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Based on document review and interview it was determined for 2 of 9 (Pt. #1 and 6) records reviewed for patients rights, the Hospital failed to ensure patient care was provided in a safe manner. As result, the Condition of Participation for Patient Rights 42 CFR 482.13 was not met.

Findings include:

1. The Hospital failed to ensure staff involved in an altercation was removed from direct patient care. Potentially exposing all 13 patients in the 2 B adult unit where E #1 was transferred to subsequent to the altercation (A 144).

2. The Hospital failed to ensure Pt. #1 was free from abuse (A 145).

3. The Hospital failed to ensure a physician's restraint order was obtained prior to application of restraints (A 168).

4. The Hospital failed to ensure restraints were discontinued at the earliest possible time
(A 174).

Based on document review and interview, it was determined that for 1 of 1 staff (E #1), identified as being involved in an altercation with a patient, the Hospital failed to ensure E #1 was removed from direct patient care, pending investigation. This potentially exposed all 13 patients in the 2 B adult unit, where E #1 was transferred to subsequent to the altercation.

Findings include:

1. The Hospital policy titled, "Plan for the Provision of Patient Care Services" (rev. 12/15/14), required, "Standard of Patient Care...The hospital staff will do the right procedures, treatments, intervention, and care. ...with respect for patient rights...."

2. An interview with a Behavioral Health Technician (BHT) (E #8) was conducted on 2/24/16. E #8 stated that he was still on orientation at the time of the incident and was responsible for observations every 15 minutes. E #8 stated that Pt. #1 had asked and received permission from another BHT to get juice from the refrigerator, however, E #1 told the patient to put it back. According to E #8, Pt. #1 did as he was asked and returned to his seat.

E #8 stated there was "a lot of arguing about the situation" and that E #1 became more upset and told Pt #1 "you think you are entitled to stuff" then told Pt #1 he could not eat in the dining room and Pt. #1 responded with "I can sue you, I have rights." E #8 stated that E #1 told Pt. #1 to eat in his room and that Pt. #1 stated he wanted to eat here (dining/day room).

E #8 stated E #1 grabbed the patient and threw him into the lunch cart, and as Pt #1 gathered himself then E #1 grabbed him and the situation spilled into the hallway. E #1 stated he separated them and held onto Pt. #1 so "he wouldn't go after...(E #1). E #8 stated that E#1 "threatened... (Pt. #1) some more" and that E #1 was angry and agitated. E #8 stated that the nurse told E #1 to "get off the unit and E #1 left. E #8 stated E #1 was reassigned somewhere else.

3. The Evening Nurse Supervisor (E #9) was interviewed by telephone on 2/24/16. E #9 stated that there is no particular protocol to follow after altercations between staff and patients. E #9 stated that after the incident between E #1 and Pt. #1, she told the staff to leave the unit and and then "switched him to another unit." E #9 indicated that the staff "seemed ok enough to go to another unit after he took about a 15 minute break."

4. The Executive Director of Behavioral Health (E #7) was interviewed on 2/24/16 at approximately 1:20 PM. E #7 stated that the staff "did not follow our procedure ...and violated the policy of the hospital." E #9, the evening supervisor transferred him to another unit after E #1 had taken a break and E #9 deemed E #1 capable of working on another behavioral health. When asked if there is a protocol to follow after an altercation between staff and patient, E #7 stated that action is based on the de-escalation process in CPI (crisis prevention intervention). E #7 stated that the evening supervisor assessed the situation and made the decision to transfer E #1 to another unit.

Based on document review and interview, it was determined that for 1 of 9 (Pt. #1) patient records reviewed, the Hospital failed to ensure Pt. #1 was free from abuse.

Findings include:

1. The Hospital policy titled, "Plan for the Provision of Patient Care Services" (rev. 12/15/14), required, "Standard of Patient Care...The hospital staff will do the right procedures, treatments, intervention, and care. ...with respect for patient rights...."

2. The Hospital policy titled, "Rights and Responsibilities: Patient's" (rev. 2/27/15) required, "Personal Safety: The patient has the right to expect personal safety insofar as the Hospital practices and the environment are concerned. Patients have the right to be free from mental, physical, sexual and verbal abuse...."

3. The clinical record for Pt. #1 was reviewed on 2/23/16. Pt. #1 was a 15 year old male admitted on 9/10/15 with diagnoses of bipolar disorder and was placed on suicide ideation (SI) and assault precaution (AP). On 1/25/16 nursing documentation at 7:13 PM indicated Pt. #1 was calm and cooperative. At 11:27 PM the nursing note indicated "...commotion in the dining area. Pt noted to be moving from one side of the room to the other. When entering the hallway area, at closer inspection, ...noted patient was being held down by staff. Patient was then becoming increasingly agitated. Writer requested patient to be released from the hold then escorted to his room. Patient agitated, tearful and pacing the room."

There was no documentation in Pt. #1's record of any incidences relating to aggression prior to the incident.

3. A video tape of the incident was reviewed on 2/23/16. The video tape showed E #1 speaking to someone (not visible on the monitor) across the room and table. E #1 suddenly rushed towards the other side of the table (not visible) and then a young male individual (identified by staff as Pt. #1) pushed on to a food cart, knocking over a plastic chair and running towards the door. E #1 is seen grabbing Pt. #1 from the back hand on the shoulder and neck area; and the altercation spilled into the hallway. From the view of the hallway monitor, E #1 is seen tackling the patient to the floor, hands on the neck/head, E #1 on top, pinning Pt. #1 down.

4. The Executive Director of Behavioral Health (E #7) was interviewed during the video tape viewing on 2/23/16 at approximately 3:00 PM. E #7 stated that the staff "did not follow our procedure ...and violated the policy of the hospital." E #7 stated that Pt. #1 was assessed by the nurse after the incident and found no bumps, bruises or scratches. E #7 stated that Pt. #1 was offered a visit to the emergency room to be examined, but that Pt. #1 refused.

Based on document review and interview, it was determined that for 1 of 2 (Pt #6) clinical records reviewed for restraints, the Hospital failed to ensure a physician's restraint order was obtained for application of restraints.

Finding include:

1. Policy entitled "Restraint/Seclusion Policy and Procedure" (Approved 2/9/16) indicated "Restraint or Seclusion for Behavioral Health Care reason. 1 a. Initiation of Restraint or Seclusion: A registered nurse may initiate restraint or seclusion in advance of the physician's order in emergent situation. 1. The registered nurse shall consult with a responsible physician about the patient...and obtain an order (telephone or written) during the emergency application of restraint or seclusion or immediately after the restraint had been applied."

2. The clinical record for Pt. #6 was reviewed on 2/26/16. Pt #6 was a 14 year old male admitted to the Adolescent Behavior Health Unit on 1/17/16 with a diagnosis of bipolar disorder. Pt #6's clinical record indicated on 1/19/16 that Pt. #6 was placed in mechanical restraints from 3:55 PM to 5:50 PM (1 hour and 55 minutes). The clinical record failed to include a physician's order for the restraint.

3. On 2/24/16 at approximately 3:00 PM the Nursing Supervisor of Behavioral Health (E #5) stated Pt #6's clinical record did not contain a physician's restraint order for 1/19/16.

Based on document review and interview it was determined, that for 1 (Pt #6) of 2 clinical records reviewed for restraints, the Hospital failed to ensure restraints were discontinued at the earliest possible time.

Findings include:

1. Policy entitled "Restraint/Seclusion Policy and Procedure" (Approved 2/9/16) indicated "General Provision 2. Discontinuation of Restraint: Restraint shall be discontinued when the registered nurse or physician assesses that the behavior or condition that was the basis for the restraint order is resolved, regardless of the duration of the enabling order. ...Discontinuing the Use of Restraint: 1. Physician/or RN (Registered Nurse) should discontinue restraints at the earliest possible time..."

2. Pt #6 was a 14 year old male admitted to the Adolescent Behavior Health Unit on 1/17/16 with a diagnosis of bipolar disorder. Pt #6's clinical record included on 1/26/16, Pt. #6 was placed in restraints. The physician's order dated 1/26/16 at 10:05 PM was unclear indicating: "Assess Restraint Behavioral Stat 2 hours: Age 9 to 12".

On the preprinted form "RN Seclusion or Restraint Note" dated 1/26/16 at 9:05 PM the note included indicated Pt #6 had been placed in restraints due to threatening staff and throwing objects at staff. The Restraint Note included time of release was on 1/26/16 at 10:55 PM. However, the "Precaution Sheet" dated 1/26/16 indicated Pt #6 was remained in restraints until 11:15 PM, 20 minutes longer than the nurse's assessment and release note.

3. On 2/23/16 at approximately 2:30 PM the findings were discussed with the Nursing Supervisor of Behavioral Health (E #5). E #5 stated the Precaution sheet reflects the actual time the patient was in restraints (20 minutes after the nurse's assessment and time of release.)