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Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the safe and appropriate use of restraints and seclusion was implemented for one of 10 sampled patients, Patient 1 (P1).

On 11/30/2023, Mental Health Technician 1 (MHT1) was observed, on the facility's video camera footage, escorting P1 with the use of a physical restraint. However, the use of MHT1's physical restraint techniques used on P1 were not per facility protocol.

The findings include:

Review of the facility's policy and procedure, titled "Restraints and Seclusion", dated 10/10/2023, revealed the policy's purpose was to establish clear criteria in practice guidelines, practice parameters, and care protocols. Further review of the policy revealed the facility was committed to the provision of a safe, secure environment, which encompassed the patient's physical, mental, and emotional welfare by encouraging the highest level of respect and dignity of the individual throughout the continuum of care. Continued review of the policy revealed the patient had a right to be free from mechanical, physical, or chemical restraints and/or the use of seclusion when used for the purposes of discipline or convenience. Additionally, the policy identified general staff responsibilities that qualified staff monitored and provided for the physical and psychological well-being of the patient who was restrained and/or secluded.

Review of the facility's policy and procedure, titled "Patient Rights and Responsibilities", dated 10/2021, revealed the patient had a right to expect reasonable safety insofar as the hospital practices and environment were concerned and to be free from all forms of abuse or harassment. Further review revealed the patient had a right to considerate and respectful care at all times and under all circumstances, and the right to expect care that optimized and recognized his or her personal dignity.

Closed record review revealed the facility admitted P1 on 10/12/2023 with diagnoses which included bipolar disorder, post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), and intellectual delay.

Review of the facility's event review, dated 11/30/2023, conducted by Risk Manager 1 (RM1), revealed during an interview with MHT1, he reported he was assisting several team members to move P1 from the fourth floor to the third floor when P1 dropped to the floor and refused to get up. MHT1 stated he pulled P1 through the door threshold to the landing, then asked her to walk down the steps, which P1 refused to do. MHT1 reported he told P1 he was going to pull her down the stairs and gently pulled her from the landing to the first step, then pulled her once more and told her to stand up, which she did, then she walked down the steps to the third floor. There was no video footage in the stairway. Continued review revealed MHT1 was current with all his required training. Additionally, the incidental findings of the investigation revealed MHT1 pulling P1 down the steps was, at best, a non-standard intervention and there was an obvious lack of recognition that pulling a patient across the floor, let alone down a flight of stairs, was not acceptable and the likelihood of injury associated with such a transport was great and the fact P1 was not cooperating with ambulating back to the unit should have precluded the use of the stairs in any event.

Review of MHT1's training record revealed he was hired on 03/06/2023 and received training on Patient Rights and Abuse on 11/07/2023 and again on 02/01/2024. Further review revealed he received training on Crisis Prevention Institute (CPI) Decision Making on 04/14/2023.

Observation of video camera footage with Risk Management (RM) staff, on 12/17/2024 and 12/19/2024, revealed, on 11/30/2023 at 11:43:22, P1 was running down the hallway on the fourth floor, then tumbled to the floor; at 11:43:31, MHT1 was in the fourth-floor hallway in front of P1, who was sitting on the floor beside the stairway door, and they were talking. Further observation revealed three (3) other staff members walking toward P1 at 11:44:05; at 11:44:08, P1 got off the floor and started running in the direction of the classroom and was blocked by Teacher 1, who P1 then pushed backward; at 11:44:13, other staff members (MHT1, MHT2, and MHT3) assisted Teacher 1; at 11:44:21, MHT1 held P1's arm and walked her toward the stairway door; at 11:44:29, P1 sat in the fourth floor hallway, at which time MHT1 grabbed P1's right arm and pulled her across the floor while Teacher 1 opened the stairway door and MHT2 then grabbed P1's left arm; at 11:44:37, MHT1 picked up P1's feet and pulled P1 through the stairway door and disappeared from camera view at 11:44:39; at 11:45:04, P1 was observed walking through the stairway door on the 3rd floor holding the left side of her face; at 11:45:06, MHT1 and Teacher 1 exited the stairway door onto the third floor; at 11:45:11, P1 sat down in the hallway and MHT1 was observed walking away from P1 while Teacher 1 stayed with P1; at 11:45:16, Nurse1 entered the video with MHT1, and Nurse1 talked with staff members present, who point to the stairway door; and, at 11:46:23, Nurse1 spoke with P1, then walked away at 11:46:27, leaving P1 sitting in the hallway floor.

During an interview with RM1, on 12/17/2024 at 3:10 PM, he stated the Risk Management department investigated the incident on 11/30/2023 as soon they were notified and did find MHT1 should not have transported P1 by pulling on her ankles because it did pose a risk of injury with transport. He further stated, since P1 was refusing to ambulate, the facility staff should have used the elevator instead of the stairs as staff should never try to use a hold situation on the stairs. He continued to state the use of a restraint bed or stretcher was available if the patient required a restraint during transport from the fourth floor to the third floor.

During an interview with Program Coordinator 1 (PC1), on 12/18/2024 at 1:43 PM, she stated a patient should never be transported on the stairs in a hold position, and staff should use a cart on the elevator if a patient must be transported while being restrained because transporting in a hold on the stairs was unsafe.

During an interview with Registered Nurse 1 (RN1), on 12/18/2024 at 2:16 PM, she stated a patient should never be transported in a stairwell in a hold position because staff might drop or hurt the patient or themself. She further stated to transport a patient in a hold position staff should use a cart or chair.

During an interview with MH2, on 12/18/2024 at 2:44 PM, he stated a patient should never be transported in a hold position in a stairwell because staff do not have control in a stairwell, and it was not good for the staff or patients. He further stated he would put patients on a cart and transport by the elevator if they needed to be transported in a hold position.

During an interview with MHT1, on 12/19/2024 at 9:31 AM, he stated he knew P1 from another facility prior to 11/30/2023 and "was just playing with her by swinging her legs side to side and she was laughing the whole time" during transport on 11/30/2023. He further stated after entering the stairway, P1 got up and ambulated down the stairs to the third floor. He continued to state he received abuse and restraint training annually and was taught training in the CPI, which included using the least restrictive restraint possible. Additionally, he stated he did not feel he had done anything incorrectly with the carry, "and sometimes you have to play and sometimes you have to be stern" with the patients.

During an interview with RM2, on 12/19/2024 at 10:11 AM, he stated once an incident is reported to RM to investigate, they try to pull camera footage, if available, and interview any staff in the vicinity of the incident, then try to determine if there was an opportunity for abuse or improper behavior to have occurred. He further stated after an investigation was completed, the RM team discussed the incident with each other and then brought it to the Administrative team, and the team made the decision to substantiate or unsubstantiate the allegation.