Internal records show workers at a state mental hospital in Butner strapped a patient to a bed face-down for more than an hour this week, violating proper procedures and endangering the patient.
A spokesman for the state Department and Health and Human Services said Friday that an extensive investigation has been started.
The incident occurred early Wednesday morning at Central Regional Hospital after a 24-year-old man resisted having his blood drawn for tests and made verbal threats, according to a staff report.
At least five health care technicians, working under the supervision of a nurse, responded by carrying the patient to a restraint room, placing him face down on a bed with his arms and legs strapped to the sides.
It is not clear from the report why he was placed face-down, rather than on his back as the staff at state mental facilities is trained to do.
The practice can cause panic in the person being strapped down, whose vision would be limited. It can also make it harder for a patient to breathe and can exacerbate the risk of heart problems.
"It's a life-threatening position," said Barbara Gardner, a retired state mental health administrator who helped run Dorothea Dix Hospital in Raleigh. "It's the most dangerous position you could have a patient in because of the difficulty breathing when the patient is face-down.
"It's an absolute no-no. You never restrain anyone face-down."
According to an internal hospital record, the patient was left restrained face-down from 6:20 a.m. until 7:25 a.m., though handwritten notes indicate he was calm, cooperative and asking to be let up for much of that time. The staff is supposed to release a patient as soon as he is no longer acting aggressively.
The staff's notes also indicate the restrained patient asked for a bandage for a bleeding finger, though an electronic record entered into the hospital's computer system indicates there was no injury.
The revelation comes at a delicate time for Central Regional. The $138 million hospital opened partially in July after repeated delays due to design flaws and safety concerns. It has not yet been accredited.
A team of state inspectors working on behalf of the federal Centers for Medicare and Medicaid Services has been at the facility all week, reviewing the hospital's operations.
It is not clear whether administrators at Central Regional immediately informed the regulators of the improper restraint. DHHS spokesman Tom Lawrence said Friday the inspectors would meet with the hospital's leaders about the issue.
There are security cameras in the restraint rooms at the new hospital, so the incident should have been recorded.
Lawrence said he could not confirm whether a tape was made. But if one was, the recording will be used to help sort out what happened, he said.
"Once the investigation is complete, any disciplinary actions will be taken," Lawrence said via e-mail. "No further comment will be made until the investigation is complete."
At stake is the state's plan to close Dix Hospital in Raleigh and transfer the patients and staff to the new facility in Butner. That plan has been stymied by regulatory hurdles and a court challenge from the advocacy group Disability Rights North Carolina.
A Superior Court judge issued a temporary order in September that bars the state from moving Dix's patients. That order is still in place.
Central Regional opened amid the closure of John Umstead Hospital, less than a mile away. That older facility, the staff of which was transferred to the new hospital, was cited by federal regulators in December after three workers beat a mentally ill woman who was strapped to a bed.
Improper restraint also has contributed to several patient deaths in state mental hospitals in recent years.
Janella Williams, 35, suffocated at Cherry Hospital in Goldsboro in 2006 after more than a dozen staff members held her down on the floor. Failing to recognize that she was in distress, they then strapped her into restraints for nearly an hour before anyone noticed she was no longer breathing.
Two years earlier, Delores Ingram Franklin, 47, died while in restraints at Cherry after a nurse gave her too many injections of an antipsychotic drug intended to calm her.
Jimmy Clifton Davis, 52, died at Dix in 2003 after he was beaten by another patient and then placed in restraints for four hours despite acute rib fractures and other internal injuries. An autopsy found large amounts of fluid that had hemorrhaged into his chest cavity.
Broughton Hospital in Morganton lost its federal accreditation for much of the past year after Anthony Dawayne Lowery, 27, was tackled by staff members who saw him rummaging through a dining room garbage can. He suffocated while being restrained on his back, with staff members sitting on his limbs and chest.
Vicki Smith, the executive director at Disability Rights, said the group will likely conduct its own inquiry into this week's incident. She expressed dismay Friday that the staff at Central Regional would restrain a patient face down.
"Of all the restraint practices, it's the most risky, because patients are at immediate risk of positional asphyxiation," Smith said. "Restraint should never be a form of punishment. Restraint is only appropriate when the person is a danger to themselves. Restraining someone because they refuse to have blood taken? Highly inappropriate."
She said DHHS administrators tend to portray each mishap is an isolated incident -- including the release of a security video this week showing an ailing patient, Steven Sabock, 50, who died April 29 after the staff at Cherry Hospital left him sitting in a chair without food or water for more than 22 hours.
The mounting evidence of problems across the state hospital system is undeniable, Smith said.
"This is systematic," she said. "This is continuing to occur because ... [top state administrators are] allowing this to be OK."