Millwood Hospital was cited by the Centers for Medicare & Medicaid Services (CMS) for failing to protect patient rights related to restraint and seclusion. CMS found that restraint and seclusion standards were not met when “the facility failed to ensure that seclusion was terminated when release behaviors were demonstrated” during a patient incident. The patient was escorted to a locked seclusion room after becoming agitated, threatening to peers, aggressive towards staff and unresponsive to verbal de-escalation. The physician orders for the seclusion intervention were for a maximum of two hours, with immediate release upon demonstration that the patient was no longer threatening to hurt self/others, responded to verbal redirection,and no longer demonstrated aggressive acts. Despite these directives, patient monitoring documentation showed that the patient was kept in seclusion for approximately 2.5 hours. The patient was not evaluated for release criteria even though s/he was not exhibiting aggressive behaviors during most of the stay in seclusion. As a result, the facility had to submit a plan of correction to address its cited deficiencies and deficient practices related to restraint and seclusion.