HospitalInspections.org

Based on policy and procedure review, medical record review, internal documents review, staff and physician interviews, the hospital failed to have an effective governing body by failing to have systems in place to ensure the protection and promotion of patient's rights for a safe environment and failed to have an organized Nursing Service to supervise and evaluate care provided.

The findings include:

1. Hospital staff failed to ensure a safe environment by failing to halt use of potentially defective equipment and a patient subsequently died after falling from a patient lift for 1 of 3 patients reviewed with patient lift use ( Patient #1).

~cross refer to 482.13 Patient Rights' Standard: Tag 0144

2. Hospital Staff failed to maintain documentation of applied physical training (APT) competencies for 3 of 4 staff involved in an emergency floor procedure (TSS #8, TSS #9, RN #12).

~cross refer to 482.13 Patient Rights' Standard: Tag 0196

3. Hospital Nursing staff failed to supervise and evaluate the care of a patient receiving a manual hold resulting in injury for 1 of 4 sampled restrained patients (Patient #6).

~cross refer to 482.23 Nursing Services Standard: Tag 0395

Based on policy review, medical records review, hospital document reviews and staff interviews the hospital failed to protect and promote patient rights by failing to ensure a safe environment for behavioral health patients.

The findings include:

1. Based on policy and procedure review, medical record review, incident report review, personnel file review, staff and physician interviews the hospital staff failed to ensure a safe environment by failing to halt use of potentially defective equipment and a patient subsequently died after falling from a patient lift for 1 of 3 patients reviewed with patient lift use ( Patient #1).

~cross refer to 482.13 Patient Rights' Standard: Tag 0144

2. Based on facility policy review, non-violent crisis intervention training review, video review, and personnel file review, the facility failed to maintain documentation of applied physical training (APT) competencies for 3 of 4 staff involved in an mergency floor procedure. (TSS #8, TSS #9, RN #12).

~cross refer to 482.13 Patient Rights' Standard: Tag 0196

Based on policy and procedure review, medical record review, incident report review, personnel file review, staff and physician interviews the hospital staff failed to ensure a safe environment by failing to halt use of potentially defective equipment and a patient subsequently died after falling from a patient lift for 1 of 3 patients reviewed with patient lift use ( Patient #1).

The findings include:

Review of policy titled "SAFETY MANUAL: Subject: Medical Equipment Management Plan" with effective date of July 26, 2021, revealed "Purpose: To minimize the risks and hazards associated with medical equipment at (Name of Facility). Policy: (Name of Facility) will operate a Medical Equipment Program in compliance with the applicable codes, standards and regulations to prevent adverse impact to life from the use of medical equipment used by (Name of facility). Definitions: Medical Equipment: Any diagnostic, treatment, adaptive or medical support device that is subject to patient contact or provides physiological/psychological patient data. Medical equipment is considered durable and usable....Repairs 1. It is the responsibility of any employee who uses a medical device to take the item out of service and to report improperly working equipment immediately to their supervisor and (Named facility MedEquip) email address."

Closed medical record review of Patient #1 revealed an 81 year old male hospitalized since 1999 after being found not guilty by reason of insanity on charges of kidnapping, crimes again nature, assault on a handicapped person, rape, assault with a deadly weapon inflicting serious injury, breaking and entering, larceny, and injury to real property in 1998. He has a documented history of mild intellectual disability secondary to an anoxic brain injury at birth., exacerbated by a frontal lobe traumatic brain injury at age 27 (hit in the head with a pool stick), resulting in significant loss of impulse control with physical and sexual aggression, further complicated by cognitive decline and cerebrovascular disease. He was transferred to (geriatric) unit on 12/15/2010 due to his falling and being vulnerable to the other patients....Patient #1 is now totally dependent on staff to care for his ADLs (activity of daily living) and to change his position in his specialized (Vesicare) Bed to prevent skin breakdown and decubitus ulcers (bedsores). He requires close observation by staff while he eats (or is spoon fed by staff) to prevent aspiration. He requires a chair alarm and bed alarm secondary to his risk for falls." Review of orders dated 02/07/2022 at 0837 revealed "Hoyer transfers".

Review of nursing progress note dated 12/27/2022 at 1533 written by TSS #14 revealed "Transferring pt (Patient #1) from geri (geriatric) chair to bed for am (morning) incontinence care and rest in bed at 0832. Had the right lift for the Pt. Lift stalled out on the way (out) of geri chair. We talked about do we need another battery for the lift. With remote lift went into the down direction and it was working with normal power. With remote lift then was set to lift and Pt was lifted further up out of chair, chair was immediately moved to the wall, lift was very slow, it seemed to stall out almost completely, at the time of becoming aware of it seemingly stalling out, that is upon the possible stalling out itself, Pt leaned forward to reach forward toward/on the top of jointed part of the lift. We immediately went for the Pt, weight went to the front of lift and out of seat of sling, Pt fell out of sling, as he fell, the front left strap became detached and hung to the floor. Pt fell out of sling where the open space now was, lower body first, hips torso, shoulder, absorbing most of the impact and it wasn't at full height at that point in the lift, Pt landed on lateral left, all skin intact, Tech (technician) immediately got the RN, Unit called Med Stat (emergency response team) and Pt was assessed along with vitals. After safety was reestablished we lift Pt off floor into gerichair, bed was set up and things moved out of the way, we moved Pt into bed, changed his brief, and positioned Pt for comfort and full visibility for Q15s (every 15 minutes)."

Review of MD #17's note dated 12/27/2022 at 0915 of "Med Stat Hoyer Lift Malfunction and fall" revealed "Falls Documentation: Subjective: Patient #1 was in the hoyer lift in the process of being transferred when the lift had an issue with its movement and then the lower left connection came undone and Patient #1 tumbled to the floor landing on his left hip/buttocks., then shoulder, then his head went to ground but the head did not bounce per the staff. Patient #1 is seen on the floor. He s (sic) moving all extremities and speaking and yelling at times. He is a limited informant and this is his baseline per staff.... He is not able to answer questions...Assessment: Mechanical witnessed fall 2/2 (secondary to) hoyer lift dysfunction. The primary site of impact per staff was buttocks/left side/hip and then flank, shoulders, and then head. He has no clear bony inury (sic) noted at this time.... Observations: no change in level of observation, neuro checks q1h x 4 (Neurological checks every 1 hour for 4 hours). Follow up: primary team t (sic) review and reassess tomorrow. Other: the hoyer lift is not to be used until evaluated by biomed (maintenance department). House Coordinator is aware and has conveyed this to (Geriatrics patient care floor)."

Review of an incident report dated 12/28/2022 written by RN #15 (charge nurse) revealed "Patient reported to have fallen out of mechanical lift during a transfer at approximately 0832. Contributing Factors: Equipment Malfunction. Fall classification: Witnessed. Mobility status at time of fall: Bed Ridden/Non-ambulatory. Attempted action prior to fall: Transferring to or from Bed, Chair, etc. Injury Details: Event Severity: Death."

Interview on 01/11/2023 at 1115 with TSS #14 revealed the staff member remembered hooking up the lift on 12/272022. Interview revealed Patient #1's seat belt (safety belt to secure patient in place to prevent sliding from chair) was still hooked during the attempt to raise patient out of chair. Interview revealed TSS #14 released the seat belt. Interview revealed the right rear wheel was seen lifted off of the floor a few inches which seemed "bizarre" then the sling got caught on the arm of the chair. Patient #1 was lowered and the sling was removed by TSS #14 from the arm of the chair. Interview revealed everything was fine and Patient #1 was raised again. The chair was positioned parallel to the bed and the lift stalled. Interview revealed a conversation between TSS #14 and TSS #16 about the battery may need replacing but no noise from the battery could be heard. Interview revealed Patient #1 was then lowered and raised normally. Interview revealed Patient #1 was up in the air and the chair was pushed away, bringing Patient #1 towards the bed. Interview revealed Patient #1 was reaching for the bar across the lift, sat up; caused Patient #1's head and shoulders to come off of the sling. TSS #14 and TSS #16 yelled "No" to Patient #1 as his lower body slid out of the sling. Interview revealed sling "disappeared from under him". Interview revealed the left lower strap of the lift was noted to be hanging after Patient #1 was on the floor.

Review of TSS #14's competency and training revealed hoyer lift training was completed on 11/16/2022. Review revealed no competency on troubleshooting or actions to take for malfunction of the hoyer lift. Review revealed TSS #14 was a contract employee with contract began on 7/18/2022 through 10/24/2022 and extended on 10/25/2022 through 1/24/2023.

Interview on 1/10/2023 at 1525 with TSS #16 revealed she was operating the remote to the hoyer lift on December 27, 2022. Interview revealed Patient #1 was retrieved from the day room, adding the patient was in the recliner while the other TSS #14 brought the lift to Patient #1's room. The straps were hooked up using same colors on the hooks and everything was ok. TSS #14 said OK. The lift stopped halfway. TSS #14 said try again. TSS #16 was pressing the button but it wasn't working and the staff member couldn't make it work. Patient #1 was "ejected" from the lift. "It happened so fast. I ran to dayroom to get staff." Interview continued Patient #1 was never raised above the height of the chair. "I saw him falling on the floor. I saw him on the floor...one strap came off the metal bar from the left...."

Review of TSS #16's competency and training revealed hoyer lift training was completed on 10/19/2022. Review revealed no competency on troubleshooting or actions to take for malfunction of hoyer lift. Review revealed TSS #16 was a contract employee with the contract started on 10/4/2022 through 1/3/2023 and extended on 01/4/2023 through 04/5/2023.

Interview on 01/10/2023 at 1610 with MD #17 revealed Patient #1 was assessed by MD #17 during the Med Stat on December 27, 2022 at 0835 on the morning of the incident. Interview revealed Patient #1 was able to follow some commands during exam on the floor. Patient #1 did not have any grimacing during examination, adding looking for signs of discomfort. Interview revealed head was supple, no hematoma, rotated hip created no grimacing, adding exams were negative. Interview added no xrays were ordered due to no grimacing or bruising. Interview revealed another Med Stat was called on Patient #1 before supper time due to hypotension (low blood pressure). Interview revealed Patient #1's symptoms had improved and Patient #1 was fed supper. Interview revealed another Med Stat was called later that evening after the patient started vomiting, and became less responsive, cool and clammy. Patient #1 was hypotensive, adding EMS (Emergency Medical Services--ambulance) was called for transfer to the hospital. Patient #1 expired at 2234 in the back of the ambulance, never arriving to the hospital.

Interview on 01/11/2023 at 1000 with RN #15, charge nurse on the day of the incident, revealed Patient #1 had fallen from lift, a Med Stat was called and RN #15 arrived in Patient's room. Neuro (Neurological) checks were ordered and all normal. Interview revealed there was not a notification from the TSSs during the malfunction of the hoyer lift. Interview revealed RN #15 was not aware of a problem with the hoyer lift until after the fall.

Interview on 01/13/2023 at 1708 with CNO #2 revealed two staff members continued to use the hoyer lift without calling the charge nurse or notifying the RN. Interview revealed the staff should have stopped using the lift and called for help. Interview revealed the facility policy was not followed.

Based on facility policy review, non-violent crisis intervention training review, video review, and personnel file review, the facility failed to maintain documentation of applied physical training (APT) competencies for 3 of 4 staff involved in an emergency floor procedure (TSS #8, TSS #9, RN #12).

The findings include:

Review on 01/10/2023 of the facility policy, "Restrictive Interventions - Behavioral" effective 10/28/2019, revealed, "... **The only prone (face down) position that is permitted is the emergency floor procedure as prescribed by the Non-Violent Crisis Intervention Applied Technique. This technique may only be used in emergency situations by properly trained NVCI (Non-violent Crisis Intervention) APT staff..."

Review on 01/13/2023 of Non-Violent Crisis Intervention Training revealed two different physical technique score sheets: Enhanced Training and APT and (named) approved techniques. Review revealed the enhanced training did not include demonstration of facility approved prone techniques.

Review on 01/11/2023 of video footage dated 12/02/2022 at 2008 revealed YPEA #7, TSS #8, TSS #9, and RN #12 were present for the prone positioning of Patient #6. Review of video footage revealed YPEA #7 and TSS #9 engaged Patient #6 in the emergency floor procedure (prone) hold while TSS #8 and RN #12 observed.

Review on 01/12/2023 of personnel files for TSS #9 failed to reveal NVCI APT training.

Review on 01/12/2023 of personnel files for TSS #8 failed to reveal NCVI APT training.

Review on 01/12/2023 of personnel files for RN #12 failed to reveal NVCI APT training.

Based on facility policy review, facility document review, incident report review, video footage review, medical record review, and staff interview, the facility's nursing staff failed to have an effective nursing service providing oversight of day-to-day operations by failing to ensure systems were in place to supervise and evaluate the care provided to behavioral health patients.

The findings include:

Nursing staff failed to supervise and evaluate the care of a patient receiving a manual hold resulting in injury for 1 of sampled restrained patients (Patient #6).

~ cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

Based on facility policy review, non-violent crisis intervention training review, incident report review, video review, medical record review, facility actions post event review, and staff interviews, the nursing staff failed to supervise and evaluate the care of a patient receiving a manual hold resulting in injury for 1 of 4 sampled restrained patients (Patient #6).

The findings included:

Review on 01/10/2023 of the facility policy, "Restrictive Interventions - Behavioral" effective 10/28/2019, revealed, "... N. The following interventions are not acceptable for use: ... 5. any manual or mechanical restraint in the prone (face down) position or carrying the patient in a prone (face down) position. **The only prone (face down) position that is permitted is the emergency floor procedure as prescribed by the Non-Violent Crisis Intervention Applied Technique. This technique may only be used in emergency situations by properly trained NVCI APT staff... Any injuries that result from a restrictive intervention or the potentially dangerous inappropriate application of an NVCI physical intervention that could lead to injury will be reported to the Chief Nursing Officer and other Executive Team members as appropriate for follow up... K. Staff Education... 2. Staff will receive education and training and will demonstrate knowledge based on the specific needs of the patient population in at least the following: ...e. How to recognize, identify signs and respond to and treat signs of physical and psychological distress in a timely manner (for example, positional asphyxia); f. The safe application and use of all approved types of restraint or seclusion..."

Review on 01/10/2023 of the facility policy, "Patient Incidents/Occurrences" effective 10/07/2019, revealed, "... A. Immediate Response and Assessment: 1. Any employee who observes or is involved with an incident/occurrence involving a patient will immediately intervene, within the scope of their ability, to protect the health and safety of the patient..."

Review on 01/10/2023 of the facility Non-Violent Crisis Intervention training materials dated 11/2019 revealed, "...Staff using physical interventions must be fully aware of the risk associated with each intervention. They must monitor the individual's safety and well-being at all times, be able to identify signs of distress, and know how to respond to medical emergencies. (See Figure 5.).... Figure 5: Risk of Restraints: Warning Signs and Corrective Actions...Warning Signs - ... Complains of pain or discomfort - Limbs positioned awkwardly... - Becomes distressed and/or cries... Corrective Actions - ... Treat as URGENT. Immediately assess level of restriction and check to ensure you are not impeding or restricting breathing. Check movement of limbs and signs of fracture/dislocation... Call for help-an independent person not involved in the physical restraint is often best to assess what is happening and what action needs to be taken..."

Review on 01/11/2023 of the incident reports related to the patient incident/occurrence dated 12/02/2022 revealed 4 reports.
Incident report review failed to reveal incident reports related to inappropriate technique usage on Patient #6 related to the 12/02/2022 manual hold.

Review on 01/11/2023 of video footage dated 12/02/2022 at 2008 involving Patient #6, TSS #8, YPEA #7, TSS #9, RN #10, and RN #12 revealed the setting consisted of the short hallway, dayroom, and seclusion suite. TSS #8 was assigned to perform 1:1 observations on Patient #6. TSS #9 was on the unit as part of the TRT (Therapeutic Response Team) response for Staff Assistance. RN #12 was the assigned nurse of Patient #6 and RN #10 was the charge nurse. Review of video footage revealed YPEA #7 grabbed Patient #6's wrists in an extended arm hold and flipped Patient #6 down to the floor by the arm while RN #12 and TSS #8 watched from the open doorway. Video footage revealed YPEA #7 got down on the floor and held Patient #6's right arm down while TSS #9 bent over to hold Patient #6's left arm down to the ground. Video and audio review revealed Patient #6 made multiple statements that she was in pain while in facility staff presence. Video review with Educator #13 (NVCI instructor) revealed YPEA #7 and TSS #9 failed to use approved manual techniques during the descent to the floor in emergency floor procedure (prone) positioning on the floor and positioning for the medication injection. Video review failed to reveal the facility staff intervened for use of inappropriate manual hold techniques. Video review failed to reveal the facility staff response to Patient #6's verbalization of pain. Video review revealed nursing failed to supervise the care being provided to Patient #6 in a manual hold.

Open medical record review of Patient #6 revealed a 14-year-old female who was voluntarily admitted to the facility on 11/14/2022 at 1515 with a chief complaint of worsening aggression. Review of the previous medical history revealed diagnoses of Attention Deficient Hyperactivity Disorder and Mild Intellectual Disability. Medical record review revealed Patient #6 was placed on aggression precautions upon admission. Record review revealed Patient #6 had a RIPP (Restrictive Intervention Prevention Plan) initiated on 11/17/2022 at 1159 with strategies to reduce the restrictive interventions due to aggression. Review of a Restrictive Intervention Team Note by RN #10 dated 12/02/2022 at 2044 revealed, "...Date /Time assessment completed Dec (December) 2, 2022 @ (at) 2055... Did the patient feel he/she experience physical injury or psychological distress as a result of the Restrictive intervention Procedure? No... Debriefing Participants: RN #10, YPEA #7... Search/Return Note: Search Witnesses: ...YPEA #7... RN #12..." Review of a Nursing Progress Note by RN #10 dated 02/21/2022 at 2135 revealed, "Patient on Q15(every 15 minutes) while in room, 1:1E (one to one) outside of room for aggression and elopement... She was hyper, pacing and scattered all over the milieu, redirected for not respecting personal space and boundaries with staff and peers, Very hyper active, verbally and physicall (sic) aggressive to peers and staff. Fight broke between her and , (sic) TRT called, staff was able to intervene before TRT arrived the unit (sic). She continue to posture for a fight, threatening and cursing peers and staff, posturing for a fight. She was placed on MH (manual hold) from 1855-1856. PDOC Dr (named physician on call) was notified, he came to assess pt. No injury noted, no complain (sic) of pain. Pt continued to agitate the peer and pacing, going back and forth trying to fight the peer. She was redirected multiple times for trying to fight peer and staff, postured to fight staff and was placed on MH from 2010-2015. Psych on call was notified, she received Zyprexa 5mg(milligrams) IM (intramuscular) PRN (as needed) for agitation and aggression. RN assessed, patient complained of mild pain on the left shoulder, MDOC Dr. (named physician on call) was notified..." Review of Medical Progress Note by MD #5 dated 12/02/2022 at 2212 revealed, "...called b/c (because) patinet (sic) c/o (complains of ) pain after a manual hold of her left shoulder... no swelling or deformty apparnt (sic) to shoulder and left arm. she is lying on her right arm and there is no obvious defromity (sic) on that side either. She seems to have full passive ROM (range of motion)... I stopped the exam when she attempted to assault me..." Review of Medical Progress Note by MD #5 dated 12/03/2022 at 2114 revealed, "... unclear injury of the left shoulder. She is far to labile.... but based on the exam last night and the limited information I can get today, she does not appear to be suffering from a significant injury. However, because the exam has constantly been limited, perhaps a plain film will help to reassure me against other more occult pathologies..." Review of Medical Progress Note by MD #5 dated 12/04/2022 at 0926 revealed, "... called by radiology initially patient was too aggressive for the plain films, however, it seems that somehow we were able to get these done. It indicated a possible fracture of mid-clavicle... If it is fractured, treatment would usually be shoulder immobilization and PT (physical therapy) for ROM exercises of the distal arm. However, given her behviors (sic) that include recurrent unpredictable aggression towards staff... If her arm does have a non-displaced fracture it should heal without a sling but will take longer than if the shoulder were immobilized..." Open medical record review revealed subsequent manual holds and seclusion incidents were performed using modified techniques to accommodate Patient #6's clavicle injury. Record review revealed RN #10 documented unwitnessed restrictive interventions. Medical record review failed to reveal documentation from RN #12 related to the 12/02/2022 manual restrictive interventions.

Review on 01/12/2023 of the facility actions post-event failed to reveal action items addressing nursing supervision of care related to nuring documentation and monitoring of witnessed restrictive interventions.

Request for interview with YPEA #7 revealed YPEA #7 had not returned to work since 12/02/2022 and was unavailable for interview.

Interview on 01/11/2023 at 1605 with TSS #9 revealed TSS #9 was involved with the hold for Patient #6 on 12/02/2022. Interview revealed TSS #9 and YPEA #7 were instructed by nursing to take Patient #6 to the seclusion room for a time out. Interview revealed TSS #9 did not hear Patient #6's cries of distress or recognize issues with the techniques utilized. Interview revealed that TSS #9 did not feel the manual holds were inappropriate until coached by executive leadership.

Interview on 01/11/2023 at 1630 with TSS #8 revealed TSS #8 was floated to the adolescent unit on 12/02/2022. Interview revealed that TSS #8 was assigned to do 1:1 observations for Patient #6. Interview revealed that Patient #6 was instructed to stay down her hallway and away from the other patients to avoid additional altercations. Interview revealed that Patient #6 was placed in time out by YPEA #7 and TSS #9 at the direction of nursing staff. Interview revealed that TSS #8 did not see any appropriate techniques used or hear any of Patient #6's cries of distress. Interview revealed TSS #8 was unaware that the manual holds were inappropriate until coached by executive leadership.

Interview on 01/12/2023 at with RN #10 revealed RN #10 was assigned as the charge nurse for 12/02/2022. Interview revealed RN #10 was only present for the medication administration for Patient #6 during the 12/02/2022 restrictive intervention. Interview revealed RN #10 did not hear Patient #6 complaining of pain during the medication administration. Interview revealed RN #10 did not recognize the manual holds were inappropriate until the facility executive leadership met with staff to do a debrief. Interview revealed RN #10 documented the restrictive intervention although she was not present for the intervention. Interview revealed that nursing commonly shared tasks or documented for each other. Interview revealed RN #10 did not receive any reports of inappropriate manual holds used with Patient #6 from other staff members.

Interview on 01/13/2023 at 1000 with RN #12 revealed that RN #12 was present for the restrictive interventions for Patient #6 on 12/02/2022. Interview revealed that Patient #6 was still attempting to instigate a fight, so RN #12 decided to place Patient #6 in time out for safety. Interview revealed RN #12 was present when Patient #6 was flipped to the ground. Interview revealed that RN #12 went to get medications to be administered to Patient #6 for aggression due to the attack of YPEA #7. Interview revealed when RN #12 returned, Patient #6 was on the floor and received an IM injection while still in the floor hold. Interview revealed RN #12 was unaware that the flip to the floor was an inappropriate technique until recent training. Interview revealed it was common practice for the nurses to share charting responsibilities and tasks, so RN #12 relied on RN #10 to write up the incidents related to Patient #6. Interview revealed RN #12 did not remember Patient #6 having any complaints of pain while in the hold, and refused to talk to RN #12 after being escorted to her room. Interview revealed Patient #6 mentioned that her shoulder hurt later on in the shift and the information was reported to the charge nurse to document and act upon.

Interview on 01/11/2023 at 1425 with MD #5 revealed MD #5 responded to Patient #6's complaints of pain on 12/02/2022, 12/03/2022, and 12/04/2022 post manual hold. Interview revealed that Patient #6 was aggressive upon assessment and refused to cooperate with a detailed exam. Interview revealed that since there was no obvious deformity and Patient #6 was still fully utilizing her arm, the initial plan was to treat with pain medication. Interview revealed that Patient #6 had additional complaints of pain, which prompted an x-ray for further examination. Interview revealed that the x-ray revealed a non-displaced clavicle fracture. Interview revealed that given Patient #6's unstable nature, the providers created a treatment plan which modified the holds utilized on Patient #6 to reduce worsening the fracture.

Interview on 01/11/2023 at 1520 with Advocate #6 revealed the investigation into the allegation of physical abuse was substantiated based on the video footage and physician medical documentation. Interview revealed inappropriate techniques were utilized by YPEA #7. Interview revealed that the investigation started on 12/05/2022 and concluded on 01/05/2023 after multiple attempts to get in touch with YPEA #7 failed. Interview revealed that the findings of the investigation were sent to the facility's leadership to create a plan to address the concerns.

Interview on 01/11/2023 at 1155 with Educator #13 revealed that YPEA #7 utilized a mixture of approved and unapproved techniques through the manual restraint video dated 12/02/2022. Interview revealed that facility staff were taught that the patient has to initiate the floor descent, not the staff member. Interview revealed that the facility had one approved prone floor position that required two staff members to be on the floor with the patient. Interview revealed that when moves were performed improperly it increased the potential for injury. Interview revealed that YPEA #7 and TSS #9 failed to use approved manual techniques during the descent to the floor, prone positioning on the floor, and prone positioning for the medication injection. Interview revealed that when a patient communicated that a hold was painful, the facility staff were taught to reposition the hold, call the nurse for assessment, and/or disengage with the patient.

Interview on 01/12/2023 at 1125 with the ACNO #3 and CEO #1 revealed the facility had taken several steps after the incident on 12/02/2022 involving Patient #6. Interview revealed the facility had awareness that the nurse who witnessed the restrictive intervention was not the nurse who documented it. Interview revealed documentation should have notated which staff member witnessed the restrictive intervention and participated in the debriefing. Interview revealed the nursing staff was expected to document what they witnessed or document, "per named staff member report." Interview revealed the facility leadership team had determined that bias towards Patient #6 may have impacted the facility staff's response to the patient's cries and statements of pain. Interview revealed the expectation that facility staff respond to patient complaints of pain and to report when holds were performed incorrectly.

Interview on 01/13/2023 at 1755 with ACNO #3 revealed the expectation that facility staff documented what tasks they performed and ensure that they clearly documented if they were documenting per report from another staff member. Interview revealed the expectation that nurses assessed for and responded to patient complaints during manual holds.

NC00196553, NC00196592, NC00196401, NC00196674