Lincoln Medical and Mental Health Center
Statement of Deficiency – Event ID 5YOE11 – Inspection release August 27, 2015
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT
CONFIDENTIALITY**
Based on video observations, staff interviews, and review of documents, during the Federal
Allegation Survey, the facility failed to ensure the Hospital Police Officers utilizing physical
take-downs and manual restraints to patients were consistent with recognized and endorsed
techniques from New York State Office of Mental Health (NYSOMH) "Preventing and
Managing Crisis Situation" (PMCS) Training. (These findings were observed in two of three
closed circuit television (CCTV) surveillance DVD's. Patients #M, #N and #L)
This failure places all patients at risk for abuse by facility staff.
Findings:
Medical record review for Patient #M revealed an [AGE]-year-old female taken to the hospital
on [DATE] escorted by New York Police Department precipitated by homicidal ideation towards
her grandmother. The patient was admitted with mood disorder and past medical history of
Bipolar Disorder and Asthma on 05/13/15 into the Acute Inpatient Behavioral Health
(Psychiatric) Unit 10 A.
On 08/24/15 at 2:45 PM, closed circuit television (CCTV) surveillance DVD #1 recorded on
05/17/15 at approximately 12:30 PM was reviewed with staff #18.
Observations revealed the rear nurses station area of inpatient Psychiatric unit 10 A.
Observed at DVD video time stamped 05:30 five male hospital police officers (HPO) are seen
struggling with Patient #M. One HPO (Staff #38) is observed to pull the patients hair causing her
head and neck to hyper-extend backwards. One of the HPO's places an open palm hand into the
patients face causing the patient to move backwards up against a wall. One of the HPO's right
elbow makes contact with the left side of Patients #M ' s face. Three (possibly four) punches
with a closed fist to the left mandible are observed. The patient is briefly placed in a choke-hold.
Then three minutes into this struggle four HPO's are observed taking the patient down to the
ground. One HPO places a knee into the patient ' s left thigh area and pulls the left leg outwards.
The patient drops backwards to the ground and no one is holding the head or neck area during
the fall. The patient ' s head hits the ground.
The patient is positioned on the floor with one HPO kneeling and pinning down the patient's
upper torso. A second HPO is observed kneeling on the patients left shoulder. A third HPO is
standing upright with his booted left foot on the top of the patient ' s left socked foot. A fourth
HPO is observed standing upright with his booted right foot standing on the patient ' s anterior
right ankle. Four HPO's are observed returning the patient to an upright position while

 continuing with the manual hold. The patient is then pushed backwards by one HPO whose right
hand is placed on the upper tracheal to lower neck region of the patient ' s body and a second
HPO is seen placing his open palm hand on the patients head and face. Four HPO's are observed
manually holding the patient and coercing her to walk in a backwards direction towards her
room. These events are observed from video recording time stamp 05:30 to 09:28 minutes.
During interview on 08/24/15 Staff #18 stated, " The reason why Patient #M was so upset was
because she wanted to go to her room but was told no she couldn't because it was near where
this fight was taking place between two other patients. That ' s what set her off and got her so
combative. After the situation is managed by the HPO's then they take her to her room where the
nurses medicated her. The patient was fighting the Officers and spit at one of them. When they
took her to her room because she was still spitting at them the patient's head was covered with a
bed sheet."
Re-review on 08/24/15 of the CCTV surveillance (DVD #1), noted at DVD time 06:48 Patient
#N was in a manual restraint ("choke hold") by a hospital police lieutenant (HPL).
The hospital police lieutenant had placed his right arm fully around Patient #N's neck and the
HPL was observed coercing Patient #N to walk through the inpatient unit, while in the choke
hold Patient #N was simultaneously held in manual holds by two HPO. One HPO held Patient
#N left lower forearm and one HPO held Patient #N's right upper extremity near the deltoid
area and to walk from his bedroom towards the seclusion room.
On 08/24/15 at 3:15 PM, CCTV surveillance DVD #2 recorded on 08/10/15 at approximately
8:40 PM was reviewed with Staff #18. Observations revealed the Medical Emergency
Department "B" Area -DD 1.
Patient #L is observed standing in the MER. Noted at video time 00:01 one hospital police
officer (HPO) is standing in the area near Patient #L. One female patient is sat in a chair in the
area. At 00:45 three clinicians who were in the area leave and two additional HPO ' s arrive.
At 01:20 Patient #L is observed standing with a HPO at his side. At 02:00, Patient #L is seen
holding onto a " Vital Signs " mobile piece of medical equipment. At 02:34 three additional
HPO ' s arrive, totaling six HPO ' s. There are no clinical staff in view. The female patient is still
sitting in a chair.
At 02:54 Patient #L picks up a thermometer in his right hand that was protruding out of the top
of the mobile medical equipment. All six HPO ' s are standing around him facing him in a semicircle. At 03:00, Patient #L makes a fist holding onto the thermometer.
At 03:14, the female patient on her volition stands up and moves away from the area. No nurses
or clinicians are in view.
At 03:39, two additional HPO ' s arrive, totaling eight HPO ' s. All eight HPO ' s are observed
wearing handcuffs in their belts and carry ASP Batons. The eight HPO ' s continue to stand
around the patient in a semi-circle. At 04:03, the HPO ' s are still standing, two with their hands

 on their hips, and two others put on their black leather police issued gloves. At 04:48, a third
HPO is also wearing black police issued gloves and is adjusting the strap on the gloves. At
05:09, no clinical staff are in the area and the patient continues to hold the thermometer in his
hand.
At 05:12, one of the HPO ' s moves a piece of furniture out of the area.
At 05:19, two nurses arrive and stand back behind the HPO ' s. They do not appear to be
interacting verbally with the patient and their lips are not observed to be moving. One of the
nurses is holding a four point restraint in her hand.
At 05:29, Patient #L remains positioned in the same area (the patient never moved forwards at
anytime in the recorded video) while still holding the thermometer and gestures in a down wards
thrusting motion in the air.
From 05:29 to 06:04 this situation continues with eight HPO standing in a semi-circle facing the
patient and the clinical staff standing behind the HPO ' s. During this time a HP Sargent is
observed verbally interacting with the patient.
Noted at 07:32, an additional Police Officer arrives now totally nine Officers. At 08:29, a HP is
observed making strap adjustments to his police issued gloves.
Observations made at video time 08:32 a Hospital Police Officer (Staff # 40) is observed to draw
his tactical impact baton (weapon) and strikes in a down wards thrusting motion towards the
patient #L ' s right hand and arm area three times in succession.
At 08:36 seven HPO ' s move forwards in unity towards Patient #L. Noted at 08:39 nine HPO ' s
are observed huddled over Patient #L and physically restrain him. The two licensed nurses and
one patient care assistant are observed in the background while the HPO ' s place Patient #L onto
a waiting stretcher.
At 09:56, the nurses apply cloth restraints to the upper right wrist, the upper left wrist, the lower
right ankle and the lower left ankle. While they apply the restraints to the patient, eight HPO ' s
are observed holding the patient in a manual restraint on the stretcher.
At 11:48, a ninth HPO arrives and is carrying a white cloth like appearing item in her hands, she
hands it to one of the eight HPO ' s standing around the stretcher.
At 12:26, the white cloth like item is observed covering the patient ' s mouth and nose area.
At 12:35, the patient is wheeled away out of view.
The HHC Crime and Incident report (Form 587) dated 08/10/15 was reviewed and witness
statement by Staff #44 documented, " On Monday 8/10/15 in the evening, nine HPO ' s
responded to a call (made by another HPO) in the Adult B Area of the Emergency Department.
Upon arrival, Patient #L was standing in the doorway of the patient ' s bathroom holding a
thermometer which was attached to the vital signs cart. Patient #L was verbally threatening to

 use the thermometer as a weapon if anyone approached him. This writer attempted to gain
control of the situation with dialogue but to no avail. At this time HPO Staff #40 extended his
ASP Baton and began striking Patient #L two to three times on the arm/hand area attempting to
knock the thermometer out of his hand. Staff #40 was not instructed by any of his three
supervisors present to use the baton. Patient #L did not walk, approach or lunge towards any
Officers that would justify use of a baton. Patient #L was placed on a stretcher and then
medicated by staff RN and placed into a four point restraint. "
Review on 08/25/15 of the facility policy titled, "Patient Bill of Rights" dated 10/13 states, "
Patients in the facility have the right to receive care in a safe setting and be free from all forms of
abuse and harassment."