Following a patient death inside the facility, the Centers for Medicare and Medicaid Services found that Arbour Hospital did not meet the condition for special medical record requirements for psychiatric hospitals, and that its failures jeopardized the patient’s right to receive care in a safe environment. CMS found that the facility failed to ensure that standing orders for as-needed medication were sufficiently prescriptive to direct nursing staff in their use, that protocols were in place to assess the effects of chemical restraints when used, that staff followed Code Blue procedures, and that staff were credentialed to provide CPR. One patient went into cardiac arrest and died after she was given high blood pressure medications in combination with chemical restraint medications, to which she was allergic. Even though the admitting physician noted the patient’s allergy to the restraint medications, he authorized their administration. Furthermore, the patient’s vital signs and reactions to the medications were not monitored. Both the facility’s clinical director and the risk manager stated that there was no protocol in place for evaluating the effects of chemical restraints. Additionally, during the patient’s cardiac episode, the defibrillator was not used because staff had not been properly trained to handle medical emergency, or “code blue” incidents.