HospitalInspections.org

Based on facility policy, facility documents, video recording review, medical record review and interview, the governing body failed to be effective in carrying out its responsibilities for the conduct of the hospital's staff and failed to ensure the staff were knowledgeable of and implemented a culture of safety for all patients in the hospital.

The failure of the Governing Body to be effective in carrying out its responsibilities to the hospital and ensure an environment of a culture of safety resulted in a SERIOUS AND IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious physical and psychological injuries.

Additionally, the hospital's failure to respond with appropriate interventions to ensure patients were safe from abuse demonstrated the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients ongoing.

The findings included:

1. The governing body failed to ensure all patient rights were promoted and protected related to receiving care in a safe setting and to be free from all forms of abuse/neglect; and restraints were used after least restrictive measures had been attempted, and staff demonstrated knowledge of the appropriate restraint techniques.
Refer to A-0063

2. The governing body failed to ensure the needs of each patient were identified and a plan developed and implemented to ensure each patient received the appropriate care and services necessary to obtain and sustain quality of care and quality of life.
Refer to A-0396

Based on facility documents, facility policy, facility video recordings, medical record review and interview, the governing body failed to ensure all patient rights were promoted and protected related to receiving care in a safe setting and to be free of abuse/neglect and restraints in accordance with hospital policies and incidences of abuse were fully investigated and appropriate actions were implemented and monitored to ensure abuse of patients did not occur for 2 of 2 (Patient's #1 and #3) sampled patients reviewed who were restrained and abused.

The failure of the facility to thoroughly investigate allegations of abuse resulted in a SERIOUS AND IMMEDIATE THREAT to the health and safety of all patients and places them in IMMEDIATE JEOPARDY and risk of serious injuries. Additionally, the hospitals failure to respond with appropriate interventions to ensure patients are safe from abuse demonstrates the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients ongoing.

The findings included:

1. Review of the facility policy "Assessment of Suspected Abuse" revealed, " ...It is the responsibility of any [Name of Hospital] employee with a suspicion or knowledge that a child or adult is a potential victim of abuse and/or neglect to report the information immediately either to their supervisor or the Nursing Supervisor on duty. Reporting suspected abuse and/or neglect solely to hospital administration and/or supervisor is not in compliance with staff...Staff will be educated on the criteria to identify and assess victims of abuse and/or neglect and that criteria will be utilized throughout the hospital ...DEFINITIONS...ABUSE-Defined as inflicting or attempting to inflict physical injury on an adult or child by other than accidental means, placing an adult or child in fear of physical harm...ADULT-A person eighteen (18) years of age or older who, because of mental or physical disability or advanced age, is unable to manage their own resources, carry out the activities of daily living, or protect them self from neglect, hazardous or abusive situations without assistance from others and who has no available, willing or responsibly able person to rely on for assistance and who may be in need of protective services...ADULT ABUSE OR NEGLECT-The infliction of physical pain, injury or mental anguish, or the deprivation of services by a caretaker which are necessary to maintain the health and welfare of an adult or situation in which an adult is unable to provide or obtain the services which are necessary to maintain that person's health or welfare ...PROCEDURE...All patients, regardless of age, who are suspected to be victims of abuse, neglect, and/or exploitation will be reported to the proper authorities ...Should a staff member have any concerns determining the suspicion of abuse/neglect, he/she can contact the Nursing Supervisor, who can assess Behavioral Health Services, if needed ..."

Review of the facility policy "Patient Abuse and Neglect" revealed, "It is the policy of [name of facility] that no patient is to be mistreated or abused physically, verbally, psychologically or sexually while in our care. Patient neglect is also prohibited ...maintains a Zero Tolerance policy for patient abuse and/or neglect ...Procedure: Patient abuse is strictly prohibited and will not be tolerated. Examples of patient abuse include but are not limited to: striking a patient; using excessive force in restraining a patient; rough handling of the patient; teasing, taunting or ridiculing a patient; speaking inappropriately with a patient and threatening a patient. Neglect would be failing to provide for the patient's basic emotional or physical needs or failing in any way that would endanger the patient's emotional or physical well-being. Failing to be fully engaged in promoting the patient treatment plans would also be considered to be neglect ..."

2. Review of the facility's video recordings of Patient #1 and Patient #3 revealed these 2 patients had been physically and emotionally abused by staff, and had been physically restrained by staff without prior least restrictive interventions utilized. There was no evidence presented to the surveyors that interventions had been developed and implemented following the abuse of Patient #1 and Patient #3 to ensure these patients and all other patients remained free from abuse and restraints.
Refer to tags A145 and A154.

3. On 2/5/19 at 9:00 AM the Risk Manager was asked to provide the facility's investigation of allegations of abuse against Patient's #1 and Patient #3. The Risk Manager provided a folder for each investigation which revealed the following:

Patient #1:
Review of the facility investigation of allegations of abuse related to Patient #1 revealed an incident report was completed on 1/16/19 by Registered Nurse (RN) #2. The time and date of the incident was 1/11/19 at 1:00 PM.

Review of the "Facts Summary of Event" documented by RN #2 revealed the statement as follows, "I was called to the day room by Patient Care Technician (PCA) #7 to assist with patient [Patient #1]. He was acting out and had paper, temp[temperature] probes, ink pen with cap, potato chip bag in mouth. I stood on his left side while tech [PCA #7] stood on his right side trying to get paper out of mouth. Pt grabbed me with his right hand by my uniform and threw me to the floor. While trying to restrain him on the floor, staff called a special duty code. Patient was secured until more staff arrived to assist with patient. As patient was sitting in wheel chair he bit himself on the left arm yelling out stating I [Nurse #2] hurt him."

Review of a witness statement with the date of event 11/11/18 (sic), (the event was 1/11/19) at 1:00 PM with PCA #7 revealed the following. There was no time or signature of when the report was completed. These sections were blank. The witness statement stated, " ...It was a piece of paper left on the floor [Patient #1] tried to get but [RN #2] was trying to get the paper off the floor. [Patient #1] got upset and started swinging at her and somehow grabbed her scrub top and slung her. [PCA #8] and I did the best we can to keep [Patient #1] from biting [RN #2] in her face. Once we got [Patient #1] under control and into a position that was safe for everyone, [PCA #8] ran and called a "special duty code". The staff arrived but things were under control so some of them left ...he crawled to the trash unlocked it and started putting things in his mouth. [RN #2] was asking him calmly to stop; we couldn't stop him so another special duty code was called. This time the staff gave [Patient #1] an injection ..."

Review of a witness statement with a date of event 01/11/19, and without a time, with PCA #8 revealed the following, " ...While she [referencing RN #2] was reaching down getting the paper, [Patient #1] grabbed her scrub top and slung her on the floor. He continued to pounce on her while me and [PCA #7] was trying to break them apart. He finally eased up a little and I ran to the phone to call for a "special duty code". When everyone arrived he began crying saying that [RN #2] was 'picking on him' and that's why he acted out ..."

Also in the investigative file provided by the facility was a copy of Patient #1's Psychiatric Evaluation, Admissions Summary Sheet and a copy of a Continuing Education Record (CER).
The CER was titled Abuse/Neglect of Patients. The dates for staff attendance was 1-23-19 to 1-28-19. The length of the course was 30 minutes, and the instructors for the course were RN #4 and Charge Nurse of the Senior Care Unit. Review of the Attendance Record for the course revealed RN #2 and PCA #7 did not attend the in-service course. There was a blank copy of the Continuing Education Record with a post-it note on it that had PCA #4's name on it but he did not attend the in-services.

There were no assessments performed O Patient #1 after each of the restraint episodes on 1/11/19. There was no assessments performed after the patient complained the nurse hurt his arm and no assessments after the patient fell several times in the day room with staff present. There was no other information in the investigative report for Patient #1.

Patient #3:
Review of the facility abuse investigation related to allegations of abuse against Patient #3 revealed a hand written statement by RN #1 dated 1/30/18 (sic) (the incident did not occur until 1/11/19). The statement revealed, " ...She was subdued by staff in front of nurse's desk. I had my leg covering her R [right] arm & [and] a tech stood holding her left arm while another tech tried to stop her from bucking off ..."

Review of an e-mail sent to the Chief Nursing Officer (CNO) on 1/29/19 by the Crisis Prevention Intervention (CPI) instructor revealed, " ...[Patient #3] stated that [RN #1] grabbed her by her hair and pulled her down the hall on Saturday 1/26/19. She also stated that there was a bruise on her right hip as a result of being dragged down the hall ...After viewing the video for Saturday 1/26/19 within the time frame of about 30 minutes to an hour (1730-1830) it shows this to be the actual time of the incident ...As they made their way to the front of the nurses station [RN #1] along with [PCA #2] (tech) restrained [Patient #3] and they fell to the floor. It appeared that [RN #1] along with [PCA #2] was holding the patient on the floor until more staff arrived. The patient's arms and legs were being held as she was kicking and swinging. [RN #1] used her elbow to restrain the patient in the neck area ...The staff did slide/drag [Patient #3] down the hall and the IDD TECH [Intellectually Delayed Disabilities] grabbed her hair as they were taking her down the hall." The facility failed to ensure that their policy and procedure was followed as evidenced by video review, inflicting physical pain on Patient #3 on 1/11/19 by dragging her by her hair down the hall when staff were available to assist to place the patient on a stretcher and carry her to a quite place.

The investigative folder also contained a copy of Patient #3's history and physical completed on 12/15/18 and Psychiatric Evaluation completed on 12/15/18.

Review of a nurse's progress note dated 1/26/19 at 6:45 PM by RN #1 documented, "[Patient #3] continued to be combative striking and spitting on staff - no attempts were successful. She was destructive to property and she continued to make attempts to attack staff. She was in hallway assaulting staff. She was continued to assault staff and prn [as needed] medication was ineffective. Numerous attempts to de-escalate. Md notified due to the level of violence from [Patient #3] increasing. Second injection give at 1920 [7:20 PM]."

Review of a nurses progress note dated 1/26/19 at 8:30 PM by RN #3 documented, "[Patient #3] in hallway and activity room disrobed and continues to escalate being very combative, destroying property and running after peers with a wooden stick as staff get them to their room. Place was put in restraints. [Name of physician] called, orders given to continue restraints as needed."

Further review of the investigation file for this incident revealed a copy of the Continuing Education Record, Program Title: CPI dates attended were 2/6/19 course length 4 hours. The attendance record revealed PCA #2, PCA #3,
PCA #5 and PCA#6 attended this course. There were Employee Coaching Forms completed by the Chief Nursing Officer for PCA #2, PCA#3, PCA#5 and PCA #6 dated 2/1/19 which documented, "Special Duty code were [where] proper CPI was not used. Call the house supervisor in the future for additional assistance if the charge nurse on the unit does not take suggestions to ensure proper CPI technique."

There was no incident report or nursing assessment related to the patient's complaint of injuries during the restraint incident. There was no other information provided in the investigative report for Patient #3. There was no monitoring implemented by the facility to ensure all staff were knowledgeable of the CPI techniques or course tests/competencies for CPI. There was no documentation the staff had been re-educated on abuse or other measures implemented to ensure patients were free from all forms of abuse. When the surveyors questioned the Education Nurse about abuse training, the Education Nurse stated she had put up abuse posters.

4. On 2/11/19 at 9:43 AM the surveyor and the Risk Manager reviewed the video of the incident of Patient #3. At the 2:25 mark on the video, RN #1 was observed biting Patient #3 on the shoulder. The Risk Manager stated, "Not something we picked up on [biting]. That clearly was not what we suspended her for."

In an interview in the conference room on 2/11/19 at 9:43 AM the Risk Manager was asked how the facility was notified/made aware of reports of abuse against [Patient's #1 and Patient #3]. The Risk Manager stated, "Originally would be a phone call from the Nurse Manager or House Supervisor, then whoever the allegation was made against was suspended pending investigation."

In an interview in the conference room on 2/11/19 at 11:20 AM the Risk Manager stated, "I did not put a monitor in place after those incidents [referring to Patient's #1 and Patient #3]. Crisis Program Intervention (CPI) is a physical teaching, they have to return demonstrations. The patient had made allegations of abuse, when he put his knee on his neck [referring to PCA #4]. We had a hospital wide in-services prior to this...after I did another self-report of abuse. Our nurse educator monitors that all staff went through training ..."
The surveyor asked if there was a hospital-wide in-service on abuse, neglect and dignity after the incidents with Patient #1 and Patient #3 and the Risk Manager stated, "Not since the posters were put up [referring to Zero Tolerance poster dated 12/3/18 - 1/3/19].
The Risk Manager was asked what the system for monitoring training received by staff was. She stated, "No system."

In an interview in the conference room on 2/11/19 at 11:35 AM when questioned what training on abuse had been implemented after the incidents with Patient #1 and Patient #3 and the Nurse Educator stated, "I put a Zero Tolerance poster outside the cafeteria with a sign in sheet. Staff signs indicating they have gone through the posters. My responsibility was to make a poster in regards to Zero Tolerance. Managers monitor and it goes in each employees files. Every employee had to go to HR [Human Resources] per their manager... [Risk Manager] covers Zero Tolerance and Health Stream corporate computer annually. Zero Tolerance is the same training for nurses and techs. For restraints, I do cover a presentation from corporate. When they are restraining, I teach about the chair, [CPI Instructor] teaches about take-downs. They get yearly refresher courses on CPI."
The surveyor asked the nurse educator if she provided in-services after the above incidents and she stated, "Only when I'm asked to do something. I'm not privy to abuse investigations. This is my first time to see this."
The surveyor asked her what is the system for monitoring training received by staff and she stated, "When it's time for evaluations, they know it's time to update their training. Managers keep it updated ...The policy and information from the Employee Handbook is what I have on the poster [Zero Tolerance]."

Based on facility policy, medical record review and interview, the facility failed to protect and promote each patient's right to receive care in a safe setting, to be free of abuse/neglect and free of restraint/seclusion.

The failure to promote and protect each patient's rights resulted in a SERIOUS AND IMMEDIATE THREAT to the health and safety for 2 of 2 (Patient #1 and 3) sampled patients.

The findings included:

1. The facility failed to provide care to all patients in a safe physical and emotional environment. The facility failed to identify abuse/neglect and investigate, respond and protect Patient #1 and 3 placing the patient's in a SERIOUS AND IMMEDIATE THREAT for their health and safety.
Refer to A 145

2. The facility failed to ensure the use of restraint/ seclusion was in accordance with facility policy, a written plan of care and with a physician order,
Refer to A 154 and A 161

Based on policy review, medical record review, video recording review, and interview, the facility failed to ensure vulnerable patients were protected at all times and their rights, dignity and well-being were preserved for 2 of 2 (Patient's #1 and #3) sampled patients who whose rights to be free from abuse were violated.

The failure of the facility to ensure patients were free from all forms of abuse resulted in a SERIOUS AND IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries. Additionally, the hospitals failure to respond with appropriate interventions to ensure patients are safe from abuse demonstrated the IMMEDIATE THREAT TO THE HEALTH AND SAFETY of patients is ongoing.

The findings included:

1. Review of the facility policy "Assessment of Suspected Abuse" revealed, "...It is the responsibility of any [Name of Hospital] employee with a suspicion or knowledge that a child or adult is a potential victim of abuse and/or neglect to report the information immediately either to their supervisor or the Nursing Supervisor on duty. Reporting suspected abuse and/or neglect solely to hospital administration and/or supervisor is not in compliance with state law. ...Staff will be educated on the criteria to identify and assess victims of abuse and/or neglect and that criteria will be utilized throughout the hospital ...DEFINITIONS ABUSE Defined as inflicting or attempting to inflict physical injury on an adult or child by other than accidental means, placing an adult or child in fear of physical harm....ADULT-A person eighteen (18) years of age or older who, because of mental or physical disability or advanced age, is unable to manage their own resources, carry out the activities of daily living, or protect them self from neglect, hazardous or abusive situations without assistance from others and who has no available, willing or responsibly able person to rely on for assistance and who may be in need of protective services....ADULT ABUSE OR NEGLECT-The infliction of physical pain, injury or mental anguish, or the deprivation of services by a caretaker which are necessary to maintain the health and welfare of an adult or situation in which an adult is unable to provide or obtain the services which are necessary to maintain that person's health or welfare ...PROCEDURE...All patients, regardless of age, who are suspected to be victims of abuse, neglect, and/or exploitation will be reported to the proper authorities...Should a staff member have any concerns determining the suspicion of abuse/neglect, he/she can contact the Nursing Supervisor, who can assess Behavioral Health Services, if needed..."

Review of the facility policy "Patient Abuse and Neglect" revealed, "It is the policy of [name of facility] that no patient is to mistreated or abused physically, verbally, psychologically or sexually while in our care. Patient neglect is also prohibited ...maintains a Zero Tolerance policy for patient abuse and/or neglect ...Procedure: Patient abuse is strictly prohibited and will not be tolerated. Examples of patient abuse include but are not limited to: striking a patient; using excessive force in restraining a patient; rough handling of the patient; teasing, taunting or ridiculing a patient; speaking inappropriately with a patient and threatening a patient. Neglect would be failing to provide for the patient's basic emotional or physical needs or failing in an way that would endanger the patient's emotional or physical well-being. Failing to be fully engaged in promoting the patient treatment plans would also be considered to be neglect..."

Review of the facility policy "Patient Rights and Responsibilities" revealed, "...All personnel are responsible for adherence to the principles as outlined in the Patient Rights and Responsibilities. Department Managers are responsible for monitoring compliance with this policy ...Patient's Rights...Respect and Dignity: The patient has the right to considerate; respectfully care at all times and under all circumstances, with recognition of his/her personal dignity..."

Review of the facility policy "Management of Aggressive/Violent Patient (Special Duty Code)" revealed, "PURPOSE: to outline techniques for defusing potentially violent situations and to describe safe use of physical control techniques when a patient has lost self-control and is aggressively acting out. POLICY STATEMENT: It the policy at the facility to use verbal de-escalation and/or physical control techniques to manage aggressive/violent behavior when it is necessary to protect the safety of patients, staff and/or visitors ...PROCEDURE...When a patient becomes defensive or threatening, the patient should be isolated by removing other patients and/or visitors to reduce pressure on both the patient and the staff...The Team Leader (or designee) will attempt to control the patient using verbal de-escalation techniques as instructed in the Nonviolent Crisis Prevention Course. If, however, the patient's threatening behavior continues and the team is unable to maintain control, the Team Leader will give the cue to implement the CPI Team Control Position...The Team Leader (or designee) will instruct the team members to transport the patient to the Quiet Room or a decision is made to mechanically restrain the patient. The method of treatment/restraint will be the least restrictive as appropriate to the patient's clinical condition and will be based on a physician's order as outlined in the Restraint Policy and Procedure...As soon as possible following each SDC [Special Duty Code], the Team Leader will meet with the team for a debriefing and will be responsible for completing the appropriate documentation, including...Documenting in the Medical Record the patient behavior which resulted in the SDC...If restraints required, the RN will document as required by the Restraint Policy and Procedure ..."

2. Medical record review for Patient (Pt) #1 revealed the Pt's date of birth was 10/27/91. The Pt was admitted to the hospital on 1/10/19 with diagnoses of Schizoaffective Disorder, Bipolar Type.

Review of the Psychiatric Evaluation for Pt #1 performed 1/10/19 revealed, "Justification for Hospitalization-Inpatient; Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment ...Inability to meet basic life and health needs ..."

Review of the Care Plan for Pt #1 dated 1/10/19 revealed no mention of PICA, medical term for an abnormal craving for and eating of substances not normally eaten or of no nutritional value.

A physician's order was given on admission 1/10/19 at 3:22 PM for "15 minute checks with line of sight monitoring ..."
Review of the Patient Assessment Report Discharge Planning dated 1/11/19 at 11:02 AM documented, "Counselor attempted to meet with [name of Patient #1] to complete psychosocial assessment. [Name of Patient #1] appeared unwilling and observed placing various objects in his mouth. Counselor will follow up at a later time."

Review of the Patient Observation sheet dated 1/11/19 from 12:00 AM through 11:45 PM revealed there was no documentation Patient #1 was agitated throughout the day.

Under the "Behavior Comment Codes" section the staff documented the patient was calm. There was no documentation of behaviors in the comment code every (q) 15 minutes from 3:15 PM through 4:45 PM and 6:00 PM through 6:30 PM.

Review of the Patient Assessment Report-Nurse Group Progress Note dated 1/11/19 at 6:53 PM documented, "Start Time: 1330 [1:00 PM] Stop Time: 1400 [2:00 PM] ...Behavior: agitated, impulsive, tearful, uncooperative ...pt has been eating everything and anything off the floor. PRN's have been given ..." There was no documentation the staff attempted to assess the patient or provide calming interventions for the pt.

Review of the Physician's orders dated 1/11/19 revealed Patient #1 was administered a 'now dose' of Lorazepam 1 mg (milligram) IM (intramuscular) at 11:27 AM and Lorazepam 2 mg IM and Haloperidol 5mg IM at 1:14 PM. There was no documentation of a reason why the medications were administered or an assessment after medications were administered to determine the effectiveness of the medications or any side effects from the medications.

Review of the Discharge Planning note dated 1/13/19 at 11:16 AM documented, "Counselor met with [name of Patient #1] while on unit. [Name of Patient #1] appeared more cognitive and willing to process with counselor...Per [name of Patient #1], "I am feeling better but staff attacked me-that's why I was acting up." [Name of Patient #1] provided names and descriptions of staff members that he felt "hurt me". Counselor informed [name of Patient #1] that information provided would be given to appropriate person."

The surveyors requested a video recording of the incident that Pt #1 had spoken about to his Counselor.

On 2/6/19 the Risk Manager provided a copy of the video recording of the incident with Patient #1 in the Senior Care Day Room. The video did not record the actual time and date of the incident. The video started at 00:00 and ended at 40:22. Per the Risk Manager the video recording was of an incident that occurred on 1/11/19 involving Patient #1. Review of the video for Patient #1 revealed the following:

00:10 - Patient #1 was observed in the dayroom crawling on the floor under tables. The patient had a hospital gown on that was open in the front. There were no staff watching the patient. The patient's diaper was observed around the patient's ankles. The patient's buttocks was exposed. There were no observation of staff attempting to assist the patient. There were multiple other patients, both male and female in the dayroom at this time.
00:38 - Pt #1 remained on the floor, crawling in different directions with his buttocks exposed and diaper around his ankles. Patient Care Assistant (PCA) #7 was observed standing in the middle of the dayroom with a cell phone in her hand, looking at screen.
00:45 - Pt #1 continued crawling on the floor and picking up objects and placing them in his mouth. There was a PCA standing in front of him. The PCA was not attempting to redirect the patient or assist the patient with clothing. The patient's buttocks remains exposed.
00:58 - 02:00 - Pt #1 continues crawling around the dayroom floor with an exposed buttocks, other pts remain in the dayroom. PCA #7 was observed looking at her cell phone. There was no observation of staff attempting to assist Pt #1.
02:22 -02:32 - Pt #1 continues to crawl around the dayroom floor with an exposed buttocks and with paper hanging out of his mouth. PCA #7 was observed walking around the pt. There was no observations of staff assisting the patient.
02:45 - Pt #1 crawled to a computer on wheels, removed gloves, and put them in his mouth. PCA #7 observed to walk away from Pt #1 without attempting to remove the items from his mouth, assist the pt or redirect the pt.
03:04 - Pt #1 crawled to the thermometer stand and removed a box of thermometer plastic probes and placed the box in his mouth. Staff observed in the back of dayroom on cell phones. Pt #1's diaper was around his ankles and buttocks are exposed.
03:33 - Two staff were observed standing at Pt #1's side. The pt was still crawling on the floor and his diaper remains around his ankles and buttocks are exposed. There is no assistance offered or provided to the pt.
03:48 - 03:53 - A staff member was observed removing the probe box from Pt #1's mouth. The pt remained on the floor with his buttocks exposed. The pt continued crawling around.
03:59 - Pt #1 observed picking up small white objects off the floor and putting them in his mouth. His buttocks was still exposed.
04:04 - RN #2 was observed standing in front of Pt #1. The patient is on the floor, and on his knees.
04:06 - 04:09 - RN #2 reached to take items out of Pt #1's mouth and he swings at her. PCA #7 then grabbed
Pt #1. The pt had a hold onto Registered Nurse (RN) #2's uniform. PCA #7 forcibly pulled Pt #1 to the floor causing RN #2 to fall to the floor too.
04:10 - PCA #7 released Pt #1. The pt was on the floor with RN #2 beside the pt.
04:14 - PCA #7 was observed attempting to assist RN #2 to stand up.
04:19 - 04:22 - RN #2 was observed kneeling on the floor at Pt #1's side with her head down on Pt #1. PCA #7 then grabbed Pt #1's left upper arm.
04:25 - 04:46 - PCA #7 was observed pressing her left hip on Pt #1's lower back area and was holding the pt's left upper arm with her hand in a restraining motion. RN #2 was observed lying over Pt #1's upper body.
04:55 - PCA #7 was observed sitting on the pts right hip and was holding both the pt's forearms down with pts arms bent upward in a restraint. RN #2 was also holding down the patients. Pt continues to have his buttocks exposed. At no time during these observations have staff attempted to de-escalate or assist the pt.
04:58 - PCA #7 has both Pt #1's upper arms restraining the Pt down on the floor. Pt #1 was face down on the floor and the Pt was kicking his legs.
05:05 - A female in khaki pants was standing at scene talking on a phone. PCA #7 was still restraining Pt #1 on the floor. The female was later identified as a Nurse Practitioner (NP). The NP walked past Pt #1 as he was being restrained on the floor by staff and the NP did not assess the Pt or the situation or attempt to intervene in any way to assist the patient. The NP was later identified by staff as a rounding nurse and not a NP.
05:19 - PCA #7 has finger tips on Pt #1's upper arms. RN #2 was still at Pt #1's head and restraining the pt from moving his upper body.
06:00 - PCA #7 released Pt #1. RN #2 continued to restrain the pt from moving his upper body.
06:11 - Staff assisted RN #1 off the floor to a standing position. Pt #1 continued to lay on the floor. Eight staff members were standing around him. There were 13 patients observed in the dayroom during this incident. The patient remained on the floor. No staff assisted the pt until 06:23.

Further review of the video recording for Patient #1:
06:23 - Pt #1 was observed on his knees attempting to get into a wheel chair. There was no assistance provided by the staff.
06:44 - Pt #1 was observed in the wheelchair holding his left upper arm with his right hand. There were eight staff members in a circle around him. No staff were observed talking with the Pt, assessing the Pt or attempting to assist the Pt in any way.
06:52 - Pt #1 reached out to staff RN #2 walked in fron of the Pt. The RN did not engage with the Pt.
06:57 - RN #2 was observed looking at Pt #1's left upper arm that the patient had been holding after the restraint. Pt #1 remains in the wheelchair in the dayroom. There were six staff members around him. The staff were not observed interacting with the Pt. in any way.

The next video observation of Pt #1 revealed:
09:03 - Pt #1 remains in the dayroom. The Pt falls forward out of the wheel chair to the floor and onto his knees with 5 staff members standing around him. There were no interventions or interactions from the staff.
09:11 - Pt #1 was observed crawling on the floor on his hands and knees and picking up white substances off the floor and placing them in his mouth. His buttocks were exposed. No staff intervenes to cover the patient's exposed body or to redirect the Pt.
09:31 - Pt #1 continued crawling on the floor with buttocks exposed with 5 staff members around him, who were not assisting the Pt.
09:40 - Pt #1 crawled to the wheelchair and pulled himself up and sat in the wheelchair. Six staff members were standing around him.
10:22 - Pt #1 stands, gets out of the wheelchair and walked over to bedside table. The Pt picked up a blue glove. The staff then grabbed the glove from the Pt causing the glove to tear. The Pt puts the torn piece of glove into his mouth.
10:33 - Pt #1 was observed walking around the dayroom. The Pt's front perineal area and buttocks were exposed.
10:37 - Pt #1 was assisted to a chair by the wall. No staff intervened to cover the patient.
11:33 - 12:26 - Pt #1 has a white towel in his mouth. There were 6 staff around him. No interventions were observed from the staff.

The next video recording of Pt #1 were as follows:
13:51 - Pt #1 stands up, walks toward the wheelchair, puts his hands on wheelchair and falls to his knees.
13:54 - Two staff within reach of Pt #1 did not assist him when falling or after he was on his hands and knees. No one assessed the patient after the fall.
14:22 - Pt #1 was crawling on his knees to a garbage can. The Pt opened the door to the front of the garbage can and was looking into the garbage can. The Pt's buttocks was exposed. No staff intervened.
15:02 - Pt #1 crawled across the room, his buttocks were exposed.
15:29 - Pt #1 crawled back towards trash can with paper in his mouth, lays down on the floor, and his front body was fully exposed. There were no staff interventions.
15:37 - Pt #1 was crawling on the floor. RN #2 was observed following the Pt with a wheel chair. The Pt crawled across the room fully exposed. No attempt was made to cover him up.
16:16 - Pt #1 was crawling on his hands and knees, stops in the middle of day room placing his head down, tucking his knees up under himself and covering his head with his hands in an upright fetal position. His buttocks was exposed. The Pt remained on the floor in a fetal position while staff walked around him.
17:31 - Pt #1 crawled across the room to the corner under 4 over-bed tables, his scrotum was exposed.
18:10 - Pt #1 attempted to cover himself with an overbed table. A folding chair that was leaning against the wall fell on Pt #1. There was no observation any staff assisted the Pt or assessed the Pt. LPN #2 was observed at Pt #1's side with a syringe in her hand.
18:15 - Licensed Practical Nurse (LPN) #2 then moved the folding chair that was on Pt #1. The Pt remained on the floor against the wall.
19:03 - Unidentified staff were observed grabbing Pt #1's right wrist, restraining his wrist.
19:05 - Pt #1 was kicking at staff. The Pt was fully exposed.
19:10 - PCA #4 then grabbed Pt #1's left wrist and right elbow restraining him.
19:32 -19:41 - LPN #2 observed bending over Pt #1 but due to staff blocking view, unable to visualize patient receiving the injection. After the injection, all staff walked away from the Pt leaving the Pt alone on floor against the wall. There was no observation any nursing personnel monitored for medication effectiveness or reactions or covered his exposed body.
19:56 - Pt #1 remained on the floor, exposed, and coughing. Staff continued walking away from him, with no attempts to assist the Pt in any way.
20:06 - 20:52 - All staff left Pt #1 on the floor, no staff had visual contact of him, no assessment observed after injection given.
21:35 - Pt #1 remains on the floor and gets up to a kneeling position.
21:44 - PT #1 crawled across the floor towards the nursing station. Pt's buttocks was exposed.
22:09 - Within arm's length of PCA #4, Pt #1 picked an object off floor and placed it in his mouth.
22:26 - Pt #1 continued crawling on floor with buttocks exposed, no staff assists the Pt or intervenes with the Pt.
22:51 - Pt #1 crawling on the floor and fell onto his right side. No staff comes to assess the patient.
23:33 - Pt #1 still lying on floor exposed and in presence of 4 staff members; one puts on gloves and goes to Pt #1, bends over his head, unable to view what staff did to him.
23:41 - Pt #1 still lying on the floor on his side with buttocks exposed.
23:42 - PCA #4 was observed to step around Pt #1, who was on the floor, and PCA #4 does a fist pump.
23:57 - Pt #1 on the floor with buttocks exposed with 4 staff members around him.
24:39 - PCA #4 and #7 observed walking away from the patient, who was still on the floor with buttocks exposed.
26:22 - Pt #1 was still on the floor with buttocks exposed.
27:55 - Pt #1 is observed getting to his knees with buttocks exposed.
28:15 - Pt #1 was observed crawling to a table and picking something up off the floor and placing it in his mouth. PCA #7 and PCA #8 are across the room behind him and do not intervene.
28:29- Pt #1 picked up something from the floor and put it in his mouth. Staff does not intervene. Pt's buttocks was exposed. No observations of staff interventions.
29:06 - Pt was observed crawling towards PCA #7 and PCA #8.
PCA #7 grabbed a box of gloves off the table.
29:19 - PCA #7 was observed taking a chair and blocking the Pt #1 from coming near her.
29:29 - PCA #7 pointed across the room as Pt #1 was using the table in front of him to support him to stand up.
29:32 - Pt #1 pushes the table towards PCA #7 and PCA #8.
29:36 - PCA #7 then shoved the table towards Pt #1, pushing the pt backwards.
29:39 - Pt #1 swings at PCA #7 across the table.
30:44 - Pt #1 was observed crawling around table with buttocks exposed. The Pt was crawling towards PCA #7 and PCA #8.
30:49 - PCA #7 was observed rapidly dodging to another area of the dayroom away from Pt #1.
30:51 - PCA #7 then runs in front of the patient, around him and runs the length of the day room.
30:58 - Pt #1 stands up, with his gown open and falling off. The Pt starts to run towards PCA #7, who had exited the day room. At this point there was one staff member, PCA #8, in the day room with 4 other elderly patients in the day room.
31:09 - PCA #8 leaves the day room and Pt #1 walked across to the doorway where PCA #8 had exited. At this time there were 5 patients in the day room with no staff present.
31:16 - PCA #4 was observed coming into the day room. Pt #1 was standing by a wheel chair. PCA #4 was talking to Pt #1.
31:31 - Pt #1 gets on his knees and begins crawling on the floor.
31:38 - An unidentified female staff member came in the door to the day room. She walks across the room and speaks to another patient sitting in a chair.
31:59 - Pt #1 was observed on the floor on his knees with his buttocks exposed, he throws a towel across the floor at PCA #4.
32:04 - PCA #4 kicks the towel towards Pt #1.
32:05 - Pt #1 picks up the towel and throws it into PCA #4's face. PCA #4 throws the towel at Pt #1 hitting him in the head.
32:10 - Pt #1 swings the towel at PCA #4 and PCA #4 forcibly shoves Pt #1 down on the floor by pushing on his right shoulder.
32:17 - PCA #4 was observed pulling Pt #1 on the floor by his gown.
32:21 - PCA #4 pulled the gown over Pt #1's head but not completely off, leaving him totally naked and exposed. The patient was grabbing at the gown and PCA #4 continued to pull it away from the patient.
32:25 - PCA #4 was observed dragging the pt by the gown to the corner of the dayroom. The patient was totally exposed and naked.
32:34 - The patient is observed to be charging at PCA #4 on his knees.
32:37 - PCA #4 was observed dodging Pt #1.
32:41 - The patient grabbed PCA #4's right leg and then the Pt fell to the floor.
32:44 - PCA #4 was observed to place a knee at patient's head but unable to visualize placement of his knee due to camera placement. The Pt was not able to free himself from PCA #4.
32:51 - Other staff members come in to assist the staff. The Pt is surrounded by staff members. The video recording stops.

There was no documentation of the facility's "Restraint and Intervention and Order Form" which includes: the physician's order, assessment of the patient within 1 hour completed by the RN, a face to face assessment, restraint flowsheet, restraint patient debriefing form, post restraint staff debriefing and a revision to the plan of care in Patient #1's medical record for 1/11/19.

There was no documentation an incident report was completed on 1/11/19 for use of restraints on Patient #1.

In an interview in the conference room on 2/5/19 at 2:10 PM RN #4 stated after viewing the video of the 1/11/19 incident with Patient #1, the staff should have moved Patient #1 back to his room when he became agitated and was laying on the floor. She verified the documentation on the 1/11/19 Patient Observation sheet was incorrect as the patient had been agitated several times throughout the day and should have been documented as such under the Behavior comment code. She also stated there was not a physician order for 1:1 observation for the patient but there was an order for the Pt to be monitored every 15 minutes because of his behavior.

In an interview in the conference room on 2/6/19 at 9:04 AM when asked why Patient #1 was placed on the Senior Care Unit (SCU) instead of the Intellectually Developmental Disabilities (IDD), RN #4 stated that the SCU had been informed by the Intake Officer that the patient was not appropriate for the IDD and was being placed in the SCU. The patient was 27 years old.

In an interview on 2/6/19 at 11:15 AM when questioned why the pt was on the SCU, the Chief Nursing Officer (CNO) stated the decision to place Pt #1 on the SCU was made due the patient needing a medical bed and assistant with Activities of Daily Living (ADLs). She stated the IDD unit had boxed beds (beds placed on cinder blocks and secured to the floor) with no side rail. The CNO stated, " ...since we have mental health we receive patients with behaviors. If needs higher observation they will do 1:1 [1 staff to 1 patient] observation or line of sight observation. 1: 1 means you are right there within arm reach of patient. Line of sight means you are in sight of the patients at all times. Looking at [Name of Pt #1] observation record the staff may have made an error on the sheet for the 1:1. All behavior health is on q 15 minute checks. 1:1 is based on clinical presentation ..."

In an interview in the conference room on 2/6/19 at 1:05 PM the Director of Quality (DOQ) verified the Interdisciplinary team (IDT) treatment plan for Pt #1 was not updated to reflect 1:1 and changes in patient status.

In an interview on 2/6/19 at 9:20 AM when asked about the incident in the dayroom with Patient #1 on 1/11/19 PCA #8 stated, "...I came back from lunch. [Name of PCA #7] told me she needed assistance with [Name of Pt #1]. I looked and he was on the floor. [PCA #7] said she had been trying to get him up. I asked her if he had something in his mouth. He had food, gloves, thermometer probes, paper and popcorn in his mouth. I helped her get it out of his mouth. [RN #2] came in then. I dropped a piece of paper on the floor and [RN #2] and [Pt #1] was reaching for the paper at the same time. He grabbed her by her scrub top and slung her onto the floor. [PCA #7] was holding him and we were trying to pull them (RN #2 and Pt #1]) apart. I put my hand on [RN #2] and [Pt #1] head to pull them apart because he was trying to bite her face. I grabbed the phone and called a Special Duty Code. After everybody responded [Pt #1] was back on the floor crawling around where other patient's had dropped popcorn. He was picking it up and eating it. I tried to make sure [RN #2] was okay. The nurse called the physician, he (Pt #1) had started acting out earlier and had got a PRN (as needed) medication but it didn't work. He got another PRN, the staff was holding him down, he was kicking, and they (staff) got him up and put him in the chair. His response was [RN #2] was picking on him. The other patient's was still in the dayroom. We felt it was safer to take other patients out of the dayroom, so we were taking them out because he was repeatedly acting out. He would swing at the other patient's ..."

When asked if Pt #1 had struck any of the patients in the dayroom PCA #8 stated, " ...no, not that I can recall ...he lay in the floor. I felt like he was going to act up again. [PCA #7] told him to get up and they would go smoke. He crawled toward us, used the table to push us and block us in against the desk. We slid across the desk. I said we needed to call the nurse and call another code ..." when asked if she or PCA #7 shoved the table at Pt #1, she stated, "...no, [Pt #1] just blocked us in ..."

3. Medical record review for Patient #3 revealed an admission date of 12/14/18 with diagnoses of Schizoaffective Disorder. Patient #3 has a past medical history that included Autism, Bipolar disorder, Posttraumatic Stress disorder and Attention deficit hyperactivity disorder.

Observation of the facility video recordings of Patient (Pt) #3 on 1/26/19 revealed the following. The video is not real time, and starts at 0023 and ends 0835. This video was a recording of the hallway at the nurses station on the Intellectual Developmental Disabilities (IDD) unit on 1/26/19: This is the recording of video #1:

0023 - Pt #3 entered the IDD hallway in front of the nurses station wearing pants, a sports bra, glasses, and carrying a shirt.
0026 - Pt #3 entered the nurses station followed by RN #1. Pt #3 picked up an object from the nurse's desk and hit herself in the forehead with the object. There was a Random Patient (RP) #1 standing in the hallway. The facility was unable to identify the RP by name when asked.
0035 - Pt #3 entered an alcove behind the nurses station and was out of view. Registered Nurse (RN) #1 followed the pt and was holding the pt's arm. RN # 3 also followed the pt behind the alcove. The video jumps forward 9 minutes as nothing was recorded during the 9 minute span.

The next observation on video #1 were as below:
0044 - Pt #3, RN #1, RN #3 and Patient Care Assistant (PCA #2) were standing behind the nurses station struggling with the pt. The pt did not have pants on as before when she went behind the alcove.
0046 - Pt #3, RN #1, RN #3 and PCA #2 continued struggling with Pt #3 behind the nurse's station. The pt was only wearing a sports bra and panties at this time and holding her shirt.
0051 - Pt #1 began spitting at the staff. PCA #2 continued struggling with and holding Pt #3 by the neck and shoulders.
0056 - RN #1 and PCA #2 grabbed Pt #3 and pulled her forcibly from behind the nurses station into hallway.
RN #1 began forcibly restraining the pt's arms; There were 2 staff members struggling and forcibly holding the patient. Pt #3's buttocks exposed. There were no staff interventions to calm the patient or de-escalate the patient. There were no observation that CPI techniques were used.
0058 - RN #1 was observed with her hand pressing on Pt #3's neck attempting to restrain pt.
0059 - RN #3 was observed kicking Pt #3's pants from behind the nurses station with her foot.
0100 - Pt #3 continued struggling with staff. PCA #2 grabbed the shirt that was in Pt #3's hand and was pulling and struggling with the pt.
0104 - Pt #3 leaned against wall and RN #1 continued to be forceful with the pt and held onto the pt's bra strap, leaning into the pt against the wall.
0111 - RN #1 still restraining Pt #3 against the wall forcefully.
0126 - PCA #2 walked toward Pt #3. Pt #3 raises her left arm attempting to strike staff. Pt #3 pulled back and restrained by the bra strap by RN #1.
0127 - PCA #2 placed her hand on Pt #3's left shoulder. RN #1 continued to push Pt #3 back against wall.
0131 - Pt #3 spit at the staff.
0132 - PCA #2 grabbed Pt #3 by the jaw, and pushed Pt #3's head forcibly sideways against the wall.
0133 - PCA #2 then began holding Pt #3's right lower arm and while she had her hand over Pt #3's lower jaw and mouth. RN #1 was still restraining Pt #3 by her bra strap and holding the pt's Left arm over her head. The pt was struggling with the staff.
0134 - RN #1 grabbed Pt #3's left arm forcibly pulling it back against the wall. PCA #2 was holding the Pt #3's right lower arm and continued to have hand over Pt #3's lower jaw and mouth.
0138 - PCA #3 entered the hallway. RN #1 was then observed pulling Pt #3's head backwards and covering Pt #3's jaw and mouth. The RN was also using her body to restrain Pt #1. PCA #2 was forcibly holding Pt #3's arm. The pt was observed struggling attempting to free herself from the staff.

The next video #1 observations revealed:
0144 - 0146 - Pt #3 was observed fallen to the floor. The pt. then was observed sitting on the floor with her legs crossed.
0147 - PCA #2 released Pt. #3's arm. RN #1 continued holding the pt. by the bra strap and right hand. The RN was aggressively pressing her body against the pt's body.
0149 - RN #1 was observed to forcibly push Pt #3 from a sitting position to a lying position on the floor.
0150 - RN #1 falls to the floor beside Pt #3 placing her arm on the pt's back.
0152 - RN #1 was observed pressing on the back area of Pt #3.

Based on policy review, medical record review, video recording review and interview, the facility failed to ensure a culture of safety was implemented and ensure all staff were knowledgeable of their policy for using restraints and staff applied restraint usage as a last alternative and in a way to minimize the risk of harm to patients for 2 of 2 (Patient #1 and 3) sampled patients restrained while hospitalized.

The failure of the hospital to ensure all staff utilized less restrictive measures before physically restraining patients, and ensure when staff used physical restraining methods those methods were used appropriately with the intention of reducing physical or psychological harm to patients placed all patients in a SERIOUS AND IMMEDIATE THREAT of psychological and physical harm. The failure of the hospital to provide sufficient education and monitoring of staff's interactions with patients placed all patients at risk for an IMMEDIATE JEOPARDY for physical and psychological harm, or potential serious injuries and/or death which is ongoing.

The findings included:

1. Review of the facility's "Restraints" policy revised on 8/2018 revealed, "...PURPOSE: It is the intent of [Hospital's name] to support the limited use of restraints through the development and promotion of preventative strategies and to use safe and effective alternatives that prevent injury to patients and others, to prevent disruption of medical services, or significant property damage.

The establishment of these guidelines supports the use of the least restrictive and most protective measures that will limit the use of restraints to those situations with appropriate adequate justification while preserving the rights, dignity, and well-being of the patient...DEFINITIONS:Physical restraint: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...Violent Self-destructive, (VSD):

Restraints used in emergency situations in which there is imminent and intentional risk of an individual physically harming him/herself, staff...Physical Holding for Forced Medication: The application of force to physically hold a patient in order to administer a medication against patient wishes is considered restraint. The patient has a right to refuse medications, but in certain emergency circumstances, patients may be medicated...PROCEDURE:VIOLENT SELF DESTRUCTIVE 1. Least Restrictive Measures:

Prior to use of restraint, effort will be made to use an alternative method that is less restrictive. Such alternatives may include:
Trigger Reduction and Elimination- limit or remove events, objects, or situations that may "set off' the problem behavior when possible...Verbal De-escalation - Allowing the patient to verbalize angry feelings and otherwise de-escalating the patient...3. If an emergency situation (risk of harm to patient or others), does not allow adequate time for the physician's order to be obtained, a registered nurse may initiate application for restraint.

As soon as possible after initiation of the restraint being initiated, a physician should be contacted to obtain an order for the action that was taken...The nurse-initiating the restraint is to obtain the order from the physician, or authorized LIP as soon as the possible after the restraint is initiated...face to face evaluation by a physician or a trained nurse, must be completed within one (1) hour for any time spent in restraint, even if the patient recovers quickly from an aggressive/violent episode and is released early...Documentation requirements:
1. Restraint Intervention & Orders Form
a. The Physician order meets the requirements as previously delineated. An assessment of patient's dangerous behavior(s) for clinical justification necessitating the use of restraints. The least restrictive interventions attempted. The type of restraint used.
Patient education regarding the reason for restraints,"Step Down" procedure, expected behavior required for release, and the patient's level of understanding. Notification and education of the family/significant other when appropriate. Restraint Face to Face Assessment...Restraint Flowsheet...Restraint Patient Debriefing Form...Post Restraint Staff Debriefing 6. Treatment Plan Creation or Revision...III. Plan of Care/Treatment Plan:The use of restraint (including chemical restraint) will be documented in the patient's plan of care/treatment plan. The use of restraint constitutes a change in a patient's plan of care based on an assessment and evaluation of the patient. PRN (as needed) orders for restraint are not allowed....Physical Holding for Forced Medication: The application of force to physically hold a patient in order to administer a medication against patient wishes is considered restraint. The patient has a right to refuse medications, but in certain emergency circumstances, patients may be medicated

In certain circumstances, a patient may consent to an injection or procedure, but may not be able to hold still for an injection, or cooperate with a procedure. In such circumstances, and at the patient's request, staff may "hold" the patient in order to safely administer an injection or to conduct a procedure. This is NOT considered a restraint."

2. Medical record review for Patient (Pt) #1 revealed an admission date of 1/10/19 with diagnoses of Schizophrenia with homicidal ideation and psychosis, Cerebral Palsy with difficulty ambulating, Asthma, Seizure disorder, Hypothyroidism and Gastroesophageal Reflux Disease. His chief admitting complaint was "hearing voices."

Review of Patient #1's Psychiatric Evaluation dated 1/10/19 revealed, " ...Pt is a 27 year old White Male (WM) admitted with increased paranoia, anxiety, and AH+. States that he hear voices that tell him to hurt himself and others. Impulsive behavior. Refusing meds and care. Unable to function ...Prognosis: Guarded. Justification for Hospitalization: Inpatient ...Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment, Emotional or behavioral conditions an complications requiring 24 hour medical and nursing care, Need for ECT [Electro-convulsive Therapy], special drug therapy, or other therapeutic program requiring continuous hospitalization, Failure of social or occupational functioning, Inability to meet basic life and health needs ..." There was no documentation in the patient's medical record the patient experienced PICA (Psychological disorder characterized by craving and eating substances with no nutritional value, such as dirt, hair, ice, paper, metal stones, and glass).

On 2/6/19, upon surveyor request, the Risk Manager provided a copy of a video recording of an incident involving Patient #1 in the Senior Care Day Room. The video recording was not timed or dated. The Risk Manager stated the video recording was for the date 1/11/19. The video recording started at 00:00 and ended at 40:22.
Review of the video for Patient (Pt) #1 revealed the following:

04:04 - RN #2 was observed standing in front of Pt #1. The patient was on his knees, and crawling around on the dayroom floor.
04:06 - Pt #1 was observed with multiple articles in his mouth as he was crawling on the floor. RN #2 reached to take the items out of Pt #1's mouth. Pt #1 then swung his arm/fist at the RN. Patient Care Assistant (PCA) #7 the reached to grab the pt.
04:08 - 04:10 - PCA #7 continued grabbing at Pt #1's right arm. The PCA forcibly pulled on the pt's arm causing him to twirl around and landing on the floor. The pt. was holding onto RN #2's uniform. The PCA's force of pulling the pt downward caused RN #2 to also fall to the floor.
04:14 - 04:25 - PCA #7 released the pt and was pulling on RN #2 to get her out of the grips of Pt #1.
PCA #7 was observed grabbing Pt #1's left upper arm, pressing her hip onto Pt #1's lower back area and holding the pt's left upper arm with her hand in a restraining motion. RN #2 was observed beside the pt on the floor.
04:43 - 05:19 - PCA #7 was observed still pressing her body on top of Pt #1, restraining him on the floor, holding both his forearms down. Pt #1's face is pressed to floor. Pt's buttocks is exposed. Other patients are observed in the dayroom during this incident.
06:00 - PCA #7 was observed releasing Pt #1.
06:11 - Staff assisted RN #2 to a standing position, and leave Pt #1 lying on the floor. At this time there are eight staff members standing around Pt as he continued lying on the floor. No assistance has yet to be offered to the pt.
06:44 - Staff assist Pt #1 to a wheelchair. The pt was holding his left upper arm with his right hand. The eight staff members were in a circle around him. There were no further observations of restraint usage at this time.

There was no observations on the video recording the staff attempted to use alternative least restrictive measures before forcibly applying restraints. There was no observations the staff had attempted to redirect the pt before forcibly applying restraints. There was no observation the staff had been directly observing the patient using the physician ordered 1:1 technique (a visual line of sight by one (1) staff member and the pt.)

In an interview in the conference room on 2/5/19 at 4:10 PM when questioned about the incident LPN #2 stated, "There was already a code [a call for assistance] on him [Patient #1]. He was on the floor close to the door. The male tech had his arms and the female had his legs. He was crying and stated he was sorry. Sometimes he could be redirected. He was a big guy, so have to call a code. Staff was in the room, [PCA #8] had him by the legs, [PCA #4] had an arm, and we called the doctor for med. Usually gave Haldol 5 mg and 1 mg Ativan IM... First couple of days he was aggressive...He doesn't like guys to 1:1 him, he wants women."

In an interview on 2/6/19 at 11:38 AM via telephone when questioned about the incident PCA #4 stated, "That day, I was coming from lunch break and told to go to the Day Room. I see she was having problems with behaviors. [Patient #1] was talking but not talking. He dropped to his knees - other patients were there, he was running around. I tried to block him. I'm the only guy on shift. He had already broke nurses' hand [there was no documentation of evidence of this]. He [Pt #1] was on the ground, he was biting, and kicking and we were trying to hold him down. There was me and nurses and 2 others. I was in front. They [facility] said I kneed him, I was in front holding his hands. If I had been doing something wrong, they would have stopped me. I've had CPI [Crisis Prevention Intervention] training, I know to be calm or defuse before physical, if physical, protect yourself. He dropped down on his knees, he made no threatening moves to the patients. He threw a wet gown in my face...I don't know if it had pee on it. I gave it back to him. That was my day off, I came in to help them ..."

In an interview in the conference room on 2/6/19 at 8:52 AM when questioned about the incident with Pt #1 PCA #7 stated, "He [Patient #1] started crawling on floor putting things in his mouth. When I tried to get stuff out of his mouth he would kneel and hide his mouth. He was not my assignment. He started crawling under the table. [name of RN #2] came over. [name of PCA #8] came in and she went to get gloves. The patient was on his knees and [name of PCA #8] was getting stuff out of his mouth. He [Pt #1] stood up [was in an upright position] on his knees...he started swinging at [name of RN #2]...He slung her to the ground...tried to bite her face...called code when everybody came he calmed down. We tried to clear pts out of the way. He was laying on the floor and I thought he was calm. I asked him did he want to smoke. [name of PCA #8] and I were behind the table and he started pushing it at us, clocking us in. I was holding the table, I was just holding the table trying to keep him from getting me. There's only so much we can do, he took his diaper off. I don't remember taking the table and shoving it."

In an interview in the conference room on 2/6/19 at 9:48 AM when questioned about the incident with Pt #1 RN #2 stated, "I was called to day room by [name of PCA #7]...got to the day room and [Patient #1] had a lot of stuff in his mouth, probes, paper...he was uncooperative and combative. [PCA #8] was on his right side and I was on the left. [PCA #8] got stuff out of his mouth and some dropped on the floor. I reached to the floor to get it and he [Patient #1] grabbed me by my uniform and because I was bending down, my balance was off and I fell to floor with him. He was yelling and trying to bite me, growling and making biting motions. My head was pressed to his head to prevent him biting me. I held him until SD [Special Duty, the group called in to assist with a code] got there. I released him... he was still on floor picking things off floor. We were trying to get folks out of day room too. The way he was acting it was not safe to get him out. He wasn't harmful to other patients but his bizarre actions...we did not know. He was crawling so fast. It was best to remove everybody else. He was crawling and moving but not at anyone. Someone else gave him meds ...He was saying "You hurt me" ...He was 1:1 after the incident. He was not my assignment ..."


3. Medical record review for Patient #3 revealed an admission date of 12/14/18 with diagnoses of Schizoaffective Disorder. Patient #3 had a past medical history that included Autism, Bipolar disorder, Posttraumatic Stress disorder and Attention deficit hyperactivity disorder.

Observation of the facility video recordings of Patient (Pt) #3 on 1/26/19 revealed the following. The video is not real time, and starts at 0023 and ends 0835. This video was a recording of the hallway at the nurses station on the Intellectual Developmental Disabilities (IDD) unit on 1/26/19: This is the recording of video #1:

0023 - Pt #3 entered the IDD hallway in front of the nurses station wearing pants, a sports bra, glasses, and carrying a shirt.
0026 - Pt #3 entered the nurses station followed by RN #1. Pt #3 picked up an object from the nurse's desk and hit herself in the forehead with the object. There was a Random Patient (RP) #1 standing in the hallway. The facility was unable to identify the RP by name when asked.
0035 - Pt #3 entered an alcove behind the nurses station and was out of view. Registered Nurse (RN) #1 followed the pt and was holding the pt's arm. RN # 3 also followed the pt behind the alcove. The video jumps forward 9 minutes as nothing was recorded during the 9 minute span.

The next observation on video #1 were as below:
0044 - Pt #3, RN #1, RN #3 and Patient Care Assistant (PCA #2) were standing behind the nurses station struggling with the pt. The pt did not have pants on as before when she went behind the alcove.
0046 - Pt #3, RN #1, RN #3 and PCA #2 continued struggling with Pt #3 behind the nurse's station. The pt was only wearing a sports bra and panties at this time and holding her shirt.
0051 - Pt #1 began spitting at the staff. PCA #2 continued struggling with and holding Pt #3 by the neck and shoulders.
0056 - RN #1 and PCA #2 grabbed Pt #3 and pulled her forcibly from behind the nurses station into hallway.
RN #1 began forcibly restraining the pt's arms; There were 2 staff members struggling and forcibly holding the patient. Pt #3's buttocks exposed. There were no staff interventions to calm the patient or de-escalate the patient. There were no observation that CPI techniques were used.
0058 - RN #1 was observed with her hand pressing on Pt #3's neck attempting to restrain pt.
0059 - RN #3 was observed kicking Pt #3's pants from behind the nurses station with her foot.
0100 - Pt #3 continued struggling with staff. PCA #2 grabbed the shirt that was in Pt #3's hand and was pulling and struggling with the pt.
0104 - Pt #3 leaned against wall and RN #1 continued to be forceful with the pt and held onto the pt's bra strap, leaning into the pt against the wall.
0111 - RN #1 still restraining Pt #3 against the wall forcefully.
0126 - PCA #2 walked toward Pt #3. Pt #3 raises her left arm attempting to strike staff. Pt #3 pulled back and restrained by the bra strap by RN #1.
0127 - PCA #2 placed her hand on Pt #3's left shoulder. RN #1 continued to push Pt #3 back against wall.
0131 - Pt #3 spit at the staff.
0132 - PCA #2 grabbed Pt #3 by the jaw, and pushed Pt #3's head forcibly sideways against the wall.
0133 - PCA #2 then began holding Pt #3's right lower arm and while she had her hand over Pt #3's lower jaw and mouth. RN #1 was still restraining Pt #3 by her bra strap and holding the pt's Left arm over her head. The pt was struggling with the staff.
0134 - RN #1 grabbed Pt #3's left arm forcibly pulling it back against the wall. PCA #2 was holding the Pt #3's right lower arm and continued to have hand over Pt #3's lower jaw and mouth.
0138 - PCA #3 entered the hallway. RN #1 was then observed pulling Pt #3's head backwards and covering Pt #3's jaw and mouth. The RN was also using her body to restrain Pt #1. PCA #2 was forcibly holding Pt #3's arm. The pt was observed struggling attempting to free herself from the staff.

The next video #1 observations revealed:
0144 - 0146 - Pt #3 was observed fallen to the floor. The pt. then was observed sitting on the floor with her legs crossed.
0147 - PCA #2 released Pt. #3's arm. RN #1 continued holding the pt. by the bra strap and right hand. The RN was aggressively pressing her body against the pt's body.
0149 - RN #1 was observed to forcibly push Pt #3 from a sitting position to a lying position on the floor.
0150 - RN #1 falls to the floor beside Pt #3 placing her arm on the pt's back.
0152 - RN #1 was observed pressing on the back area of Pt #3. PCA #3 was observed attempting to grab Pt #3 by the legs. Pt #3 was observed kicking her legs and struggling.
0153 - Pt #3 attempted to stand up and PCA #3 was observed placing her hand on the pt's head and pushing her back down on to the floor. Pt #3 was observed kicking at staff and struggling.
0155 - 0157 - RN #1 attempting to stand, Pt #3 being restrained by PCA #2 and PCA #3. Pt #3 kicking and struggling.

Next on the video #1:
0158 - RN #1 grabbed Pt #3 by the leg and pushed her legs back. The pt continued to struggle.
0209 - 0213 - RN #1 was then observed on her knees beside Pt #3 holding the pt's right wrist and right upper shoulder with her knee on pt's right upper arm restraining her. RN #1 was pressing her body weight in to the pt's right upper arm. PCA #2 holding the pt's left leg and PCA #3 holding the pt's left arm.
0222- RN #1 places her right knee on Pt #3's right upper arm. Pt #3 continued struggling and attempted to get up.
0224 - Pt #3 was observed lying on floor on her right side being restrained by 3 staff.
0225 - RN #1 was observed leaning over Pt. #3 with her body pressing into the pt. RN #1 then placed her face on the pt's left upper arm and appeared to be biting the patient. When RN #1 raised her head from the pt's upper arm area there was a crescent-shaped red mark on the pt's upper arm area where RN #1's face had been.
0228 - Pt #3 was observed struggling. The staff continued holding the pt down by the arms and legs.
0232 - 0235 - RN #1 was observed with her right elbow and forearm pressing with her body weight into the neck of Pt #3. Pt. #3's neck and head were hyperextended restraining pt. The pt. appeared to be in distress.
0241 - 0307 - Pt #3 began struggling, her mouth was open, and her eyes were wide-eyed. RN #1 continued pressing forcibly with her right elbow and forearm on Pt #3's neck. The RN was using her body weight to push against the pt's neck.
RN #1 continued pressing her right elbow and forearm on Pt #3's neck.
PCA #3 was observed holding the pt's left hand and the PCA's foot was under the pt's head. There was no observations of any interventions from other staff to assist the pt.
0321 - Pt #3 remains restrained by staff. Pt. continues struggling. RN #1 continues pressing her elbow and forearm into the pt's neck.
0329 - RN #1 places right forearm under Pt #3's throat
0334 - 0349 - Pt #3 laying on the floor on her back, RN #1 has right forearm on Pt #3's neck. PCA #3 holding pt's left wrist and arm. Pt #3's mouth open, appears to be in distress.
The RN continued to use her body weight to press in to the neck of the pt.
0357 - 0404 - Pt #3 laying on the floor on her back struggling with staff. RN #1 has right forearm on Pt #3's neck and shoulders. PCA #3 holding pt's left wrist. Staff were observed laughing.
0409 - 0443 - Pt #3 still being restrained by staff. Pt continued struggling, wiggling. The pt was unable to free herself from the staff.
0443 - LPN #1 removed Pt #3's glasses and placed them at the nurses station.
0448 - Pt #3 still being restrained by staff. Pt continued struggling, wiggling.
0453 - PCA #3 released the pt's arm and was standing above pt with the pt's left arm between her legs.
0458 PCA #3 grabs pt's wrist bending the wrist down.
0511 - PCA #3 was then observed with her right knee pressing against Pt #3's neck,
0515 - Pt #3 still laying on the floor on her back. RN #1 again presses her elbow on Pt #3's neck. The pt again begins to struggle.
0533 - PCA #5 was holding Pt #3's hand.
0542 - Pt #3 continued laying on her back. PCA #5 continued talking to the pt.
RN #1 began holding Pt #3's right arm flat on the floor, holding her by the wrist with her elbow continued pressing in the pt's neck restraining the pt. Pt's right arm that was being restrined by RN #1 appears mottled in color. Pt #3 was now observed crying.
0552 - RN #1 was observed on her knees with her hand pressed down on Pt #3's right wrist restraining pt.
0554 - Pt #3 began kicking at staff and struggling. PCA #3 began holding the pt's leg and ankles down. PCA #5 holding pt's right wrist.
0559 - RN #1 uses her right arm on the pt's right mid abdomen pushes to stand up.
0601 - RN #1 was observed standing over Pt #3 with both her thumbs pressing into the pt's right wrist.
0603 - RN #1 jerks pt's right arm up holding to pt's wrist.
0606 - RN #1 was observed releasing the pt's wrist. PCA #3 was observed holding the pt's right leg and PCA #5 was holding the pt's left wrist.
Pt #3 was crying and covering her eyes with right hand.
0610 - RN #1 walked away from Pt #3.
0613 - PCA #3 released the pt. PCA #3 holding the pt's right wrist and PCA #5 holding the pt's left wrist
0620 - PCA #5 holding pt's wrist talking to her. It appears PCA #5 was attempting to deescalate the pt.
0642 - Pt #3 kicking, PCA #5 holding the pt's right ankle and left wrist.
0656 - Pt #3 kicked her foot against PCA #3.
0700 - PCA #3 grabbed Pt #3's right wrist and bent it downward hyperflexes the wrist.
0708 - Pt #3 remains on the floor and restrained by staff.
0721 - RN #1 walks back towards the pt. and attempted to place a face shield on the pt. The pt. struggled and removed the face shield.
0729 - PCA #3 and #5 restraining pt. staff were observed standing over the pt. and laughing.
0731 - 0742 - PCA #5 restraining pt.
0745 - PCA #5 then restrained both hands of the pt. The pt is still lying on the floor.
0753 - Pt #3 remains restrained on floor by staff. PCA #3pulling on pt's right wrist
0755- PCA #5 holding pt's left forearm. LPN #1 walks around to pt's feet and grabs left ankle and placed her right hand at the bend of left knee and forces it down. Pt's head comes off the floor.
0803 - RN #1 attempts to place face shield on Pt #3.
0806 _ PCA #6 enters hallway.
0814 - Pt #3 removes face shield, PCA #6 grabs pt's right wrist
0821 - PCA #5 and #6 were observed restraining the pt by her arms and legs. The pt still remained on the floor struggling.
0834 - Pt #3 remained restrained on the floor by PCA # 5 and PCA #6.
End of video #1.

These are the observations of the recording of Video #2. This recording occurred in the hallway of the IDD unit as well:
0001 - RN #1 was standing in the hallway. Pt #3 was not in view.
0016 - 0021 - Pt #3 was observed on the floor laying on her back, being dragged around the corner and down the hallway. PCA #5 was holding the pt's left arm extended upwards, and PCA #6 was holding the pt's right arm. PCA #2 was holding pt's left leg upwards and PCA #3 was holding the pt's right leg. They were dragging the pt down the hallway.
Pt was struggling with the staff. Pt buttocks was exposed. RN #1 was observed standing against the opposite wall smiling.
0023 - Pt #3 was struggling with staff.
PCA #3 dropped the pt's leg on floor. RN #1 and PCA #3 were observed laughing.
0024 -0029 - Pt #3 was kicking at staff, and struggling. PCA #3, 5, and 6 were restraining the pt.
RN #1, LPN #1, PCA #3 and a physician were observed standing off to side watching.
0033 - 0037 - PCA #3 grabbed Pt #3 by the hair, jerked her head upwards, and holding Pt #3 by the hair, pulled the pt down the hallway.
LPN #1, PCA # 2, PCA #5 and PCA #6 were observed pulling the pt by her arms and legs down the hallway.
0038 - Pt #3 was observed lying on her back on the hallway floor.
LPN #1, PCA # 2, PCA #3, PCA #5 and PCA #6 continued restraining the pt and pulling the pt down the hallway. Pt #3's breast and buttocks exposed.
0042 - Pt #3 has been dragged down the hallway and out view of the video recording. And staff out of camera range.
RN #1 was observed walking into another patient's room. Physician walked down the hallway. Video ends.

The record for Patient #3 revealed there was no physician order for a restraint to include the clinical justification for each episode of restraint, a time limit to include a start and end date and time and the type(s) of restraint to be applied on 1/26/19. There was no documentation a physician had been notified the patient had been restrained on 1/26/19.

There was no documentation of the facility's "Restraint and Intervention and Order Form" which includes: the physician's order, assessment of the patient within 1 hour completed by the RN, a face to face assessment, restraint flowsheet, restraint patient debriefing form, post restraint staff debriefing and a revision to the plan of care in Patient #3's medical record on 1/26/19.

There was no documentation an incident report was completed on 1/26/19 for use of restraints on Patient #3.

In an interview on 2/5/19 at 2:52 PM with PCA #5 when asked about the incident with Pt #3 the PCA stated, " ...I came in when they called Special Duty ...When I got there (Pt #3) was on the floor. I told them (other staff) to let her get calm. Ask (RN #1) if she (Pt #3) could stay on the floor until she calmed down. (Name of RN #1) said we are going to get her down to her room. When I got so far I let her go of her and talked to her to get her to calm down. I did see (RN #1) pulling her hair. I asked (RN #1) to let her (Pt #3) go. I moved her (Pt #3) away from the nurses desk, she had been trying to get objects off the desk to cut herself. I kept trying to redirect her. (Name of Nurse #1) had told us to pick her up and take her to her room. After pulling her (Pt #3) so far, I stopped and told (RN #1) I wasn't going to do it anymore. I knew it wasn't right and that's why I stopped ..."

In a telephone interview with RN #1 on 2/8/19 at 5:38 PM , RN #1 stated she was returning my telephone call. I asked her to please explain the events that occurred with Pt #3. She stated, "We thought we were about the get off. The person who was doing 1:1 with Pt #3 left at 3:00 PM. I took over. I had her in view at the desk. A doctor came up wanting report on a patient [this doctor was viewed on the video as a short gray haired female in a lab coat]. I was standing with Pt #3 and asked her to step away so I could talk to (Name of physician). Pt #3 started pacing and saying, "I'm really anxious, I'm angry". She took her shirt off and stated, "I'm going to kill myself." She tore the bottom of the shirt off and put it around her neck and started to tighten it. I stuck my hand in it to stop her from tightening it. PCA #2 took it from her. She started pacing again. Then she went into the nurses station and picked up a pen and motioned like she was going to stab herself in the head. (Name of physician) asked me, "Can you handle her?" She had been agitated for about 2 and a half hours, I had 5 incident reports on her. We were subduing her from self -harm behavior. She wanted to call her dad."

The surveyor asked RN #1 about the incident involving struggling with the pt to the floor take in front of the nurse's station and RN #1 stated, "When she was beating her head against the wall, one tech went to get 3 men from MH [mental health]...she bit me...hit me multiple times. She even pushed the other nurse down. It got so bad I just told her to hit me...I was never any intent to hurt (Name of Pt. #3). I did not want her to hurt herself and I did not want her to hurt us. So we was just like holding her down, holding her down. The next thing I knew I was being called and told I was terminated."

The surveyor asked RN #1 if it was appropriate to drag Pt #3 down the hallway and RN #1 stated, "Number one, no. When (name of PCA #5) came, a tall man and (Name of PCA #6), I went to the nurse's station. I'm going to tell you, I'm an older woman it takes a lot for me to try to wrestle with someone to keep them from hurting themselves. I sat at the desk and said, 'Lord we got to document all this'. When they said (Name of RN #1) you dragged her down the hall by her hair, I said I swear I didn't. I wasn't even with there, I know I wasn't cause I was tired. I remember them saying they were going to pull her to her room and I said No. I remember saying this, you don't have to do this, she will stand up, come on (Name of Pt #3), get up. She did get up and made it around that corner, then she laid on the floor and started kicking and hitting and they said just let her lay here until she gets tired. That was in the hallway by the room doors. I never went to the room with her and I was still 1:1 with her; I was trying to catch my breath. Every time they let her go, she would come back to the desk and try to fight. When they finally got her in the room and settled, I got the clip board and said it's fixing to be 7:00 it's time for us to go, I got to get this board caught up for the next shift. I went into that room and anybody could tell you they could hear me screaming, 'Help Help" She was like, 'I got your now you M F'er' ... (Name of PCA #3) came in the room; she's the one that talked her down. PCA #3 the one that filled out the clip board cause I was just trying to keep her from hitting my face. I ran down to another room and even grabbed a patient into the room with me. She was in full attack mode. All I wanted to keep everyone safe. They [referring to Administration] said, you put your arm on her neck. I can't remember that, all I could think is we gotta protect her but we got protect ourselves. All I wanted to do was hold her down until somebody came."

RN #1 then stated, "They terminated me for excessive force because I put my arm on her neck. I asked them in the mist of her fighting so how was I at that moment supposed to know at that moment where my arm was, she's a big girl. I've been a nurse for 26 years ..."

The surveyor asked RN #1 how Pt #3's pants came off and RN #1 stated, "She took her pants off and peed, oh excuse me, I mean she urinated at the nurses station ... one of us took each arm and one was holding her body and took her down to the ground, we tried to sit her down, she rolled to her side and we just started to lay across her, she was in a rage, she had been escalating all week, but never 2 and half hours.. We gave her 2 PRN's [medications as needed]. We used a restraint chair. We don't use it for our ID patients, but we restrained her that night. I gave her Ativan 2mg and 50 mg Thorazine. The second time she went between 6-7, she got 50 mg Benadryl 50 mg, Thorazine and 1 mg Ativan, this was the second PRN. She was still raging saying 'kill kill' and beating doors."

RN #1 went on to say, "We did 5 incidents and restraint reports that night. During 2 and half hours, we and Special Duty codes. No one came until my tech went to get him and Security continued to call Special Code even after she was in the restraint chair which mean

Based on facility policy, medical record review and interview, the facility failed to ensure a Registered Nurse (RN) supervised care to all patients.

The failure to supervise resulted in a lack of intervention to protect Patient #1 and Patient #3 from restraint /seclusion that resulted in abuse/neglect constituting a SERIOUS AND IMMEDIATE THREAT to the health and safety of the patients.

The findings included:

1. The Registered Nurse (RN) failed to provide supervision and evaluation to ensure adequate monitoring was initiated and complete for Patient #1 and #3 while receiving one-to-one (1:1) observation every(q) 15 minutes.
Refer to A 395

2. The facility failed to ensure the nursing staff developed and/or revised a nursing plan of care to address Patient #1 and #2's behaviors such as aggression and the use of restraint /seclusion.
Refer to A396

Based on policy review, medical record review and interview the facility failed to ensure the facility staff implemented physician's orders to monitor every (q) 15 minutes and/or receive one-to-one (1:1) observation for 2 of 2 (Patient #1 and 3) sampled patients were receiving care for behavioral issues with the potential to harm him/herself or others.

The failure of the hospital to ensure all staff fully implemented physician's order and document behaviors placed all patients in a SERIOUS AND IMMEDIATE THREAT of psychological and physical harm. The failure of the hospital to implement physician's orders placed all patients at risk for an IMMEDIATE JEOPARDY for physical and psychological harm, or potential serious injuries an/or death which is ongoing.

The findings included:

1. Review of the facility policy "15 Minute Checks and 1:1 Observation" revealed "... PURPOSE: To establish guidelines for the treatment team to accurately and consistently assess the patient and to establish appropriate actions toward preventing the patient from self-harm behaviors ...Observation...The patient will be evaluated by an Registered Nurse (RN) or Medical Doctor) M.D. to be an immediate risk to self or others (including fall precautions )...A staff member will be assigned to stay within arm's reach of the patient at all times while on a one staff to 1one patient (1:1) status, and the attending physician or his/her designee will be notified by the RN of the patient's condition. If the R.N. determines that for staff safety, (i.e. due to patient aggression) the staff member assigned to the 1:1 should be more than arm's reach, that will be discussed with the physician and documented in the progress notes. However, the staff member should be able to directly see and hear the patient at all times...1:1 Observation may be initiated by an RN. The physician must be notified as soon as possible...The attending physician will be accountable for denoting whether the precautions are to be renewed or discontinued. The physician may also choose to change the level of supervision if the patient's condition warrants.... Hazardous patient belongings (i.e. razors, metal objects, aerosol sprays, but not limited to) are not permitted for patient use...The patient will be placed in a room as close to the nurses station as possible...On the 11:00 p.m. to 7:00 a.m./7:00 p.m. to 7:00 a.m. shift, the Charge RN will complete two sets of patient checks-one at the beginning of the shift and one at the end of the shift. The Nurse will document this on the Activity Record. Exception: On the Dual Diagnosis Unit, the RN will complete checks at midnight, 3:00 a.m., and 5:00 a.m. at a minimum...The staff member assigned to the 1:1 will document patient checks every 15- minute on the 1:1 Observation Flow Sheet as well as the Patient Activity Record. Respirations will be counted every hour while asleep and will be documented in the "Respirations" section of the Patient Activity Record. Any number < 16 or > 20, or any concern about a patient's health, will be reported to the Nurse ASAP. I. Every two hours, the staff member performing the 1:1 will be relieved by another staff member on the floor for a period of approximately 15 minutes, during which time he/she will assume the duties of the relieving staff member (e.g., 15-minute checks, vital signs, etc·.) ...Line of Sight Observation. This would indicate that the patient is to be in staff eyesight at all times. This is not an indication for an additional staff member, but that the patient is not allowed in a room without staff present - all other areas should already be staff supervised at all times. It can be just during waking hours, but if not it would mean that the staff member would have to sit in the doorway of the patient at night ...Documentation ...Activity Record .B. Interdisciplinary Progress Notes ...Nursing Daily Re-assessment...1:1 Observation Flow Sheet ... POLICY STATEMENT: Any patient who verbalizes ideations involving thoughts of self¿ harm or suicide, thoughts of harming others, or other self-harm behaviors (i.e., falls) will be placed on either 15 minute assessment and documentation or 1:1 Observation (staff member constantly with the patient not more than an arm's length away and documents at 15 minute intervals) depending on the intensity of the thoughts and feelings or behaviors..."

2. Medical record review for Patient (Pt) #1 revealed an admission date of 1/10/19 with diagnoses of Schizophrenia with homicidal ideation and psychosis, Cerebral Palsy with difficulty ambulating, Asthma, Seizure disorder, Hypothyroidism and Gastroesophageal Reflux Disease. His chief admitting complaint was "hearing voices."

Review of Patient #1's Psychiatric Evaluation dated 1/10/19 revealed, " ...Pt is a 27 year old White Male (WM) admitted with increased paranoia, anxiety, and AH+. States that he hear voices that tell him to hurt himself and others. Impulsive behavior. Refusing meds and care. Unable to function ...Prognosis: Guarded. Justification for Hospitalization: Inpatient ...Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment, Emotional or behavioral conditions an complications requiring 24 hour medical and nursing care, Need for ECT [Electro-convulsive Therapy], special drug therapy, or other therapeutic program requiring continuous hospitalization, Failure of social or occupational functioning, Inability to meet basic life and health needs ..." There was no documentation in the patient's medical record the patient experienced PICA (Psychological disorder characterized by craving and eating substances with no nutritional value, such as dirt, hair, ice, paper, metal stones, and glass).

Review of a physician order dated 1/10/19 at 3:22 PM revealed Patient #1 was to receive every 15 minute checks with line of sight monitoring. There was no documentation of an incident that precipitated the order for every 15 minute checks and for the patient to be in line of sight.

Review of the Patient Observation sheet dated 1/11/19 revealed no documentation the patient was agitated throughout the day between 12:00 AM to 11:45 PM. Under the "Behavior Comment Codes" the staff documented "#1" indicating the patient was calm.

There was no documentation of every 15 minute checks or behaviors in the "Behavior Comment Codes" section on 1/11/19 from 3:15 PM through 4:45 PM and 6:00 PM through 6:30 PM.

In an interview in the conference room on 2/5/19 at 2:10 PM, RN #4 verified the documentation on the 1/11/19 Patient Observation sheet was incorrect because the patient had been agitated several times throughout the day. RN #4 further verified agitated behaviors should have been documented under the Behavior comment code. RN #4 verified Patient Care Assistant (PCA) #1 failed to document Patient #1's behaviors on 1/11/19, between the hours of 3:15 PM and 4:45 PM as well as between the hours of 6:00 PM and 6:30 PM. There was no documentation of every (q) 15 minute checks.

In an interview in the conference room on 2/5/19 at 2:40 PM, RN #4 verified there was no physician's order for 1:1 observation for the patient.Registered Nurse (RN) #4 stated Pt #1 was being monitored q 15 minutes because of his behavior.

3. Medical record review for Patient #3 revealed an admission dated of 12/14/18 with diagnoses of Schizoaffective Disorder. Patient #3 has a past medical history that included Autism, Bipolar disorder, Posttraumatic Stress disorder and Attention deficit hyperactivity disorder.

Review of physician orders revealed:
On 12/15/18 at 12:23 AM: 1:1 observation, Frequency: once. There was no documentation in the medical record what type of behaviors the patient experienced. The Risk Manager was unable to clarify what this order meant when questioned by the surveyors.

On 12/15/18 at 2:14 PM: 1:1 observation, Frequency: once every 8 hours. There was no documentation in the medical record what type of behaviors the patient experienced. The Risk Manager was unable to clarify what this order meant when questioned by the surveyors.

On 12/17/18 at 2:22 PM: Discontinue 1:1 Frequency: once.

On 1/1/19 at 1:13 PM: 15 minute checks, Frequency: every 15 minutes, Comments: (name of Pt #3) Requires line of site for self harm behaviors. There was no documentation in the medical record what type of behaviors the patient experienced.

On 1/19/19 at 4:29 PM: 15 minute checks, Frequency: every hour. There was no documentation in the medical record what type of behaviors the patient experienced. The Risk Manager was unable to clarify what this order meant when questioned by the surveyors.

On 1/23/19 at 11:22 AM: 1:1 observation, Frequency: every hour. Comments: (Name of Pt #3) is aggressive and assaulting staff. spitting at staff. continues to escalate. Destructive behavior. When the Risk Manager was asked by the surveyor what was meant by 'frequency every hour' the Risk Manager was unable to clarify what this order meant .

On 1/26/19 at 11:35 AM: patient behavior requires 1:1 observation, Frequency: once. There was no documentation in the medical record what type of behaviors the patient experienced. The Risk Manager was unable to clarify what this order meant when questioned by the surveyors.

On 2/1/19 at 4:59 PM nursing documented discontinue 1:1 Pt no longer requires 1:1.

Review of a nurse progress note dated 1/30/19 at 12:15 PM, revealed Registered Nurse (RN) #5 documented, " ...(Name of physician) rounded and does not want (Name of Patient #3) removed from one on one at this time. He stated that (Name of Patient #3) is suicidal and homicidal and needs to stay on one on one.

Review of a nurse shift assessment dated 1/30/19 at 1:44 PM, revealed RN #5 documented under comments, "...Continue one on one observations per Medical Doctor (MD) orders..." There was no documentation of an MD order for one on one on 1/30/19.

There was no documentation Pt #3 received 1:1 observations and every 15 minute checks which included the patient location, behavior and activity.

In an interview on 2/11/19 at 1:30 PM, the Director of Risk Management verified there was no documentation on a patient Observation sheet that Patient #3 received 1:1 observations and every 15 minute checks.

Refer to A145 and A154.

Based on medical record review and interview, the hospital failed to ensure the nursing care plan developed appropriate nursing interventions in response to identified nursing care needs. The hospital failed to ensure the nursing care plan was kept current by ongoing assessments of the patients' needs and of the patients' response to interventions, and update or revise the nursing care plan in response to nursing assessments of the patients' current status for 2 of 2 (Patient #1 and 3) sampled patients reviewed.

The failure of the hospital to ensure all staff developed appropriate nursing interventions and kept the care plan current by updating or revising in response to the patients' needs and of the patients' response to interventions, placed all patients in a SERIOUS AND IMMEDIATE THREAT OF psychological and physical harm. The failure of the hospital to implement and document interventions and maintain a current individualized nursing care plan placed all patients at risk for an IMMEDIATE JEOPARDY for physical and/or psychological harm, or potential for serious injuries and/or death which is ongoing.

The findings included:

1. Medical record review for Patient (Pt) #1 revealed an admission date of 1/10/19 with diagnoses of Schizophrenia with homicidal ideation and psychosis, Cerebral Palsy with difficulty ambulating, Asthma, Seizure disorder, Hypothyroidism and Gastroesophageal Reflux Disease. His chief admitting complaint was "hearing voices."

Review of Patient #1's Psychiatric Evaluation dated 1/10/19 revealed, " ...Pt is a 27 year old WM [white male] admitted with increased paranoia, anxiety, and AH+. States that he hear voices that tell him to hurt himself and others. Impulsive behavior. Refusing meds and care. Unable to function ...Prognosis: Guarded. Justification for Hospitalization: Inpatient ...Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment, Emotional or behavioral conditions an complications requiring 24 hour medical and nursing care, Need for ECT [Electro-convulsive Therapy], special drug therapy, or other therapeutic program requiring continuous hospitalization, Failure of social or occupational functioning, Inability to meet basic life and health needs ..." There was no documentation in the patient's medical record the patient experienced PICA (Psychological disorder characterized by craving and eating substances with no nutritional value, such as dirt, hair, ice, paper, metal stones, and glass).

Review of a physician's order given on admission day of 1/10/19 at 3:22 PM revealed "15 minute checks with line of sight monitoring..." There was no documentation of any incident that precipitated the q 15 minute checks and line of sight monitoring.

Review of the Care Plan dated 1/10/19 revealed no documentation the patient experienced PICA and no interventions for the PICA. The care plan had not been updated to reflect every 15 minute checks with line of sight monitoring. Patient #1 was discharged from the facility 1/14/19. There was no documentation the patient's care plan was kept current by ongoing assessments of the patient's needs and of the patient's response to interventions. There was no documentation the patient's care plan had been updated or revised in response to those assessments during hospitalization.

On 2/6/19, upon surveyor request, the Risk Manager provided a copy of a video recording of an incident involving Patient #1 in the Senior Care Day Room. The video recording was not timed or dated. The Risk Manager stated the video recording was for the date 1/11/19. Review of the video for Patient (Pt) #1 revealed the patient was exhibiting behaviors of placing gloves, paper, temperature probes and trash off the floor, into his mouth.

2. Medical record review for Patient #3 revealed an admission dated of 12/14/18 with diagnosis of Schizoaffective Disorder. Patient #3's past medical history included Autism, Bipolar disorder, Posttraumatic Stress disorder and Attention deficit hyperactivity disorder. Patient #3 was discharged from the facility 2/1/19.

Review of Patient #3's plan of care revealed it was initiated on 12/15/18. Patient #3 was discharged from the facilty 2/1/19.

Review of physician orders revealed the following:
On 12/15/18 at 12:23 AM: 1:1 observation. There was no documentation of an incident precipitating this order. There was no documentation the plan of care was revised to reflect the precipitating factors or order.

On 12/15/18 at 2:14 PM: 1:1 observation. There was no documentation of an incident precipitating this order. There was no documentation the plan of care was revised to reflect the precipitating factors or order.

On 1/1/19 at 1:13 PM: 15 minute checks, Frequency: every (q) 15 minutes, Comments: (name of Pt #3) Requires line of site for self harm behaviors. There was no documentation of an incident precipitating this order. There was no documentation the plan of care was revised to reflect the precipitating factors or order.

On 1/19/19 at 4:29 PM: 15 minute checks, Frequency: every hour. There was no documentation of an incident precipitating this order. There was no documentation the plan of care was revised to reflect the precipitating factors or order.

On 1/23/19 at 11:22 AM: 1:1 observation , Frequency: every hour. Comments: (Name of Pt #3) is aggressive and assaulting staff. spitting at staff. continues to escalate. Destructive behavior. There was no documentation of an incident precipitating this order. There was no documentation the plan of care was revised to reflect the precipitating factors or order.

On 1/26/19 at 11:35 AM: patient behavior requires 1:1 observation, Frequency: once. There was no documentation of an incident precipitating this order. There was no documentation what type of behaviors the patient experienced. There was no documentation the plan of care was revised to reflect the precipitating factors or order.