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Based on record review and interview, facility performance improvement failed to identify the cause of an adverse patient event. Facility failed to identify opportunity for improvement in its internal investigation of the cause of injury for Patient ID# 9.

Review of record showed that Patient ID# 9 was on 3/29/13 with the diagnosis Schizoaffective Disorder Bipolar type. On 5/2/13 at 12:20am, patient was agitated, grabbed Staff ID# 52 ' s pen and refused to release it. Staff ID# 52 tried to remove pen from patient and in the process, patient hit " something " and sustained a nasal fracture.

Review of internal investigation revealed that the techniques used by staff ID# 52 were not analyzed during the investigation. Result of investigation was inconclusive of the cause of injury.

Interview with Staff ID# 52 on 9/11/13 at 9:45am over the phone revealed that staff was trying to remove a harmful object (pen) from resisting patient without calling for help. She stated that she grabbed patient ' s hand and tried to remove the pen. Patient held tightly to the pen, flailing around, yelling " mine " and then she noticed that patient was bleeding from the nose and mouth and she called for help. She stated that she did not know how patient sustained the injury. She acknowledged that in hindsight she should have called for help to remove the pen from patient.


Interview with Staff ID# 53/Director of Education and Training on 9/10/13 at 11:40am in the Program Director ' s office, she stated that all staff completed the CPI training for safe management of disruptive and assaultive behaviors in orientation and in annual training. She explained and showed surveyor the curriculum of the program. She added that staff was trained in safe techniques to remove object from an agitated patient. Staff was instructed to wait for assistance before approaching an aggressive patient with harmful object. She acknowledged that Staff ID# 52 failed to follow instructions given in training by not calling/waiting for help before attempting to remove the pen.


Interview with Staff ID# 51Program Director, on 9/10/13 in her office, she stated " staff was suspended during the investigation and result showed that there was nothing the staff did wrong. " She explained that investigation did not review the technique used by staff in removing the object from the patient. She acknowledged that staff should not have attempted to release the pen and called for help.