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Based on interview and document review, the facility failed to keep patients safe when safety hold techniques were implemented for 1 of 1 patients (P1) reviewed whom had a safety restraint applied that resulted in a nose fracture. The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13. The cumulative effect of this system failure resulted in the hospital's inability to ensure patient rights were protected and promoted.

Findings include:

P1's Emergency Room Record, dated 1/3/20, identified P1 presented to the emergency room with police and in handcuffs, had gotten into an altercation with staff member at CBHH and had injury to the nose, left forehead area, mild neck pain and also complained of mid back pain. A CT scan of the Maxillofacial area revealed an acute minimally displaced anterior nasal bone fracture, slightly more angulated on the left.

The facility's Critical Event Report, identified staff used the appropriate techniques on P1's hold, and followed the facility specific training. The agency training did not identify a patient should be pushed/moved during a physical hold causing an increased risk for injury. While P1 was being pushed by staff during the hold, P1's face subsequently hit the wall and medication window three times, resulting in a nose fracture. See A167 and A196 for additional information.

Based on observation, interview and document review the facility failed to safely use hold techniques for 1 of 1 patient (P1) who required emergent intervention, and sustained a fractured nose as a result of the hold and takedown.

Findings include:

-P1's Direct Care and Treatment Face Sheet, printed 1/8/20, listed P1 had been admitted to the facility on 12/5/19 with diagnoses which included Bipolar disorder, antisocial personality disorder, cannibus dependence, and attention-deficit hyperactivity disorder. The face sheet indicated P1 had been transferred out of the facilty to a different location on 1/4/20.

-P1's Emergency Room Record, dated 1/3/20, revealed P1 presented to the emergency room with police and in handcuffs, had gotten into an altercation with staff member at CBHH and had injury to the nose, left forehead area, mild neck pain and also complained of mid back pain. A CT scan of the Maxillofacial area revealed an acute minimally displaced anterior nasal bone fracture, slightly more angulated on the left.

A review of the facility security camera footage of the incident with P1 on 1/3/20 was conducted on 1/22/20. The camera footage, without sound, identified on 1/3/20 at 17:36:45 P1 opened the half door of the nursing station and entered into the nursing station where four staff were sitting/standing including, mental health professional assistant (MHPA)-A, health services technician (HST)-C, licensed practical nurse (LPN)-B a and an unidentified staff member. MHPA-A was leaning on the counter of the nursing station when P1 started walking forward toward him. MHPA-A stood up and started walking towards P1. P1 had his hand down near his side, walked toward to MHPA-A but made no threatening hand gestures. MHPA-A suddenly grabbed P1's hands/wrist and then started to push P1 backwards out of the nursing station through the half door with his upper body. While MHPA-A was holding and pushing P1 out of the nursing station two additional staff, HST-A, and MHPA-B came to assist MHPA-A. HST-A and MHPA-A grabbed P1 arms, upper body, and held P1's behind his neck. As P1 was being pushed out of the nursing station and continued to move in a forward motion, P1's face subsequently hit against the wall twice, and then hit his face on the closed medication window. At 17:36:56 the three staff members and P 1 suddenly fell to the floor. MHPA-A, MHPA-B, HST-A and LPN-B continued to hold P1 on the floor behind the nursing station. At 17:44:30:01 two law enforcement officers entered the area and assisted with P1. At 17:49:23 LPN-A, with gloves on, brought a towel and handed it to staff whom were holding P1 on the floor. At 17:45:44 P1 was physically assisted to the facility restraint chair without any resistance and had his hands cuffed behind his back. The restraint chair was wheeled into an annex of the seclusion room that was adjacent to the nursing station. The seclusion camera view identified, P1 had some discoloration under his nose and LPN-A was providing medical treatment for P1's nose. At 17:58:57 P1 left the facility via stretcher with Emergency Medical Services and was sent to the hospital for evaluation.

Review of P1's Alexandria Police Department Offense Narrative report, APD202000000119, listed on 1/3/20 at approximately 5:40 p.m. an officer responded to an assault/fight type call at the hospital. It was reported a patient was out of control and currently being restrained by staff. Upon arrival, the officer placed handcuffs on P1, for everyone's safety. P1 was noted to have bleeding from the nose and was later transported to the local hospital via ambulance for his bloody nose.

On 1/21/20, at 4:16 p.m. the above incident was discussed with HST- B whom stated he was aware of an incident with P1 and staff that occurred on 1/3/20. He stated he came to the desk when the emergency alarm sounded and P1 was already on the floor with MHPA-A, HST-A and MHPA-B holding him down. He stated P1 was kicking and he assisted to hold P1's legs, down. HST-A stated he saw blood on P1's face and heard P1 yelling several times "you broke my nose, you bastards."

On 1/22/20, at 12:22 p.m. during a telephone interview, MHPA-A stated he was at the nurses station, when P1 came to the nurses station, yelling and stated "I'm going to break her fucking jaw" about another female patient in the facilty. He stated P1 yelled at him, calling him names such as "Wimp," "Pussy," and walked into the nurses station where MHPA-A was sitting. MHPA-A stated P1 continued to yell at him and stated "I've been to prison twice, and I can go again." MHPA-A stated he was not sure of P1's intentions, felt threatened and planned to move him out of the nurses station. MHPA-A stated he felt asking P1 to leave the nurses station would not of worked, and felt he was not going to listen. He stated P1 had his hands were up, in a "fighting stance" and he walked towards P1. MHPA-A placed both hands on his wrists and attempted to push him backwards out of the nurses station. He stated P1 "resisted" being pushed and struggled with him. He stated he continued to struggle to remove P1 from the nurses station, pushing him backward, and with assistance from other staff members. MHPA-A confirmed P1's face and body had been pressed against the white board and wall outside of the nurses station during the struggle, prior to him falling on the floor. He stated P1 sustained a bloody nose and was not sure if that happened when his face was pressed to the white board or wall or when he hit the floor. MHPA-A stated he and HST-A, HST-B, and MHPA-B held P1 on the ground until law enforcement arrived and placed handcuffs on him.

MHPA-A stated he also had been injured during the incident, had missed work and currently was on light duty assignment. He stated at the time of the incident he had injured his left arm and neck which continued to be sore. MHPA-A stated the facility had a Effective and Safe Engagement (EASE) program, which trained staff how to protect the patient and themselves during holds. He stated the EASE program instructed us on how to hold the patient and avoid being hurt and taught different techniques for hits, blocks, and hair pulls. He stated the EASE program did not teach us any de-escalation techniques, only holds. MHPA-A stated the facility had various practice sessions, and the last time he had attended a session was last week.

On 1/22/20, at 2:05 p.m. licensed practical nurse (LPN)-A stated she had worked the shift P1 was injured. She stated she had been in the medication room,heard a loud noise and came into the nurses desk to P1 being held on the floor by several staff members. She stated P1 had a bloody nose and the nose area was black and blue right away. She stated he complained or severe pain, and stated "a 9 out of 10" (pain scale of 10 being the worst and 0 no pain.) She stated she applied an ice pack to his nose area right away. She stated he also had complaints of severe back pain and placed a pillow behind his back when he was positioned in the restraint chair.

LPN-A stated the usual practice was to "use your words" to get away from the threatening situations and she stated she felt it was not good technique to get into the person's space and stated "you can't touch people."

On 1/22/20, at 3:10 p.m. MHPA-B stated he was aware of the event with P1, and had assisted with the takedown. MHPA-B stated he was standing at the desk, near P1, who was yelling at MHPA-A. He stated he was looking down briefly, and did not see MHPA-A initiate contact with P1 but looked up when MHPA-A had hands on both wrists and was trying to move him out of the nurses station. He stated he immediately assisted by grabbing his arm. MHPA-B stated HST-A joined in to assist, P1 continued to struggle and everyone lost their balance and fell to the floor by the nurses desk.

He stated staff were taught how to avoid escalating the behavior, ways to talk to them respectfully and holds, blocks was the "last resort" in situations such as P1's escalating behavior. MHPA-B stated he had not seen actual contact, was not sure if P1 had been trying to swing or hit but stated he felt he would not have reached out and grabbed P1. He stated "typically you do not move them" once in a hold and stated it was usual to "try not to push on someone." MHPA-B stated P1 had been "building" up for much of the day, and felt the facility had not done a great job debriefing on the event. He stated he felt the facility had missed a lot of opportunities to head the takedown off, in the hour or so before the incident.

On 1/23/20, at 1:16 p.m. Regional Operation Director North (RODN) stated the wrist grab technique was part of the training for the EASE program, however, the training approach was to apply the wrist grab from the back, not the front. She stated the facility practice was to hold a debriefing session after emergent events occurred. She stated a group of staff got together, both staff that were involved and staff who were not involved in the event. RODN stated the purpose of the meeting was to "ask if everyone was ok." The meeting was not mandatory, and was for anyone who was available and wished to attend. She stated the official debriefing of the event was when employee assistance (EAP) staff came on site to offer assistance to any staff that wished for assistance.

RODN confirmed P1's critical event report (CER) had been completed by various individuals, however, the CER lacked a supervisor review of the event. RD confirmed a overall investigation of the event had not been conducted.

On 1/23/20, at 2:05 p.m. during a telephone interview, EASE Instructor (EI)-A stated staff were required to be EASE certified annually, every 12 months. She stated EASE techniques were used if there was a potential for immediate violence and stated the usual practice was to get behind patient and grab wrists and indicated it was best to be closer to patient to implement the EASE strategies. She indicated once a hold was initiated, it was best to hold patient stationary or move to the restraint chair. She stated "typically we do not move them" during a hold and stated staff were instructed to try not to push on someone.

EI-A confirmed she had reviewed the video footage of the event on 1/3/20 with P1, and confirmed she was aware MHPA-A has been attempting to move P1 backwards out of the nurses station. She stated she would of definitely waited to move P1 until more staff assisted. E1-A added, that anytime there is movement there is a risk for injury. She stated following review of the video footage, she had recommended staff be trained on front hold techniques, and practiced these techniques with a few staff in the facility the day she had viewed the footage. She stated EASE procedures instructed to use the shoulder maneuver if the staff member was behind the patient, not in front.

Review of the Direct Care and Treatment, Official Employee Transcripts, printed 1/22/20 revealed the following:

-MHPA-A-- EASE skills assessment with certified instructor had been completed last 9/13/18, and then completed next on 1/14/20 (11 days after the event)

-MPHA-B--EASE skills assessment with certified instructor had completed last on 3/12/18, and then completed on 1/14/20 (11 days after the event)

On 1/23/20, at 3:54 p.m. during a follow up interview, RODN confirmed annual certification in the EASE program was required for each staff member and stated the training was required to be completed every 12 months. She confirmed the findings of the training records for MHPA-A and MHPA-B.

The facility's Seclusion or Restraint policy effective 2/5/19, indicated direct care staff would be competent on EASE techniques, techniques to identify triggers of circumstances which required use of seclusion or restraint, use of nonphysical intervention skills, and safe implementation of seclusion and restraints.

Based on interview and document review the facility failed to maintain certification in application of hold and restraints for according to facilty policy for 2 of 5 staff members in an attempt to maintain safety of both patients and staff during emergent holds and takedowns.

Findings include:

Review of P1's clinical record revealed on 1/3/20, he had been exhibited escalating behaviors, verbalizing threats to a peer and staff in the facilty. Staff determined that due to P1's escalating behaviors there was imminent danger for patients and staff, and because of the imminent danger placed P1 in a hold and takedown which resulted in a nasal fracture for P1 and mental health professional assistant (MHPA)-A injury.

The facility's policy titled Seclusion or Restraint, effective 2/5/19, indicated trained staff would provide for the safety of patients who pose an imminent risk of harm to self or others by using the least restrictive intervention available including seclusion and or restraint. The policy indicated all staff who engaged in direct patient contact would participate in training and competency demonstration prior to participating in a seclusion or restraint and annually or as indicated on the following topics: EASE training, techniques to identify triggers of circumstances requiring use of seclusion or restraint, use of nonphysical intervention skills, choosing least restrictive interventions and safe implementation of seclusion and application of restraints.

Review of the facility booklet titled Effective and Safe Engagement (EASE) participant book, revised 9/19, revealed the booklet included strategies to deal with behaviors which included active listening, de-escalation techniques and physical safety strategies used when clients, staff, or others are at imminent risk of harm in an emergency situation where all available, less restrictive and intrusive methods have been unsuccessful in re-establishing safety. The use of physical safety strategies to control or restrict movements of the client is considered a restraint.

Review of the Direct Care and Treatment, Official Employee Transcripts, printed 1/22/20 revealed the following:

-MHPA-A-- EASE skills assessment with certified instructor had been completed last 9/13/18, and then completed next on 1/14/20 (11 days after the event)

-MPHA-B--EASE skills assessment with certified instructor had completed last on 3/12/18, and then completed on 1/14/20 (11 days after the event)

On 1/22/20, at 12:22 p.m. during a telephone interview, mental health professional assistant (MHPA)-A stated he was at the nurses station, when P1 came to the nurses station, yelling and stated "I'm going to break her fucking jaw" about another female patient in the facilty. He stated P1 yelled at him, calling him names such as "Wimp," "Pussy," and walked into the nurses station and up to MHPA-A. MHPA-A stated P1 continued to yell at him and stated "I've been to prison twice, and I can go again." MHPA-A stated he was not sure of P1's intentions, felt threatened and planned to move him out of the nurses station. MHPA-A stated he felt asking P1 to leave the nurses station would not of worked, and felt he was not going to listen. He stated P1 had his hands up, in a "fighting stance" and he walked towards P1, placed both hands on his wrists and attempted to push him backwards out of the nurses station. He stated P1 "resisted" being pushed and struggled with him. He stated he continued to struggle to remove P1 from the nurses station, pushing him backward, and with assistance from other staff members. MHPA-A confirmed P1's face and body had been pressed against the white board and wall outside of the nurses station during the struggle, prior to him falling on the floor. He stated P1 sustained a bloody nose and was not sure if that happened when his face was pressed to the white board or wall or when he hit the floor. MHPA-A stated he and HST-A, HST-B, and MHPA-B held P1 on the ground until law enforcement arrived and placed handcuffs on him.

MHPA-A stated he also had been injured during the incident, had missed work and currently was on light duty assignment. He stated at the time of the incident he had injured his left arm and neck and continued to be sore. MHPA-A stated the facility had a Effective and Safe Engagement (EASE) program, which trained staff how to protect the patient and themselves during holds. He stated the EASE program instructed on how to hold the patient and avoid being hurt, which taught different techniques for hits, blocks, and hair pulls. He stated the EASE program did not teach de-escalation techniques, only holds. MHPA-A stated the facility had various practice sessions, and the last time he had attended a session was last week.

On 1/22/20, at 2:05 p.m. licensed practical nurse (LPN)-A stated she had worked the shift P1 was injured. She stated she had been in the medication room,heard a loud noise and came into the nurses desk to P1 being held on the floor by several staff members. She stated P1 had a bloody nose and the nose area was black and blue right away. She stated he complained or severe pain, and stated "a 9 out of 10" (pain scale of 10 being the worst and 0 no pain.) She stated she applied an ice pack to his nose area right away. She stated he also had complaints of severe back pain and placed a pillow behind his back when he was positioned in the restraint chair.

LPN-A stated the usual practice was to "use your words" to get away from the threatening situations and she stated she felt it was not good technique to get into the person's space and stated "you can't touch people."

On 1/22/20, at 3:10 p.m. MHPA-B stated staff were taught how to avoid escalating the behavior, ways to talk to them respectfully and holds, blocks was the "last resort" in situations such as P1's escalating behavior. MHPA-B stated he had not seen actual contact, was not sure if P1 had been trying to swing or hit but stated he felt he would not have reached out and grabbed P1. He stated "typically you do not move them" once in a hold and stated it was usual to "try not to push on someone." MHPA-B stated P1 had been "building" for much of the day, and felt the facility had not done a great job debriefing on the event. He stated he felt the facility had missed a lot of opportunities to head the takedown off, in the hour or so before the incident.

On 1/23/20, at 2:05 p.m. during a telephone interview, EASE Instructor (EI)-A stated staff were required to be EASE certified annually, every 12 months.

On 1/23/20, at 3:54 p.m. Regional Operation Director North(RODN) confirmed annual certification in the EASE program was required for each staff member and stated the training was required to be completed every 12 months. She confirmed the current facility policy and confirmed the findings of the training records for MHPA-A and MHPA-B.