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Based on interview, the facility's Governing Board failed to ensure adequate oversight of patient care as related to the prevention, identification, reporting and remedial actions related to the abuse and/or neglect of four patients (#1, #2, #3 and #4) (0084). The Governing Board also failed to ensure nursing staff adequately assessed and provided care to the needs of three patients (#1, #2 and #4) (0084). This had the potential to affect all patients in the hospital. The facility census was 384. The Psychiatric Center census was 27.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.12 Condition of Participation: Governing Body, and resulted in the facility's failure to ensure quality health care and safety, while preventing abuse and neglect of patients.

Based on interview, the facility's Governing Board failed to ensure adequate oversight of patient care as related to the prevention, identification, reporting and remedial actions related to the abuse and/or neglect of four patients (#1, #2, #3 and #4). The Governing Board also failed to ensure nursing staff adequately assessed and provided care to the needs of three patients (#1, #2 and #4). This had the potential to affect all patients in the hospital. The facility census was 384. The Psychiatric Center census was 27.

Findings included:

1. Patient #1 presented to the Emergency Department (ED) with left arm numbness. The patient registered and was placed in the waiting room, and cursed while he visited with his friend. Staff D, Security Guard approached the patient and cautioned him about his language, and left the patient. While the patient waited in the waiting room, the patient slid off of the chair on to the floor with his body shaking. Staff G, ED Registered Nurse (RN), failed to assess the patient when his condition changed and showed no sense of urgency. When staff attempted to place the patient on a gurney, he became more agitated, and decided to leave, cursing and agitated. Staff D, followed the patient and friend outside of the building and was joined by Staff C, Security Guard. Bantering occurred between the patient and the security guards, and Staff C then pushed the patient two times and the friend two times. As the situation escalated, Staff C grabbed the patient's arm and with the assistance of Staff D, wrestled him to the ground and handcuffed the patient. During the struggle, the patient face struck the concrete two times, creating an abrasion on his forehead. Staff D then informed the Staff G, RN about the patient's possible injury and Staff G failed to go assess the patient.

2.Patient #2 was admitted to the psychiatric unit voluntarily for treatment of suicidal ideation with major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder and a chest wall contusion. After the patient became agitated and loud on the unit, security was called to assist, and the patient was guided into a lunchroom area by Staff N, Security Guard and Staff M, Behavioral Health Technician (BHT). The patient stated she was thirsty and bantered back and forth with the Staff N. The patient walked over to a pitcher of tea, and Staff N grabbed her. The patient responded by hitting Staff N, Security Guard, with the pitcher as he wrestled her to the floor. Staff O, Security Guard, joined to restrain the patient and a Code 10 (emergency code for assistance with a violent person) was called. Staff N, Staff O and Staff M carried the patient over to the seclusion room to place in restraints. In the hallway, she grabbed the hair of Staff M. They set the patient down on the floor to attempt to release the Staff M's hair. This was unsuccessful and Staff F, Security Guard arrived and proceeded to use an unauthorized technique to release the hair. With a closed fist, Staff F pounded the patient's hand 3-4 times. After the patient released the Staff M's hair, the patient was brought into the seclusion room where she was placed in 5 point restraints.

3. Patient #3 was an 18 year old female who was admitted for a 96 hour hold to the facility's Psychiatric Center on 04/28/17 at 9:05 PM, with a diagnosis of altered mental status. On 04/30/17, the patient was held down by two staff and administered a medication that she had refused.

4. Patient #4 was a 22 year old female admitted voluntarily to the facility's Psychiatric Center after she reportedly attempted to harm herself by wrapping a shoelace around her neck. During her hospitalization, the patient was placed in seclusion for refusing to exit her bathroom. While in seclusion, she picked at a healing wound on her arm, which caused it to bleed, and when staff attempted to deescalate her, she continued to escalate. A Code 10 was called and with security guard lead, the patient was placed in restraints, even after the patients stated that she would calm down and stop self-harming. During a manual hold, the patient's thumb/hand was bent toward her wrist by a security guard, which caused pain and injury to the patient. The patient also sustained swelling to the right side of her face, above her eyebrow. Both of the patient's arms were restrained above her head, and the patient remained in restraint and seclusion for hours after the patient had deescalated and contracted for her safety.

5. During an interview on 08/25/17 at approximately 9:30 AM, Staff JJ, Chief Operating Officer; Staff VV, Governing Board member; Staff WW, Chief Executive Officer and Governing Board member; and Staff XX, Governing Board member, stated:
- Incidents of concern related to quality and safety were reported to the Quality and Safety Committee, which was a sub-committee of the Governing Board.
- There were four incidents (which included Patients #1, #2 and #4) that were recently reviewed by various corporate level leaders, who voiced concerns with patient abuse.
- Governing Board members did not review the videos related to Patients #1, #2 and #4 until after the on-site survey was initiated (08/22/17).
- When the Governing Board members reviewed the videos, the videos were much different than what was reported to the Governing Board.
- The Governing Board had concerns with the management of the patients, felt the mismanagement of the patients were engrained in their culture, and that it was not the manner in which the hospital expected their patients to be treated.
- The Governing Board found the facility failed to adequately report to the Governing Board, the details of the incidents related to Patients #1, #2 and #4, failed to have a neutral party involved in the oversight (investigation) of the incidents, and added that the Governing Board should have been more involved in what the follow-up to these incidents should have included.

Based on observation, interview, record review, policy review and video review, the facility failed to:
- Immediately remove seven staff (C, D, F, N, CC, II and QQ) from patient care after allegations of staff to patient abuse and/or neglect of four patients (#1, #2, #3 and #4) of four patients reviewed (0144);
- Prevent abuse and/or neglect for four patients (#1, #2, #3 and #4) of four patients reviewed (0145);
- Adequately investigate allegations of staff to patient abuse and/or neglect in a timely manner for four patients (#1, #2, #3 and #4) of four patients reviewed for allegations of abuse (0145);
- Use the least restrictive method to control behavioral symptoms for three patients (#1, #2, and #4) of four patients placed in restraint (0164); and
- To follow facility policy regarding restraint use for management of behavioral symptoms for three patients (#1, #2, and #4) of four patients reviewed with restraints.

These failures had the potential to place all patients in an unsafe environment and at risk for abuse, neglect, the use of unnecessary restrain and prolonged restraint.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient Rights, resulting in a condition of Immediate Jeopardy (IJ).

On 08/24/17 at 12:55 PM, the survey team notified the facility of the Immediate Jeopardy related to Conditions of Participation: Patient Rights, and on 08/25/17 at 8:45 AM the facility responded with a Plan of Correction (POC), and at 3:45 PM the facility responded with a revised POC to remove the IJs.

The facility's POC failed to:
- Ensure the primary focus of the facility's corrective actions would prevent abuse of patients.
- Explain how the facility ensured administrators who provided oversight of real-time patient safety events, were qualified and trained to recognize patient abuse and respond appropriately should abuse occur.
- Ensure the secondary focus of the facility's corrective actions would involve restraint education which included the regulation the state "...All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff."
- Ensure that POC completion dates were timely, and did not extend beyond 09/01/17.

The plan was subsequently rejected by CMS, and the facility was notified by CMS on 08/28/17 that the POC was not accepted and the IJs remained ongoing.




36473

Based on interview, record review, policy review and review of recorded video surveillance, the facility failed to immediately remove seven staff (C, D, F, N, CC, II and QQ) from patient care after allegations of staff to patient abuse and/or neglect of four patients (#1, #2, #3 and #4) of four patients reviewed. These failures placed all patients in an unsafe environment and at risk for abuse. The facility census was 384. The Psychiatric Center census was 27.

Findings included:

1. Record review of the facility's policy titled, "Reporting and Investigating Allegations of Patient Abuse, Neglect, or Harassment," dated 02/2017, showed that:
- All forms of abuse, neglect, and harassment whether reportedly inflicted by coworkers, patients, or other persons are prohibited.
- Coworkers are too immediately report witnessed, alleged, or suspected signs of abuse, neglect, or harassment to their immediate supervisor, charge nurse, manager, or house supervisor.
- The supervisor who receives the report should assess the patient, document findings, assure patient safety, notify the physician and escalate to leadership to initiate the investigation.
- Coworker(s) involved in the allegation will be immediately removed from any patient care/contact and will be placed on investigatory leave.
- The Director of Patient Safety will initiate the self-report to the State agency within 24 hours of discovery.

4. Record review of the facility's internal investigation of a Code 10 response to Patient #4 on 08/15/17 showed:
- Staff R, Psychiatric Center Nurse Manager and Staff X, Psychiatric Center Director, reviewed video recordings of the Code 10 that resulted in the restraint and seclusion of Patient #4.
- Event Review Summaries signed by Staff Y, Behavioral Health Technician (BHT); Staff Staff Z, BHT; Staff T, Charge Registered Nurse (RN); Staff DD, RN and Staff AA, RN; documented that the patient was self-harming and placed in restraints.
- Event Review Summary signed by Staff EE, Licensed Practical Nurse (LPN) on 08/16/17 at 3:59 PM, documented that a Security Guard (unnamed) was witnessed during the restraint process, to forcefully bend the patient's thumb back. Staff EE heard a "crack" and the patient screamed out in pain. The patient complained of shooting pain from her thumb into her forearm, right ankle, back, and right side of face above the patient's eye (swelling was visible). The patient's pain was communicated to nursing four times in four hours, but pain medication was never administered. The patient remained in restraints for several hours after she met criteria for restraints to be discontinued, because Staff CC would not release the patient from restraints. The charge nurse (unnamed) was informed, who shrugged her shoulders and stated it was Staff CC's "call".
- Event Review Summery signed by Staff DD, RN, on 08/15/16 at 6:57 PM, documented that the patient calmed down after she was placed in restraints.

Observation on 08/23/17 at 2:08 PM, of recorded video surveillance on 08/15/17, showed the following in the Psychiatric Center:
- At 6:36 PM, the patient was carried by multiple staff from one room into another, where restraints were prepared on a bed, the patient was laid face up on the bed, and staff began to restrain the patient.
-At 6:38 PM, a security guard on the patient's right, who held the patient's right arm, lifted and pressed his right knee on the patients bent elbow. The patient attempted to grab the security guard's arm, the security guard's motion and intensity increased, and the patient repeatedly screamed, "Ow!"
- At 6:39 (and :04 seconds) PM, the same security guard pulled the patient's right hand/portion of the hand down toward the patient's wrist (partially visible) then readjusted his grip and grabbed the patient's entire hand and pulled it toward the patient's wrist. At the same time, a Psychiatric Center staff member taps the Security Guard's hand and then gently placed her hand over the security guard's hand while the security guard held the patient's hand down against her wrist. Security guard then responded, "You stop fighting, we stop (inaudible)". At 6:39 (and :15 seconds) PM, the patient stated "You broke my fucking thumb", and continued to scream about her thumb.
- At 6:40 PM, after the patient was fully restrained, 12 staff stood around the patient, when the same security guard bent over the patient and stated, "You brought this on", and the patient responded, "You don't have to hurt me though". The patient appeared to look at her right thumb and said, "My fucking thumb is swollen" and then cried out, "My fucking neck".

Record review of an email dated 08/31/17 at 11:59 PM, showed the facility identified the security guard in question as Staff QQ.

During a telephone interview on 08/30/17 at 3:22 PM, Staff II, RN stated that during the Code 10 seclusion and restraint called for Patient #4 on 08/15/17:
- She saw a security guard (unnamed, but stood to the patient's right side during restraint application) press the patient's thumb against the patient's wrist, and the security guard had his body weight on the patient's right shoulder and right arm, while the patient screamed that her thumb was breaking.
- She told the security guard that he was breaking the patient's thumb, and asked him to let up on the patient, but he wouldn't do it and ignored her (Staff II).
- Other staff witnessed the security guards excessive force with the patient.
- Once the patient's right arm was restrained, she could see Patient #4's right thumb and palm area "was turning purple".
- She confronted the security guard and told him that he had applied to much pressure to the patient, but the security guard responded that the patient was too agitated not to.
- She believed the security guard abused Patient #4.

During an interview on 08/24/17 at 4:15 PM, Staff T, BHT, stated that during the Code 10 seclusion and restraint called for Patient #4 on 08/15/17:
- She heard the patient state that staff were hurting her neck, her arm and her wrist.
- She saw Staff QQ, Security Officer, used a thumb hold on the patient (to bend the patient's thumb toward the patient's wrist, to get the patient to comply), while the patient said that she was hurt.
- The patient expressed that she thought her thumb was broken and that her neck hurt.

During a telephone interview on 08/25/17 at 11:04 AM, Staff FF, RN, stated that during the time Patient #4 was placed in restraints on 08/15/17, the Patient #4 stated that she was being hurt, so she (Staff FF) told security to be "easy" with the patient.

During an interview on 08/25/17 at 2:04 PM, Staff EE, LPN, stated that during the Code 10 seclusion and restraint called for Patient #4 on 08/15/17:
- During the restraint placement, she saw one of the security guards (name unknown) bend the patient thumb, and heard it pop.
- When she saw what happened to the patient, she reported to Staff TT, Charge RN, "I think they just broke her thumb".
- She reported this to Staff X, Psychiatric Center Director, on 08/16/17, who had her (Staff EE) watch the video, and point out the staff who bent the patient's thumb.

During an interview on 08/25/17 at 12:20 PM, Staff Y, BHT, stated that after the Code 10 seclusion and restraint of Patient #4 on 08/15/17, the patient appeared to be in pain, had facial swelling above her right eye, and complained of arm pain and thumb pain and requested Ibuprofen.

Record review of Patient #4's medical record showed a Progress Note dated 05/15/17 at 7:06 PM by Staff RR, Psychiatrist, which documented that the patient believed her right wrist and thumb were broken because security had bent it and she (the patient) heard a crack.

During an interview on 08/24/17 at 1:42 PM, Staff QQ, Security Guard, stated that all of the techniques used on Patient #4 during the restraint of Patient #4 on 08/15/17, were approved techniques and were not abuse.

Record review of Staff QQ's "Time Detail" record (documentation of actual time worked) showed that he was not immediately removed from patient care, that he worked the remainder of his shift until 08/16/17 at 12:09 AM, and continued to work five shifts (through 08/23/17), after he was alleged to have abused Patient #4.

During an interview on 09/05/17 at 8:41 AM, Staff R, Psychiatric Center Manager, stated that after she reviewed the video of Patient #4's Code 10 seclusion and restraint, and the Event Summaries submitted by staff, she did not know if Staff QQ was removed from patient care, and understood that failure to remove the security guard from patient care could allow continued abuse of patients.

During a telephone interview on 09/05/17 at 3:53 PM, Staff X, Psychiatric Center Director, stated that she didn't know if Staff QQ continued to work with patients after the alleged abuse on 08/15/17. "Obviously there was the potential for continued abuse, but that wasn't my call."

Observation on 08/23/17 at 2:08 PM, of recorded video surveillance on 08/15/17 which showed the following in the Psychiatric Center:
- At 7:01 PM, Staff RR, Psychiatrist, and another female staff member entered Patient #4's room, when the patient stated that she thought her thumb and wrist were broken. At 7:04 PM, the staff member grabbed the patient's right hand, and the patient yelled out in pain.
- From 7:00 PM until 8:00 PM, Patient #4 repeatedly cried out and complained of right thumb, wrist, forearm and elbow pain, repeatedly requested pain medication (Ibuprofen) and repeatedly requested x-rays. The patient informed a total of four staff (including Staff RR, Physician) of the patient's pain. Other than crying out in pain, the patient remained calm and compliant during this time.
- From 8:06 PM, the patient complained of continued pain to a fifth staff member, and stated her thumb, wrist and forearm were throbbing.
- At 8:39 PM, the patient cried out that her right arm pain was unbearable, and at 8:41 PM, stated, "It hurts."
- At 8:50 PM, a nurse (verified by the facility to be Staff CC, RN) stood in the doorway and asked the patient what happened. The patient responded, "I wouldn't stop hurting myself." The nurse replied to the patient, "That's not why you ended up in here", when the patient repeated that it was the reason. The nurse then asked the patient what could be done differently (to ensure the patient didn't end up in seclusion/restraints), when the patient responded that she agreed she would talk to staff when she became upset. Staff CC checked the restraints, but did not loosen or remove the restraints.
- At 8:56 PM, the patient complained of pain, and when medications were administered, the patient did not receive pain medication.

Record review of a Progress Note dated 08/15/17 at 7:06 PM by Staff RR, Psychiatrist, that the patient did not receive ordered medications for aggression, "due to the patient being able to calm herself down".

Record review of an assessment completed on 08/15/17 at 7:40 PM, showed Staff CC, RN (as confirmed by hospital staff), documented that Patient #4:
- Was guarded and unwilling to participate;
- Was agitated and uncooperative;
- Was irritable;
- Was unwilling to commit (to safety plan) and unwilling to answer questions about if she was having hallucinations;
- Refused to answer if she would harm others,
- Denied pain; and
- Was in five point restraints (restraint of both arms, legs, and the waist).
When compared to video review, no staff completed the assessment as documented on or around the time of 7:40 PM. Video showed that the patient was calm and cooperative but continually complained of pain. Video also showed that Staff CC was not in the patient's room until after 8:50 PM.

During an interview on 08/25/17 at 2:04 PM, Staff EE, LPN, stated that after Patient #4's restraint episode on 08/15/17:
- She reported four times to Staff CC, RN, that the patient needed pain medication, but Staff CC never administered pain medication to the patient.
- She reported to Staff CC, that the patient was safe to come out of the restraints, when Staff CC responded, "Her (Patient #4) actions have consequences".
- The patient complained of a blister on her foot, and the restraint was so tight that she (Staff EE) couldn't pull the patient's sock down to assess the patient's foot. She reported the tightness of the restraint to Staff CC, but Staff CC refused to loosen the restraint.
- She reported Staff CC's actions to Staff FF, Charge Nurse, who responded that it was Staff CC's decision, and shrugged her shoulders.
- She reported her concerns to Staff X, Psychiatric Center Director, on 08/16/17.

During an interview on 08/25/17 at 12:20 PM, Staff Y, BHT, stated that after Patient #4's restraint episode on 08/15/17:
- The patient appeared to be in pain, had facial swelling above her right eye, and complained of arm pain and thumb pain and requested Ibuprofen.
- Staff EE, LPN, had requested Staff CC, RN, to get the patient something for pain, but pain medication was not administered to the patient.
- She had concerns with the amount of time that the patient remained in restraints and voiced her concerns to Staff CC, because the patient was calm for several hours while she continued to be restrained.
- Staff CC, voiced that she believed Patient #4 was "gaming" (manipulation), wouldn't release the patient from restraints at the request of staff, and informed staff that she was in charge and that staff couldn't tell her what to do.
- Staff FF, Charge Nurse, was informed of Staff CC's care of Patient #4, when Staff FF responded that it was Staff CC's "call".

During an interview on 09/05/17 at 10:05 AM, Staff CC, RN, stated:
- She did not assume care of Patient #4 until after 8:00 PM, because the patient was not her responsibility until she received report.
- The report she received from Staff AA, RN, was that the patient's thumb or hand may have been injured during restraint/seclusion.
- The BHT requested pain medication for the patient several times.
- During her initial assessment of the patient, she loosened the patient's right wrist and right leg restraint because the patient complained of pain to both (not seen on video review).
- She (Staff CC) never administered pain medication to the patient and did not contact the physician for a pain medication order, because the doctor did not order pain medication when the doctor was made aware of the thumb injury.
- The patient stated that she was placed in restraints because she continued to harm herself, but the real reason the patient went into restraints was because she was aggressive.
- There were many factors for assessing whether the patient could be removed from restraints, and included if they could contract for safety (agree to not harm self or others).
- Patient #4 stated that she would not harm herself, but she (Staff CC) didn't feel the patient was safe because of "the way she said things".
- She contacted the physician for continued restraint orders, because the patient had underlying hostility.
- Patient #4 remained in restraints and seclusion not only because of Patient's 4's behavior, but because of the behavior of other patients on the unit.
- None of the staff voiced that they felt the patient needed to come out of restraints.
- Assessment for the release of restraint should occur every two hours.
- She believe her assessment of Patient #4, and the time she continued to restrain the patient, were appropriate.

Record review of 15 minute monitoring on 08/15/17 of Patient #4's restraint and seclusion showed that the patient was calm but remained in restraints on from 7:15 PM until 10:45 PM, and slept in restraints on 08/16/17 from 12:00 AM through 1:00 AM.

Record review of an email dated 08/29/17 at 4:13 PM, showed the facility's review of video showed that Patient #4 remained in restraints until 08/16/17 at 12:35 AM, and remained in seclusion until 08/16/17 at 9:39 AM.

During an interview on 09/05/17 at 8:41 AM, Staff R, Psychiatric Center Manager, stated that staff should process patients out of restraint and/or seclusion as soon as they are able to process and state they won't hurt themselves.

During a telephone interview on 09/05/17 at 3:53 PM, Staff X, Psychiatric Center Director, stated that during abuse and neglect training, the first step to take with witnessed or reported abuse or neglect, was to remove staff from patient care.

Record review of Staff CC's "Time Detail" record showed that she was not immediately removed from patient care, continued to work the remainder of her shift until 08/16/17 at 6:48 AM, and worked again on 06/21/17 for 12 hours, after she was alleged to have neglected Patient #4.

An action plan related to the facility's internal investigation of the events on 08/15/17, as related to the Code 10 restraint and seclusion of Patient #4, did not include immediate interventions to ensure all staff were educated on the process to immediately removal staff from patient care, who were alleged to have abused or neglected a patient.

3. Record review of Patient #1's medical record dated 06/24/17 showed the following:
- Patient #1 arrived to the Emergency Department (ED), via private vehicle, accompanied by a friend at 11:21 PM for left arm numbness.
- The patient's current medications were Ativan (for anxiety), Hydrocodone (for pain), Seroquel (anti-psychotic used to treat schizophrenia, bipolar and depression) and Atarax (used to treat allergies and anxiety).
- The patient's vital signs were within normal range.
- The patient was then seated in the waiting room next to his friend.
- Staff D, Security Guard, approached the patient and asked him not to use foul language.
- Staff D, left the patient and walked back over to his desk.
- Staff G, Registered Nurse (RN), documented that the patient flopped himself on the floor and the friend told her he was having a seizure.
- Staff G asked Staff D to bring a gurney for the patient to lie on.
- The patient yelled and stated profanities, then threw himself off of the gurney, cursed at security and stated that he was going to another fucking hospital for help where they did not treat Veterans like this.
- At this time the patient, friend and security went out the ED entrance.
- The Patient Refusal of Services form dated 06/25/17 at 12:15 AM showed that the patient left without being seen-before triage.

Review of the recorded video surveillance dated 06/24/17 showed the following:
- At 11:19 PM, Patient #1 entered the ED with a complaint of left arm numbness, sat down, registered, Staff H, ED Technician, took the patient's vital signs and the patient calmly gave Staff G, RN, a pocket knife to keep until his discharge.
- At 11:27 PM, the patient entered the waiting room, walking with a cane, and sat down next to his friend.
- At 11:28 PM, Staff D, Security Guard, entered the waiting room and asked the patient not to use foul language. The patient responded calmly at this time. Staff D continued to banter with the patient and the patient stated, "I am a veteran and I know my rights." Staff D responded and stated, "He was a veteran too and that didn't matter." The patient and Staff D continued to banter back and forth, then the patient's friend stated calmly, "Please leave him alone, can't you see that he has something wrong?"
At this time, Staff D, walked away over to the desk.
- At 11:33 PM, showed that Patient #1 slid slowly out of his chair, onto the floor and was visibly shaking and in distress. The patient's friend alerted the staff that the patient had a seizure. Staff G, RN, walked over by the patient and spoke to him. Staff G did not lean down to speak with the patient, stood near him and stated, "You're alright," in a sarcastic tone. Staff G then asked Staff D, Security Guard, to bring a gurney.
- At 11:35 PM, Staff D, wheeled a gurney over and the patient became agitated when he saw that it was Staff D bringing the gurney. The patient stated that he did not want Staff D to help at all and that he did not like him. The patient's agitation had escalated. Staff D remained in sight of the patient which continued to escalate the patient. Staff H, ED Technician, Staff I, RN and Staff G, RN, came out to assist with the patient. Banter between the patient and the staff continued with the patient cursing. The patient's friend helped the patient to stand up and the patient physically staggered over to the gurney. At this time, Staff D, Security Guard, stood next to the gurney. The patient escalated more, moved off of the gurney, stated that he wanted to go to another fucking hospital where he would be treated better and walked with his friend with a cane toward the exit.
- At 11:37 PM, showed Staff D followed the patient and his friend out into the driveway. Staff D continued to follow them toward the parking lot, bantering back and forth, which escalated the patient more.
- At 11:38 PM, showed that Staff C, Security Guard, joined Staff D outside at the scene. Staff C walked next to Staff D and reached in his pocket and put his gloves on. Staff C walked forward and attempted to intimidate the patient and his friend. Staff C then pushed the patient's back, pushed the friends back, pushed the patient's back and then pushed the friend with the cane two times while walking back and forth between them. The patient's friend then sat down on the curb with his cane beside him. Staff C and Staff D continued to banter with both the patient and his friend. Staff C paced on the sidewalk until he reached out with left hand and grabbed the patient. Staff D joined Staff C and tackled the patient to the ground. The patient's head hit the ground two times and had a visible scrape on his forehead. Staff C then placed handcuffs on the patient's hands behind his back, lying on his stomach.
- At 11:41, Staff C, picked patient up and placed him on the curb next to his friend.
- At 11:47, the local police department arrived and assessed the situation.
- At 11:52, Staff G, RN, brought the patient's pocket knife in a baggy out and handed it to the local police officer.
- At 11:58, after speaking with the patient and his friend away from Staff C and Staff D, the local police officers took the handcuffs off of the patient and allowed them to leave.

Record review of the facility's Mercy Safety Event Review dated 06/30/17 at 11:10 AM showed the review of the incident with Patient #1 was documented as emotional distress or inconvenience and reviewed by the Leadership Team on 06/29/17 where they developed an action plan. The action plan was to provide education on PTSD (post traumatic stress disorder) to all nurses, technicians and security, security officer involved was provided one on one education on de-escalation and the video of the incident was utilized as training for security officers. The investigation showed no interviews with staff, no further investigation and no self report to the state office.

During an interview on 08/24/17 at 4:50 PM, Staff D, Security Guard, stated that he never felt threatened and that Staff C, Security Guard, initiated the contact with Patient #1 outside in the circle drive of the ED. He stated that he never touched the patient and that he felt that Staff C handled this inappropriately and exaggerated the situation. He also stated that when Staff C grabbed the patient that at that time he needed to support his fellow officer and continue with the take down and handcuffs. Staff D stated that he did report this to his supervisor, Staff JJ, Third Shift Sergeant.

During an interview on 08/25/17 at 11:14 AM, Staff C, Security Guard, stated that:
- He arrived on the scene when Staff D, Security Officer was outside of the ED in the driveway with Patient #1 and his friend.
- He told the patient that they would detain him because he thought Staff D was in danger.
- He felt that his actions were appropriate and he didn't remember pushing the patient.
- He had never been coached or reprimanded after the incident.

During an interview on 08/24/17 at 5:00 PM, Staff G, RN, stated that she never spoke to her supervisor about this incident.

During an interview on 08/25/17 at 11:00 AM, Staff HH, Third Shift Sergeant for Security, stated that Staff C should not have shoved the patient in the back and he felt like this escalated the situation. He expected the officers to do the least and if the patient wasn't attacking them then they should have created space between them. He also stated that he reported this incident to his supervisor, Staff LL.

During an interview on 08/25/17 at 2:37 PM, Staff E, Director of Security, stated that:
- He wasn't proud of this video.
- After he reviewed the video on Monday 08/26/17, he spoke with Staff C and Staff D about de-escalation and told them that once the patient was at the exit door they should have let him go without following him.
- He had 1:1 coaching with Staff C and Staff D.
- He reported this to his supervisor, Staff TT, Vice President of Support Services.

Record review of Staff C, Security Guard's time card showed that he continued to work 29 shifts from 06/24/17 to 08/25/17 and Staff D, Security Guard's time card showed that he continued to work 40 shifts from 06/24/17 to 08/24/17. The documentation showed that Staff C and Staff D continued to work and were not put on leave or removed from patient care. The staff did not recognize this as abuse and did not follow their policy to remove these coworkers.

4. Record review of Patient #2's medical record dated 04/30/17 through 05/02/17 showed the following:
- Patient #2 was a 28 year old female that voluntarily was admitted to the psychiatric unit on 04/30/17 at 5:40 PM for treatment of suicidal ideation.
- History and physical (H&P) reviewed showing the patient had major depressive disorder, generalized anxiety disorder, PTSD and a chest wall contusion. The patient's current medications were Benadryl (antihistamine), Haldol (antipsychotic), Atarax (used to treat allergies and anxiety), Motrin (antiinflamatory), Ativan (for anxiety), Remeron (antidepressant), Nicoderm patch (to help with withdrawal from smoking) and Zyprexa (antipsychotic).
- On 05/01/17 at 4:44 PM, the patient was taken by manual hold to the seclusion area after physically attacking Staff M, Behavioral Health Technician (BHT).
- The patient was place in 4-point restraints with 1:1 and video monitoring.
- At 6:00 PM the restraints were removed.
- At 6:45 PM the patient had returned to her room.

Review of the recorded video surveillance dated 05/01/17 showed the following:
- At 4:27 PM Patient #2 was yelling at staff upset about her roommate being touched by a male patient on the unit.
- She became loud and agitated so nursing called security.
- At 4:33 PM, Staff N, Security Guard and Staff M, BHT guided the patient into the lunchroom away from other patients.
- The patient stated that she was thirsty and continued to yell about not wanting to be by herself with any male staff.
- The patient did not understand why she was being isolated in the lunchroom area.
- Staff M, BHT, was in and out of the room taking care of other patients.
- Staff N continued to question the patient and the patient made it clear she wanted him to leave her alone and stated that she was not the one that was attacked.
- After a few minutes, the patient walked over to the sink to pick up a pitcher of tea and pour into a cup. At this time, Staff N, Security Guard, grabbed the patient. The patient responded by throwing the pitcher of tea at Staff N. Staff N wrestled the patient to the floor and Staff O, Security Guard, joined in restraining the patient on the floor. Staff M, BHT was not in the room at this time. She was at the door.
- Staff R, RN, called a Code 10 (emergency code for assistance with a violent person).
- When the patient was being restrained on the floor by Staff N, Staff O and Staff M, the video was blocked, but it appeared that when Staff N repositioned his knee the patient screamed out, "Get off of my arm," and the patient continued to cry.
- At 4:41 PM Staff R, RN entered the room and assisted with carrying the patient to the seclusion room.
- During this transport, the patient grabbed Staff M, BHT's hair. At that time, they brought the patient down to the floor. Staff N and Staff O were unsuccessful in removing the BHT's hair from the patient's hand.
- Staff F, Security Guard, and Code 10 Responder, arrived and instructed the staff to let go of the patient and with a closed fist he hit the back of the patient's hand 3-4 times. The patient began crying out and released the BHT's hair.
- The patient was then carried to the seclusion room and placed in 5-point locked restraints. The patient's right arm was twisted off of the bed. The screamed out, "You are hurting my arm" and "I just wanted to get a drink and he attacked me."
- Restraints were on from 4:45 PM until 6:45 PM.

Record review of the facility's Mercy Safety Event Review dated 05/01/17 at 11:22 PM showed that it was documented as emotional distress or inconvenience and assault by a patient. Action response documented by Staff R, RN Manager, stated that the Treatment Team met, reviewed the Code 10 and identified break down in the process. A lead communicator was not assigned which left security and a BHT to de-escalate the situation. Re-education was done with the patient's RN and security was re-educated on de-escalation skills. Staff did not recognize this as assault on a patient.

During an interview on 08/25/17 at 11:45 AM, Staff N, Security Guard, stated the following:
- He was called to psychiatric unit by nursing to help with an agitated patient.
- He heard female yelling and upset with nursing staff.
- Nursing staff requested that he go speak with Patient #2.
- He tried to speak with her, but she was upset with Staff M, BHT.
- Staff M stepped forward talking to the patient and then the patient escalated again.
- The patient moved forward quickly toward the tea pitcher and he backed away from her.
- He was between the patient and Staff M, BHT and the patient took the tea jug and ran.
- He grabbed patient's right arm with his right and left arm, she threw the tea jug at his face and then he remembered being on the ground restraining her.
- He asked for guidance from Staff R, RN Manager.
- He tried to adjust his body when he had restrained the patient and his knee was above her.
- He remembered that the patient yelled about pain.
- When he, Staff O and Staff M carried the patient the patient grabbed Staff M's hair.
- He attempted to open the patient's hand to free Staff M's hair and was unsuccessful.
- Staff F, Security Guard, walked up and used two fingers, tapped the patient's hand and the patient let go of the hair.
- He remembered the patient stated, "They didn't know how to put on restraints" and he left the room.

During an interview on 08/25/17 at 12:23 PM, Staff M, BHT, stated that:
- Before the incident Patient #2 asked for a drink at the nurse's station.
- She brought the patient in the lunchroom for a drink and the patient continued to escalate.
- A Code 10 was called.
- Security arrived and when she turned to leave the patient grabbed the tea pitcher and made motion to throw. At this time Staff N, Security Guard, restrained the patient.
- She had the patient's legs during the transport and the patient got a hand loose and grabbed her hair.
- During the time Staff F, Security Guard, used a technique to release her hair, her face was to the ground and didn't see it.
- She declined going to the ED for medical attention.

During an interview on 08/24/17 at 3:45 PM, Staff F, Security Guard, stated that:
- He was the supervisor on duty that day.
- He came on the scene after the Code 10 was called and arrived when they were moving the patient to the seclusion room.
- He saw that Staff O's attempt of releasing the Staff M's hair was unsuccessful.
- He wrapped his knuckles 4 times onto the patient's hand and she released Staff M's hair.
- This was not an approved hospital technique but one he had used with his previous training.

During an interview on 08/25/17 at 12:48 PM, Staff O, Security Guard, stated that he recalled that Staff F took his door knocking knuckles and tapped the patient on the back of her hand.

During an interview on 08/25/17 at 1:30 PM, Staff U, BHT, stated that Staff F pounded the patient's hand with a closed fist downward two times to release Staff M's hair. He also stated that this was not approved training.

During an interview on 08/25/17 at 2:37 PM, Staff E, Director of Security, stated that Staff N shouldn't have gone toward the patient and should have given the patient space. He also stated that Staff F

Based on observation, interview, record review, policy review and review of recorded video surveillance the facility failed to:
- Prevent abuse and/or neglect for four patients (#1, #2, #3 and #4) of four patients reviewed;
- Adequately investigate allegations of staff to patient abuse and/or neglect in a timely manner for four patients (#1, #2, #3 and #4) of four patients reviewed for allegations of abuse; and
- Allow staff involved in the allegations of abuse to continue to work with patients;
These failures had the potential to place all patients admitted to the facility at risk for their safety from abuse and neglect by staff. The facility census was 384. The Psychiatric Center census was 27.

Findings included:

1. Record review of the facility's policy titled, "Reporting and Investigating Allegations of Patient Abuse, Neglect, or Harassment," dated 02/2017, showed that:
- All forms of abuse, neglect, and harassment whether reportedly inflicted by coworkers, patients, or other persons are prohibited.
- Coworkers are to immediately report witnessed, alleged, or suspected signs of abuse, neglect, or harassment to their immediate supervisor, charge nurse, manager, or house supervisor.
- The supervisor who receives the report should assess the patient, document findings, assure patient safety, notify the physician and escalate to leadership to initiate the investigation.
- Coworker(s) involved in the allegation will be immediately removed from any patient care/contact and will be placed on investigatory leave.
- The Director of Patient Safety will initiate the self-report to the State agency within 24 hours of discovery.

2. Record review of the facility's policy titled, "Security Department Use of Control Policy," dated 05/2017, showed that:
- Only the least amount of force reasonable is used to overcome the level of resistance offered.
- The use of excessive control or force, regardless of the subject's threats, will result in disciplinary measures up to and including termination of employment.
- Handcuffs should only be used after an active aggressive incident and used as a safety measure for the officer, victim, witnesses, or when there is a prior knowledge that active aggressive acts could occur.

3. Record review of the facility's policy titled, "MCA (Marion Center Available Staff, [Psychiatric Unit]) Security Response and De-escalation Training," dated 05/05/17, showed the following:
- Medical staff should always be present when Security is dealing with a patient.
- Security should not escalate to a hands-on situation except when a violent act has been committed or there is reasonable expectation that it will occur.
- Security will wait to intervene unless requested by medical staff or if the situation is violent and/or could cause harm to the patient or others.

4. Record review of the Missouri Department of Mental Health policy titled, "Use of Seclusion and Restraints," dated 07/01/16 showed that:
- Restraint and seclusion shall be utilized only to ensure the immediate physical safety of the individual, a staff member, or others and discontinued at the earliest possible time.
- Restraint and seclusion are only used when less restrictive interventions have been determined to be ineffective.
- Restraint and seclusion should be initiated only in those individual specific situations in which an emergency safety need is identified, and these interventions should be implemented only by competent, trained staff.

5. Record review of the facility's internal investigation of a Code 10 response to Patient #4 on 08/15/17 showed:
- Staff R, Psychiatric Center Nurse Manager and Staff X, Psychiatric Center Director, reviewed video recordings of a Code 10 that resulted in the restraint and seclusion of Patient #4.
- Event Review Summary signed by Staff EE, Licensed Practical Nurse (LPN) on 08/16/17 at 3:59 PM, documented that a Security Guard (unnamed) was witnessed during the restraint process, to forcefully bend the patient's thumb. Staff EE heard a "crack" and the patient screamed out in pain. The patient complained of shooting pain from her thumb into her forearm, right ankle, back, and right side of face above the patient's eye (swelling was visible). The patient's pain was communicated to nursing four times in four hours, but pain medication was never administered. The patient remained in restraints for several hours after she met criteria for restraints to be discontinued, because Staff CC, Registered Nurse (RN) would not release the patient from restraints. The charge nurse (unnamed) was informed, who shrugged her shoulders and stated it was Staff CC's "call".
- Event Review Summery signed by Staff DD, RN, on 08/15/16 at 6:57 PM, documented that the patient calmed down after she was placed in restraints.
- Findings in the investigation review from Staff R, Psychiatric Nurse Manager and Staff X, Psychiatric Center Director, dated 08/16/17 at 4:00 PM, did not include abuse or neglect of the patient.
- Documented interviews related to the investigation were not initiated until 08/23/17. (Indicated that the facility investigation was not immediate).

6. Observation on 08/23/17 at 2:08 PM, of recorded video surveillance on 08/15/17, showed the following in the Psychiatric Center:
- At 6:36 PM, Patient #4 was carried by multiple staff from one seclusion room into another, where restraints were prepared on a bed, the patient was laid face up on the bed, and staff began to restrain the patient.
-At 6:38 PM, a security guard on the patient's right, who held the patient's right arm, lifted and pressed his right knee on the patients bent elbow. The patient attempted to grab the security guard's arm, the security guard's motion and intensity increased, and the patient repeatedly screamed, "Ow!"
- At 6:39 PM, the same security guard pulled the patient's right hand/portion of the hand down toward the patient's wrist (partially visible) then readjusted his grip and grabbed the patient's entire hand and pulled it toward the patient's wrist. At the same time, a Psychiatric Center staff member tapped the Security Guard's hand and then gently placed her hand over the security guard's hand while the security guard held the patient's hand down against her wrist. Security guard then responded, "You stop fighting, we stop (inaudible)". At 6:39 (and :15 seconds) PM, the patient stated "You broke my fucking thumb", and continued to scream about her thumb.
- At 6:40 PM, after the patient was fully restrained, 12 staff stood around the patient, when the same security guard bent over the patient and stated, "You brought this on", and the patient responded, "You don't have to hurt me though". The patient appeared to look at her right thumb and said, "My fucking thumb is swollen" and then cried out, "My fucking neck".

Record review of an email dated 08/31/17 at 11:59 PM, showed the facility identified the security guard in question as Staff QQ.

During a telephone interview on 08/30/17 at 3:22 PM, Staff II, RN stated that during the Code 10 seclusion and restraint called for Patient #4 on 08/15/17, she saw a security guard (unnamed, but stood to the patient's right side during restraint application) press the patient's thumb against the patient's wrist, and the security guard had his body weight on the patient's right shoulder and right arm, while the patient screamed that her thumb was breaking. Staff II stated that she believed the security guard abused the patient, but did not report the abuse until 08/30/17.

During an interview on 08/24/17 at 4:15 PM, Staff T, Behavioral Health Technician (BHT), stated that during the Code 10 seclusion and restraint called for Patient #4 on 08/15/17, she saw Staff QQ, Security Guard, used a thumb hold on the patient (to bend the thumb toward the wrist, to gain compliance).

During an interview on 08/25/17 at 2:04 PM, Staff EE, LPN, stated that during the Code 10 seclusion and restraint called for Patient #4 on 08/15/17, she saw one of the security guards (name unknown) bend the patient's thumb and heard it pop, which she immediately reported to Staff TT, Charge RN, and on 08/16/17, reported it to Staff X, Psychiatric Center Director.

During an interview on 08/24/17 at 1:42 PM, Staff QQ, Security Guard, stated that all of the techniques used on Patient #4 during the restraint of Patient #4 on 08/15/17, were approved techniques and were not abuse.

During a telephone interview on 09/05/17 at 8:41 AM, Staff R, Psychiatric Center Manager, stated that she reviewed the video of Patient #4's Code 10 seclusion and restraint, as well as the Event Summaries submitted by staff, but did not know the security guard alleged of abuse, or the outcome of the investigation. Staff R stated that she and Staff X, Psychiatric Center Director, had previously reported concerns about security guards escalating patients and the holds used on patients to upper leadership, which included Staff YY, Chief Nursing Officer, but leadership stated the techniques used by security were appropriate.

During a telephone interview on 09/05/17 at 3:53 PM, Staff X, Psychiatric Center Director, stated that she was concerned the allegation that the security guard bent Patent #4's thumb back was abuse, that there were times when security staff were abusive toward patients, and reported her concerns to Staff YY, Chief Nursing Officer.

Record review of an email from Staff JJ, Chief Operating Officer, dated 09/05/17 at 4:28 PM, showed that the investigation related to Staff QQ's alleged abuse of Patient #4 was complete. A written statement signed by Staff QQ, Security Guard was attached to the email and dated 09/05/17. This showed that the facility's investigation of abuse continued for 21 days after the abuse was alleged to have occurred. The facility found that the allegation that Staff QQ abused Patient #4 was unsubstantiated.

Observation on 08/23/17 at 2:08 PM, of recorded video surveillance on 08/15/17 between 7:00 PM and 8:50 PM, showed that Patient #4 was calm (except when she cried out in pain) and cooperative, continued to remain in restraints, and complained of pain to five patient care staff. At 8:50 PM, a nurse (verified by the facility to be Staff CC, RN) stood in the doorway and asked the patient what happened, and what could have been done to prevent restraints/seclusion, when the patient responded that she agreed she would talk to staff when she became upset. The nurse checked the patient's restraints, but did not loosen or remove the restraints. At 8:56 PM, the patient complained of pain, and when medications were administered, the patient did not receive pain medication.

Record review of an assessment completed on 08/15/17 at 7:40 PM, showed Staff CC, RN (as confirmed by hospital staff), documented that Patient #4:
- Was guarded and unwilling to participate;
- Was agitated and uncooperative;
- Was irritable;
- Was unwilling to commit (to safety plan) and unwilling to answer questions about if she was having hallucinations;
- Refused to answer if she would harm others,
- Denied pain; and
- Was in restraints.
When compared to video review, no staff completed the assessment as documented on or around 7:40 PM. Video showed that the patient was calm and cooperative but continually complained of pain. Video also showed that Staff CC was not in the patient's room until after 8:50 PM (verified by hospital staff), and therefore could not have performed an assessment of the patient, or accurately documented the patient's condition.

During an interview on 08/25/17 at 2:04 PM, Staff EE, LPN, stated that after Patient #4's restraint episode on 08/15/17:
- She reported four times to Staff CC, RN, that the patient needed pain medication, but Staff CC never administered pain medication to the patient.
- She reported to Staff CC, that the patient was safe to come out of the restraints, when Staff CC responded, "Her actions have consequences".
- The patient complained of a blister on her foot, and the restraint was so tight that she (Staff EE) couldn't pull the patient's sock down to assess the patient's foot.
- She reported the tightness of the restraint to Staff CC, but Staff CC refused to loosen the restraint.
- She reported Staff CC's actions to Staff FF, Charge Nurse, who responded that it was Staff CC's decision, and shrugged her shoulders.
- She reported her concerns to Staff X, Psychiatric Center Director, on 08/16/17.

During an interview on 08/25/17 at 12:20 PM, Staff Y, BHT, stated that after Patient #4's restraint episode on 08/15/17:
- The patient appeared to be in pain, had facial swelling above her right eye, and complained of arm pain and thumb pain and requested Ibuprofen.
- Staff EE, LPN, had requested Staff CC, RN, to get the patient something for pain, but pain medication was not administered to the patient.
- She had concerns with the amount of time that the patient remained in restraints and voiced her concerns to Staff CC, because the patient was calm for several hours while she continued to be restrained.
- Staff CC, voiced that she believed Patient #4 was "gaming" (manipulation) and wouldn't release the patient from restraints at the request of staff.
- Staff FF, Charge RN, was informed of Staff CC's care of Patient #4, when Staff FF responded that it was Staff CC's "call".

During a telephone interview on 09/05/17 at 10:05 AM, Staff CC, RN, stated:
- She did not assume care of Patient #4 until after 8:00 PM, because the patient was not her responsibility until she received report.
- The report she received from Staff AA, RN, was that the patient's thumb or hand may have been injured during restraint/seclusion.
- The BHT requested pain medication for the patient several times.
- During her (Staff CC's) initial assessment of the patient, she loosened the patient's right wrist and right leg restraint because the patient complained of pain to both (not seen on video review).
- She (Staff CC) never administered pain medication to the patient and did not contact the physician for a pain medication order, because the doctor did not order pain medication when the doctor knew about the thumb injury.
- The patient stated that she was placed in restraints because she continued to harm herself, but the real reason the patient went into restraints was because she was aggressive.
- There were many factors for assessing whether the patient could be removed from restraints, and included if they could contract for safety (contract to not harm self or others).
- Although Patient #4 agreed not harm herself, she (Staff CC) didn't feel the patient was safe because of "the way she said things".
- She contacted the physician for continued restraint orders, because the patient had "underlying hostility".
- Patient #4 remained in restraints and seclusion not only because of Patient's 4's behavior, but because of the behavior of other patients on the unit.
- None of the staff voiced that they felt the patient needed to come out of restraints.
- Assessment for the release of restraint should occur every two hours.
- She believed her assessment of Patient #4, and the time she continued to restrain the patient, were appropriate.

Record review of 15 minute monitoring on 08/15/17 of Patient #4's restraint and seclusion showed that the patient was calm but remained in restraints on from 7:15 PM until 10:45 PM, continued in restraints, and slept in restraints on 08/16/17 from 12:00 AM through 1:00 AM.

Record review of an email dated 08/29/17 at 4:13 PM, showed the facility's review of video showed that Patient #4 remained in restraints until 08/16/17 at 12:35 AM, and remained in seclusion until 08/16/17 at 9:39 AM.

During a telephone interview on 09/05/17 at 8:41 AM, Staff R, Psychiatric Center Manager, stated that staff should process patients out of restraint and/or seclusion as soon as they are able to process and state they won't hurt themselves.

Video and record review showed that the patient remained calm and cooperative, but remained in restraints, even while she slept. The patient repeatedly complained of pain to the right thumb/wrist/forearm, but no pain medication or alternatives to pain medication were provided to the patient by Staff CC, RN. Staff CC documented assessments of the patient that were not completed (falsified), and did not include factual assessment details related to the patient's condition.

An action plan related to facility's internal investigation of the events on 08/15/17, as related to the Code 10 restraint and seclusion of Patient #4, did not include immediate interventions to prevent the abuse and neglect of patients through the education of all facility staff in:
- The identification of abuse and neglect;
- The process for immediately reporting abuse and neglect;
- Appropriate management of patient reported pain;
- The complete, accurate and appropriate documentation of patient assessments; and
- The immediate removal of patients from restraint or seclusion.
The action plan also did not include education to departmental leadership and upper level management, related to timely and thorough investigations and reporting of abuse and neglect.

7. Record review of Patient #1's medical record dated 06/24/17 showed the following:
- Patient #1 arrived to the Emergency Department (ED), via private vehicle, accompanied by a friend, who walked with a cane, at 11:21 PM for left arm numbness.
- The patient's current medications were Ativan (for anxiety), Hydrocodone (for pain), Seroquel (anti-psychotic used to treat schizophrenia, bipolar and depression) and Atarax (used to treat allergies and anxiety).
- The patient's vital signs were within normal range.
- The patient was then seated in the waiting room next to his friend.
- Staff D, Security Guard, approached the patient and asked him not to use foul language.
- Staff D, left the patient and walked back over to his desk.
- Staff G, Registered Nurse (RN), documented that the patient flopped himself on the floor and the friend told her he was having a seizure.
- Staff G asked Staff D to bring a gurney for the patient to lie on.
- The patient yelled and stated profanities, then threw himself off of the gurney, cursed at security and stated that he was going to another fucking hospital for help where they did not treat Veterans like this.
- At this time the patient, his friend and security went out the ED entrance.
- The Patient Refusal of Services form dated 06/25/17 at 12:15 AM showed that the patient left without being seen-before triage.

Review of the recorded video surveillance dated 06/24/17 showed the following:
- At 11:19 PM, Patient #1 entered the ED with a complaint of left arm numbness, sat down, registered, Staff H, ED Technician, took the patient's vital signs and the patient calmly gave Staff G, RN, a pocket knife to keep until his discharge.
- At 11:27 PM, the patient entered the waiting room and sat down next to his elderly friend.
- At 11:28 PM, Staff D, Security Guard, entered the waiting room and asked the patient not to use foul language. The patient responded calmly at this time. Staff D continued to banter with the patient and the patient stated, "I am a veteran and I know my rights." Staff D responded and stated, "He was a veteran too and that didn't matter." The patient and Staff D continued to banter back and forth, then the patient's friend stated calmly, "Please leave him alone, can't you see that he has something wrong?"
At this time, Staff D, walked away over to the desk.
- At 11:33 PM, showed that Patient #1 slid slowly out of his chair, onto the floor and was visibly shaking and in distress. The patient's friend alerted the staff that the patient had a seizure. Staff G, RN, walked over by the patient and spoke to him. Staff G did not lean down to speak with the patient, stood near him and stated, "You're alright," in a sarcastic tone. Staff G then asked Staff D, Security Guard, to bring a gurney.
- At 11:35 PM, Staff D, wheeled a gurney over and the patient became agitated when he saw that it was Staff D bringing the gurney. The patient stated that he did not want Staff D to help at all and that he did not like him. The patient's agitation had escalated. Staff D remained in sight of the patient which continued to escalate the patient. Staff H, ED Technician, Staff I, RN and Staff G, RN, came out to assist with the patient. Banter between the patient and the staff continued with the patient cursing. The patient's friend helped the patient to stand up and the patient physically staggered over to the gurney. At this time, Staff D, Security Guard, stood next to the gurney. The patient escalated more, moved off of the gurney, stated that he wanted to go to another fucking hospital where he would be treated better and walked with his friend toward the exit.
- At 11:37 PM, showed Staff D followed the patient and his friend walking with a cane out into the driveway. Staff D continued to follow them toward the parking lot, bantering back and forth, which escalated the patient more.
- At 11:38 PM, showed that Staff C, Security Guard, joined Staff D outside at the scene. Staff C walked next to Staff D and reached in his pocket and put his gloves on. Staff C walked forward and attempted to intimidate the patient and his friend. Staff C then pushed the patient's back, pushed the friends back, pushed the patient's back and then pushed the friend two times while walking back and forth between them. The patient's friend then sat down on the curb with his cane beside him. Staff C and Staff D continued to banter with both the patient and his friend. Staff C paced on the sidewalk until he reached out with left hand and grabbed the patient. Staff D joined Staff C and tackled the patient to the ground. The patient's head hit the ground two times and had a visible scrape on his forehead. Staff C then placed handcuffs on the patient's hands behind his back, lying on his stomach.
- At 11:41, Staff C, picked patient up and placed him on the curb next to his friend.
- At 11:47, the local police department arrived and assessed the situation.
- At 11:52, Staff G, RN, brought the patient's pocket knife in a baggy out and handed it to the local police officer.
- At 11:58, after speaking with the patient and his friend away from Staff C and Staff D, the local police officers took the handcuffs off of the patient and allowed them to leave.

Record review of the facility's Mercy Safety Event Review dated 06/30/17 at 11:10 AM showed the review of the incident with Patient #1 was documented as emotional distress or inconvenience and reviewed by the Leadership Team on 06/29/17 where they developed an action plan. The action plan was to provide education on PTSD (post traumatic stress disorder) to all nurses, technicians and security, security officer involved was provided one on one education on de-escalation and the video of the incident was utilized as training for security officers. The investigation showed no interviews with staff, no further investigation and no self report to the state office.

During an interview on 08/24/17 at 4:50 PM, Staff D, Security Guard, stated that he never felt threatened and that Staff C, Security Guard, initiated the contact with Patient #1 outside in the circle drive of the ED. He stated that he never touched the patient and that he felt that Staff C handled this inappropriately and exaggerated the situation. He also stated that when Staff C grabbed the patient that at that time he needed to support his fellow officer and continue with the take down and handcuffs. Staff D stated that he did report this to his supervisor, Staff JJ, Third Shift Sergeant.

During an interview on 08/25/17 at 11:14 AM, Staff C, Security Guard, stated that:
- He arrived on the scene when Staff D, Security Officer was outside of the ED in the driveway with Patient #1 and his friend.
- He told the patient that they would detain him because he thought Staff D was in danger.
- He felt that his actions were appropriate and he didn't remember pushing the patient.
- He had never been coached or reprimanded after the incident.

During an interview on 08/24/17 at 5:00 PM, Staff G, RN, stated that she never spoke to her supervisor about this incident.

During an interview on 08/25/17 at 2:20 PM, Staff L, Nurse Manager of the ED, stated that she reviewed the video and that this involved non clinical staff. She also stated that Staff G should have been more compassionate with the patient and once the patient was outside they considered them to be discharged. She felt there needed to be better communication between the staff and security.

During an interview on 08/25/17 at 11:00 AM, Staff HH, Third Shift Sergeant for Security, stated that Staff C should not have shoved the patient in the back and he felt like this escalated the situation. He expected the officers to do the least and if the patient wasn't attacking them then they should have created space between them. He also stated that he reported this incident to his supervisor, Staff LL.

During an interview on 08/25/17 at 2:37 PM, Staff E, Director of Security, stated that:
- He wasn't proud of this video.
- After he reviewed the video on Monday 08/26/17, he spoke with Staff C and Staff D about de-escalation and told them that once the patient was at the exit door they should have let him go without following him.
- He had 1:1 coaching with Staff C and Staff D.
- He reported this to his supervisor, Staff TT, Vice President of Support Services.

Record review of Staff C, Security Guard's time card showed that he continued to work 29 shifts from 06/24/17 to 08/25/17 and Staff D, Security Guard's time card showed that he continued to work 40 shifts from 06/24/17 to 08/24/17.

8. Record review of Patient #2's medical record dated 04/30/17 through 05/02/17 showed the following:
- Patient #2 was a 28 year old female that voluntarily was admitted to the psychiatric unit on 04/30/17 at 5:40 PM for treatment of suicidal ideation.
- History and physical (H&P) reviewed showing the patient had major depressive disorder, generalized anxiety disorder, PTSD and a chest wall contusion. The patient's current medications were Benadryl (antihistamine), Haldol (antipsychotic), Atarax (used to treat allergies and anxiety), Motrin (antiinflamatory), Ativan (for anxiety), Remeron (antidepressant), Nicoderm patch (to help with withdrawal from smoking) and Zyprexa (antipsychotic).
- On 05/01/17 at 4:44 PM, the patient was taken by manual hold to the seclusion area after physically attacking Staff M, Behavioral Health Technician (BHT).
- The patient was place in 4-point restraints with 1:1 and video monitoring.
- At 6:00 PM the restraints were removed.
- At 6:45 PM the patient had returned to her room.

Review of the recorded video surveillance dated 05/01/17 showed the following:
- At 4:27 PM Patient #2 was yelling at staff upset about her roommate being touched by a male patient on the unit.
- She became loud and agitated so nursing called security.
- At 4:33 PM, Staff N, Security Guard and Staff M, BHT guided the patient into the lunchroom away from other patients.
- The patient stated that she was thirsty and continued to yell about not wanting to be by herself with any male staff.
- The patient did not understand why she was being isolated in the lunchroom area.
- Staff M, BHT, was in and out of the room taking care of other patients.
- Staff N continued to question the patient and the patient made it clear she wanted him to leave her alone and stated that she was not the one that was attacked.
- After a few minutes, the patient walked over to the sink to pick up a pitcher of tea and pour into a cup. At this time, Staff N, Security Guard, grabbed the patient. The patient responded by throwing the pitcher of tea at Staff N. Staff N wrestled the patient to the floor and Staff O, Security Guard, joined in restraining the patient on the floor. Staff M, BHT was not in the room at this time. She was at the door.
- Staff R, RN, called a Code 10 (emergency code for assistance with a violent person).
- When the patient was being restrained on the floor by Staff N, Staff O and Staff M, the video was blocked, but it appeared that when Staff N repositioned his knee the patient screamed out, "Get off of my arm," and the patient continued to cry.
- At 4:41 PM Staff R, RN entered the room and assisted with carrying the patient to the seclusion room.
- During this transport, the patient grabbed Staff M, BHT's hair. At that time, they brought the patient down to the floor. Staff N and Staff O were unsuccessful in removing the BHT's hair from the patient's hand.
- Staff F, Security Guard, and Code 10 Responder, arrived and instructed the staff to let go of the patient and with a closed fist he hit the back of the patient's hand 3-4 times. The patient began crying out and released the BHT's hair.
- The patient was then carried to the seclusion room and placed in 5-point locked restraints. The patient's right arm was twisted off of the bed. The screamed out, "You are hurting my arm" and "I just wanted to get a drink and he attacked me."
- Restraints were on from 4:45 PM until 6:45 PM.

Record review of the facility's Mercy Safety Event Review dated 05/01/17 at 11:22 PM showed that it was documented as emotional distress or inconvenience and assault by a patient. Action response documented by Staff R, RN Manager, stated that the Treatment Team met, reviewed the Code 10 and identified break down in the process. A lead communicator was not assigned which left security and a BHT to de-escalate the situation. Re-education was done with the patient's RN and security was re-educated on de-escalation skills. Staff did not recognize this as assault on a patient.

During an interview on 08/25/17 at 11:45 AM, Staff N, Security Guard, stated the following:
- He was called to psychiatric unit by nursing to help with an agitated patient.
- He heard female yelling and upset with nursing staff.
- Nursing staff requested that he go speak with Patient #2.
- He tried to speak with her, but she was upset with Staff M, BHT.
- Staff M stepped forward talking to the patient and then the patient escalated again.
- The patient moved forward quickly toward the tea pitcher and he backed away from her.
- He was between the patient and Staff M, BHT and the patient took the tea jug and ran.
- He grabbed patient's right arm with his right and left arm, she threw the tea jug at his face and then he remembered being on the ground restraining her.
- He asked for guidance from Staff R, RN Manager.
- He tried to adjust his body when he had restrained the patient and his knee was above her.
- He remembered that the patient yelled about pain.
- When he, Staff O and Staff M carried the patient the patient grabbed Staff M's hair.
- He attempted to open the patient's hand to free Staff M's hair and was unsuccessful.
- Staff F, Security Guard, walked up and used two fingers, tapped the patient's hand and the patient let go of the hair.
- He remembered the patient stated, "They didn't know how to put on restraints" and he left the room.

During an interview on 08/25/17 at 12:23 PM, Staff M, BHT, stated that:
- Before the incident Patient #2 asked for a drink at the nurse's station.
- She brought the patient in the lunchroom for a drink and the patient continued to escalate.
- A Code 10 was called.
- Security arrived and when she turned to leave the patient grabbed the tea pitcher and made motion to throw. At this time Staff N, Security Guard, restrained the patient.
- She had the patient's legs during the transport and the patient got a hand loose and grabbed her hair.
- During the time Staff F, Security Guard, used a technique to release her hair, her face was to the ground and didn't see it.
- She declined going to the ED for medical attention.

During an interview on 08/24/17 at 3:45 PM, Staff F, Security Guard, stated that:
- He was the supervisor on duty that day.
- He came on the scene after the Code 10 was called and arrived when they were moving the patient to the seclusion room.
- He saw that Staff O's attempt of releasing the Staff M's hair was unsuccessful.
- He wrapped his knuckles 4 times onto the patient's hand and she released Staff M's hair.
- This was not an approved hospital technique but one he had used with his previous training.

During an interview on 08/25/17 at 12:48 PM, Staff O, Security Guard, stated that he recalled that Staff F took his door knocking knuckles and tapped the patient on the back of her hand.

During an interview on 08/25/17 at 1:30 PM, Staff U, BHT, stated that Staff F pounded the patient's

Based on interview, record review, policy review and video review the facility failed to use the least restrictive method to control behavioral symptoms for three patients (#1, #2, and #4) of four patients placed in restraints. These failures had the potential to place all patients admitted to the facility at risk for their right to be free from restraints used to impose for coercion, discipline or convenience. The facility census was 384. The Psychiatric Center census was 27.

Findings included:

1. Record review of the facility's policy titled, "Security Department Use of Control Policy," dated 05/2017, showed that:
- Only the least amount of force reasonable is used to overcome the level of resistance offered.
- The use of excessive control or force, regardless of the subject's threats, will result in disciplinary measures up to and including termination of employment.
- Handcuffs should only be used after an active aggressive incident and used as a safety measure for the officer, victim, witnesses, or when there is a prior knowledge that active aggressive acts could occur.

2. Record review of the facility's policy titled, "MCA (Marion Center Available Staff, [Psychiatric Unit]) Security Response and De-escalation Training," dated 05/05/17, showed the following:
- Medical staff should always be present when Security is dealing with a patient.
- Security should not escalate to a hands-on situation except when a violent act has been committed or there is reasonable expectation that it will occur.
- Security will wait to intervene unless requested by medical staff or if the situation is violent and/or could cause harm to the patient or others.

3. Record review of the Missouri Department of Mental Health policy titled, "Use of Seclusion and Restraints," dated 07/01/17, showed that:
- Restraint and seclusion shall be utilized only to ensure the immediate physical safety of the individual, a staff member, or others and discontinued at the earliest possible time.
- Restraint and seclusion are only used when less restrictive interventions have been determined to be ineffective.
- Restraint and seclusion should be initiated only in those individual specific situations in which an emergency safety need is identified, and these interventions should be implemented only by competent, trained staff.

4. Observation on 08/23/17 at 2:08 PM, of recorded video surveillance on 08/15/17 of Patient #4 in the Psychiatric Center seclusion room showed:
- At 6:00 PM, while in seclusion, Patient #4 stated, "I hope you like the sight of blood", after it appeared that her right forearm wound was bleeding. The patient continued to appear to self-injure and made multiple comments that she self-injured, until 6:27 PM.
- At 6:30, Patient #4 threw her foam mattress off of the bed, which landed in front of the patient's seclusion door, and the patient squats down in a corner of the room (no self-harm observed).
- At 6:31 PM, Staff II, Registered Nurse (RN), attempted to contract with Patient #4. The patient began to curse and continued to curse and became increasing agitated with continued conversation between her and staff, and when the patient turned her head away from the conversation, staff continued to converse with her and asked the patient is she wanted to buy a ticket into four-point restraints. Multiple staff began to arrive outside of the patient's seclusion room (no self-harm observed) for a Code 10.
- At 6:32 PM, Staff II, RN, informed the patient that they were going to move her to another room and place her in restraints (no self-harm observed). .
- At 6:33, Security Guards and staff discussed which part of Patients #4's body they are going to control. Patient #4 makes multiple requests for staff to not enter the room and to leave her alone. The patient remained seated in the corner of the room (no self-harm observed). .
- At 6:34, Patient #4 and various staff continue to talk, and the patient began to yell and repeatedly stated that she would stop scratching herself, when eight staff enter the patient's seclusion room.
- At 6:35 PM, Patient #4 stated "I will calm down if you leave me alone, that's the condition", when Staff II responded, "You don't make the conditions, I'm sorry", and staff placed the patient in a manual hold and the patient was taken to another seclusion room and restrained in five-point restraints (both arms, both legs and waist are restrained).

During an interview on 08/24/17 at 2:09 PM, Staff PP, Security Guard, stated that restraint was used as a last resort for Patient #4.

During a telephone interview on 08/25/17 at 11:04 AM, Staff FF, RN, stated she did not see Patient #4 self-harm.

During an interview on 08/24/17 at 1:42 PM, Staff QQ, Security Guard, stated he did not see Patient #4 self-harm.

During an interview on 08/24/17 at 2:55 PM, Staff SS, Security Guard, stated he did not see Patient #4 self-harm.

During an interview on 08/25/17 at 2:04 PM, Staff EE, Licensed Practical Nurse (LPN), stated she did not see Patient #4 self-harm.

During an interview on 08/25/17 at 12:20 PM, Staff Y, Behavioral Health Technician (BHT), stated:
- She did not see Patient #4 self harm;
- Soft wrist restraints were not available on the Psychiatric Center; and
- Five-point restraints were the only restraint device available in the Psychiatric Center.

During an interview on 08/25/17 at 11:35 AM, Staff DD, RN, stated that when Psychiatric Center staff called a Code 10, "it's already determined that they (the patient) are going into restraint", although other options to restraints would be to provide one-to-one observation (one staff observes one patient at all times) of the patient.

During an interview on 08/23/17 at 3:45 PM, Staff A, RN, stated a patient could be assigned a sitter (staff who stay with the patient at all times) as an alternative to placing a patient in restraints.

During an interview on 08/24/17 at 1:25 PM, Staff U, BHT, stated options to restraints were one-on-one observation and continuous observation.

Observation on 08/23/17 at 2:08 PM, of recorded video surveillance on 08/15/17 between 7:00 PM and 8:50 PM, showed that Patient #4 was calm and cooperative, but continued to remain in restraints. At 8:50 PM, a nurse (verified by the facility to be Staff CC, RN) stood in the doorway, when Patient #4 agreed that she would talk to staff when she became upset to avoid restraint and seclusion. The nurse checked the restraints, but did not loosen or remove the restraints.

During a telephone interview on 09/05/17 at 8:41 AM, Staff R, Psychiatric Center Manager, stated that staff should process patients out of restraint and/or seclusion as soon as they are able to process and state they wouldn't hurt themselves.

Record review of 15 minute monitoring on 08/15/17 of Patient #4's restraint and seclusion showed that the patient was calm but remained in restraints on from 7:15 PM until 10:45 PM, continued in restraints, and slept in restraints on 08/16/17 from 12:00 AM through 1:00 AM.

Record review of an email dated 08/29/17 at 4:13 PM, showed the facility's review of video showed that Patient #4 remained in restraints until 08/16/17 at 12:35 AM, and remained in seclusion until 08/16/17 at 9:39 AM.

This showed that no interventions were put into place when Patient #4 self-harmed. After the patient had harmed for approximately 30 minutes, staff repeatedly spoke to the patient which cause the patient to escalate verbally. Patient #4 was then placed in restraints after she stopped self-harming, and when alternatives to five point restraints were not utilized. The patient then remained in restraint for hours after the patient was calm, and remained calm.

5. Record review of Patient #1's medical record dated 06/24/17 showed that the patient arrived to the Emergency Department (ED), via private vehicle, accompanied by a friend at 11:21 PM for left arm numbness. The patient's current medications were Ativan (for anxiety), Hydrocodone (for pain), Seroquel (anti-psychotic used to treat schizophrenia, bipolar and depression) and Atarax (used to treat allergies and anxiety).

Review of the recorded video surveillance dated 06/24/17 showed the following:
- At 11:19 PM, Patient #1 entered the ED with a complaint of left arm numbness, sat down, registered, Staff H, ED Technician, took the patient's vital signs and the patient calmly gave Staff G, RN, a pocket knife to keep until his discharge.
- At 11:27 PM, the patient entered the waiting room and sat down next to his friend, who walked with a cane.
- At 11:28 PM, Staff D, Security Guard, entered the waiting room and asked the patient not to use foul language. The patient responded calmly at this time. Staff D continued to banter with the patient and the patient stated, "I am a veteran and I know my rights." Staff D responded and stated, "He was a veteran too and that didn't matter." The patient and Staff D continued to banter back and forth, then the patient's friend stated calmly, "Please leave him alone, can't you see that he has something wrong?"
At this time, Staff D, walked away over to the desk.
- At 11:33 PM, showed that Patient #1 slid slowly out of his chair, onto the floor and was visibly shaking and in distress. The patient's friend alerted the staff that the patient had a seizure. Staff G, RN, walked over by the patient and spoke to him. Staff G did not lean down to speak with the patient, stood near him and stated, "You're alright," in a sarcastic tone. Staff G then asked Staff D, Security Guard, to bring a gurney.
- At 11:35 PM, Staff D, wheeled a gurney over and the patient became agitated when he saw that it was Staff D bringing the gurney. The patient stated that he did not want Staff D to help at all and that he did not like him. The patient's agitation had escalated. Staff D remained in sight of the patient which continued to escalate the patient. Staff H, ED Technician, Staff I, RN and Staff G, RN, came out to assist with the patient. Banter between the patient and the staff continued with the patient cursing. The patient's friend helped the patient to stand up and the patient physically staggered over to the gurney. At this time, Staff D, Security Guard, stood next to the gurney. The patient escalated more, moved off of the gurney, stated that he wanted to go to another fucking hospital where he would be treated better and walked with his friend toward the exit.
- At 11:37 PM, showed Staff D followed the patient and his friend out into the driveway. Staff D continued to follow them toward the parking lot, bantering back and forth, which escalated the patient more.
- At 11:38 PM, showed that Staff C, Security Guard, joined Staff D outside at the scene. Staff C walked next to Staff D and reached in his pocket and put his gloves on. Staff C walked forward and attempted to intimidate the patient and his friend. Staff C then pushed the patient's back, pushed the friends back, pushed the patient's back and then pushed the friend two times while walking back and forth between them. The patient's friend then sat down on the curb with his cane beside him. Staff C and Staff D continued to banter with both the patient and his friend. Staff C paced on the sidewalk until he reached out with left hand and grabbed the patient. Staff D joined Staff C and tackled the patient to the ground. The patient's head hit the ground two times and had a visible scrape on his forehead. Staff C then placed handcuffs on the patient's hands behind his back, lying on his stomach.
- At 11:41, Staff C, picked patient up and placed him on the curb next to his friend.
- At 11:47, the local police department arrived and assessed the situation.
- At 11:52, Staff G, RN, brought the patient's pocket knife in a baggy out and handed it to the local police officer.
- At 11:58, after speaking with the patient and his friend away from Staff C and Staff D, the local police officers took the handcuffs off of the patient and allowed them to leave.
No de-escalation techniques were used by nursing or security.

Record review of the facility's Mercy Safety Event Review dated 06/30/17 at 11:10 AM showed the review of the incident with Patient #1 was documented as emotional distress or inconvenience and reviewed by the Leadership Team on 06/29/17 where they developed an action plan. The action plan was to provide education on PTSD (post traumatic stress disorder) to all nurses, technicians and security, security officer involved was provided one on one education on de-escalation and the video of the incident was utilized as training for security officers. The investigation showed no interviews with staff, no further investigation and no self report to the state office.

During an interview on 08/24/17 at 4:50 PM, Staff D, Security Guard, stated that he never felt threatened and that Staff C, Security Guard, initiated the contact with Patient #1 outside in the circle drive of the ED. He stated that he never touched the patient and that he felt that Staff C handled this inappropriately and exaggerated the situation. He also stated that when Staff C grabbed the patient that at that time he needed to support his fellow officer and continue with the take down and handcuffs. Staff D stated that he did report this to his supervisor, Staff JJ, Third Shift Sergeant.

During an interview on 08/25/17 at 11:14 AM, Staff C, Security Guard, stated that:
- He arrived on the scene when Staff D, Security Officer was outside of the ED in the driveway with Patient #1 and his friend.
- He told the patient that they would detain him because he thought Staff D was in danger.
- He felt that his actions were appropriate and he didn't remember pushing the patient.
He had never been coached or reprimanded after the incident.

During an interview on 08/25/17 at 11:00 AM, Staff HH, Third Shift Sergeant for Security, stated that Staff C should not have shoved the patient in the back and he felt like this escalated the situation. He expected the officers to do the least and if the patient wasn't attacking them then they should have created space between them. He also stated that he reported this incident to his supervisor, Staff LL.

During an interview on 08/25/17 at 2:37 PM, Staff E, Director of Security, stated that:
- He wasn't proud of this video.
- After he reviewed the video on Monday 08/26/17, he spoke with Staff C and Staff D about de-escalation and told them that once the patient was at the exit door they should have let him go without following him.

During an interview on 08/24/17 at 5:00 PM, Staff G, RN, stated that when the patient flopped to the floor his friend had said that the patient had PTSD (post traumatic stress disorder) so she didn't put herself in harm's way by getting too close to him. She saw that his color looked good, eyes open and he did have jerking motions so she asked Staff D to bring a gurney. After the verbal altercation between Staff D and the patient, and they walked outside, she no longer considered him a patient. After Staff D requested that she assess the patient post incident in the driveway, she said that only if he signed back in and she never spoke to her supervisor about this incident.

During an interview on 08/25/17 at 2:20 PM, Staff L, Nurse Manager of the ED, stated that she reviewed the video and that this involved non clinical staff. She also stated that Staff G, RN, should have been more compassionate with the patient and once the patient was outside they considered them to be discharged. She felt there needed to be better communication between the staff and security.

6. Record review of Patient #2's medical record dated 04/30/17 through 05/02/17 showed that Patient #2 was a 28 year old female that voluntarily was admitted to the psychiatric unit on 04/30/17 at 5:40 PM for treatment of suicidal ideation.

Review of the recorded video surveillance dated 05/01/17 showed the following:
- At 4:27 PM Patient #2 was yelling at staff upset about her roommate being touched by a male patient on the unit.
- She became loud and agitated so nursing called security.
- At 4:33 PM, Staff N, Security Guard and Staff M, BHT guided the patient into the lunchroom away from other patients.
- The patient stated that she was thirsty and continued to yell about not wanting to be by herself with any male staff.
- The patient did not understand why she was being isolated in the lunchroom area.
- Staff M, BHT, was in and out of the room taking care of other patients.
- Staff N continued to question the patient and the patient made it clear she wanted him to leave her alone and stated that she was not the one that was attacked.
- After a few minutes, the patient walked over to the sink to pick up a pitcher of tea and pour into a cup. At this time, Staff N, Security Guard, grabbed the patient. The patient responded by throwing the pitcher of tea at Staff N. Staff N wrestled the patient to the floor and Staff O, Security Guard, joined in restraining the patient on the floor. Staff M, BHT was not in the room at this time. She was at the door.
- Staff R, RN, called a Code 10 (emergency code for assistance with a violent person).
- When the patient was being restrained on the floor by Staff N, Staff O and Staff M, the video was blocked, but it appeared that when Staff N repositioned his knee the patient screamed out, "Get off of my arm," and the patient continued to cry.
- At 4:41 PM Staff R, RN entered the room and assisted with carrying the patient to the seclusion room.
- During this transport, the patient grabbed Staff M, BHT's hair. At that time, they brought the patient down to the floor. Staff N and Staff O were unsuccessful in removing the BHT's hair from the patient's hand.
-Staff F, Security Guard, and Code 10 Responder, arrived and instructed the staff to let go of the patient and with a closed fist he hit the back of the patient's hand 3-4 times. The patient began crying out and released the BHT's hair.
- The patient was then carried to the seclusion room and placed in 5-point locked restraints. The patient's right arm was twisted off of the bed. The screamed out, "You are hurting my arm" and "I just wanted to get a drink and he attacked me."
- Restraints were on from 4:45 PM until 6:45 PM.
No de-escalation techniques were used by nursing or security.

Record review of the facility's Mercy Safety Event Review dated 05/01/17 at 11:22 PM showed that it was documented as emotional distress or inconvenience and assault by a patient. Action response documented by Staff R, RN Manager, stated that the Treatment Team met, reviewed the Code 10 and identified break down in the process. A lead communicator was not assigned which left security and a BHT to de-escalate the situation. Re-education was done with the patient's RN and security was re-educated on de-escalation skills. Staff did not recognize this as assault on a patient.

During an interview on 08/25/17 at 11:45 AM, Staff N, Security Guard, stated the following:
- He was called to psychiatric unit by nursing to help with an agitated patient.
- He heard female yelling and upset with nursing staff.
- Nursing staff requested that he go speak with Patient #2.
- He tried to speak with her, but she was upset with Staff M, BHT.
- Staff M stepped forward talking to the patient and then the patient escalated again.
- The patient moved forward quickly toward the tea pitcher and he backed away from her.
- He was between the patient and Staff M, BHT and the patient took the tea jug and ran.
- He grabbed patient's right arm with his right and left arm, she threw the tea jug at his face and then he remembered being on the ground restraining her.
- He asked for guidance from Staff R, RN Manager.
- He tried to adjust his body when he had restrained the patient and his knee was above her.
- He remembered that the patient yelled about pain.
- When he, Staff O and Staff M carried the patient the patient grabbed Staff M's hair.
- He attempted to open the patient's hand to free Staff M's hair and was unsuccessful.
- Staff F, Security Guard, walked up and used two fingers, tapped the patient's hand and the patient let go of the hair.
- He remembered the patient stated, "They didn't know how to put on restraints" and he left the room.

During an interview on 08/25/17 at 12:23 PM, Staff M, BHT, stated that:
- Before the incident Patient #2 asked for a drink at the nurse's station.
- She brought the patient in the lunchroom for a drink and the patient continued to escalate.
- A Code 10 was called.
- Security arrived and when she turned to leave the patient grabbed the tea pitcher and made motion to throw. At this time Staff N, Security Guard, restrained the patient.
- She had the patient's legs during the transport and the patient got a hand loose and grabbed her hair.
- During the time Staff F, Security Guard, used a technique to release her hair, her face was to the ground and didn't see it.

Record review of Staff ZZ, RN, nurse's note dated 05/01/17 at 6:45 PM showed that she was at the nurse's station during the incident and did not witness the attack. She stated that she and Staff R, Psychiatric Nurse Manager, performed a head to toe assessment and skin surveillance after the incident on Patient #2. She stated that both of the patient's upper arms had slight bruises to the medial surface and the left forearm had a small darkened circular area on the lateral surface. The patient did not accept any responsibility for her behavior.

Record review of Patient #2's H&P performed on 05/02/17 showed that Staff AAA, Physician, stated that the patient had muscle pains related to being restrained by security the previous day.

Record review of physician notes performed on 05/03/17 showed that Staff BBB, Physician, stated that the patient had rib and neck pain since the security guard jumped her.
























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Based on interview, record review, policy review and video review, the facility failed to follow their own policy regarding restraint use for management of behavioral symptoms for three patients (#1, #2, and #4) of four patients reviewed with restraints. These failures had the potential to place all patients admitted to the facility at risk for their right to be free from restraints imposed as a means of coercion, discipline or convenience. The facility census was 384. The Psychiatric Center census was 27.

Findings included:

1.

1. Record review of the facility's policy titled, "Security Department Use of Control Policy," dated 05/2017, showed that:
- Only the least amount of force reasonable is used to overcome the level of resistance offered.
- The use of excessive control or force, regardless of the subject's threats, will result in disciplinary measures up to and including termination of employment.
- Handcuffs should only be used after an active aggressive incident and used as a safety measure for the officer, victim, witnesses, or when there is a prior knowledge that active aggressive acts could occur.

2. Record review of the facility's policy titled, "MCA (Marion Center Available Staff, [Psychiatric Center]) Security Response and De-escalation Training," dated 05/05/17, showed the following:
- Medical staff should always be present when Security is dealing with a patient.
- Security should not escalate to a hands-on situation except when a violent act has been committed or there is reasonable expectation that it will occur.
- Security will wait to intervene unless requested by medical staff or if the situation is violent and/or could cause harm to the patient or others.

3. Record review of Patient #4's medical record showed the patient was admitted on 08/14/17, with a recent history of self-harm and reported suicide attempt. A seclusion order by Staff LL, Psychiatrist, dated 08/15/17 at 4:33 PM, was written because the patient was a danger to self and others.

Observation on 08/23/17 at 2:08 PM, of recorded video surveillance of Patient #4 in the seclusion room of the Psychiatric Center on 08/15/17, showed that during the patient's Code 10 seclusion and restraint event:
- At 6:31 PM, Multiple staff began to arrive outside of the patient's seclusion room.
- At 6:32 PM, Staff II, Registered Nurse (RN), informed the patient that they were going to move her to another room and place her in restraints.
- At 6:33 PM, Security Guards and staff discuss which part of Patients #4's body they are going to control.
- At 6:34, Eight staff (Per facility report, Staff QQ, Security Guard, Staff OO, Security Guard, Staff SS, Security Guard and Staff PP, Security Guard) entered the patient's seclusion room (with four additional patient care staff).
- At 6:35 PM, The patient stated that she would calm down if she was left alone, when Security Guard QQ grabbed Patient #4's right arm, and several Security Guards and patient care staff grab various parts of the patient's body, and the patient was placed in a manual hold and lifted onto a wooden boxed bed frame (without a mattress), while the patient and staff struggled.
-At 6:38 PM, Staff QQ (verified by hospital administration) held Patient #4's right arm, placed his right knee on the patients bent elbow. The patient's attempted to grab the patient, the security guard's motion and intensity increased, and the patient repeatedly screamed, "Ow".
- At 6:39 PM, the same security guard is seen bending the patient's all or a potion of the patient's right hand toward the patient's wrist, when the patient stated, "You broke my fucking thumb", and continued to scream about her thumb. Both the patient's right and left arm were restrained above her head.

During an interview won 08/23/17 at 3:30 PM, Staff A, RN stated that when patients were restrained, one or both arms should be restraint at the patient's waist, and that both arms should never be restrained above a patient's head.

This showed that staff incorrectly restrained the patient, when both of the patient's arms were restrained above her head.

During a telephone interview on 08/30/17 at 3:22 PM, Staff II, RN stated that during the Code 10 seclusion and restraint called for Patient #4 on 08/15/17, she saw a security guard press the patient's thumb against the patient's wrist, and the security guard had his body weight on the patient's right shoulder and right arm, while the patient screamed that her thumb was breaking. Staff II informed the security guard that he was breaking her thumb and asked him to let up, but he refused.

During an interview on 08/24/17 at 4:15 PM, Staff T, Behavioral Health Technician (BHT), stated that during the Code 10 seclusion and restraint called for Patient #4 on 08/15/17, she saw Staff QQ, Security Guard, use a thumb hold (thumb is bent toward the wrist, to gain compliance) on the patient.

During an interview on 08/25/17 at 2:04 PM, Staff EE, LPN, stated that during the Code 10 seclusion and restraint called for Patient #4 on 08/15/17, she saw one of the security guards (name unknown) bend the patient's thumb and heard it pop.

During an interview on 08/25/17 at 12:20 PM, Staff Y, Behavioral Health Technician (BHT), stated that after the patient was placed in restraints, she complained of right thumb and arm pain, and had swelling above her right eye.

During an interview on 08/24/17 at 1:42 PM, Staff QQ, Security Guard, stated that all of the techniques used on Patient #4 during the restraint of Patient #4 on 08/15/17, were approved techniques.

During a telephone interview on 09/05/17 at 8:41 AM, Staff R, Psychiatric Center Manager, stated that she and Staff X, Psychiatric Center Director, had previously reported concerns about security guards escalating patients and the holds used on patients to upper leadership, but leadership stated the techniques used by security were appropriate.

During a telephone interview on 09/05/17 at 3:53 PM, Staff X, Psychiatric Center Director, stated that she had previously reported that she had concerns with the way security guards managed patient's during Code 10 situations to Staff YY, Chief Nursing Officer.

This showed that pain was inflicted on the patient in order to gain the patient's compliance which resulted in injury during the restraint episode.

4. Record review of Patient #1's medical record dated 06/24/17 showed that the patient arrived to the Emergency Department (ED), via private vehicle, accompanied by a friend at 11:21 PM for left arm numbness. The patient's current medications were Ativan (for anxiety), Hydrocodone (for pain), Seroquel (anti-psychotic used to treat schizophrenia, bipolar and depression) and Atarax (used to treat allergies and anxiety).

Review of the recorded video surveillance dated 06/24/17 showed the following:
- At 11:19 PM, Patient #1 entered the ED with a complaint of left arm numbness, sat down, registered, Staff H, ED Technician, took the patient's vital signs and the patient calmly gave Staff G, RN, a pocket knife to keep until his discharge.
- At 11:27 PM, the patient entered the waiting room and sat down next to his friend.
- At 11:28 PM, Staff D, Security Guard, entered the waiting room and asked the patient not to use foul language. The patient responded calmly at this time. Staff D continued to banter with the patient and the patient stated, "I am a veteran and I know my rights." Staff D responded and stated, "He was a veteran too and that didn't matter." The patient and Staff D continued to banter back and forth, then the patient's friend stated calmly, "Please leave him alone, can't you see that he has something wrong?"
At this time, Staff D, walked away over to the desk.
- At 11:33PM, showed that Patient #1 slid slowly out of his chair, onto the floor and was visibly shaking and in distress. The patient's friend alerted the staff that the patient had a seizure. Staff G, RN, walked over by the patient and spoke to him. Staff G did not lean down to speak with the patient, stood near him and stated, "You're alright," in a sarcastic tone. Staff G then asked Staff D, Security Guard, to bring a gurney.
- At 11:35 PM, Staff D, wheeled a gurney over and the patient became agitated when he saw that it was Staff D bringing the gurney. The patient stated that he did not want Staff D to help at all and that he did not like him. The patient's agitation had escalated. Staff D remained in sight of the patient which continued to escalate the patient. Staff H, ED Technician, Staff I, RN and Staff G, RN, came out to assist with the patient. Banter between the patient and the staff continued with the patient cursing. The patient's friend helped the patient to stand up and the patient physically staggered over to the gurney. At this time, Staff D, Security Guard, stood next to the gurney. The patient escalated more, moved off of the gurney, stated that he wanted to go to another fucking hospital where he would be treated better and walked with his friend toward the exit.
- At 11:37 PM, showed Staff D followed the patient and his friend out into the driveway. Staff D continued to follow them toward the parking lot, bantering back and forth, which escalated the patient more.
- At 11:38 PM, showed that Staff C, Security Guard, joined Staff D outside at the scene. Staff C walked next to Staff D and reached in his pocket and put his gloves on. Staff C walked forward and attempted to intimidate the patient and his friend. Staff C then pushed the patient's back, pushed the friends back, pushed the patient's back and then pushed the friend two times while walking back and forth between them. The patient's friend then sat down on the curb with his cane beside him. Staff C and Staff D continued to banter with both the patient and his friend. Staff C paced on the sidewalk until he reached out with left hand and grabbed the patient. Staff D joined Staff C and tackled the patient to the ground. The patient's head hit the ground two times and had a visible scrape on his forehead. Staff C then placed handcuffs on the patient's hands behind his back, lying on his stomach.
- At 11:41, Staff C, picked patient up and placed him on the curb next to his friend.
- At 11:47, the local police department arrived and assessed the situation.
- At 11:52, Staff G, RN, brought the patient's pocket knife in a baggy out and handed it to the local police officer.
- At 11:58, after speaking with the patient and his friend away from Staff C and Staff D, the local police officers took the handcuffs off of the patient and allowed them to leave.

No de-escalation techniques were used by nursing or security prior to the patient being placed in handcuffs.

During an interview on 08/24/17 at 4:50 PM, Staff D, Security Guard, stated that he never felt threatened and that Staff C, Security Guard, initiated the contact with Patient #1 outside in the circle drive of the ED. He stated that he never touched the patient and that he felt that Staff C handled this inappropriately and exaggerated the situation. He also stated that when Staff C grabbed the patient that at that time he needed to support his fellow officer and continue with the take down and handcuffs. Staff D stated that he did report this to his supervisor, Staff JJ, Third Shift Sergeant.

During an interview on 08/25/17 at 11:14 AM, Staff C, Security Guard, stated that:
- He arrived on the scene when Staff D, Security Officer was outside of the ED in the driveway with Patient #1 and his friend.
- He told the patient that they would detain him because he thought Staff D was in danger.
- He felt that his actions were appropriate and he didn't remember pushing the patient.
- He had never been coached or reprimanded after the incident.

During an interview on 08/25/17 at 11:00 AM, Staff HH, Third Shift Sergeant for Security, stated that Staff C should not have shoved the patient in the back and he felt like this escalated the situation. He expected the officers to do the least and if the patient wasn't attacking them then they should have created space between them. He also stated that he reported this incident to his supervisor, Staff LL.

During an interview on 08/25/17 at 2:37 PM, Staff E, Director of Security, stated that:
- He wasn't proud of this video.
- After he reviewed the video on Monday 08/26/17, he spoke with Staff C and Staff D about de-escalation and told them that once the patient was at the exit door they should have let him go without following him.

The security guards escalated the incident with Patient #1 and then inappropriately placed the patient in handcuffs.

Record review of Patient #2's medical record dated 04/30/17 through 05/02/17 showed that Patient #2 was a 28 year old female that voluntarily was admitted to the psychiatric unit on 04/30/17 at 5:40 PM for treatment of suicidal ideation.

Review of the recorded video surveillance dated 05/01/17 showed the following:
- At 4:27 PM Patient #2 was yelling at staff upset about her roommate being touched by a male patient on the unit.
- She became loud and agitated so nursing called security.
- At 4:33 PM, Staff N, Security Guard and Staff M, BHT guided the patient into the lunchroom away from other patients.
- The patient stated that she was thirsty and continued to yell about not wanting to be by herself with any male staff.
- The patient did not understand why she was being isolated in the lunchroom area.
- Staff M, BHT, was in and out of the room taking care of other patients.
- Staff N continued to question the patient and the patient made it clear she wanted him to leave her alone and stated that she was not the one that was attacked.
- After a few minutes, the patient walked over to the sink to pick up a pitcher of tea and pour into a cup. At this time, Staff N, Security Guard, grabbed the patient. The patient responded by throwing the pitcher of tea at Staff N. Staff N wrestled the patient to the floor and Staff O, Security Guard, joined in restraining the patient on the floor. Staff M, BHT was not in the room at this time. She was at the door.
- Staff R, RN, called a Code 10 (emergency code for assistance with a violent person).
- When the patient was being restrained on the floor by Staff N, Staff O and Staff M, the video was blocked, but it appeared that when Staff N repositioned his knee the patient screamed out, "Get off of my arm," and the patient continued to cry.
- At 4:41 PM Staff R, RN entered the room and assisted with carrying the patient to the seclusion room.
- During this transport, the patient grabbed Staff M, BHT's hair. At that time, they brought the patient down to the floor. Staff N and Staff O were unsuccessful in removing the BHT's hair from the patient's hand.
- Staff F, Security Guard, and Code 10 Responder, arrived and instructed the staff to let go of the patient and with a closed fist he hit the back of the patient's hand 3-4 times. The patient began crying out and released the BHT's hair.
- The patient was then carried to the seclusion room and placed in 5-point locked restraints. The patient's right arm was twisted off of the bed. The screamed out, "You are hurting my arm" and "I just wanted to get a drink and he attacked me."
- Restraints were on from 4:45 PM until 6:45 PM.
No de-escalation techniques were used by nursing or security.

During an interview on 08/25/17 at 11:45 AM, Staff N, Security Guard, stated the following:
- He was called to psychiatric unit by nursing to help with an agitated patient.
- He heard female yelling and upset with nursing staff.
- Nursing staff requested that he go speak with Patient #2.
- He tried to speak with her, but she was upset with Staff M, BHT.
- Staff M stepped forward talking to the patient and then the patient escalated again.
- The patient moved forward quickly toward the tea pitcher and he backed away from her.
- He was between the patient and Staff M, BHT and the patient took the tea jug and ran.
- He grabbed patient's right arm with his right and left arm, she threw the tea jug at his face and then he remembered being on the ground restraining her.
- He asked for guidance from Staff R, RN Manager.
- He tried to adjust his body when he had restrained the patient and his knee was above her.
- He remembered that the patient yelled about pain.
- When he, Staff O and Staff M carried the patient the patient grabbed Staff M's hair.
- He attempted to open the patient's hand to free Staff M's hair and was unsuccessful.
- Staff F, Security Guard, walked up and used two fingers, tapped the patient's hand and the patient let go of the hair.
- He remembered the patient stated, "They didn't know how to put on restraints" and he left the room.

During an interview on 08/25/17 at 12:23 PM, Staff M, BHT, stated that:
- Before the incident Patient #2 asked for a drink at the nurse's station.
- She brought the patient in the lunchroom for a drink and the patient continued to escalate.
- A Code 10 was called.
- Security arrived and when she turned to leave the patient grabbed the tea pitcher and made motion to throw. At this time Staff N, Security Guard, restrained the patient.
- She had the patient's legs during the transport and the patient got a hand loose and grabbed her hair.
- During the time Staff F, Security Guard, used a technique to release her hair, her face was to the ground and didn't see it.

Record review of Staff ZZ, RN, nurse's note dated 05/01/17 at 6:45 PM showed that she was at the nurse's station during the incident and did not witness the attack. She stated that she and Staff R, Psychiatric Nurse Manager, performed a head to toe assessment and skin surveillance after the incident on Patient #2. She stated that both of the patient's upper arms had slight bruises to the medial surface and the left forearm had a small darkened circular area on the lateral surface. The patient did not accept any responsibility for her behavior.
Staff ZZ, RN, failed to follow the facility's policy and remain with patient when security was with the patient.

The incident with Patient #2 showed that Staff N, Security Guard, escalated the patient's agitation and inappropriately restrained the patient, which lead to placing the patient in 5 point restraints.

Based on interview, record review, policy review, and review of the facility's recorded video surveillance the facility failed to:
- Identify and treat the mental health status of four discharged patients (#1, #2, #3 and #4) of four to prevent escalation (increased intensity) of an agitated state;
- Ensure that the patient's nurse served as the team leader in code 10 (emergency code for assistance with a violent person) situations per the facility's policy, for two discharged patients (#2 and #4) of two to instruct coworkers regarding safe techniques to adequately help the patients;
- Ensure adequate nursing physical assessment for three discharged patients (#1, #3 and #4) of four discharged patients following physical assaults by staff members (A-0395).
The severity and cumulative effect of this systemic practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). The facility census was 411.

On 08/24/17 at 12:55 PM, the survey team notified the facility of the Immediate Jeopardy related to Conditions of Participation: Nursing Services, and on 08/25/17 at 8:45 AM the facility responded with a Plan of Correction (POC), and at 3:45 PM the facility responded with a revised POC to remove the IJs.

The facility's POC failed to ensure the secondary focus of the facility's corrective actions would involve restraint education and nsure that POC completion dates were timely, and did not extend beyond 09/01/17.

The plan was subsequently rejected by CMS, and the facility was notified by CMS on 08/28/17 that the POC was not accepted and the IJs remained ongoing.

Based on interview, record review, policy review, and review of the facility's recorded video surveillance the facility failed to:
- Identify and treat the mental health status of four discharged patients (#1, #2, #3 and #4) of four to prevent escalation (increased intensity) of an agitated state;
- Ensure that the patient's nurse served as the team leader in code 10 (emergency code for assistance with a violent person) situations per the facility's policy, for two discharged patients (#2 and #4) of two to instruct coworkers regarding safe techniques to adequately help the patients;
- Ensure adequate nursing physical assessment for three discharged patients (#1, #3 and #4) of four discharged patients following physical assaults by staff members (A-0395).
The severity and cumulative effect of this systemic practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). The facility census was 411.
Findings included:

1. Record review of the facility's policy titled, "Reporting and Investigating Allegations of Patient Abuse, Neglect, or Harassment," dated 02/2017, showed that:
-All forms of abuse, neglect, and harassment whether reportedly inflicted by coworkers, patients, or other persons are prohibited.
-Coworkers are too immediately report witnessed, alleged, or suspected signs of abuse, neglect, or harassment to their immediate supervisor, charge nurse, manager, or house supervisor.
-The supervisor who receives the report should assess the patient, document findings, assure patient safety, notify the physician and escalate to leadership to initiate the investigation.
-Coworker(s) involved in the allegation will be immediately removed from any patient care/contact and will be placed on investigatory leave.
-The Director of Patient Safety will initiate the self-report to the State agency within 24 hours of discovery.

2. Record review of the facility's policy titled, "Violence/Crisis Response Team (Code 10)," showed that:
-All co-workers assigned to the psychiatric unit will be trained to respond in the event of violence/crisis through training within 3 months of hire and annual recertification.
-The patient's primary Registered Nurse (RN) will serve as the Code 10 leader and will provide direction to the staff in attempts to de-escalate the patient.
-The RN will determine the appropriate therapeutic intervention (medication administration or application of restraint/seclusion).

3. Record review of the facility's policy titled, "MCA (Marion Center Available Staff, [Psychiatric Unit]) Security Response and De-escalation Training," dated 05/05/17, showed the following:
-Medical staff should always be present when Security is dealing with a patient.
-Security should not escalate to a hands-on situation except when a violent act has been committed or there is reasonable expectation that it will occur.
-Security will wait to intervene unless requested by medical staff or if the situation is violent and/or could cause harm to the patient or others.

4. Record review of the facility's, "Medical Staff Rules and Regulations," dated 03/22/17, showed that prior to the application of violent of self-destructive behavior restrain application, the nurse or physician must complete a comprehensive patient assessment.

5. Observation on 08/23/17 at 2:08 PM, of recorded video surveillance on 08/15/17 which showed the following in the Psychiatric Center:
- At 4:34 PM, Patient #4 escalated, and Staff AA, RN, states, "Call a Code 10", but the patient voluntarily walked to the seclusion room.
- At 6:00 PM, while in seclusion, Patient #4 stated, "I hope you like the sight of blood", after it appeared that her right forearm wound was bleeding. The patient continued to appear to self-injure and made multiple comments that she self-injured, until 6:27 PM, while the patient was directly observed by staff, and without nursing intervention. No assessment of the patient was observed on video.
- At 6:36 PM, the patient was carried by multiple staff into a room where restraints were prepared on a bed, and staff began to restrain the patient. During the restraint process, a physical struggle occurred, and the patient repeatedly cried out that she had pain in her right thumb/wrist area.
- At 7:01 PM, Staff RR, Psychiatrist, along with Staff AA, RN (verified by hospital staff) entered the seclusion room where Patient #4 was restrained. Staff AA assessed the patient's restraints and right thumb, when the patient complained of pain.

Record review of Patient #4's medical record showed:
- The patient was admitted on 08/14/17, with a recent history of self-harm and reported suicide attempt.
- A seclusion order by Staff LL, Psychiatrist, dated 08/15/17 at 4:33 PM, because the patient was a danger to self and others.
- A nurse assessment on 08/15/17 at 6:00 PM by Staff AA, RN, who documented that the patient's neurological assessment was within defined limits (WDL, normal), but there was no documentation related to the patient self-injuring behavior, or psychological (mental) health since before the patient was placed in seclusion (Last documented assessment was at 3:57 PM).
- A manual hold and restraint order by Staff RR, Psychiatrist, dated 08/15/17 at 6:35 PM because the patient was a danger to self and others.
- Medication orders dated 08/15/17 at 6:43 PM by Staff RR, Psychiatrist, for Zyprexa 10 milligrams (mg, unit of measure) by injection and Benadryl, 50 mg by injection (both drugs are used to decrease agitation when used together).
- An assessment dated 08/15/17 at 7:00 PM, by Staff AA, documented that she completed a cardiac (heart) and respiratory (lungs) assessment on the patient and was WDL (video review did not indicate that Staff AA listened to the patient's heart or lung sounds). The assessment also documented that pain management interventions included an x-ray of the right hand (this is not a pain management intervention).
- A Progress Note dated 08/15/17 at 7:06 PM by Staff RR, Psychiatrist, which documented that the patient stated she thought her right wrist and thumb were broken, and an x-ray was ordered. Also documented was that the patient did not receive the Zyprexa or Benadryl, "due to the patient being able to calm herself down".

During a telephone interview on 08/25/17 at 3:43 PM, Staff RR, Psychiatrist, stated that when she came to assess Patient #4 on 08/15/17 at 7:00 PM, she was initially under the impression that the patient had received the medications that she order for agitation.

During a telephone interview on 08/31/17 at 4:14 PM, Staff AA, RN, stated:
- In seclusion, nurses were required to assess the patient every two hours, which included the patient's behavior (According to the patient's medical record, this was not done).
- Staff BB, RN, notified her (Staff AA) that Patient #4 was self-harming. Staff AA did not see the patient self-harming, but saw blood on the patient's mattress and the patient stated that she was not going to stop self-harming. Staff AA made the decision that the patient would be restrained, but was not present when the patient was restrained (When the Code 10 occurred).
- She did not administer the physician ordered medications because the doctor stated that she would be right over to assess the patient, and so she waited for the physician.
- She and Staff RR, Psychiatrist, assessed the patient and felt the patient was calming down and no longer needed the medications that were ordered.
- When she assessed Patient #4 with Staff RR, she completed a head to toe assessment (this did not occur per video review).
- Patient #4 complained of pain to her right hand and said it was from security moving her into restraints.
- She assessed the patient's right wrist and thumb, and the patient flinched when she touched the patient's thumb.
- The patient was still agitated during the assessment.

This showed Staff AA, primary RN for Patient #4:
- Was unaware the patient self-harmed for 27 minutes while the patient was under direct observation of staff while in seclusion;
- Failed to perform assessments of the patient's behavior every two hours while in seclusion;
- Failed to administer physician ordered medication for the patient's agitation;
- Failed to act as Code 10 lead when the Code 10 was called;
- Failed to complete a comprehensive assessment of the patient prior to restraints (per policy),
- Documented assessments that did not occur, and
- Failed to address the patient's complaints of pain with pain management interventions.

Observation on 08/23/17 at 2:08 PM, of recorded video surveillance of Patient #4 in the seclusion room of the Psychiatric Center on 08/15/17, showed:
- At 6:31 PM, Staff II, RN, attempted to contract with Patient #4. The patient began to curse and continued to curse and become increasing agitated with continued conversation between her and staff. The patient turned her head away from the conversation, but staff continued to converse with her and asked the patient if she wanted to buy a ticket into four-point restraints. Multiple staff began to arrive outside of the patient's seclusion room.
- At 6:32 PM, Staff II, RN, informed the patient that they were going to move her to another room and place her in restraints.
- At 6:33, Patient #4 makes multiple requests for staff to not enter the room and to leave her alone. At this time, the patient was not self-injuring, and remained seated on the floor, in the corner of the room.
- At 6:34, Patient #4 and various staff continue to talk, and the patient began to escalate and yell repeatedly stated that she would stop scratching (self-harm) herself. Eight staff (Per facility report, Staff QQ, Security Guard, Staff OO, Security Guard, Staff SS, Security Guard and Staff PP, Security Guard) entered the patient's seclusion room (with four additional staff, which included, Staff II, RN).
- At 6:35 PM, Patient #4 stated "I will calm down if you leave me alone, that's the condition", when Staff II responded, "You don't make the conditions, I'm sorry", and the patient was placed in a manual hold and at 6:36 PM, the patient was carried by multiple staff into a room where restraint were prepared on a bed, and staff began to restrain the patient.
-At 6:38 PM, a security guard on the patient's right, who held the patient's right arm, placed his right knee on the patients bent elbow. The patient's attempted to grab the patient, the security guard's motion and intensity increased, and the patient repeatedly screamed, "Ow".
- At 6:39 PM, the same security guard is seen bending the patient's right thumb back toward the patient's wrist, when the patient stated "You broke my fucking thumb", and continued to scream about her thumb.
- At 6:46 PM, two female staff assess the patient's right thumb, when Staff II, RN, raised and lowered her own thumb and shook her head up and down to the other female staff, while she whispered (inaudible) to the staff who assessed the patient's thumb (indicated that she knew the patient's thumb was injured). One of the female staff who assessed the patient's thumb reached down and touched the patient's thumb, and patient cried out. The second staff who assessed the patient's thumb stated, "It's probably bruised", when the patient responded, "I felt it crack". Staff II, RN, moved to the patient and stated she hated to do these things (restrain a patient) because "Somebody always gets hurt", and Staff II appeared to visually assess the patient's thumb.

During a telephone interview on 08/30/17 at 3:22 PM, Staff II, RN, stated:
- She tried to de-escalate Patient #4 on 08/15/17 at the request of Staff AA, RN.
- While she attempted to talk to the patient, the patient kept yelling fuck you repeatedly.
- She did not witness the patient self-harm, and there was no reason she felt the patient needed to go into restraints.
- When the patient stated that she would comply if she was left alone, the charge nurse outside of the patient's door stated the patient did not get that choice.
- Staff applied a manual hold and carried the patient to the room which was already prepared to restrain her.
- She saw a security guard injured the patient when he applied his body weight on the patient's right shoulder and right arm, and pressed the patient's thumb back against her wrist, and the patient screamed that her thumb was breaking.
- When she assessed the patient's right thumb, she could see that it was swollen and turning purple.

Record review of Patient #4's medical record showed no documentation by Staff II, RN, related to Code 10 restraint and seclusion of the patient, no assessment of the patient's witnessed thumb injury, and no pain medication or pain interventions were administered to the patient.

This showed that Staff II failed to provide care to Patient #4 in a manner to de-escalate the patient. Staff II attempted to de-escalate the patient when the patient turned her head away from the conversation, repeatedly cursed during continued conversation, and escalated. When the patient verbally contracted to stop self-harming if staff would leave her alone, the patient was placed in a manual hold and restrained, even though Staff II did not see the patient self-harm. During the restraint episode, Staff II witnessed physical injury to the patient's thumb and after the patient complained of pain, pain medication was not administered.

Observation on 08/23/17 at 2:08 PM, of recorded video surveillance on 08/15/17 between 7:00 PM and 8:50 PM, showed that Patient #4 was calm (except when she cried out in pain) and cooperative, but continued to remain in restraints. The patient complained of pain to five patient care staff. At 8:50 PM, a nurse (verified by the facility to be Staff CC, RN) stood in the doorway, when Patient #4 agreed that she would talk to staff when she became upset to avoid restraint and seclusion. The nurse checked the restraints, but did not loosen or remove the restraints. At 8:56 PM, the patient complained of pain, and when medications were administered, the patient did not receive pain medication.

Record review of an assessment completed on 08/15/17 at 7:40 PM, showed Staff CC, RN (as confirmed by hospital staff), documented that Patient #4:
- Was guarded and unwilling to participate;
- Was agitated and uncooperative;
- Was irritable;
- Was unwilling to commit (to safety plan) and unwilling to answer questions about if she was having hallucinations;
- Refused to answer if she would harm others,
- Denied pain; and
- Was in restraints.
When compared to video review, Staff CC did not complete an assessment of Patient #4 as documented on or around 7:40 PM. Video showed that the patient was calm and cooperative but continually complained of pain. Video also showed that Staff CC was not in the patient's room until after 8:50 PM (verified by hospital staff).

RBD During an interview on 08/25/17 at 2:04 PM, Staff EE, LPN, stated that after Patient #4's restraint episode on 08/15/17:
- She reported four times to Staff CC, RN, that the patient needed pain medication, but Staff CC never administered pain medication to the patient.
- She reported to Staff CC, that the patient was safe to come out of the restraints, when Staff CC responded, "Her actions have consequences".
- The patient complained of a blister on her foot, and the restraint was so tight that she (Staff EE) couldn't pull the patient's sock down to assess the patient's foot.
- She reported the tightness of the restraint to Staff CC, but Staff CC refused to loosen the restraint.
- She reported Staff CC's actions to Staff FF, Charge Nurse, who responded that it was Staff CC's decision, and shrugged her shoulders.
- She reported her concerns to Staff X, Psychiatric Center Director, on 08/16/17.

During an interview on 08/25/17 at 12:20 PM, Staff Y, BHT, stated that after Patient #4's restraint episode on 08/15/17:
- The patient appeared to be in pain, had facial swelling above her right eye, and complained of arm pain and thumb pain and requested Ibuprofen.
- Staff EE, LPN, had requested Staff CC, RN, to get the patient something for pain, but pain medication was not administered to the patient.
- She had concerns with the amount of time that the patient remained in restraints and voiced her concerns to Staff CC, because the patient was calm for several hours while she continued to be restrained.
- Staff CC, voiced that she believed Patient #4 was "gaming" (manipulation), wouldn't release the patient from restraints at the request of staff, and informed staff that she was in charge and that staff couldn't tell her what to do.
- Staff FF, Charge Nurse, was informed of Staff CC's care of Patient #4, when Staff FF responded that it was Staff CC's "call".

During an interview on 09/05/17 at 10:05 AM, Staff CC, RN, stated:
- She did not assume care of Patient #4 until after 8:00 PM, because the patient was not her responsibility until she received report.
- The report she received from Staff AA, RN, was that the patient's thumb or hand may have been injured during restraint/seclusion.
- The BHT requested pain medication for the patient several times.
- During her initial assessment of the patient, she loosened the patient's right wrist and right leg restraint because the patient complained of pain to both (not seen on video review).
- She (Staff CC) never administered pain medication to the patient and did not contact the physician for a pain medication order, because the doctor did not order pain medication when the doctor was made aware of the thumb injury.
- Patient #4 stated that she would not harm herself, but she (Staff CC) didn't feel the patient was safe because of "the way she said things".
- She contacted the physician for continued restraint orders, because the patient had underlying hostility.
- None of the staff voiced that they felt the patient needed to come out of restraints.
- Assessment for the release of restraint should occur every two hours.
- She believe her assessment of Patient #4, and the time she continued to restrain the patient, were appropriate.

Record review of 15 minute monitoring on 08/15/17 of Patient #4's restraint and seclusion showed that the patient was calm but remained in restraints on from 7:15 PM until 10:45 PM, and slept in restraints on 08/16/17 from 12:00 AM through 1:00 AM.

Record review of an email dated 08/29/17 at 4:13 PM, showed the facility's review of video showed that Patient #4 remained in restraints until 08/16/17 at 12:35 AM, and remained in seclusion until 08/16/17 at 9:39 AM.

During a telephone interview on 09/05/17 at 8:41 AM, Staff R, Psychiatric Center Manager, stated that staff should process patients out of restraint and/or seclusion as soon as they are able to process and state they won't hurt themselves.

Video and record review showed that the patient remained calm and cooperative, but remained in restraints, even while she slept. The patient repeatedly complained of pain to the right thumb/wrist/forearm, but no pain medication or alternatives to pain medication were provided to the patient by Staff CC, RN. Staff CC documented assessments of the patient that were not completed, and did not include factual assessment details related to the patient's condition.

During an interview on 08/25/17 at 2:58 PM, Staff FF, Charge RN, stated:
- None of the staff approached her and informed her that Patient #4 needed to come out of restraints.
- It was the responsibility of Staff CC to determine restraint release criteria for the patient.
- She met with Staff CC and asked if Patient #4 was ready to come out of restraints after four hours.
- She was informed that Staff CC had contacted Staff RR, Psychiatrist several times, and agreed that the patient should not come out of restraints.
- The Charge Nurse responsibilities were not her job, she was not "officially employed as a charge nurse" and was not trained in charge nurse duties, although she had attended a charge nurse class and received charge nurse pay.
- She wasn't taking any responsibility for Patient #4.

During a telephone interview on 08/25/17 at 3:43 PM, Staff RR, Psychiatrist, stated that she was not contacted by Staff CC, RN, for release of Patient #4 from restraints (per Staff RR, cell phone incoming call log did not show additional calls made to her after she assessed the patient on 08/15/17 at approximately 7:00 PM).

Staff FF, Charge RN, failed to ensure that patient's in the Psychiatric Center were appropriately assessed and needs were met, under her role as a Charge RN.

6. Record review of Patient #1's medical record dated 06/24/17 showed the following:
-Patient #1 arrived to the Emergency Department (ED), via private vehicle, accompanied by a friend at 11:21 PM for left arm numbness.
- The patient's current medications were Ativan (for anxiety), Hydrocodone (for pain), Seroquel (anti-psychotic used to treat schizophrenia, bipolar and depression) and Atarax (used to treat allergies and anxiety).
- The patient's vital signs were within normal range.
- The patient was then seated in the waiting room next to his friend.
- Staff D, Security Guard, approached the patient and asked him not to use foul language.
- Staff D, left the patient and walked back over to his desk.
- Staff G, Registered Nurse (RN), documented that the patient flopped himself on the floor and the friend told her he was having a seizure.
- Staff G asked Staff D to bring a gurney for the patient to lie on.
- The patient yelled and stated profanities, then threw himself off of the gurney, cursed at security and stated that he was going to another fucking hospital for help where they did not treat Veterans like this.
- At this time the patient, friend and security went out the ED entrance.
- The Patient Refusal of Services form dated 06/25/17 at 12:15 AM showed that the patient left without being seen-before triage.

Review of the recorded video surveillance dated 06/24/17 showed the following:
- At 11:19 PM, Patient #1 entered the ED with a complaint of left arm numbness, sat down, registered, Staff H, ED Technician, took the patient's vital signs and the patient calmly gave Staff G, RN, a pocket knife to keep until his discharge.
- At 11:27 PM, the patient entered the waiting room and sat down next to his friend (an older gentleman who walked with a cane)
- At 11:28 PM, Staff D, Security Guard, entered the waiting room and asked the patient not to use foul language. The patient responded calmly at this time. Staff D continued to banter with the patient and the patient stated, "I am a veteran and I know my rights." Staff D responded and stated, "He was a veteran too and that didn't matter." The patient and Staff D continued to banter back and forth, then the patient's friend stated calmly, "Please leave him alone, can't you see that he has something wrong?"
At this time, Staff D, walked away over to the desk.
- At 11:33 PM, showed that Patient #1 slid slowly out of his chair, onto the floor and was visibly shaking and in distress. The patient's friend alerted the staff that the patient had a seizure. Staff G, RN, walked over by the patient and spoke to him. Staff G did not lean down to speak with the patient, stood near him and stated, "You're alright," in a sarcastic tone. Staff G then asked Staff D, Security Guard, to bring a gurney.
- At 11:35 PM, Staff D, wheeled a gurney over and the patient became agitated when he saw that it was Staff D bringing the gurney. The patient stated that he did not want Staff D to help at all and that he did not like him. The patient's agitation had escalated. Staff D remained in sight of the patient which continued to escalate the patient. Staff H, ED Technician, Staff I, RN and Staff G, RN, came out to assist with the patient. Banter between the patient and the staff continued with the patient cursing. The patient's friend helped the patient to stand up and the patient physically staggered over to the gurney. At this time, Staff D, Security Guard, stood next to the gurney. The patient escalated more, moved off of the gurney, stated that he wanted to go to another fucking hospital where he would be treated better and walked with his friend, who walked with a cane, toward the exit.
- At 11:37 PM, showed Staff D followed the patient and his friend out into the driveway. Staff D continued to follow them toward the parking lot, bantering back and forth, which escalated the patient more.
- At 11:38 PM, showed that Staff C, Security Guard, joined Staff D outside at the scene. Staff C walked next to Staff D and reached in his pocket and put his gloves on. Staff C walked forward and attempted to intimidate the patient and his friend. Staff C then pushed the patient's back, pushed the friends back, pushed the patient's back and then pushed the friend two times while walking back and forth between them. The patient's friend then sat down on the curb with his cane beside him. Staff C and Staff D continued to banter with both the patient and his friend. Staff C paced on the sidewalk until he reached out with left hand and grabbed the patient. Staff D joined Staff C and tackled the patient to the ground. The patient's head hit the ground two times and had a visible scrape on his forehead. Staff C then placed handcuffs on the patient's hands behind his back, lying on his stomach.
- At 11:41, Staff C, picked patient up and placed him on the curb next to his friend.
- At 11:47, the local police department arrived and assessed the situation.
- At 11:52, Staff G, RN, brought the patient's pocket knife in a baggy out and handed it to the local police officer.
- At 11:58, after speaking with the patient and his friend away from Staff C and Staff D, the local police officers took the handcuffs off of the patient and allowed them to leave.

During an interview on 08/24/17 at 4:50 PM, Staff D, Security Guard, stated that he noticed that Patient #1's head was bumped during the takedown and asked Staff G, RN, to assess the patient. He also stated that she told him that the patient refused care earlier so she wasn't going to assess him.

During an interview on 08/24/17 at 5:00 PM, Staff G, RN, stated that when the patient flopped to the floor his friend had said that the patient had PTSD (post traumatic stress disorder) so she didn't put herself in harm's way by getting too close to him. She saw that his color looked good, eyes open and he did have jerking motions so she asked Staff D to bring a gurney. After the verbal altercation between Staff D and the patient, and they walked outside, she no longer considered him a patient. After Staff D requested that she assess the patient post incident in the driveway, she said that only if he signed back in and she never spoke to her supervisor about this incident.

During an interview on 08/25/17 at 2:20 PM, Staff L, Nurse Manager of the ED, stated that she reviewed the video and that this involved non clinical staff. She also stated that Staff G, RN, should have been more compassionate with the patient and once the patient was outside they considered them to be discharged. She felt there needed to be better communication between the staff and security.

7. Record review of Patient #2's medical record dated 04/30/17 through 05/02/17 showed the following:
- Patient #2 was a 28 year old female that voluntarily was admitted to the psychiatric unit on 04/30/17 at 5:40 PM for treatment of suicidal ideation.
- History and physical (H&P) reviewed showing the patient had major depressive disorder, generalized anxiety disorder, PTSD and a chest wall contusion. The patient's current medications were Benadryl (antihistamine), Haldol (antipsychotic), Atarax (used to treat allergies and anxiety), Motrin (antiinflamatory), Ativan (for anxiety), Remeron (antidepressant), Nicoderm patch (to help with withdrawal from smoking) and Zyprexa (antipsychotic).
- On 05/01/17 at 4:44 PM, the patient was taken by manual hold to the seclusion area after physically attacking Staff M, Behavioral Health Technician (BHT).
- The patient was place in 4-point restraints with 1:1 and video monitoring.
- At 6:00 PM the restraints were removed.
- At 6:45 PM the patient had returned to her room.

Review of the recorded video surveillance dated 05/01/17 showed the following:
- At 4:27 PM Patient #2 was yelling at staff upset about her roommate being touched by a male patient on the unit.
- She became loud and agitated so nursing called security.
- At 4:33 PM, Staff N, Security Guard and Staff M, BHT guided the patient into the lunchroom away from other patients.
- The patient stated that she was thirsty and continued to yell about not wanting to be by herself with any male staff.
- The patient did not understand why she was being isolated in the lunchroom area.
- Staff M, BHT, was in and out of the room taking care of other patients.
- Staff N continued to question the patient and the patient made it clear she wanted him to leave her alone and stated that she was not the one that was attacked.
- After a few minutes, the patient walked over to the sink to pick up a pitcher of tea and pour into a cup. At this time, Staff N, Security Guard, grabbed the patient. The patient responded by throwing the pitcher of tea at Staff N. Staff N wrestled the patient to the floor and Staff O, Security Guard, joined in restraining the patient on the floor. Staff M, BHT was not in the room at this time. She was at the door.
- Staff R, RN, called a Code 10 (emergency code for assistance with a violent person).
- When the patient was being restrained on the floor by Staff N, Staff O and Staff M, the video was blocked, but it appeared that when Staff N repositioned his knee the patient screamed out, "Get off of my arm," and the patient continued to cry.
- At 4:41 PM Staff R, RN entered the room and assisted with carrying the patient to the seclusion room.
- During this transport, the patient grabbed Staff M, BHT's hair. At that time, they brought the patient down to the floor. Staff N and Staff O were unsuccessful in removing the BHT's hair from the patient's hand.
- Staff F, Security Guard, and Code 10 Responder, arrived and instructed the staff to let go of the patient and with a closed fist he hit the back of the patient's hand 3-4 times. The patient began crying out and released the BHT's hair.
- he patient was then carried to the seclusion room and placed in 5-point locked restraints. The patient's right arm was twisted off of the bed. The screamed out, "You are hurting my arm" and "I just wanted to get a drink and he attacked me."
- Restraints were on from 4:45 PM until 6:45 PM.

Record review of Patient #2's nursing notes dated 05/01/17 at 4:45 PM, showed documentation by Staff ZZ, RN, that stated she was not present during the security takedown of the patient in the lunchroom. She also stated that before security could talk to the patient, the patient physically attacked Staff M, BHT, which contradicted what was on the video.

During an interview on 08/25/17 at 1:30 PM, Staff U, BHT, stated that during the Code 10, nursing did not take the lead.

During an interview on 09/05/17 at 1:50 PM, Staff R, Nurse Manager Psychiatric Unit, stated that Staff ZZ should have lead the incident and after review of the video she advised her supervisor Staff X, Psychiatric Center Director, that this should have been reported to the state office. She felt that security was inappropriate.

Record review of the facility's Mercy Safety Event Review dated 05/01/17 at 11:22 PM showed that it was documented as emotional distress or inconvenience and assault by a patient. Action response documented by Staff R, RN, Nurse Manager Psychiatric Unit, stated that the Treatment Team met, reviewed the Code 10 and identified break down in the process. A lead communicator was not assigned which left security and a BHT to de-escalate the situation. Re-education was done with the patient's RN and security was re-educated on de-escalation skills. Staff did not recognize this as assault on a patient.

During an interview on 09/05/17 at 3:30 PM, Staff X, Psychiatric Center Director, stated that she felt at times security was abusive and this should have been reported to the state office. She also stated that the staff involved should have been sent home.

8. Record review of a H&P dated 04/29/17, showed Patient #3's was an 18 year old female, admitted for a 96 hour hold to the facility's Psychiatric Center, with a diagnosis of altered mental status.

Record review of a Shift Narrative on 05/01/17 at 1:38 AM, showed Staff II, RN, documented that the patient:
- Exhibited confused behavior, unste