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Based on observation, interview, record review, policy review and review of recorded video surveillance, the facility failed to:
- Identify a physical altercation between security staff and one patient (#6) as an incident of abuse. (A-145)
- Thoroughly investigate the staff to patient altercation for possible abuse. (A-145)
- Remove two security guards (Staff R and Staff Q) from duty after a physical altercation with one patient (#6). (A-144)
- Provide proper oversight of the use of restraints/seclusion and response of staff to Code 10 alerts (notification to the entire facility for assistance to aid in de-escalation [therapeutic attempts to calm] of a patient). (A-145)
- Report an incident of staff to patient abuse. (A-145)
- To identify all items considered contraband to nursing staff in order for them to complete proper contraband (harmful material) checks for all patients in the Neuro Psychiatric Unit (NPU). (A-144)
- Complete thorough contraband/environmental checks of all areas in the NPU. (A-144)
- Recognize the inappropriate use of law enforcement restraints, and restraint techniques, in the hospital setting. (A-144)

These deficient practices resulted in the facility's non-compliance with specific requirements found under 42 CFR 482.13 Condition of Participation: Patient's Rights. The facility census was 52. The NPU census was 12.

The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 08/29/18, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following:
- The facility initiated a policy for all Code 10's, applications of violent restraints, and seclusions to be reviewed by administration, risk management, and the director of the involved unit, including observation notes, clinical record, and video (when available) within 12 hours of each event.
- Real time monitoring of every Code 10 response, violent restraint placement, and seclusion, by the House Supervisor. If any abuse is suspected, the Administrator on Call is to be notified immediately.
- 100% of all behavioral restraints require notification of the House Supervisor, Administrator on Call, and the director of the area where they are being used.
- Real time observations, compliance monitoring, and use of drills (application of scenarios) to ensure compliance with de-escalation techniques, appropriate use of restraints, minimization of risks, and use of physical interventions.
- Updated policies for Restraint usage, and Code 10 use.
- Mandatory training for all staff on recognizing abuse/neglect, and reporting appropriately.
- Mandatory education for Security, Intensive Care Unit, Neuro Psych Unit, and the Emergency department regarding the use of proper de-escalation techniques, interventions to prevent harm, minimizing risks with physical interventions, and identifying the purpose of Non Violent Crisis Intervention (NVCI).

The facility's plan of correction (POC) to remove the immediacy was ultimately accepted by CMS on 08/29/18 at 4:40 PM.

Based on interview, record review, policy review and review of recorded video surveillance, the facility failed to:
- Recognize escalating behavior which resulted in the delayed activation of a Code 10 (notification to the entire facility for assistance from the Crisis Intervention Team and Security to aid in de-escalating a potential danger in a patient's behavior) and a physical altercation which resulted in patient abuse of one patient (#6) of one patient reviewed for abuse.
- Immediately remove two staff (Q and R) from patient care, after they abused one patient (#6) of one patient reviewed for abuse.
- Ensure contraband (objects that patients can use to harm themselves) room checks were completed appropriately for one patient (#11) of one patient reviewed.
- Ensure patients were not given access to contraband without supervision.
These failures had the potential to place all patients in an unsafe environment and at risk for abuse and/or neglect. The facility census was 52. The Neuro Psychiatric Unit (NPU) census was 12.

Findings included:

1. Review of the facility's policy titled, "Physical Violence in the Workplace (Code 10)," revised 08/2018 showed directives for staff to do the following:
- When a patient demonstrates behavior that is verbally or physically disruptive, a Code 10 is announced.
- Personnel have the responsibility to recognize levels of anxiety in individuals that may escalate, if not managed and to initiate interventions to avoid potentially violent behavior.
- Personnel must be aware of their level of comfort in handling situations that may escalate beyond their capability and be knowledgeable in how to obtain help.
- Personnel are responsible for using the least intrusive interventions necessary to reduce the risk of assault and injury to themselves, patients or anyone that may be in the surrounding area.
- Nonviolent Crisis Intervention (NVCI, interventions used to calm a patient) techniques are used when dealing with individuals who are agitated and there is the potential they will lose control and become violent.

Review of the participant workbook used and taught by the facility titled, "Nonviolent Crisis Intervention," dated 2016, showed the directive for staff to do the following:
- Any physical intervention should be used only when all other options have been exhausted and when an individual was a danger to self or others.
- There may be times when other strategies, such as continuing verbal intervention and calling for further assistance would precede and possibly prevent any physical intervention.
- Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breathe.
- This includes sitting or lying across a person's back or stomach.

Review of the facility's policy titled, "Restraints/Seclusion," revised 08/2018, showed the following:
- Patients requiring restraint or seclusion are treated in such a manner as to preserve dignity.
- To be used only in emergency situations when the patient's behavior is violent or aggressive and poses an immediate, serious danger to the safety of the patient or others.
- Consideration is given to the use of least restrictive measures such as relaxation activity, de-escalation (therapeutic methods used to calm a patient), verbal limits and redirection.

Review of recorded video surveillance dated 07/16/18, showed the following in the Observation Seclusion Area (OSA) and inside the restraint/seclusion room on the NPU:
- At 9:09:03 AM, Patient # 6 walked outside of his room, arms at his side, fists clenched and stood in front of Staff Q, Security Guard.
- At 9:09:04 AM, Staff Q, Security Guard, lunged at Patient #6 and grabbed the patient around the neck with his left arm and they both fell to the ground. Patient #6 was positioned on top of Staff Q, Security Guard. Staff W, PCT and Staff G, NPU Clinical Supervisor attempted to restrain Patient #6 with physical holds.
- At 9:09:45 AM, Staff R, Security Guard, arrived and along with Staff G, NPU Clinical Supervisor and Staff W, NPU PCT, rolled Patient #6 off of Staff Q, Security Guard, and onto his back.
- At 9:10:34 AM, Staff Q, Security Guard, leaned on top of Patient #6's chest with his left arm wrapped around the patient's neck.
- At 9:10:45 AM, Staff Q, Security Guard, released his hold on the patient and got up, Staff R, Security Guard, kneeled between the patients legs, leaned over the patient and held the patients arms down by placing his hands over the patient's biceps (the muscle that lies on the upper arm between the shoulder and the elbow).
- At 9:11:25 AM, Staff had a physical hold on the patient's wrists and Staff R, Security Guard, released his grip from the patient's biceps. The patient got his left hand free, Staff R, Security Guard, grabbed the patient's left hand and placed it on the patient's chest, while he leaned over the patient and put his full upper body weight over the patient's chest.
- At 09:16:36 AM, Patient #6 was carried into the restraint/seclusion room by seven staff members and placed on the restraint bed. Staff R, Security Guard, straddled the patient's legs and placed his full body weight on top of the patient's torso. Staff R, Security Guard, placed his right knee on top of the patient's left knee to restrain the patient's leg.
- At 09:16:57 AM, Patient #6 was placed in five point restraints, which included a restraint placed across the patient's chest.
- At 09:18:06 AM, Patient #6 attempted to sit up and the chest restraint appeared tight against his chest.
- At 09:26:11 AM, Staff G, NPU Clinical Supervisor, Staff W, NPU PCT, Staff V and R, Security Guards, entered the restraint/seclusion room. Staff V, Security Guard, appeared to push the patient's head down with his left hand and appeared to place his right forearm over the patient's upper chest and neck area. Staff R, Security Guard, straddled the patient's legs and placed his upper body over the patient's stomach and upper legs.

During an interview on 08/29/18 at 8:30 AM, Staff Q, Security Guard, stated that on 07/16/18, Patient #6 had been agitated in his room, punched the wall and punched himself. The staff attempted to talk to him for 10 or 15 minutes, and Staff Q felt something had to be done.

Review of the facility's "Security Incident Report Form," dated 07/16/18, showed that Staff Q, Security Guard, stated that he made a split second decision to grab the patient so he could be restrained. (Per Staff Q's interview, the patient had been agitated for 10 or 15 minutes before Staff Q physically intervened).

During an interview on 08/28/18 at 1:30 PM, Staff G, Registered Nurse (RN), NPU Clinical Supervisor, stated that while Patient #6 was in his assigned room, he yelled, threatened, removed his shirt and pounded on his chest, and hit the walls, but no de-escalation techniques were initiated. Staff G stated that she did not see anything wrong with the takedown (the way that patient was managed by security before restraint) or restraint of Patient #6, and would not have done anything differently.

During an interview on 08/29/18 at 10:30 AM, Staff DD, NPU RN, stated that verbal de-escalation, and redirection were the first steps that were taught in NVCI and that a Code 10 should be called when staff felt the patient escalated beyond their control.

During an interview on 08/29/18 at 12:50 PM, Staff X, RN, House Supervisor, stated that staff were taught in NVCI to recognize signs of escalation and to verbally de-escalate before anything else.

During an interview on 08/29/18 at 10:00 AM, Staff W, PCT, stated that she was taught to call a Code 10 when a patient could not be de-escalated, and admitted that she should have called a Code 10 earlier in the situation with Patient #6.

The patient, showed signs of agitation and escalation over a period of 10 to 15 minutes, staff failed to announce a Code 10, and instead, managed the patient with force and physical restraint, placing the patient and staff at risk for injury or death.

2. Review of facility's policy titled, "Reporting Abuse, Neglect, or Exploitation of a Patient," revised 08/2018, showed that:
- Abuse included handling of a patient with more force than is reasonable and/or recklessly handling a patient in a brutal or inhumane manner.
- Abuse is to be reported immediately.
- The employee involved is removed from patient contact.
- The employee involved will remain suspended or removed from patient contact until the conclusion of the investigation.

Review of facility document titled, "Security Incident Report Form," dated 07/16/18, showed that:
- Staff Q, Security Guard completed the incident report.
- Staff Q placed Patient #6 in a "head/neck" hold and went to the floor.
- Staff Q grabbed Patient #6's arm and put it behind his back.
- Staff Q moved his left arm and pushed Patient #6's head down towards his armpit area.

During an interview on 08/29/18 at 8:30 AM, Staff Q, Security Guard, stated that he felt something needed to be done with Patient #6, and did not consult with staff before he physically restrained the patient.

During an interview on 08/29/18 at 10:00 AM, Staff W, PCT, stated that lying on top of a patient to restrain them was not part of the NVCI instruction that she received.

During an interview on 08/29/18 at 10:30 AM, Staff DD, NPU RN, stated NVCI did not teach staff to lie on top of a patient.

During an interview on 08/29/18 at 12:50 PM, Staff X, RN, House Supervisor, stated that NVCI did not teach staff to lie on top of patients and that she saw Staff R lying on top of Patient #6, but did not feel it was inappropriate.

During an interview on 08/28/18 at 2:10 PM, Staff T, RN, Quality Director, stated that she taught NVCI training at the facility, that laying on top of a patient to restrain them was inappropriate and not taught at the facility, and that videos of restraint and seclusion episodes were not "normally" reviewed.

During an interview on 08/28/18 at 1:30 PM, Staff G, RN, NPU Clinical Supervisor, stated that she did not see anything wrong with the takedown (the way that patient was managed by security before restraint) or restraint of Patient #6, and would not have done anything differently.

This indicates that leadership was unable to recognize abuse of a patient.

During an interview on 08/28/18 at 3:55 PM, Staff Y, Chief Executive Officer (CEO), stated that he just watched the video (approximately 40 days later) of the incident which involved Patient #6.

During an interview on 08/28/18 at 3:55 PM, Staff F, Chief Nursing Officer (CNO), stated that leader ship was unaware of the incident that involved Patient #6 and added that they should have reviewed video.

During an interview on 08/29/18 at 10:30 AM, Staff U, Facilities Director, stated that Staff R, Security Guard was suspended from his duties on 08/28/18 (approximately 40 days after the abuse of Patient #6) and was to be terminated from the facility on 08/29/18.

Review of the facility's personnel file of Staff Q, Security Guard, showed that he resigned from his duties on 08/24/18 (approximately 35 days after the abuse of Patient #6).

The facility failed to identify staff abuse toward Patient #6, which allowed Staff Q and Staff R to continue to work and possibly abuse other patients.

3. Record review of facility policies showed no definition of contraband (items that can be used to harm self or others) or for staff directives on contraband checks (assessment of all areas accessible to patients, to ensure the areas free of contraband).

Review of the facility's Electronic Medical Record (EMR) showed that staff were to complete Environmental Checks (assessment of safety in areas) at 2:00 AM, 8:00 AM, 2:00 PM, and 8:00 PM on the NPU, in areas accessible to psychiatric patients, including the patient rooms. Staff were to ensure the environment was free from exposure to dangerous items.

Review of Patient #11's Medical Record showed the following:
- He was a 29 year old male admitted to the facility's NPU on 08/21/18 at 11:59 AM, for anxiety (extreme worry) and depression (extreme sadness) with suicidal ideations (thoughts of killing self).
- On 08/21/18 at 5:00 PM, he told staff that he had tobacco wrapped in saran wrap in his rectum (area of the body where stool is passed) and wanted to know what else could be done to pass it.
- He was not placed on one-to-one (1:1, one staff member assigned to observe one patient at all times, for safety of the patient) observation.
- No precautions (specific safety observations made for high risk behaviors) were documented on the 15 Minute Patient Observation flowsheet dated 08/21/18.
- Documentation of the 15 minute observation flowsheet on 08/22/18 showed the patient was sleeping in his room except at 1:01 AM and 2:00 AM, where he was documented awake and at the nurses' station.
- On 08/22/18 at 9:55 AM, the patient was found to be unresponsive and a rapid response (a team of health care providers that respond to patients who show signs of a health emergency) was initiated. The patient was intubated (placement of a tube in the patient's throat to assist breathing) and transported to the Emergency Department (ED) and later to the Intensive Care Unit (ICU).
- The ED physician documented on 08/22/18 at 10:18 AM, that Gabapentin (a medication used to prevent and control seizures) and Klonopin (a medication used to treat anxiety) tablets were found in the patient's bedside table. These were brought into the unit in the patient's rectum (area of the body where stool is passed) passed in stool and collected from the stool.

4. During an interview on 08/29/18 at 10:00 AM, Staff W, NPU PCT, stated the following:
- When Environmental Checks were performed, she did not look in the patient bedside tables for contraband.
- The PCT's were not given a list of what contraband to look for.
- Patients were allowed to have pens, pencils and headphones with batteries (items considered contraband as they pose the potential for self-injury or injury of others) in their rooms.
- Plastic knives, forks and spoons (items considered contraband) were not counted after every meal (risk of concealing and use for self-injury or injury of others).
- A patient recently tried to hide a spoon (so it could be removed from supervised areas).

During an interview on 08/28/18 at 11:00 AM, Staff G, NPU, Clinical Supervisor, stated the following:
- The facility had no policy that defined contraband and there was no checklist or directive for staff to follow when looking for contraband.
- Contraband was items that patients could use to harm themselves or others.
- Patients were allowed to have pens and pencils in their rooms unsupervised.
- There was no documentation that plastic ware was accounted for after every meal.

These failures had the potential to place all NPU patients and staff in danger when contraband was not properly checked for and accessed without supervision.

Based on interview, record review, policy review and review of recorded video surveillance, the facility failed to identify, report, investigate, and prevent staff to patient abuse of one patient (#6) of one patient reviewed for abuse. This failure placed all patients in the facility at risk for abuse and neglect by staff. The census was 52. The Neuro Psychiatric Unit (NPU) census was 12.

Findings included:

1. Review of facility's policy titled, "Reporting Abuse, Neglect, or Exploitation of a Patient," revised 08/2018, provided direction for staff to:
- Define abuse as handling of a patient with more force than is reasonable and/or recklessly handling a patient in a brutal or inhumane manner.
- Report any incident in which they witness, or receive an allegation, of abuse/neglect/exploitation of a patient, immediately to a charge nurse or above for activation of the chain of command.
- Document all information in an Event Report and submit it to his/her supervisor /leader, prior to leaving your shift.
- Ensure that the supervisor/leader who receives the report immediately removes the employee involved from patient contact.
- Ensure that during the investigation of allegations, the employee will remain suspended and/or removed from patient contact until the investigation is completed.
- Ensure zero tolerance for abuse, neglect, and exploitation.

Review of Patient #6's Emergency Department (ED) medical record showed that:
- He was a 28 year old male, admitted to the facility on 07/13/18.
- He was placed on an involuntary 96 hour hold (mandatory, court ordered hospitalization for review of psychiatric stability) for depression (extreme sadness), hallucinations (perception of something not present), suicidal (thoughts of killing self) and homicidal (thoughts of killing others) thoughts.
- He appeared unkempt, behaved paranoid and was agitated.
- He was placed on one-to-one (1:1, one staff member observes one patient at all times, for safety) observation.

Review of Patient #6's History and Physical showed that:
- He was placed in the private room off of the Observation Seclusion Area (OSA) with a 1:1 security sitter (person assigned to provide 1:1 observation).
- He had become agitated, made threats to staff, and escalated enough to have additional security contacted.
- The psychiatrist had been threatened by the patient.
- The psychiatrist had contacted administration about Patient #6's potentially dangerous and harmful behavior, because of his outbursts.

During an interview on 08/29/18 at 8:30 AM, Staff Q, Security Guard. stated that on 07/16/18, Patient #6 was agitated in his room, punched the wall and punched himself. Staff attempted to talk to the patient for 10 or 15 minutes, when Staff Q felt "something had to be done."

Review of recorded video surveillance dated 07/16/18, showed the following in the OSA inside the restraint/seclusion room on the NPU:
- At 9:09:03 AM, Patient #6 walked outside of his room, arms at his side, fists clenched and stood in front of Staff Q, Security Guard.
- At 9:09:04 AM, Staff Q, Security Guard, lunged at Patient #6 and grabbed the patient around the neck with his left arm and they both fell to the ground. Patient #6 was positioned on top of Staff Q, Security Guard. Staff W, Patient Care Technician (PCT) and Staff G, NPU Clinical Supervisor attempted to restrain Patient #6 with physical holds.
- At 9:09:45 AM, Staff R, Security Guard, arrived, and with Staff G, NPU Clinical Supervisor and Staff W, NPU PCT, rolled Patient #6 off of Staff Q, Security Guard, and onto his back.
- At 9:10:34 AM, Staff Q, Security Guard, leaned on top of Patient #6's chest with his left arm wrapped around the patient's neck.
- At 9:10:45 AM, Staff Q, Security Guard, released his hold on the patient and got up, Staff R, Security Guard, kneeled between the patients legs, leaned over the patient and held the patients arms down by placing his hands over the patients biceps (the muscle that lies on the upper arm between the shoulder and the elbow).
- At 9:11:25 AM, Staff had a physical hold on the patient's wrists and Staff R, Security Guard, released his grip from the patient's biceps. The patient got his left hand free, Staff R, Security Guard, grabbed the patient's left hand and placed it on the patient's chest, while he leaned over the patient and put his full upper body weight over the patient's chest.
- At 09:16:36 AM, Patient #6 was carried into the restraint/seclusion room by seven staff members and placed on the restraint bed. Staff R, Security Guard, straddled the patient's legs and placed his full body weight on top of the patient's torso. Staff R, Security Guard, placed his right knee on top of the patient's left knee to restrain the patient's leg.
- At 09:16:57 AM, Patient #6 was placed in five point restraints, which included a restraint placed across the patient's chest.
- At 09:18:06 AM, Patient #6 attempted to sit up and the chest restraint appeared tight against his chest.
- At 09:26:11 AM, Staff G, NPU Clinical Supervisor, Staff W, NPU PCT, Staff V and R, Security Guards, entered the restraint/seclusion room. Staff V, Security Guard, appeared to push the patient's head down with his left hand and appeared to place his right forearm over the patient's upper chest and neck area. Staff R, Security Guard, straddled the patient's legs and placed his upper body over the patient's stomach and upper legs.

Review of facility document titled, "Security Incident Report Form," dated 07/16/18, showed that:
- Staff Q, Security Guard completed the form.
- A Code 10 (an overhead page for all available staff to assist with a potentially violent patient) was called on 07/16/18 at 9:09 AM. (according to Staff Q's interview, this was 10-15 minutes after the patient became agitated, had punched himself and the wall of his room. This resulted in a delay in Code 10 activation).
- Patient #6 approached Staff W, PCT, and Staff Q, Security Guard who provided 1:1 observation of the patient.
- Staff W backed up, but Staff Q attempted to block the doorway so Patient #6 would not walk out of his room.
- Staff Q then made a split second decision to try and grab Patient #6 for the purpose of physical restraint to prevent injury to staff members.
- Staff Q placed Patient #6 in a "head/neck" hold and went to the floor.
- Staff Q grabbed Patient #6's arm and put it behind his back.
- Staff Q moved his left arm and pushed Patient #6's head down towards his arm pit area.

During an interview on 08/29/18 at 8:35 AM, Staff Q, Security Guard, stated that:
- He was trained in both basic and advanced Non Violent Crisis Intervention (NVCI, techniques used to calm a patient, without using force).
- He was the 1:1 sitter assigned to Patient #6 on 07/16/18.
- A nurse asked Patient #6 to calm down, but he was unsure if any medications were offered.
- He felt that Patient #6 would have been more dangerous if backed into a corner, so he grabbed the patient and went to the floor.
- He was never instructed to do a hold on his own with a combative patient.

During an interview on 08/29/18 at 10:00 AM, Staff W, PCT, stated that:
- Patient #6 was upset.
- While in his room, he pounded his chest, punched his head, and punched the wall, then advanced towards the doorway with his fists clenched.
- Staff Q, Security Guard, stood up when Patient #6 advanced, then attempted to take Patient #6 to the ground.
- She should have called a Code 10 or hit the emergency button (signals tor staff to come quickly) when she realized he was escalating and was unable to talk him down (de-escalate).
- Staff were taught to talk the patient down first and to use restraints as a last resort in NVCI.
- NVCI did not teach staff to lay on top of a patient.

During an interview on 08/29/18 at 10:30 AM, Staff DD, NPU Registered Nurse (RN), stated that:
- She was trained in basic NVCI;
- Verbal de-escalation, and redirection were the first steps that were taught in NVCI;
- A Code 10 should be called when staff felt the patient was escalating beyond their control; and
- NVCI did not teach staff to lay on top of a patient.

During an interview on 08/29/18 at 10:50 AM, Staff V, Security Guard, stated that NVCI did not teach staff to lay on top of a patient with their full body weight.

During an interview on 08/29/18 at 12:50 PM, Staff X, RN, House Supervisor, stated that:
- She was trained in basic NVCI;
- Staff were taught in NVCI to recognize signs of escalation and to verbally de-escalate before anything else;
- NVCI did not teach to lay on top of patients; and
- She saw Staff R laying on top of Patient #6, and did not feel it was inappropriate.

Review of video surveillance of the incident which involved Patient #6, along with concurrent interview on 08/28/18 at 1:30 PM, Staff U, Facilities and Planning Director and Staff T, Quality Director, both voiced that they had not reviewed the video. Staff T, added that video was not "normally" reviewed, and restraint episodes were not reviewed unless there was a concern or question about the incident.

During an interview on 08/28/18 at 1:30 PM, Staff G, RN, NPU Clinical Supervisor, stated that while Patient #6 was in his assigned room, he yelled, threatened, removed his shirt and pounded on his chest, and hit the walls, but no de-escalation (therapeutic methods used to calm a patient) techniques were initiated. Staff G stated that she did not see anything wrong with the takedown (the way that patient was managed by security before restraint) or restraint of Patient #6, and would not have done anything differently.

During an interview on 08/28/18 at 1:30 PM, Staff T, RN, Quality Director, stated that:
- All employees were trained with basic NVCI, and Security staff were taught the advanced course.
- Staff were taught that they should never make the first motion.
- There was no therapeutic hold that involved laying on top of a patient.
- Staff should "absolutely never put full body weight on a patient."

During an interview on 08/29/18 at 8:55 AM, Staff Z, Plant Operations, stated that he had responded to the Code 10 on 07/16/18, which involved Patient #6, and added that staff were taught to de-escalate verbally first, and not to lay across a patient's chest.

During an interview on 08/29/18 at 9:30 AM, Staff BB, NPU RN, stated that laying on top of a patient was not part of the NVCI holds that are taught, that staff should try to talk down a patient first, and restraints were only used as a last resort.

During an interview on 08/29/18 at 9:40 AM, Staff CC, RN, Stepdown Unit Clinical Supervisor, stated that:
- He had responded to the Code 10 on 07/16/18 involving Patient #6;
- He did not feel that any inappropriate holds were used; and
- He had been trained in basic NVCI, and it was not acceptable for staff to lay on top of a patient.

During an interview on 08/28/18 at 3:55 PM, Staff Y, Chief Executive Officer (CEO), stated that he had just watched the video of Patient #6, and that the facility should have reported the incident.

During an interview on 08/28/18 at 3:55 PM, Staff F, Chief Nursing Officer (CNO), stated that had leadership known about the incident, they would have done things differently, and added that they should have reviewed video.

Although requested, the facility failed to provide an investigation for this incident, and failed to identify abuse.

The facility failed to recognize and fully investigate the abuse of Patient #6, when Staff Q initiated physical contact with the patient, leading to physical abuse and excessive restraint of the patient by Staff R. The initial abuse was not reported or investigated, and video was not reviewed, therefore placing Patient #6, as well as all patients, at risk for staff to patient abuse.

Based on interview, record review, policy review and video review, the facility failed to use the least restrictive method to control behavioral symptoms for one patient (#6) of one patient placed in restraints. This failure had the potential to place all patients admitted to the facility at risk for their right to be free from restraints and the potential harm from being restrained inappropriately. The facility census was 52. The Neuro Psychiatric Unit (NPU) census was 12.

Findings included:

1. Review of the facility's policy titled, "Restraints/Seclusion," revised 08/2018, showed the following:
- A physical restraint was defined as any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.
- It gave directives for staff to avoid restricting patient's breathing when restraints were in use.
- Patients requiring restraint or seclusion are treated in such a manner as to preserve dignity.
- To be used only in emergency situations when the patient's behavior is violent or aggressive and poses an immediate, serious danger to the safety of the patient or others.
- Consideration is given to the use of least restrictive measures such as relaxation activity, de-escalation (therapeutic techniques used to calm a patient), verbal limits and redirection, involvement of family member.

Review of the participant workbook used and taught by the facility titled, "Nonviolent Crisis Intervention," reprinted 2016, showed the directive for staff to do the following:
- Any physical intervention should be used only when all other options have been exhausted and when an individual was a danger to self or others.
- There may be times when other strategies, such as continuing verbal intervention and calling for further assistance would precede and possibly prevent any physical intervention.
- Staff members must be especially careful not to use their own bodies in ways that restrict the restrained person's ability to breathe.
- This includes sitting or lying across a person's back or stomach.

Observation of recorded video surveillance dated 07/16/18, showed the following in the Observation Seclusion Area (OSA) and inside the restraint/seclusion room on the NPU:
- At 9:09:03 AM, Patient # 6 walked outside of his room, arms at his side, fists clenched and stood in front of Staff Q, Security Guard.
- At 9:09:04 AM, Staff Q, Security Guard, lunged at Patient #6 and grabbed the patient around the neck with his left arm and they both fell to the ground. Patient #6 was positioned on top of Staff Q, Security Guard. Staff W, PCT and Staff G, NPU Clinical Supervisor attempted to restrain Patient #6 with physical holds.
- At 9:09:45 AM, Staff R, Security Guard, arrived and along with Staff G, NPU Clinical Supervisor and Staff W, NPU PCT, rolled Patient #6 off of Staff Q, Security Guard, and onto his back.
- At 9:10:34 AM, Staff Q, Security Guard, leaned on top of Patient #6's chest with his left arm wrapped around the patient's neck.
- At 9:10:45 AM, Staff Q, Security Guard, released his hold on the patient and got up, Staff R, Security Guard, kneeled between the patients legs, leaned over the patient and held the patients arms down by placing his hands over the patient's biceps (the muscle that lies on the upper arm between the shoulder and the elbow).
- At 9:11:25 AM, Staff had a physical hold on the patient's wrists and Staff R, Security Guard, released his grip from the patient's biceps. The patient got his left hand free, Staff R, Security Guard, grabbed the patient's left hand and placed it on the patient's chest, while he leaned over the patient and put his full upper body weight over the patient's chest.
- At 09:16:36 AM, Patient #6 was carried into the restraint/seclusion room by seven staff members and placed on the restraint bed. Staff R, Security Guard, straddled the patient's legs and placed his full body weight on top of the patient's torso. Staff R, Security Guard, placed his right knee on top of the patient's left knee to restrain the patient's leg.
- At 09:16:57 AM, Patient #6 was placed in five point restraints, which included a restraint placed across the patient's chest.
- At 09:18:06 AM, Patient #6 attempted to sit up and the chest restraint appeared tight against his chest.
- At 09:26:11 AM, Staff G, NPU Clinical Supervisor, Staff W, NPU PCT, Staff V and R, Security Guards, entered the restraint/seclusion room. Staff V, Security Guard, appeared to push the patient's head down with his left hand and appeared to place his right forearm over the patient's upper chest and neck area. Staff R, Security Guard, straddled the patient's legs and placed his upper body over the patient's stomach and upper legs.

During an interview on 08/29/18 at 8:30 AM, Staff Q, Security Guard, stated that Patient #6 was agitated in his room, punched the wall and punched himself. The staff attempted to talk to him for 10 or 15 minutes, and he felt something had to be done. He did not consult with staff before he restrained the patient.

During an interview on 08/27/18 at 2:55 PM, Staff D, Security Guard, stated that all security staff were trained in basic and advanced in Non-Violent Crisis Intervention (NVCI, non-violent interventions used to de-escalate a patient).

During an interview on 08/29/18 at 10:00 AM, Staff W, PCT, stated that she had NVCI training and that laying on top of a patient to restrain them was not taught in the class.

During an interview on 08/29/18 at 10:50 AM, Staff V, Security Guard, stated that he had the Advanced NVCI training and that full body weight on top of a patient could restrict the patient's airway. Staff V added that laying on top of a patient to restrain them was not taught in NVCI training.

During an interview on 08/28/18 at 2:10 PM, Staff T, Registered Nurse (RN), Quality Director, stated that she taught basic and advanced NVCI training at the facility and laying on top of a patient to restrain them was inappropriate and not taught at the facility.

The failure to appropriately use the least restrictive form of restraint had the potential to harm all patients that are placed in restraints.

2. Observation on 08/27/18 at 2:45 PM, showed a law enforcement type restraint chair located in the Emergency Department (ED). The restraint chair was equipped with wrist, ankle, waist and chest restraints.

During an interview on 08/27/18 at 2:55 PM, Staff D, Security Guard, stated that:
- All security staff were trained in basic and advanced NVCI.
- They utilize restraint beds with five point restraints and restraint chairs.
- There were two restraint chairs, one in the ED and a second on the NPU.

During an interview on 08/27/18 at 2:30 PM, Staff C, ED Charge RN, stated that all RN's, Paramedics, and Security staff received yearly training on proper application of all restraints, including five point restraints and chair restraints.

Observation on 08/27/18 at 3:00 PM in the NPU, showed two restraint/seclusion rooms. Each room had a bed equipped with wrist, ankle and chest restraints.

During an interview on 08/27/18 at 3:00 PM, Staff E, Medical Surgical and NPU Director, stated that the restraint room was always set up with five point restraints, and that there was a chair restraint available on the unit to use if necessary.

During an interview on 08/28/18 at 11:00 AM, Staff G, NPU RN, Clinical Supervisor, stated that five point restraints included the use of both wrist restraints, both ankle restraints, and a chest strap. She was not aware that five point restraints could not be used in the hospital setting.

Restraint chairs and five point restraints are primarily used in law enforcement and should not be used in the hospital setting for psychiatric patients.