The cumulative effect of these systemic failures resulted in the facility’s inability to ensure the provision of safe use of restraints and seclusion.In order to correct these deficiencies, the facility had to revise its policies and provide training on them to all staff.
The Centers for Medicare and Medicaid (CMS) found that Old Vineyard Behavioral Health failed to ensure the safety of residents requiring emergency safety interventions. Among other failures, CMS found that facility policies were not consistent with regulatory requirements, medical treatment was not immediately obtained for a resident injured in an emergency safety intervention, residents were not properly assessed after interventions, physicians responsible for ordering restraints were not trained in their use, and the facility failed to prevent the use of standing and as needed orders for restraints. In one instance, a 16-year-old resident had to wait overnight with a groin injury from an emergency safety intervention before being taken to an emergency room for treatment. He was not seen by a physician at the facility until four days after his injury. CMS wrote: