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Based on review of the clinical record for Patient #1, and facility policies and procedures, the governing body failed to ensure the facility followed its own policies to provide a safe setting for Patient #1, who sustained a nasal fracture while in a personal restraint.

Findings were:

Review of facility policy #1200.315, Seclusions and Restraints revealed that restraint and seclusion require a physician ' s order, and that " any patient in a physical (manual) restraint will have a staff person who is not participating in the hold observing him/her for any signs of distress or incorrect holding procedures ... physical restraints (holds) may only be done using techniques trained through the aggression management program. Additionally, except in extreme emergencies, one-person holds are not to be used. "

Review of the clinical record revealed that Patient #1 was secluded and restrained using an incorrect hold, by only one staff person, without a staff person not participating in the hold observing the patient for signs of distress, and without an order for the seclusion. Patient #1 fell and suffered a nasal fracture during the restraint due to the incorrect hold.

Based on review of the clinical record for Patient #1, and facility policies and procedures, and staff interview, the governing body failed to ensure the facility followed its own policies to provide a safe setting for Patient #2 and Patient #3, who were threatened and required to perform oral sex on Staff #4.

Findings were:

Review of the Hospital Employee Guidelines - Therapeutic Boundaries revealed that sexual relations between staff and patients are not allowed.

Review of the clincal record for Patient #2 and Patient #3 revealed that Patient #2 and Patient #3 were threatened by and engaged in oral sex with Staff #4 on 7-19-11.

Review of the facility investigation documents revealed that Staff #4, a male, was observed during and after his shift on the adolescent female unit multiple times while Patient #2 and Patient #3, adolescent females, were present, yet no one questioned him as to why he was on the unit.

The above was confirmed in interviews with the Chief Executive Officer, the Director of Risk Management, and the Director of Nursing, who confirmed that male staff are not allowed on the adolescent female unit, yet none of the nurses or staff questioned why a male staff was on the adolescent female unit, and Staff #4 was permitted to spend time on the adolescent female unit.

Based on review of the clinical record for Patient #1, staff interviews and facility videotape, the facility failed to provide a safe setting for Patient #1, who sustained a nasal fracture while in a personal restraint.

Findings were:

Review of the facility video on 7-28-2011 revealed that Patient #1 was secluded and restrained using an improper hold, which resulted in Patient #1 falling face down on the floor sustaining a nasal fracture on 5-22-11.

Review of the medical record for Patient #1 revealed a CT scan result on 5-23-11 confirming a nasal fracture as a result of traumatic injury.


Based on review of the clinical record for Patient #2 and Patient #3, staff interviews, and facility investigation documents, the facility failed to provide a safe stetting for Patient #2 and Patient #3, adolescent females, who were threatened by Staff #4, a male, and were required to engaged in oral sex with him.

Findings were:

Review of the clinical record for Patient #2 and Patient #3, two adolescent females, revealed that Staff #4, a male mental health technician was found by Staff #7 in their room with the lights off at 11:25 pm on 7-19-11. Staff #4 requested that Patient #2 and Patient #3 engage in oral sex with Staff #4, threatened them with verbal threats, and Patient #2 and Patient #3 disclosed that the did engage in oral sex with Staff #4.

Review of facility investigation documents revealed that Staff #4 was found in the room of Patient #2 and Patient #3 at 11:25 pm on 7-19-11. Patient #2 and Patient #3 were interviewed by Staff #3 and Staff #6 and stated that they engaged in oral sex with Staff #4, and that Staff #4 threatened Patient #2 and Patient #3.

The above was confirmed in interviews with the Chief Executive Officer, the Director of Risk Management, and the Director of Nursing.

Based on review of the clinical record for Patient #1, facility videotape, facility policies and procedures, Staff #5 failed to implement restraint and seclusion in accordance with hospital policy while restraining Patient #1 on 5-22-11, who sustained a nasal fracture while being restrained.

Findings were:

Review of Facility Policy #1200.315, Seclusions and Restraints, revealed that " any patient in a physical (manual) restraint will have a staff person who is not participating in the hold observing him/her for any signs of distress or incorrect holding procedures ... physical restraints (holds) may only be done using techniques trained through the aggression management program. Additionally, except in extreme emergencies, one-person holds are not to be used. "

Review of the facility video of Patient #1 being restrained while in the seclusion room revealed that Patient #1 was restrained incorrectly by only one staff member, Staff #5. Staff #5 was sitting on the bed with his legs wrapped around Patient #1 while Patient #1, a small six-year old boy, wriggled and struggled. Due to the incorrect hold, Staff #5 was unable to restrict the free movement of Patient #1. A nurse was observed in the videotape watching Staff #5 and Patient #1 as they struggled, then the nurse walked out of the room after a moment without assisting to correct the incorrect hold, or intervening to prevent injury while Staff #1 struggled with Patient #5. After the nurse left the seclusion room, there was no staff person not participating in the hold to observe for signs of distress or incorrect holding procedures.

Review of the clinical record for Patient #1 revealed that the Seclusion/Restraint Staff Debriefing dated 5-22-11 at 9:00 am stated that the restraint could have been prevented " maybe if another tech had been present at time of fall to help hold patient. "

The above was confirmed in interviews with the Chief Executive Officer, the Director of Risk Management, and the Director of Nursing.

Based on review of facility policies and procedures and the clinical record for Patient #1, the facility failed to ensure that a physician ' s order for seclusion was given for Patient #1 who was secluded on 5-22-11.

Findings were:


Review of the clinical record for Patient #1 revealed that there was an order for restraint on 5-22-11 at 8:15 am, but there was no order for seclusion on that date.

Review of facility video revealed that Patient #1 was held by Staff #5 for at least 6.5 minutes in the seclusion room and was physically prevented from leaving.

Review of Facility Policy #1200.315, Seclusions and Restraints revealed that restraint and seclusion of a patient require a physician ' s order. The policy includes in the definition of seclusion which is, " The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave that room, the room is considered locked, whether or not the door is actually locked or not. "

Based on review of the clinical record for Patient #1, facility videotape, the registered nurse failed to supervise and evaluate the nursing care for Patient #1, as the patient was incorrectly restrained and suffered a nasal fracture on 5-22-11.

Findings were:

Review of Facility Policy #1200.315, Seclusions and Restraints, revealed that " any patient in a physical (manual) restraint will have a staff person who is not participating in the hold observing him/her for any signs of distress or incorrect holding procedures ... physical restraints (holds) may only be done using techniques trained through the aggression management program. Additionally, except in extreme emergencies, one-person holds are not to be used. "

Review of the facility video of Patient #1 being restrained while in the seclusion room revealed that Patient #1 was restrained by only one staff member, Staff #5, yet the nurse was present in the room for the initial part of the restraint and did not assist or provide another staff member to assist in the restraint. Staff #5 was observed in the video sitting on the bed with his legs wrapped around Patient #1 while Patient #1, a small six-year old boy, wriggled and struggled. A nurse was observed in the videotape watching Staff #5 and Patient #1 as they struggled, yet the nurse walked out of the room after a moment without assisting to correct the incorrect hold, or intervening to prevent injury while Staff #1 struggled with Patient #5. After the nurse left the seclusion room, there was no staff person not participating in the hold to observe for signs of distress or incorrect holding procedures.


Based on review of the clinical records for Patient #2 and Patient #3, facility investigation documents and staff interviews, the registered nurse failed to supervise and evaluate the nursing care for Patient #2 and Patient #3, as Staff #4, a male, was on the adolescent female unit and in an adolescent female patient room alone and required Patient #2 and Patient #3 to engage in oral sex with him.

Findings were:

Review of the clinical records for Patient #2 and Patient #3 revealed that Staff #4 was found in the room of Patient #2 and Patient #3 at 11:25 pm on 7-19-11 and required them to engage in oral sex with him.

Review of the facility investigation documents revealed that Staff #4, a male, was in the adolescent female unit multiple times during and after his shift while Patient #2 and Patient #2 were at the facility. Staff #4 was found in a adolescent female room and Patient #2 and Patient #3 engaged in oral sex with him, threatened them with verbal threats, and Patient #2 and Patient #3 disclosed that the did engage in oral sex on Staff #4.

The above was confirmed in interviews with the Chief Executive Officer, the Director of Risk Management, and the Director of Nursing, who also confirmed that male staff are not allowed on the adolescent female unit, yet none of the nurses or staff questioned why a male staff was on the adolescent female unit.