Utah State Hospital

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 49789 Based on observation, interview, and record review, the hospital did not ensure that restraints were implemented only when necessary to protect the immediate physical safety of the patient, staff, or others for 1 of 11 sample patients. Specifically, physical restraint and seclusion were imposed in a situation in which no immediate safety threat was documented or observed (Patient identifier: 11). Findings include: On December 3, 2025, patient 11, a 12-year-old female, was admitted to the hospital with a diagnosis of Major Depressive Disorder. On December 26, 2025, at 8:45 PM, a Seclusion/Restraint Report indicated patient 11 requested and was administered 325 milligrams of Tylenol for a headache. Approximately 20 minutes later, patient 11 informed RN 4 that she had “cheeked” the medication to save it for a planned overdose. When prompted to surrender the pill, patient 11 refused. RN 4 advised patient 11 that staff would have to physically remove the medication if she did not comply; however, patient 11 continued to refuse. At that point, RN 4 and two technicians restrained patient 11 to secure the medication. Campus police responded to the incident, and patient 11 was taken to seclusion at 9:50 PM. An order for the restraint and seclusion was obtained from the psychiatrist on call, and the patient remained in seclusion for a total of 54 minutes. During the incident, patient 11 incurred a minor skin injury to her right great toe, which required a bandage. The surveyor reviewed the training records for RN 4, which confirmed their completion of the hospital’s required annual restraint training on June 26, 2025, along with three subsequent quarterly refreshers. This training specifically mandated that restraints be utilized only in response to an immediate safety threat. The surveyor reviewed the facility’s “Strategies to Manage Patient Safety” policy. The policy stated that staff must use alternative strategies, including de-escalation procedures collaboratively identified by the patient and staff, such as increased observation and safety checks, to minimize the use of seclusion and restraint. The policy explicitly required these strategies to be considered before seclusion or restraint when a patient was agitated or exhibited potential for harm. The surveyor reviewed the facility’s restraint training manual. The manual emphasized maintaining a therapeutic, non-abusive environment with a goal of “zero harm.” It highlighted de-escalation as the primary response and instructed staff to use the “STOP” rule to observe a situation before reacting. On February 17, 2026, the surveyor interviewed the training director, whose responsibilities included hospital staff training. The training director was asked about the scenario involving patient 11 that occurred on December 26, 2025. The training director acknowledged that facility policies and practices were not followed and that alternative techniques should have been utilized to prevent the use of physical holds. The training director further confirmed that RN 4 had received this information during training and should have been aware of the proper protocols at the time of the incident. On February 17, 2026, the surveyor interviewed the clinical director regarding the events of December 26, 2025 involving patient 11. The clinical director acknowledged that the initiation of a physical hold on patient 11 to retrieve a Tylenol pill while she was threatening self-harm was an unnecessary intervention and was not required to obtain the medication.”

“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: 49789 Based on observation, interview, and record review, the hospital did not ensure that restraints were implemented in accordance with safe and appropriate techniques as determined by hospital policy for 1 of 11 sample patients. Specifically, during an incident, staff completed a one-person unapproved hold instead of a two-person approved hold as required by hospital policy. (Patient #5). Findings include: On October 22, 2025, patient 5, a 13-year-old female, was admitted to the hospital with a diagnosis of Major Depressive Disorder. On December 23, 2025 at 3:01 PM, RN 5 documented in a seclusion/restraint report (PIRS) that patient 5 charged and tried to hit the staff who was providing one-to-one supervision. RN 5 further documented that staff placed patient 5 in an approved hold, and campus police were called. On February 5, 2026, the surveyor reviewed video footage of the incident on December 23, 2025 at 3:01 PM with the campus police chief. At 2:56 PM, patient 5 was observed inside the doorway of the antechamber to the seclusion room, talking with psychiatric technician (psych tech) 5, who stood outside the doorway of the antechamber. Patient 5 was then observed to move toward psych tech 5, attempting to hit him. Psych tech 5 was observed to grab patient 5’s right arm and move into the antechamber with patient 5, taking them further into the room. Patient 5 was observed to fall face-first onto the ground. Psych tech 5 was observed to bend patient 5’s arm behind their back without assistance from other staff. During the video review, the police chief stated a one-person hold was not appropriate for this type of situation and that holds of patients should be performed with two staff members. The police chief stated that psych tech 5 could have moved away from patient 5, closed the door, and waited for a team to assemble. On February 10, 2026, the surveyor reviewed the hospital’s restraint training manual, which documented that a staff member should try to keep something between themselves and the dysregulated patient, move towards an exit, and not trap themselves in a corner. If space was lost between staff and patient, the staff were to deflect strikes, create space, and get away if possible. The surveyor reviewed the training records for psych tech 5, which confirmed their completion of the hospital’s required annual restraint training on June 9, 2025. On February 10, 2026 at 12:10 PM, the surveyor reviewed the video of the incident between patient 5 and psych tech 5 with the facility’s training director, whose responsibilities included overseeing restraint use and hospital staff training. The training director stated that the hold psych tech 5 performed on patient 5 on December 23, 2025 was not an approved hold. The facility’s training director stated psych tech 5 could have moved away from patient 5.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 45710 Based on interview and record review, the hospital did not ensure the hospital documented in the staff personnel records that the training and demonstration of competency for restraint and seclusion were successfully completed. Specifically, for 9 of 11 sampled personnel there was no documented evidence for current restraint and seclusion training. (Personnel identifiers: 1, 2, 3, 4, 7, 8, 9, 10 and 11) Findings include: 1. During the survey entrance interview on 2/21/2024, surveyors requested: a) hospital policy and procedures regarding use of restraint and seclusion, and b) a list of hospital personnel 2. On 2/21/24 at 11:41 AM, the hospital provided a list of personnel. Surveyors chose a sample of 11 personnel (2 registered nurses, 2 licensed practical nurses, and 6 psychiatric techs). Surveyors requested the personnel records and training received by the personnel on the sample list. 3. On 2/21/24 at 11:12 AM, the hospital provided a policy titled “Utah State Hospital Operational Policy and Procedure Manual Chapter: Special Procedures (SP) Section 3: Restraint and Seclusion.” The hospital policy stated: “2. Training: USH trains all staff directly involved in the use of seclusion or restraint at orientation, before participating in the use of restraint, or seclusion, and annually thereafter. This training includes: 2.1 Strategies to identify staff and patient behavior, events and environmental factors that may trigger circumstances that require the use of restraint or seclusion. 2.2 Use of non-physical intervention skills (Safety Intervention Training). 2.3 Methods for choosing the least restrictive intervention based on assessment of the patient ’ s medical or behavioral status or condition. 2.4 For those who participate in the application of seclusion or restraint, the safe application of each type used. 2.5 How to recognize and respond to signs of physical distress such as asphyxia and psychological distress such as disassociation related to seclusion or restraint. 2.6 Identification of discontinuation criteria being met. 2.7 Monitoring the physical well-being of the patient who is restrained or secluded including, but not limited to, constant visualization of the patient, respiratory and circulatory status, skin integrity, vital signs. 2.8 Use of first-aid techniques and response to possible cardiopulmonary arrest. 2.9 The USH documents in staff records that restraint and seclusion training and demonstration of competence are current.” 4. Interviews were conducted with 8 personnel members (1 nurses, and 6 techs and a unit administrator) on 2/21/2024. All 8 personnel stated that had training for restraint and seclusion upon hire and annually or monthly since hire. 5. Review of the personnel records revealed that for 9 of 11 sampled personnel (identifiers: 1, 2, 3, 4, 7, 8, 9, 10 and 11) they did not have current training for restraint and seclusion. 6. In an interview with the hospital superintendent on 2/26/2024 at 2:45 PM, the superintendent stated that the hospital changed their process for restraint training, and that in 2023 the hospital had tried to find a way to track who had received the training. He stated that monthly reinforcing training was completed, however he stated the hospital did not track the training. He stated the meeting minutes show what the leaders (unit managers) were told to teach to their team members, but that the hospital did not document which individual employees received the training.”