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Based on record review and interview, the facility failed to immediately re-educate all staff on appropriate and inappropriate de-escalation techniques following an incident that occurred with 1 of 1 patient (Patient #1) in a total of 1 facility-submitted Misconduct Report reviewed.

Findings Include:

A review of the entity-submitted Misconduct Incident Report (MIR) on 03/28/2024 revealed an incident that occurred on 03/20/2024 involving several staff members [Registered Nurse (RN) A, RN B, and Mental Health Technician (MHT) C)] who used their feet to push and scoot Patient #1 off the elevator and down the hallway towards the unit after Patient #1 refused to walk.

A review of Patient #1's medical record revealed Patient #1 was a 10-year-old who was voluntarily admitted to the facility on 03/15/2024 for combative and aggressive behavior and was discharged to home on 03/22/2024. Patient #1 had a diagnosis of ADHD (Attention Deficit Hyperactivity Disorder). Chief complaint for admission is documented as, "[Patient #1] says is here "because of anger issues."

A review of the "Incident Report" dated 03/20/2024 (no time) completed by Director of Nursing (DON) D revealed, "Unit staff reported to me during staff debriefing that staff used their feet to pull, push, and scoot the patient onto an off the elevator." Documentation of actions taken included: 03/21/2024-video reviewed. 03/21/2024-A review with compliance, Human Resources, Chief Operating Officer, and Patient Safety occurred. 03/21/2024- Employees observed placed on paid leave until investigation is completed..."

During an interview on 04/24/2024 at 9:40 AM MHT C stated on 03/20/2024 s/he was asked to help with Patient #1 who was trying to fight with another patient. MHT C stated 2 nurses went down to the cafeteria to assist Patient #1 back to the unit. Patient #1 was very agitated, refusing to get off the elevator, and started rolling around on the floor in the elevator. Patient #1 did eventually walk off the elevator and once in the hallway laid on the floor. Patient #1 was using his/her head to run into the shins of the staff and was banging his/her head on the wall. MHT C stated the two nurses used their legs to guide Patient #1 forward down the hall toward the unit.

During an interview on 04/24/2024 at 11:25 AM Vice President (VP) of Compliance M stated as part of the investigation the video of the incident with Patient #1 was reviewed on 03/21/2024 by patient safety staff. VP of Compliance M stated the staff did not report the use of their legs/feet to scoot Patient #1 out of the elevator in the incident report. When the video was reviewed by Patient Safety Staff, it was determined the involved staff used a practice that was not a technique the staff is trained to use.

During an interview on 04/25/2024 at 12:20 PM Director of Nursing (DON) D stated s/he had concerns with the maneuver staff used to get Patient #1 on and off the elevator and the use of the feet/legs to force the patient off the elevator and down the hall was a technique that was not taught in CPI (Crisis Prevention Institute) training (crisis intervention and de-escalation skills that reduce challenging behaviors). DON D stated that when RN A, RN B and MHT C were asked about the technique they used with their legs to "scoot the patient off the elevator" they stated that was a "technique that was taught in previous training." DON D stated this was not a technique that is used or taught currently in crisis intervention or de-escalation skills for patients who are exhibiting challenging behaviors. DON D stated RN A and RN B voluntarily terminated their employment while the staff was on suspension during investigation of the incident with Patient #1. MHT C was informed that NCI (Nonviolent Crisis Intervention) training needed to be completed prior to returning to work.

A review of attendance sheet titled, "Nonviolent Crisis Intervention Refresher Training" dated 04/17/2024 at 8:00 AM-12:00 PM revealed MHT C was included in the roster, as well as signature by MHT C.

There was no evidence found that all facility staff were re-educated on appropriate de-escalation techniques immediately following the incident.

Based on record review and interview, the facility failed to develop policy to ensure that the Director of Nursing (DON) has a valid Wisconsin license in 1 of 1 DON position descriptions reviewed.

Findings include:

Review of facility document entitled "Job Description Director of Nursing Inpatient," last revised 09/06/2023 revealed, "The Director of Nurses.....will manage department staff ...manage care of patients ranging in age from 4 to geriatric and will be expected to function clinically on an inpatient unit, if necessary, and/or assist with patient care issues as they arise...assume the manager role on the inpatient units in a clinical capacity as needed..6. Assist with development and maintenance of policies and procedures with the Vice President of Nursing."

Review of facility DON (Director of Nurses) job description education/training requirements revealed no criteria for Wisconsin state licensure or that any registered nurse license was required.

Review of memo announcement informing staff of Staff D starting at the facility in the official role as the new DON is dated 10/12/2023 at 2:29 PM. Review of DON D's personnel file found that DON D held a current Registered Nurse license from another state (non-compact state) and a Wisconsin Registered Nurse License was obtained on 11/14/2023. DON D did not hold a valid nursing license to practice in Wisconsin in the period from 10/12/2023 to 11/14/2023.

In an interview with Vice President M on 4/25/24 at 10:25 AM when asked about the training Staff D received and if they provided care prior to orientation being completed, M stated, "Staff D had 30 days of shadowing with our previous DON and had an additional 30 days of training with the DON. We have found no evidence of Staff D providing care before receiving their Wisconsin Nursing License, but they were licensed in the state of Illinois.

Although DON D now holds a current Wisconsin nursing license, there is no evidence that the facility has updated their policy or the DON Job Description to require a valid Wisconsin nursing license at the time of appointment to the DON role.

Based on record review and interview the facility failed to clearly define, communicate and provide training on the expectation of how ADL (Activities of Daily Living) are provided to patients by the MHTs (Mental Health Technicians) in 1 of 1 Employee Orientation Process reviewed.

Findings Include:

Review of facility policy titled, "New Employee Orientation (NEO)," effective date of 01/01/2022 revealed, "Purpose: To assure each employee has a thorough understanding of [Facility Name] policies, services, and philosophy, as well as the duties of their job....In order to assure successful completion of the orientation period, each employee will be oriented to all facets of his/her job and working conditions based on the job description....Orientation to working conditions and specific aspects of the job will be conducted by the manager or an individual appointed by the department manager on an "on-the-job" basis.....Clinical employees will continue orientation to complete Patient Care Orientation (PCO)...[Facility Name] Practical Skills are provided during orientation, role-specific onboarding, and on the job training."

Review of facility document titled, "Inpatient Mental Health Technician (MHT) Initial Competency Checklist," revealed under patient care tasks, no competencies or return demonstration required specific to ADLs.

Review of Nursing Services Orientation for MHTs, titled, "ADL's (Activities of Daily Living) Roles Activity," no date, revealed, "This activity is designed to understand what surrounding ADLS an MHT is expected to support....In the hospital setting, ADLs, or Activities of daily living, encompass the essential tasks patients need assistance with to maintain their well-being and facilitate their recovery process...Personal Hygiene: Assisting patients with bathing, grooming, and oral care to promote cleanliness and prevent infections....Dressing and undressing: Helping patients put on and take off clothing as needed, considering any medical devices or equipment they may require...Mobility assistance: Supporting patient with walking, transferring from bed to chair, or using mobility aids to prevent muscle atrophy and maintain mobility...Toileting: Helping patients with using the toilet and maintaining continence, addressing any issues related to mobility or medical conditions...Basic household (patient room) tasks...this may involve ensuring the patient's immediate environment is clean and comfortable...In our setting, nurses and MHTs work together to assist patients with these ADLs as part of their comprehensive plan."

Review of the Facility document titled, "Mental Health Technician job description," revealed, "The Mental Health Technician functions as an active part of the treatment team, providing continuous patient care....Job Duties and Responsibilities: 1. Assist patients with performing activities of daily living. 2. Assists in direct patient care in group or one-to-one setting."

Review of Personnel files for MHTs C, G and H revealed completed nursing services orientation but no specific training or competency assessment relating to the performance of ADLs.

In interviews conducted with MHTs Staff G and H between 04/23/2024 and 04/25/2024, both stated there is no clear expectation on what is expected of MHTs when assisting patient who require assistance with ADLs and what that means.

Review of email sent to all facility MHTs from Staff D on 03/07/2024 at 11:37 revealed, "We are committed to accepting patients in a psychiatric/behavioral crisis at our facility. Our decision to accept a patient is based on specific criteria and hospital required standards....A patient in psychiatric/behavioral crisis may also need assistance with activities of daily living or have other needs that may be unfamiliar to some. Once a patient is accepted, it becomes our collective responsibility to prioritize their safety, well being, and ensuring that their needs are met. We are dedicated to providing a therapeutic, clean and supportive environment for all patients under our care....I have attached the job description for all to review."

In an interview with Staff D on 04/25/2024 at 12:20 PM, when asked if staff are expected to provide patient care without being trained or certified, Staff D stated, "We try to assign a CNA (Certified Nursing Assistant) to all the patients that need assistance with ADLs. We don't require our MHTs to be CNAs. We do accept patients that have a need for assistance with ADLs but this is more on the adult unit. MHTs would assist nurses and do what they are comfortable to do, but we don't have a specific training/competency for ADLs. We don't take patients that require total care with ADLs."