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Based on video surveillance review of the Psychiatric Emergency Services (PES) Room 2, staff interviews, and review of facility documents, it was determined that the facility failed to: 1) ensure safety is maintained when staff on the PES unit place a patient in a therapeutic hold and protect patients from abuse during investigation of an incident where a staff member physically assaulted a patient while the patient was being held (A0144); and 2) respond to signs of physical distress while a patient is restrained (A0202).

On July 23, 2024, at 1:30 PM, an Immediate Jeopardy (IJ) finding was identified for the facility's failure to ensure that staff on the PES unit provide care to patients in a safe setting (A0144). On July 23, 2024 at 4:33 PM, the IJ template was presented to the administration and a removal plan was requested. The facility implemented the following to address the IJ: re-education of all PES Unit mental health technicians, crisis workers, physicians, and nursing staff prior to starting their next shift. PES policy for medical emergencies was received and reviewed. Document review of staff education was conducted, and staff on other behavioral health units received re-education, verified through review of employee attestations. The IJ was removed on July 25, 2024 at 12:00 PM, after the State Survey Agency verified the full implementation of the removal plan, and Condition Level non-compliance remains (A0144).

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting
482.13(f)(2)(iv) Patient Rights: Safe Application and Use of All Types of Restraint or Seclusion Used in the Hospital, including Training on How to Respond to Signs of Physical and Psychological Distress (for example, positional asphyxia)

Based on video surveillance review and staff interviews, it was determined that the facility failed to: 1) ensure safety is maintained when staff on the Psychiatric Emergency Services (PES) unit place a patient in a therapeutic hold; and 2) protect patients from abuse during investigation of an incident where a staff member physically assaulted a patient while the patient was being held down.

Findings include:

On 07/23/24, during an entrance conference conducted in the presence of Staff (S)1 (VP [Vice President], Department of Behavioral Health [BH]), S2 (DON [Director of Nursing], Department of BH), and S3 (Director of Quality and Patient Safety) the following was revealed:

On 07/18/24, Patient (P)1 was transferred from the hospital's Emergency Department (ED) to the PES (Psychiatric Emergency Services) unit for a psychiatric evaluation after the ED physician medically cleared the patient. The patient was calm and cooperative upon his/her arrival to PES and the nursing admission assessment was completed without any issue. At approximately 4:30 AM on 07/18/24, a Mental Health Worker (MHW) observed that the patient appeared to be agitated and he/she alerted the Registered Nurse (RN). The RN contacted the attending psychiatrist for orders to administer medication for agitation to the patient.

On 07/23/24 at 12:12 PM, review of video footage recorded on 07/18/24 from the PES unit (view from inside of PES Room 2), was conducted in the presence of S1, S3, S8 (Vice President of Support Services), and S9 (Security Manager). S3 confirmed that S1, S3, S8 and S9 had previously watched the video footage. S3 identified the patient and staff members in the video footage. S8 indicated that the timestamps in the video are two hours and 25 minutes behind actual time. The video footage review revealed the following:

At 4:27 AM (Timestamp: 2:02 AM), P1 appeared to be alone in PES Room 2 and was observed to be pacing in and out of camera view.

At 4:28 AM (Timestamp: 2:03 AM), S13 (Mental Health Worker [MHW]) walked into the room with P1 then left.

At 4:30 AM (Timestamp: 2:05 AM), P1 appeared to be speaking to someone out of the view of the camera. The patient began pacing around the room in and out of camera view.

At 4:42:03 AM (Timestamp: 2:17:03 AM), S4 (Security Officer), S5 (Security Supervisor) and S13 entered Room 2.

At 4:42:13 AM (Timestamp: 2:17:13 AM), S7 (Registered Nurse [RN]), entered Room 2.

At 4:42:20 AM (Timestamp: 2:17:20 AM), P1 walked towards S13 and swung (his/her) right fist towards S13 and appeared to strike the S13 on the chin.
S4, S5, and S13 grabbed P1, then brought him/her face down to the floor. The patient remained face-down and was observed to be kicking his/her legs.
S13 was observed to be holding P1 while lying beside the left side of the patient's head; S5 was observed to be kneeling with his/her right knee placed in the center of P1's spine; and S4 was knelt beside the patient's right shoulder.

At 4:43:10 AM (Timestamp: 2:18:10 AM), S4, S5, and S13 continued to restrain P1 to the floor. S4 punched P1 four times with his/her closed fist, striking the patient each time in the right side of the head. S5 and S13 continued to hold the patient while S4 punched the patient. An antenna was observed in S4's right hand while [he/she] punched P1. After the fourth strike to the patient's head, a walkie-talkie radio was thrown from the staff member's right hand onto the patient's bed. P1 was observed kicking his/her legs while still being restrained by S4, S5, and S13. S7 observed to administer an IM (intra-muscular) medication into the patient's gluteal muscle, then moved next to the patient's bed.

At 4:43:54 AM (Timestamp: 2:18:54 AM), P 1 stopped kicking his/her legs. S4, S5, and S13 continued to hold the patient while he/she remained face down on the floor. S7 does not interact with or assess P1, who was not observed to be moving.

At 4:44:17 AM (Timestamp: 2:19:17 AM), P1 kicked his/her legs then became motionless. S4, S5, and S13 continued to hold the patient face down on the floor. S7 checked the restraints on the bed and did not look towards the patient.

At 4:45:22 AM (Timestamp: 2:20:22 AM), S4, S5, and S13 picked up P1's limp body and placed the patient face down facing towards the foot of the bed. S7 stood at the head of the bed, and not observed to assess P1, who remained motionless.

At 4:45:53 AM (Timestamp: 2:20:53 AM), P1 was rotated towards the head of the bed then turned to supine position onto his/her back. P1 remained motionless. Staff placed the patient's right ankle into a restraint on the bed.

At 4:45:58 AM (Timestamp: 2:20:58 AM), Staff in room consists of: S4, S5, S6 (Security Officer), S7, S13, S14 (PES Screener), S15 (Security Officer), S16 (Security Officer), S17 (RN), and S18 (RN).

At 4:46 AM (Timestamp: 2:21 AM), S7 performed a sternal rub on P1 and the patient did not move. S7 repeatedly touched P1's face and the patient remained motionless. S7 performed five chest compressions. S7 was not observed checking for the patient's pulse.

At 4:46:32 AM (Timestamp: 2:21:32 AM), P1 began convulsing, as if he/she was having a seizure. P1 was turned onto his/her right side by staff. P1 continued convulsing while staff held the patient and S7 rubbed the patient's back. P1 continued convulsing for five minutes and 26 seconds.

At 4:51:58 AM (Timestamp: 2:26:58 AM), P1 stopped convulsing. S7 removed P1's shirt. The patient was turned onto his/her back. Facility staff resumed placing the patient's left ankle, right wrist, and left wrist into restraints while the patient flailed his/her arms and legs.

1) On 07/23/24 at 1:05 PM, S8 confirmed that the video footage revealed that S4 struck P1 four times in the head. S8 confirmed that hospital administration had previously reviewed the video footage and was aware the staff member struck the patient.

2) On 07/23/24 At 10:50 AM, S3 confirmed that the facility's investigation of the incident that occurred on 07/18/24 had been completed, but the final report was pending. Upon interview at 1:05 PM, S8 was asked what the expectation was when a staff member assaults a patient. S8 confirmed that S4 received a "verbal warning" and returned to work on 07/22/24 (Sunday Night) at 12:00 AM. S8 stated that S4 was "counseled by ___ [S21 (Security supervisor)] prior to returning to work on 07/22/24." Review of the staff schedule confirmed S4 worked on 07/22/24. S8 confirmed that S4 did not receive any formal de-escalation re-education and was permitted to return to work while the incident was under investigation by the facility. The facility failed to provide a policy for investigating incidents of assault upon surveyor request.

Based on review of video surveillance of the Psychiatric Emergency Services (PES) unit Room 2, staff interview, and review of facility policy, it was determined that the facility staff failed to respond to signs of physical distress while a patient is restrained.

Findings include:

Reference: Policy titled "Restraint/Seclusion Use of, In Acute Care" (Reviewed 12/23) states, " ...V. Personnel Training: Staff will receive training in the implementation and use of the restraint/seclusion. ...E. Training content includes: ...8. Monitoring of the physical and psychological wellbeing of the patient who is restrained or secluded, including, but not limited to: a. Respiratory and circulatory status. ... ."

On 7/23/24 at 12:12 PM, review of video footage from the PES unit (view from inside of Room 2, [Patient (P)1's room] directed towards bed) recorded on 7/18/24, was conducted in the presence of Staff (S)1 (Vice President of Behavioral Health Department), S3 (Director of Quality and Patient Safety), S8 (Vice President of Support Services), and S9 (Security Manager). S3 confirmed that S1, S3, S8 and S9 had previously watched the video footage. S3 confirmed the identity of P1 and identified the staff members observed in the footage from 07/18/24 PES Room 2.

S8 indicated that there is a two hour and 25-minute difference between the video surveillance timestamp and the 'correct' time. The video footage revealed the following:

At 4:42:03 AM (Timestamp: 2:17:03 AM), S4 (Security Officer), S5 (Security Supervisor) and S13 (Mental Health Worker) enter PES Room 2.

At 4:42:13 AM (Timestamp: 2:17:13 AM), S7 (Registered Nurse [RN]), enters Room 2.

At 4:42:20 AM (Timestamp: 2:17:20 AM), P1 walks towards S13 and swings (his/her) right fist towards S13 and appears to strike him/her on the chin.

S4, S5, and S13 grab P1, and bring him/her face down to the floor. The patient remains face down and is observed to be kicking his/her legs.
S13 is observed to be holding P1 beside the left side of the patient's head; S5 is observed to be kneeling with his/her right knee placed in the center of P1's back; and S4 is kneeling beside the patient's right shoulder.

At 4:43:10 AM (Timestamp: 2:18:10 AM), S4, S5, and S13 continue to restrain P1 face down to the floor. S4 punches the patient four times with his/her closed fist, striking the patient each time in the right side of the head.
An antenna was observed in S4's right hand while [he/she] punched P1. After the fourth strike to the patient's head, a walkie-talkie radio was thrown from S4's right hand onto the patient's bed. P1 continued to kick his/her legs while still being restrained by S4, S5, and S13. S7 appeared to administer an IM (intra-muscular) medication into the patient's gluteal muscle, then moved next to the patient's bed.

At 4:43:54 AM (Timestamp: 2:18:54 AM), P 1 stopped kicking his/her legs. S4, S5, and S13 continued to hold the patient while he/she remained face down on the floor. S7 does not interact with or assess P1, who was not observed to be moving.

At 4:44:17 AM (Timestamp: 2:19:17 AM), P1 kicked his/her legs then became motionless. S4, S5, and S13 continued to hold the patient face down on the floor. S7 was not observed to look towards the patient and began to check the restraints secured to the bed.

At 4:45:22 AM (Timestamp: 2:20:22 AM), S4, S5, and S13 pick up P1's limp body and place the patient face down towards the foot of the bed. S7 was not observed to assess P1, who remained motionless.

At 4:45:53 AM (Timestamp: 2:20:53 AM), P1 is rotated towards the head of the bed then turned onto his/her back. P1 remains motionless.

At 4:46 AM (Timestamp: 2:21 AM), S7 performs a sternal rub on P1, the patient did not move. S7 repeatedly touches P1's face and the patient remained motionless. S7 places his/her hands on P1's chest and performs five chest compressions. S7 was not observed to check for the patient's pulse.

At 4:46:32 AM (Timestamp: 2:21:32 AM), P1 begins convulsing, as if he/she was having a seizure. P1 is turned onto his/her right side. S7 observed to be rubbing the patient's back. P1 continues convulsing.

At 4:50:58 AM (Timestamp: 2:25:58 AM), P1 stops convulsing and observed to be moving. S7 removes P1's shirt. The patient is turned onto his/her back. Facility staff begin to place restraints on the patient's ankle and wrists. S7 is observed to be wiping P1's face.

At 4:52:57 AM (Timestamp: 2:27:57 AM), S7 climbed on top of P1 and lays across the patient's upper legs while staff placed the patient's left ankle, left wrist, and right wrist into restraints. S7 then climbs off of P1.

At 4:53:20 AM (Timestamp: 2:28:20 AM), S7 walks around P1's bed and appears to check the restraints. All staff members except S13 exit Room 2. S13 is sitting in a chair away from the side of the patient's bed while P1 remained in four-point restraints. P1 was observed to be moving.

Upon interview with S7 on 07/24/24 at 2:51 PM, it was confirmed that he/she was the nurse that cared for P1 during the incident on 07/18/24. When asked at what time he/she realized P1 was unresponsive, S7 stated, "I administered the medication to the patient and immediately checked the restraints on the bed. After that, I noticed the patient was not moving and told them (S4, S5, and S13) to put the patient on the bed. I checked the patient and (he/she) wasn't breathing. I panicked. I've never had a patient have a seizure before. The patient was combative and tried to bite me when (he/she) came out of the seizure, and we put (him/her) in restraints. I know I messed up."

On 07/23/24 at 12:25 PM, S3 confirmed that S7 did not respond to signs of patient distress or assess the patient when he/she was motionless on the floor after being placed in a physical hold by staff.