As Behavioral Management Issues in Hospitals Increases, Non-Compliance to TJC PC.01.03.03 Likely to Increase
- EvaluCare
- Jun 3
- 6 min read
Updated: 2 days ago
As the US population ages, hospitals are encountering a growing number of older adults presenting with cognitive impairments such as dementia and Alzheimer’s disease. These conditions can lead to a range of behavioral challenges, from agitation and wandering to aggression and paranoia, that make medical and surgical units particularly vulnerable to safety and care planning failures. Behavioral management is no longer an isolated concern for psychiatric units; it is now a central issue for general hospitals across the country. Even for hospitals with good plans in place will be challenged with the scope of the problem and protocols being carried out in areas with less experience staff.
This evolving landscape places increasing importance on compliance with The Joint Commission Standard PC.01.03.03 – “The Hospital Defines Its Behavioral Management Policies.” This standard requires hospitals to not only define but implement and evaluate behavioral management strategies in a way that protects patient rights, ensures safety, and complies with legal and ethical mandates.
In this blog, we’ll examine this critical standard and its Elements of Performance (EPs), explore real-world malpractice cases where failures in behavioral management led to patient harm, and highlight how EvaluCare serves as a resource for medical care review.
Understanding Standard PC.01.03.03
This standard sets the expectation that hospitals must develop, document, and follow clear policies to manage patient behavior safely and respectfully. Importantly, these policies must align with legal and ethical standards, particularly regarding patients who are unable to advocate for themselves, like those with dementia or Alzheimer’s.
Element of Performance 1
The hospital defines the types of interventions used to manage patient behavior.
Example:
A hospital must clearly delineate which interventions are permissible, such as verbal de-escalation, medication, or, as a last resort, physical restraints. Policies should define when these interventions are appropriate and outline a hierarchy of responses.
Case Study:
In a widely publicized case in Florida (2019), a 78-year-old patient with dementia was restrained without physician order or assessment after becoming agitated during an IV insertion. The restraints led to bruising, immobility, and a rapid decline in condition. The court found that the hospital’s behavioral policies were vague and inconsistently applied, a breach of duty that contributed to medical malpractice.
Element of Performance 2
The hospital uses interventions only as permitted by law and regulation.
Example:
Interventions such as chemical sedation or physical restraint must meet strict legal standards. These typically require physician oversight, documentation of necessity, and frequent reassessment.
Case Study:
In Massachusetts (2021), a hospital was sued after administering sedatives to a non-consenting patient with Alzheimer’s who was resisting a routine catheterization. The patient fell into a coma and later died. The hospital lacked a protocol for behavioral intervention in patients lacking decision-making capacity, and the use of medication without legal authority was central to the lawsuit.
Element of Performance 3
The hospital trains staff in the use of behavioral management techniques.
Example:
Behavioral health training must be given to nurses, aides, and clinicians, especially those on units where cognitive impairment is common (e.g., geriatrics, medical-surgical). Training includes verbal de-escalation, non-coercive communication, and how to recognize early signs of agitation.
Case Study:
In Illinois, a nurse was assaulted by a dementia patient after she attempted to reposition him without explaining what she was doing. The patient, fearing he was under attack, reacted violently. The hospital had not trained staff in dementia communication techniques, and the incident led to injuries and a workers' compensation lawsuit, as well as a malpractice claim by the patient’s family, who argued that behavioral mismanagement contributed to the escalation.
Element of Performance 4
The hospital evaluates and documents behavioral interventions.
Example:
Hospitals must document when behavioral interventions are used, the rationale, the patient’s response, and the follow-up plan. Failure to document is both a clinical and legal risk.
Case Study:
In a Texas case (2022), a 65-year-old patient with frontotemporal dementia was chemically sedated several times during a three-day hospital stay. None of the interventions were documented in the electronic health record. When the patient aspirated and died, the family sued. Discovery revealed no behavioral policy documentation, no physician orders, and no rationale for sedation. The jury awarded $3.4 million.
Element of Performance 5
The hospital uses the least restrictive intervention necessary to ensure safety.
Example:
Hospitals must show that all less restrictive methods (e.g., distraction, redirection) were attempted before resorting to medications or restraints.
Case Study:
An elderly man hospitalized for pneumonia in Ohio developed confusion and agitation, likely due to delirium. Instead of investigating reversible causes or using non-pharmacologic techniques, the staff restrained him to the bed, leading to pressure sores and sepsis. The court ruled that noncompliance with PC.01.03.03 EP5 was a breach of standard care, awarding the family damages for neglect.
Why This Standard Matters More Than Ever
Behavioral health management is not optional. As the aging population grows, general hospitals, not just psychiatric units, are on the front lines of managing behavior in patients with dementia, delirium, schizophrenia, and other complex conditions. A failure to plan for this behavioral complexity often results in:
Physical injury to patients or staff
Prolonged hospitalizations
Increased risk of malpractice
Emotional trauma for families
Regulatory violations and fines
Recognizing the signs of poor behavioral management is crucial. Warning signs include:
Repeated use of restraints or sedation
Lack of staff communication
Agitation or aggression that escalates over time
Inconsistent documentation
Staff complaints about “difficult patients”
Family reports of unexplained bruising or injuries
Conclusion
As hospitals grapple with an increasing number of older patients living with behavioral and cognitive challenges, the importance of clearly defined behavioral management policies has never been greater. The Joint Commission Standard PC.01.03.03 provides the blueprint for safe, ethical, and effective management, but it is only effective if implemented correctly.
When these standards are ignored, real patients suffer, and so do their families.
Through organizations like EvaluCare, harm can be prevented in partnership with hospitals to provide thorough medical care reviews of inpatient care. Doing so identifies compliance to standards of care to enhance an organization's quality assurance.
There’s a path forward: train staff, define clear policies, prioritize non-restrictive care, and document every step and review constantly to prevent drift. Because behavioral health isn’t just a psychiatric issue anymore, it’s everyone’s responsibility.
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Eva, EvaluCare’s AI-powered SaaS, delivers quality review for inpatient care by checking adherence to thousands of evidence-based guidelines and protocols. It identifies care gaps, routes clear actions to the right clinicians, and accelerates improvement cycles, strengthening documentation and coding while reducing HACs, HAIs readmissions, length of stay and more. The result is an ROI, starting in the seven figures even for critical access hospitals. Learn more at evalucare.net or contact info@evalucare.net.
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About the Author
Jason Minor is a healthcare quality and transformation leader with nearly 30 years of continuous improvement experience. A Certified Lean Six Sigma Black Belt, Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, and Certified Utilization Review Professional, he has led thousands of end‑to‑end improvement projects, mentored dozens of quality professionals, and pioneered healthcare SaaS innovations.
As Board Chair of the Vermont Program for Quality in Health Care, Jason has partnered with hospitals, non‑profits, and state agencies to elevate patient safety and care quality statewide. Previously, as Network Vice President of Quality at the UVM Health Network and through the Jeffords Institute for Quality, he guided the redesign of a system‑wide quality framework and led initiatives that achieved a number‑one patient safety ranking among the nation’s top academic medical centers.
In 2020, Jason founded EvaluCare to help organizations shift from episodic improvement to a robust quality assurance approach.
EvaluCare’s Eva platform leverages AI‑powered natural language processing, machine learning, and agentic orchestration to analyze and improve inpatient care and support comprehensive quality, mortality, peer, and utilization reviews.
Jason Minor, EvaluCare Executive Director
Network Director Continuous Systems Improvement Jeffords Institute for Quality UVM Health
Board Chair Vermont Program for Quality in Health Care Inc.,
Vice Chair Northwestern Counseling & Support Services, Inc
Lecturer UVM College of Nursing & Health Sciences in Healthcare Quality
Quality Peer Reviewer Vermont Care Partners: Centers of Excellence
Resources and Additional Reading
The Joint Commission Standards – https://www.jointcommission.org
National Institute on Aging – Alzheimer’s & Dementia – https://www.nia.nih.gov/health/alzheimers
Centers for Medicare & Medicaid Services Restraint Guidelines – CMS.gov
EvaluCare Behavioral Care Reviews – www.evalucare.com
