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Based on document review, interview, and observation, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

CFR 482.13 Patient Rights

Based on a review of a video tape, medical record review, and staff interview, it was determined that the facility failed to ensure all patient rights are protected.

Findings include:

1. The facility failed to ensure all patients are kept free of abuse or harassment.
(N.J.A.C.). Refer to Tag A-145.

2. The facility failed to ensure all patients are restrained with safe and appropriate restraint techniques. Refer to Tag A-167.

3. The facility failed to ensure that all patients in restraints are provided with safe and appropriate CPR (Cardiac Pulmonary Resuscitation). Refer to Tag A-206.

Based on medical record review, review of a video recording, and staff interview, it was determined that the facility failed to ensure all patients are kept free of abuse or harassment.

Findings include:

1. A video recording of the incident that occurred on 3/31/15 was reviewed and revealed the following:

a. Patient #1 was escorted to the seclusion room at 9:09 PM by 3 security officers. An attempt to place the patient on the bed so that she could be placed in 4-point restraints was made.

b. Patient #1 fell down to her knees beside the bed with the upper part of her body on the bed.

c. Staff #3 was kneeling on the opposite side of the bed, on top of the bed, pushing the patient's shoulder, neck and head down into the bed for several minutes. (9:09-9:12 pm).

d. During the time that the patient was being held down a towel was placed over her head.

2. Staff #3, who was trained in restraint techniques, placed Patient #1 in an inappropriate hold for placing a patient in restraints.

3. Placing a towel over a patient's face is not treating the patient with dignity and respect.

3. The above was confirmed by Staff #1.

Based on medical record review, review of a video recording, and staff interview, it was determined that the facility failed to ensure all patients are restrained with safe and appropriate restraint techniques.

Findings include:

1. A video recording of the incident that occurred on 3/31/15 was reviewed and revealed the following:

a. Patient #1 was escorted to the seclusion room at 9:09 PM by 3 security officers. An attempt to place the patient on the bed so that she could be placed in 4-point restraints was made.

b. Patient #1 fell down to her knees beside the bed with the upper part of her body on the bed.

c. Staff #3 was kneeling on the opposite side of the bed, on top of the bed, pushing the patient's shoulder, neck and head down into the bed for several minutes. (9:09-9:12 pm).

d. During the time that the patient was being held down a towel was placed over her head.

e. The patient was then turned over onto her back onto the mattress by the security officers and the other staff in the room applied the 4-point restraints.

f. Patient #1 did not appear to be moving from the time she was turned over onto he back on the mattress, until after CPR was initiated.

g. Vital signs were taken at 9:15 pm by the nurse and CPR was initiated and a rapid response was called at 9:19 pm. Resuscitation was unsuccessful and the patient was pronounced dead at 10:00 pm.

2. Staff #3, who was trained in restraint techniques, placed Patient #1 in an inappropriate hold for placing a patient in restraints.

3. The above was confirmed by Staff #1.

Based on medical record review, review of a video recording, and staff interview, it was determined that the facility failed to ensure all patients in restraints are provided with safe and appropriate CPR (Cardiac Pulmonary Resuscitation).

Findings include:

1. A video recording of the incident that occurred on 3/31/15 was reviewed and revealed the following:

a. Patient #1 was escorted to the seclusion room at 9:09 PM by 3 security officers. An attempt to place the patient on the bed so that she could be placed in 4-point restraints was made.

b. Patient #1 fell down to her knees beside the bed with the upper part of her body on the bed.

c. Staff #3 was kneeling on the opposite side of the bed, on top of the bed, pushing the patient's shoulder, neck and head down into the bed for several minutes. (9:09-9:12 pm).

d. The patient was then turned over onto her back onto the mattress by the security officers and the other staff in the room applied the 4-point restraints.

e. Patient #1 did not appear to be moving from the time she was turned over onto he back on the mattress, until after CPR was initiated.

f. Vital signs were taken at 9:15 pm by the nurse and CPR was initiated and a rapid response was called at 9:19 pm.

g. Several staff members attempted to perform CPR on the patient while the patient was in the bed on a soft mattress.

h. The patient was not placed on a hard surface, such as a back board or floor.

i. Resuscitation was unsuccessful and the patient was pronounced dead at 10:00 pm.

2. The above was confirmed by Staff #1.

Based on medical record review and staff interview, it was determined that the facility failed to ensure all medication orders are written in accordance with State laws.

Findings include:

Reference: NJ State Hospital Regulations, Chapter 43G Hospital Licensing Standards 8:43G-23.6(g) states, "All medication orders shall specify the name of the drug, dose, frequency, and route of administration, and shall be dated and signed (or approved by authorization code if ordered through computer entry) by the prescriber."

1. A review of Medical Record #1 was completed on 4/6/15.

2. A medication order written on 3/31/15 at 7:00 am stated, "Thorazine 50mg PO/IM every 6 hours as needed for agitation." and an order for "Cogentin 1mg PO/IM PRN EPS."

3. The order is written, giving the nurse the choice of administration, which is not within his/her scope of practice.

4. The above was confirmed by Staff #1.