HospitalInspections.org

482.13 Tag A-0115

The information reviewed during the unannounced survey on March 23, 2023, provided evidence the facility failed to provide a safe environment for a patient during a physical restraint on March 16, 2023, as evidenced by: video surveillance clearly showing a staff member (PF1) pushing patient aggressively causing the patient to fall backwards, hitting their back off a wall and then falling to the ground. Further observation of the security footage shows a staff member (PF2) striking the patient in the head area with their knee, a few moments later staff member (PF1) strikes the patient in head with their knee causing the patient's head to strike the wall. Interviews with facility leadership and staff confirmed this was not consistent with safe restraint practices and a physcian order was not obatined prior to the physcial hold performed on MR1. Prior to the survey the staff member's (PF1 and PF2) employment was terminated, local law enforcement was notified, the facility self-reported to the Agency, facility begin refresher training to a portion of the staff and initiated an internal investigation.
A discussion took place with the survey team and the facility's administrative staff (EMP1), (EMP10), and (EMP11) regarding the survey team's concerns related to Patient's Rights on March 23, 2023, at 3:07 PM.
Cross reference
§482.13 (c)(3) Patient Rights: Free from all forms of abuse/harassment.
§482.13(e)(5) Patient Rights: Restraint or Seclusion

Based on a review of surveillance video, the facility's policy, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure a patient in the senior behavioral health unit (SBHU) was free from abuse from the facility's security staff for one of twelve medical records reviewed.

Findings Include:

Review of security footage "2nd floor S.B.H.U. Seclusion 3-16-23 [patient name redacted] in seclusion.exe" on March 23, 2023, revealed, on March 16, 2023, at 2:14:45 AM MR1 is escorted into seclusion room by three staff members. Two staff members (PF1 and PF3) are restraining each of MR1 arms while a third staff member (PF2) follows behind MR1. At 2:15:54 AM MR1 is held face first against the wall with PF1 and PF3 still holding patient's arms. At 2:15:57 AM PF1 puts MR1's left arm into "chicken wing hold" PF1 is observed to also be aggressively pulling up on the MR1's left wrist. Congruently, PF3 is holding MR1 's right arm straight out and against PF3 body. At 2:16:12 AM patient is released from the wall and staff walk out of the camera's view. At 2:16:18 AM, MR1 is observed walking to the upper left frame of the video, and appears MR1 is throwing a punch out of the camera's view with his right hand. 2:16:20 AM MR1 can be seen pushing and struggling with someone out of the camera's frame. 2:16:21 AM PF1 can be seen in frame pushing and grabbing MR1. PF1 then pushes MR1 aggressively. MR1 can be seen falling backwards and hitting his back off the wall. 2:16:23 MR1 can be seen on his hands and knees on a blue pad on the floor of the room and PF2 can be seen grabbing MR1 by the head. 2:16:24 AM PF2 can be seen hitting MR1 with his left knee on the right side of MR1's head. 2:16:26 AM PF2 falls backward into a seating position while his hands can be seen around the neck area of MR1. For approximately the next 16 seconds PF1 and PF2 can be seen pushing down on MR1 while MR1 is on his hands and knees. At 2:16:41 AM PF1 can be seen aggressively pushing MR1's head against the wall with his right leg/knee, and PF2 stands up and goes hands off. From 2:16:41 AM - 2:16:54 AM PF1 appears to be holding the patient down while the patient is on his hands and knees. It is unclear what exactly is happing because PF1's body is blocking the view of the camera. 2:16:55 AM PF1, and PF3 take hands off the patient and leave the room. PF3 can be seen at the top middle of the video from 2:16:26 AM - 2:16:54 AM with his hand on the back of MR1. 2:17:02 AM MR1 is seen alone in the room getting up from the floor and stumbling. 2:17:09 AM MR1 punches at something outside of the camera's view. 2:17:31 AM MR1 is seen holding the right side of his face while pacing in the room. 2:22:45 AM MR1 stops pacing in the room and sits down on the mat in the room. 2:23:46 AM staff (appears to be PF1, PF2, PF3 and PF5) enter the room. 2:24:01 AM, it appears PF5 (RN) is attempting to give an injection (staff member PF3 is blocking the camera view). 2:24:32 AM MR1 is escorted out of the room by PF3 and appears to be PF1, PF2, and PF5.
Review on March 23, 2023, of facility policy, Patient Rights & Responsibilities, revised June 2022, revealed "... Patient Rights... 6. The patient has the right to receive care in a safe setting. 6. The patient has the right to be free from all forms or abuse or harassment ... 9. All patients have the right to be free from physical or mental abuse ..."
Review on March 23, 2023, of facility policy, Abuse/Neglect Allegations Reporting, Reviewed March 2022, revealed, "...PURPOSE To establish a uniform policy and procedures for reporting and responding to all abuse/neglect allegations and deaths ... DEFINITIONS... 12. Physical abuse: An employee's non-accidental and inappropriate contact with an individual that causes bodily harm. "Physical abuse" includes actions that cause bodily harm as a result of an employee directing an individual or person to physically abuse another individual. 13. Mandatory reporter: Any employee who suspects, witnesses, or is informed of an allegation of any one or more of the following: mental abuse, physical abuse, sexual abuse, financial exploitation or neglect ...POLICY...4. The following steps shall be followed in the instance a patient reports any type of abuse or harassment on-site during their admission. 4.1 Protect the patient during the investigations. Report the allegation to the unit director of [sic] House Supervisor Immediately. 4.2 Investigate: The unit director or House Supervisor shall notify the Risk Manager and complete an objective investigate [sic] in a timely and thorough manner. 4.3 Report and Respond: any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law ..."
Interview with EMP1 on March 23, 2023, at 10:49 AM confirmed PF1 and PF2 on March 16, 2023, used "excessive force" on patient (MR1), and PF1 and PF2's employment was terminated on March 20, 2023, due to "abuse and assault" of a patient (MR1). Further interview with EMP1 confirmed local law enforcement was contacted on March 22, 2023.
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Based on a review of facility policy, facility documents and interview with staff (EMP), it was determined that the facility failed to ensure a patient in the senior behavioral health unit was free from abuse as evidenced by the facility retaining employment of staff member [PF2] with a documented record of striking a patient.

Review on March 23, 2023, of facility policy, Standards of Conduct, revised November 2022, revealed, "...POLICY... In serious cases or in cases where an employee has previously violated the same or other rules or is not performing to an acceptable level, the employee may be subject to immediate discharge ... Violations of any of following the rules, because of their seriousness, may result in immediate discharge without warning ... Disorderly conduct including fighting, horseplay, threatening, or abusing any individual, staff, employee, patient, visitor, or member of the public ..."
Review of facility document, Lower Bucks Hospital Security Department Incident report dated July 17, 2018, on March 23 revealed, "...Security was called to ER crisis #25 ...as we attempted to put the patient on his bed[,] the patient scratched this writer's face and then attempted to spit on me. At this point I hit the patient in his head. Patient was restrained without further incident ...Investigating Officer/Date: S/O [employee name redacted PF2] ..."
Review of facility document, email from [employee name redacted] to [employee name redacted], dated July 17, 2018, revealed "...[PF2] then proceeded with a closed hand and hit the patient in the left side of his temple area ..."
Review of facility document, Performance Improvement Form for PF2, dated July 18, 2018, on March 23 revealed PF2 received a verbal warning for "Improper use of Defensive Maneuvers"
Interview with EMP1 on March 23, 2023, at approximately 7:43 PM confirmed on July 17, 2018, staff member [PF2] punched a patient with a closed fist and was given a documneted verbal warning on July 18, 2018.

Based on review of facility security footage, facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to obtain an order for the use of a restraint in one of twelve medical records reviewed (MR1).

Findings include:

Review of security footage "2nd floor S.B.H.U. Seclusion 3-16-23 [patient name redacted] in seclusion.exe" on March 23, 2023, revealed, on March 16, 2023, at 2:14:45 AM MR1 is escorted into seclusion room by three staff members. Two staff members (PF1 and PF3) are restraining each of MR1 arms while a third staff member (PF2) follows behind MR1. At 2:15:54 AM MR1 is held face first against the wall with PF1 and PF3 still holding patient's arms. At 2:15:57 AM PF1 puts MR1's left arm into "chicken wing hold" PF1 is observed to also be aggressively pulling up on the MR1's left wrist. Congruently, PF3 is holding MR1 's right arm straight out and against PF3 body. At 2:16:12 AM patient is released from the wall and staff walk out of the camera's view. At 2:16:18 AM, MR1 is observed walking to the upper left frame of the video, and appears MR1 is throwing a punch out of the camera's view with his right hand. 2:16:20 AM MR1 can be seen pushing and struggling with someone out of the camera's frame. 2:16:21 AM PF1 can be seen in frame pushing and grabbing MR1. PF1 then pushes MR1 aggressively. MR1 can be seen falling backwards and hitting his back off the wall. 2:16:23 MR1 can be seen on his hands and knees on a blue pad on the floor of the room and PF2 can be seen grabbing MR1 by the head. 2:16:24 AM PF2 can be seen hitting MR1 with his left knee on the right side of MR1's head. 2:16:26 AM PF2 falls backward into a seating position while his hands can be seen around the neck area of MR1. For approximately the next 16 seconds PF1 and PF2 can be seen pushing down on MR1 while MR1 is on his hands and knees. At 2:16:41 AM PF1 can be seen aggressively pushing MR1's head against the wall with his right leg/knee, and PF2 stands up and goes hands off. From 2:16:41 AM - 2:16:54 AM PF1 appears to be holding the patient down while the patient is on his hands and knees. It is unclear what exactly is happing because PF1's body is blocking the view of the camera. 2:16:55 AM PF1, and PF3 take hands off the patient and leave the room. PF3 can be seen at the top middle of the video from 2:16:26 AM - 2:16:54 AM with his hand on the back of MR1. 2:17:02 AM MR1 is seen alone in the room getting up from the floor and stumbling. 2:17:09 AM MR1 punches at something outside of the camera's view. 2:17:31 AM MR1 is seen holding the right side of his face while pacing in the room. 2:22:45 AM MR1 stops pacing in the room and sits down on the mat in the room. 2:23:46 AM staff (appears to be PF1, PF2, PF3 and PF5) enter the room. 2:24:01 AM, it appears PF5 (RN) is attempting to give an injection (staff member PF3 is blocking the camera view). 2:24:32 AM MR1 is escorted out of the room by PF3 and appears to be PF1, PF2, and PF5.
Review on March 23, 2023, of facility policy, Restraints: Violent Behavior OR Seclusion, revised March 2022, revealed, " ...DEFINTIONS ...Restraint - Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ...GENERAL POLICY APPLICABLE TO ALL RESTRAINT USE ...1. This policy and procedure is in effect for all departments and services in the acute care facility. 2. All patients have the right to be free from physical or mental abuse ... 12. The use of restraint or seclusion is ... 12.2 Implemented in accordance with safe and appropriate restraint techniques and in accordance with state law ... ASSESSMENT/MONITORING/CARE- Violent or Self-Destructive Restraints or Seclusion ... 5. If the patient is in a physical hold, a second person is assigned to observe the patient ... "
Review on March 23, 2023, of facility document, Behavioral Violence Prevention B.V.P., Participant Manual, no date, revealed, "...Mechanical restraints include any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to moves his or her arms, legs, body, or hands freely. Under this definition, the following practices or devices could meet the definition of restraint ...The application of force to physically hold a patient in order to administer medication against the patient's wishes ..."
Interview with EMP13 on March 23, 2023, at 1:49 PM confirmed there was no physician order or documentation of the physical restraint (as witnessed on the security footage, " 2nd floor S.B.H.U. Seclusion 3-16-23 [patient name redacted] in seclusion.exe " ) of MR1 on March 16, 2023.