify in the hospital policy the training requirements for physicians and other licensed practitioners (refer to A176 Patient Rights: Restriant or Seclusion); failed to conduct a face-to-face evaluation by a qualified practitioner within 1 hour after the initiation of a restraint (refer to A178 Patient Rights: Restraint or Seclusion); and failed to have training and competencies in the safe application of a restraints for staff, contracted staff, and physicians (refer to A196 Patient Rights: Restrains or Seclusion). 43002 47129”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 26364 Based on interview and record review, the hospital failed to implement policies and procedures to ensure safe and appropriate chemical and physical hold restraint usage for 2 of 11 patients reviewed for restraints. Findings include: Patient #1 Review on 5/10/24 of Patient #1’s nursing progress note dated 12/31/24 at 4:25 a.m. revealed: “...visualized [patient] on floor with many security and medical staff assisting with physical hold after reported immediate physical threat...” Review on 5/10/24 of Patient #1’s physician order revealed that there was no physicians order for this physical hold. Interview on 5/10/24 at approximately 1:25 p.m. with Staff C (Emergency Department Supervisor) confirmed the above. Review on 5/10/24 of Patient #1’s Patient Care Timeline revealed that he/she arrived to the Emergency Department (ED) on 12/26/23 at 6:58 a.m. for altered mental status. Further review revealed a nursing note at 1:00 p.m. for “Behavior Issue Restraint” and Restraint Type listed as: “locked restraining left and right wrists and ankles.” Review on 5/10/24 of Patient #1’s nursing progress note dated 12/31/24 at 1:31 a.m. revealed “...Violent restraint order provided and initiated at [1:00 a.m.].” Review on 5/10/24 of Patient #1’s physician’s order revealed an order dated 12/31/24 at 1:03 a.m. for “Violent and Self-Destructive Patient Restraints”. Review on 5/10/24 of Patient #1’s provider notes written by Staff S (Medical Doctor) dated 12/31/23 revealed there was no documentation that a face-to-face evaluation was conducted for the above physical restraint. Interview on 5/10/24 at approximately 12:15 p.m. Staff C (Emergency Department Supervisor) confirmed the above. Patient #11 Review on 5/9/24 of Patient#11’s Patient Care Timeline revealed that he/she arrived to the ED on 2/22/24 at 4:41 p.m. with a chief complaint of Aggressive Behavior. Further review revealed on 2/25/24 at 8:38 p.m. there was a nursing note that read, “Physical hold utilized while administering IM [Intramuscular] Lorazepam as patient began hitting [pronoun omitted] head off [pronoun omitted] mattress and was cursing and threatening to kill [pronoun omitted] and staff after [pronoun omitted] father left for the night. Attempts at verbal deescalation were met with screaming profanities from the patient. Four staff members were utilized to hold each limb for [less than] 5 [minutes]...”. Review on 5/9/24 of Patient #11’s physician’s notes written by Staff R (Medical Doctor) on 2/25/24 at 3:07 p.m. revealed: “No medical or behavior concerns on the prior shift” and at 11:05 p.m; “Care turned over to [provider name omitted]”. There was no documentation by Staff R regarding the above physical hold, including that a face-to-face evaluation was conducted. Interview on 5/10/24 at approximately 12:15 p.m. with Staff C confirmed the above. Review on 5/10/24 of the facility’s policy Restraints Policy approved on 9/30/22 revealed, “...A... Restraints or seclusion must be ordered by an [Authorized Licensed Provider] upon the use of restraint or seclusion prior to, or during/immediately following restraint application... An ALP [Authorized Licensed Provider] performs a face-to-face evauation of the patient within one (1) hour after the intitial restraint application or placement in seclusion...” 43002 47129”

“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: 43002 Based on interview and record review, it was determined that the facility failed to have a physicians order for the use of restraints for 1 of 11 patients reviewed for restraints (Patient Identifier is Patient #1). Findings include: Patient #1 Review on 5/10/24 of Patient #1’s nursing progress note dated 12/31/24 at 4:25 a.m. revealed: “...visualized [patient] on floor with many security and medical staff assisting with physical hold after reported immediate physical threat...” Review on 5/10/24 of Patient #1’s physician order revealed that there was no physicians order for this physical hold. Interview on 5/10/24 at approximately 1:25 p.m. with Staff C (Emergency Department Supervisor) confirmed the above. Review on 5/10/24 of the facility’s policy “Restraints Policy”, approved on 9/30/22 revealed: “...To establish standardized decision-making criteria and practical procedures for the use and discontinuation of restraint... to protect the patient’s health and safety and the safety of others, as well as to preserve the patient’s dignity, rights, and well-being... A. Restraints or seclusion must be ordered by an [Authorized Licensed Provider] upon the use of restraint or seclusion prior to, or during/immediately following restraint application...” Review on 5/15/24 of the Title XI: Hospitals and Sanitaria, Chapter 151, Residential Care and Health Facility Licensing, Patients’ Bill of Rights, Section: 151:21IX, “The patient shall be free from chemical and physical restraints except when they are authorized in writing by a physician for a specific and limited time necessary to protect the patient or others from injury. In an emergency, restraints may be authorized by the designated professional staff member in order to protect the patient or others from injury. The staff member must promptly report such action to the physician and document same in the medical records.” 47129”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 43002 Based on record review and interview, it was determined that the hospital failed to specify in the hospital policy the training requirements for physicians and other licensed practitioners. Findings include: Review on 5/10/24 of the facility’s policy titled “Restraint - Policy”, approval date 12/23/2022, revealed no training requirements for physicians and other licensed practitioners. Interview on 5/10/24 at 2:00 p.m. with Staff L (Senior Director of Quality and Patient Safety) revealed that the above policy was the current facility policy. 47129”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 26364 Based on interview and record review, it was determined the facility failed to conduct a face-to-face evaluation by a qualified practitioner within 1 hour after the initiation of a restraint used for management of violent or self-destructive behaviors for 2 of 11 patients reviewed for restraints (Patient Identifiers are #1 and #11). Findings include: Patient #1 Review on 5/10/24 of Patient #1’s Patient Care Timeline revealed that he/she arrived to the Emergency Department (ED) on 12/26/23 at 6:58 a.m. for altered mental status. Further review revealed a nursing note at 1:00 a.m. for “Behavior Issue Restraint” and Restraint Type listed as: “locked restraining left and right wrists and ankles.” Review on 5/10/24 of Patient #1’s nursing progress note dated 12/31/24 at 1:31 a.m. revealed “...Violent restraint order provided and initiated at [1:00 a.m.].” Review on 5/10/24 of Patient #1’s physician’s order revealed an order dated 12/31/24 at 1:03 a.m. for “Violent and Self-Destructive Patient Restraints”. Review on 5/10/24 of Patient #1’s provider notes written by Staff S (Medical Doctor) dated 12/31/23 revealed there was no documentation that a face-to-face evaluation was conducted for the above physical restraint. Interview on 5/10/24 at approximately 12:15 p.m. Staff C (Emergency Department Supervisor) confirmed the above. Patient #11 Review on 5/9/24 of Patient#11’s Patient Care Timeline revealed that he/she arrived to the ED on 2/22/24 at 4:41 p.m. with a chief complaint of Aggressive Behavior. Further review revealed on 2/25/24 at 8:38 p.m. there was a nursing note that read, “Physical hold utilized while administering IM [Intramuscular] Lorazepam as patient began hitting [pronoun omitted] head off [pronoun omitted] mattress and was cursing and threatening to kill [pronoun omitted] and staff after [pronoun omitted] father left for the night. Attempts at verbal deescalation were met with screaming profanities from the patient. Four staff members were utilized to hold each limb for [less than] 5 [minutes]...”. Review on 5/9/24 of Patient #11’s physician’s notes written by Staff R (Medical Doctor) on 2/25/24 at 3:07 p.m. revealed: “No medical or behavior concerns on the prior shift” and at 11:05 p.m; “Care turned over to [provider name omitted]”. There was no documentation by Staff R regarding the above physical hold, including that a face-to-face evaluation was conducted. Interview on 5/10/24 at approximately 12:15 p.m. with Staff C confirmed the above. Review on 5/10/24 of the facility’s policy “Restraints Policy,” approved on 9/30/22, revealed: “...To establish standardized decision-making criteria and practical procedures for the use and discontinuation of restraint... to protect the patient’s health and safety and the safety of others, as well as to preserve the patient’s dignity, rights, and well-being... A... An [Authorized Licensed Provider] performs a face-to-face evaluation of the patient within one (1) hour after initial restraint application or placement in seclusion...” 47129 43002”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 47129 26364 Based on interview and record review, it was determined the facility failed to have training and competencies for the safe application of restraints for staff, contracted staff, and physicians for 4 of 9 staff and 7 of 7 providers reviewed. Findings include: Interview on 5/10/24 at approximately 10:00 a.m. with Staff N (Medical Staff Coordinator) revealed that the facility does not provide restrain training to providers. Interview on 5/10/24 at approximately 10:30 a.m. with Staff D (Director of Emergency Department (ED)) revealed that Staff O (Registered Nurse (RN)) received a one hour on line restraint modular training but had no hands on competency demonstration. Interview on 5/10/24 at 11:00 a.m. with Staff E (ED Provider) revealed that none of the providers that work in the ED have had any restraint training. Review on 5/13/24 of the online training provided by the facility revealed that there was no documentation that restraint training had been completed for Staff K (Paramedic), Staff O, and Staff V (RN). Interview via phone call on 5/15/24 at 8:30 a.m. with Staff A (Accreditation and Regulatory Compliance Manager) revealed that the facility does not require training for providers on restraints and that there was no documented records of restraint training completed for Staff O and Staff K. Review on 5/13/24 of the facility’s policy “Restraints Policy”, approved on 9/30/22 revealed that the policy did not address training and competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint. 43002”