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Based on review of video, facility documents and staff interview it was determined the facility failed to ensure that patient care was provided in a safe manner while a psychiatric emergency occurred. This failure has the potential to negatively impact all patients during a psychiatric emergency.

Findings include:

1. During a 'Code Grey" on 11/2/17 the House Supervisor (HS) failed to supervise patient #1 while the code was ongoing. A review of the facility policy entitled 'Code Grey' states in part, '...the charge nurse assumes responsibility for managing the code and the safety of the environment.'

2. A review of the video for the alleged incident revealed the HS and the registered nurse getting on the elevator after the patient was medicated leaving the patient without nursing supervision while the 'Code Grey' was ongoing. The patient was left without nursing supervision documented by video from 4:28 p.m. to 4:35 p.m. when the patient is carried into the seclusion room on 11/2/17.

3. A review of the video of the alleged incident revealed patient #1 was carried off the playground by staff members and security at 4:19 p.m. There was no camera available in the hallway coming into the building from the playground. The patient was not back on camera until 4:35 p.m.

4. While viewing the video on 12/4/17 at 11:20 a.m. the Director of Quality Assessment and Performance Improvement agreed with the above findings.

Based on video, document review and staff interview it was determined the House Supervisor (HS) and Security Guard (SG) #1 failed to follow facility policy related to abuse and neglect. This failure has the potential to negatively impact any patient in a psychiatric emergency.

Findings include:

1. A review of the facility policy entitled, 'Abuse and Neglect Procedure' states in the 'Definitions of Abuse and Neglect' WV state code definitions are as follows: 1.1 49-1-201. Child abuse and neglect paragraph (B) "Abused child" means a child whose health or welfare is being harmed or threatened by: A parent, guardian, or custodian who knowingly or intentionally inflicts, attempts to inflict or knowingly allows another person to inflict physical injury or mental or emotional injury, upon the child or another child in the home. Physical injury may include any injury to the child as a result of excessive corporal punishment.:" The policy further states in the paragraph entitled '2.4 Abusive Behaviors of Caregivers', " As you interact with caregivers, you should be on the lookout for certain behaviors that may indicate that this person is an abuser. Caregiver behaviors to look for include: ....Devalues the person...Displays unwelcoming or uncooperative attitude...rough physical handling...unnecessary or excessive use of restraints..."

2. In an interview with the Case Manager of patient #1 on 12/4/17 at 1:10 p.m. it was revealed patient #1 was refusing to come inside from the playground so the Behavioral Health Technician on duty called upstairs to tell the Registered Nurse (RN). The RN was the only nurse on the unit and was unable to leave so the HS was notified. She stated when the HS arrived on the play ground she told patient #1 to either come on his own or they would make him come inside. She stated while the HS and SG #1 were attempting to get patient off of the play ground equipment she overheard HS call the patient 'a little shit and you little bastard' while trying to remove him from the playground. When questioned if the patient could have heard the HS remarks the Case Manager stated, "I was standing down on the ground and heard her. She was standing over his head." Once the patient was brought into the hallway from the playground an injection was ordered to attempt to calm the patient down. The HS called the RN on the unit to bring the injection down leaving the unit without a nurse. While holding the patient for the injection the HS 'was holding his right arm down with both knees'. When asked if this was a proper hold technique the case manager stated, "No! We were never taught to hold the patient that way." The Case Manager further stated after the injection was given the HS told the RN to go back upstairs because she had stuff to do. The HS stated, 'I don't have time for this I have better things to do,' and left the patient while still escalated without any nursing supervision. The Case Manager stated, "I have never had a nurse leave while a code is still going on. The nurse always stays until the situation has resolved." The Case Manager stated after patient #1 was brought into the seclusion room and was restrained, the patient was fighting the restraints. "I was trying to get him to calm down, telling him if he would relax we wouldn't have to restrain his arm." The Case Manager stated the HS came in and said to hold him and patient started saying' I was relaxing, I was relaxing,' then the HS stated 'you weren't relaxing to me', and gave the patient the injection in the right leg. The Case Manager stated she felt the HS used 'excessive force' when giving the injection.

3. In an interview with the Children's and Adolescent Therapist on 12/5/17 at 9:07 a.m. it was revealed that she was notified of patient #1 refusing to come off of playground by the RN on the unit. She stated we we gave him choices about playing games, playing chess, anything to get him to come inside, the patient still refused. The HS came outside and told patient #1 to "come inside or I'm going to make you come inside." The HS told SG #1 to assist with getting the patient inside. The therapist stated while trying to remove the patient from the playground equipment she heard the HS tell patient #1 'you little bastard.' After getting patient #1 carried to the hallway he was still fighting. The HS called for an injection while holding the patient for the injection. The therapist stated she saw the HS place knees and hands on patients right arm to hold him. She stated after the injection was given the HS told the RN to go back upstairs she had patients to tend too. She stated the HS left at this time as well. When asked if normal for the HS to leave in a 'Code Grey' situation she stated "I have never had anyone leave during a code like that."

4. In an interview with the Lead Behavioral Health Technician (BHT) on 12/5/17 at 11:20 a.m. it was revealed that she saw the HS with her knees on the patient's right arm to hold his arm down. The BHT stated she was not trained to hold a patient that way. The BHT stated when the patient was placed in the seclusion room she witnessed SG #1 forcefully push patient #1 back into the room causing the patient to fall. The RN started to restrain the patient after he began banging his head on the seclusion room door. The BHT stated the patient was 'hitting his head hard on the door'. That was when decision was made to place patient in restraints. The BHT stated when the HS gave the injection in the right leg, while the patient was in restraints she felt she was 'overly forceful with the injection'. She stated once a patient is placed in restraints 'someone must be with the patient at all times.'

5. A review of the video for the alleged incident revealed the House Supervisor and the registered nurse getting on the elevator after the patient was medicated leaving the patient without nursing supervision during a 'Code Grey'. The patient was left without nursing supervision documented by video from 4:28 p.m. to 4:35 p.m. when the patient is carried into the seclusion room on 11/2/17.

6. A review of the video of the above incident on 12/4/17 at 11:20 a.m. revealed after the patient was placed in restraints the Lead BHT left patient #1 unattended from 5:19:21 to 5:19:50 with the patient still pulling at restraints.

7. The Director of QA/PI concurred with the above findings on 12/4/17 at approximately 11:40 a.m.

8. In a joint interview with the Site Supervisor for Security America and the Director of Facility Services, Safety and Security on 12/4/17 at 1:57 p.m. it was revealed that all security guards at the facility go through the facility's CPI: Nonviolent Crisis Intervention training when they begin working at the facility. The Site Supervisor stated SG #1 had completed the training. The Site Supervisor stated that as soon as he viewed the video he called the corporate office to notify them SG #1 had used 'excessive force' in dealing with a patient. He stated that SG #1 was not trained to use excessive force. He stated SG #1 was suspended immediately and was terminated on 11/3/17.

Based on review of medical records, facility policy and staff interview it was determined the medical staff failed to sign telephone Hold/Seclusion/Restraint orders given to nursing staff in a timely manner. This failure has the potential to allow inappropriate care to be provided to the patients receiving telephone orders.

Findings include:

1. A review of the medical record of patient #1 revealed from 11/3/17 to 12/3/17 there were twelve (12) telephone Hold/Seclusion/Restraint orders not signed by the ordering physician.

2. A review of the document entitled, 'Highland-Clarksburg Hospital Medical Staff Rules and Regulations' states in part '...Telephone orders involving narcotics, restraint(including seclusion and hold) and emergency medical transfers must be signed by the physician providing the order or the covering provider within 24 hours'.

3. In an interview with the Chief Medical and Clinical Officer (CMCC) on 12/5/17 at 12:05 p.m. she stated it was her expectation that any physician providing the verbal orders should sign the order within a 'couple of days'. The CMCC stated, "There really is no reason the physician should not have signed these orders. She is here Monday to Friday. There is no excuse for that."

Based on video, facility document and staff interview it was determined the facility failed to ensure that a registered nurse was immediately available to supervise or care for a patient during a psychiatric emergency. This failure has the potential to negatively effect any patient during a psychiatric emergency.

Findings include:

1. During a 'Code Grey" on 11/2/17 the house supervisor failed to supervise patient #1 during the code. A review of the facility policy entitled 'Code Grey' states in part, '...the charge nurse assumes responsibility for managing the code and the safety of the environment.'

2. A review of the video for the alleged incident revealed the House Supervisor and the registered nurse getting on the elevator after the patient was medicated leaving the patient without nursing supervision during a 'Code Grey'. The patient was left without nursing supervision documented by video from 4:28 p.m. to 4:35 p.m. when the patient is carried into the seclusion room on 11/2/17.

3. A review of the document entitled, 'Highland Hospital-Clarksburg Job Description House Supervisor', states in part '...rounds to all inpatient treatment units to provide monitoring, supervision, direction, and assistance as needed...'. The document further states the House Supervisor, '...Identifies safety hazards and intervenes in an emergency basis...'.

4. In an interview with the Director of QA/PI and Risk Management on 12/5/17 at 4:08 p.m. she concurred with the above findings.

Based on video, document review and staff interview it was determined the facility failed to have a registered nurse supervising a patient during a psychiatric emergency. This failure has the potential to cause harm to the patient during a psychiatric emergency.

Findings include:

1. A review of the video for the alleged incident revealed the House Supervisor and the registered nurse getting on the elevator after the patient was medicated leaving the patient without nursing supervision during a 'Code Grey'. The patient was left without nursing supervision documented by video from 4:28 p.m. to 4:35 p.m. when the patient was carried into the seclusion room on 11/2/17.

2. During a 'Code Grey" on 11/2/17 the house supervisor failed to supervise patient #1 while the code was ongoing. A review of the facility policy entitled 'Code Grey' states in part, '...the charge nurse assumes responsibility for managing the code and the safety of the environment. This includes: ...assessing the patient's needs, medication intervention, body management and seclusion/restraint considering the least restrictive alternatives. Leading, directing and supervising the actions of the code team, ...members of the code team are required to follow the direction of the charge nurse during the code...'

3. While viewing the video on 12/4/17 at 11:20 a.m. the Director of Nursing and the Director of QA/PI agreed the HS left the patient without nursing supervision from 4:28 p.m. to 4:35 p.m. Both agreed the HS did not follow the facility policy entitled 'Code Grey'.