This story is part of a partnership between **__MedPage Today_** _and VICE News.

For every 1,000 hours that psychiatric patients spent at a rural North Carolina hospital from July 1 through December 31, 2013, more than 800 of those hours were spent in some kind of physical restraint.

That works out to being restrained, frequently with one's arms and legs bound, for more than 3 days out of 4. It's also more than six times the rate of the hospital with the next highest restraint rate, and more than 800 times the national average, which is less than an hour of restraint out of every 1,000, according to an analysis of the most recent figures from the Centers for Medicare and Medicaid Services (CMS).

Park Ridge Health in Hendersonville, North Carolina, is an outlier in an industry that two decades ago decided that the harm restraint causes to patients outweighs any potential benefits to their health or to hospital staff. Even so, mental health experts say that restraining patients is much more common than should be, and is often a sign of overworked and understaffed personnel at facilities.

According to rules set by CMS, hospital staff may restrain patients only when medically necessary and should use the least restrictive form of restraint possible. The most restrictive form involves simultaneously binding a person's arms and legs with leather straps called four-point restraints, but hospital staff can also employ soft Velcro straps, roll belts, or sedative drugs to subdue patients. The CMS database does not include restraint with sedatives, however, and is limited to psychiatric patients in general hospitals and freestanding psychiatric hospitals.

"One of the things you're taught early on is you don't restrain unless there is no other way," said Jean Ross, president of National Nurses United, the largest nursing union in the United States. Restraints may be used to prevent a patient from inflicting self-harm or harming others, she said, but they are meant to be applied for as little time as possible before being substituted with a less restrictive form of control.

The issue of patient restraint has changed a lot over the last 20 years, said Boston University health law professor George Annas_._

"I think it's just become recognized as just abusive, used for the convenience of staff, not for welfare of the patient," he said. "There are hardly any medical indications for restraining someone. What could there be? It's much more an act of a jailer than it is of a physician or a nurse or a nursing assistant."

Inspection reports obtained by VICE News/MedPage Today indicate that Park Ridge's restraint practices have repeatedly been called into question over the last 15 years. The reports, called CMS-2567s, are compiled by state officials, and serious deficiencies are submitted to CMS.

In 2010, for instance, a man in his late 30s who spoke very little English was found "roaming" around the Park Ridge Health emergency department, according to one of the inspection reports, "initially looking for his brother" and acting "increasingly hostile." After talking with police, he said that he had pain in his "left chest" and calmed down.

But the man refused behavioral medication, and the situation escalated. Four sheriffs, three nurses, and a physician restrained the patient with his face down on the floor. They then administered an intramuscular shot and handcuffed him. Once the man was allowed to stand, they applied four-point soft restraints but neglected to observe a time limit on those restraints, which hospital, state, and CMS policy stipulates should be no longer than four hours.

Nursing notes mentioned in the inspection report said that the patient had "cognitive impairment that interferes with medical care," noting that he could remove medical devices, tubes, and dressings if left unrestrained. He was "unable to follow safety instructions," the inspection report reads, quoting staff notes. "Less restrictive methods have been determined ineffective."

But investigators concluded that the hospital staff did not attempt to use "less restrictive methods" before allowing the sheriff's department to use handcuffs. The hospital's most restrictive option, called "Dr. Strong" — a code word for getting assistance from additional hospital staff trained in acceptable patient restraint — was not employed before the patient was handcuffed.

"If the police were not there, we would have handled it as best we could," an inspection report quotes a physician at the hospital as saying. "No, we do not have handcuffs. They are not appropriate."

Two years before that report, Park Ridge was inspected because a patient at the hospital died while he was restrained. Although all patient deaths associated with restraints or seclusion are required to be reported to CMS, a 2008 inspection report reveals that Park Ridge didn't report the death of a 75-year-old man with dementia, which occurred while he was being restrained via a lap belt. (He also had other ailments, including coronary artery disease. The report doesn't mention a cause of death, saying only that a nurse found him not breathing and without a pulse.)

The day before, a doctor had written a 24-hour order for restraints — the maximum length of time permitted — which a federal law on patient rights requires for such confinement, though a patient is not supposed to be restrained for more than four hours without a recurring order. Inspectors noted that Park Ridge did not maintain a log of deaths reported to CMS.

According to a separate report, another patient at the hospital in 2010 was restrained for 22 hours and 37 minutes before a physician wrote the required order. The report also chronicles other incidents in which patients at risk of falling were kept in restraints for up to 13 hours without being monitored. Hospital policy requires monitoring for such patients every two hours, according to the report. In the case of one patient who wasn't monitored as regularly as required, the intravenous tubing and bags had "change by" dates up to five days earlier than the date when inspectors toured the facility.

Over the course of the VICE News/MedPage Today investigation, both the North Carolina Nurses Association and Disability Rights North Carolina said they were unaware of Park Ridge Health's CMS restraint records, which have been public since 2014.

Kristine Sullivan, a lawyer for Disability Rights North Carolina, reviewed the 15 years of inspection reports obtained by VICE News/MedPage Today. She said that the hospital was cited again and again for overusing roll belt restraints to prevent falls from 2002 to 2013, culminating in citations for abuse, neglect, and the death of the 75-year-old dementia patient.

"As we have learned from our work in adult care homes and nursing homes, restraint use actually increases the likelihood of falls and can cause additional harm to patients who fall while in restraint," Sullivan said. "CMS has put a lot of information out about avoiding the use of restraints in response to falls."

Sullivan noted that it's important to remember that Park Ridge isn't the only hospital with patients that exhibit "undesirable behaviors." Across the state, a lack of sufficient community mental health services results in such patients turning to the emergency room, where they're sometimes met with medical workers who don't know better than to restrain them for convenience.

"That said, the sheer number of restraints that are used at Park Ridge suggest that this problem goes much deeper than a typical lack of knowledge or expertise," Sullivan remarked. "It suggests a systemic over-reliance on practices that are outdated and harmful; possible understaffing; and the need for a change in the hospital's treatment philosophy that must come from the top levels of management."

Although Park Ridge has the highest restraint rate in the country, according to the latest CMS data, there are dozens of hospitals throughout the country with rates that exceed 10 hours per 1,000 patient hours. These include Sentara Virginia Beach General Hospital in Virginia, Sparks Regional Medical Center in Arkansas and West Springs Hospital in Colorado, with 132, 99 and 95 hours per 1,000 patient hours, respectively. The national average is 0.66 hours for every 1,000 hours.

Here's a look at the hospitals with the highest psychiatric restraint rates:

And here's how they stack up against the rest of the hospitals in the database:

CMS's online hospital comparison tool does not include the restraint data. It is only available in a downloadable data set. The data includes the last six months of 2013. Restraint data for all of 2014 is due to be published next month.

When asked about its unusually high restraint rate in the federal data, Park Ridge's chief nursing officer, Craig Lindsey, said it was the result of a reporting error. But the hospital couldn't indicate what the correct number would be.

"In the Behavioral Health [unit], it is not uncommon to place patients in restraints at the start of their treatment and then remove the restraints as we stabilize the patient," Lindsey said through a hospital spokesperson. "The error resulted from a disconnect between the way that we were documenting the removal of restraints and where our [electronic medical record] 'looks' for the documentation of removal."

Lindsey also said the hospital had never been contacted by CMS regarding its restraint rate.

"We did not go back to recalculate the accurate number as we would have needed to dig through too many charts, and it was not worth the effort once we identified what the issue was," he said in response to a follow-up question.

When asked about the inspection reports, Lindsey said he couldn't comment because they happened before his tenure as chief nursing officer.

Park Ridge Health spokesperson Victoria Dunkle stressed that the most recent CMS restraint numbers are from 2013.

"The data in question are outdated and based on an EMR reporting error calculated in 2013," she said in an email. "It is simply inaccurate. Park Ridge Health is confident the steps we have taken to address the issue will remove the disparity between our apparent use of restraints and the rates at other facilities."

VICE News/MedPage Today also asked CMS about Park Ridge's restraint data, and why the high rate never prompted an investigation of some kind at Park Ridge.

Although we supplied the restraint data and inspection reports obtained via our public records request to a CMS official, who spoke on background and refused to be identified, the official did not comment on whether the rate was a cause for concern, whether CMS had ever reached out to Park Ridge regarding the rate, or whether the data could be inaccurate.

Instead, the official said that the restraint measurement is part of its Inpatient Psychiatric Facility Quality Reporting program, which is intended to encourage facilities to improve the quality of their inpatient care and disseminate information to the public so that they can be better informed when they choose their health care providers.

The official said the inspection reports "speak to the situation at Park Ridge," and that, in general, hospitals with violations must submit plans of correction for CMS approval, and may be subject to a follow-up inspection to be sure they're in compliance.

Restraint investigations haven't been the only source of trouble for the rural hospital.

Last fall, Park Ridge's parent company, Adventist Health, reached an agreement with the US Department of Justice to pay a settlement of $115 million stemming from charges it violated the False Claims Act by miscoding payments and having improper compensation agreements with physicians.

Several of the whistleblowers were at Park Ridge. One doctor made more than a $1 million in one year while only working three days a week, according to published reports.

Other citations against the hospital over the years included repeated violations of emergency treatment requirements, which state that a CMS participant hospital must treat its patients or stabilize them before discharging or transferring them to another hospital.

"The most recent one involved discharging a 14-year-old pregnant girl who was in premature labor and led to [Park Ridge] coming very close to having their Medicare participation terminated," Sullivan said.

On June 6, 2012, CMS sent Park Ridge a letter stating that the deficiencies uncovered as a result of this incident were "so serious" that Park Ridge's emergency patients faced an "immediate threat" to their health and safety. The letter went on to state that Park Ridge's Medicare provider agreement would terminate on June 29, 2012 if the hospital couldn't demonstrate compliance. The date was then backed up to July 6, 2012. CMS wrote on June 27, 2012 that it had received and accepted the hospital's plan to correct its deficiencies, stopping CMS from terminating the Medicare provider agreement.