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The Condition of Governing Body was not met as evidenced by the hospital failure to have an effective Govening Body to ensure that hospital functions were carried out in a safe and effective manner when there was an allegation of patient abuse. As a result, noncompliance with multiple Conditions of Participation are identified in this survey.

Additionally, three Immediate Jeopardy (IJ) findings and Condition Level noncompliance deficiencies were identified in previous surveys as part of this enforcement.


The Condition of Governing Body was not met as evidenced by:

1. Staff failed to report to administration that suspected or actual abuse had occurred;

2. Staff failed to immediately implement their abuse policy to protect the patient when a staff member was accused of physical abuse;

3. Failed to report, analyze, and implement the appropriate corrective action, remedial or disciplinary action timely due to the hospital's administrative protocols;

4. Failed to ensure that a patient was not treated in a rough manner when staff held a spit shield down on a patient who was agitated and in 4-point restraints;

5. The hospital staff failed to immediately intervene when a patient was in 4-point restraints and his/her head was hyperextended and in a potentially unsafe position and/or failed to ensure that the restraint bed was free of hazard;

6. The hospital failed to ensure that the restraint was applied in accordance with hospital policies and/or protocols and/or that staff received training in safe application of mechanical restraints.

7. Contracted staff failed to identify a possible act of physical abuse while observing video monitors during a restraint episode;

8. The hospital failed to conduct a comprehensive investigation after a patient accused a staff member of physical abuse;

9. Staff violated their work rules and/or neglected their duties when they failed to maintain continuous observation;

10. The hospital failed to ensure that staff was attentive and the patient remained in the line of sight when conducting continuous observations and/or that the patient was free of seclusion;

11. The hospital failed to follow their own policies regarding abuse, neglect, and exploitation regarding completing reporting documents and/or notification to the PSRB;

12. The hospital staff failed to ensure that medical record documentation was complete to reflect staff who conducted continuous observations; and



Please reference A057, A084, A115, A144, A145, A154, A167, A263, A385, and A395.

Although a Chief Executive Officer (CEO) was appointed for managing the hospital, the failures to mitigiate any further risk to patients continued to occur after an allegation of abuse.


Please reference A115, A144, A145, A 263 and A385.

Based on observation of video, review of facility documentation, and interviews for two of two contracted security staff (SO #1 and SO #2), the staff failed to identify a potential incident of physical abuse during video observation during a restraint episode on Patient #401. The finding includes:

Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/8/17 directed fifteen minute checks and Continuous Observation with one extra staff, at least one male, for aggressive and unpredictable behavior.

The Nurse's note dated 12/8/17 for the 3-11pm shift identified that the patient walked into his/her room slamming the door so sitters could not view him/her, would not follow directions to open the door, then came out of his/her room swinging as if to punch a female sitter in the face. A protective hold and staff takedown occurred and the patient was placed in 4 point restraints at 5:10pm.

On 12/22/17 and 1/8/18, the video recording of the 12/8/17 restraint episode was reviewed with the Director of Human Resources, the CEO, Police, and DN2 #2, The video recording identified that two staff, RN #343 and FTS #366 walked with the patient towards his/her room, and RN #343 was talking with the patient who was in his/her room. As the patient attempted to come out of room, he/she was blocked by FTS #366. The video showed multiple staff walking down the hallway towards Patient # 401's room. There was a total of eight staff outside the patient's room. As the patient came out of his/her room and raised his/her arm at FTS #367, the patient's raised arm was blocked by FTS #367 and another staff. The patient was placed in a physical hold and was taken down and held down on the floor by multiple staff. There were eight staff around and/or holding the patient down on to the floor. Three agency police officers came down the hall towards the patient as he/she was held down on the floor. As the video continued, FTS #367 was seen hovering over the patient (view of his/her backside) and FTS #367's right arm moved up and down in a repetitive motion X 2 towards the patient's head area and then FTS #367 threw something into the patient ' s room. A restraint bed was wheeled down the hall and the patient was assisted to the bed while resisting and was restrained with 4-point restraints.

Review of Security Officer (SO) Documentation for 12/8/17 from 4:00 PM through 12:00 AM included that SO #1 was on duty and all equipment was operational. Per SO #1 documentation, there was nothing else to report. SO #1 documented that he/she was off duty at 12:00 AM. The contracted security staff failed to identify the repetitive arm motion of FTS #367 during video monitoring as an incident of potential abuse.

Interviews with SO #1 and SO #2 on 01/11/18 at 4:00 PM identified that there were two banks of monitors that the SO's watched during their shift. SO #1 was responsible for monitoring the bank of monitors that visualized the Whiting Forensic maximum security units from 4:00 PM through 12:00 AM on 12/8/17. SO #1 identified that at approximately 5:01 PM, he/she saw a group of staff congregating on unit six. Although there was no audio component, SO #1 could see that staff was talking to each other. SO #1 further identified that he/she visualized a male patient lunge at a female staff member and the staff began to take the patient down to the floor. Five male staff then pinned the patient to the floor. SO #1 identified that he/she had not observed any activity that required reporting to the agency Police and he/she did not see anything that appeared like staff abusing a patient. SO #1 further identified that he/she had reviewed the video documentation as part of the hospital's internal investigation and was able to visualize FTS #367 raise his/her elbow and, rapidly, bring it forward in a jesture consistent with a punch or hit directed towards Patient #401's head area. SO #1 identified that he/she had missed the patient's elbow moving and did not see it during the time of the occurrence but had thought that FTS #367 was trying to find a way to remove the patient's glasses. SO #1 identified that subsequent to the occurrence, all observed incidents of patient take downs and/or physical interactions between patients and staff required notification of agency Police as well as documentation in the Log Book.

Interview with the Police Chief on 1/8/18 identified that the contracted Security Officers receive training by reviewing the Post Orders with the agency Police Officers but there was no documentation to reflect specific training on the definition of abuse/neglect or documentation to reflect the training although interviews with SO's #1 and #2 on 1/1l/18 were able to describe examples of abuse, mistreatment and neglect.

Review of the Post Orders for the Video Monitoring Center identified that the monitoring center is monitored 24/7 by on security officer to each work station. All personnel involved in the use and monitoring of security cameras will receive training on how to utilize the video monitoring system by the agency police. Safety and security purposes for video monitoring include, but are not limited to the protection of persons, property and buildings, confirmation of alarms, video patrol of patient/public areas, and investigation of criminal activity. Security Officers monitoring video should focus on identifying disruptive activity, assaultive/abusive behavior, criminal/suspicious activity, and medical/psychiatric emergencies. Security Officers on duty will complete log entries documenting incidents related to safety / security concerns within the building they are monitoring or technical issues occurring in the Video Monitoring Center (VMC). Any activity identified in the VMC as a security or safety concern will be reported to the agency police immediately. The SO will complete log entries documenting incidents related to safety/security concerns within the building they are monitoring and/or technical issues and should include date, time and a brief description of the event and whether or not the agency police were notified.

Review of the contract for security services identified that security personnel' s responsibility is to perform all duties as specified by the Client Agency.


27691

The Condition of Patient Rights was not met as evidenced by:

The Hospital failed to protect and promote each patient's rights and/or failed to ensure that patients received care in a safe setting as evidenced by:

1. Staff failed to report to administration that suspected or actual abuse had occurred;

2. Staff failed to immediately implement their abuse policy to protect the patient when a staff member was accused of physical abuse;

3. The hospital failed to ensure that an allegation of abuse was reported and analyzed, and the appropriate corrective action, remedial or disciplinary action occurred timely due to the hospital's administrative protocols;

4. Staff failed to ensure that a patient was not treated in a rough manner when staff held a spit shield down on a patient who was agitated and in 4-point restraints;

5. The hospital staff failed to immediately intervene when a patient was in 4-point restraints and his/her head was hyperextended and in a potentially unsafe position;

6. Contracted staff failed to identify a possible act of physical abuse during a restraint episode;

7. The hospital failed to conduct a comprehensive investigation after a patient accused a staff member of physical abuse;

8. Staff violated their work rules and/or neglected their duties when they failed to maintain continuous observation;

9. The hospital failed to ensure that staff was attentive and the patient remained in the line of sight when conducting continuous observations and/or that the patient was free of seclusion;

10. The hospital failed to follow their own policies regarding abuse, neglect, and exploitation;

11. The hospital staff failed to ensure that medical record documentation was complete to reflect staff who conducted continuous observations; and



Please reference A084, A144, A145, A154, A167, A385, and A395.

27691




1. Based on observation of video, review of the medical record, review of hospital documentation, interviews and review of policies for two patients (Patient #'s 81 and #401), the hospital failed to ensure that care was provided in a safe setting when the restraint room and/or bedroom door was kept closed during continuous observation (CO) and/or when staff assigned to CO were inattentive. The findings include:


Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/08/17 directed Continuous Observation (CO) with one extra staff (at least one male) related to aggressiveness and unpredictability.

Review of Seclusion/Restraint documentation dated 12/08/17, RN #343 identified that Patient #401 exhibited specific behaviors that included swearing and threatening to assault staff in very explicit ways. He/she refused redirection to keep his/her bedroom door open, threw his/her glasses on the floor, and ran out of the bedroom, striking at a female staff member. According to RN #343, Patient #401 refused personal safety preference based interventions and presented an imminent risk of serious physical assault and serious self-destructive behavior. A physical restraint (take down) was initiated at 5:05 PM and discontinued at 5:10 PM when the patient was placed in four point restraints until 7:05 PM.

Review of continuous video documentation in the unit six hallway and restraint room on 1/8/18 with the CEO and DN2 #2 identified that once the patient was transferred to the restraint bed in the hallway and brought to the restraint room from approximately 5:17 PM through discontinuation of the restraint at 7:05 PM, the door to Patient #401's room remained closed except when staff were providing care or assessing the patient. Various staff members provided CO while sitting outside the restraint room door which had an elongated window. During the time period of approximately 5:23 PM and 5:41 PM, FTS #367 was observed sitting on a rolling chair in front of the restraint room door talking with other staff and security guards, but failed to maintain visual contact with Patient #401 in accordance with hospital policy.

Patient #81, who resided in a room two doors down from the restraint room also required CO, and the staff member assigned to Patient #81 was also observed conversing with FTS #367 and looking away from the patient's doorway while assigned to perform CO. Although hospital staff had been trained in the requirements of CO, they continued to engage in conversations with the staff member assigned to CO creating a safety hazard for the patients.

Hospital policy for Restraint Use for the Management of Violent or Self Destructive Behavior identified that the patient who is restrained is monitored on continuous observation by competently trained nursing staff and, further the CO policy identified that the nursing staff assigned provided ongoing monitoring to ensure his/her safety and the safety of others. The nursing staff assigned provides that by having a clear view and unimpeded access to the patient at all times.



2. Based on observation, review of clinical records, hospital video documentation, and staff interviews, for one patient who exhibited agitation with spitting, Patient #401, the hospital failed to ensure that personal protective equipment (face shield) was properly applied in accordance with hospital training materials. The findings include:

Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A monthly Treatment Plan Review (TPR) dated 12/12/2017 by MD #6 identified a psychiatric history that included spitting at staff and additionally, Patient #401 had experienced a difficult month, exhibiting unpredictable, aggressive behaviors and refusal of a monthly injection of an antipsychotic medication.

A physical restraint (take down) was initiated at 5:05 PM and discontinued at 5:10 PM when the patient was placed in four point restraints that were discontinued at 7:05 PM.

Review of continuous video documentation in the unit six hallway and the restraint room on 1/8/18 with the CEO and DN2 #2 identified that during the restraint episode on 12/08/17 at approximately 5:10 PM when the staff was applying the four point restraints, Patient #301 began spitting, and the nursing supervisor. RN #342 was observed kneeling on the head of the restraint bed attempting to a apply a clear plastic face shield to the patient's face. The patient appeared to resist, moving his/her head back and forth. At 5:11 PM, an agency Police Officer (PO) attempted to apply the shield, pressing the shield down over the patient's cheek bones. At 5:14 PM the PO continued to press on the patient's face as the staff attempted to position the patient on the restraint bed and apply the four point restraints.

A post restraint physical assessment performed by MD #1 identified no injuries. A psychiatric assessment performed by MD #6 on 12/09/17 at 10:20 AM identified that the patient alleged that he/she was hit in the face during the restraint and was noted to have mild reddening/swelling anterior and inferior to the right ear, additionally the patient had mild/diffuse bruising on the posterior head and an approximate 1.5 inch bruise on the left bicep. The patient was reportedly banging his/her head while in restraints.

Interview with MD #1 on 1/2/18 at 10:25am identified that the mattress on the restraint bed was not secure and slipped down in the bed. MD #1 further identified that he/she assessed the patient after the patient calmed down and the patient complained of face hurting. The patient had pain under both eyes upon palpation, no bruising, but had bruises under head, from head banging.

Interview with MD # 6, who examined the patient the next day on 12/9/17 identified that the patient had a bruised arm, bicep, from a restraint, and a bruise on the back of head from head banging while in restraints. There was fullness and redness to the right cheek area. The patient continued to allege that he/she was hit.

According to the Incident Report, the patient was assessed by MD #1 on 12/8/17 at 5:20pm with no injuries on the initial exam. The patient complained of pain under bilateral eyes, no redness or bruising was noted. A 2x2 cm bruise was noted on crown of head due to self-injurious behavior of head banging. Interview with MD #1 on 1/2/18 at 10:25am identified that while the patient was in the restraint room and looking at FTS #367 said he/she said he was hit. The patient further stated "you punched me in the head three times and when I get out of here ...." and other threatening words.

Review of staff training materials for droplet or modified droplet precautions identified that the hospital utilized masks with face shields. A CDC poster was utilized as a visual aid for training staff in preparation for infectious outbreaks and directed to place the face shield over the face and eyes and adjust to fit. A pictorial representation identified a headband-like device with a plastic shield attached that extended above and below the headband. The headband is slid over the face, above the eyebrows, and over the ears, positioning the plastic shield over the whole face, protecting eyes, nose and mouth from droplets and attaching to the head, behind the ears via pressure.

Observation of the staff attempting to place the shield on Patient #401 while he/she was supine, lying on the restraint bed, identified that the shield was positioned with the head band area below the eyes and was not consistent with the pictorial instructions. Staff failed to properly apply the spit shield in accordance with the hospital's training materials.

The hospital policy for Restraint Use for the Management of Violent or Self Destructive Behavior identified that Due to the risk of asphyxiation, the use of any item such as a towel, washcloth, or pillowcase over the face or mouth of a patient who may bite or spit is not permitted. Face shields for staff and patients (when indicated) are available on each unit. The use of personal protective gear is recommended in these instances. The policy lacked instruction as to when a face shield was indicated for patient use.


3. Based on observation, review of clinical records, hospital video documentation, and staff interviews, for one patient who exhibited self-injurious behaviors while in four point mechanical restraints, Patient #401, the hospital failed to ensure that the restraint bed was free from hazard. The findings include:

Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/08/17 directed CO with one extra staff (at least one male) related to aggressiveness and unpredictability.

Review of Seclusion/Restraint documentation dated 12/08/17 by RN #343 identified that Patient #401 exhibited specific behaviors that included swearing and threatening to assault staff. He/she refused redirection to keep his/her bedroom door open, threw his/her glasses on the floor, and ran out of the bedroom, swinging at a female staff member. According to RN #343, Patient #401 refused personal safety preference based interventions and presented an imminent risk of serious physical assault and serious self-destructive behavior. A physical restraint (take down) was initiated at 5:05 PM and discontinued at 5:10 PM when the patient was placed in four point restraints until discontinuation at 7:05 PM.

Review of continuous video documentation of the unit six hallway and restraint room on 1/8/18 with the CEO and DN2 #2 identified that the patient was transferred to the restraint bed in the hallway at approximately 5:08 PM and was observed to be fighting and resisting as the staff attempted to place the four point restraints and the face shield. At 5:12 PM, FTS #58 was observed preparing the restraint room as Sergeant #2 pulled the restraint bed with the patient into the restraint room. At 5:14 PM the patient was observed to have the four point restraints in place, however, the mattress appeared to be sliding out from under Patient #401's head and extending greater than twelve inches below the patient's feet and off the foot of the bed. The restraints were positioned in such manner that the patient was able to sit up. RN #27 and RN #343 entered the room and administered medications, intramuscularly (IM) into Patient #401's right shoulder. Although the patient was in 4-point restraints, at 5:18 PM the patient was able to sit fully upright on the bed and began to rock side to side attempting to knock over the restraint bed. He/she then threw him/herself backwards, forcefully, coming in contact with the exposed, hard plastic surface of the restraint bed. The mattress did not effectively cover the bed as it had begun to slide off the foot of the bed.

Although the patient was on CO, no interventions to prevent injury from the head banging occurred until 5:21 PM when three staff approached the patient and placed what appeared to be a foam wedge at the end of the bed, covering the exposed, hard plastic deck of the restraint bed. The patient continued to bang his/her head on the exposed area and by 5:46 PM the foam wedge was no longer providing any protection and the patient's head/neck appeared hyperextended. No staff were observed entering the restraint room from 5:21PM to 6:09 PM until two PO's entered the room and appeared to be speaking to the patient and taking pictures of the patient's head area. The mattress continued to be ill fitting and the patient's head appeared hyperextended. At 6:30 PM, RN #27 and FTS #370 entered the room and repositioned the mattress so that the bed decking was covered and the patient's head appeared to be supported and in a neutral position.

During review of video documentation, DN2 #2 identified that it looked like the mattress was sliding off the bed. A psychiatric assessment performed by MD #6 on 12/09/17 at 10:20 AM identified that the patient alleged that he/she was hit in the face during the restraint and was noted to have mild reddening/swelling anterior and inferior to the right ear, additionally the patient had mild/diffuse bruising on the posterior head and an approximate 1.5 inch bruise on the left bicep. According to MD # 6's documentation, the patient was reportedly banging his/her head while in restraints.

Review of product information for the restraint bed identified that the bed has a curved top for added comfort and a slightly textured surface. Fire resistant mattress and restraint systems sold separately.

Interview with the Safety Education Instructor on 1/12/18 at 1:00 PM identified that proper application of four point restraints on a restraint bed included tightening the straps that secure the restraint to the bed sufficiently to ensure the mattress does not slip off the bed.


4. Based on observation of a video, review of the medical record, review of hospital documentation, and interviews for one patient who alleged physical abuse by a staff member (Patient #401), the hospital failed to ensure care was provided in a safe setting following an allegation of abuse. The findings include:

a. Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/8/17 directed fifteen minute checks and Continuous Observation with one extra staff, at least one male, for aggressive and unpredictable behavior. The Nurses noted dated 12/8/17 for the 3-11pm shift identified that the patient walked into his/her room slamming the door so sitters could not view him/her, would not follow directions to open the door, then came out of his/her room swinging as if to punch a female sitter in the face. A protective hold and staff takedown occurred and the patient was placed in 4 point restraints at 5:10pm.

On 12/22/17 and 1/8/18, the video recording of the 12/8/17 restraint episode was reviewed with the Director of Human Resources, the COO, Police Chief, DN2 #1 and/or DN2 #2. The video recording identified that two staff RN #343 and FTS #366 with the patient towards walking his/her room. As the patient attempted to come out of room, he/she was blocked by TS #366. The video showed multiple staff walking down the hallway towards Patient #401's room. There was a total of eight staff outside the patient's room. As the patient came out of his/her room, he/she raised his/her arm at FTS # 367. The patient's raised arm was blocked by FTS # 367 and another staff. The patient was placed in a physical hold and held down on the floor by multiple staff. There were eight staff around and/or holding the patient down on to the floor. Three agency PO's came down the hall towards the patient as he/she was held down on the floor. As the video continued, FTS #367 was seen hovering over the patient (view of his/her backside) and FTS #367' s right arm moved up and down x 2 towards the patient ' s head area and then threw something into the patient ' s room. A restraint bed was wheeled down the hall and the patient was assisted to the bed while resisting and was restrained with 4-point restraints.

Interview with the COO on 12/22/17 at approximately 11:55am identified that FTS # 367 held the wrist of the patient initially, the patient fell to the floor with approximately 5 staff to hold the patient down. The COO further identified that FTS # 367 should have removed herself as she was an "agitant" to the patient.

On 12/22/17 the Work Rule Violation Report initiated on 12/8/17 was reviewed. The report identified that the Director of Rehabilitation Therapies, the manager on duty, was on the nursing unit during Patient #401's restraint episode. While observing the staff roll the restraint bed to the restraint room, the patient was agitated, making racial slurs to staff, swearing at staff, threatening staff, and spitting at them.

Interview with MD #1 and Director of Rehabilitation Therapies on 1/2/18 identified that when the patient arrived in the restraint room, while in restraints, the patient made an allegation that he/she was struck in the face by a staff member. MD #1 identified on 1/2/18 that the patient made this allegation of accusing FTS # 367 of hitting him/her or was looking at FTS #367 while stating this. FTS #367, who was in the doorway while the patient made this allegation. MD #1 then directed Director of Rehabilitation Therapies to start the incident reports and to get statements from staff. Further interview with MD #1 on 1/2/18 identified that FTS # 367 provided Continuous Observation for Patient #401 even after this allegation was made. Interview with FTS # 58 on 1/10/18 at 10:15am identified that FTS #367 was the first staff member to provide CO when the patient was in the restraint room. Further review of the video on 1/8/18 identified that at approximately 5:22pm, FTS #368 walked by and closed the door to the restraint room which was not in accordance with facility policy. FTS #367 was observed sitting outside the restraint room providing CO for Patient #401 from 5:23pm to 5:41pm when he/she was relieved by another FTS. The medical record failed to identify FTS # 367' s initials to reflect that she conducted the CO checks. Multiple staff also walked by the restraint room while the door to Patient #401's room was closed and no staff intervened to open the door. At 5:43pm, FTS # 367 was observed holding a jacket and a bag as he/she left the unit. On her way out of the unit, while FTS #368 was on CO for Patient #401 in the restraint room, FTS # 367 opened the door of the restraint room and looked into Patient #401's room but observation of the video was unable to identify if any verbal or nonverbal interaction occured since there was no audio component in the video, FTS # 367 then left the unit. FTS #368, who was performing CO, did not intervene when FTS #367 opened the door to Patient #401's room. The door to the restraint room remained closed until 6:28pm when it was opened by RN #27.

Although MD #1 and the Director of Rehabilitation Therapies were aware that Patient #401 accused FTS # 367 of hitting him/her during the restraint episode, FTS # 367 was allowed to be in contact with Patient #401 and potentially other patients on the unit. Additionally, multiple staff failed to intervene to open the door of the restraint room when it was occupied.

Interview with Director of Rehabilitation Therapies on 1/2/18 and the Police Chief on 1/8/18 identified that Administration was notified and Director of Rehabilitation Therapies reviewed the videotaped restraint episode on 12/8/17 with Sergeant #2 and the CEO. Although the COO was contacted and made aware of the allegation and that she was on campus, the COO did not come to the Whiting building or review the video that day. An entry dated 12/9/17 on the MHAS-20 report by Director of Rehabilitation Therapies identified that after review of the videotape, it appeared that FTS #367 punched twice with her right hand/arm in the head area of the patient while the patient was restrained on the floor.

Interview with Director of Rehabilitation Therapies on 1/2/18 at 9:3am, who was the Manager on Duty on 12/8/17, identified that after the patient was wheeled into the restraint room via the restraint bed, she and MD #1 heard the patient say that he/she was hit in the face. MD #1 directed the Director of Rehabilitation Therapies to complete the paperwork regarding the allegation of abuse. The Director of Rehabilitation Therapies further identified that she left the area and called the Program Manager, the COO, and CEO. The Police Chief came in with Sergeant #2, the CEO, and Director of Rehabilitation Therapies who reviewed the video tape of the restraint episode on 12/8/17. FTS #367 complained of an injured hand sometime after the restraint episode and left the hospital for a medical evaluation. The agency PO were instructed by Director of Rehabilitation Therapies not to let FTS #367 into the nursing units because the plan was to place the employee on administrative leave of absence (ALOA) while investigating the allegation of abuse by FTS # 367 to Patient #401. Since FTS #367 retuned from a medical evaluation and sustained a right hand injury, he/she was out of work on a medical leave and not ALOA. On 1/4/18, FTS #367 was issued a notice to reflect that she was on an ALOA for an allegation of work rule violation #19. This violation included physical violence, verbal abuse, inappropriate or indecent conduct and behavior that endangers the safety and welfare of persons or property is prohibited.

Interview with DN2 #2 on 1/2/18 at 11:07am identified that she reviewed the 12/8/17 video of the restraint episode on 12/9/17 and saw the concerns of FTS #367' s elbow coming up and at the patient in the video.

According to the Incident Report, the patient was assessed by MD #1 on 12/8/17 at 5:20pm with no injuries on the initial exam. The patient complained of pain under bilateral eyes, no redness or bruising but also complained of right shoulder pain, the area where he/she received an intramuscular injection. A 2x2 cm bruise was noted on crown of head due to self-injurious behavior of head banging. Interview with MD #1 on 1/2/18 at 10:25am identified that while the patient was in the restraint room and looking at FTS #367 said he/she said he was hit. The patient further stated "you punched me in the head three times and when I get out of here ...." and other threatening words. MD #1 further stated that she asked RN #342 to do an incident report and obtain witness statements. MD #1 left the unit between 5:30-5:40pm and FTS #367 left sometime after that.

Interview with MD #6 on 1/2/18 at 11:25am and review of the progress note dated 12/9/17 at 10: 20am written by MD #1 identified that the patient alleged that he/she was hit in the face during the restraint. The patient was noted to have mild reddening/swelling anterior and inferior to the right ear, and mild/diffuse bruising on posterior head and a 1.5 inch bruise on the left bicep. Further interview identified that the patient was moved to another unit on 12/20/17 for administrative reasons and the patient was at risk for victimization.

Interview with DN2 #2 on 1/8/18 at approximately 3pm identified that FTS #367 should not have been on sit (CO) for Patient #401 after the allegation was made. DN2 #2 further identified that the hospital policy was to keep the restraint room door open while a patient was in the restraint room.

Review of the Assessment and Reporting of Victims of Abuse, Neglect, or Exploitation policy directs that the preliminary investigation (Supervisor or Manager), for instances of physical or sexual abuse, the Supervisor, the Unit Director or Discipline Chair will immediately remove the alleged perpetrator form patient care pending the outcome of the preliminary investigation.

The Patient Safety Event and Incident Management policy directs that incidents that involve allegations of abuse, neglect, or exploitation, the alleged perpetrator(s) is immediately removed from patient care pending the outcome of the preliminary investigation.

On 12/22/17, the Department requested an immediate action plan to mitigate any potential further risks to patients. The plan included assuring patient safety and adherence to the requirements in the Assessment and Reporting of Victims of Abuse, Neglect, or Exploitation and the expectation of the site manager, education, competency testing, rounding expectations, and reporting and recording expectations. Additionally, the plan shall include all restraint and seclusion episodes (video review) in Whiting for appropriateness, need for re-education, and changes to the treatment plan and daily reporting to the Department regarding the progress of the action plan.

On 1/8/18, the hospital began to rollout education to all staff reinforcing the need to have unimpeded access to the patient while on CO and no distractions while performing this critical patient safety duty. A mandatory online training was planned to begin on 1/9/18 for all nursing staff.



b. The allegation of abuse regarding Patient #401 was made known to staff on 12/8/17, however, the hospital failed to conduct an investigation in a timely manner due to their "administrative policies". As of 1/8/18, the Human Resource/Labor Relations investigation was on "hold" due to the agency police investigation and direction of the Director of Human Resources.

The Reporting Alleged Violations of Policies, Procedures, Regulations or Work Rules Policy directs in part, that every employee of the Department of Mental Health and Addiction Services (DMHAS) has an obligation to report incidents which are alleged violations of DMHAS policies, procedures, regulations or work rules. The reporting obligations arises under the following three conditions: when an employee is directly involved in an incident which is an alleged violation, when an employee observes an incident which is an alleged violation, and when an employee is made aware of an incident which is an alleged violation. Failure to report such incidents when an employee has incurred a reporting obligation may result in disciplinary action against that employee. An employee must make an oral report immediately to the employee's supervisor and to the supervisor of the area in which the violation occurred.

Subsequent to the 12/8/17 incident, the DMHAS Commissioner issued a memorandum on 12/20/17 (12 days after the allegations of abuse) to inform all DMHAS employees of the recent incident at Whiting Maximum Security. The memorandum directed that staff who witness abuse or any other violation of DMHAS Policies, Regulations, or Work Rules, must immediately report it to their supervisor.


c. Patient #81' s diagnosis included schizoaffective disorder. Physician orders dated 12/6/17 directed Continuous Observation by male staff for aggressive, sexualized behaviors and fall risk. On 12/22/17 and 1/8/18, the video recording of the 12/8/17 restraint episode of Patient #401 was reviewed with the Police Chief and DN2 #2. Observation identified FTS #369 was posted in the hallway to the room next to Patient #401. Patient #81, was in the room next to Patient #401 with the door was closed. FTS #369 was performing CO and was observed talking to staff in the hallway, including FTS #367 and was not looking directly into Patient #81's room.

Interview with DN2 #2 on 1/8/18 identified that FTS #369 was conducting CO for Patient #81 and that when a patient is on CO, the door to the room should remain open. The CEO on 1/8/18 identified that during her review of the video on 12/18/17 or 12/19/17, although she noticed that the doors to Patient #401 and Patient #81's rooms were closed and should have been open, no action or discipline was initiated because the administrative investigation was hold secondary to an active police investigation related to an allegation of patient abuse on Patient #401.


Review of the Assessment and Reporting of Victims of Abuse, Neglect, or Exploitation policy directs that the preliminary investigation (Supervisor or Manager), for instances of physical or sexual abuse, the Supervisor, the Unit Director or Discipline Chair will immediately remove the alleged perpetrator from patient care pending the outcome of the preliminary investigation.

The Patient Safety Event and Incident Management policy directs that incidents that involve allegations of abuse, neglect, or exploitation, the alleged perpetrator(s) is immediately removed from patient care pending the outcome of the preliminary investigation.

The Continuous observation policy directs Continuous Observation is an observation in which the patient requires ongoing monitoring to ensure his/her safety and/or the safety of others. The nursing staff assigned provides that by having a clear view and unimpeded access to the patient at all times.

On 1/8/18, the hospital began to rollout education to all staff reinforcing the need to have unimpeded access to the patient while on CO and no distractions while performing this critical patient safety duty. A mandatory online training was planned to begin on 1/9/18 for all nursing staff.

Based on observation of a video, review of the medical record, review of hospital documentation, and interviews for one patient who alleged physical abuse by a staff member (Patient #401), the hospital failed to ensure immediate removal of the staff member to protect Patient #401 and potentially other patients who received care and services in the maximum security unit after an allegation of abuse and/or failed to ensure that staff assigned to CO had a clear view and unimpeded access to the patients, Patient #401 and #81 at all times. The findings include:

Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/8/17 directed fifteen minute checks and continuous observation with one extra staff, at least one male, for aggressive and unpredictable behavior. The Nurses notes dated 12/8/17 for the 3-11pm shift identified that the patient walked into his/her room slamming door so sitters could not view him/her, would not follow directions to open the door, then came out of his/her room swinging to punch a female sitter in the face. A protective hold and staff takedown occurred and the patient was placed in 4 point restraints at 5:10pm.

On 12/22/17 and 1/8/18, the video recording of the 12/8/17 restraint episode was reviewed with the Director of Human Resources, the COO, Police Chief, DN2 #1 and/or DN2 #2. The video recording identified that RN #343 and FTS #366 accompanied the patient towards his/her room. As the patient attempted to come out of room, he/she was blocked by FTS #366. The video showed that multiple staff walked down the hallway towards Patient #401's room. There was a total of eight staff outside the patient's room. As the patient came out of his/her room and raised his/her arm at FTS # 367. The patient's raised arm was blocked by FTS # 367 and another staff. The patient was placed in a physical hold and the patient was held down on the floor by multiple staff. There were eight staff around and/or holding the patient down on to the floor. Three agency PO's came down the hall towards the patient as he/she was held down on the floor. As the video continued, FTS #367 is seen hovering over the patient (view of his/her backside) and FTS #367' s right arm moved up and down x 2 towards the patient ' s head area and then FTS #367 threw something into the patient ' s room. A restraint bed was wheeled down the hall and the patient was assisted to the bed while resisting and he/she was restrained with 4-point restraints.

Interview with the COO on 12/22/17 at approximately 11:55am identified that FTS # 367 held the wrist of the patient initially. The patient fell to the floor with approximately 5 staff to hold the patient down. The COO further identified that FTS # 367 should have removed herself as she was an "agitant" to the patient.

On 12/22/17 the Work Rule Violation Report initiated on 12/8/17 was reviewed. The report identified that the Director of Rehabilitation Therapies, the manager on duty, was on the nursing unit during Patient #401's restraint episode. While observing the staff roll the restraint bed to the restraint room, the patient was agitated, making racial slurs to staff, swearing at staff, threatening staff, and spitting at them.

Interview with MD #1 and Director of Rehabilitation Therapies on 1/2/18 identified that when the patient arrived in the restraint room, while in restraints, the patient made an allegation that he/she was struck in the face by a staff member. MD #1 identified on 1/2/18 that the patient made this allegation of accusing FTS # 367 of hitting him/her or was looking at FTS #367 while stating this. FTS #367, was in the doorway while the patient made this allegation. MD #1 then directed Director of Rehabilitation Therapies to start the incident reports and to get statements from staff. Further interview with MD #1 on 1/2/18 identified that FTS # 367 provided continuous observation for Patient #401 even after this allegation was made. Interview with FTS # 58 on 1/10/18 at 10:15am identified that FTS # 367 was the first staff member to provide CO when the patient was in the restraint room. Further review of the video on 1/8/18 identified that at approximately 5:22pm, FTS #368 walked by and closed the door to the restraint room which was not in accordance with facility policy. FTS # 367 was observed sitting outside the restraint room providing CO for Patient #401 from 5:23pm to 5:41pm and then was relieved by another FTS. The medical record failed to identify FTS # 367 ' s initials to reflect that he/she conducted the CO checks. Multiple staff also walked by the restraint room while the door to Patient #401's room was closed and no staff intervened to open the door.

At 5:43pm, FTS # 367 was observed holding a jacket and a bag as she left the unit. On her way out of the unit, while FTS #368 was on CO for Patient #401 in the restraint room, FTS # 367 opened the door of the restraint room and looked into Patient #401's room but observation of the video was unable to identify if any verbal/nonverbal interaction occurs since there was no audio component to the video. FTS # 367 then left the unit. FTS #368, who was performing CO, did not intervene when FTS #367 opened the door to Patient #401's room. The door to the restraint room remained closed until 6:28pm when it was opened by RN #27.

Although MD #1 and the Director of Rehabilitation Therapies were aware that Patient #401 had accused FTS # 367 of hitting him/her during the restraint episode, FTS # 367 was allowed to be in contact with Patient #401 and potentially other patients on the unit. Additionally, multiple staff failed to intervene to open the door of the restraint room when it was occupied.

Interview with Director of Rehabilitation Therapies on 1/2/18 and the Police Chief on 1/8/18 identified that Administration was notified and Director of Rehabilitation Therapies reviewed the videotaped restraint episode on 12/8/17 with Sergeant #2 and the CEO. Although the COO was contacted and made aware of the allegation and that she was on campus, the COO did not come to the Whiting building or review the video that day. An entry dated 12/9/17 on the MHAS-20 report by Director of Rehabilitation Therapies identified that after review of the videotape, it appeared that FTS #367 had punched twice with her right hand/arm in the head area of the patient while the patient was restrained on the floor.

Interview with Director of Rehabilitation Therapies on 1/2/18 at 9:3am who was the Manager on Duty on 12/8/17 identified that after the patient was wheeled into the restraint room via the restraint bed, she and MD #1 heard the patient say that he/she was hit in the face. MD #1 directed the Director of Rehabilitation Therapies to complete the paperwork regarding the allegation of abuse. The Director of Rehabilitation Therapies further identified that she left the area and called the Program Manager, the COO, and CEO. The Police Chief came in with Sergeant #2, the CEO, and Director of Rehabilitation Therapies who reviewed the video tape of the restraint episode on 12/8/17. FTS #367 complained of an injured hand sometime after the restraint episode and left the hospital for a medical evaluation. The agency PO were instructed by Director of Rehabilitation Therapies not to let FTS #367 into the nursing units because the plan was to place the employee on administrative leave of absence (ALOA) while investigating the allegation of abuse by FTS # 367 to Patient #401. Since FTS #367 returned from a medical evaluation and sustained a right hand injury, he/she was out of work on a medical leave and not ALOA. On 1/4/18, FTS #367 was issued a notice to reflect that she was on an ALOA for an allegation of work rule violation #19. This violation included physical violence, verbal abuse, inappropriate or indecent conduct and behavior that endangers the safety and welfare of persons or property is prohibited.

Interview with DN2 #2 on 1/2/18 at 11:07am identified that she had reviewed the 12/8/17 video of the restraint episode on 12/9/17 and saw the concerns of FTS #367' s elbow coming up and at the patient in the video.

According to the Incident Report, the patient was assessed by MD #1 on 12/8/17 at 5:20pm with no injuries on the initial exam. The patient complained of pain under bilateral eyes, no redness or bruising but also complained of right shoulder pain, the area where he/she received an intramuscular injection. A 2x2 cm bruise was noted on crown of head due to self-injurious behavior of head banging. Interview with MD #1 on 1/2/18 at 10:25am identified that while the patient was in the restraint room and looking at FTS #367 said he/she said he was hit. The patient further stated "you punched me in the head three times and when I get out of here ...." and other threatening words. MD #1 further stated that she asked RN #342 to do an incident report and obtain witness statements. MD #1 left the unit between 5:30-5:40pm and FTS #367 left sometime after that.

Interview with MD #6 on 1/2/18 at 11:25am and review of the progress note dated 12/9/17 at 10: 20am written by MD #1 identified that the patient alleged that he/she was hit in the face during the restraint. The patient was noted to have mild reddening/swelling anterior and inferior to the right ear, and mild/diffuse bruising on posterior head and a 1.5 inch bruise on the left bicep. Further interview identified that the patient was moved to another unit on 12/20/17 for administrative reasons and the patient was at risk for victimization.

Interview with DN2 #2 on 1/8/18 at approximately 3pm identified that FTS #367 should not have been on CO for Patient #401 after the allegation of abuse was made. DN2 #2 further identified that the hospital policy was to keep the restraint room door open while a patient is in the restraint room.

Review of the Assessment and Reporting of Victims of Abuse, Neglect, or Exploitation policy directs that the preliminary investigation (Supervisor or Manager), for instances of physical or sexual abuse, the Supervisor, the Unit Director or Discipline Chair will immediately remove the alleged perpetrator form patient care pending the outcome of the preliminary investigation.

The Patient Safety Event and Incident Management policy directs that incidents that involve allegations of abuse, neglect, or exploitation, the alleged perpetrator(s) is immediately removed from patient care pending the outcome of the preliminary investigation.

The Continuous observation policy directs Continuous Observation is an observation in which the patient requires ongoing monitoring to ensure his/her safety and/or the safety of others. The nursing staff assigned provides that by having a clear view and unimpeded access to the patient at all times.

On 12/22/17, the Department requested an immediate action plan to mitigate any potential further risks to patients. The plan included assuring patient safety and adherence to the requirements in the Assessment and Reporting of Victims of Abuse, Neglect, or Exploitation and the expectation of the site manager, education, competency testing, rounding expectations, and reporting and recording expectations. Additionally, the plan shall include all restraint and seclusion episodes (video review) in Whiting to be reviewed for appropriateness, need for re-education, and changes to the treatment plan and daily reporting to such to the Department regarding the progress of the action plan.

On 1/8/18, the hospital began to rollout education to all staff reinforcing the need to have unimpeded access to the patient while on CO and no distractions while performing this critical patient safety duty. A mandatory online training was planned to begin on 1/9/18 for all nursing staff.


b. Patient #81' s diagnosis included schizoaffective disorder. Physician orders dated 12/6/17 directed Continuous observation by male staff for aggressive, sexualized behaviors and fall risk. On 12/22/17 and 1/8/18, the video recording of the 12/8/17 restraint episode of Patient #401 was reviewed with the Police Chief and DN2 #2. Observation identified FTS #369 was posted in the hallway to the room next to Patient #401. Patient #81, was in the room next to Patient #401 with the door was closed. FTS #369 was performing CO and was observed talking to staff in the hallway, including FTS #367 and was not looking directly into Patient #81's room.

Interview with DN2 #2 on 1/8/18 identified that FTS #369 was conducting CO for Patient #81 and that when a patient is on CO, the door to the room should remain open. The CEO on 1/8/18 identified that during her review of the video on 12/18/17 or 12/19/17, although she noticed that the doors to Patient #401 and Patient #81's rooms were closed and should have been open, no action or discipline was initiated because the administrative investigation was hold secondary to an active police investigation related to an allegation of patient abuse on Patient #401.

Review of the Assessment and Reporting of Victims of Abuse, Neglect, or Exploitation policy directs that the preliminary investigation (Supervisor or Manager), for instances of physical or sexual abuse, the Supervisor, the Unit Director or Discipline Chair will immediately remove the alleged perpetrator from patient care pending the outcome of the preliminary investigation.

The Patient Safety Event and Incident Management policy directs that incidents that involve allegations of abuse, neglect, or exploitation, the alleged perpetrator(s) is immediately removed from patient care pending the outcome of the preliminary investigation.

The Continuous observation policy directs Continuous Observation is an observation in which the patient requires ongoing monitoring to ensure his/her safety and/or the safety of others. The nursing staff assigned provides that by having a clear view and unimpeded access to the patient at all times.

On 1/8/18, the hospital began to rollout education to all staff reinforcing the need to have unimpeded access to the patient while on CO and no distractions while performing this critical patient safety duty. A mandatory online training was planned to begin on 1/9/18 for all nursing staff.


c. On 12/22/17 and 1/8/18, the video recording of the 12/8/17 restraint episode on Patient #401 was reviewed with the Director of Human Resources, the COO, Police Chief, DN2 #1 and DN2 #2. The video recording showed multiple staff walked down the hallway towards Patient #301 ' s room. There was a total of eight staff outside the patient ' s room. As the patient came out of his/her room and raised his/her arm at FTS # 367. The patient's raised arm was blocked by FTS # 367 and another staff. The patient was placed in a physical hold and held down on the floor by multiple staff. There were eight staff around and/or holding the patient down on to the floor. Three agency police officers came down the hall towards the patient as he/she was held down on the floor. The patient was escorted to the restraint bed, 4-point restraints were applied and the patient was brought to the restraint room. The patient was spitting at staff and resisting the restraints. A spit shield was applied to the patient. The mattress on the restraint bed was observed sliding off towards the foot of the bed which allowed the patient' s head to have direct contact with the hard surface of the restraint bed (molded deep perimeter bed). The patient ' s head was thrashing and resisting when RN #342 held the patient ' s head down on the firm surface as the patient was attempting to sit up. At 5:10pm, Police Officer (PO)#1 was forcefully holding the patient ' s spit shield down on his/her face in order to hold the patient' s head down on the bed. PO #1' s thumbs were pressing down on the patient ' s cheeks and hands are around the patients jaw area. It was not until 5:21pm, two PO' s and RN #27 placed a wedge under the patient ' s head for support. The patient received intramuscular medications at 5:15pm for agitated behaviors. The patient ' s restraints are removed at 6:55pm. As the patient was sitting up in the restraint bed, bruising is noted to the back of the head.

According to the Incident Report, the patient was assessed by MD #1 on 12/8/17 at 5:20pm with no injuries on the initial exam. The patient complained of pain under bilateral eyes, no redness or bruising but also complained of right shoulder pain, the area where he/she received an intramuscular injection. A 2x2 cm bruise was noted on crown of head due to self-injurious behavior of head banging.

Interview with MD #1 on 1/2/18 at 10:25am identified that the mattress on the restraint bed was not secure and slipped down in the bed. MD #1 further identified that she assessed the patient after he/she calmed down and the patient complained of face hurting. The patient had pain under both eyes upon palpation, no bruising, but had bruises under head, from head banging.

Interview with MD # 6, who examined the patient the next day on 12/9/17 identified that the patient had a bruised arm, bicep, from a restraint, and a bruise on the back of head from head banging while in restraints. There was fullness and redness to the right cheek area. The patient continued to allege that he/she was hit.

d. Further review of the Work Rule Violation Report identified statements from ten staff members were obtained from the 12/8/17 restraint episode, but statements were not obtained from FTS # 364, who participated in the restraining of the patient and from FTS #369, who worked on the unit at the time of the restraint episode in accordance with hospital policy.

The Unit Director/Supervisor Checklist for investigations of abuse, neglect, and exploitation of patients was completed and signed by the former Assistant Division Director signed off that the checklist was complete to reflect that all aspects of the Work Rule Violation Form was complete, including that the report was submitted to appropriate parties and appropriate staff were notified. However, review of the packet and incident report on 12/22/17 failed to reflect that the Client Rights staff was notified or statements from all staff working on the unit prior to the end of the shift was obtained in accordance with hospital policy.

e. Statements obtained from staff including FTS #365, FTS #366, and RN #342 were obtained on 12/8/17, however, the statements did not identify the "punching action" from FTS # 367 to the patient. According to interview with the COO on 12/22/17, it was not until the agency police initiated their investigation and when they interviewed FTS # 364 on 12/19/17, who then identified that he/she saw FTS #367 punch the patient X 2 during the 12/8/17 restraint episode when the patient was on the floor.

FTS # 364 failed to immediately report his observation of FTS # 367 punching the patient while he/she was restrained on the floor in accordance with the abuse policy. FTS # 364, FTS #366, FTS #368, and RN #342 were subsequently placed on administrative leave on 12/19/17 for not immediately reporting the allegation of abuse on 12/8/17.

Interview with the Police Chief on 1/8/18 identified that the agency police began their investigation immediately, reviewed the video on 12/8/17, reviewed the documentation but Sergeant #1 (police investigator), was not assigned until 12/11/17, (3 days later) since Sergeant #1 only worked Monday through Friday and the incident occurred on the Friday before.

f. Interview with the HR Specialist, LR Division and the Supervisor of Labor Relations on 1/2/18 at 12:30pm identified that they received the faxed report of Patient #401 ' s allegation of abuse on 12/11/17, since their office is closed on the weekends. The investigation was assigned to a HR Specialist, LR Division who interviewed the patient during the week of 12/11/17 and identified that the investigation had been on hold since 12/18/17 per the direction of the Director of Human Resources.

g. Addendum B of the Incident Report, Investigation Section was completed on 12/12/17 in accordance with the policy but had only addressed the issue of the patient spitting into FTS#366's eye during the restraint episode. A second Addendum B of the Incident Report was in the investigation packet and was blank and therefore did not identify precipitating patient events, unit acuity/staffing issues, milieu/environmental factors, actions take to protect the victim, if applicable, direct care staff actions related to the incident or any recommendations/further actions in accordance with hospital policy.

h. The Second Level Review (Addendum C) was to be completed by the Division Director and documented on the Incident Report Form within seven (7) working days was not in the Incident Report and was not included in the packet as being completed in accordance with hospital policy. The information should include a minimum of additional information to Level I Review by the Unit Director, analysis of contributing factors including staff actions, actions by other individuals, staffing ration/mix, therapeutic milieu factors, actions to prevent recurrence, and recommendations and referrals.

i. Review of the Work Rule Violation Report and the Incident Report failed to reflect that the Psychiatric Security Review Board (PSRB) was notified of the 12/8/17 allegation of abuse on Patient #401 in accordance with hospital policy. Interview with the CEO and Medical Director on 1/2/18 at 2:20pm identified that they didn't consider the allegation of abuse a Critical Incident and their policy was confusing.

The Patient Safety and Incident Management policy directs in part, that critical incident reports are forwarded to the Director of Health Care Systems at the Office of the Commissioner within one (1) business day. A critical incident includes in part, alleged patient physical and psychosocial abuse; serious behavior committed or allegedly committed on or by a patient, or a staff member, or a visitor to the facility that resulted in or may result in a felony arrest; and alleged or suspected patient abuse or neglect, non-accidental injury or patient rights violation, including confidentiality breaches having serious consequences or potentially serious consequences for the patient.

j. The allegation of abuse was made known to staff on 12/8/17, however, the hospital failed to conduct an investigation in a timely manner due to their "administrative policies". As of 1/8/18, the Human Resource/Labor Relations investigation was on "hold" due to the agency police investigation and direction of the Director of Human Resources.

k. Interview with the CEO and Medical Director on 1/2/18 at 2:20pm identified that the DMHAS Office of the Commissioner was called on 12/8/17, however, the Critical Incident Submission Form was not completed.

The Assessment and reporting of Abuse, Neglect and Exploitation policy directs in part, external notification includes the Director of the Psychiatric Security Review Board (PSRB) for all patients under the jurisdiction of the PSRB. The first level review of an incident is to be completed by the Unit Director and documented on the Incident Form (Addendum B) within three (3) working days. The information includes at minimum precipitating events, actions taken to protect the victim, unit acuity, staffing ration and mix, location of staff and changes, staff actions related to the incident, therapeutic milieu factors and environmental factors. The Second Level Review is to be completed by the Division Director and documented on the Incident Report Form (Addendum C) within seven (7) working days and includes a minimum of additional information to Level I Review by the Unit Director, analysis of contributing factors including staff actions, actions by other individuals, staffing ratio/mix, therapeutic milieu factors, actions to prevent recurrence, and recommendations and referrals.

The written notification /reporting directs that the Critical Incident Verbal and Written Notice Form (DMHAS/CVH-601) be completed as soon as possible, and no later than the end of the shift in which the incident occurred. The Chief Executive Officer (CEO) forwards a copy of the Incident Report Form and Critical Incident Verbal and Written Notice Form to the Director of Health Care Systems at the Office of the Commissioner within one (1) business day.

The Reporting Alleged Violations of Policies, Procedures, Regulations or Work Rules Policy directs in part, that every employee of the Department of Mental Health and Addiction Services (DMHAS) has an obligation to report incidents which are alleged violations of DMHAS policies, procedures, regulations or work rules. The reporting obligations arises under the following three conditions: when an employee is directly involved in an incident which is an alleged violation, when an employee observes an incident which is an alleged violation, and when an employee is made aware of an incident which is an alleged violation. Failure to report such incidents when an employee has incurred a reporting obligation may result in disciplinary action against that employee. An employee must make an oral report immediately to the employee's supervisor and to the supervisor of the area in which the violation occurred.

Subsequent to the 12/8/17 incident, the DMHAS Commissioner issued a memorandum on 12/20/17 (12 days after the allegations of abuse) to inform all DMHAS employees of the recent incident at Whiting Maximum Security. The memorandum directed that staff who witness abuse or any other violation of DMHAS Policies, Regulations, or Work Rules, must immediately report it to their supervisor.




27691

Based on observation, review of clinical records, hospital video documentation, and staff interviews, for one patient reviewed for use of mechanical restraints, Patient #401, the hospital failed to ensure that the patient was free of seclusion. The findings include:

Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/08/17 directed CO with one extra staff (at least one male) related to aggressiveness and unpredictability. Review of Seclusion/Restraint documentation dated 12/08/17, RN #343 identified that Patient #401 exhibited specific behaviors that included swearing and threatening to assault staff in very explicit ways. He/she refused redirection to keep his/her bedroom door open, threw his/her glasses on the floor, and ran out of the bedroom, swinging at a female staff member. According to RN #343, Patient #401 refused personal safety preference based interventions and presented an imminent risk of serious physical assault and serious self-destructive behavior. A physical restraint (take down) was initiated at 5:05 PM and discontinued at 5:10 PM when the patient was placed in four point restraints, where he/she remained until 7:05 PM. RN #343 notified the patient of criteria for discontinuation at 5:50 PM. Nursing supervisor, RN #342 reviewed the imminent need for restraint at 5:30 PM and reviewed all restraint documentation for completeness at 7:18 PM.

Review of continuous video documentation in the unit six hallway and restraint room on 1/8/18 with the CEO and DN2 #2 identified that once the patient was transferred to the restraint bed in the hallway and brought to the restraint room from approximately 5:17 PM through discontinuation of the restraint at 7:05 PM, the door to the patient's room remained closed except when staff were providing care or assessing the patient. The staff member assigned to perform CO sat outside the door and visualized the patient through an elongated window in the door. In addition to the four point restraints which immobilized and/or reduced the patient's ability to move his/her arms, legs, body, or head freely; the closed door, further restricted his/her ability to leave the room at will. Review of the clinical record lacked an assessment or physician's order for the use of seclusion (closed door) in addition to the four point restraints.

Hospital policy for Restraint Use for the Management of Violent or Self Destructive Behavior identified that mechanical restraint was not to be used in combination with seclusion.

Based on observation, review of clinical records, hospital policies and procedures, hospital video documentation, and staff interviews, for one patient who required four point restraints, Patient #401, the hospital failed to ensure that the restraint was applied in accordance with hospital policies. The findings include:

Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/08/17 at 5:05 PM by MD #1 directed to apply a mechanical restraint (four point to bed) not to exceed two hours due to imminent risk of physical assault as evidenced by threatening, spitting, posturing, and lunging at staff to assault. An initial assessment by the RN and MD identified that Patient #401 was placed in 4 point restraints at 5:10 PM. The restraints were discontinued at 7:05 PM by RN #343 and approved by the nursing supervisor, RN #342 at 7:10 PM.

Review of continuous video documentation of the unit six hallway and restraint room on 1/8/18 with CEO and DN2 #2 identified that the patient was transferred to the restraint bed in the hallway at approximately 5:08 PM and was observed to be fighting and resisting as the staff attempted to place the four point restraints and the face shield. At 5:12 PM, FTS #58 was observed preparing the restraint room as Police Sergeant #2 pulled the restraint bed with the patient into the restraint room. At 5:14 PM the patient was observed to have the four point restraints in place, however, the mattress appeared to be sliding out from under Patient #401's head leaving the hard plastic surface of the concave restraint bed exposed. The mattress extended greater than twelve inches below the patient's feet and off the foot of the bed. The restraints were positioned in such a manner that the patient was able to sit up. RN #27 and RN #343 entered the room and administered medications, intramuscularly (IM) into Patient #401's right shoulder. Although the patient was in 4-point restraints at 5:18 PM, the patient was able to sit fully upright on the bed. The patient began to rock side to side attempting to knock over the restraint bed. He/she then threw him/herself backwards, forcefully, coming in contact with the exposed, hard plastic surface of the restraint bed. Additionally, Patient #401's ankle restraints were observed to be positioned mid-way between the knee and the ankle.

Interview with the Safety Education Instructor #1 on 1/12/18 at 1:00 PM identified that the 4-point restraints should be applied to the bed in such a way that the mattress is firmly in contact with the bed and the position of the restraints is unable to shift when the patient is moving in the bed. Also, ankle restraints should be applied to the patient's ankles in such a way that the restraint would not be able to move up the patient's leg. Staff failed to implement 4 point restraint in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy.

The Condition of Quality Assessment and Performance Improvement was not met as evidenced by the hospital's failure to:

1. Recognize safety concerns with the restraint bed mattress;

2. Identify rough treatment by staff during a 4-point restraint episode;

3. Ensure staff was conducting continuous observation of patient's in accordance with hospital policy;

4. Ensure that the patient was free of seclusion;

5. Ensure staff who was accused of physical assault did not have contact with the patient;

6. Ensure all required paperwork for reporting allegations of abuse was submitted in accordance with hospital policy; and

7. Ensure timely investigation of abuse to ensure appropriate action was taken.



Please reference A144, A145, A154, A167, A385, and 395.

The Condition of Nursing Services was not met as evidenced by staff failing to follow the plan of care/policies and procedures when staff failed to ensure that documentation accurately identified the staff conducting the continuous observation (CO) and/or failed to ensure that staff intervened when the door to the restraint room was closed while occupied and/or failed to ensure that Patient #401 was free of seclusion and/or failed to ensure that restraints were applied in accordance with hospital protocol.

Please reference to A 395

1. Based on observation of a video, review of the medical record, and interview for one patient who required Continuous Observation (CO) while in 4-point restraints (Patient #401), the staff failed to ensure that documentation accurately reflected the staff member who conducted the CO and/or failed to ensure that staff intervened when the door to the restraint room was closed while occupied and/or failed to ensure FTS #367 did not have contact with Patient #401 after an allegation of abuse. The finding includes:

Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/8/17 directed fifteen minute checks and continuous observation with one extra staff, at least one male, for aggressive and unpredictable behavior. The Nurses noted dated 12/8/17 for the 3-11pm shift identified that the patient walked into his/her room slamming door so sitters could not view him/her, would not follow directions to open the door, then came out of his/her room swinging to punch a female sitter in the face. A protective hold and staff takedown occurred and the patient was placed in 4 point restraints at 5:10pm.

On 12/22/17 and 1/8/18, the video recording of the 12/8/17 restraint episode was reviewed with the Director of Human Resources, the COO, Police Chief, DN2 #1 and/or DN2 #2. The video recording identified that as the patient came out of his/her room and raised his/her arm at FTS #367. The patient's raised arm was blocked by FTS #367 and another staff. The patient was placed in a physical hold and held down on the floor by multiple staff. There were eight staff around and/or holding the patient down on to the floor. As the video continued, FTS #367 is seen hovering over the patient (view of his/her backside) and FTS #367's right arm moved up and down x 2 towards the patient' s head area and then FTS #367 threw something into the patient' s room. A restraint bed was wheeled down the hall and the patient was assisted to the bed while resisting and was restrained with 4-point restraints.

Interview with the COO on 12/22/17 at approximately 11:55am identified that FTS # 367 held the wrist of the patient initially and the patient fell to the floor with approximately 5 staff to hold the patient down. The COO further identified that FTS #367 should have removed herself, as she was an "agitant" to the patient.

On 12/22/17 the Work Rule Violation Report initiated on 12/8/17 was reviewed. The report identified that Director of Rehabilitation Therapies was the Manager on Duty and on the nursing unit during Patient # 301's restraint episode. While observing the staff roll the restraint bed to the restraint room, the patient was agitated, making racial slurs to staff, swearing at staff, threatening staff, and spitting at them.

Interview with MD #1 and Director of Rehabilitation Therapies on 1/2/18 identified that when the patient arrived in the restraint room in 4-point restraints, the patient made an allegation that he/she was struck in the face by a staff member. MD #1 identified on 1/2/18 that the patient made this allegation of accusing FTS #367 of hitting him/her or was looking at FTS #367 who was in the doorway while making this all allegation. MD #1 then directed Director of Rehabilitation Therapies to start the incident reports and obtain staff statements. Further interview with MD #1 on 1/2/18 identified that FTS #367 provided Continuous Observation for Patient #401 even after this allegation was made.

Interview with FTS #58 on 1/10/18 at 10:15am identified that FTS #367 was the first staff member to provide CO when the patient was in the restraint room. Review of the video on 1/8/18 identified that at approximately 5:22pm, FTS #368 walked by and closed the door to the restraint room which was not in accordance with facility policy. FTS #367 was observed sitting outside the restraint room providing CO for Patient #401 from 5:23pm to 5:41pm then was relieved by another FTS. Multiple staff walked by Patient #401's room but failed to intervene and open the door.

At 5:43pm, FTS # 367 was observed holding a jacket and a bag as he/she left the unit. On her way out of the unit, while FTS #368 was on CO for Patient #401 in the restraint room, FTS # 367 opened the door of the restraint room and looked into Patient #401's room but observation of the video was unable to identify if any verbal/nonverbal interaction occured since there was no audio component to the video. FTS # 367 then left the unit. FTS #368, who was performing CO, did not intervene when FTS #367 opened the door to Patient #401's room. The door to the restraint room remained closed until 6:28pm when it was opened by RN #27.

Although video observation identified FTS #367 conducted the CO from 5:23pm to 5:41pm, corresponding documentation on the Behavioral Support Plan and Special Observations flowsheet failed to accurately identify FTS #367's initials to reflect that he/she conducted the CO checks. Review of the Initial Assessment by RN/MD and Nursing Observation and Care of the Patient dated 12/8/17 also failed to identify documentation to reflect FTS #367 conducted the checks / continuous observation from 5:23pm to 5:41pm.

The Continuous Observation policy directs Continuous Observation is an observation in which the patient requires ongoing monitoring to ensure his/her safety and/or the safety of others. The nursing staff assigned provides that by having a clear view and unimpeded access to the patient at all times.


2. Based on observation, review of clinical records, hospital video documentation, and staff interviews, for one patient reviewed for use of mechanical restraints, Patient #401, nursing staff failed to ensure that the patient was free of seclusion. The findings include:

Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/08/17 directed CO with one extra staff (at least one male) related to aggressiveness and unpredictability. Review of Seclusion/Restraint documentation dated 12/08/17, RN #343 identified that Patient #401 exhibited specific behaviors that included swearing and threatening to assault staff in very explicit ways. He/she refused redirection to keep his/her bedroom door open, threw his/her glasses on the floor, and ran out of the bedroom, swinging at a female staff member. According to RN #343, Patient #401 refused personal safety preference based interventions and presented an imminent risk of serious physical assault and serious self-destructive behavior. A physical restraint (take down) was initiated at 5:05 PM and discontinued at 5:10 PM when the patient was placed in four point restraints, where he/she remained until 7:05 PM. RN #343 notified the patient of criteria for discontinuation at 5:50 PM. Nursing supervisor, RN #342 reviewed the imminent need for restraint at 5:30 PM and reviewed all restraint documentation for completeness at 7:18 PM.

Review of continuous video documentation in the unit six hallway and restraint room on 1/8/18 with the CEO and DN2 #2 identified that once the patient was transferred to the restraint bed in the hallway and brought to the restraint room from approximately 5:17 PM through discontinuation of the restraint at 7:05 PM, the door to the patient's room remained closed while an FTS was in the hallway except when staff were providing care or assessing the patient. Multiple staff including Registered Nurses walked by the patient's room while the door was closed and was occupied by Patient #401. An FTS or RN was sitting outside the room. In addition to the four point restraints which immobilized and/or reduced the patient's ability to move his/her arms, legs, body, or head freely; the closed door, further restricted his/her ability to leave the room at will. Review of the clinical record lacked an assessment or physician's order for the use of seclusion (closed door) in addition to the four point restraints.

Hospital policy for Restraint Use for the Management of Violent or Self Destructive Behavior identified that mechanical restraint was not to be used in combination with seclusion.


3. Based on observation, review of clinical records, hospital policies and procedures, hospital video documentation, and staff interviews, for one patient who required four point restraints, Patient #401, the nursing staff failed to ensure that the restraint was applied in accordance with hospital policies. The findings include:

Patient #401 was admitted to the forensic division of the hospital on 4/30/1998 under the jurisdiction of the Psychiatric Security Review Board (PSRB). Primary diagnosis included personality disorder with secondary diagnosis that included unspecified intellectual disabilities. A physician order dated 12/08/17 at 5:05 PM by MD #1 directed to apply a mechanical restraint (four point to bed) not to exceed two hours due to imminent risk of physical assault as evidenced by threatening, spitting, posturing, and lunging at staff to assault. An initial assessment by the RN and MD identified that Patient #401 was placed in 4 point restraints at 5:10 PM. The restraints were discontinued at 7:05 PM by RN #343 and approved by the nursing supervisor, RN #342 at 7:10 PM.

Review of continuous video documentation of the unit six hallway and restraint room on 1/8/18 with CEO and DN2 #2 identified that the patient was transferred to the restraint bed in the hallway at approximately 5:08 PM and was observed to be fighting and resisting as the staff attempted to place the four point restraints and the face shield. At 5:12 PM, FTS #58 was observed preparing the restraint room as Police Sergeant #2 pulled the restraint bed with the patient into the restraint room. At 5:14 PM the patient was observed to have the four point restraints in place, however, the mattress appeared to be sliding out from under Patient #401's head leaving the hard plastic surface of the concave restraint bed exposed. The mattress extended greater than twelve inches below the patient's feet and off the foot of the bed. The restraints were positioned in such a manner that the patient was able to sit up. RN #27 and RN #343 entered the room and administered medications, intramuscularly (IM) into Patient #401's right shoulder. At 5:18 PM the patient sat fully upright on the bed and began to rock side to side as if attempting to knock over the restraint bed. He/she then threw him/herself backwards, forcefully, coming in contact with the exposed, hard plastic surface of the restraint bed. Additionally, Patient #401's ankle restraints were observed to be positioned mid-way between the knee and the ankle.

Interview with the Safety Education Instructor #1 on 1/12/18 at 1:00 PM identified that the 4-point restraints should be applied to the bed in such a way that the mattress is firmly in contact with the bed and the position of the restraints is unable to shift when the patient is moving in the bed. Also, ankle restraints should be applied to the patient's ankles in such a way that the restraint would not be able to move up the patient's leg. Staff failed to implement 4 point restraint in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy.