Methodist Hospital Stone Oak

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45179 Based on record reviews and interviews, the hospital failed to ensure that nursing staff kept the nursing care plan current that reflected the ongoing nursing care provided by promptly documenting the ongoing assessments of the patient’s needs, patient’s response to interventions, and updating the nursing care plan promptly in accordance with the facility’s policy for 1 of 1 patient reviewed (Patient #1). Findings include: Record review of the facility’s “Assessment Timelines/ Reassessment Timelines” rev. 9/2014 states in part, that the nurse will monitor and document for Labor and Delivery “L&D: Phase 1- every hour; Phase 2 - every 15 minutes.” Review of complaint intake, TX00542458, received 5/8/25 alleges RN #1 “fabricated documentation” of Patient #1’s medical records when the notes are dated and time-stamped between 7:37 AM and 9:40 AM on July 1, 2024; between 5 and 7 plus hours after Patient #1’s son was born, not breathing at 2:36 AM. RN #1’s shift ends at 07:30 AM, yet she stayed over 2 hours beyond her shift to document each patient encounter. RN #1 retroactively wrote very specific times in her notes, however she was not taking all those notes while she was instructing me to push. Review of Patient #’1’s Obstetric (OB) Nurses Notes Chronological Selection indicate that the patient delivered via cesarean section on 7/1/2025 at 2:36 AM. OB NURSE NOTES (Chronological Selection): Review of the OB Nurses notes dated 6/30/24 - 7/1/24 revealed the following patient care activities were documented anywhere from 5 hours and 50 minutes up to 9 hours and 35 minutes after the following treatment and assessments occurred by Primary care registered nurse (S#1): At 07/01/24 07:32 AM, S#1 documents for 07/01/24 02:09AM, “monitors turned off for pt to be taken back to OR for urgent csection At 07/01/24 07:37 AM, S#1 documents for 07/01/24 04:50 AM, SpO2 97% P 113 Comments: pt agrees to csection at this time and csection is called. At 07/01/24 07:37 AM, S#1 documents for 07/01/24 01:47 AM, csection called at this time by Physician - A (S#2), pt questioning if there are any other choices stating she does not want a csection, S#2 explaining to pt that due to her tracing her babys heart tracing is nonreassuring with the deep variables and her pushing is not effective to bring baby down further into her pelvis, pt keeps saying she does not want a section, midwife & doula at bedside questioning if pt has to have csection, physician explains again about the nonreassuring fetal heart tones and she recommends urgent section At 07/01/24 08:21 AM, S#1 documents for 06/30/24 23:59 PM, ISE applied, (S#2) at bedside; VE performed At 7/01/24 08:22 AM, S#1 documents for 07/01/24 00:01 AM, S#2 at bedside explaining to pt for her to push with ctx for delivery of infant At 07/01/24 08:25 AM, S#1 documents for 07/01/24 00:03 AM, Pt pushes with ctx but is ineffective with her pushing and breathing techniques At 07/01/24 08:25 AM, S#1 documents for 07/01/24 00:04 AM, documents for Pt states she does not want to push At 07/01/24 08:25 AM, S#1 documents for 07/01/24 00:05 AM, Pt requests epidural; SpO2 96%, P 83 At 07/01/24 08:26 AM, S#1 documents for 07/01/24 00:07 AM, 2 RN AT BEDSIDE EXPLAINING TO PT THE FETAL TRACING IS NONREASSURING AT THIS TIME, PHYSICIAN TO BEDSIDE EXPLAINING TO PT IF SHE CANNOT PUSH AND BABY DOES NOT RECOVER SHE WILL NEED AN EMERGENCY CSECTION At 07/01/24 08:27 AM, S#1 documents for 07/01/24 00:04 AM Left lateral At 07/01/24 08:27 AM, S#1 documents for 07/01/24 00:10 AM, BP 109/68 M 83 P 80 SpO2 96% P 83 Right Lateral At 07/01/24 08:27 AM, S#1 documents for 07/01/24 00:12 AM, Hands-Knees At 08:29 AM, S#1 documents for 07/01/24 00:13 AM, PT PLACED INTO STIRRUPS TO TRY PUSHING AGAIN WITHOUT EPIDURAL At 07/01/24 08:31 AM, S#1 documents for 07/01/24 at 00:10, Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Decels A: Late, Variable, Category II, Provider rvw FMS: Yes, Comments Fetus A: in between pushing baseline noted to be 110, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 60-90 At 07/01/24 08:33 AM, S#1 documents for 07/01/24 00:20 AM SpO2 98% P80 At 07/01/24 08:33 AM, S#1 documents for 07/01/24 00:20, Continuous Fetal Monitoring, Mon Mode A: Internal Moderate 6-25bpm, Accels A: Absent, Decels A: Late, Variable, Category II, FHR Baseline Rate A: 110, Provider rvw FMS: Yes, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 60-80 At 07/01/24 08:34 AM, S#1 documents for 07/01/24 00:27 AM, Oxygen Amount: 10, Face Mask At 07/01/24 08:34 AM, S#1 documents for 07/01/24 00:30 AM, SpO2 83% P 100 SpO2 97% P 85 Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Variable, Prolonged, Category II, FHR Baseline Rate A: 110, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed. Contraction Freq: 2-3, Contraction Duration: 60-70 At 07/01/24 08:41 AM, S#1 documents for 07/01/24 00:29 AM, pt resting through this contraction, no pushing to allow fetus to recover, midwife at bedside talking to pt to just keep pushing, RN explained that pushing every ctx is not beneficial at this time as the fetus needs an opportunity to rest, pt verbalized understanding At 07/01/24 08:46 AM, S#1 documents for 07/01/24 00:40 AM, SpO2 96% P 113 Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Variable, Category II, FHR Baseline Rate A: unable to determine baseline, Comments Fetus A: audible heart tones in between pushing 145s, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 60, Contraction Comments: pt pushing with ctx At 07/01/24 08:47 AM, S#1 documents for 07/01/24 00:50 AM, SpO2 97% P 94 Continues Fetal Monitoring, Mon Mode A: Internal, Moderate 6-125 bpm, Accels A: Absent, Decels A: Late, Variable, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Duration: 60-70, Contraction Comments: pt pushing with ctx At 07/01/24 08:48 AM, S#1 documents for 07/01/24 00:47 AM, RN asking pt if she wants an epidural for pain management, pt declines and does not want epidural At 07/01/24 08:56 AM, S#1 documents for 07/01/24 00:55 AM, RN explaining to pt her fetal tracing remains nonreassuring with pushing, IV fluids continue blousing, oxygen face mask on pt, pt declines option for csection states she does not want a section, midwife @bedside asking if physician will do a vacuum delivery RN said she would ask, physician reviewed tracing no new orders received states to keep pushing at this time At 07/01/24 08:59 AM, S#1 documents for 07/01/24 01:00 AM, Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Variable, Category II, FHR Baseline Rate A: 150, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Greq: 2-3, Contraction Comments: pt pushing with ctx At 07/01/24 09:03, S#1 documents for 07/01/24 01:10 AM, SpO2 98% P 89 Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Variable, Category II, FHR Baseline Rate ‘A’: indeterminate, Comments Fetus A: audible heart tones in between pushing in the 150s, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 40-60, Contraction Comments: pt pushing with ctx At 07/01/24 09:04 AM, S#1 07/01/24 documents for 01:02 AM, documents for midwife at bedside having pt push while doing tug of war At 07/01/24 09:04 AM, S#1 documents for 07/01/24 01:15 AM, SpO2 93% P 78 SpO2 97% P 89 RN explains to pt to rest with this ctx, no pushing, allow fetus to recover At 07/01/24 09:06 AM, S#1 documents for 07/01/24 01:20 AM, SpO2 97% P 109 Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Late, Variable, Category II, FHR Baseline Rate ‘A’: indeterminate, Comments Fetus A: audible heart tones in the 155s between pushing, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 40-70 At 07/01/24 09:08 AM, S#1 documents for 07/01/24 01:19 AM, RN once again educating p on fetal tracing and also offers epidural, pt declines epidural, midwife asking again about vacuum delivery RN explaining that the baby has to be low enough in pelvis and at this time the baby is not low enough to perform a safe vacuum also with limited care with birth center physician might not, pt verbalized understanding and states that she wants to keep pushing and also declines a csection At 07/01/24 09:10 AM, S#1 documents for 07/01/24 01:30 AM, SpO2 98% P 87 Continuous Fetal Monitoring, Mon Mode A: Internal, Minimal - Undetectable to <5bpm, Accels A: Absent, Decels A: Variable, Category II, FHR Baseline Rate ‘A’: indeterminate, Comments Fetus A: audible heart tones in 150s between pushing, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: Irregular, Contraction Duration: 40-60 At 07/01/24 09:12 AM, S#1 documents for 07/01/24 01:31 AM, S#2 reviewed fetal tracing and recommended pitocin, RN notified physician that strip does not meet criteria to start pitocin at this time At 07/01/24 09:17 AM, S#1 documents for 07/01/24 00:50 AM, Iv Bolus, Oxygen At 07/01/24 09:17 AM, S#1 documents for 07/01/24 01:30 AM, IV Bolus, Oxygen At 07/01/24 09:19 AM, S#1 documents for 07/01/24 00:10 AM IV Bolus, Oxygen 07/01/24 09:23 AM, S#1 documents for 07/01/24 02:00 AM, Continuous Fetal Monitoring, Mon Mode A: Internal, Minimal - Undetectable to <5bpm, Accels A: Absent, Decels A: Variable, IV Bolus, Oxygen, Category II, FHR Baseline Rate ‘A’: 150, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 40-70 At 07/01/24 09:40 AM, S#1 documents for 07/01/24 01:45 AM, SpO2 97% P 75 Comments: S#2 at bedside assessing pts pushing efforts, midwife and pt asking to do vacuum delivery, physician explains to pt that is not an option at this point, the tracing is not reassuring and the station of the fetus is not low enough for safe vacuum, pt states she wants to keep pushing then and refuses csection At 07/01/24 09:41 AM, S#1 documents for 07/01/24 01:30 AM, pt using squat bar to push with ctx At 07/01/24 09:43 AM, S#1 documents for 07/01/24 00:08 AM, pt verbalized she refuses a csection At 07/01/24 09:44 AM, S#1 documents for 07/01/24 01:21 AM, Left Lateral At 07/01/24 09:44 AM, S#1 documents for 07/01/24 00:13 AM, Lithotomy At 07/01/24 09:45 AM, S#1 documents for 07/01/24 01:29 AM, Squatting 07/01/24 09:30 AM, S#1 documents for 07/01/24 02:09 AM, Continuous Fetal Monitoring, Mon Mode A: Internal, Minimal - Undetectable to <5bpm, Accels A: Absent, Decels A: Variable, Prolonged, Category II, FHR Baseline Rate ‘A’: 150, Provider rvw FMS: Yes, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 40-80 Interview conducted with S# 1 6/26/2025 6:23 PM stated in part, that nurses have 24 hours to document in the patient’s chart but document before going home. It is common practice to make quick notes on the monitor strip or scrubs or even an arm if needed until she can chart in the record. When surveyor requested to review the monitor strip S#1 stated “We don’t keep them because it is kept electronically. The paper ones are shredded.” Interview conducted with S#4 at 6/24/2025 2:45 PM stated in part, staff has a 24 hour timeline to document in a patients record. IT provided the guideline or was provided during nurse training. Surveyor requested for documentation policy or education provided to staff with the 24hour timeline but none was provided. Interview conducted with S#5 at 6/24/2025 3:40 PM with S #4 stated in part, staff has a 24 hour timeline to document in a patients record. Surveyor requested for documentation policy or education provided to staff with the 24hour timeline but none was provided. Texas Board of Nursing-Title 22, Part 11, Chapter 217, Rule 217.11 in part states, o The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse’s license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board’s rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse’s current area of nursing practice; (D) Accurately and completely report and document: (i) the client’s status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client’s status;”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A 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 or dosage for the patient’s condition. This Standard is not met as evidenced by: 32143 Based on document review and interviews, the facility failed to ensure: A.chemical restraints/emergency behavioral medications (EBM) administered Intramuscular (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as a restraint in 2 (Patient’s #6 and #5) of 2 medical records reviewed. B. the policy and procedure titled “Patient Seclusion and Restraint” gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint/EBM in 2 (Patient’s #6 and #5) of 2 medical records reviewed. C. the policy and procedures for “Patient Restraint and Seclusion” were followed to prevent a restraint from being ordered as a PRN or as-needed order. D. chemical restraints/EBM’s were not identified in the facility’s restraints report for 2 (Patient’s #6 and #5) of 2 medical records reviewed. E. that all staff received appropriate training for the use, administration, and assessment of all patients receiving chemical restraints/EBM. Findings included: A review of the facility’s Restraints Report from 4/8/25 thru 5/5/25 did not identify any use of Chemical Restraints/EBM’s being administered for behavioral emergencies. Patient #6 A review of patient # 6’s medical record revealed the patient was brought to the Emergency Room (ER) on 4/25/25 at 1632. A review of the ER physician notes revealed patient #6 was 58 years old with a diagnosis of dementia and was having outbursts of yelling, confusion, and aggressive behavior. A review of the nurse’s notes dated 4/25/25 at 2044 stated, “Pt (patient) began yelling and throwing sheets off of self when this RN (Registered Nurse) heard the occurrence.” The nurse notified the provider and charge nurse. The nurse documented that a sitter was ordered at 2107. There was no documentation of any de-escalation or interventions before a chemical restraint/EBM was ordered and administered. A review of patient #6’s ER record revealed the following physician orders (PO): “4/25/25 at 2047 Haldol (antipsychotic) 5 mg IV once.” There was not a diagnosis indicated or the reason for a chemical restraint/EBM on the physicians order. Haldol was documented as administered at 2053 in the left hand. There was no documentation of the medication’s effectiveness or the patient’s behaviors after the chemical restraint/EBM. The nurse documented vital signs at 2101. Patient #6’s blood pressure was elevated at 147/105 and a pulse of 119. The next set of vital signs was taken one hour later at 2201. Patient #6’s blood pressure was still elevated at 160/94 and a pulse of 100. There was no documentation that the physician was aware of the patients vitals. There was no further documentation of whether the physician was aware of the patient’s behavioral and medical status, or whether further care was given. A review of patient #6’s ER record revealed that on 4/25/25 at 2221, the nurse documented, “Pt began yelling and having similar outbursts to before, notified the provider and charge nurse.” There was no documented information from the provider at this time. There were no documented interventions by the nursing staff. A review of patient #6’s ER record revealed the following physician orders: “4/25/25 at 2221 Ativan (sedative) 2 mg IV once.” There was not a diagnosis indicated or the reason for a chemical restraint/EBM on the physician order. Ativan was documented as administered at 2227 in the left hand. Vital signs were documented at 2330. There was no documentation of the medication’s effectiveness or whether the medication was effective. A review of patient #6’s medical record revealed she was admitted to the hospital on 4/26/25 at 1427 for a Urinary Tract Infection and Aggressive behavior. A review of patient #6’s record revealed the following physician orders: 4/26/25 at 1517 Haldol 5 mg IV every 6 Hours as needed/PRN for Agitation/Anxiety. Haldol was documented as administered at 1517 in the left antecubital. A review of the facility’s policy and procedure “Patient Restraint/Seclusion” last revised 04/2025 indicated, in part; “Order for a Restraint or Seclusion; 1. An order for restraint or seclusion may not be written as a standing order, protocol, or as a PRN or ‘as needed’ order.” According to the FDA.gov, “While Haloperidol injection is FDA-approved for intramuscular (IM) use, its IV use is considered ‘off-label’ in the United States. This means the FDA has not specifically approved it for this route of administration, but it is a practice supported by clinical experience and evidence. All antipsychotic medications carry a black box warning due to the increased risk of death in elderly patients with dementia-related psychosis. This warning highlights that these drugs are not approved for treating behavioral symptoms in this specific patient population and carry a significant risk of death. The FDA issued the initial warning for atypical antipsychotics in 2005, and later extended it to all conventional antipsychotics in 2008. Patient Monitoring: If Haloperidol is administered IV, close monitoring of the patient’s heart rhythm (ECG) is crucial to identify and manage any potential complications. Risks and Benefits: The potential benefits of rapid calming and reduced agitation need to be weighed against the risks associated with IV administration, such as QT prolongation and the potential for a rare but serious heart rhythm disturbance called torsades de pointes.” Haldol has black box warnings for the a life-threatening adverse event called catalepsy, which leaves patients in a trance-like state accompanied by rigid muscles and abnormal, uncontrollable movements. There is no antidote.” Patient # 5 A review of patient #5’s medical record revealed he was a 75-year-old male who arrived as a walk-in to the ER on 4/25/25 at 2316. The patient had a ground-level fall, pt was hypotensive. A review of the physician notes dated 4/25/25 stated the patient had a history of dementia presenting for syncope and hypotension. A review of the physician orders dated 4/26/25 at 0413 stated, “Haloperidol Lactate Inj (Haldol Injection) 2 mg IV.” Patient #5’s Emergency Patient Record revealed Haldol Lactate 2 mg IV administered on 4/26/25 at 0426. A review of the Emergency Provider Report, physician’s notes dated 4/26/25 stated, “Patient did receive Haldol for an episode of sundowning at which time he was pulling out his IV and pulling off all of his monitoring.” https://pmc.ncbi.nlm.nih.gov. Sundowning is a syndrome recognized in patients with dementia or delirium who display symptoms of neuropsychiatric symptoms (NPS) in the late afternoon or early evening; agitation in particular, that may result in disruptive behaviors and psychological disturbances. Further review of Patient #5’s medical record revealed there were no nursing notes that described any unwanted behaviors or any pulling at lines. There was no documentation in the patient’s record of any inappropriate behaviors or “sundowning” episodes. There was no documentation that interventions had been attempted before ordering and administering a chemical restraint/EBM. There was no documentation that interventions had been attempted before ordering and administering a chemical restraint. There were no nursing notes that stated the medication was administered, the effectiveness of the medication, or if the patient was reassessed after the medication was administered. At 0436 the nurse documented vital signs. Interview on 5/7/25 at 3:05PM with Staff #26 stated in part when asked by surveyor, if there had been any restraint monitoring or documentation for Patient #5, responded, “No, I don’t see any.” Review of the facility’s Restraint/Seclusion Policy last revised 04/2025 indicated the following, in part; “Policy: The facility will comply with state laws when initiating restraints to, B. Ensure the least restrictive methods of intervention are used, and C. Attempt alternatives whenever possible and only initiate restraint when those attempts are determined ineffective. 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. 5. Describe the specific behaviors which constituted the behavioral emergency which resulted in the need for restraint or seclusion. 7. Monitoring the Patient in Restraints a. Patients are assessed by an 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. c. More frequent monitoring and notification of the ordering physician occurs when: 1. Patient’s medical and emotional needs and health status change 2. The type and design of the device or intervention poses increased risk 9. Face-to-face assessment by a Physician or LIP: a. A face-to-face assessment by a physician or LIP, physician assistant or a RN who is trained with demonstrated competence in assessing medical and psychiatric stability, other than the nurse who initiated the use of violent restraint or seclusion, shall conduct a face to face evaluation of the individual within one hour following the initiation of the 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 Appendix A: Training Requirements B. Staff who conduct the one hour face-to-face evaluation The purpose of the 1-hour face-to-face evaluation is to complete a comprehensive review of the patient’s condition and determine if other factors such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis etc. are contributing to the patient’s violent or self destructive behavior. Training for the RN or PA who conduct the 1-hour face-to-face will include: 1. Application of restraints. 2. Implementation of seclusion. 3. Monitoring, assessment and providing care for a patient in restraint or seclusion, including: a. The patient’s immediate situation b. The patient’s reaction to the intervention c. The patient’s medical and behavioral condition Appendix D: Definitions, C. Drugs as restraints: A 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 or dosage for the patient’s condition is considered a restraint. A medication that is not being used as a standard treatment or in a dosage for the patient’s medical or psychiatric condition and that results in controlling the patient’s behavior and/or in restricting his or her freedom would be a drug used as a restraint. e. “Chemical restraint” is defined as the use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, for purposes of restraining an individual and which is not standard treatment for the individual’s medical or psychiatric conditions.” Further review of the policy and procedure Patient Restraint/Seclusion revealed there was no direction on how soon, how frequently, and for how long the patient should be assessed after the administration of a chemical restraint/EBM. An interview with staff #2 on 5/7/25 at 2:00 PM revealed that there were no specific time frames listed in the policy for the assessment of a patient after the administration of a chemical restraint/EBM. Staff #2 confirmed there were no patients listed on the restraint log that had received a chemical restraint/EBM. Staff #2 confirmed that there were only mechanical/physical restraints listed. An interview was conducted on 5/5/25 at 7:30 PM with RN staff #18 and RN staff #19. RN Staff #18 was asked if she could define a chemical restraint, when it should be administered, and how she would assess the patient afterward. Staff #18 stated that a chemical restraint was “a bunch of medications all mixed together or anything that would calm a patient down like Ativan or Haldol.” Staff #18 stated that she was not aware of any specific time frames for the reassessment following administration of a chemical restraint/EBM. Staff #18 stated that she reassessed the patient every 5 minutes until she thought the patient was safe. Staff #18 was asked if there was an antidote for psychotropic meds, and she stated she was not aware. She also stated that she was not aware that the medications had black box warnings. Staff #18 stated that she had chemical restraint training recently, but she was not sure she understood the training. Staff #18 stated that there was no post-test to validate the training comprehension. Staff #19 stated that when she had a psychiatric patient who needed a chemical restraint, she would ask the doctor for something like Ativan IV or IM. Patient #19 stated that she was not sure of any antidotes for psychotropic medications or that any of these medications had black box warnings for administration. Staff #19 stated that she was not aware of any policy or process that gave information on how to assess and reassess a patient after the administration of a chemical restraint/EBM. Staff #19 stated that she would stay with her patient and check vitals every five minutes. Staff #19 stated that she would continue until the patient was stable but was not able to give a time frame or her definition of “stable”. Staff #19 stated that she had some recent training on restraints but was told that they do not give chemical restraints or emergency behavioral medications, and it was not part of the training. Staff #18 stated that she was taught how to de-escalate and hold the patient, but not how to assess patients after chemical restraints/EBM. An interview was conducted with Pharmacist Staff # 12 and the Manager of Pharmacy, Staff #13 on 5/7/25 at 9:20 am. Staff #12 stated they do complete retrospective data collection on antipsychotic medications monthly that are provided to the hospital’s patient safety and quality department but have not specifically been looking into reasons for ordering or appropriate use of the medications. Staff #12 and #13 confirmed that currently the pharmacy does not have a process for alerts or black box warnings for antipsychotic medications and have not been assessing or ensuring the PO’s for appropriate use. Staff # 12 stated the ER department uses the Automated Medication Dispensing Unit (AMDU) which is accessible for any medication from the doctor’s order due to the urgency in that unit. Staff #12 and #13 confirmed the pharmacy department has not been asked, nor has it attended any process improvement meetings related to medication restraints. Staff #12 was asked if they have screens in the electronic medical record or the AMDU that are specific to restraint medications the hospital uses and he stated no; that would have to be submitted to corporate level because they oversee the standard screens, and that process could take up to a year if approved. A review of the education materials “ Restraint Use” and “Welcome to Restraint Bootcamp” was developed and provided to staff during April of 2025. The training revealed education on definitions, examples, orders, monitoring, alternatives during de-escalation, and documentation of violent vs nonviolent restraints, seclusions, physical holds, mechanical restraints, and Emergency Behavioral Medications. However, there was no training or policy that directed the nurse on patient assessment after the administration of a chemical restraint. 21863 Interview on 5/5/25 at 5:37 PM with RN #22 stated he received restraint re-training within the last month including the types of restraints and their uses. RN #22 stated emergency medications used for restraint included Haldol, Ativan, and Zyprexa; but that Haldol was the “go to.” RN #22 stated sometimes medications are used for “agitation” and trying to calm the patient down. RN #22 said their unit used the “RASS” (Richmond Agitation-Sedation Scale) score for agitation. [The RASS is a tool used to assess a patient’s level of agitation and sedation by using a numerical score]. RN #22 stated there was an electronic policy and protocol for the use of violent restraints and medications used for restraints, but when asked to review the protocol, he was unable to locate it on the computer-based system the facility uses. Interview on 5/5/25 at 6:08 PM with Staff #21 stated the restraints are audited by the charge nurse on every shift. The newly implemented process is for the unit directors to review the restraint documentation and process twice weekly. Staff #21 stated with this new process the biggest identified issue was the “documentation gaps; either in the orders or missing documentation.” Interview on 5/5/25 at 7:30 PM with Staff #23 said she conducts the restraint chart audits by checking the orders and identifying any “fall outs.” Staff #23 stated as the process has progressed, they have identified issues to address and follow up with the staff, or for administration to explore how to remove the barriers to ensure compliance. Staff #23 said that sometimes it just the staff are “not picking the right choice” in the menu. Staff #23 stated there had been conversations about adapting the Electronic Medical Record (EMR) to ensure all areas for restraints are completed, as required. Staff #23 said a chemical restraint was if you “snow” [the slang term used when a patient is heavily or overly sedated in order to make them drowsy or unconscious] the patient, and an emergency medication restraint was “not to subdue” but to change their behavior, if given for anxiety,” and not their normal medication regimen. Staff #23 said sometimes medications were given for “disruptive” behavior, but only if their safety was going to be affected. Interview on 5/6/25 at 12:50 PM with RN Staff #24 stated she was not sure about the process for the use of chemical restraints when asked, and further stated, “restraints in PACU [Post-Anesthesia Care Unit] are covered under procedure orders.” Interview on 5/6/25 at 12:52 PM with RN Staff #25 when asked about violent restraints, stated violent restraints are not used in the PACU and there had only been one restraint in the past year, but she could not remember. Interview on 5/6/25 at 1:50 PM with Staff #2 indicated the restraint reports are reviewed daily for a specific set of parameters from a work tool (spread sheet) we have developed. If there is a discrepancy, error, or omission is found they address it with that staff prior to the end of shift. There was training for the RN’s in the ER department that included monitoring patients while restraints are used. Staff #2 stated the clinical documentation has improved after the training.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 21863 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.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21863 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.”

“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: 21863 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 the room because Patient #1 was being restrained by 4 male staff and the female nurse had left to get medications. Patient #1 “was on her chest” and the SO’s were at her arms and legs holding all extremities. Staff #1 said she did not observe anyone on top of Patient #1 during these observations. Staff #1 said as a “chaperone” she is to ensure “patient safety;” that everyone is “doing the right thing” and if an allegation is made, she is there as a witness. Staff #1 was asked if she had been trained on restraints and she responded, “no.” Interview on 2/5/25 at 8:00 PM with APO Staff #5 stated the following: on 4/9/24 he remembered Patient #1 and began to describe the detailed events about her being verbally aggressive, saying she was going to leave, screaming at others, etc. Staff #5 said Patient #1 was sitting on the gurney and began to bang her head on a box that was on the wall. SO #1 then grabs Patient #1 by the arm and head. SO #1 yelled over to ask if he could put the railing on. SO#1 had a leg on the mattress and Patient #1 was part on her stomach and part on her side. SO #1 got onto the stretcher with the patient and got on top of her trying to gain control of Patient #1. APO #5 said he was checking to ensure that SO #1 was not putting all his weight on Patient #1 or obstructing her breathing because SO #1 was a very large guy. APO Staff #5 said he held Patient #1’s right ankle. Staff #5 said the RN #2 was in and out and came in with 2 shots. RN #2 pulled down Patient #1’s sweatpants to administer the 2 shots and Patient #1 was “on her stomach, struggling.” Staff #5 said they were holding all of Patient #1’s extremities waiting on restraints. One of the SO’s brought in “soft restraints” and he was told that those restraints would not work as she would bust through them, and to go get the “security” [rigid] restraints and that took a while. When SO #3 returned with the restraints, he took the foot Staff #5 was holding and he stepped back from the bed and positioned himself at the door. PCT #9 started to secure the restraints to the bed and when he was ready with the restraints, he called to flip Patient #1 over so they could secure her with the restraints. When Patient #1 was turned over, she was not struggling or yelling and Staff #5 thought “maybe the meds were working.” APO Staff #5 said he looked at Patient #1’s chest and didn’t see a rise and he asked if Patient #1 was breathing. PCT #9 checked Patient #1 for a pulse and said he felt one, stating “yeah, a little bit.” They continued to secure Patient #1 with restraints and APO Staff #5 did not see Patient #1’s chest rising (respirations) and asked again, “Are you sure she’s breathing?” PCT #9 checked her pulse again and this time he responded that Patient #1 did not have a pulse. PCT #9 called for an emergency Code and they began CPR on Patient #1. APO Staff #5 said Patient #1 was not connected to any vital monitoring in the room. APO #5 said he would speak up if he saw anything wrong with the restraints. APO Staff #5 said he had not been trained by the facility in restraints, but he had been an APO for many years and was not aware of any medical regulations that a patient could not be held in a prone position. APO Staff #5 said that for any patient restraints, that an order has to come from a Doctor to place them in restraints. Staff #5 said the soft restraints are blue and the security/rigid restraints were “leather-ish, but nylon” and were “hardly used.” Staff #5 said he didn’t think about physically holding a patient was considered a “restraint.” Staff #5 said the SO’s receive CPI training for restraints. 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. 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. 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, B. Ensure the least restrictive methods of intervention are used, C. Attempt alternatives whenever possible and only initiate restraint when those attempts are determined ineffective and 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. f. Order for Restraint with Violent or Self Destructive Behavior. Orders for restraint in response to a behavioral emergency must not exceed: 1. 15 minutes for personal restraint (physical hold). 6. Application of Restraints a. Restraints are applied by staff with demonstrated competence in restraint application. d. Only authorized staff who have met training requirements may initiate personal restraint in a behavioral emergency. 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 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 that 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. “ Review of the Crisis Prevention Institute (CPI) training manual, Participant Workbook, 2nd Edition, 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 small number of restraint-related deaths reported in health, educational, and social care environments occurring during and/or in close proximity to physical restraint (Independent Advisory Panel on Deaths in Custody, 2011), these are often perceived to have occurred as a result of positional asphyxia. This has led the view that prone restraint is the main risk and therefore should be abolished in favor of alternative positions (seated, standing, or supine), which are incorrectly perceived as less harmful. Prolonged physical restraint increases the risk of restraint-related death. Whenever possible, all reasonable and alternative non-restrictive interventions should be used if the duration of a physical restraint exceeds 10 minutes (NICE, 2015).” Review of the CPI Holding Skills on Page 59 included: -Principles of Holding in a Seated Position, demonstrated a person (staff) on each side of the patient, each person sitting next to the patient, and each person using their hands to hold the patient’s arms; and -Principles of Holding in a Standing Position, demonstrated a person (staff) on each side of the patient, each person standing next to the patient, and each person using their hands to hold the patient’s upper arm. The demonstrated/pictured Holding Skills did not include holding a patient in a prone position, getting on top of a patient, or straddling a patient. 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.” Review of the Posey Limb Holders, 2551, Quilted, Quick-Release [known as the soft restraints] Application Instructions for wrist and ankle, Rev E 06/19/2024, indicated the following: Contraindications: None Review of State law, Texas Administrative Code, Title 25 Chapter 415, Subchapter F, §415.254 General Requirements for the use of Restraint, §415.255 Prohibited and Restricted Practices in 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, §320.109 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. 3.) Prohibited and Restricted Practices in the use of restraint, §320.109(a)(1)(A), §320.109(a)(1)(B), and §320.109(b) (a) The following practices are prohibited: (1) a personal or mechanical restraint shall not be used that: (A) obstructs the individual’s airway, including a procedure that places anything in, on, or over the individual’s mouth or nose; (B) impairs the individual’s breathing, including applying pressure to the individual’s torso or neck, and (b) A prone or supine hold shall not be used during a personal restraint. Should an individual become prone or supine during a restraint, then any staff member involved in administering the restraint shall immediately transition the individual to a side lying or other appropriate position. Further review of TAC §415.261 Time Limitation on an Order for Restraint Initiated in Response to a Behavioral Emergency at §415.261(a)(1) limits a physician ordered personal restraint [physical hold restraint] not to exceed “15 minutes for personal restraint.””

“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: 21863 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.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 21863 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.”

“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: 21863 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 small number of restraint-related deaths reported in health, educational, and social care environments occurring during and/or in close proximity to physical restraint (Independent Advisory Panel on Deaths in Custody, 2011), these are often perceived to have occurred as a result of positional asphyxia. This has led the view that prone restraint is the main risk and therefore should be abolished in favor of alternative positions (seated, standing, or supine), which are incorrectly perceived as less harmful. Prolonged physical restraint increases the risk of restraint-related death. Whenever possible, all reasonable and alternative non-restrictive interventions should be used if the duration of a physical restraint exceeds 10 minutes (NICE, 2015). Review of the CPI Holding Skills on Page 59 included: -Principles of Holding in a Seated Position, demonstrated a person (staff) on each side of the patient, each person sitting next to the patient, and each person using their hands to hold the patient’s arms; and -Principles of Holding in a Standing Position, demonstrated a person (staff) on each side of the patient, each person standing next to the patient, and each person using their hands to hold the patient’s upper arm. The demonstrated/pictured Holding Skills did not include holding a patient in a prone position, getting on top of a patient, or straddling a patient.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 29242 Based on record reviews and interviews, the facility failed to ensure that nursing staff developed a comprehensive nursing care plan for each patient that reflects the patient’s goals and meets the patient’s current nursing care needs for 1 of 1 patients (Patient #1). Record review of the facility medical record for Patient #1, dated 12/21/2023 to 02/26/2024 revealed the following information: Nursing Care Plans, Dated 12/21/2023 to 02/26/2024 Section entitled: ASPIRATION RISK PROBLEM: “Aspiration risk problem expected to: Improve/Resolve Target date: 02/29/24. Aspiration risk problem is: Stabilizing/Maintaining” Further review of the nursing care plans revealed no evidence of nursing actions/ interventions related to the identified aspiration risk, and/or any evidence that nursing staff were analyzing and reviewing data regarding the patient’s responses to the plan of care. Record review of the facility Policy entitled: Documentation the Provision of Care; Last revised:12/2021, revealed the following information: -Screening and Risk Assessment: 3. Nutritional Screening is performed for inpatients and any outpatients. Inpatient screenings are completed within 24 hours of admission. Positive screens are referred for nutritional evaluation. 4. Functional Screening is performed for inpatients and for any outpatients. Inpatient screenings are completed within 24 hours of admission. Positive screens are referred for physical therapy evaluation. 5. Risk of injury from falls is assessed for inpatients. Emergency department patients and surgical patients are assumed to be at high risk for falls and given appropriate assistance and supervision. Inpatients with positive screens are provided with appropriate supervision and injury reduction interventions. -ASSESSMENT AND REASSESSMENT: Registered Nurses (RNs) perform and document assessments. Licensed Practical Nurses/ Licensed Vocational Nurses (LPN/LVNs) and nursing assistants Patient Care Technicians (PCTs) may assist with assessments by collecting data and entering it into the EHR. RNs are responsible for reviewing and analyzing the data, drawing conclusions and taking appropriate actions. -PLAN OF CARE: Each clinician involved in the patient’s care contributes to the Plan of Care by identifying problems; establishing goals; setting time frames and developing interventions. Comprehensive assessment and screening, along with patient and family input, helps to identify patient-specific problems which are prioritized focus areas for this hospitalization. The clinician assigns an expected outcome (Improve/Resolve, Stabilize/Maintain or Deteriorate) and target date for each problem added to the Plan of Care. For each problem added to the Plan of Care, the EHR will suggest the appropriate Physiological, Functional, Psychological or Health Behavior related interventions. The clinician will review and add the suggested interventions. In an interview conducted on 03/18/2024 at 1:10 pm, the facility VP of Operations confirmed the above findings and the facility’s deficient practice.”