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Based on video observation and interview it was determined the facility failed to ensure patients the right to be free from abuse and harassment as evidence by one of one RN #1 (Registered Nurse) was speaking loudly, using derogatory remarks, and slapped one of one Patient #1's right hand. The failed practice did not ensure an environment free from abuse and harassment and had the potential to affect all patients receiving care from RN#1. See-A145

Based on video observation and interview it was determined the Facility failed to ensure patients the right to be free from abuse and harassment as evidence by one of one RN #1 (Registered Nurse) was speaking loudly, using derogatory remarks, and slapped one of one Patient #1's right hand. The failed practice did not ensure an environment free from abuse and harassment and had the potential to affect all patients receiving care from RN#1.
Findings Follow:
A. Review of video on 04/27/22 at 1:00 PM of RN #1 interacting with
Patient #1 on Unit 6 Upper on 04/06/22 from 09:25 AM to 09:28 AM in the patient's Day Area showed the following.
09:16:40 AM RN #1 entered the day area where Patient #1 was sitting down, picking at an old wound on her left leg with her fingers. RN #1 stated, "What are you doing?" (In a calm voice). RN #1 stated, "That wound is looking pretty good if you would leave it alone. You not going to leave it alone?"
Patient #1 stated "It isn't looking good."
RN #1 stated "Yes, it is"
Patient #1 stated "No, it's not."
09:17:34 AM RN #1 stated, "You not going to quit?" as he walked out of the Day Room.
RN #1 left the Day Room for approximately four minutes and left Patient #1 in Day Area alone, sitting in the corner in a chair, continuing to pick her left leg.
09:21:33 AM RN #1 returned to Day Area, called Patient #1's name, "Are you going to come take your medicine?" Patient #1 had no response.
RN #1, in a loud voice, called Patient #1's name and then stated, "Are you taking your medicine?"
09:21:45 AM RN #1 then stated, "Let's do it," and hit the alarm button, which alarms for assistance to place Patient #1 in a 6-point restraint chair.
09:22:48 AM While two techs were holding Patient #1 in a day room chair (waiting on more assistance), RN # 1 stated, "Are you Happy Now? Are you?"
09:22:58AM additional staff entered the Day Area with restraint chair.
09:23:23 AM Patient #1 stated, "Get off my knee."
09:23:24 AM RN #1 stated "No"
09:23:31 AM RN #1 stated, "You want to know why I got my hand on you because you bit me the other day." Patient #1 stated, "I didn't bite you." RN #1 "You bit me with your gum."
09:28:34 AM RN #1 was getting up from the floor, Patient #1 made a muffled comment, and RN #1 slapped her secured right arm. RN #1 then used his right hand on her secured right arm to stand himself up. Patient #1 stated don't ever touch me again. Patient #1 was then rolled into the seclusion room.
B. During interview with the Lieutenant Public Safety Officer on 04/26 /22 at 9:30 AM, he stated that he does have the video of the incident that occurred on 04/06/22 with Patient #1, and he did call Adult Protective Services concerning the incident. He stated in the video RN #1 did slap Patient #1.
C. During interview with the Lieutenant Public Safety Officer on 04/27 /22 at 9:30 AM he stated Sergeant Public Officer and Public Safety Officer did write statements that they saw RN #1 slap Patient #1 on the hand.
D. During interview on 04/26/22 at 10:00 AM, Surveyor #2 asked Public Safety Officer to recall an incident involving RN #1 and Patient #1 on 04/06/22. He stated RN #1 was verbally inappropriate during the incident by yelling at Patient #1. RN#1 hit Patient #1 after she grabbed his hand. Public Safety Officer stated during this incident, RN #1 stated to Patient #1 that she bit him the day before.
E. During interview on 04/26/22 at 10:30 AM, Surveyor #2 asked Unit Security Officer (USO) #1 to recall an incident involving RN#1 and Patient #1 on 04/06/22, he stated the following:
RN #1 was verbally inappropriate during the incident by yelling at the patient.
F. During interview on 04/27/2022, at 11:30 AM, Surveyor #2 asked Registered Nurse (RN) #1 the following:
What is the RN's role during times when Patients are escalating into inappropriate behavior RN #1 stated, "We direct the situation to make sure the patient and staff remain safe?"
Can you recall the details of an incident with Patient #1 on 04/06/2022? RN #1 stated Patient #1 was doing self-harm (picking at a sore on her leg) and wouldn't stop, so RN #1 decided to call a Dr. Stat. Patient #1 was then placed in a Team Hold and put in a 6-point restraint chair. RN #1 stated he got involved because he thought the team was taking too long to get the right leg secured in the restraint. When RN#1 had his hand on the arm of the chair, Patient #1 grabbed his hand, so he "slapped her hand like he was a toddler." RN #1 stated he had a bad weekend with Patient #1 when she bit him and was hoping it would be better when he came back to work. When Surveyor #2 asked why chemical restraint was not done as the less restrictive treatment, RN #1 stated we just go straight to team hold and mechanical restraint.
G. During Interview on 04/27/22 at 12:15 PM with Administrative Review Team which consisted of CEO (Chief Executive Officer, Human Resource Analyst, DON (Director of Nursing) and ADON (Assistant Director of Nursing) they stated they reviewed the video of the incident that occurred with Patient #1 on 04/06/22 on Unit 6 Upper. Disciplinary action for RN #1 consisted of giving him a verbal warning and removing him from that unit and placing him on anther unit. Surveyor #1 asked if any further disciplinary action was taken or any teaching and/or retraining etc. All members agreed that after review of the video no further disciplinary action was necessary.
H. The above findings in A were verified by the COO on 04/27/22 at 8:30 AM.

Based on policy and procedure review, clinical record review, and interview, it was determined the facility failed to ensure self-harm behavior was identified, interventions and goals identified and implemented on the Master Treatment Plan (MTP) for one of one Patient #1 identified with self-harm precautions ordered. Failure to identify self-harm behavior, interventions, and goals on the MTP did not assure communication among disciplines as to what behaviors were problematic, the treatment and interventions to be implemented, and the goals for any patient with self-harm behavior. The failed practice affected Patient # 1 during the course of hospitalization and had the likelihood to affect all patients requiring an individualized interdisciplinary seclusion and restraint plan of care. Findings follow:

A. Review of the policy and procedure titled "Treatment Planning" revised 03/23/2021 showed:
1. Master Treatment Planning (MTP) will be completed within 5 days of admission.
2. Identification of problems specific to symptoms and/or behaviors.
3. Specific interventions must be identified to be utilized to help patients achieve goals.
4. Modification pf the MTP should occur within two business days whenever clinical circumstances occur including episodes of seclusion and restraint. Review of the policy and procedure titled "Use of Restraint or Seclusion" revised 8/15/2018 showed:
1. Restraint shall be used only when, and to the extent necessary to ensure the immediate physical safety of the patient and staff.
2. Nonphysical interventions should be the implemented first in managing patient behavior. An example is the Crisis and Recovery Empowerment (CARE) Care Tool.
3. All restraint orders must be limited to a specific episode and must never be written as a standing order or as needed basis.
4. If a patient requires Restraint for safety, the patient's MTP must address the issue.
5. The type or technique of restraint used must be the least restrictive intervention that will be effective to protect the patient, staff, and others.
6. Documentation must include the description of the patient's behavior, interventions and alternatives or other less restrictive intervention attempts.

B. Review of the policy and procedure titled "Interventions to Utilize to Prevent Seclusion and Restraint of Patients" effective 12/20/2013 showed:
1. Keep calm, speak in soft non-threatening voice.
2. Reinforce positive progress in treatment.
3. Offer PRN (as needed) medications first.
3. Provide appropriate activities.
4. Refrain from using loud, abusive language, and/or negative comments when addressing negative behaviors.

C. Review of the policy and procedure titled "Documentation of Nursing" revised 10/27/2020 showed an observation should be written at any time using descriptive verbs to communicate precise pertinent information about the behavior and treatment utilized.

D. Review of Patient #1's clinical record showed the history and physical/psychiatric evaluation showed a history and treatment for Borderline intellectual disorder and Somatic symptom disorder. Review of the Master Treatment Plan did not show any problems, interventions, or goals related to self-harm behavior.

1. Review of Medication Administration Record (MAR) showed evidence of PRN medication given as less restrictive for the CARE plan for Seclusion and Restraint occurrences on 02/12/2022, 02/17/2022, 03/24/2022, 04/02/2022, 04/05/2022, and 04/17/2022.

2. Care Tool dated 05/13/2019 shows patient stress levels triggers that increases becomes dangerous behaviors and less restrictive activity to decrease(help) the dangerous behavior.

3. MTP dated 04/14/2022 showed no evidence of documentation for patient self-harm.

4. Positive Behavior Support Plan (PBSP) dated 07/09/2020 shows:
a. Reasons for the development of the Behavior Program (BP) is to decrease the occurrences of dangerous behaviors and acting out toward others.
b. Staff should give positive reinforcement for her good behavior while using a soft calm voice to minimize occurrences for dangerous behavior.

5. Review of the Seclusion and Restraint report showed no evidence of detailed less restrictive treatment for disruptive behavior.
a. 01/28/2022- Team Hold (TH) 7:53 PM-7:55 PM, Chemical Restraint (CR) 9:20 PM, Mechanical Restraint (MR) 7:56 PM-10:49 PM
b. 01/31/2022-TH 12:45 PM-1:00 PM, CR 1:38 PM, MR 1:00 PM-1:45 PM
c. 02/12/2022 TH 7:30 PM-7:40 PM, CR 9:19 PM, MR 7:41 PM-9:38 PM
d. 02/17/2022 TH 5:30 AM-5:31 AM, MR 5:52 AM-6:20 AM
e. 03/24/2022 TH 10:35 AM-10:40 AM, CR 10:42 AM, MR 10:40 AM-11:45 AM
f. 03/31/2022 TH 5:24 PM-5:25 PM, CR 5:40 PM
g. 04/02/2022 TH 7:40 AM-7:52 AM, CR 8:11 AM, MR 7:54 AM-9:15 AM
h. 04/02/2022 TH 10:00 AM-10:01 AM
i. 04/02/2022 TH 2:55 PM-2:57 PM, CR 3:08 PM, MR 3:03 PM-4:00 PM
j. 04/02/2022 TH 6:15 PM-6:19 PM, CR 6:30 PM, MR 6:20 PM-8:00 PM
k. 04/05/2022 TH 6:57 PM-7:00 PM, MR 7:00 PM-7:40 PM
l. 04/06/2022 TH 9:25 AM-9:29 AM, CR 9:34 AM, MR 9:30 AM-9:47 AM
m. 04/17/2022 TH 2:53 PM-7:55 PM, CR 3:30 PM, MR 2:59 PM-4:48 PM

E. During an interview at 04/27/2022 at 11:30 AM, Surveyor #2 asked Registered Nurse (RN) #1 the following:
1. When asked RN #1 what the RN role during bad behavior occurrences is requiring TH/CR/MR, RN #1 stated, "We direct the situation to make sure the patient and staff remain safe"
2. During an incident on 04/06/2022, Surveyor #2 asked RN#1 to recall the details of Patient #1, RN #1 stated the following:
a. Patient #1 was doing self-harm (picking at a sore on her leg) and wouldn't stop so RN #1 decided to call a Dr Stat.
b. Patient #1 was placed in TH and then put in 6-point restraint chair.
c. RN #1 states he got involved because he thought the team was taking too long to get the right leg restraint secured.
d. When RN#1 had his hand on the arm of the chair, Patient #1 grabbed his hand, so he slapped her hand like she was a toddler.
e. RN #1 stated he had a bad weekend with patient #1 when she bit him and was hoping it would be better when he came back to work.
3. When Surveyor #2 asked why CR was not done as the less restrictive treatment, RN #1 stated we just go straight to TH and MR.

F. During an interview on 04/28/2022 at 09:30 AM, the Assistant Director of Nursing confirmed the findings in A- E.