Geisinger Holy Spirit Hospital in Cumberland County has been cited by the Pennsylvania Department of Health as a result of a patient who died after being placed in restraints on Sept. 26.

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among other things, that hospital staff failed "to protect the patient's safety during restraint application."

According to the health department's report, the unnamed patient had become agitated and belligerent and tried to push past staff and leave the hospital.

Two security guards held the patient down on a bed as a doctor and nurse applied restraints. Eventually, the patient went limp, with his face turning blue, and the patient appearing to foam at the mouth, according to the health department report. Staff declared a code blue, generally used to designate a patient in cardiac arrest. The patient died of what the hospital determined to be "diffuse anoxic brain injury."

The department said the violations included failing to obtain the required order from a doctor for some of the restraints that were used.

In addition to the restraint-related violations, the department faulted Holy Spirit for not reporting the incident, considered a "serious event," to the Pennsylvania Patient Safety Authority, and not notifying the patient's family of the serious event as required.

Holy Spirit's first plan of correction was rejected by the state but a second one was approved, according to the health department's report.

The plan of correction includes educating staff about use of restraints and creation of a "code grey team."

A statement to PennLive from Geisginger Holy Spirit said in part, "Geisinger Holy Spirit shares the DOH's commitment to providing a safe environment for our patients, visitors and employees. While we would prefer not to restrain patients, at times such measures are indicated for the safety of all involved."

"We are saddened whenever a patient passes away, and are confident that the care our team provided was consistent with Geisinger Holy Spirit's mission of delivering professional and compassionate care to all."

Holy Spirit is among the region's hospitals that have a locked mental heath unit and specialize in mental health crisis situations.