'I cannot trust these hospitals'

Craig Fisher struggled to breathe as COVID-19 weakened his lungs last month, but he refused to seek hospital care despite knowing the decision could cost his life. After being improperly restrained at a hospital for nearly 34 hours earlier this year, Fisher's fear of getting strapped to a hospital bed outweighed the coronavirus' threat, he said. Fisher, 35, instead took COVID-19 antiviral pills and fought the respiratory disease at his Rochester-area home. Following a grueling recovery, his concerns deepened that the restraint-incident trauma could keep him from pursuing emergency care in the future. "I cannot trust these hospitals here," he said, "and that is scary."

Fisher responded to a community feedback request in the USA TODAY Network's investigation in April, which revealed thousands of patients are restrained in New York hospitals with limited oversight.

Some details of Fisher's restraint experience at Unity Hospital underscored some of the investigation findings, such as his claims that his medical records lacked evidence of restraint use.

Workers also failed to conduct all required restraint check-ups on Fisher, he claims, which is a violation of safety standards present in many of the 50 cases of improper patient restraint in New York between 2015 and 2018, as uncovered by USA TODAY Network.

Officials at Rochester Regional Health, the parent company of Unity Hospital, declined to be interviewed for this article and declined comment on the incident, citing patient privacy laws.

The hospital previously asserted Fisher received appropriate care in connection to the restraint incident, according to a health insurance document that Fisher provided.

Still, Fisher's wrist and arm went numb from an overly tight wrist restraint during the incident, potentially reaggravating a prior injury, according to Fisher and medical documents he provided.

"I truly hope that no patient would ever have to experience what I did," he said.

"To be so completely trapped like a prisoner," he added, "and to suffer physically, emotionally, and mentally as a result."

A New York hospital restraint story

Fisher's restraint story began in late December after he had a tooth extracted by a dentist. The wound had become infected, his throat was swelling and he was rushed by ambulance to Unity Hospital.

Much of the next two weeks passed in a blur for Fisher, then 35-years-old, as doctors performed an emergency tracheostomy and two surgeries on him to address the infection.

Throughout that period, Fisher was heavily sedated, placed on a ventilator and restrained to the hospital bed, which is common to prevent patients from unintentionally removing the breathing tube.

When Fisher awoke from the drug-induced coma on Jan. 10, his restraints were removed to start the recovery process. At one point during the recovery, Fisher said he accidentally removed his feeding tube, prompting nurses to reapply the wrist restraints.

Unable to speak due to the trach tube, Fisher spent the next 34 hours desperately trying to let hospital workers know through head nods and pained facial expressions that one wrist restraint was too tight, he recounted recently.

"They basically tied me to the rack, and I was a prisoner in my own body," he added.

Fisher asserted hospital workers conducted intermittent check-ups that fell short of typical restraint-use monitoring standards, generally one check-up every 15 to 30 minutes. He noted the workers also failed to temporarily release his restraints every two hours as required.

After reading the USA TODAY Network investigation — which explained that many details of restraint use at hospitals remain shrouded in secrecy due to poor government oversight and limited public-reporting requirements — Fisher said he wanted to tell his story to drive transparency and accountability.

"Thinking back on it...it's just crazy, and I can't believe that they did that to me," he said.

Health system claims proper restraint use

Rochester Regional Health asserted workers at Unity Hospital followed health and safety standards for restraint use in connection to Fisher's case, according to a copy of an insurance document provided by Fisher.

The document stemmed from a complaint Fisher filed with his health insurance provider, claiming the restraint use injured his wrist and arm, requiring orthopedic treatments.

In the document, Rochester Regional acknowledged the restraint use that occurred while Fisher was sedated, noting workers released his restraints every two hours and assessed the skin. It added that no injuries were reported in his medical records, which included a history of aggression.

But the health network's response in the document did not address Fisher's claims that wrist restraints were reapplied after he woke from sedation, and that this incident is missing from his medical records.

In other words, the ongoing insurance complaint process boiled down to pitting Fisher's word against the medical records. Despite the struggle, Fisher said he also plans to pursue a complaint with the state Department of Health.

Fisher's case, in some ways, highlights the general lack of required restraint reporting in hospital settings. Hospitals need only publicly report restraint use in cases connected to deaths or cases in psychiatric units.

Further, independent review of restraint incidents consists primarily of state Health Department inspections, which focus on specific complaints and safety violations rather than systemic issues. Many patients are also unfamiliar with — or unaware of — the Health Department complaint process, experts said.

As a result, thousands of restraint incidents in hospital emergency rooms and other wards receive limited independent oversight.

"Restraints, especially restraints with a device or mechanical restraints, are really something we would like to avoid almost at all costs in terms of not harming patients and not traumatizing patients," said Vincent Staggs, a University of Missouri-Kansas City medical school professor.

"But if you don't know what too much restraint use looks like, you can have hospitals using it far more often than is acceptable, or necessary," added Staggs, who studies gaps in restraint-use reporting nationally.

David Robinson is the state health care reporter for the USA TODAY Network New York. He can be reached at [email protected] and followed on Twitter: @DrobinsonLoHud