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Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to ensure each patient's rights were protected and promoted by failing to ensure staff followed facility's policy and procedure to protect patients from abuse and by failing to provide care and treatment in a safe setting for two (2) of ten (10) sampled patients (Patients #1 and #3).

The facility admitted Patient #3 on 09/21/16 with diagnoses that included: Mood Affective Disorder, Attention Deficit Hyperactivity Disorder (ADHD); and Victim of Physical Abuse and Neglect. On 10/15/16 at approximately 10:00 AM, Patient #3 was placed in an "incorrect" restraint (a restraint immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. The facility failed to ensure MHT #3 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he performed the "improper" hold on Patient #3 on 10/15/16, and MHT #1 was allowed to continue working with patients.

The facility admitted Patient #1 on 09/01/16 with diagnoses that included: Oppositional Defiant Disorder, Affective Disorder, Cannabis Abuse, Abuse, Nicotine Abuse, and Insomnia. On 10/16/16 at 10:45 AM, Patient #1 began to kick the door of the group/therapy room. Per interview and review of staff statements, MHT #1 "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down (prone). The patient was then turned over and placed in a "supine" restraint. This was an improper restraint technique that was not taught in Nonviolent Crisis Intervention (NCI) training, nor was it in the facility's policy. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed Patient #1 was discharged with a Head Injury, Concussion, Abrasion of Face, Strain of Neck Muscle, and Cervical Sprain. After the incident related to Patient #1, the facility failed to complete a thorough investigation to include questioning other patients who may have witnessed the incident, or may have been unnecessarily placed in restraints by MHT #1. Additionally, there was no documented evidence the Department of Community Based Services (DCBS), received the allegation of physical abuse as per the facility's policy and state regulations. Interview with the DCBS worker revealed his state agency did not receive a report from the facility of the incident, dated 10/16/16, and would have regarded the incident as physical abuse.

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to protect and promote patient rights and receive care in a safe setting for two (2) of ten (10) sampled patients (Patient #1 and Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. There was no documented evidence staff referred to the patients Treatment Plan for less restrictive interventions and there was no documentation related to the use of the restraint. Additionally, there was no documented evidence to support MHT #1 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he was observed to use the improper restraint, and MHT #1 continued to work with patients.

On the next day, 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. MHT #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then the patient was turned over and placed in a "supine" restraint. This was an an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Staff interviews revealed they did not refer to the patient's treatment plan for a less restrictive intervention. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

The findings include:

Review of the facility's policy, titled "Restraint" , revised April 2010, and reviewed July 2013, revealed the patient had the right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff. A physical restraint was defined as the application of physical force alone restricting the free movement of the whole or portion of an individual's body in order to control physical activity. It was the policy of the facility to limit the use of restraints to emergencies in which there was an imminent risk of a patient physically harming him/herself or others.

Further review of the Policy, revealed Restraints would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to the patient or others prior to the application of restraints. Attempts to use less restrictive measures, as well as the patient's response to those measures would be recorded on the Seclusion and Restraints Assessment form. Further review revealed the facility was committed to preventing, reducing and striving to eliminate the use of restraints, as well as preventing emergencies that have the potential to lead to the use of restraints.

Review of the facility's Employee Training Manual, titled, " Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior " , copyright date 2005, revealed the Nonviolent Crisis Intervention (CPI) program was a safe, non-harmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint was recommended only when all less-restrictive methods of intervening had been exhausted, and when the individual presented a danger to self or others.

Additionally, review of the Training Manual, revealed any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention. Continued review revealed face down (prone) floor restraints and positions in which a person was bent over in such a way made it difficult to breathe and was extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively. Finally, the training emphasized the NPCI's intent was to calm the individual, to keep the individual off the floor, thus reducing risks of Restraint-Related positional asphyxia and other injuries. Continued review of the training manual stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor to restrain an individual, and floor restraints were not part of the teaching of NCI. Per the Manual, team interventions would be used when necessary and the NPCI would be used only as a last resort when someone presents a danger.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients; and intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior; use verbal techniques to de-escalate behavior; demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level; provide for the care, welfare, safety and security of all those who were involved in a crisis situation; and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint presentation for training titled, "Code Class", dated 2016, revealed the team support, de-escalation assistance, should be called when the patient was defensive and at the beginning stage of loss of rationality. Crisis Development Model Level two (2) was a stage in which an individual often becomes belligerent and challenges authority. Continued review revealed staff should be directive, an approach in which a staff member takes control of a potentially escalating situation. Staff should remember that the patient may not be able to respond to the rational context of your words. Instead the patient may be more in tune with other types of communication such as your tone of voice, and your proximity to him/her or your body posture. Additionally, the code yellow was used for Psychiatric Emergency, when the patient was "acting-out" in which they had total loss of rationale. In this situation, staff would use Nonviolent Physical Crisis Intervention (NCI), which was a safe non-harmful restraint with positions to control an individual until the Patient could gain control of his/her own behavior. This would be used as the last resort.

Review of the facility's PowerPoint presentation for training titled, "Identifying and Managing Risk Factors Associated with Seclusion and Restraint", undated, in the "Seclusion, Take Downs, and Physical Holds" section, revealed risk factors for an individual in a restraint in a "prone position" was positional asphyxia, and staff should: quickly respond to any person's complaint that they could not breath; ensure staff, object, or body positioning was not contributing to diminished air flow; reposition staff and/or client to alleviate pressure; utilize any safety procedures/devices associated with the behavior management system to eliminate pressure; recognize that just because a person could talk or yell did not mean they had adequate oxygen; and discontinue hold/restraints immediately if positional asphyxia was thought to exist. Continued review of the presentation for training revealed risk factors for an individual in a restraint in a "supine" position included the risk for aspiration and staff should monitor breathing closely (face visible); if the individual experiences semi-consciousness and/or unconsciousness, then place individual immediately on their side and check for aspiration; and if vomiting occurred immediately turn the person on their side and clear mouth of any matter. Additional review of the training, revealed for individuals in prone or supine positions, no pressure should be on the individual's neck, chest, or back as spinal injuries/fractures could occur with any age group depending on force and position and children/adolescents with developing/immature bones were more vulnerable to breakage. The training further revealed injury could occur if behavior management techniques were not performed as designed and staff should follow all policies and procedures defined in the approved facility behavior management system.

Review of the facility's PowerPoint for training titled, "Seclusion and Restraint; Registered Nurse (RN) Competency Training", undated, revealed seclusion and restraint were only used as an absolute last resort when all other less restrictive and non-physical interventions were utilized and failed and when there was imminent danger to the physical safety of the patient, staff member, or others. Additionally, seclusion and or/restraints were to be initiated and applied only by trained and competent staff and discontinued at the earliest possible time. Further review of the PowerPoint revealed that only an RN who had been certified through their facility's behavior management program, which included CPI, attended and completed training to be deemed competent, had current Cardiopulmonary Resuscitation (CPR) certification, and had been trained in the safe use and application of restraints may initiate the use of seclusion and restraints after they had deemed that the patient's behavior presented an imminent danger to themselves or others and they ensured all less restrictive measures had been tried or were ineffective at the time. Additionally, the RN who was Certified in Behavior Management CPI was responsible for supervising the Licensed Practical Nurse (LPN) and Mental Health Technician (MHT) for safe use of restraints that included physical hold techniques, correct application, and removal of restraints.

1. Review of Patient #1's Medical Record revealed the patient was admitted by the facility on 09/01/16 with diagnosis to include Oppositional Defiant Disorder, Affective Disorder, Abuse, and Insomnia. The patient was admitted with the chief complaint of homicidal ideation against his/her grandfather.

Review of Patient #1's Initial Nursing Treatment Plan dated 09/02/16, revealed the Short-Term Goals included the patient would notify staff of thoughts of harming self and would demonstrate the use of Music as a coping skill when having thoughts of harming self. Interventions included staff questioning the patient to see if he/she was having thoughts of harming self, mouth checks, and removal of personal items to prevent self-injurious behavior.

Review of Patient #1's Restraint/Seclusion Order/Record, completed by Registered Nurse (RN) #4, dated 10/16/16 at 10:45 with no AM or PM specified, revealed an incident occurred on Unit 6 with the intervention of a Physical Restraint. The Clinical Justification for the Intervention was "danger to others." Patient #1's behavior exhibited included stepping on peers ankle on purpose and then punching ceiling tile and furniture cushion. The Patient verbally threatened staff and then tried to kick down the group room door. Further review revealed less restrictive interventions were attempted which included verbal de-escalation/redirection, Psychoactive medication (non-restraint), and one on one (1:1) processing. Continued review of the Restraint/Seclusion record revealed the patient complained of left shoulder pain, complained the cheek bone "felt like somebody smashed it" and rated pain at a five (5) out of ten (10).

Review of the Internal Risk Management Worksheet, completed by the Director of Risk Management, dated 10/26/16 at 11:44 AM, revealed the incident was documented by RN #4 to have occurred on 10/16/16 at 10:45 AM and entered in at 10/16/16 at 6:38 PM, and stated, "this writer observed patient on the ground in a supine hold restraint." Further review, revealed an abrasion was noted to the left side of the face after release from the restraint, and the patient complained of left shoulder, left face, and right wrist pain.

Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed Patient #1's diagnoses for the ED visit included: Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

Review of Therapist #2's statement, dated 10/17/16, revealed Patient #1 could be heard hitting and kicking walls while MHT #1 could be heard saying, "stop doing that" , "stop kicking" . Further review revealed a commotion in the hall was heard and some of the patients stated MHT #1 slammed Patient #1 to the floor and Patient #1 was "tackled." Interview with the Therapist could not be attempted by the State Agency, as the Therapist was out of the facility on leave.

Per statement of Patient #2, on 10/19/16, Patient #1 was observed to kick the door and MHT #1 picked Patient #1 up and threw him/her on the ground, "slammed him/her down."

Interview with Patient #4, on 10/27/16 at 2:55 PM, revealed earlier that day he/she heard MHT #1 state that if anyone did anything that day, he would restrain them. Patient #4 stated he saw Patient #1 placed in the restraint by MHT #1. The patient stated he/she was in group and observed Patient #1 kicking the door approximately one (1) time and Patient #1 was "slammed" to the ground by MHT #1. Further interview revealed a code was not called, but was often called before a patient was placed in a restraint. Patient #4 stated he/she did not believe the patient should have been placed in a restraint and believed it was inappropriate. Further interview with Patient #4 revealed the facility did not question him/her about the details of the event.

Review of Patient #1's statement, dated 10/19/16, revealed the patient could not recall what he/she was mad about that day, but thought it was because he/she could not reach his/her step-mother on the phone. Further review of the statement revealed MHT #1 told Patient #1 to "stop it" and Patient #4 told Patient #1 that MHT #1 came into work wanting to restrain somebody. Continued review of Patient #1's statement revealed MHT #1 took the arm of the chair out of his/her hands. Patient #1's statement revealed he/she hugged MHT #2, and MHT #2 stated "boundaries" and MHT #1 stated, "bullshit " and got in my face. Patient #1 told MHT #1, that he (MHT #1) had a very punchable face and walked away from MHT #1 and kicked the door. Further review of the statement revealed MHT #1 told Patient #1 to punch him (MHT #1), adding MHT #2 and MHT #3 might have been there. Patient #1's statement revealed MHT #1 took the patient's arms behind him/her and pushed the patient down forcefully and his/her face hit the ground and his/her face got carpet burned. Further review revealed MHT #1 put his hands on the patient's arms and pushed him/her at the neck/shoulder, adding the Emergency Room (ER) informed him/her that he/she had a mild concussion, kink in the neck, and stated, "see my face." Continued review of the statement, revealed the patient thought he/she was in the restraint for approximately three (3) minutes. Per the statement, MHT #1 was told to leave the restraint.

Interview with Patient #1, on 10/26/16 at 1:30 PM, revealed he/she liked MHT #1 before this incident occurred. Patient #1 stated, on the day of the incident, he/she recalled removing an arm from a chair and hitting the corner of a wall. Patient #1 stated MHT #1 took the arm of the chair from him/her and flung it behind him/her. Per interview, MHT #1 then told the patient to go to his/her room, but before he/she went to his/her room, the patient gave MHT #2 a hug, and MHT #2 stated to him/her "boundaries. " Patient #1 stated he/she told MHT #1 that he (MHT #1) had a "punchable " face and MHT #1 stated "do it. " The Patient stated he/she turned around and kicked the door to the group room and MHT #1 grabbed him/her from behind and "flung" him/her to the ground. Patient #1 stated he/she was in a restraint in which four (4) people responded. He/she could not recall everyone who responded but revealed MHT #1, MHT #2, and MHT #3 were there.

Review of MHT #1's statement, dated 10/18/16, revealed he was on his way back to the unit from break when MHT #2 texted him and told him that Patient #1's behavior had been escalating. Per the statement, when he arrived, Patient #1 was in the consult room on Unit 6 and had ripped off the arm of one of the chairs and was swinging it around, (like a weapon) hitting the wall. MHT #1's statement revealed he took this away and asked the patient to get out of the consult room. At this time MHT #2 had another male patient (Patient #2) in the hall as well. Patient #1's behavior continued to escalate and MHT #1 stayed close by. Patient #1 went over to the peer (Patient #2) and stepped onto Patient #2's ankle hurting his/her peer. Patient #1 laughed and told MHT #1 he/she had done it because he/she "made a funny noise." Patient #1 then proceeded to approach MHT #2, wrapping his/her arms around her saying "you are so beautiful." MHT #1 yelled at Patient #1 to stop, as did MHT #2. MHT #1's statement revealed, due to Patient #1's sexually inappropriate history, he (MHT #1) got between MHT #2 and the patient at which time Patient #1 threatened to punch MHT #1 in the face. MHT #1's statement revealed he responded to the patient by saying "just do it" to deflect the attention off of MHT #2 and the other male patient (Patient #2). MHT #1's statement revealed Patient #1 turned and kicked the group room door and seemed to be escalating even more. Per the statement, it was at that time, MHT #1 put his arms through the patient's arms in the back and then "put him/her down".

Further review of MHT #1's statement, revealed when staff arrived the patient was turned. Per the statement, when this happened Patient #1 stated "Now I am really pissed " and started resisting, and that is when he leaned over to hold the patient's knees. MHT #1 was then told to switch out, which he did with MHT #2. He was told to go to the ARC Unit. The Nursing supervisor/Registered Nurse (RN) #2, then asked MHT #1 to go home and he was suspended until an internal investigation of the event was completed. Continued review of the statement revealed he took the patient down by himself, thinking of the safety of "my" staff and the other patient. Per the statement, he used force to protect MHT #2 and the patient, and there was not a code button and he did not think to ask MHT #2 to call a code. Per the statement, he did not utilize approved NCI tactics and his mindset was on protecting staff and the other patient. Per the statement, MHT #1 initially stated he felt he had done the right thing, but then when questioned, he stated he would have done things differently and would have followed policy and procedure, and had other staff call team support or code yellow.

Telephone interview with MHT #1, on 10/27/16 at 9:58 AM, revealed on the day of the incident, he went on lunch break while the patients were in group therapy. He stated he asked MHT #2 to contact him if the patients were escalating and if she needed assistance with them. Continued interview with MHT #1, revealed he received a text message from MHT #2 to come back to the facility because Patient #1 was going off. He stated when he got back to the facility, Patient #1 was observed in the Consult room, on Unit 6, to rip off the arm of a chair and was swinging at the wall, laughing about it. MHT #1 stated he caught the chair arm, mid swing, from Patient #1. MHT #1 stated the patient tried to grab the table, but he (MHT #1) sat on the table. MHT #1 revealed Patient #4 was out of group and laughing about the whole situation and then ended up going back to therapy. Further interview revealed Patient #1 and Patient #2 were observed to be out of group and Patient #1 then stepped on Patient #2's ankle while Patient #1 laughed hysterically. MHT #1 stated he asked Patient #1 why he/she would stand on Patient # 2's ankle and the patient stated he/she made a "funny" noise, adding he (MHT #1) attempted to verbally de-escalate Patient #1. MHT #1 stated this did not work because Patient #1 was ignoring him.

Further interview with MHT #1, revealed Patient #1 then turned his/her attention to MHT #2 and backed her into the corner of the wall on the Unit and started to make sexually inappropriate comments, adding the patient stated to MHT #2, she was beautiful and wrapped his/her arms around her while attempting to touch her. He stated MHT #2 yelled for Patient #1 to get off of her. MHT #1 revealed his focus was to get the attention taken off of MHT #2 and Patient #2. According to MHT #1, Patient #1 then asked him if he was trying to get hit, and MHT #1 told the patient, "go ahead and do it." He stated at that point Patient #1 turned and kicked the door to the group room, where other patients were in the room for therapy. MHT #1 revealed he could not de-escalate the patient, thus MHT #1 grabbed Patient #1's arms from behind and looped his/her arms around where the patient's elbows bent and Patient #1 hit the ground, falling face down. He stated he flipped the patient over and other staff came to assist with the hold. MHT #1 stated MHT #2 "was in shock" and he acted for the safety of the patients, who were in group therapy, and "staff ", being MHT #2. When staff came to assist with the hold, he stated they asked him what happened, but before he could answer he grabbed Patient #1's leg to make sure he/she did not kick anyone in the face. He stated that while in the hold, he told RN #4 that Patient #1 needed to be in 1A ( a seclusion room he reported was on the geriatric unit) because he/she was a "danger."

Continued interview with MHT #1, revealed MHT #2 was asked to replace him in the hold and he walked to the ARC unit, adding he did not provide care for other patients while there. He stated he was informed by the nursing supervisor, RN #2, that the patient had carpet burns from the restraint and the facility would conduct an investigation. MHT #1 stated he was told by staff that the patient had concussion like symptoms and that the patient hit the ground pretty hard. MHT #1 stated the only people involved in the incident or who observed the incident were MHT #2, Patient #2, and Patient #1. Additionally, MHT #1 revealed the restraint he placed Patient #1 in was not an appropriate restraint, adding, "it was an old military move" he learned from being in the military and "knew" it would not hurt the patient. He stated he knew the patient was large and had him "beat" in weight. He revealed it was not a proper NCI hold, but it was a restraint that could be used for someone larger than you. MHT #1 stated there was no other hold he could have performed to de-escalate the situation, adding " others would have gotten hurt". MHT #1 stated there was nothing he would have done differently, but added he could have had MHT #2 or somebody to call a code for additional team support to put the patient in a "safer" hold.

Interview with MHT #2, on 10/27/16 at 1:02 PM, revealed the facility provided NCI training upon hire and annually. She stated staff was taught that there were different stages of crisis and also taught what was going on in a patient's mind during those stages. She further stated when a patient was anxious, they would start losing rational thought and they paid more attention to the staff members' body language instead of words. MHT #2 revealed a physical restraint was the last resort and should only be used when there was imminent danger to patient and/or staff. Additionally, MHT #2 conveyed, when putting a patient in a physical restraint, staff should communicate with each other, adding it took two (2) people to properly restrain a person, as per NCI techniques. She stated staff would talk about what they would do, often attempting to verbally de-escalate the patient first, which often did not work. She further stated a code would not be called unless there was danger to patient and/or staff. MHT #2 stated, on the day of the incident, there were patients who were excused from group therapy and they were exhibiting behaviors. She stated Patient #1 obtained objects from the ceiling, tore signs off the wall, and grabbed a piece off a chair and was throwing it. She further stated she was on the unit by herself, thus went to the nursing station and texted MHT #1 to come back to work.

Continued interview with MHT #2, revealed it was not safe for her at that point to be left alone with the other patients. She stated Patient #1 was aggravating Patient #2, stepped on Patient #2's ankle, and Patient #1 was not easily redirected. MHT #2 stated Patient #1 then turned to give her a hug and she told him/her to respect her boundaries, and not to touch her. MHT #2 stated, MHT #1 then told Patient #1 not to touch staff. She stated Patient #1 then grabbed her and wrapped his/her arms around her. She stated this made her feel violated and she "froze". She further stated Patient #1 then kicked the door, which lead to the group room, adding, "there were other patients in the room." MHT #2 revealed Patient #1 turned to MHT #1, and she thought the patient was going to hit her or MHT #1, and thought the patient was hostile. She further stated that at that moment, neither she nor MHT #1 could de-escalate Patient #1. However, MHT #2 revealed she did not refer to Patient #1's treatment plan, which provided suggestions to use to de-escalate the patient. MHT #2 stated she was not aware of the patient's treatment plan, but added it would have been important to have referred to it for interventions in which to calm the patient. Continued interview with MHT #2, revealed MHT #1 then "took" the patient down by getting behind the patient, taking him/her to the ground. She stated she switched out with MHT #1 after Patient #1 was calm. MHT #2 stated Patient #1 was not placed in a proper restraint, as taught by NCI, but MHT #1 was "on his own." Further interview revealed it would have been helpful to have had someone to assist MHT #1 with Patient #1. She stated she called the house supervisor/RN #2, and could have pressed the button to call a code, but felt it was more important to call the supervisor. MHT #2 stated, the importance for calling a code was to send more people to assist and for the safety of the patient, as well as staff.

Interview with MHT #3, on 10/26/16 at 2:15 PM, revealed it was the facility's policy to verbally de-escalate the patient before staff would place hands on the patient. She stated staff should always offer an alternative solution. Continued interview with MHT #3 revealed Patient #1 was a difficult patient based upon his/her history, however; the patient was not aggressive with staff, adding she had a good rapport with the patient. MHT #3 revealed the incident occurred on a Saturday or Sunday, in the morning, around 10:00 AM or 11:00 AM. She stated she was working on Unit 5 and was in the nurse's station to get something when she heard Patient #1 punching something. She further stated when she looked up, she saw MHT #1 take the patient from behind and " lifted " Patient #1 off the ground and " slammed " him/her on the floor. Further interview, revealed by the time she got there, the patient was on the ground face down. MHT #3 stated she told MHT #1 the patient had to be turned face up. She stated she was on the patient's left side while MHT #1 was on the right side of the patient. She further stated the patient was attempting to get off the floor and he/she was making threats to MHT #1. MHT #2 stated MHT #1 did not say anything at that time, but rather grabbed the patient's knee with both of his hands. She stated she told MHT #1 that he needed to hold the patient "correctly".

Further interview with MHT #3, revealed two (2) nurses came in to assist with the hold, and RN #4 was at the patient's head and RN #3 took the patient's leg. MHT #3 stated at this time, MHT #2 was standing about five (5) feet away and never intervened, until she was told to replace MHT #1 to hold the patient's arm. Continued interview revealed MHT #1 then yelled " I want him/her out of here, off the unit. I want him/her on 1A ", as Patient #1 was crying and yelling at MHT #1. Per interview, the patient was in the hold, from beginning to end, no more than five (5) minutes. MHT #3 stated she did not see the incident which lead up to the restraint, but from what she knew of the patient, he/she often banged on walls, and it was therapeutic for him/her. Thus, thought it was unnecessary to place the patient in a restraint. She revealed that once the patient was in the restraint, it was necessary to continue the restraint for the safety of the staff and the patient.

Interview with RN #3, on 10/27/16 at 3:28 PM, revealed the facility provided training on the proper NCI techniques. She stated physical restraint would not be used unless the patient was harming self and/or others and staff should try to verbally de-escalate the patient first. She further stated, often staff would ask the patient upon admission what worked for them when they were upset, and it would be developed in the patients Treatment Plan. RN #3 revealed, if the patient was banging and hitting things, then ideally staff would want to back away to determine what triggered the behavior. Per interview with RN #3, if verbal de-escalation did not work, a code would be called to get more people involved so that staff and/or the patient would not be in danger.

Continued interview with RN #3 revealed, on the day of the incident with Patient #1, she was the charge nurse on a different unit. She stated that while in the nurses station, she looked up and saw MHT #1 take Patient #1 down. Patient #1's arms were behind him/her and MHT #1 was behind him/her holding his/her arms and pushed the patient down on the ground. She stated the patient was observed to be on his/her stomach, but eventually, got on his/her back. Further interview with RN #3, revealed MHT #3 was on Patient #1's right leg, RN #4 was on the patient's right arm, MHT #3 was on the patient's left arm while she had the patient's left leg. RN #3 revealed RN #4 knew something was not right with the way MHT #1 was holding the patient's leg and he was "worked" up, saying, " Patient #1 needed to be sent over to 1A ( an area in which patients were sent when they were not safe to be with other patients). RN #3 stated Patient #1 started to calm down, so she was not holding the patient's leg tight. She stated MHT #1 then reached over and pinned the patient's leg down, which was the leg RN #3 was holding. Continued interview with RN #3, revealed that was not an appropriate move, adding staff should not cross into another area in which a staff member was holding. RN #3 stated MHT #1 needed to be switched out because there "wasn't something right", related to the way MHT #1 was talking.

Further interview with RN #3, revealed she could not remember a code being called, but it would have been appropriate for a code to have been called. She stated the restraint Patient #1 was placed in, was not a proper restraint/take down. She further stated historically, the patient was aggressive in the sense of "punching" things, but had not physically hurt staff or his/her peers. Per interview, she did not feel the restraint was appropriate because the patient did not appear to be a danger to himself/herself or anyone else. Additionally, she stated she did not know if re-education would have been effective for MHT #1, because he/she was impulsive at time

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to ensure patients had the right to be free from all forms of abuse or harassment. Additionally, the facility failed to immediately report allegations of abuse and failed to ensure a thorough investigation was completed for allegations of abuse for one (1) of ten (10) sampled patients (Patient #1 ).

On 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. Mental Health Technician (MHT) #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then the patient was turned over in a "supine" restraint which was an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Additionally, staff interviews revealed they did not refer to the patients Treatment Plan for a less-restrictive intervention. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, Strain of Neck Muscle, and Cervical Sprain.

The facility failed to conduct a thorough investigation and failed to question other patients who may have witnessed the incident related to Patient #1, or may have been unnecessarily placed in restraints by MHT #1, and failed to question staff as to whether other patients had been improperly restrained by MHT #1. In addition, the facility did not ensure the Department of Community Services (DCBS), received the allegation of abuse related to Patient #2 as per facility's policy and state regulations.

The findings include:

Review of the facility's Employee Training Manual, titled, " Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior ", copyright date 2005, revealed the Nonviolent Crisis Intervention (CSI) program was a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Additionally, the training manual conveyed that any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention. Continued review of the training manual, stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor to restrain an individual, and floor restraints were not part of the teaching of NCI. Continued review revealed face down (prone) floor restraints and positions in which a person was bent over in such a way made it difficult to breathe and was extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review of the policy revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients, intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior, use verbal techniques to de-escalate behavior, demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level, provide for the care, welfare, safety and security of all those who were involved in a crisis situation, and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint presentation for training titled, "Identifying and Managing Risk Factors Associated with Seclusion and Restraint", undated, in the "Seclusion, Take Downs, and Physical Holds" section, revealed risk factors for an individual in a restraint in a "prone position" was positional asphyxia, and staff should: quickly respond to any person's complaint that they could not breath; ensure staff, object, or body positioning was not contributing to diminished air flow; reposition staff and/or client to alleviate pressure; utilize any safety procedures/devices associated with the behavior management system to eliminate pressure; recognize that just because a person could talk or yell ddid not mean they had adequate oxygen; and discontinue hold/restraints immediately if positional asphyxia was thought to exist. Continued review revealed risk factors for an individual in a restraint in a supine position included the risk for aspiration and staff should monitor breathing closely (face visible); if the individual experiences semi-consciousness and/or unconsciousness then place individual immediately on their side and check for aspiration; and if vomiting occurred then immediately turn the person on their side and clear mouth of any matter. Additional review of the training presentation revealed for individuals in prone or supine positions, no pressure should be on the individual's neck, chest, or back and spinal injuries/fractures could occur with any age group depending on force and position and children/adolescents with developing/immature bones were more vulnerable to breakage. The training presentation further revealed injury could occur if behavior management techniques were not performed as designed and staff should follow all policies and procedures defined in the approved facility behavior management system.

Review of the facility's "Suspected Patient Neglect and Abuse by Staff" Policy, revised May 2007, revealed it was the purpose of the facility to protect the patient's rights, health and safety. Per Policy, abuse was defined as any physical or verbal action directed towards a patient, who was or could be harmful or demeaning to his/her safety, welfare and well being and the facility did not condone any action, which could be constructed as neglect or abuse. Every staff member was expected to report any incident of possible neglect or abuse and any suspected or witnessed incidents of either neglect or abuse immediately to the staff member's immediate supervisor or in his/her absence, to the Director of Nursing and Director of Clinical Services. All allegations were to be immediately investigated by a team to include the Risk Manager, in collaboration with the Department/Unit Manager, Director of Nursing and Director of Clinical Services. The Director of Human Resources would be notified and provide oversight and direction to assure that the Human Resources policies were followed. The Chief Executive Officer (CEO) would be immediately apprised of the allegation and investigation results and approve the final decision in all cases. Additionally, the Investigative Team would conduct the investigation by interviewing those involved and complete a report of each interview. The employee's personal record would be reviewed for prior complaints or counseling and if disciplinary action was needed, the Director of Human Resources would ensure appropriate actions were taken by the Hospital. The Director of Clinical Services or designee would make external notification to the appropriate State Agency. Any supervisor who received information, written or oral of alleged patient abuse or neglect, and failed to respond, would be subject to disciplinary action up to and including employment termination.

Review of the facility's "Reporting Child Abuse" Policy, revised July 2013, revealed, According to Kentucky Revised Status (KRS) 199.001, adults who abuse or neglect children (under eighteen 18 years of age) were committing a Class A misdemeanor. Failure to report the abuse or neglect of a child in Kentucky to the Cabinet for Human Resources was a Class B misdemeanor. It was essential that the facility protected children in accordance with KRS 199.001 and make appropriate referral to the Cabinet for Human Services. Continued review of the policy revealed any staff member of the facility who observed or received report of a child being abused or neglected or had reason to suspect that a child had been abused or neglected, must report this information immediately to the twenty-four (24) hour Kentucky (KY) Abuse Hotline, and to the Unit Charge Nurse and Department Manager, or Nursing House Supervisor. When reporting abuse or neglect, staff should be mindful if the perpetrator was responsible for caring for the child at the time of the abuse. Continued review, revealed the report would be called to the Department for Community Based Services, in the community where the child resides. Further review of the policy revealed the criteria for identification or potential victims of abuse would include visible observation of bruises, lacerations, or broken bones that lead staff to suspect abuse.

Review of MHT #1's "CPI" (Nonviolent Crisis Intervention Program) Blue Card revealed he completed eight (8) hours of training in the Nonviolent Crisis Intervention Training Program, issued December 2015 and expired December 2016.

Review of MHT #1's ninety (90) day Performance Appraisal, dated 05/12/16, revealed MHT #1 was "Unsatisfactory" in adherence to policies and regulations, Quality and/or Accuracy of work, and in Service Excellence, which incorporated practicing Teamwork. Additional review revealed the Supervisor Comments conveyed MHT #1 displayed poor therapeutic boundaries, for example, self-disclosure, sharing information about one (1) patient to another. He did not use the best judgement concerning milieu management (The physical or social setting in which something occurs or develops), for example MHT #1 had the knowledge that two (2) of the patients were "boyfriend" and "girlfriend" and they should not have attended any groups together. This information should have been reported to other staff and did not occur. He attempted to practice outside of his scope by making medical diagnoses and by running groups that were therapy-based instead of educationally based. MHT #1 needed to show improvement in these areas. Further review revealed MHT #1 used inappropriate language in front of and directed toward patients on at least one occasion as reported by a co-worker.

Review of MHT #1's ninety (90) day Performance Appraisal, dated 06/21/16, revealed he met expectations, with one (1) incident related to safety. Continued review revealed MHT #1 needed to focus on MHT #1's duties related to Milieu Management (The physical or social setting in which something occurs or develops), verbal de-escalation, providing groups, and letting the therapist do the therapy.

Review of Patient #1's Medical Record revealed the patient was admitted by the facility on 09/01/16 with diagnosis to include Oppositional Defiant Disorder, Affective Disorder, Abuse, and Insomnia. The patient was admitted with the chief complaint of homicidal ideation against his/her grandfather.

Review of Patient #1's Initial Nursing Treatment Plan, dated 09/02/16, revealed the Short-Term Goals included the patient would notify staff of thoughts of harming self and would demonstrate the use of Music as a coping skill when having thoughts of harming self. Interventions included staff questioning the patient to see if he/she was having thoughts of harming self, mouth checks, and removal of personal items to prevent self-injurious behavior.

Review of Patient #1's Restraint/Seclusion Order/Record, completed by Registered Nurse (RN) #4, dated 10/16/16 at 10:45 with no AM or PM specified, revealed an incident occurred on Unit 6 with the intervention of a Physical Restraint. The Clinical Justification for the Intervention was "danger to others". Patient #1's behavior exhibited included stepping on peers ankle on purpose and then punching ceiling tile and furniture cushion. The Patient verbally threatened staff and then tried to kick down the group room door. Further review revealed less restrictive interventions were attempted which included verbal de-escalation/redirection, Psychoactive medication (non-restraint), and one on one (1:1) processing. Continued review of the Restraint/Seclusion record revealed the patient complained of left shoulder pain, complained the cheek bone "felt like somebody smashed it" and rated pain at a five (5) out of ten (10).

Review of the Facility's "Form/Document", titled "Report of Suspected Abuse/Neglect", dated 10/16/16, signed by Registered Nurse (RN) #4, revealed Patient #1 incurred injuries after being placed in a restraint by staff; however; there was no documented evidence the document was sent to DCBS.

Review of the Internal Risk Management Worksheet, completed by the Director of Risk Management, dated 10/26/16 at 11:44 AM, revealed the incident was documented by RN #4 to have occurred on 10/16/16 at 10:45 AM and entered in at 10/16/16 at 6:38 PM, stating, "this writer observed patient on the ground in a supine hold restraint." Further review, revealed an abrasion was noted to the left side of the face after release from the restraint, and the patient complained of left shoulder, left face, and right wrist pain.

Review of the Hospital's Emergency Department (ED) "After Visit Summary " , dated 10/17/16, revealed Patient #1's diagnoses for the ED visit included: Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle with diagnoses including a Head injury, Concussion, Abrasion of Face, Strain of Neck Muscle, and Cervical Sprain.

Per statement of Patient #2, on 10/19/16, Patient #1 was observed to kick the door and MHT #1 picked Patient #1 up and threw him/her on the ground, "slammed him/her down." Further review, revealed they made Patient #2 go back to group. Patient #2 recalled MHT #3 in the nurse's station.

Interview with Patient #4, on 10/27/16 at 2:55 PM, revealed earlier that day he/she heard MHT #1 state that if anyone did anything that day, he would restrain them. Patient #4 stated he/she saw Patient #1 placed in the restraint by MHT #1. The patient stated he/she was in group and he/she observed Patient #1 kicking the door approximately one (1) time and Patient #1 was "slammed" to the ground by MHT #1. Further interview revealed he/she did not believe Patient #1 should have been placed in a restraint and believed it was inappropriate. Further interview with Patient #4 revealed the facility did not question him/her about the details of the event and all the other patients who observed the incident had since been discharged from the facility.

Review of Patient #1's statement, dated 10/19/16, revealed the patient could not recall what he/she was mad about that day, but thought it was because he/she could not reach his/her step-mother on the phone. Further review of the statement revealed MHT #1 told him/her to "stop it" and Patient #4 told him/her that MHT #1 came into work wanting to restrain somebody. Continued review of the statement revealed MHT #1 took the arm of the patient's chair out of his/her hands. Patient #1 stated he/she hugged MHT #2 and she stated "boundaries" and MHT #1 stated "bullshit" and got in my face. Per the statement Patient #1 told MHT #1, that MHT #1 had a very punchable face and walked away from him and kicked the door. Further review of the statement revealed the patient noted MHT #1 to punch him/her, adding MHT #2 and MHT #3 might have been there. Patient #1's statement revealed, MHT #1 took his/her arms behind him/her and pushed him/her down forcefully and his/her face hit the ground and his/her face got carpet burned. Further review revealed MHT #1 put his hands on the patient's arms and pushed him/her at the neck/shoulder, adding the Emergency Room (ER) informed him/her that he/she had a mild concussion, kink in the neck, and stated, "see my face."

Interview with Patient #1, on 10/26/16 at approximately 1:30 PM, revealed he/she liked MHT #1 before this incident occurred. Patient #1 stated that on the day of the incident, he/she recalled removing an arm from a chair and hitting the corner of a wall. He/she stated MHT #1 took the arm of the chair from him/her and flung it behind him/her. Per interview, MHT #1 then told the patient to go to his/her room, but before he/she went to his/her room, the patient gave MHT #2 a hug, and MHT #2 stated to him/her "boundaries" . Patient #1 stated he/she told MHT #1 that MHT #1 had a "punchable" face and MHT #1 stated "do it". The Patient stated he/she turned around and kicked the door to the group room and MHT #1 grabbed him/her from behind and "flung" him/her to the ground.

Review of MHT #1's statement, dated 10/18/16, revealed he was on his way back to the unit from break when MHT #2 texted him and told him that Patient #1's behavior had been escalating. Per the statement, when he arrived, Patient #1 was in the consult room on Unit 6 and had ripped off the arm of one of the chairs and was swinging it around, (like a weapon) hitting the wall. MHT #1's statement revealed he took this away and asked the patient to get out of the consult room. At this time MHT #2 had another male patient (Patient #2) in the hall as well. Patient #1's behavior continued to escalate and MHT #1 stayed close by. Patient #1 went over to the peer (Patient #2) and stepped onto Patient #2's ankle hurting his/her peer. Patient #1 laughed and told MHT #1 he/she had done it because he/she "made a funny noise." Patient #1 then proceeded to approach MHT #2, wrapping his/her arms around her saying "you are so beautiful." MHT #1 yelled at Patient #1 to stop, as did MHT #2. MHT #1's statement revealed, due to Patient #1's sexually inappropriate history, he got between MHT #2 and the patient at which time Patient #1 threatened to punch MHT #1 in the face. MHT #1's statement revealed he responded to the patient by saying "just do it" to deflect the attention off of MHT #2 and the other patient (Patient #2). MHT #1's statement revealed Patient #1 turned and kicked the group room door and seemed to be escalating even more. Per the statement, it was at that time, MHT #1 put his arms through the patient's arms in the back and then "put him/her down".

Further review of MHT #1's statement, revealed when staff arrived the patient was turned. Per the statement, when this happened Patient #1 stated "Now I am really pissed " and started resisting, and that is when he leaned over to hold the patient's knees. MHT #1 was then told to switch out, which he did with MHT #2. He was told to go to the ARC Unit. The Nursing supervisor/Registered Nurse (RN) #2, then asked MHT #1 to go home and he was suspended until an internal investigation of the event was completed. Continued review of the statement revealed he took the patient down by himself, thinking of the safety of "my" staff and the other patient. Per the statement, he used force to protect MHT #2 and the patient, and there was not a code button and he did not think to ask MHT #2 to call a code. Per the statement, he did not utilize approved NCI tactics and his mindset was on protecting staff and the other patient. Per the statement he initially stated he felt he had done the right thing, but then when questioned he stated he would have done things differently and would have followed policy and procedure, and had other staff call team support or code yellow.

Telephone interview with MHT #1, on 10/27/16 at 9:58 AM, revealed on the day of the incident, he went on lunch break while the patients were in group therapy. He stated he asked MHT #2 to contact him if the patients were escalating and if she needed assistance with them. Continued interview with MHT #1, revealed he received a text message from MHT #2 to come back to the facility because Patient #1 was going off. He stated when he got back to the facility, Patient #1 was observed in the Consult room, on Unit 6, to rip off the arm of a chair and was swinging at the wall, laughing about it. MHT #1 stated he caught the chair arm, mid swing, from Patient #1. He stated the patient tried to grab the table, but MHT #1 sat on the table. MHT #1 revealed Patient #4 was out of group and laughing about the whole situation and then ended up going back to therapy. Further interview revealed Patient #1 and Patient #2 were observed to be out of group and Patient #1 then stepped on Patient #2's ankle while Patient #1 laughed hysterically. MHT #1 stated he asked Patient #1 why he/she would stand on Patient # 2's ankle and he/she stated the patient made a "funny" noise, adding he attempted to verbally de-escalate Patient #1. MHT #1 stated this did not work because Patient #1 was ignoring him.

Further interview with MHT #1, revealed Patient #1 then turned his/her attention to MHT #2 and backed her into the corner of the wall and started to make sexually inappropriate comments. MHT #1 revealed Patient #1 stated to MHT #2, she was beautiful and wrapped his/her arms around her while attempting to touch her. He stated MHT #2 yelled for Patient #1 to get off of her. MHT #1 revealed his focus was to get the attention taken off of MHT #2 and Patient #2. According to MHT #1, Patient #1 then asked him if he was trying to get hit, and MHT #1 told the patient, "go ahead and do it." He stated at that point Patient #1 turned and kicked the door to the group room, where other patients were in the room for therapy. MHT #1 revealed he could not de-escalate the patient, thus MHT #1 grabbed Patient #1's arms from behind and looped his/her arms around where the patient's elbows bent and Patient #1 hit the ground, falling face down. He stated he flipped the patient over and other staff came to assist with the hold. MHT #1 stated MHT #2 "was in shock" and he acted for the safety of the patients, who were in group therapy, and "staff ", being MHT #2. When staff came to assist with the hold, he stated they asked him what happened, but before he could answer, he grabbed Patient #1's leg to make sure he/she did not kick anyone in the face. He stated that while in the hold, he told RN #4 that Patient #1 needed to be in 1A ( a seclusion room he reported was on the geriatric unit) because he/she was a "danger."

Continued interview with MHT #1, revealed MHT #2 was asked to replace him in the hold and he walked to the ARC unit, adding he did not provide care for other patients while there. He stated he was informed by the nursing supervisor, RN #2, that the patient had carpet burns from the restraint and the facility would conduct an investigation. MHT #1 stated he was told by staff that the patient had concussion like symptoms and that the patient hit the ground pretty hard. MHT #1 stated the only people involved in the incident or who observed the incident were MHT #2, Patient #2, and Patient #1. Additionally, MHT #1 revealed the restraint he placed Patient #1 in was not an appropriate restraint, adding, "it was an old military move" he learned from being in the military and "knew" it would not hurt the patient. He stated he knew the patient was large and had him "beat" in weight. He revealed it was not a proper NCI hold, but it was a restraint that could be used for someone larger than you. MHT #1 stated there was no other hold he could have performed to de-escalate the situation, adding " others would have gotten hurt". MHT #1 stated there was nothing he would have done differently, but added he could have had MHT #2 or somebody to call a code for additional team support to put the patient in a "safer" hold.

Review of MHT #2's statement, dated 10/16/16, revealed that at approximately 10:45 AM, Patient #1 tried to touch MHT #2 by reaching out his/her hands to come in for a hug and she proceeded to hold her hands up and redirect him/her for boundaries. Per the statement, MHT #1 redirected Patient #1 as well to "stop touching " people. Further review revealed Patient #1 threatened MHT #1 by saying "I am going to punch you in the face." Patient #1 then turned around and kicked the group room door. Per the statement, this was when MHT #1 responded with the take down by putting his arms under Patient #1's arms and taking him/her down to the ground. MHT #1 then restrained the patient on the floor and MHT #3, RN #4, RN #3, came to help hold the patient down. In order to get MHT #1 out of the situation, MHT #2 stated she replaced him in the restraint while trying to talk to the patient calmly. Further review of the statement revealed they were able to let the patient go, and the patient go up, then tore the casing off of the camera, as well as hit a door.

Interview with MHT #2, on 10/27/16 at 1:02 PM, revealed the facility provided NCI training upon hire and annually. She stated staff was taught that there were different stages of crisis and also taught what was going on in a patients mind during those stages. She further stated when a patient was anxious, they would start losing rational thought and they paid more attention to the staff members' body language instead of words. MHT #2 revealed a physical restraint was the last resort and should only be used when there was imminent danger to patient and/or staff. Additionally, MHT #2 conveyed, when putting a patient in a physical restraint, staff should communicate with each other, adding it took two (2) people to properly restrain a person, as per NCI techniques. She stated staff would talk about what they would do, often attempting to verbally de-escalate the patient first, which often did not work. She further stated a code would not be called unless there was danger to patient and/or staff. MH #2 stated, on the day of the incident, there were patients who were excused from group therapy and they were exhibiting behaviors. She stated Patient #1 obtained objects from the ceiling, tore signs off the wall, and grabbed a piece off a chair and was throwing it. She further stated she was on the unit by herself, thus went to the nursing station and texted MHT #1 to come back to work.

Continued interview with MHT #2, revealed it was not safe for her at that point to be left alone with the other patients. She stated Patient #1 was aggravating Patient #2, stepped on Patient #2's ankle, and Patient #1 was not easily redirected. MHT #2 stated Patient #1 then turned to give her a hug and she told him/her to respect her boundaries, and not to touch her. MHT #2 stated, MHT #1 then told Patient #1 not to touch staff. She stated Patient #1 then grabbed her and wrapped his/her arms around her. She stated this made her feel violated and she "froze". She further stated Patient #1 then kicked the door, which lead to the group room, adding, "there were other patients in the room." MHT #2 revealed Patient #1 turned to MHT #1, and she thought the patient was going to hit her or MHT #1, and thought the patient was hostile. She further stated that at that moment, neither she nor MHT #1 could de-escalate Patient #1. However, MHT #2 revealed she did not refer to Patient #1's treatment plan, which provided suggestions to use to de-escalate the patient. MHT #2 stated she was not aware of the patient's treatment plan, but added it would have been important to have referred to it for interventions in which to calm the patient.

Continued interview with MHT #2, revealed MHT #1 then "took" the patient down by getting behind the patient, taking him/her to the ground. She stated she switched out with MHT #1 after Patient #1 was calm. MHT #2 stated Patient #1 was not placed in a proper restraint, as taught by NCI, but MHT #1 was "on his own." Further interview revealed the incident happened so quick that she could not call a code, but it would have been helpful to have had someone to assist MHT #1 with Patient #1. She stated she called the house supervisor/RN #2. Additionally, she stated she could have pressed the button to call a code, but felt it was more important to call the supervisor. MHT #2 stated, the importance for calling a code was to send more people to assist and for the safety of the patient, as well as staff.

Review of MHT #3's statement, undated, revealed she heard yelling coming from Unit 6. MHT #1 grabbed Patient #1 and "took him/her down." Per review of the statement, by the time she got to the incident, MHT #1's hand was on Patient #1's head/neck area and his knee was on the Patient's back, face down, holding him/her down by himself. She assisted MHT #1 with getting Patient #1 on his/her back. Per the statement, MHT #1 moved his knee to the patient's arm and chest, across them. Continued review of the statement, revealed MHT #3 was angry, and she as well as, RN #4 yelled for MHT #1 to get off of the patient. Per the statement, MHT #1 could be heard saying, "I want him/her on 1A, I'm tired of this shit " and MHT #1 was told to switch out with MHT #2. Further review of the statement revealed there was no team support called stating, "it was like no remorse. It was rough. It was bad and I would be afraid for the patients if MHT #1 ever did this again."

Interview with MHT #3, on 10/26/16 at 2:15 PM, revealed it was the facility's policy to verbally de-escalate the patient before staff would place hands on the patient and staff should always offer an alternative solution. Continued interview with MHT #3 revealed Patient #1 was a difficult patient based upon his/her history, however; the patient was not aggressive with staff, adding she had a good rapport with the patient. MHT #3 revealed the incident occurred on a Saturday or Sunday, in the morning, around 10:00 AM or 11:00 AM. She stated she was working on Unit 5 and was in the nurse's station to get something when she heard Patient #1 punching something. She further stated when she looked up, she saw MHT #1 take the patient from behind and " lifted " Patient #1 off the ground and " slammed " him/her on the floor.

Further interview with MHT #3, revealed by the time she got there, the patient was on the ground face down. MHT #3 stated she told MHT #1 the patient had to be turned face up. She stated she was on the patient's left side while MHT #1 was on the right side of the patient. She further stated the patient was attempting to get off the floor and he/she was making threats to MHT #1. MHT #2 stated MHT #1 did not say anything at that time, but rather grabbed the patient's knee with both of his hands. She stated she told MHT #1 that he needed to hold the patient "correctly". Per interview, two (2) nurses came in to assist with the hold, and RN #4 was at the patient's head and RN #3 took the patient's leg. MHT #3 stated at this time, MHT #2 was standing about five (5) feet away and never intervened, until she was told to replace MHT #1 to hold the patient's arm. Continued interview revealed MHT #1 then yelled " I want him/her out of here, off the unit. I want him/her on 1A ", as Patient #1 was crying and yelling at MHT #1.

Continued interview with MHT #3, revealed Patient #1 was in the hold, from beginning to end, no more than five (5) minutes. MHT #3 stated she did not see the incident which lead up to the restraint, but from what she knew of the patient, he/she often banged on walls, and it was therapeutic for him/her. She revealed that once the patient was in the restraint, it was necessary to continue the restraint for the safety of the staff and the patient, but felt it was an unnecessary restraint. Further interview with MHT #3 revealed the incident with Patient #1 was abusive and the Department of Community Based Services (DCBS) should have been notified immediately.

Review of RN #3's statement, dated 10/17/16, revealed she was in the nurses' station when the incident occurred, adding it was a "blur". Per the statement, the incident occurred outside group room Hall 6 and she saw MHT #1 taking Patient #1 down. Per the statement she only recalled RN #4 and MHT #3 responding. Further review of the statement revealed Patient #

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to ensure all patients were free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff for two (2) of ten (10) sampled patients (Patient #1 and Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. There was no documented evidence staff attempted less restrictive interventions prior to use of the restraint, no documented evidence a Physician's order was obtained for the restraint, and no documentation related to the use of the restraint. Additionally, there was no documented evidence to support MHT #1 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he was observed to use the improper restraint, and MHT #1 continued to work with patients.

On the next day, 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. MHT #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then turned the patient over in a "supine" restraint. This was a an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Staff interviews revealed they did not attempt a less restrictive intervention prior to the restraint. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

The findings include:

Review of the facility's policy, titled "Restraint" , revised April 2010, and reviewed July 2013, revealed the patient had the right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff. A physical restraint was defined as the application of physical force alone restricting the free movement of the whole or portion of an individual's body in order to control physical activity. It was the policy of the facility to limit the use of restraints to emergencies in which there was an imminent risk of a patient physically harming him/herself or others. Restraints would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to the patient or others prior to the application of restraints. Attempts to use less restrictive measures, as well as the patient's response to those measures would be recorded on the Seclusion and Restraints Assessment form. Further review revealed the facility was committed to preventing, reducing and striving to eliminate the use of restraints, as well as preventing emergencies that have the potential to lead to the use of restraints.

Review of the facility's Employee Training Manual, titled, " Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior " , copyright date 2005, revealed the Nonviolent Crisis Intervention (CSI) program was a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint was recommended only when all less-restrictive methods of intervening had been exhausted, and when the individual presented a danger to self or others. Additionally, the training manual conveyed that any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention.

Continued review of the training manual stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor to restrain an individual, and floor restraints were not part of the teaching of NCI. Further review revealed face down (prone) floor restraints and positions in which a person was bent over in such a way made it difficult to breathe and was extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively. Finally, the training emphasizes the NPCI's intent was to calm the individual, to keep the individual off the floor, thus reducing risks of Restraint-Related positional asphyxia and other injuries. Team interventions would be used when necessary and the NPCI would be used only as a last resort when someone presents a danger.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients; and intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior; use verbal techniques to de-escalate behavior; demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level; provide for the care, welfare, safety and security of all those who were involved in a crisis situation; and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint presentation for training titled, "Code Class", dated 2016, revealed the team support, de-escalation assistance, should be called when the patient was defensive and at the beginning stage of loss of rationality. Crisis Development Model Level two (2) was a stage in which an individual often becomes belligerent and challenges authority. Continued review revealed staff should be directive, an approach in which a staff member takes control of a potentially escalating situation. Staff should remember that the patient may not be able to respond to the rational context of your words. Instead the patient may be more in tune with other types of communication such as your tone of voice, and your proximity to him/her or your body posture. Additionally, the code yellow was used for Psychiatric Emergency, when the patient was "acting-out" in which they had total loss of rationale. In this situation, staff would use Nonviolent Physical Crisis Intervention (NCI), which was a safe non-harmful restraint with positions to control an individual until the Patient could gain control of his/her own behavior. This would be used as the last resort.

Review of the facility's PowerPoint presentation for training titled, "Identifying and Managing Risk Factors Associated with Seclusion and Restraint", undated, in the " Seclusion, Take Downs, and Physical Holds " section, revealed risk factors for an individual in a restraint in a " prone position " was positional asphyxia, and staff should: quickly respond to any person's complaint that they could not breath; ensure staff, object, or body positioning is not contributing to diminished air flow; reposition staff and/or client to alleviate pressure; utilize any safety procedures/devices associated with the behavior management system to eliminate pressure; recognize that just because a person can talk or yell does not mean that they have adequate oxygen; and discontinue hold/restraints immediately if positional asphyxia is thought to exist. Continued review of the training presentation revealed risk factors for an individual in a restraint in a supine position included the risk for aspiration and staff should monitor breathing closely (face visible); if the individual experiences semi-consciousness and/or unconsciousness then place individual immediately on their side and check for aspiration; and if vomiting occurs then immediately turn the person on their side and clear mouth of any matter. Addition review of the training presentation revealed for individuals in prone or supine positions, no pressure should be on the individual's neck, chest, or back and spinal injuries/fractures could occur with any age group depending on force and positon and children/adolescents with developing/immature bones are more vulnerable to breakage. The training presentation further revealed injury could occur if behavior management techniques were not performed as designed and staff should follow all policies and procedures defined in the approved facility behavior management system.

1. Review of Patient #1's Medical Record revealed the patient was admitted by the facility on 09/01/16 with diagnosis to include Oppositional Defiant Disorder, Affective Disorder, Abuse, and Insomnia. The patient was admitted with the chief complaint of homicidal ideation against his/her grandfather.

Review of Patient #1's Initial Nursing Treatment Plan dated 09/02/16, revealed the Short-Term Goals included the patient would notify staff of thoughts of harming self and would demonstrate the use of Music as a coping skill when having thoughts of harming self. Interventions included staff questioning the patient to see if he/she was having thoughts of harming self, mouth checks, and removal of personal items to prevent self-injurious behavior.

Review of Patient #1's Restraint/Seclusion Order/Record, completed by Registered Nurse (RN) #4, dated 10/16/16 at 10:45 with no AM or PM specified, revealed an incident occurred on Unit 6 with the intervention of a Physical Restraint. The Clinical Justification for the Intervention was "danger to others." Patient #1's behavior exhibited included stepping on peers ankle on purpose and then punching ceiling tile and furniture cushion. The Patient verbally threatened staff and then tried to kick down the group room door. Further review revealed less restrictive interventions were attempted which included verbal de-escalation/redirection, Psychoactive medication (non-restraint), and one on one (1:1) processing. Continued review of the Restraint/Seclusion record revealed the patient complained of left shoulder pain, complained the cheek bone "felt like somebody smashed it" and rated pain at a five (5) out of ten (10).

Review of the Internal Risk Management Worksheet, completed by the Director of Risk Management, dated 10/26/16 at 11:44 AM, revealed the incident was documented by RN #4 to have occurred on 10/16/16 at 10:45 AM and entered in at 10/16/16 at 6:38 PM, and stated, "this writer observed patient on the ground in a supine hold restraint." Further review, revealed an abrasion was noted to the left side of the face after release from the restraint, and the patient complained of left shoulder, left face, and right wrist pain.

Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed Patient #1's diagnoses for the ED visit included: Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

Review of Therapist #2's statement, dated 10/17/16, revealed Patient #1 could be heard hitting and kicking walls while MHT #1 could be heard saying, "stop doing that" , "stop kicking" . Further review revealed a commotion in the hall was heard and some of the patients stated MHT #1 slammed Patient #1 to the floor and Patient #1 was "tackled." Interview with the Therapist could not be attempted by the State Agency, as the Therapist was out of the facility on leave.

Per statement of Patient #2, on 10/19/16, Patient #1 was observed to kick the door and MHT #1 picked Patient #1 up and threw him/her on the ground, "slammed him/her down."

Interview with Patient #4, on 10/27/16 at 2:55 PM, revealed earlier that day he/she heard MHT #1 state that if anyone did anything that day, he would restrain them. Patient #4 stated he saw Patient #1 placed in the restraint by MHT #1. The patient stated he/she was in group and observed Patient #1 kicking the door approximately one (1) time and Patient #1 was "slammed" to the ground by MHT #1. Further interview revealed a code was not called, but was often called before a patient was placed in a restraint. Patient #4 stated he/she did not believe the patient should have been placed in a restraint and believed it was inappropriate. Further interview with Patient #4 revealed the facility did not question him/her about the details of the event.

Review of Patient #1's statement, dated 10/19/16, revealed the patient could not recall what he/she was mad about that day, but thought it was because he/she could not reach his/her step-mother on the phone. Further review of the statement revealed MHT #1 told him/her to "stop it" and Patient #4 told him/her that MHT #1 came into work wanting to restrain somebody. Continued review of Patient #1's statement revealed MHT #1 took the arm of the chair out of his/her hands. Patient #1's statement revealed he/she hugged MHT #2, and MHT #2 stated "boundaries" and MHT #1 stated, "bullshit " and got in my face. Patient #1 told MHT #1, that MHT #1 had a very punchable face and walked away from MHT #1 and kicked the door. Further review of the statement revealed MHT #1 told Patient #1 to punch MHT #1, adding MHT #2 and MHT #3 might have been there. Patient #1's statement revealed MHT #1 took the patient's arms behind him/her and pushed the patient down forcefully and his/her face hit the ground and his/her face got carpet burned. Further review revealed MHT #1 put his hands on the patient's arms and pushed him/her at the neck/shoulder, adding the Emergency Room (ER) informed him/her that he/she had a mild concussion, kink in the neck, and stated, "see my face." Continued review of the statement, revealed the patient thought he/she was in the restraint for approximately three (3) minutes. Per the statement, MHT #1 was told to leave the restraint.

Interview with Patient #1, on 10/26/16 at 1:30 PM, revealed on the day of the incident, he/she recalled removing an arm from a chair and hitting the corner of a wall. He/she stated MHT #1 took the arm of the chair from him/her and flung it behind him/her. Per interview, MHT #1 then told the patient to go to his/her room, but before he/she went to his/her room, the patient gave MHT #2 a hug, and MHT #2 stated to him/her "boundaries. " Patient #1 stated he/she told MHT #1 that MHT #1 had a "punchable " face and MHT #1 stated "do it. " The Patient stated he/she turned around and kicked the door to the group room and MHT #1 grabbed him/her from behind and "flung" him/her to the ground. Patient #1 stated he/she was in a restraint in which four (4) people responded. He/she could not recall everyone who responded, but revealed MHT #1, MHT #2, and MHT #3 were there.

Review of MHT #1's statement, dated 10/18/16, revealed he was on his way back to the unit from break when MHT #2 texted him and told him that Patient #1's behavior had been escalating. Per the statement, when he arrived, Patient #1 was in the consult room on Unit 6 and had ripped off the arm of one of the chairs and was swinging it around, (like a weapon) hitting the wall. MHT #1 statement revealed he took this away and asked the patient to get out of the consult room. At this time MHT #2 had another male patient (Patient #2) in the hall as well. Patient #1's behavior continued to escalate and MHT #1 stayed close by. Patient #1 went over to the peer (Patient #2) and stepped onto Patient #2's ankle hurting his/her peer. Patient #1 laughed and told MHT #1 he/she had done it because he/she "made a funny noise." Patient #1 then proceeded to approach MHT #2, wrapping his/her arms around her saying "you are so beautiful." MHT #1 yelled at Patient #1 to stop, as did MHT #2. MHT #1's statement revealed, due to Patient #1's sexually inappropriate history, he got between MHT #2 and the patient at which time Patient #1 threatened to punch MHT #1 in the face. MHT #1's statement revealed he responded to him by saying "just do it" to deflect the attention off of MHT #2 and the other male patient (Patient #2). MHT #1's statement revealed Patient #1 turned and kicked the group room door and seemed to be escalating even more. Per the statement, it was at that time, MHT #1 put his arms through the patient's arms in the back and then "put him/her down".

Continued review of the statement, revealed when staff arrived the patient was turned. Per the statement, when this happened Patient #1 stated "Now I am really pissed " and started resisting, and that is when he leaned over to hold the patient's knees. MHT #1 was then told to switch out, which he did with MHT #2. He was told to go to the ARC Unit. The Nursing supervisor/Registered Nurse (RN) #2, then asked MHT #1 to go home and he was suspended until an internal investigation of the event was completed. Continued review of the statement revealed he took the patient down by himself, thinking of the safety of "my" staff and the other patient. Per the statement, he used force to protect MHT #2 and the patient, and there was not a code button and he did not think to ask MHT #2 to call a code. Per the statement, he did not utilize approved NCI tactics and his mindset was on protecting staff and the other patient. Per the statement, he initially stated he felt he had done the right thing, but then when questioned he stated he would have done things differently and would have followed policy and procedure, and had other staff call team support or code yellow.

Telephone interview with MHT #1, on 10/27/16 at 9:58 AM, revealed on the day of the incident, he went on lunch break while the patients were in group therapy. He stated he asked MHT #2 to contact him if the patients were escalating and if she needed assistance with them. Continued interview with MHT #1, revealed he received a text message from MHT #2 to come back to the facility because Patient #1 was going off. He stated when he got back to the facility, Patient #1 was observed in the Consult room, on Unit 6, to rip off the arm of a chair and was swinging at the wall, laughing about it. MHT #1 stated he caught the chair arm, mid swing, from Patient #1. He stated the patient tried to grab the table, but MHT #1 sat on the table. MHT #1 revealed Patient #4 was out of group and laughing about the whole situation and then ended up going back to therapy. Further interview revealed Patient #1 and Patient #2 were observed to be out of group and Patient #1 then stepped on Patient #2's ankle while Patient #1 laughed hysterically. MHT #1 stated he asked Patient #1 why he/she would stand on Patient # 2's ankle and he/she stated the patient made a "funny" noise, adding he attempted to verbally de-escalate Patient #1. MHT #1 stated this did not work because Patient #1 was ignoring him.

Further interview with MHT #1, revealed Patient #1 then turned his/her attention to MHT #2 and backed her into the corner of the wall and started to make sexually inappropriate comments. Per interview the patient stated to MHT #2, she was beautiful and wrapped his/her arms around her while attempting to touch her. He stated MHT #2 yelled for Patient #1 to get off of her. MHT #1 revealed his focus was to get the attention taken off of MHT #2 and Patient #2. According to MHT #1, Patient #1 then asked him if he was trying to get hit, and MHT #1 told the patient, "go ahead and do it." He stated at that point Patient #1 turned and kicked the door to the group room, where other patients were in the room for therapy. MHT #1 revealed he could not de-escalate the patient, thus MHT #1 grabbed Patient #1's arms from behind and looped his/her arms around where the patient's elbows bent and Patient #1 hit the ground, falling face down. He stated he flipped the patient over and other staff came to assist with the hold. MHT #1 stated MHT #2 "was in shock" and he acted for the safety of the patients, who were in group therapy, and "staff ", being MHT #2. When staff came to assist with the hold, he stated they asked him what happened, but before he could answer he grabbed Patient #1's leg to make sure he/she did not kick anyone in the face. He stated that while in the hold, he told RN #4 that Patient #1 needed to be in 1A ( a seclusion room he reported was on the geriatric unit) because he/she was a "danger."

Continued interview with MHT #1, revealed MHT #2 was asked to replace him in the hold and he walked to the ARC unit, adding he did not provide care for other patients while there. He stated he was informed by the nursing supervisor, RN #2, that the patient had carpet burns from the restraint and the facility would conduct an investigation. MHT #1 stated he was told by staff that the patient had concussion like symptoms and that the patient hit the ground pretty hard. MHT #1 stated the only people involved in the incident or who observed the incident were MHT #2, Patient #2, and Patient #1. Additionally, MHT #1 revealed the restraint he placed Patient #1 in was not an appropriate restraint, adding, "it was an old military move" he learned from being in the military and "knew" it would not hurt the patient. He stated he knew the patient was large and had him "beat" in weight. He revealed it was not a proper NCI hold, but it was a restraint that could be used for someone larger than you. MHT #1 stated there was no other hold he could have performed to de-escalate the situation, adding " others would have gotten hurt". MHT #1 stated there was nothing he would have done differently, but added he could have had MHT #2 or somebody to call a code for additional team support to put the patient in a "safer" hold.

Interview with MHT #2, on 10/27/16 at 1:02 PM, revealed the facility provided NCI training upon hire and annually. She stated staff was taught that there were different stages of crisis and also taught what was going on in a patients mind during those stages. She further stated when a patient was anxious, they would start losing rational thought and they paid more attention to the staff members' body language instead of words. MHT #2 revealed a physical restraint was the last resort and should only be used when there was imminent danger to patient and/or staff. Additionally, MHT #2 conveyed, when putting a patient in a physical restraint, staff should communicate with each other, adding it took two (2) people to properly restrain a person, as per NCI techniques. She stated staff would talk about what they would do, often attempting to verbally de-escalate the patient first, which often did not work. She further stated a code would not be called unless there was danger to patient and/or staff. MHT #2 stated, on the day of the incident, there were patients who were excused from group therapy and they were exhibiting behaviors. She stated Patient #1 obtained objects from the ceiling, tore signs off the wall, and grabbed a piece off a chair and was throwing it. She further stated she was on the unit by herself, thus went to the nursing station and texted MHT #1 to come back to work.

Continued interview with MHT #2, revealed it was not safe for her at that point to be left alone with the other patients. She stated Patient #1 was aggravating Patient #2, stepped on Patient #2's ankle, and Patient #1 was not easily redirected. MHT #2 stated Patient #1 then turned to give her a hug and she told him/her to respect her boundaries, and not to touch her. MHT #2 stated, MHT #1 then told Patient #1 not to touch staff. She stated Patient #1 then grabbed her and wrapped his/her arms around her. She stated this made her feel violated and she "froze". She further stated Patient #1 then kicked the door, which lead to the group room, adding, "there were other patients in the room." MHT #2 revealed Patient #1 turned to MHT #1, and she thought the patient was going to hit her or MHT #1, and thought the patient was hostile. She further stated that at that moment, neither she nor MHT #1 could de-escalate Patient #1. However, MHT #2 revealed she did not refer to Patient #1's treatment plan, which provided suggestions to use to de-escalate the patient. MHT #2 stated she was not aware of the patient's treatment plan, but added it would have been important to have referred to it for interventions in which to calm the patient. Continued interview with MHT #2, revealed MHT #1 then "took" the patient down by getting behind the patient, taking him/her to the ground. She stated she switched out with MHT #1 after Patient #1 was calm. MHT #2 stated Patient #1 was not placed in a proper restraint, as taught by NCI, but MHT #1 was "on his own." Further interview revealed the incident happened so quick that she could not call a code, but it would have been helpful to have had someone to assist MHT #1 with Patient #1. She stated she called the house supervisor/RN #2. Additionally, she stated she could have pressed the button to call a code, but felt it was more important to call the supervisor. MHT #2 stated, the importance for calling a code was to send more people to assist and for the safety of the patient, as well as staff.

Interview with MHT #3, on 10/26/16 at 2:15 PM, revealed it was the facility's policy to verbally de-escalate the patient before staff would place their hands on the patient. She stated staff should always offer an alternative solution. Continued interview with MHT #3 revealed Patient #1 was a difficult patient based upon his/her history, however; the patient was not aggressive with staff, adding she had a good rapport with the patient. MHT #3 revealed the incident occurred on a Saturday or Sunday, in the morning, around 10:00 AM or 11:00 AM. She stated she was working on Unit 5 and was in the nurse's station to get something when she heard Patient #1 punching something. She further stated when she looked up, she saw MHT #1 take the patient from behind and "lifted" Patient #1 off the ground and "slammed" him/her on the floor.

Further interview with MHT #3, revealed by the time she got there, the patient was on the ground face down. MHT #3 stated she told MHT #1 the patient had to be turned face up. She stated she was on the patient's left side while MHT #1 was on the right side of the patient. She further stated the patient was attempting to get off the floor and he/she was making threats to MHT #1. MHT #2 stated MHT #1 did not say anything at that time, but rather grabbed the patient's knee with both of his hands. She stated she told MHT #1 that he needed to hold the patient "correctly". Per interview, two (2) nurses came in to assist with the hold, and RN #4 was at the patient's head and RN #3 took the patient's leg. MHT #3 stated at this time, MHT #2 was standing about five (5) feet away and never intervened, until she was told to replace MHT #1 to hold the patient's arm. Continued interview revealed MHT #1 then yelled " I want him/her out of here, off the unit. I want him/her on 1A ", as Patient #1 was crying and yelling at MHT #1. Per interview, the patient was in the hold, from beginning to end, no more than five (5) minutes. MHT #3 stated she did not see the incident which lead up to the restraint, but from what she knew of the patient, he/she often banged on walls, and it was therapeutic for him/her. She revealed that once the patient was in the restraint, it was necessary to continue the restraint for the safety of the staff and the patient, but felt it was an unnecessary restraint.

Interview with RN #3, on 10/27/16 at 3:28 PM, revealed the facility provided training on the proper NCI techniques. She stated physical restraint would not be used unless the patient was harming self and/or others and staff should try to verbally de-escalate the patient first. She further stated, often staff would ask the patient upon admission what worked for them when they were upset, and it would be developed in the patients Treatment Plan. RN #3 revealed, if the patient was banging and hitting things, then ideally staff would want to back away to determine what triggered the behavior. Per interview with RN #3, if verbal de-escalation did not work, a code would be called to get more people involved so that staff and/or the patient would not be in danger.

Continued interview with RN #3 revealed, on the day of the incident with Patient #1, she was the charge nurse on a different unit. She stated that while in the nurses station, she looked up and saw MHT #1 take Patient #1 down. Patient #1's arms were behind him/her and MHT #1 was behind him/her holding his/her arms and pushed the patient down on the ground. She stated the patient was observed to be on his/her stomach, but eventually, got on his/her back. Further interview with RN #3, revealed MHT #3 was on Patient #1's right leg, RN #4 was on the patient's right arm, MHT #3 was on the patient's left arm while she had the patient's left leg. RN #3 revealed RN #4 knew something was not right with the way MHT #1 was holding the patient's leg and he was "worked" up, saying, " Patient #1 needed to be sent over to 1A ( an area in which patients were sent when they were not safe to be with other patients). RN #3 stated Patient #1 started to calm down, so she was not holding the patient's leg tight. She stated MHT #1 then reached over and pinned the patient's leg down, which was the leg RN #3 was holding. Continued interview with RN #3, revealed that was not an appropriate move, adding staff should not cross into another area in which a staff member was holding. RN #3 stated MHT #1 needed to be switched out because there "wasn't something right", related to the way MHT #1 was talking.

Further interview with RN #3, revealed she could not remember a code being called, but it would have been appropriate for a code to have been called. She stated the restraint Patient #1 was placed in, was not a proper restraint/take down. She further stated historically, the patient was aggressive in the sense of "punching" things, but had not physically hurt staff or his/her peers. Per interview, she did not feel the restraint was appropriate because the patient did not appear to be a danger to himself or anyone else. Additionally, she stated she did not know if re-education would have been effective for MHT #1, because he was impulsive at times and she was told by a staff member that Patient #3 was placed in an improper hold recently; although, she could not remember which staff member informed her of this. RN #3 stated she had been told during shift report to keep a closer eye on MHT #1. She stated this was abuse because it was an improper hold which led to physical harm for Patient #1, and was reportable and a violation of the resident's rights. RN #3 stated the patient should have been placed on his/her back to protect his/her airways.

Review of the statement from RN #4, on 10/16/16 and 10/18/16, revealed she was on Unit 6 on 10/16/16 and did not see the incident with Patient #1 because she was in the medication room at the time. Per the statement, a patient told her staff did a "take-down" on Patient #1 and she ran out to the hall in response. Further review, revealed she assisted other staff to hold the patient on the floor and the team turned the patient on his/her back as the patient was taken down in the forward position and was on his/her chest. RN #4 documented Patient #1 was trying to kick, was struggling in the process, and MHT #1 had his knee across Patient #1's arm and chest and RN #4 ordered him to get off of the patient. Per the statement, MHT #1 then grabbed the patient's arm. RN #4 told MHT #2 to switch out with MHT #1 and she did. MHT #1 kept saying "he/she needs to be on 1A" and RN #4 replied "not now". Per the statement, she told MHT #1 to go to t

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to ensure residents were free from unnecessary or improper restraints (a restraint is any manual method, physical or mechanical device, material, or equipment that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely) for two (2) of ten (10) sampled patients (Patient #1 and Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. There was no documented evidence staff attempted less restrictive interventions prior to use of the restraint, no documented evidence a Physician's order was obtained for the restraint, and no documentation related to the use of the restraint. Additionally, there was no documented evidence to support MHT #1 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he was observed to use the improper restraint, and MHT #1 continued to work with patients.

On the next day, 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. MHT #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then the patient was turned over in a "supine" restraint. This was an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Staff interviews revealed they did not attempt a less restrictive intervention prior to the restraint. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

The findings include:

Review of the facility's policy, titled "Restraint" , revised April 2010, and reviewed July 2013, revealed the patient had the right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff. A physical restraint was defined as the application of physical force alone restricting the free movement of the whole or portion of an individual's body in order to control physical activity. It was the policy of the facility to limit the use of restraints to emergencies in which there was an imminent risk of a patient physically harming him/herself or others. Restraints would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to the patient or others prior to the application of restraints. Attempts to use less restrictive measures, as well as the patient's response to those measures would be recorded on the Seclusion and Restraints Assessment form. Further review revealed the facility was committed to preventing, reducing and striving to eliminate the use of restraints, as well as preventing emergencies that have the potential to lead to the use of restraints.

Review of the facility's Employee Training Manual, titled, "Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior", copyright date 2005, revealed the Nonviolent Crisis Intervention (CSI) program was a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint was recommended only when all less-restrictive methods of intervening had been exhausted, and when the individual presented a danger to self or others. Additionally, the training manual conveyed that any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention. Further review of the training manual, stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor, and floor restraints were not part of the teaching of NCI.

Continued review of the Manual revealed face down (prone) floor restraints and positions in which a person was bent over in such a way was difficult to breathe and extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively. Finally, the training emphasizes the NPCI's intent was to calm the individual, to keep the individual off the floor, thus reducing risks of Restraint-Related positional asphyxia and other injuries. Team interventions would be used when necessary and the NPCI would be used only as a last resort when someone presents a danger.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients; and intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior; use verbal techniques to de-escalate behavior; demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level; provide for the care, welfare, safety and security of all those who were involved in a crisis situation; and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint presentation for training titled, "Code Class", dated 2016, revealed the team support, de-escalation assistance, should be called when the patient was defensive and at the beginning stage of loss of rationality. Crisis Development Model Level two (2) was a stage in which an individual often becomes belligerent and challenges authority. Continued review revealed staff should be directive, an approach in which a staff member takes control of a potentially escalating situation. Staff should remember that the patient may not be able to respond to the rational context of your words. Instead the patient may be more in tune with other types of communication such as your tone of voice, and your proximity to him/her or your body posture. Additionally, the code yellow was used for Psychiatric Emergency, when the patient was "acting-out" in which they had total loss of rationale. In this situation, staff would use Nonviolent Physical Crisis Intervention (NCI), which was a safe non-harmful restraint with positions to control an individual until the Patient could gain control of his/her own behavior. This would be used as the last resort.

Review of the facility's PowerPoint for training presentation titled, "Identifying and Managing Risk Factors Associated with Seclusion and Restraint", undated, in the "Seclusion, Take Downs, and Physical Holds" section, revealed risk factors for an individual in a restraint in a "prone position" was positional asphyxia, and staff should: quickly respond to any person's complaint that they could not breath; ensure staff, object, or body positioning was not contributing to diminished air flow; reposition staff and/or client to alleviate pressure; utilize any safety procedures/devices associated with the behavior management system to eliminate pressure; recognize that just because a person could talk or yell did not mean they have adequate oxygen; and discontinue hold/restraints immediately if positional asphyxia was thought to exist. Continued review revealed risk factors for an individual in a restraint in a supine position included the risk for aspiration and staff should monitor breathing closely (face visible); if the individual experiences semi-consciousness and/or unconsciousness then place individual immediately on their side and check for aspiration; and if vomiting occurred, then immediately turn the person on their side and clear mouth of any matter. Additional review revealed for individuals in prone or supine positions, no pressure should be on the individual's neck, chest, or back and spinal injuries/fractures could occur with any age group depending on force and position and children/adolescents with developing/immature bones were more vulnerable to breakage. The training presentation further revealed injury could occur if behavior management techniques were not performed as designed and staff should follow all policies and procedures defined in the approved facility behavior management system.

1. Review of Patient #1's Medical Record revealed the patient was admitted by the facility on 09/01/16 with diagnosis to include Oppositional Defiant Disorder, Affective Disorder, Abuse, and Insomnia. The patient was admitted with the chief complaint of homicidal ideation against his/her grandfather.

Review of Patient #1's Initial Nursing Treatment Plan dated 09/02/16, revealed the Short-Term Goals included the patient would notify staff of thoughts of harming self and would demonstrate the use of Music as a coping skill when having thoughts of harming self. Interventions included staff questioning the patient to see if he/she was having thoughts of harming self, mouth checks, and removal of personal items to prevent self-injurious behavior.

Review of Patient #1's Restraint/Seclusion Order/Record, completed by Registered Nurse (RN) #4, dated 10/16/16 at 10:45 with no AM or PM specified, revealed an incident occurred on Unit 6 with the intervention of a Physical Restraint. The Clinical Justification for the Intervention was "danger to others." Patient #1's behavior exhibited included stepping on peers ankle on purpose and then punching ceiling tile and furniture cushion. The Patient verbally threatened staff and then tried to kick down the group room door. Further review revealed less restrictive interventions were attempted which included verbal de-escalation/redirection, Psychoactive medication (non-restraint), and one on one (1:1) processing. Continued review of the Restraint/Seclusion record revealed the patient complained of left shoulder pain, complained the cheek bone "felt like somebody smashed it" and rated pain at a five (5) out of ten (10).

Review of the Internal Risk Management Worksheet, completed by the Director of Risk Management, dated 10/26/16 at 11:44 AM, revealed the incident was documented by RN #4 to have occurred on 10/16/16 at 10:45 AM and entered in at 10/16/16 at 6:38 PM, and stated, "this writer observed patient on the ground in a supine hold restraint." Further review, revealed an abrasion was noted to the left side of the face after release from the restraint, and the patient complained of left shoulder, left face, and right wrist pain.

Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed Patient #1's diagnoses for the ED visit included: Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

Review of Therapist #2's statement, dated 10/17/16, revealed Patient #1 could be heard hitting and kicking walls while MHT #1 could be heard saying, "stop doing that" , "stop kicking" . Further review revealed a commotion in the hall was heard and some of the patients stated MHT #1 slammed Patient #1 to the floor and Patient #1 was "tackled." Interview with the Therapist could not be attempted by the State Agency, as the Therapist was out of the facility on leave.

Per statement of Patient #2, on 10/19/16, Patient #1 was observed to kick the door and MHT #1 picked Patient #1 up and threw him/her on the ground, "slammed him/her down."

Interview with Patient #4, on 10/27/16 at 2:55 PM, revealed earlier that day he/she heard MHT #1 state that if anyone did anything that day, he would restrain them. Patient #4 stated he saw Patient #1 placed in the restraint by MHT #1. The patient stated he/she was in group and observed Patient #1 kicking the door approximately one (1) time and Patient #1 was "slammed" to the ground by MHT #1. Further interview revealed a code was not called, but was often called before a patient was placed in a restraint. Patient #4 stated he/she did not believe the patient should have been placed in a restraint and believed it was inappropriate. Further interview with Patient #4 revealed the facility did not question him/her about the details of the event.

Review of Patient #1's statement, dated 10/19/16, revealed the patient could not recall what he/she was mad about that day, but thought it was because he/she could not reach his/her step-mother on the phone. Further review of the statement revealed MHT #1 told him/her to "stop it" and Patient #4 told him/her that MHT #1 came into work wanting to restrain somebody. Continued review of Patient #1's statement revealed MHT #1 took the arm of the chair out of his/her hands. Patient #1's statement revealed he/she hugged MHT #2, and MHT #2 stated "boundaries" and MHT #1 stated, "bullshit " and got in my face. Patient #1 told MHT #1 that MHT #1 had a very punchable face and walked away from MHT #1 and kicked the door. Further review of the statement revealed MHT #1 told Patient #1 to punch him, adding MHT #2 and MHT #3 might have been there. Patient #1's statement revealed MHT #1 took the patient's arms behind him/her and pushed the patient down forcefully and his/her face hit the ground and his/her face got carpet burned. Further review revealed MHT #1 put his hands on the patient's arms and pushed him/her at the neck/shoulder, adding the Emergency Room (ER) informed him/her that he/she had a mild concussion, kink in the neck, and stated, "see my face." Continued review of the statement, revealed the patient thought he/she was in the restraint for approximately three (3) minutes. Per the statement, MHT #1 was told to leave the restraint.

Interview with Patient #1, on 10/26/16 at 1:30 PM, revealed on the day of the incident, he/she recalled removing an arm from a chair and hitting the corner of a wall. He/she stated MHT #1 took the arm of the chair from him/her and flung it behind him/her. Per interview, MHT #1 then told the patient to go to his/her room, but before he/she went to his/her room, the patient gave MHT #2 a hug, and MHT #2 stated to him/her "boundaries. " Patient #1 stated he told MHT #1 that MHT #1 had a "punchable " face and MHT #1 stated "do it. " The Patient stated he/she turned around and kicked the door to the group room and MHT #1 grabbed him/her from behind and "flung" him/her to the ground. Patient #1 stated he/she was in a restraint in which four (4) people responded. He/she could not recall everyone who responded, but revealed MHT #1, MHT #2, and MHT #3 were there.

Review of MHT #1's statement, dated 10/18/16, revealed he was on his way back to the unit from break when MHT #2 texted him and told him that Patient #1's behavior had been escalating. Per the statement, when he arrived, Patient #1 was in the consult room on Unit 6 and had ripped off the arm of one of the chairs and was swinging it around, (like a weapon) hitting the wall. MHT #1 statement revealed he took this away and asked the patient to get out of the consult room. At this time MHT #2 had another male patient (Patient #2) in the hall as well. Patient #1's behavior continued to escalate and MHT #1 stayed close by. Patient #1 went over to the peer (Patient #2) and stepped onto Patient #2's ankle hurting his/her peer. Patient #1 laughed and told MHT #1 he/she had done it because he/she "made a funny noise." Patient #1 then proceeded to approach MHT #2, wrapping his/her arms around her saying "you are so beautiful." MHT #1 yelled at Patient #1 to stop, as did MHT #2. MHT #1's statement revealed, due to Patient #1's sexually inappropriate history, he got between MHT #2 and the patient at which time Patient #1 threatened to punch MHT #1 in the face. MHT #1's statement revealed he responded to the patient by saying "just do it" to deflect the attention off of MHT #2 and the other patient (Patient #2). MHT #1's statement revealed Patient #1 turned and kicked the group room door and seemed to be escalating even more. Per the statement, it was at that time, MHT #1 put his arms through the patient's arms in the back and then "put him/her down".

Continued review of the statement, revealed when staff arrived the patient was turned. Per the statement, when this happened Patient #1 stated "Now I am really pissed" and started resisting, and that is when he leaned over to hold the patient's knees. MHT #1 was then told to switch out, which he did with MHT #2. He was told to go to the ARC Unit. The Nursing supervisor/Registered Nurse (RN) #2, then asked MHT #1 to go home and he was suspended until an internal investigation of the event was completed. Continued review of the statement revealed he took the patient down by himself, thinking of the safety of "my" staff and the other patient. Per the statement, he used force to protect MHT #2 and the patient, and there was not a code button and he did not think to ask MHT #2 to call a code. Per the statement, he did not utilize approved NCI tactics and his mindset was on protecting staff and the other patient. Per the statement, he initially stated he felt he had done the right thing, but then when questioned he stated he would have done things differently and would have followed policy and procedure, and had other staff call team support or code yellow.

Telephone interview with MHT #1, on 10/27/16 at 9:58 AM, revealed on the day of the incident, he went on lunch break while the patients were in group therapy. He stated he asked MHT #2 to contact him if the patients were escalating and if she needed assistance with them. Continued interview with MHT #1, revealed he received a text message from MHT #2 to come back to the facility because Patient #1 was going off. He stated when he got back to the facility, Patient #1 was observed in the Consult room, on Unit 6, to rip off the arm of a chair and was swinging at the wall, laughing about it. MHT #1 stated he caught the chair arm, mid swing, from Patient #1. He stated the patient tried to grab the table, but MHT #1 sat on the table. MHT #1 revealed Patient #4 was out of group and laughing about the whole situation and then ended up going back to therapy. Further interview revealed Patient #1 and Patient #2 were observed to be out of group and Patient #1 then stepped on Patient #2's ankle while Patient #1 laughed hysterically. MHT #1 stated he asked Patient #1 why he/she would stand on Patient # 2's ankle and he/she stated the patient made a "funny" noise, adding he attempted to verbally de-escalate Patient #1. MHT #1 stated this did not work because Patient #1 was ignoring him.

Further interview with MHT #1, revealed Patient #1 then turned his/her attention to MHT #2 and backed her into the corner of the wall and started to make sexually inappropriate comments. MHT #1 stated revealed Patient #1 stated to MHT #2, she was beautiful and wrapped his/her arms around her while attempting to touch her. He stated MHT #2 yelled for Patient #1 to get off of her. MHT #1 revealed his focus was to get the attention taken off of MHT #2 and Patient #2. According to MHT #1, Patient #1 then asked him if he was trying to get hit, and MHT #1 told the patient, "go ahead and do it." He stated at that point Patient #1 turned and kicked the door to the group room, where other patients were in the room for therapy. MHT #1 revealed he could not de-escalate the patient, thus MHT #1 grabbed Patient #1's arms from behind and looped his/her arms around where the patient's elbows bent and Patient #1 hit the ground, falling face down. He stated he flipped the patient over and other staff came to assist with the hold. MHT #1 stated MHT #2 "was in shock" and he acted for the safety of the patients, who were in group therapy, and "staff ", being MHT #2. When staff came to assist with the hold, he stated they asked him what happened, but before he could answer he grabbed Patient #1's leg to make sure he/she did not kick anyone in the face. He stated that while in the hold, he told RN #4 that Patient #1 needed to be in 1A ( a seclusion room he reported was on the geriatric unit) because he/she was a "danger."

Continued interview with MHT #1, revealed MHT #2 was asked to replace him in the hold and he walked to the ARC unit, adding he did not provide care for other patients while there. He stated he was informed by the nursing supervisor, RN #2, that the patient had carpet burns from the restraint and the facility would conduct an investigation. MHT #1 stated he was told by staff that the patient had concussion like symptoms and that the patient hit the ground pretty hard. MHT #1 stated the only people involved in the incident or who observed the incident were MHT #2, Patient #2, and Patient #1. Additionally, MHT #1 revealed the restraint he placed Patient #1 in was not an appropriate restraint, adding, "it was an old military move" he learned from being in the military and "knew" it would not hurt the patient. He stated he knew the patient was large and had him "beat" in weight. He revealed it was not a proper NCI hold, but it was a restraint that could be used for someone larger than you. MHT #1 stated there was no other hold he could have performed to de-escalate the situation, adding " others would have gotten hurt". MHT #1 stated there was nothing he would have done differently, but added he could have had MHT #2 or somebody to call a code for additional team support to put the patient in a "safer" hold.

Interview with MHT #2, on 10/27/16 at 1:02 PM, revealed the facility provided NCI training upon hire and annually. She stated staff was taught that there were different stages of crisis and also taught what was going on in a patients mind during those stages. She further stated when a patient was anxious, they would start losing rational thought and they paid more attention to the staff members' body language instead of words. MHT #2 revealed a physical restraint was the last resort and should only be used when there was imminent danger to patient and/or staff. Additionally, MHT #2 conveyed, when putting a patient in a physical restraint, staff should communicate with each other, adding it took two (2) people to properly restrain a person, as per NCI techniques. She stated staff would talk about what they would do, often attempting to verbally de-escalate the patient first, which often did not work. She further stated a code would not be called unless there was danger to patient and/or staff. MHT #2 stated, on the day of the incident, there were patients who were excused from group therapy and they were exhibiting behaviors. She stated Patient #1 obtained objects from the ceiling, tore signs off the wall, and grabbed a piece off a chair and was throwing it. She further stated she was on the unit by herself, thus went to the nursing station and texted MHT #1 to come back to work.

Continued interview with MHT #2, revealed it was not safe for her at that point to be left alone with the other patients. She stated Patient #1 was aggravating Patient #2, stepped on Patient #2's ankle, and Patient #1 was not easily redirected. MHT #2 stated Patient #1 then turned to give her a hug and she told him/her to respect her boundaries, and not to touch her. MHT #2 stated, MHT #1 then told Patient #1 not to touch staff. She stated Patient #1 then grabbed her and wrapped his/her arms around her. She stated this made her feel violated and she "froze". She further stated Patient #1 then kicked the door, which lead to the group room, adding, "there were other patients in the room." MHT #2 revealed Patient #1 turned to MHT #1, and she thought the patient was going to hit her or MHT #1, and thought the patient was hostile. She further stated that at that moment, neither she nor MHT #1 could de-escalate Patient #1. However, MHT #2 revealed she did not refer to Patient #1's treatment plan, which provided suggestions to use to de-escalate the patient. MHT #2 stated she was not aware of the patient's treatment plan, but added it would have been important to have referred to it for interventions in which to calm the patient. Continued interview with MHT #2, revealed MHT #1 then "took" the patient down by getting behind the patient, taking him/her to the ground. She stated she switched out with MHT #1 after Patient #1 was calm. MHT #2 stated Patient #1 was not placed in a proper restraint, as taught by NCI, but MHT #1 was "on his own." Further interview revealed the incident happened so quick that she could not call a code, but it would have been helpful to have had someone to assist MHT #1 with Patient #1. She stated she called the house supervisor/RN #2. Additionally, she stated she could have pressed the button to call a code, but felt it was more important to call the supervisor. MHT #2 stated, the importance for calling a code was to send more people to assist and for the safety of the patient, as well as staff.

Interview with MHT #3, on 10/26/16 at 2:15 PM, revealed it was the facility's policy to verbally de-escalate the patient before staff would place hands on the patient. She stated staff should always offer an alternative solution. Continued interview with MHT #3 revealed Patient #1 was a difficult patient based upon his/her history, however; the patient was not aggressive with staff, adding she had a good rapport with the patient. MHT #3 revealed the incident occurred on a Saturday or Sunday, in the morning, around 10:00 AM or 11:00 AM. She stated she was working on Unit 5 and was in the nurse's station to get something when she heard Patient #1 punching something. She further stated when she looked up, she saw MHT #1 take the patient from behind and " lifted " Patient #1 off the ground and " slammed " him/her on the floor. Further interview, revealed by the time she got there, the patient was on the ground face down. MHT #3 stated she told MHT #1 the patient had to be turned face up. She stated she was on the patient's left side while MHT #1 was on the right side of the patient. She further stated the patient was attempting to get off the floor and he/she was making threats to MHT #1. MHT #2 stated MHT #1 did not say anything at that time, but rather grabbed the patient's knee with both of his hands. She stated she told MHT #1 that he needed to hold the patient "correctly".

Further interview with MHT #3, revealed two (2) nurses came in to assist with the hold, and RN #4 was at the patient's head and RN #3 took the patient's leg. MHT #3 stated at this time, MHT #2 was standing about five (5) feet away and never intervened, until she was told to replace MHT #1 to hold the patient's arm. Continued interview revealed MHT #1 then yelled " I want him/her out of here, off the unit. I want him/her on 1A ", as Patient #1 was crying and yelling at MHT #1. Per interview, the patient was in the hold, from beginning to end, no more than five (5) minutes. MHT #3 stated she did not see the incident which lead up to the restraint, but from what she knew of the patient, he/she often banged on walls, and it was therapeutic for him/her. She revealed that once the patient was in the restraint, it was necessary to continue the restraint for the safety of the staff and the patient, but felt it was an unnecessary restraint.

Interview with RN #3, on 10/27/16 at 3:28 PM, revealed the facility provided training on the proper NCI techniques. She stated physical restraint would not be used unless the patient was harming self and/or others and staff should try to verbally de-escalate the patient first. She further stated, often staff would ask the patient upon admission what worked for them when they were upset, and it would be developed in the patients Treatment Plan. RN #3 revealed, if the patient was banging and hitting things, then ideally staff would want to back away to determine what triggered the behavior. Per interview with RN #3, if verbal de-escalation did not work, a code would be called to get more people involved so that staff and/or the patient would not be in danger.

Continued interview with RN #3 revealed, on the day of the incident with Patient #1, she was the charge nurse on a different unit. She stated that while in the nurses station, she looked up and saw MHT #1 take Patient #1 down. Patient #1's arms were behind him/her and MHT #1 was behind him/her holding his/her arms and pushed the patient down on the ground. She stated the patient was observed to be on his/her stomach, but eventually, got on his/her back. Further interview with RN #3, revealed MHT #3 was on Patient #1's right leg, RN #4 was on the patient's right arm, MHT #3 was on the patient's left arm while she had the patient's left leg. RN #3 revealed RN #4 knew something was not right with the way MHT #1 was holding the patient's leg and he was "worked" up, saying, " Patient #1 needed to be sent over to 1A ( an area in which patients were sent when they were not safe to be with other patients). RN #3 stated Patient #1 started to calm down, so she was not holding the patient's leg tight. She stated MHT #1 then reached over and pinned the patient's leg down, which was the leg RN #3 was holding. Continued interview with RN #3, revealed that was not an appropriate move, adding staff should not cross into another area in which a staff member was holding. RN #3 stated MHT #1 needed to be switched out because there "wasn't something right", related to the way MHT #1 was talking.

Further interview with RN #3, revealed she could not remember a code being called, but it would have been appropriate for a code to have been called. She stated the restraint Patient #1 was placed in, was not a proper restraint/take down. She further stated historically, the patient was aggressive in the sense of "punching" things, but had not physically hurt staff or his/her peers. Per interview, she did not feel the restraint was appropriate because the patient did not appear to be a danger to himself/herself or anyone else. Additionally, she stated she did not know if re-education would have been effective for MHT #1, because he/she was impulsive at times and she was told by a staff member that Patient #3 was placed in an improper hold recently; although, she could not remember which staff member informed her of this. RN #3 stated she had been told during shift report to keep a closer eye on MHT #1. She stated this was abuse because it was an improper hold which led to physical harm for Patient #1, and was reportable and a violation of the resident's rights. RN #3 stated the patient should have been placed on his/her back to protect his/her airways.

Review of the statement from RN #4, on 10/16/16 and 10/18/16, revealed she was on Unit 6 on 10/16/16 and did not see the incident with Patient #1 because she was in the medication room at the time. Per the statement, a patient told her staff did a "take-down" on Patient #1 and she ran out to the hall in response. Further review, revealed she assisted other staff to hold the patient on the floor and the team turned the patient on his/her back as the patient was taken down in the forward position and was on his/her chest. RN #4 documented Patient #1 was trying to kick, was struggling in the process, and MHT #1 had his knee across Patient #1's arm and chest and RN #4 ordered him to get off of the patient. Per the statement, MHT #1 then grabbed the patient's arm. RN #4 told MHT #2 to switch out with MHT #1 and she did. MHT #1 kept saying "he/she needs to be on 1A" and RN #4 replied "not now". Per the statement, she told MHT #1 to go to the ARC unit and stay there until further notic

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the use of restraint or seclusion was in accordance with the patient's plan of care for one (1) of ten (10) sampled patients (Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (a restraint immobilize or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. There was no documented evidence staff followed and implemented Patient #3's Individual Treatment Plan's regarding de-escalation interventions attempting less restrictive interventions prior to use of the restraint. In addition, there was no documented evidence of a Physician's order obtained for the restraint, and no documentation related to the use of the restraint.

The findings include:

Review of the facility's policy titled, "Restraint", with a revision date of April 2010, revealed the use of restraints was to be limited to emergencies in which there was an imminent risk of a patient physically harming him/herself or others and the restraint would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Further review of the policy revealed the patient had a right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff and restraint would not be based on history of past use or dangerous behavior, or as convenience for staff. Continued review of the Policy, revealed PRN (as needed) orders may not be used to authorize the use of restraints. Per Policy, prior to the application of restraints, attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to patients or others and the attempts along with the patient's response to the attempts would be recorded on the seclusion and restraints assessment form.

Further review of the policy revealed restraints required an order from a physician unless the physician was absent and then the Registered Nurse may authorize the initiation of restraints. The policy further stated the physician must be contacted as soon as possible, but no longer than one (1) hour after initiation of the restraints to obtain an order. Per Policy, the Physician's order for the use of restraints would be recorded on the Seclusion/Restraint Order Form and include the following: reason for using the restraints including specific behaviors and safety issues, type of restraint used, the nurse receiving the order, the physician giving the order, and the nurse transcribing the orders with appropriates date and times. Continued review of the policy revealed any restraint episode for a patient that was under the ages of sixteen (16) shall require notification of the parent, guardian, family member, or conservator. Additional review of the policy revealed the use of restraints would be thoroughly documented in the patient's medical record and include specific behaviors; detailed description of events leading up to the incident and other pertinent information; the rationale for use of restraints; and time of initiation and termination of restraints.

Review of Patient #3's medical record revealed, the facility admitted the patient on 09/21/16 with the chief complaint of Suicidal Ideation. Review of the Psychiatric Admission Assessment dated 09/22/16 revealed the following diagnoses were identified: Mood Affective Disorder (set of psychiatric diseases with the main types being Depression, Bipolar Disorder, and Anxiety Disorder), Attention Deficit Hyperactivity Disorder (ADHD); and Victim of Physical Abuse and Neglect.

Review of Patient #3's Individual Treatment Plan (ITP), dated 09/23/16, revealed the patient was identified to have problematic behaviors that included aggression when the patient was upset. Review of Patient #3's ITP, dated 10/11/16 revealed the patient was identified to have dangerous behavior toward self and others which included threatening peers and physical aggression towards staff. Further review of both Patient #3's ITP's, revealed the following interventions were to be used to de-escalate the patient: verbal interventions such as talking quietly with the patient, relaxation techniques, physical activity, pain control, psychoactive medications, reality orientation, quiet time, time out, exercise, music, stress ball, walking, and use of a weighted blanket. Continued review of the ITP's revealed the patient had the following short term goals: Patient will identify at least two strategies to prevent acting out or that will assist patient to regain self-control and patient would remain free of emotional or physical injury when exhibiting dangerous behaviors to self or others for three (3) consecutive days prior to discharge. Further review of both Patient #3's ITP's revealed the use of a restraint only should be as a last resort and only after the less restrictive interventions have been tried and have failed.

Review of the Group Note for Patient #3, dated 10/15/16, at 11:45 AM, revealed the patient did not attend group therapy due to unsafe behavior. Continued review of the Group Note under the comments/concerns, revealed when staff told Patient #3 he would not be allowed to join group due to aggression towards staff and peers, Patient #3 began attempting to push staff, tried to run through doors, and made threats toward staff. Further review of the Group Note, revealed Patient #3 had calmed down for an hour and a half, and then the patient became agitated again, pushing staff and was given a PRN (meaning "as needed" ) Haldol 2 milligram (mg) (short acting anti-psychotic) medication Intramuscular injection.

Review of Patient #3's 24 Hour Nursing Progress Note, dated 10/15/16, revealed Registered Nurse (RN) #1 documented at 10:00 AM, "Patient #3 postured at staff, 2 mg Haldol Intramuscular (IM) given, patient went to sleep".

Review of the Attending Psychiatrist Note, dated 10/16/16, revealed Patient #3 required PRN medication on 10/15/16 due to slamming and banging on doors and refusing redirection.

Interview, on 10/27/16 at 1:02 PM, with MHT #2, revealed on 10/15/16 at approximately 9:00 AM, she was removing another patient from unit 5 to unit 6 because Patient #3 was "going off", punching walls. Continued interview with MHT #2, revealed while on unit 5, she observed patient #3 hit MHT #3 in the face. MHT #2 further stated, she was told by MHT #3 not to call a code. MHT #2 stated Patient #3 was "out for blood" so when she arrived to unit 6, she stayed there and asked MHT #1 to go to unit 5 and assist with Patient #3. Continued interview with MHT #2, revealed she stood at the nurse's station which allowed her to see MHT #1 who had Patient #3 in a restraint with the patients hands held behind his/her back. MHT #2 stated it took two (2) people to properly restrain a person using Nonviolent Crisis Intervention (NCI). MHT #2 further stated physical restraints were the last resort and if a restraint was used then an Incident Report was to be completed.

Interview, on 10/27/16 at 9:58 AM with MHT #1, revealed on 10/15/16 per MHT #2's request, he went to the children's unit to assist with Patient #3 who was acting out. MHT #1 stated he said to Patient #3, "what is going on buddy" , and that is when the patient raised his hand. Continued interview with MHT #1, revealed he then placed Patient #3 in a "bear hug" so RN #1 could deliver the IM injection. Further interview revealed MHT #3 then came over and told MHT #1, he could not do that hold and showed him a new hold by placing the patient in the hold to prepare him for the IM injection. MHT #1 stated RN #1 gave the IM injection and then thanked him for helping him out.

Interview, with MHT #3 on 10/26/16 at 2:15 PM and post survey interview on 11/02/16 at 5:54 PM, revealed on 10/15/16 during the morning shift, she was assigned to unit 5 and MHT #1 was assigned to unit 6. Continued interview with MHT #3 revealed Patient #3 was redirected several times that day by her and was placed in the hallway to practice his/her coping skills. She stated Patient #3 did better when a crowd was not around so she moved the other patients to the "overflow" room while Patient #3 was left in the hallway. MHT #3 stated, when she left with the other patients, Patient #3 was hitting the wall and postured to hit her, but his/her hits never landed or made contact on her. MHT #3 stated she did not know how MHT #1 got to the unit since he was working Unit 6 that day, but when she returned to check on Patient #3, she observed MHT #1 holding the patient in an "incorrect" hold, adding MHT #1 had both his hands on Patient #3 with the patient's hands pulled behind his/her back, and RN #1 was standing with the patient's Haldol injection. MHT #3 further stated she told MHT #1, this was not a proper restraint and then they together put Patient #3 in a child hold so the patient could receive his/her PRN medication. Continued interview with MHT #3, revealed after they released Patient #3 from the restraint, she retrained MHT #1 on a couple of moves so the next time he would be familiar with how to correctly complete a hold by himself. MHT #3 further stated RN #1 was a house supervisor, and observed the retraining, and she would have expected the nurse to have reported the incident to upper management. She further stated she notified the facility in her statement the next day, MHT #1 did an incorrect hold on Patient #1.

Further review of Patient #3's medical record, revealed there was no documented evidence the patient's ITP's were followed and de-escalation interventions were implemented prior to the use of the restraint. In addition, there was no documented evidence the Physician was notified for an order for the restraint, no documented evidence the seclusion and restraint packet was completed per facility policy, and no documented evidence of an assessment by medical staff for injuries after the restraint had ended. In addition, there was no documented evidence of an updated treatment plan for the occurrence of this restraint.

Interview, with RN #1, on 10/27/16 at 6:26 PM, and 10/28/16 at 4:40 PM, revealed on 10/15/16 during the morning shift, he was working as the floor nurse and not as the house supervisor. Continued interview revealed on 10/15/16 at approximately 10:00 AM, Patient #3 was placed in a physical restraint for becoming agitated and engaging in the maladaptive behavior of physical aggression towards MHT #1; however, he stated what he witnessed was an improper restraint on Patient #3 by MHT #1. He stated Patient #3 was administered a PRN medication of Haldol 2mg IM because historically oral PRN medication had proved to be ineffective for the patient, so they had to "step it up" to IM injection. RN #1 stated even though MHT #3 was not an NCI instructor, she re-educated MHT #1 on the correct way to do a restraint. RN #1 further stated he could not remember if he reported the restraint and the improper hold to the shift supervisor, but per policy he should have. Continued interview with RN #1, revealed he documented on the Nurse's Notes, Patient #3 postured (RN #1 stated postured mean't position of hitting) towards MHT #1. RN #1 admitted he did not witness Patient #3 posturing towards MHT #1; however, stated the patient had engaged in this behavior before. RN #1 acknowledged there was no documentation related to the restraint as the Seclusion and Restraints Assessment form was not completed. Further interview, revealed there was no documented evidence Patient #3's treatment plan was followed by staff attempting less restrictive interventions to de-escalate the situation prior to the physical restraint and no documented evidence the patients Treatment Plan was updated after the restraint. RN #1 further admitted, there was no documented evidence Patient #3 was assessed by medical staff for possible injuries after the patient was released from the restraint.

Interview with the Chief Executive Officer (CEO) and Director of Performance Improvement, on 10/28/16 at 7:36 PM, revealed it would have been their expectation that there would have been documentation by RN #1 to support the restraint, and that the restraint policy would have been followed. Further interview, revealed the Treatment Plan should have been followed related to using less restrictive interventions prior to the restraint being used as the Care Plan/Treatment Plan guided the care of the patient. Per interview, the Care Plan should also have been updated after use of the restraint.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure documentation was completed in the patient's medical record which including behaviors and interventions used to support the use of a restraint for one (1) of ten (10) sampled patients (Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (a restraint immobilize or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. However, there was no documented evidence of a clear description of the patient's behavior that warranted use of the restraint, no documented evidence of the use of the restraint or the completion of the seclusion and restraint packet as per policy, and no documented evidence of the patient's clinical response to the restraint intervention.

The findings include:

Review of the facility's policy titled, "Restraint", with a revision date of April 2010, revealed the use of restraints was to be limited to emergencies in which there was an imminent risk of a patient physically harming him/herself or others and the restraint would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Further review of the policy revealed the patient had a right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff and restraint would not be based on history of past use or dangerous behavior, or as convenience for staff. Continued review of the Policy, revealed PRN (as needed) orders may not be used to authorize the use of restraints. Per Policy, prior to the application of restraints, attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to patients or others and the attempts along with the patient's response to the attempts would be recorded on the seclusion and restraints assessment form.

Further review of the policy revealed restraints required an order from a physician unless the physician was absent and then the Registered Nurse may authorize the initiation of restraints. The policy further stated the physician must be contacted as soon as possible, but no longer than one (1) hour after initiation of the restraints to obtain an order. Per Policy, the Physician's order for the use of restraints would be recorded on the Seclusion/Restraint Order Form and include the following: reason for using the restraints including specific behaviors and safety issues, type of restraint used, the nurse receiving the order, the physician giving the order, and the nurse transcribing the orders with appropriates date and times. Continued review of the policy revealed any restraint episode for a patient that was under the ages of sixteen (16) shall require notification of the parent, guardian, family member, or conservator. Additional review of the policy revealed the use of restraints would be thoroughly documented in the patient's medical record and include specific behaviors; detailed description of events leading up to the incident and other pertinent information; the rationale for use of restraints; and time of initiation and termination of restraints.

Review of Patient #3's medical record revealed, the facility admitted the patient on 09/21/16 with the chief complaint of Suicidal Ideation. Review of the Psychiatric Admission Assessment dated 09/22/16 revealed the following diagnoses were identified: Mood Affective Disorder (set of psychiatric diseases with the main types being Depression, Bipolar Disorder, and Anxiety Disorder), Attention Deficit Hyperactivity Disorder (ADHD); and Victim of Physical Abuse and Neglect.

Review of Patient #3's Individual Treatment Plan (ITP), dated 09/23/16, revealed the patient was identified to have problematic behaviors that included aggression when the patient was upset. Review of Patient #3's ITP, dated 10/11/16 revealed the patient was identified to have dangerous behavior toward self and others which included threatening peers and physical aggression towards staff. Further review of both Patient #3's ITP's, revealed the following interventions were to be used to de-escalate the patient: verbal interventions such as talking quietly with the patient, relaxation techniques, physical activity, pain control, psychoactive medications, reality orientation, quiet time, time out, exercise, music, stress ball, walking, and use of a weighted blanket. Continued review of the ITP's revealed the patient had the following short term goals: Patient will identify at least two strategies to prevent acting out or that will assist patient to regain self-control and patient would remain free of emotional or physical injury when exhibiting dangerous behaviors to self or others for three (3) consecutive days prior to discharge. Further review of both Patient #3's ITP's revealed the use of a restraint only should be as a last resort and only after the less restrictive interventions have been tried and have failed.

Review of the Group Note for Patient #3, dated 10/15/16, at 11:45 AM, revealed the patient did not attend group therapy due to unsafe behavior. Continued review of the Group Note under the comments/concerns, revealed when staff told Patient #3 he would not be allowed to join group due to aggression towards staff and peers, Patient #3 began attempting to push staff, tried to run through doors, and made threats toward staff. Further review of the Group Note, revealed Patient #3 had calmed down for an hour and a half, and then the patient became agitated again, pushing staff and was given a PRN (meaning "as needed" ) Haldol 2 milligram (mg) (short acting anti-psychotic) medication Intramuscular injection.

Review of Patient #3's 24 Hour Nursing Progress Note, dated 10/15/16, revealed Registered Nurse (RN) #1 documented at 10:00 AM, "Patient #3 postured at staff, 2 mg Haldol Intramuscular (IM) given, patient went to sleep".

Review of the Attending Psychiatrist Note, dated 10/16/16, revealed Patient #3 required PRN medication on 10/15/16 due to slamming and banging on doors and refusing redirection.

Interview, on 10/27/16 at 1:02 PM, with MHT #2, revealed on 10/15/16 at approximately 9:00 AM, she was removing another patient from unit 5 to unit 6 because Patient #3 was "going off", punching walls. Continued interview revealed while on unit 5, she observed patient #3 hit MHT #3 in the face. MHT #2 further stated, she was told by MHT #3 not to call a code. MHT #2 stated Patient #3 was "out for blood" so when she arrived to unit 6, she stayed there and asked MHT #1 to go to unit 5 and assist with Patient #3. Continued interview with MHT #2, revealed she stood at the nurse's station which allowed her to see MHT #1 who had Patient #3 in a restraint with the patients hands held behind his/her back. MHT #2 stated it took two (2) people to properly restrain a person using Nonviolent Crisis Intervention (NCI). MHT #2 further stated physical restraints were the last resort and if a restraint was used then an incident report was to be completed.

Interview, on 10/27/16 at 9:58 AM with Mental Health Tech (MHT) #1, revealed on 10/15/16 per MHT #2's request, he went to the children's unit to assist with Patient #3 who was acting out. MHT #1 stated he said to Patient #3, "what is going on buddy" , and that is when the patient raised his hand. Continued interview with MHT #1, revealed he then placed Patient #3 in a "bear hug" so RN #1 could deliver the IM injection. Further interview revealed MHT #3 then came over and told MHT #1, he could not do that hold and showed him a new hold by placing the patient in the hold to prepare him for the IM injection. MHT #1 stated RN #1 gave the IM injection and then thanked him for helping him out.

Interview, with MHT #3 on 10/26/16 at 2:15 PM and post survey interview on 11/02/16 at 5:54 PM, revealed on 10/15/16 during the morning shift, she was assigned to unit 5 and MHT #1 was assigned to unit 6. Continued interview with MHT #3 revealed Patient #3 was redirected several times that day by her and was placed in the hallway to practice his/her coping skills. She stated Patient #3 did better when a crowd was not around so she moved the other patients to the "overflow" room while Patient #3 was left in the hallway. MHT #3 stated that when she left with the other patients, Patient #3 was hitting the wall and postured to hit her, but his/her hits never landed or made contact on her. MHT #3 stated she did not know how MHT #1 got to the unit since he was working Unit 6 that day, but when she returned to check on Patient #3, she observed MHT #1 holding the patient in an "incorrect" hold, adding MHT #1 had both his hands on Patient #3 with the patient's hands pulled behind his/her back, and RN #1 was standing with the patient's Haldol, a one (1) time injection. MHT #3 further stated she told MHT #1 that this was not a proper restraint and then they together put Patient #3 in a child hold so the patient could receive his/her PRN medication. Continued interview with MHT #3, revealed after they released Patient #3 from the restraint, she retrained MHT #1 on a couple of moves so the next time he would be familiar with how to correctly complete a hold by himself. MHT #3 further stated RN #1 was a house supervisor, and observed the retraining, and she would have expected the nurse to have reported the incident to upper management.

Further review of Patient #3's medical record, revealed there was no documented evidence of a clear description of the patient's behavior that warranted use of the restraint, no documented evidence the restraint was used, and no documented evidence of the patient's clinical response to the intervention.

Interview, with RN #1, on 10/27/16 at 6:26 PM, revealed on 10/15/16 during the morning shift he was working as the floor nurse and not as the house supervisor. Continued interview revealed he witnessed an improper restraint on Patient #3 by MHT #1. RN #1 stated even though MHT #3 was not a NCI instructor, she re-educated MHT #1 on the correct way to do a restraint. RN #1 further stated he could not remember if he reported the restraint and the improper hold to the shift supervisor but he should have. Continued interview with RN #1, on 10/28/16 at 4:40 PM, revealed on 10/15/16 at approximately 10:00 AM, Patient #3 was placed in a physical restraint for becoming agitated and engaging in the maladaptive behavior of physical aggression towards Mental Health Tech (MHT) #1. Continued interview with RN #1, revealed Patient #3 was administered a PRN medication of Haldol 2mg IM. RN #1 further stated, historically oral PRN medication had proved to be ineffective for him/her, so they had to "step it up" to IM injection. Continued interview with RN #1, revealed he documented on the Nurse's Notes, Patient #3 postured (RN states postured means position of hitting) towards MHT #1. RN #1 admitted he did not witness Patient #3 posturing towards MHT #1; however, stated the patient had engaged in this behavior before. Further interview with RN #1, revealed Patient #3's Level of Supervision (LOS) was within the line of sight of staff and the patient was on the hall by himself after all other patients were removed from the area. RN #1 stated he did not know how, but when he came on to the unit, Patient #3 had MHT #1 and MHT #3 backed into a corner with no way for staff to get out of the corner even though during Nonviolent Crisis Intervention (NCI), both MHT's were taught deflective moves to distance themselves from aggressive patients. RN #1 stated at that point, no other less restrictive interventions should have been attempted by the staff. RN #1 admitted there was no documented evidence that Patient #3's treatment plan was followed by staff attempting less restrictive interventions prior to the physical restraint and the PRN IM injection of Haldol. RN #1 further admitted, per facility policy, he should have notified the physician to obtain an order for the restraint after the restraint occurred. RN # 1 further stated he should have completed a seclusion and restraint packet as required by the facility's policy, but failed to do both. Continued interview revealed there was no documented evidence Patient #3 was assessed by medical staff for possible injuries after the patient was released from the restraint.

Interview with the Chief Executive Officer (CEO) and Director of Performance Improvement, on 10/28/16 at 7:36 PM, revealed it would have been their expectation that there would have been documentation by RN #1 to support the use of the resistant, and a restraint packet should have been completed as per policy. Further interview revealed the the restraint policy was developed to keep staff and patients safe and should have been followed.

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to ensure nursing services were furnished and supervised for each patient for two (2) of ten (10) sampled patients (Patient #1 and #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1 in order for the Patient to receive an Intramuscular (IM) injection of Haldol (antipsychotic medication). There was no documented evidence staff referred to the patient's Treatment Plan for less restrictive interventions prior to the use of the restraint, no documented evidence of the use of the restraint or the completion of the seclusion and restraint packet as per policy, no documented evidence of a Physician's order for the restraint, and no documented evidence of an assessment of the patient for injuries after the restraint was used. Additionally, the RN involved failed to notify the Nursing Supervisor on duty of the improper restraint used on Patient #3, and there was no documentation to support MHT #1 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he was observed to use the improper restraint and MHT #1 was allowed to continue to work with patients.

Furthermore, although Patient #3 had Physician's orders for Risperdal tablet (antipychotic medication) 1 mg by mouth (oral) every four (4) hours PRN (as needed) for severe agitation and aggression, and Haldol 2mg IM PRN every eight (8) hours for severe agitation and aggression for refusal of oral medication, review of the Medication Administration Record (MAR) revealed Patient #3 received Haldol 2mg IM on 10/15/16 at 10:05 AM, although there was no documentation of the refusal of the oral antipsychotic on 10/15/16.

Subsequently, the next day, on 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. MHT #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then the patient was turned over in a "supine" restraint. This was an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Staff interviews revealed they did not refer to the patient's treatment plan for a less restrictive intervention. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for two (2) of ten (10) sampled patients (Patient #1 and #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (a restraint immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1 in order for the Patient to receive an Intramuscular (IM) injection of Haldol (antipsychotic medication). There was no documented evidence staff referred to the patient's Treatment Plan for less restrictive interventions prior to the use of the restraint, no documented evidence of the use of the restraint or the completion of the seclusion and restraint packet as per policy, no documented evidence of a Physician's order for the restraint, and no documented evidence of an assessment of the patient for injuries after the restraint was used. Additionally, the RN involved failed to notify the Nursing Supervisor on duty of the improper restraint used on Patient #3, and there was no documentation to support MHT #1 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he was observed to use the improper restraint and MHT #1 was allowed to continue to work with patients.

Furthermore, Patient #3 had Physician's orders for Risperdal tablet (antipsychotic medication) 1 mg by mouth (oral) every four (4) hours PRN (as needed) for severe agitation and aggression, and Haldol 2mg IM PRN every eight (8) hours for severe agitation and aggression for refusal of oral medication. However, review of the Medication Administration Record (MAR) revealed Patient #3 received Haldol 2mg IM on 10/15/16 at 10:05 AM, although there was no documentation of the refusal of the oral antipsychotic on 10/15/16.

Subsequently, the next day, on 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. MHT #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then was turned over and placed in a "supine" restraint. This was an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Staff interviews revealed they did not refer to the patient's treatment plan for a less restrictive intervention. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

The findings include:

Review of the facility's policy, titled "Restraint" , revised April 2010, and reviewed July 2013, revealed the patient had the right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff. A physical restraint was defined as the application of physical force alone restricting the free movement of the whole or portion of an individual's body in order to control physical activity. It was the policy of the facility to limit the use of restraints to emergencies in which there was an imminent risk of a patient physically harming him/herself or others. Restraints would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to the patient or others prior to the application of restraints. Attempts to use less restrictive measures, as well as the patient's response to those measures would be recorded on the Seclusion and Restraints Assessment form. Further review revealed the facility was committed to preventing, reducing and striving to eliminate the use of restraints, as well as preventing emergencies that have the potential to lead to the use of restraints.

Interview, on 10/28/16 at 7:36 PM, with the Director of Performance Improvement (PI) revealed the facility did not have a policy regarding the use of the facility developed supine restraint. Additionally the facility did not having any training materiel on to perform a supine restraint, but is demonstrated to staff by RN#1.

Review of the facility's Employee Training Manual, titled, " Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior " , copyright date 2005, revealed the Nonviolent Crisis Intervention (NCI) program was a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint was recommended only when all less-restrictive methods of intervening had been exhausted, and when the individual presented a danger to self or others. Additionally, the training manual conveyed that any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention.

Continued review of the training manual, revealed face down (prone) floor restraints and positions in which a person was in any face down position on a bed or mat or was bent over in such a way, made it difficult to breathe and was extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively. Finally, the training emphasizes the NPCI's intent was to calm the individual, to keep the individual off the floor, thus reducing risks of Restraint-Related positional asphyxia and other injuries. Continued review of the training manual, stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor to restrain an individual, and floor restraints were not part of the teaching of NCI. Team interventions would be used when necessary and the NPCI would be used only as a last resort when someone presented a danger.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients; and intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior; use verbal techniques to de-escalate behavior; demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level; provide for the care, welfare, safety and security of all those who were involved in a crisis situation; and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint for training presentation titled, "Code Class", dated 2016, revealed the team support, de-escalation assistance, should be called when the patient was defensive and at the beginning stage of loss of rationality. Crisis Development Model Level two (2) was a stage in which an individual often becomes belligerent and challenges authority. Continued review revealed staff should be directive, an approach in which a staff member takes control of a potentially escalating situation. Staff should remember that the patient may not be able to respond to the rational context of your words. Instead the patient may be more in tune with other types of communication such as your tone of voice, and your proximity to him/her or your body posture. Additionally, the code yellow was used for Psychiatric Emergency, when the patient was "acting-out" in which they had total loss of rationale. In this situation, staff would use Nonviolent Physical Crisis Intervention (NCI), which was a safe non-harmful restraint with positions to control an individual until the Patient could gain control of his/her own behavior. This would be used as the last resort.

Review of the facility's PowerPoint for training presentation titled, "Identifying and Managing Risk Factors Associated with Seclusion and Restraint", undated, in the "Seclusion, Take Downs, and Physical Holds " section, revealed risk factors for an individual in a restraint in a "prone position" was positional asphyxia, and staff should: quickly respond to any person's complaint that they could not breath; ensure staff, object, or body positioning was not contributing to diminished air flow; reposition staff and/or client to alleviate pressure; utilize any safety procedures/devices associated with the behavior management system to eliminate pressure; recognize that just because a person could talk or yell did not mean they had adequate oxygen; and discontinue hold/restraints immediately if positional asphyxia was thought to exist. Continued review revealed risk factors for an individual in a restraint in a supine position included the risk for aspiration and staff should monitor breathing closely (face visible); if the individual experiences semi-consciousness and/or unconsciousness then place individual immediately on their side and check for aspiration; and if vomiting occurred immediately turn the person on their side and clear mouth of any matter. Additional review of the training presentation revealed for individuals in prone or supine positions, no pressure should be on the individual's neck, chest, or back and spinal injuries/fractures could occur with any age group depending on force and position and children/adolescents with developing/immature bones were more vulnerable to breakage. The training presentation further revealed injury could occur if behavior management techniques were not performed as designed and staff should follow all policies and procedures defined in the approved facility behavior management system.

1. Review of Patient #1's Medical Record revealed the patient was admitted by the facility on 09/01/16 with diagnosis to include Oppositional Defiant Disorder, Affective Disorder, Abuse, and Insomnia. Further review revealed the patient was admitted with the chief complaint of homicidal ideation against his/her grandfather.

Review of Patient #1's Initial Nursing Treatment Plan dated 09/02/16, revealed the Short-Term Goals included the patient would notify staff of thoughts of harming self and would demonstrate the use of Music as a coping skill when having thoughts of harming self. Interventions included staff questioning the patient to see if having thoughts of harming self, mouth checks, and removal of personal items to prevent self-injurious behavior.

Review of Patient #1's Restraint/Seclusion Order/Record, completed by Registered Nurse (RN) #4, dated 10/16/16 at 10:45 with no AM or PM specified, revealed an incident occurred on Unit 6 with the intervention of a Physical Restraint. The Clinical Justification for the Intervention was "danger to others." Patient #1's behavior exhibited included stepping on peers ankle on purpose and then punching ceiling tile and furniture cushion. The Patient verbally threatened staff and then tried to kick down the group room door. Further review revealed less restrictive interventions were attempted which included verbal de-escalation/redirection, Psychoactive medication (non-restraint), and one on one (1:1) processing. Continued review of the Restraint/Seclusion record revealed the patient complained of left shoulder pain, complained the cheek bone "felt like somebody smashed it" and rated pain at a five (5) out of ten (10).

Review of the Internal Risk Management Worksheet, completed by the Director of Risk Management, dated 10/26/16 at 11:44 AM, revealed the incident was documented by RN #4 to have occurred on 10/16/16 at 10:45 AM and entered in at 10/16/16 at 6:38 PM, and stated, "this writer observed patient on the ground in a supine hold restraint." Further review, revealed an abrasion was noted to the left side of the face after release from the restraint, and the patient complained of left shoulder, left face, and right wrist pain.

Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed Patient #1's diagnoses for the ED visit included: Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

Review of Therapist #2's statement, dated 10/17/16, revealed Patient #1 could be heard hitting and kicking walls while MHT #1 could be heard saying, "stop doing that" , "stop kicking" . Further review revealed a commotion in the hall was heard and some of the patients stated MHT #1 slammed Patient #1 to the floor and Patient #1 was "tackled." Interview with the Therapist could not be attempted by the State Agency, as the Therapist was out of the facility on leave.

Per statement of Patient #2, on 10/19/16, Patient #1 was observed to kick the door and MHT #1 picked Patient #1 up and threw him/her on the ground, "slammed him/her down."

Interview with Patient #4, on 10/27/16 at 2:55 PM, revealed earlier that day he/she heard MHT #1 state that if anyone did anything that day, he would restrain them. Patient #4 stated he saw Patient #1 placed in the restraint by MHT #1. The patient stated he/she was in group and observed Patient #1 kicking the door approximately one (1) time and Patient #1 was "slammed" to the ground by MHT #1. Further interview revealed a code was not called, but was often called before a patient was placed in a restraint. Patient #4 stated he/she did not believe the patient should have been placed in a restraint and believed it was inappropriate. Further interview with Patient #4 revealed the facility did not question him/her about the details of the event.

Review of Patient #1's statement, dated 10/19/16, revealed the patient could not recall what he/she was mad about that day, but thought it was because he/she could not reach his/her step-mother on the phone. Further review of the statement revealed MHT #1 told him/her to "stop it" and Patient #4 told him/her that MHT #1 came into work wanting to restrain somebody. Continued review of Patient #1's statement revealed MHT #1 took the arm of the chair out of his/her hands. Patient #1's statement revealed he/she hugged MHT #2, and MHT #2 stated "boundaries" and MHT #1 stated, "bullshit " and got in my face. Patient #1 told MHT #1 that MHT #1 had a very punchable face and walked away from him and kicked the door. Further review of the statement revealed MHT #1 told Patient #1 to punch him, adding MHT #2 and MHT #3 might have been there. Patient #1's statement revealed MHT #1 took the patient's arms behind him/her and pushed the patient down forcefully and his/her face hit the ground and his/her face got carpet burned. Further review revealed MHT #1 put his hands on the patient's arms and pushed him/her at the neck/shoulder, adding the Emergency Room (ER) informed him/her that he/she had a mild concussion, kink in the neck, and stated, "see my face." Continued review of the statement, revealed the patient thought he/she was in the restraint for approximately three (3) minutes. Per the statement, MHT #1 was told to leave the restraint.

Interview with Patient #1, on 10/26/16 at 1:30 PM, revealed he/she liked MHT #1 before this incident occurred. Patient #1 stated, on the day of the incident, he/she recalled removing an arm from a chair and hitting the corner of a wall. He/she stated MHT #1 took the arm of the chair from him/her and flung it behind him/her. Per interview, MHT #1 then told the patient to go to his/her room, but before he/she went to his/her room, the patient gave MHT #2 a hug, and MHT #2 stated to him/her "boundaries. " Patient #1 stated he told MHT #1 he had a "punchable " face and MHT #1 stated "do it. " The Patient stated he/she turned around and kicked the door to the group room and MHT #1 grabbed him/her from behind and "flung" him/her to the ground. Patient #1 stated he/she was in a restraint in which four (4) people responded. He/she could not recall everyone who responded but revealed MHT #1, MHT #2, and MHT #3 were there.

Review of MHT #1's statement, dated 10/18/16, revealed he was on his way back to the unit from break when MHT #2 texted him and told him that Patient #1's behavior had been escalating. Per the statement, when he arrived, Patient #1 was in the consult room on Unit 6 and had ripped off the arm of one of the chairs and was swinging it around, (like a weapon) hitting the wall. MHT #1 statement revealed he took this away and asked the patient to get out of the consult room. At this time MHT #2 had another male patient (Patient #2) in the hall as well. Patient #1's behavior continued to escalate and MHT #1 stayed close by. Patient #1 went over to the peer (Patient #2) and stepped onto Patient #2's ankle hurting his/her peer. Patient #1 laughed and told MHT #1 he/she had done it because he/she "made a funny noise." Patient #1 then proceeded to approach MHT #2, wrapping his/her arms around her saying "you are so beautiful." MHT #1 yelled at Patient #1 to stop, as did MHT #2. MHT #1's statement revealed, due to Patient #1's sexually inappropriate history, he got between MHT #2 and the patient at which time Patient #1 threatened to punch MHT #1 in the face. MHT #1's statement revealed he responded to the patient by saying "just do it" to deflect the attention off of MHT #2 and the other male patient (Patient #2). MHT #1's statement revealed Patient #1 turned and kicked the group room door and seemed to be escalating even more. Per the statement, it was at that time, MHT #1 put his arms through the patient's arms in the back and then "put him/her down". Further review, revealed when staff arrived the patient was turned. Per the statement, when this happened Patient #1 stated "Now I am really pissed " and started resisting, and that is when he leaned over to hold the patient's knees. MHT #1 was then told to switch out, which he did with MHT #2. He was told to go to the ARC Unit. The Nursing supervisor/Registered Nurse (RN) #2, then asked MHT #1 to go home and he was suspended until an internal investigation of the event was completed. Continued review of the statement revealed he took the patient down by himself, thinking of the safety of "my" staff and the other patient. Per the statement, he used force to protect MHT #2 and the patient, and there was not a code button and he did not think to ask MHT #2 to call a code. Per the statement, he did not utilize approved NCI tactics and his mindset was on protecting staff and the other patient. Per the statement he initially stated he felt he had done the right thing, but then when questioned he stated he would have done things differently and would have followed policy and procedure, and had other staff call team support or code yellow.

Telephone interview with MHT #1, on 10/27/16 at 9:58 AM, revealed on the day of the incident, he went on lunch break while the patients were in group therapy. He stated he asked MHT #2 to contact him if the patients were escalating and if she needed assistance with them. Continued interview with MHT #1, revealed he received a text message from MHT #2 to come back to the facility because Patient #1 was going off. He stated when he got back to the facility, Patient #1 was observed in the Consult room, on Unit 6, to rip off the arm of a chair and was swinging at the wall, laughing about it. MHT #1 stated he caught the chair arm, mid swing, from Patient #1. He stated the patient tried to grab the table, but MHT #1 sat on the table. MHT #1 revealed Patient #4 was out of group and laughing about the whole situation and then ended up going back to therapy. Further interview revealed Patient #1 and Patient #2 were observed to be out of group and Patient #1 then stepped on Patient #2's ankle while Patient #1 laughed hysterically. MHT #1 stated he asked Patient #1 why he/she would stand on Patient # 2's ankle and he stated the patient made a "funny" noise, adding he attempted to verbally de-escalate Patient #1. MHT #1 stated this did not work because Patient #1 was ignoring him. Further interview with MHT #1, revealed Patient #1 then turned his/her attention to MHT #2 and backed her into the corner of the wall on the Unit and started to make sexually inappropriate comments. MHT #1 revealed, Patient #1 stated to MHT #2, she was beautiful and wrapped his/her arms around her while attempting to touch her. He stated MHT #2 yelled for Patient #1 to get off of her. MHT #1 revealed his focus was to get the attention taken off of MHT #2 and Patient #2. According to MHT #1, Patient #1 then asked him if he was trying to get hit, and MHT #1 told the patient, "go ahead and do it." He stated at that point Patient #1 turned and kicked the door to the group room, where other patients were in the room for therapy. MHT #1 revealed he could not de-escalate the patient, thus MHT #1 grabbed Patient #1's arms from behind and looped his/her arms around where the patient's elbows bent and Patient #1 hit the ground, falling face down. He stated he flipped the patient over and other staff came to assist with the hold. MHT #1 stated MHT #2 "was in shock" and he acted for the safety of the patients, who were in group therapy, and "staff ", being MHT #2. When staff came to assist with the hold, he stated they asked him what happened, but before he could answer he grabbed Patient #1's leg to make sure he/she did not kick anyone in the face. He stated that while in the hold, he told RN #4 that Patient #1 needed to be in 1A ( a seclusion room he reported was on the geriatric unit) because he/she was a "danger."

Further interview with MHT #1, revealed MHT #2 was asked to replace him in the hold and he walked to the ARC unit, adding he did not provide care for other patients while there. He stated he was informed by the nursing supervisor, RN #2, that the patient had carpet burns from the restraint and the facility would conduct an investigation. MHT #1 stated he was told by staff that the patient had concussion like symptoms and that the patient hit the ground pretty hard. MHT #1 stated the only people involved in the incident or who observed the incident were MHT #2, Patient #2, and Patient #1. Additionally, MHT #1 revealed the restraint he placed Patient #1 in was not an appropriate restraint, adding, "it was an old military move" he learned from being in the military and "knew" it would not hurt the patient. He stated he knew the patient was large and had him "beat" in weight. He revealed it was not a proper NCI hold, but it was a restraint that could be used for someone larger than you. MHT #1 stated there was no other hold he could have performed to de-escalate the situation, adding " others would have gotten hurt". MHT #1 stated there was nothing he would have done differently, but added he could have had MHT #2 or somebody to call a code for additional team support to put the patient in a "safer" hold.

Interview with MHT #2, on 10/27/16 at 1:02 PM, revealed the facility provided NCI training upon hire and annually. She stated staff was taught that there were different stages of crisis and also taught what was going on in a patients mind during those stages. She further stated when a patient was anxious, they would start losing rational thought and they paid more attention to the staff members' body language instead of words. MHT #2 revealed a physical restraint was the last resort and should only be used when there was imminent danger to patient and/or staff. Additionally, MHT #2 conveyed, when putting a patient in a physical restraint, staff should communicate with each other, adding it took two (2) people to properly restrain a person, as per NCI techniques. She stated staff would talk about what they would do, often attempting to verbally de-escalate the patient first, which often did not work. She further stated a code would not be called unless there was danger to patient and/or staff. MHT #2 stated, on the day of the incident, there were patients who were excused from group therapy and they were exhibiting behaviors. She stated Patient #1 obtained objects from the ceiling, tore signs off the wall, and grabbed a piece off a chair and was throwing it. She further stated she was on the unit by herself, thus went to the nursing station and texted MHT #1 to come back to work.

Continued interview with MHT #2, revealed it was not safe for her at that point to be left alone with the other patients. She stated Patient #1 was aggravating Patient #2, stepped on Patient #2's ankle, and Patient #1 was not easily redirected. MHT #2 stated Patient #1 then turned to give her a hug and she told him/her to respect her boundaries, and not to touch her. MHT #2 stated, MHT #1 then told Patient #1 not to touch staff. She stated Patient #1 then grabbed her and wrapped his/her arms around her. She stated this made her feel violated and she "froze". She further stated Patient #1 then kicked the door, which lead to the group room, adding, "there were other patients in the room." MHT #2 revealed Patient #1 turned to MHT #1, and she thought the patient was going to hit her or MHT #1, and thought the patient was hostile. She further stated that at that moment, neither she nor MHT #1 could de-escalate Patient #1. However, MHT #2 revealed she did not refer to Patient #1's treatment plan, which provided suggestions to use to de-escalate the patient. MHT #2 stated she was not aware of the patient's treatment plan, but added it would have been important to have referred to it for interventions in which to calm the patient. Continued interview with MHT #2, revealed MHT #1 then "took" the patient down by getting behind the patient, taking him/her to the ground. She stated she switched out with MHT #1 after Patient #1 was calm. MHT #2 stated Patient #1 was not placed in a proper restraint, as taught by NCI, but MHT #1 was "on his own." Further interview revealed the incident happened so quick that she could not call a code, but it would have been helpful to have had someone to assist MHT #1 with Patient #1. She stated she called the house supervisor/RN #2. Additionally, she stated she could have pressed the button to call a code, but felt it was more important to call the supervisor. MHT #2 stated, the importance for calling a code was to send more people to assist and for the safety of the patient, as well as staff.

Interview with MHT #3, on 10/26/16 at 2:15 PM, revealed it was the facility's policy to verbally de-escalate the patient before staff would place hands on the patient. She stated staff should always offer an alternative solution. Continued interview with MHT #3 revealed Patient #1 was a difficult patient based upon his/her history, however; the patient was not aggressive with staff, adding she had a good rapport with the patient. MHT #3 revealed the incident occurred on a Saturday or Sunday, in the morning, around 10:00 AM or 11:00 AM. She stated she was working on Unit 5 and was in the nurse's station to get something when she heard Patient #1 punching something. She further stated when she looked up, she saw MHT #1 take the patient from behind and " lifted " Patient #1 off the ground and " slammed " him/her on the floor. Further interview, revealed by the time she got there, the patient was on the ground face down. MHT #3 stated she told MHT #1 the patient had to be turned face up. She stated she was on the patient's left side while MHT #1 was on the right side of the patient. She further stated the patient was attempting to get off the floor and he/she was making threats to MHT #1. MHT #2 stated MHT #1 did not say anything at that time, but rather grabbed the patient's knee with both of his hands. She stated she told MHT #1 that he needed to hold the patient "correctly". Per interview, two (2) nurses came in to assist with the hold, and RN #4 was at the patient's head and RN #3 took the patient's leg. MHT #3 stated at this time, MHT #2 was standing about five (5) feet away and never intervened, until she was told to replace MHT #1 to hold the patient's arm. Continued interview revealed MHT #1 then yelled " I want him/her out of here, off the unit. I want him/her on 1A ", as Patient #1 was crying and yelling at MHT #1. Per interview, the patient was in the hold, from beginning to end, no more than five (5) minutes. MHT #3 stated she did not see the incident which lead up to the restraint, but from what she knew of the patient, he/she often banged on walls, and it was therapeutic for him/her. She revealed that once the patient was in the restraint, it was necessary to continue the restraint for the safety of the staff and the patient, but felt it was an unnecessary restraint.

Interview with RN #3, on 10/27/16 at 3:28 PM, revealed the facility provided training on the proper NCI techniques. She stated physical restraint would not be used unless the patient was harming self and/or others and staff should try to verbally de-escalate the patient first. She further stated, often staff would ask the patient upon admission what worked for them when they were upset, and it would be developed in the patients Treatment Plan. RN #3 revealed, if the patient was banging and hitting things, then ideally staff would want to back away to determine what triggered the behavior. Per interview with RN #3, if verbal de-escalation did not work, a code would be called to get more people involved so that staff and/or the patient would not be in danger. RN #3 revealed, on the day of the incident with Patient #1, she was the charge nurse on a different unit. She stated that while in the nurses station, she looked up and saw MHT #1 take Patient #1 down. Patient #1's arms were behind him/her and MHT #1 was behind him/her holding his/her arms and pushed the patient down on the ground. She stated the patient was observed to be on his/her stomach, but eventually, got on his/her back. Further interview with RN #3, revealed MHT #3 was on Patient #1's right leg, RN #4 was on the patient's right arm, MHT #3 was on the patient's left arm while she had the patient's left leg. RN #3 revealed RN #4 knew something was not right with the way MHT #1 was holding the patient's leg and he was "worked" up, saying, " Patient #1 needed to be sent over to 1A ( an area in which patients were sent when they were not safe to be with other patients). RN #3 stated Patient #1 started to calm down, so she was not holding the patient's leg tight. She stated MHT #1 then reached over and pinned the patient's leg down, which was the leg RN #3 was holding. Continued interview with RN #3, revealed that was not an appropriate move, adding staff should not cross into another area in which a staff member was holding. RN #3 stated MHT #1 needed to be switched out because there "wasn't something right", related to the way MHT #1 was talking.

Further interview with RN #3, revealed she could not remember a code being called, but it would have been appropriate for a code to have been called. She stated the restraint Patient #1 was placed in, was not a proper restraint/take down. She further stated historically, the patient was aggressive in the sense of "punching" things, but had not physically hurt staff or his/her peers. Per interview, she did not feel the restraint was appropriate because the patient did not appear to be a danger to himself or anyone else. Additionally, she stated she did not know if re-education would have been effective for MHT #1, because he was impulsive at times and she was told by a staff member that Patient #3 was placed in an improper hold recently; although, she could not remember which staff member informed her of this. RN #3 state

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to protect and promote patient rights and receive care in a safe setting for two (2) of ten (10) sampled patients (Patient #1 and Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. There was no documented evidence staff referred to the patients Treatment Plan for less restrictive interventions and there was no documentation related to the use of the restraint. Additionally, there was no documented evidence to support MHT #1 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he was observed to use the improper restraint, and MHT #1 continued to work with patients.

On the next day, 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. MHT #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then the patient was turned over and placed in a "supine" restraint. This was an an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Staff interviews revealed they did not refer to the patient's treatment plan for a less restrictive intervention. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

The findings include:

Review of the facility's policy, titled "Restraint" , revised April 2010, and reviewed July 2013, revealed the patient had the right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff. A physical restraint was defined as the application of physical force alone restricting the free movement of the whole or portion of an individual's body in order to control physical activity. It was the policy of the facility to limit the use of restraints to emergencies in which there was an imminent risk of a patient physically harming him/herself or others.

Further review of the Policy, revealed Restraints would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to the patient or others prior to the application of restraints. Attempts to use less restrictive measures, as well as the patient's response to those measures would be recorded on the Seclusion and Restraints Assessment form. Further review revealed the facility was committed to preventing, reducing and striving to eliminate the use of restraints, as well as preventing emergencies that have the potential to lead to the use of restraints.

Review of the facility's Employee Training Manual, titled, " Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior " , copyright date 2005, revealed the Nonviolent Crisis Intervention (CPI) program was a safe, non-harmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint was recommended only when all less-restrictive methods of intervening had been exhausted, and when the individual presented a danger to self or others.

Additionally, review of the Training Manual, revealed any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention. Continued review revealed face down (prone) floor restraints and positions in which a person was bent over in such a way made it difficult to breathe and was extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively. Finally, the training emphasized the NPCI's intent was to calm the individual, to keep the individual off the floor, thus reducing risks of Restraint-Related positional asphyxia and other injuries. Continued review of the training manual stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor to restrain an individual, and floor restraints were not part of the teaching of NCI. Per the Manual, team interventions would be used when necessary and the NPCI would be used only as a last resort when someone presents a danger.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients; and intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior; use verbal techniques to de-escalate behavior; demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level; provide for the care, welfare, safety and security of all those who were involved in a crisis situation; and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint presentation for training titled, "Code Class", dated 2016, revealed the team support, de-escalation assistance, should be called when the patient was defensive and at the beginning stage of loss of rationality. Crisis Development Model Level two (2) was a stage in which an individual often becomes belligerent and challenges authority. Continued review revealed staff should be directive, an approach in which a staff member takes control of a potentially escalating situation. Staff should remember that the patient may not be able to respond to the rational context of your words. Instead the patient may be more in tune with other types of communication such as your tone of voice, and your proximity to him/her or your body posture. Additionally, the code yellow was used for Psychiatric Emergency, when the patient was "acting-out" in which they had total loss of rationale. In this situation, staff would use Nonviolent Physical Crisis Intervention (NCI), which was a safe non-harmful restraint with positions to control an individual until the Patient could gain control of his/her own behavior. This would be used as the last resort.

Review of the facility's PowerPoint presentation for training titled, "Identifying and Managing Risk Factors Associated with Seclusion and Restraint", undated, in the "Seclusion, Take Downs, and Physical Holds" section, revealed risk factors for an individual in a restraint in a "prone position" was positional asphyxia, and staff should: quickly respond to any person's complaint that they could not breath; ensure staff, object, or body positioning was not contributing to diminished air flow; reposition staff and/or client to alleviate pressure; utilize any safety procedures/devices associated with the behavior management system to eliminate pressure; recognize that just because a person could talk or yell did not mean they had adequ

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to ensure patients had the right to be free from all forms of abuse or harassment. Additionally, the facility failed to immediately report allegations of abuse and failed to ensure a thorough investigation was completed for allegations of abuse for one (1) of ten (10) sampled patients (Patient #1 ).

On 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. Mental Health Technician (MHT) #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then the patient was turned over in a "supine" restraint which was an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Additionally, staff interviews revealed they did not refer to the patients Treatment Plan for a less-restrictive intervention. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, Strain of Neck Muscle, and Cervical Sprain.

The facility failed to conduct a thorough investigation and failed to question other patients who may have witnessed the incident related to Patient #1, or may have been unnecessarily placed in restraints by MHT #1, and failed to question staff as to whether other patients had been improperly restrained by MHT #1. In addition, the facility did not ensure the Department of Community Services (DCBS), received the allegation of abuse related to Patient #2 as per facility's policy and state regulations.

The findings include:

Review of the facility's Employee Training Manual, titled, " Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior ", copyright date 2005, revealed the Nonviolent Crisis Intervention (CSI) program was a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Additionally, the training manual conveyed that any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention. Continued review of the training manual, stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor to restrain an individual, and floor restraints were not part of the teaching of NCI. Continued review revealed face down (prone) floor restraints and positions in which a person was bent over in such a way made it difficult to breathe and was extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review of the policy revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients, intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior, use verbal techniques to de-escalate behavior, demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level, provide for the care, welfare, safety and security of all those who were involved in a crisis situation, and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint presentation for training titled, "Identifying and Managing Risk Factors Associated with Seclusion and Restraint", undated, in the "Seclusion, Take Downs, and Physical Holds" section, revealed risk factors for an individual in a restraint in a "prone position" was positional asphyxia, and staff should: quickly respond to any person's complaint that they could not breath; ensure staff, object, or body positioning was not contributing to diminished air flow; reposition staff and/or client to alleviate pressure; utilize any safety procedures/devices associated with the behavior management system to eliminate pressure; recognize that just because a person could talk or yell ddid not mean they had adequate oxygen; and discontinue hold/restraints immediately if positional asphyxia was thought to exist. Continued review revealed risk factors for an individual in a restraint in a supine position included the risk for aspiration and staff should monitor breathing closely (face visible); if the individual experiences semi-consciousness and/or unconsciousness then place individual immediately on their side and check for aspiration; and if vomiting occurred then immediately turn the person on their side and clear mouth of any matter. Additional review of the training presentation revealed for individuals in prone or supine positions, no pressure should be on the individual's neck, chest, or back and spinal injuries/fractures could occur with any age group depending on force and position and children/adolescents with developing/immature bones were more vulnerable to breakage. The training presentation further revealed injury could occur if behavior management techniques were not performed as designed and staff should follow all policies and procedures defined in the approved facility behavior management system.

Review of the facility's "Suspected Patient Neglect and Abuse by Staff" Policy, revised May 2007, revealed it was the purpose of the facility to protect the patient's rights, health and safety. Per Policy, abuse was defined as any physical or verbal action directed towards a patient, who was or could be harmful or demeaning to his/her safety, welfare and well being and the facility did not condone any action, which could be constructed as neglect or abuse. Every staff member was expected to report any incident of possible neglect or abuse and any suspected or witnessed incidents of either neglect or abuse immediately to the staff member's immediate supervisor or in his/her absence, to the Director of Nursing and Director of Clinical Services. All allegations were to be immediately investigated by a team to include the Risk Manager, in collaboration with the Department/Unit Manager, Director of Nursing and Director of Clinical Services. The Director of Human Resources would be notified and provide oversight and direction to assure that the Human Resources policies were followed. The Chief Executive Officer (CEO) would be immediately apprised of the allegation and investigation results and approve the final decision in all cases. Additionally, the Investigative Team would conduct the investigation by interviewing those involved and complete a report of each interview. The employee's personal record would be reviewed for prior complaints or counseling and if disciplinary action was needed, the Director of Human Resources would ensure appropriate actions were taken by the Hospital. The Director of Clinical Services or designee would make external notification to the appropriate State Agency. Any supervisor who received information, written or oral of alleged patient abuse or neglect, and failed to respond, would be subject to disciplinary action up to and including employment termination.

Review of the facility's "Reporting Child Abuse" Poli

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to ensure all patients were free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff for two (2) of ten (10) sampled patients (Patient #1 and Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. There was no documented evidence staff attempted less restrictive interventions prior to use of the restraint, no documented evidence a Physician's order was obtained for the restraint, and no documentation related to the use of the restraint. Additionally, there was no documented evidence to support MHT #1 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he was observed to use the improper restraint, and MHT #1 continued to work with patients.

On the next day, 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. MHT #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then turned the patient over in a "supine" restraint. This was a an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Staff interviews revealed they did not attempt a less restrictive intervention prior to the restraint. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

The findings include:

Review of the facility's policy, titled "Restraint" , revised April 2010, and reviewed July 2013, revealed the patient had the right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff. A physical restraint was defined as the application of physical force alone restricting the free movement of the whole or portion of an individual's body in order to control physical activity. It was the policy of the facility to limit the use of restraints to emergencies in which there was an imminent risk of a patient physically harming him/herself or others. Restraints would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to the patient or others prior to the application of restraints. Attempts to use less restrictive measures, as well as the patient's response to those measures would be recorded on the Seclusion and Restraints Assessment form. Further review revealed the facility was committed to preventing, reducing and striving to eliminate the use of restraints, as well as preventing emergencies that have the potential to lead to the use of restraints.

Review of the facility's Employee Training Manual, titled, " Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior " , copyright date 2005, revealed the Nonviolent Crisis Intervention (CSI) program was a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint was recommended only when all less-restrictive methods of intervening had been exhausted, and when the individual presented a danger to self or others. Additionally, the training manual conveyed that any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention.

Continued review of the training manual stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor to restrain an individual, and floor restraints were not part of the teaching of NCI. Further review revealed face down (prone) floor restraints and positions in which a person was bent over in such a way made it difficult to breathe and was extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively. Finally, the training emphasizes the NPCI's intent was to calm the individual, to keep the individual off the floor, thus reducing risks of Restraint-Related positional asphyxia and other injuries. Team interventions would be used when necessary and the NPCI would be used only as a last resort when someone presents a danger.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients; and intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior; use verbal techniques to de-escalate behavior; demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level; provide for the care, welfare, safety and security of all those who were involved in a crisis situation; and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint presentation for training titled, "Code Class", dated 2016, revealed the team support, de-escalation assistance, should be called when the patient was defensive and at the beginning stage of loss of rationality. Crisis Development Model Level two (2) was a stage in which an individual often becomes belligerent and challenges authority. Continued review revealed staff should be directive, an approach in which a staff member takes control of a potentially escalating situation. Staff should remember that the patient may not be able to respond to the rational context of your words. Instead the patient may be more in tune with other types of communication such as your tone of voice, and your proximity to him/her or your body posture. Additionally, the code yellow was used for Psychiatric Emergency, when the patient was "acting-out" in which they had total loss of rationale. In this situation, staff would use Nonviolent Physical Crisis Intervention (NCI), which was a safe non-harmful restraint with positions to control an individual until the Patient could gain control of his/her own behavior. This would be used as the last resort.

Review of the facility's PowerPoint presentation for training titled, "Identifying and Managing Risk Factors Associated with Seclusion and Restraint", undated, in the " Seclusion, Take Downs, and Physical Holds " section, revealed risk factors for an individual in a restraint in a " prone position " was positional asphyxia, and staff should: quickly respond to any person's complaint that they could not breath; ensure staff, object, or body positioning is not contributing to diminished air flow; reposition staff and/or client to alleviate pressure; utilize any safety procedures/devices associated with the behavior management system to eliminate pressure; recognize that just because a pe

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to ensure residents were free from unnecessary or improper restraints (a restraint is any manual method, physical or mechanical device, material, or equipment that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely) for two (2) of ten (10) sampled patients (Patient #1 and Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. There was no documented evidence staff attempted less restrictive interventions prior to use of the restraint, no documented evidence a Physician's order was obtained for the restraint, and no documentation related to the use of the restraint. Additionally, there was no documented evidence to support MHT #1 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he was observed to use the improper restraint, and MHT #1 continued to work with patients.

On the next day, 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. MHT #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then the patient was turned over in a "supine" restraint. This was an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Staff interviews revealed they did not attempt a less restrictive intervention prior to the restraint. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

The findings include:

Review of the facility's policy, titled "Restraint" , revised April 2010, and reviewed July 2013, revealed the patient had the right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff. A physical restraint was defined as the application of physical force alone restricting the free movement of the whole or portion of an individual's body in order to control physical activity. It was the policy of the facility to limit the use of restraints to emergencies in which there was an imminent risk of a patient physically harming him/herself or others. Restraints would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to the patient or others prior to the application of restraints. Attempts to use less restrictive measures, as well as the patient's response to those measures would be recorded on the Seclusion and Restraints Assessment form. Further review revealed the facility was committed to preventing, reducing and striving to eliminate the use of restraints, as well as preventing emergencies that have the potential to lead to the use of restraints.

Review of the facility's Employee Training Manual, titled, "Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior", copyright date 2005, revealed the Nonviolent Crisis Intervention (CSI) program was a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint was recommended only when all less-restrictive methods of intervening had been exhausted, and when the individual presented a danger to self or others. Additionally, the training manual conveyed that any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention. Further review of the training manual, stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor, and floor restraints were not part of the teaching of NCI.

Continued review of the Manual revealed face down (prone) floor restraints and positions in which a person was bent over in such a way was difficult to breathe and extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively. Finally, the training emphasizes the NPCI's intent was to calm the individual, to keep the individual off the floor, thus reducing risks of Restraint-Related positional asphyxia and other injuries. Team interventions would be used when necessary and the NPCI would be used only as a last resort when someone presents a danger.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients; and intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior; use verbal techniques to de-escalate behavior; demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level; provide for the care, welfare, safety and security of all those who were involved in a crisis situation; and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint presentation for training titled, "Code Class", dated 2016, revealed the team support, de-escalation assistance, should be called when the patient was defensive and at the beginning stage of loss of rationality. Crisis Development Model Level two (2) was a stage in which an individual often becomes belligerent and challenges authority. Continued review revealed staff should be directive, an approach in which a staff member takes control of a potentially escalating situation. Staff should remember that the patient may not be able to respond to the rational context of your words. Instead the patient may be more in tune with other types of communication such as your tone of voice, and your proximity to him/her or your body posture. Additionally, the code yellow was used for Psychiatric Emergency, when the patient was "acting-out" in which they had total loss of rationale. In this situation, staff would use Nonviolent Physical Crisis Intervention (NCI), which was a safe non-harmful restraint with positions to control an individual until the Patient could gain control of his/her own behavior. This would be used as the last resort.

Review of the facility's PowerPoint for training presentation titled, "Identifying and Managing Risk Factors Associated with Seclusion and Restraint", undated, in the "Seclusion, Take Downs, and Physical Holds" section, revealed risk factors for an individual in a restraint in a "prone position" was positional asphyxia, and staff should: quickly respond to any person's complaint that they could not breath; ensure staff, object, or body positioning was not contributing to diminished air flow; reposition staff and/or client to alleviate pressure; utilize any safety procedures/devices associated with the behavior management system to eliminate pressure; recognize that just because a person could talk or

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the use of restraint or seclusion was in accordance with the patient's plan of care for one (1) of ten (10) sampled patients (Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (a restraint immobilize or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. There was no documented evidence staff followed and implemented Patient #3's Individual Treatment Plan's regarding de-escalation interventions attempting less restrictive interventions prior to use of the restraint. In addition, there was no documented evidence of a Physician's order obtained for the restraint, and no documentation related to the use of the restraint.

The findings include:

Review of the facility's policy titled, "Restraint", with a revision date of April 2010, revealed the use of restraints was to be limited to emergencies in which there was an imminent risk of a patient physically harming him/herself or others and the restraint would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Further review of the policy revealed the patient had a right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff and restraint would not be based on history of past use or dangerous behavior, or as convenience for staff. Continued review of the Policy, revealed PRN (as needed) orders may not be used to authorize the use of restraints. Per Policy, prior to the application of restraints, attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to patients or others and the attempts along with the patient's response to the attempts would be recorded on the seclusion and restraints assessment form.

Further review of the policy revealed restraints required an order from a physician unless the physician was absent and then the Registered Nurse may authorize the initiation of restraints. The policy further stated the physician must be contacted as soon as possible, but no longer than one (1) hour after initiation of the restraints to obtain an order. Per Policy, the Physician's order for the use of restraints would be recorded on the Seclusion/Restraint Order Form and include the following: reason for using the restraints including specific behaviors and safety issues, type of restraint used, the nurse receiving the order, the physician giving the order, and the nurse transcribing the orders with appropriates date and times. Continued review of the policy revealed any restraint episode for a patient that was under the ages of sixteen (16) shall require notification of the parent, guardian, family member, or conservator. Additional review of the policy revealed the use of restraints would be thoroughly documented in the patient's medical record and include specific behaviors; detailed description of events leading up to the incident and other pertinent information; the rationale for use of restraints; and time of initiation and termination of restraints.

Review of Patient #3's medical record revealed, the facility admitted the patient on 09/21/16 with the chief complaint of Suicidal Ideation. Review of the Psychiatric Admission Assessment dated 09/22/16 revealed the following diagnoses were identified: Mood Affective Disorder (set of psychiatric diseases with the main types being Depression, Bipolar Disorder, and Anxiety Disorder), Attention Deficit Hyperactivity Disorder (ADHD); and Victim of Physical Abuse and Neglect.

Review of Patient #3's Individual Treatment Plan (ITP), dated 09/23/16, revealed the patient was identified to have problematic behaviors that included aggression when the patient was upset. Review of Patient #3's ITP, dated 10/11/16 revealed the patient was identified to have dangerous behavior toward self and others which included threatening peers and physical aggression towards staff. Further review of both Patient #3's ITP's, revealed the following interventions were to be used to de-escalate the patient: verbal interventions such as talking quietly with the patient, relaxation techniques, physical activity, pain control, psychoactive medications, reality orientation, quiet time, time out, exercise, music, stress ball, walking, and use of a weighted blanket. Continued review of the ITP's revealed the patient had the following short term goals: Patient will identify at least two strategies to prevent acting out or that will assist patient to regain self-control and patient would remain free of emotional or physical injury when exhibiting dangerous behaviors to self or others for three (3) consecutive days prior to discharge. Further review of both Patient #3's ITP's revealed the use of a restraint only should be as a last resort and only after the less restrictive interventions have been tried and have failed.

Review of the Group Note for Patient #3, dated 10/15/16, at 11:45 AM, revealed the patient did not attend group therapy due to unsafe behavior. Continued review of the Group Note under the comments/concerns, revealed when staff told Patient #3 he would not be allowed to join group due to aggression towards staff and peers, Patient #3 began attempting to push staff, tried to run through doors, and made threats toward staff. Further review of the Group Note, revealed Patient #3 had calmed down for an hour and a half, and then the patient became agitated again, pushing staff and was given a PRN (meaning "as needed" ) Haldol 2 milligram (mg) (short acting anti-psychotic) medication Intramuscular injection.

Review of Patient #3's 24 Hour Nursing Progress Note, dated 10/15/16, revealed Registered Nurse (RN) #1 documented at 10:00 AM, "Patient #3 postured at staff, 2 mg Haldol Intramuscular (IM) given, patient went to sleep".

Review of the Attending Psychiatrist Note, dated 10/16/16, revealed Patient #3 required PRN medication on 10/15/16 due to slamming and banging on doors and refusing redirection.

Interview, on 10/27/16 at 1:02 PM, with MHT #2, revealed on 10/15/16 at approximately 9:00 AM, she was removing another patient from unit 5 to unit 6 because Patient #3 was "going off", punching walls. Continued interview with MHT #2, revealed while on unit 5, she observed patient #3 hit MHT #3 in the face. MHT #2 further stated, she was told by MHT #3 not to call a code. MHT #2 stated Patient #3 was "out for blood" so when she arrived to unit 6, she stayed there and asked MHT #1 to go to unit 5 and assist with Patient #3. Continued interview with MHT #2, revealed she stood at the nurse's station which allowed her to see MHT #1 who had Patient #3 in a restraint with the patients hands held behind his/her back. MHT #2 stated it took two (2) people to properly restrain a person using Nonviolent Crisis Intervention (NCI). MHT #2 further stated physical restraints were the last resort and if a restraint was used then an Incident Report was to be completed.

Interview, on 10/27/16 at 9:58 AM with MHT #1, revealed on 10/15/16 per MHT #2's request, he went to the children's unit to assist with Patient #3 who was acting out. MHT #1 stated he said to Patient #3, "what is going on buddy" , and that is when the patient raised his hand. Continued interview with MHT #1, revealed he then placed Patient #3 in a "bear hug" so RN #1 could deliver the IM injection. Further interview revealed MHT #3 then came over and told MHT #1, he could not do that hold and showed him a new hold by placing the patient in the hold to prepare him for the IM injection. MHT #1 stated RN #1 gave the IM injection and then thanked him for helping him out.

Interview, with MHT #3 on 10/26/16 at 2:15 PM and post survey interview on 11/02/16 at 5:54 PM, revealed on 10/15/16 during the morning shift, she was assigned to unit 5 and MHT #1 was assigned to unit 6. Continued interview with MHT #3 revealed Patient #3 was r

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure documentation was completed in the patient's medical record which including behaviors and interventions used to support the use of a restraint for one (1) of ten (10) sampled patients (Patient #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (a restraint immobilize or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1. However, there was no documented evidence of a clear description of the patient's behavior that warranted use of the restraint, no documented evidence of the use of the restraint or the completion of the seclusion and restraint packet as per policy, and no documented evidence of the patient's clinical response to the restraint intervention.

The findings include:

Review of the facility's policy titled, "Restraint", with a revision date of April 2010, revealed the use of restraints was to be limited to emergencies in which there was an imminent risk of a patient physically harming him/herself or others and the restraint would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Further review of the policy revealed the patient had a right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff and restraint would not be based on history of past use or dangerous behavior, or as convenience for staff. Continued review of the Policy, revealed PRN (as needed) orders may not be used to authorize the use of restraints. Per Policy, prior to the application of restraints, attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to patients or others and the attempts along with the patient's response to the attempts would be recorded on the seclusion and restraints assessment form.

Further review of the policy revealed restraints required an order from a physician unless the physician was absent and then the Registered Nurse may authorize the initiation of restraints. The policy further stated the physician must be contacted as soon as possible, but no longer than one (1) hour after initiation of the restraints to obtain an order. Per Policy, the Physician's order for the use of restraints would be recorded on the Seclusion/Restraint Order Form and include the following: reason for using the restraints including specific behaviors and safety issues, type of restraint used, the nurse receiving the order, the physician giving the order, and the nurse transcribing the orders with appropriates date and times. Continued review of the policy revealed any restraint episode for a patient that was under the ages of sixteen (16) shall require notification of the parent, guardian, family member, or conservator. Additional review of the policy revealed the use of restraints would be thoroughly documented in the patient's medical record and include specific behaviors; detailed description of events leading up to the incident and other pertinent information; the rationale for use of restraints; and time of initiation and termination of restraints.

Review of Patient #3's medical record revealed, the facility admitted the patient on 09/21/16 with the chief complaint of Suicidal Ideation. Review of the Psychiatric Admission Assessment dated 09/22/16 revealed the following diagnoses were identified: Mood Affective Disorder (set of psychiatric diseases with the main types being Depression, Bipolar Disorder, and Anxiety Disorder), Attention Deficit Hyperactivity Disorder (ADHD); and Victim of Physical Abuse and Neglect.

Review of Patient #3's Individual Treatment Plan (ITP), dated 09/23/16, revealed the patient was identified to have problematic behaviors that included aggression when the patient was upset. Review of Patient #3's ITP, dated 10/11/16 revealed the patient was identified to have dangerous behavior toward self and others which included threatening peers and physical aggression towards staff. Further review of both Patient #3's ITP's, revealed the following interventions were to be used to de-escalate the patient: verbal interventions such as talking quietly with the patient, relaxation techniques, physical activity, pain control, psychoactive medications, reality orientation, quiet time, time out, exercise, music, stress ball, walking, and use of a weighted blanket. Continued review of the ITP's revealed the patient had the following short term goals: Patient will identify at least two strategies to prevent acting out or that will assist patient to regain self-control and patient would remain free of emotional or physical injury when exhibiting dangerous behaviors to self or others for three (3) consecutive days prior to discharge. Further review of both Patient #3's ITP's revealed the use of a restraint only should be as a last resort and only after the less restrictive interventions have been tried and have failed.

Review of the Group Note for Patient #3, dated 10/15/16, at 11:45 AM, revealed the patient did not attend group therapy due to unsafe behavior. Continued review of the Group Note under the comments/concerns, revealed when staff told Patient #3 he would not be allowed to join group due to aggression towards staff and peers, Patient #3 began attempting to push staff, tried to run through doors, and made threats toward staff. Further review of the Group Note, revealed Patient #3 had calmed down for an hour and a half, and then the patient became agitated again, pushing staff and was given a PRN (meaning "as needed" ) Haldol 2 milligram (mg) (short acting anti-psychotic) medication Intramuscular injection.

Review of Patient #3's 24 Hour Nursing Progress Note, dated 10/15/16, revealed Registered Nurse (RN) #1 documented at 10:00 AM, "Patient #3 postured at staff, 2 mg Haldol Intramuscular (IM) given, patient went to sleep".

Review of the Attending Psychiatrist Note, dated 10/16/16, revealed Patient #3 required PRN medication on 10/15/16 due to slamming and banging on doors and refusing redirection.

Interview, on 10/27/16 at 1:02 PM, with MHT #2, revealed on 10/15/16 at approximately 9:00 AM, she was removing another patient from unit 5 to unit 6 because Patient #3 was "going off", punching walls. Continued interview revealed while on unit 5, she observed patient #3 hit MHT #3 in the face. MHT #2 further stated, she was told by MHT #3 not to call a code. MHT #2 stated Patient #3 was "out for blood" so when she arrived to unit 6, she stayed there and asked MHT #1 to go to unit 5 and assist with Patient #3. Continued interview with MHT #2, revealed she stood at the nurse's station which allowed her to see MHT #1 who had Patient #3 in a restraint with the patients hands held behind his/her back. MHT #2 stated it took two (2) people to properly restrain a person using Nonviolent Crisis Intervention (NCI). MHT #2 further stated physical restraints were the last resort and if a restraint was used then an incident report was to be completed.

Interview, on 10/27/16 at 9:58 AM with Mental Health Tech (MHT) #1, revealed on 10/15/16 per MHT #2's request, he went to the children's unit to assist with Patient #3 who was acting out. MHT #1 stated he said to Patient #3, "what is going on buddy" , and that is when the patient raised his hand. Continued interview with MHT #1, revealed he then placed Patient #3 in a "bear hug" so RN #1 could deliver the IM injection. Further interview revealed MHT #3 then came over and told MHT #1, he could not do that hold and showed him a new hold by placing the patient in the hold to prepare him for the IM injection. MHT #1 stated RN #1 gave the IM injection and then thanked him for helping him out.

Interview, with MHT #3 on 10/26/16 at 2:15 PM and post survey interview on 11/02/16 at 5:54 PM, revealed on 10/15/16 during the morning shift, she was assigned to unit 5 and MHT #1 was assigned to unit 6. Continued interview

Based on interview, record review and review of the facility's policies and documents, it was determined the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for two (2) of ten (10) sampled patients (Patient #1 and #3).

On 10/15/16, at approximately 10:00 AM, Patient #3 was placed in an "incorrect" physical restraint (a restraint immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) by Mental Health Technician (MHT) #1, which was observed by MHT #3 and Registered Nurse (RN) #1 in order for the Patient to receive an Intramuscular (IM) injection of Haldol (antipsychotic medication). There was no documented evidence staff referred to the patient's Treatment Plan for less restrictive interventions prior to the use of the restraint, no documented evidence of the use of the restraint or the completion of the seclusion and restraint packet as per policy, no documented evidence of a Physician's order for the restraint, and no documented evidence of an assessment of the patient for injuries after the restraint was used. Additionally, the RN involved failed to notify the Nursing Supervisor on duty of the improper restraint used on Patient #3, and there was no documentation to support MHT #1 received additional training from the Nonviolent Crisis Intervention (NCI) trainers after he was observed to use the improper restraint and MHT #1 was allowed to continue to work with patients.

Furthermore, Patient #3 had Physician's orders for Risperdal tablet (antipsychotic medication) 1 mg by mouth (oral) every four (4) hours PRN (as needed) for severe agitation and aggression, and Haldol 2mg IM PRN every eight (8) hours for severe agitation and aggression for refusal of oral medication. However, review of the Medication Administration Record (MAR) revealed Patient #3 received Haldol 2mg IM on 10/15/16 at 10:05 AM, although there was no documentation of the refusal of the oral antipsychotic on 10/15/16.

Subsequently, the next day, on 10/16/16 at 10:45 AM, Patient #1 was on the Adolescent Unit, Unit 6, and began to kick the door of the group/therapy room. MHT #1, per interviews and record review, "lifted" Patient #1 off the floor and "slammed" him/her to the ground face down; then was turned over and placed in a "supine" restraint. This was an improper restraint technique that was not taught by the Nonviolent Crisis Intervention (NCI) training nor was it in the facility's policy. Staff interviews revealed they did not refer to the patient's treatment plan for a less restrictive intervention. Review of the Hospital's Emergency Department (ED) "After Visit Summary", dated 10/17/16, revealed the patient was discharged with a Head Injury, Concussion, Abrasion of Face, and Strain of Neck Muscle, and Cervical Sprain.

The findings include:

Review of the facility's policy, titled "Restraint" , revised April 2010, and reviewed July 2013, revealed the patient had the right to be free from restraint imposed as a means of coercion, punishment, discipline, or retaliation by staff. A physical restraint was defined as the application of physical force alone restricting the free movement of the whole or portion of an individual's body in order to control physical activity. It was the policy of the facility to limit the use of restraints to emergencies in which there was an imminent risk of a patient physically harming him/herself or others. Restraints would only be employed after the use of less restrictive, nonphysical measures had been attempted and had proven unsuccessful. Attempts would be made to use less-restrictive measures to control the behavior that may potentially cause injury to the patient or others prior to the application of restraints. Attempts to use less restrictive measures, as well as the patient's response to those measures would be recorded on the Seclusion and Restraints Assessment form. Further review revealed the facility was committed to preventing, reducing and striving to eliminate the use of restraints, as well as preventing emergencies that have the potential to lead to the use of restraints.

Interview, on 10/28/16 at 7:36 PM, with the Director of Performance Improvement (PI) revealed the facility did not have a policy regarding the use of the facility developed supine restraint. Additionally the facility did not having any training materiel on to perform a supine restraint, but is demonstrated to staff by RN#1.

Review of the facility's Employee Training Manual, titled, " Nonviolent Crisis Intervention; A Program Focusing on the Safe Management of Disruptive and Assaultive Behavior " , copyright date 2005, revealed the Nonviolent Crisis Intervention (NCI) program was a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible care and welfare of disruptive, assaultive, and out of control persons, even during their most violent moments. Continued review revealed the training emphasis was on the Care, Welfare, Safety, and Security of both those in your care and yourself. Physical restraint was recommended only when all less-restrictive methods of intervening had been exhausted, and when the individual presented a danger to self or others. Additionally, the training manual conveyed that any physical intervention was potentially dangerous and should be looked at as an emergency response procedure. Risk involved with physical intervention could be minimized when staff members regularly rehearsed procedures for team intervention.

Continued review of the training manual, revealed face down (prone) floor restraints and positions in which a person was in any face down position on a bed or mat or was bent over in such a way, made it difficult to breathe and was extremely dangerous. Additionally, when someone was lying face down, even pressure to the arms and legs could impact that person's ability to breathe effectively. Finally, the training emphasizes the NPCI's intent was to calm the individual, to keep the individual off the floor, thus reducing risks of Restraint-Related positional asphyxia and other injuries. Continued review of the training manual, stressed the program was designed to maximize safety and offer a safer alternative to techniques that involve the floor to restrain an individual, and floor restraints were not part of the teaching of NCI. Team interventions would be used when necessary and the NPCI would be used only as a last resort when someone presented a danger.

Review of the facility's policy, titled "Crisis Intervention", reviewed September 2016, revealed all clinical staff were mandated to receive annual training in Non-Violent Crisis Intervention (NCI), training. Continued review revealed NCI was a safe, non-harmful method of handling agitated, aggressive or out of control patients. The course included techniques for noticing, assessing and intervening in the anxiety states of patients; managing defensive behaviors exhibited by clients; and intervening physically with out of control or dangerously aggressive clients. Further review revealed the objectives were to identify useful nonverbal techniques which could help to prevent acting out behavior; use verbal techniques to de-escalate behavior; demonstrate principles of personal safety to avoid injury if behavior escalates to a physical level; provide for the care, welfare, safety and security of all those who were involved in a crisis situation; and understand and develop team intervention strategies and techniques.

Review of the facility's PowerPoint for training presentation titled, "Code Class", dated 2016, revealed the team support, de-escalation assistance, should be called when the patient was defensive and at the beginning stage of loss of rationality. Crisis Development Model Level two (2) was a stage in which an individual often becomes belligerent and challenges authority. Continued review revealed staff should be directive, an approach in which a staff member takes control of a potentially escalating situation. Staff should remember that the patient may not be able to res