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Based on observation, interview, record review, policy review and digital video recording review, the facility's Governing Body failed to:
- Ensure the Chief Executive Officer (CEO, appointed by the Governing Body) effectively managed the facility in order to meet applicable regulatory requirements.
- Ensure adequate oversight of patient care as related to the prevention, identification and investigation of the abuse and/or neglect of one patient (#11).
- Recognize an internal policy, used to guide Security Officers, gave direction for security staff to strike patients and use law enforcement techniques and restraints which was abusive to patients.
- Ensure staff followed Crisis Prevention Institute guidelines (CPI, a type of training whereby staff use physical holds which restrict a persons' movement) on carrying a patient and disengagement training when a patient was biting.
- Ensure nursing staff maintained responsibility of the patient when security responded to an event.
- Ensure the least restrictive method to control behavioral symptoms for one patient (#11) of one patient placed in restraints was used.

These failures had the potential to affect all patients in the hospital. The facility census was 248.

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, safety and the prevention of patient abuse and neglect.

Refer to A 0057 for further details.

Based on observation, interview, record review, policy review, and video review, the Governing Body (referred to as the "Board of Directors") failed to ensure the Chief Executive Officer (CEO) was responsible for the management and oversight of the entire facility, and included accountability for the effective oversight of the staff to comply with the requirements under the Conditions of Participation for Patient Rights. These failures had the potential to adversely affect all patients in the facility. The facility census was 248.

Findings Included:

Review of the facility's document titled, "Bylaws of Heartland Regional Medical Center," dated 10/2015, showed the following:
- The board of directors shall have all of the power and authority permitted by law to supervise, control, direct and manage the property, affairs and activities of the hospital, to determine the policies of the hospital and to do or cause to be done any and all lawful things for and on behalf of the hospital.
- The president shall be the CEO of the hospital.
- The CEO shall have the authority to direct and administer all the activities and departments of the hospital.
- The CEO shall be responsible for the implementation of all policies established by the board of directors.
- The CEO shall be responsible, except as otherwise provided by the board of directors or in these bylaws, for selecting, employing, controlling and discharging employees, and for developing and maintaining personnel policies and practices for the hospital.
- The CEO shall submit regular reports to the Board of Directors, its authorized committees and the medical staff on the overall activities of the hospital, as well as on appropriated federal, state and local developments that affect the operation of the hospital.

During an interview on 05/30/19 at 11:30 AM, Staff FF, Physician and Board of Directors Chairman, stated that as a board member, he was responsible for approving hospital policies. He was unaware that the hospital had a use of force policy and it was unacceptable for any caregiver to use force on a patient.

During an interview on 05/30/19 at 11:35 AM, Staff EE, CEO, stated that he was involved in the hospital policy making process. He was not aware the hospital had a policy that involved the use of force. He acknowledged that striking patients was abuse and there was zero tolerance for hitting patients. The board of directors meet 10 times a year, there was no meeting in July and December and the last meeting was 05/29/19. He explained to the board members yesterday the reason for the CMS survey and the findings so far.

Review of the facility's document titled, "Heartland/Mosaic Board of Trustees Executive Session," dated 05/29/19, showed that Staff FF reported that several months ago an incident occurred with a mental health patient where security staff was called, was unable to successfully de-escalate the incident with the patient, which then resulted in the patient biting the security staff and the security staff striking the patient. This matter was self-reported to the Department of Health.

This incident was self-reported to the Department of Health and Senior Services on 04/18/19. There was a Board of Directors meeting on 04/24/19, but this incident was not brought to the board's attention until 05/29/19.

The CEO failed to ensure:
- Adequate oversight of patient care as related to the prevention, identification and investigation of abuse and/or neglect.
- Recognize an internal policy, used to guide Security Officers, gave direction for security staff to strike patients and use law enforcement techniques and restraints which was abusive to patients.
- Staff followed Crisis Prevention Institute guidelines (CPI, a type of training whereby staff use physical holds which restrict a persons' movement) on carrying a patient and disengagement training when a patient was biting.
- Nursing staff maintained responsibility of the patient when security responded to an event.
- The least restrictive method to control behavioral symptoms for one patient (#11) of one patient placed in restraints was used.

The lack of oversight of patient care and safety by the CEO, resulted in the facility's failure to ensure quality healthcare, safety, and the prevention of patient abuse and neglect.

Based on interview, record review, policy review and digital video recording review, the facility failed to:
- Provide appropriate education for the understanding of abuse and neglect before allowing one staff member (J) to return to work after he struck one patient (#11) three times.(A-0144)
- Identify a physical altercation between security staff and one patient (#11) as an incident of abuse. (A-0145)
- Adequately investigate allegations of staff to patient abuse for one patient (#11) of one patient reviewed for abuse. (A-0145).
- Recognize an internal policy, used to guide Security Officers, gave direction for security staff to strike patients and use law enforcement techniques and restraints which was abusive to patients. (A-0145)
- Follow Crisis Prevention Institute guidelines (CPI, a type of training whereby staff use physical holds which restrict a persons' movement) on carrying a patient and disengagement training when a patient was biting. (A-0145)
- Maintain Nursing responsibilities when security responded to an event. (A-0145)
- Use the least restrictive method to control behavioral symptoms for one patient (#11) of one patient placed in restraints. (A-0164)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The facility census was 248.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 05/29/19, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 05/30/19, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Decision was made to inactivate the Use of Force Continuum policy.
- Reeducation was given to Clinical Support Services Vice Presidents and Mental Health, Emergency Department and Security Directors on what constitutes patient abuse/neglect and review of the investigation process.
- All patient care staff were educated on the revised Patient Abuse/Neglect policy to include zero tolerance by the organization regarding abuse, neglect or exploitation of patients.
- Scenario based education given to Mental Health, Emergency Department and Security staff which included calling for backup, patient escort techniques, appropriate techniques when caregiver was being bitten and backing away from the patient if the patient was not an immediate danger to self or others.
- Educate Mental Health, Emergency Department and Security staff regarding the responsibilities of patient care and direction of security staff was to be maintained by the nursing staff.
- Crisis Prevention Institute (CPI, a type of training whereby staff use physical holds which restrict a persons movement) will be taught by clinical certified instructors.

Based on interview, record review, policy review and digital video recording review, the facility failed to provide appropriate education for the understanding of abuse and neglect before allowing one staff member (J) to return to work after he struck one patient (#11) three times in the head. These failures had the potential to place all patients in the facility at risk for their safety. The facility census was 248.

Findings included:

Review of the facility's policy titled, "Patient Abuse, Neglect or Exploitation by Workforce, Other Patients or Visitors," revised 08/03/16, showed the following:
- The patient has a right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation.
- Physical abuse includes hitting, slapping, pinching, kicking, etc.
- Caregivers and volunteers will receive ongoing abuse, neglect and exploitation education including reporting, prevention and identification.
- The organization will prevent further potential abuse while the investigation is in progress.
- Any caregiver/volunteer alleged to be involved in suspected abuse, neglect or misappropriation will be removed immediately from direct care until completion of the investigation.

Review of Patient #11's History and Physical (H&P), dated 04/16/19, showed that she was a 29 year old female who presented to the Emergency Department with suicidal (thoughts to harm self) and homicidal ideations (thoughts to harm another person). She had a past medical history of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks).

Review of the facility's video recording titled, "Officer Strike 4-17-19," showed Staff J, R and U, Security Officers, escorting Patient #11 down hallway B of the Mental Health floor. Patient #11 tripped and fell to the ground, along with all three security officers. Patient # 11 was lying face down and Staff J appeared to strike Patient #11 three times in the area of her head.

Review of the facility's document titled, "Case Report," submitted 04/17/19 at 7:20 PM by Staff J, Security Officer showed that on 04/17/19 at approximately 3:30 PM, officers responded to Mental Health Unit (MHU) for a combative patient. Once on the ground, as I was attempting to gain control of her right arm, she began biting my left hand. I used approximately three distractionary strikes with my right hand to the side of her head in an attempt to remove my hand from her teeth.

Review of the facility's document titled, " Investigation Summary, Security strike of Mental Health (MH) patient," showed that in conclusion, based on review of caregiver statements/interviews and camera footage and use of the organizational Just Culture algorithm, it was determined that the security officer did not abuse the patient and it was a system failure.

Review of the facility's document titled, "Just Culture Algorithm," showed directives for the investigative team if the cause was System Failure was to reassign staff member to different role, coach, retrain, improved supervision and assess overall process.

During an interview on 05/29/19 at 11:00 AM, Staff J, Security Officer, stated that he was placed on administrative leave on 04/17/19. He returned to his duties as a Security Officer, working in all areas of the hospital on 05/08/19. He was not given any verbal discipline related to the incident because he did not do anything wrong. He had not received any abuse and neglect education since the incident.

During an interview on 05/28/19 at 4:15 PM, Staff E, Security Director, stated the following:
- He reviewed the videos involving the incident on 04/17/19 between Patient #11 and Staff J, Security Officer.
- He did not think the actions of Staff J, striking Patient #11 was abuse.
- He would have acted in the same manner, Staff J did not have any other choice.
- Staff J tried to free his hand from Patient #11's mouth by trying to feed the bite as taught in CPI, but was unsuccessful.
- A quick rap behind the head was justified in that case.
- Security staff have not received any education on abuse/neglect since the incident.

During an interview on 05/29/19 at 10:10 AM, Staff C, Inpatient Behavioral Health Director, stated that hitting patients was a form of abuse. After reviewing the video titled Officer Strike 04/17/19, it appeared that Staff J struck Patient #11 three times. Staff have not been educated on abuse and neglect since the incident and there were no mechanisms in place to prevent this from happening again.

Based on observation, interview, record review, policy review, and digital recording review the facility failed to:
- Identify a physical altercation between security staff and one patient (#11) as an incident of abuse.
- Adequately investigate allegations of staff to patient abuse for one patient (#11) of one patient reviewed for abuse.
- Recognize an internal policy, used to guide Security Officers, gave direction for security staff to strike patients and use law enforcement techniques and restraints which was abusive to patients.
- Follow Crisis Prevention Institute guidelines (CPI, a type of training whereby staff use physical holds which restrict a persons' movement) on carrying a patient and disengagement training when a patient was biting.
- Maintain Nursing responsibilities when security responded to an event.
These failed practices had the potential to place all patients in an unsafe environment and at risk for abuse and or neglect. The facility census was 248.

Findings included:

Review of the facility policy titled, "Patient Abuse, Neglect or Exploitation by Workforce, Other Patients or Visitors," Revised 08/03/16 showed that:
- The purpose of the policy is to define a process for protecting patients while in the care of the organization from mental, physical, sexual and verbal abuse, neglect and exploitation.
- Physical abuse included hitting, slapping, pinching, kicking, etc. It also included controlling behavior through corporal punishment (physical punishment on a person's body).
- The patient has the right to be free from mental, physical, sexual and verbal abuse, neglect (fail to care for) and exploitation (treating someone poorly to then benefit from them).
-Upon hiring, as part of orientation, new caregivers, medical staff members and volunteers will review the standards on abuse, neglect and exploitation.
- Caregivers and volunteers will receive ongoing abuse, neglect and exploitation education including reporting, prevention, and identification.

Review of Patient #11's Medical Record showed that:
- She was admitted to the facility on 04/15/19 with suicidal and homicidal ideations and bipolar disorder.
- Her insight and judgement were very poor.
- On 04/17/19 the patient began hallucinating and screaming while by herself in the shower.
- Security was called to assist Staff in transporting Patient #11 from the shower room to the seclusion room.

Review of the facility's video recording titled, "Officer Strike 04/17/19," from 3:28 PM, showed Staff J, R and U, Security Officers, escorted Patient #11 down hallway B of the Mental Health floor. Patient #11 tripped and fell to the ground, along with all three security officers. Patient #11 was lying face down and it showed Staff J's right elbow quickly move down and up in a striking motion three times into the direction of Patient #11's head and neck area.

During an interview on 05/28/19 at 3:35 PM, Staff F, Associate Director RN, stated that:
- She was the leader on call the day of 04/17/19 and she was called right after the event.
- Patient #11 was bleeding from the mouth.
- She does not feel patients should ever get hit.

During an interview on 05/29/19 at 10:10 AM, Staff C, Director of Behavioral Health, after watching the video recording from above the Pyxis in the nursing station, that Staff J appears to strike Patient #11 three times.

During an interview on 05/29/19 at 11:00 AM, Staff J stated that he reacted with striking Patient #11 once, then with a verbal command to stop biting, and then striking her maybe two more times toward the back side of her head. After the third strike he was able to get his hand free from Patient #11.

During an interview on 05/29/19 at 2:05 PM, Staff K, Behavioral Health Clinician, stated that striking a patient was not ok.

During an interview on 05/29/19 at 2:25 PM, Staff L, Behavioral Health Clinician, stated that she absolutely believes hitting a patient was considered abuse and in her opinion there was no reason to ever strike a patient.

During an interview on 05/29/19 at 2:55 PM, Staff Q, Recreation Therapist, stated that she has had education about abuse and neglect. She believes hitting a patient was abuse.

During an interview on 05/30/19 at 8:47 AM, Staff DD, Chief Nurse Executive stated that:
- She believes striking a patient was abuse.
- There was no reason to strike a patient.
- Her expectation would be that Mosaic keeps their patients safe.

During an interview on 05/30/19 at 11:35 AM, Staff EE, Chief Executive Officer, stated that he does not believe there was ever a reason to hit a patient.

Review of facility's undated document titled, "Investigation Summary Security Strike of MH Patient" showed that:
- Staff J, Security Officer, reported striking the patient in the head as a "distractionary technique" (a law enforcement technique used to regain control of an encounter) to get patient #11 to release her bite.
- Per a number of caregivers, while attempting to take patient #11 to the restraints/seclusion room, Patient #11 bit Staff J who in turn "punched" patient #11 a couple of times in the head.
- Patient #11 was complaining of mouth pain after the incident and was provided an ice pack due to swelling on her lip.
- Staff W, Registered Nurse (RN), assisted with restraining patient #11's left ankle, Staff U, Security Officer, restrained Patient #11's right ankle, Staff J, Security Officer, restrained Patient #11's left wrist and Staff R, Security Officer restrained Patient #11's right wrist and they all lifted her from the floor and carried her to the seclusion room.
- Based on review of caregiver statements/interviews and camera footage and use of the organizational Just Culture algorithm, it was determined that the security officer did not abuse the patient and it was a system failure.

During an interview on 05/28/19 at 3:35 PM, Staff F, Associate Director RN, stated that there was a committee that met to investigate this incident and everyone agreed to let Staff J come back to work.

During an interview on 05/28/19 at 4:45 PM, Staff A, Director of Regulatory Affairs stated that:
- The investigation closed officially on April 23rd.
- A committee determined that the incident was not abuse but a system failure.
- Striking a patient was not encouraged.
- The organizational policy was that staff should not strike a patient.

During an interview on 05/29/19 at 11:00 AM, Staff J stated that he did not receive any disciplinary action because he did not do anything wrong.

Review of facility's policy titled, "Use of Force Continuum," dated 11/01/18 showed that officers may use:
- Open hand techniques; (strikes used in the martial arts to attack or defend without curling the hand into a fist)
- Handcuffs; (law enforcement restraint)
- Strikes;
- Batons; (law enforcement restraint)
- Tasers; (law enforcement restraint) and
- Firearms (law enforcement restraint) when necessary to control a situation.

During an interview on 05/28/19 at 4:15 PM, Staff E, Director of Safety and Security, stated that:
- He did believe Staff J followed policy as CPI was not effective then they were to follow their use of force policy.
- His general consensus was that Staff J had no other choice but to deliver a quick rap to the back of the head.
- The security staff would use a baton, taser or handcuffs as needed.

During an interview on 05/29/19 at 11:00 AM, Staff J reported that he learned distractionary techniques as a part of his law enforcement training and reported these distractionary techniques were learned outside the facility's setting.

Review of the facility's approved nonviolent crisis intervention (CPI), reprinted 2014, showed that CPI transport position will assist you in safely moving an individual.
- Prior to moving an individual, assist the person into a more upright position and remove your hand from the individual's shoulder.
- Reach under the individual's arm to grab your own wrist.
- This cross-grain grip better secures the individual between staff during transport.
- Remove your leg from directly in front of the individual prior to transport while maintaining close body contact.
- It is not recommended to transport an individual who is struggling.
- If necessary, return to the CPI team control position (physical hold) if the individual's and/or staff's safety is at risk.

Review of the facility's approved nonviolent crisis intervention (CPI), reprinted 2014, showed the disengagement skills to release a bite.
- Avoid pulling away from the bite.
- Lean into, or feed the bite, using the minimum amount of force necessary to cause the jaw of the person to open.
- Concurrently, use your finger in a vibrating motion to stimulate the person's upper lip.
- The vibrating motion may result in a parasympathetic response (relaxation) that causes the mouth to open.
- At the same time, you can gain a psychological advantage by using a verbal distraction or an element of surprise.
- Once the bite releases attempt to move out of the way to maintain safety.
Nowhere in the CPI training program did it give instruction to strike a patient, or inflict injury to a patient.

Review of the video recording from approximately 3:28 PM on 04/17/19 showed Patient #11:
- Was escorted by three security officers, one on each side and one behind her down a hallway.
- Fell forward face down along with 3 security officers to the floor.
- Was carried face down by each wrist and each ankle by Staff W, Staff U, Staff J and Staff R in a hallway.

During an interview on 05/28/19 at 4:45 PM, Staff A, Director of Regulatory Affairs stated that she does not know if the way the patient was carried down the hall was appropriate but she did not like the way it looked on video.

During an interview on 05/29/19 at 11:00 AM, Staff J stated that:
- He did know about CPI and he did have training on CPI and did use this on patients when needed.
- He did try to feed the bite but was unable to due to his angle.
- They all picked up a limb and carried Patient #11 to the restraint room.

During an interview on 05/29/19 at 2:55 PM, Staff Q, Recreational Therapist stated that in her CPI training she was taught to carry patients being hooked and supported.

Although requested the facility failed to provide a policy on maintaining nursing responsibilities.

Review of the facility's undated document showed additional talking points added to the mental health skills day on 04/30/19 included that the primary nurse is to take charge of a restraint episode. Security comes in blind and will need cues from the mental health nurse. The mental health nurse delegates responsibilities.

During an interview on 05/29/19 at 4:30 PM, Staff W, Registered Nurse (RN), stated that:
- He felt frustrated that too many people were talking to Patient #11.
- He should have taken charge of the situation but he didn't.
- Nursing staff was responsible for the patients.

During an interview on 05/30/19 at 8:47 AM, Staff DD, Chief Nurse Executive, stated that an RN should be in charge of a patient at all times.

Interviews and video recordings showed that Patient #11 was physically abused by Staff J when he struck her three times. The facility failed to prevent abuse and did not adequately investigate the abuse. This placed all of the patients in the Mental Health Units and the Emergency Department at risk for serious harm.

Based on interview, record review, policy review and video review the facility failed to use the least restrictive method to control behavioral symptoms for one patient (#11) of one patient 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 248.

Findings included:

Review of the facility's policy titled, "Restrains/Seclusion," revised 02/26/19, showed that:
- A physical restraint was any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to freely move their arms, legs, body or head.
-The philosophy on restraints was the facility was committed to preventing, reducing and eliminating the use of restraints.
- Restrains should be used in the least restrictive manner possible and only when less restrictive interventions have been determined to be ineffective.
-Patients have the right to be free from restraints in any form that was used for coercion, discipline, convenience or retaliation by staff.

Review of the facility's undated employee orientation education titled, "Restraints and Seclusion," showed the following:
- Physical restraints includes holding a patient manually.
- Restraints should be used in the least restrictive manner possible.
- Alternatives to restraints were to be implemented, assessed and documented prior to applying restraints.

Review of Patient #11's medical record showed that she was a 29 year old female brought voluntarily by police after her mother called 911 as the patient was threatening to kill the entire world and herself. Patient #11's chief complaint was "I was hearing and seeing things." The patient had a past medical history of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks). Review of the face to face by RN, dated 04/17/19, showed shortly after 3:00 PM, the patient was in the shower, started yelling and screaming and hitting the shower walls. Staff G, Licensed Practical Nurse (LPN) attempted to instruct her to be quiet. Other staff arrived from other units and began to show up around the bathroom door. Staff J, Security Officer, arrived and used nonviolent crisis intervention (CPI, a type of training whereby staff use physical holds which restrict a persons' movement) hold to her arms and told Patient #11 that she needed to go from the shower room. Security walked down the hall toward the seclusion room where she went to the floor and began spitting and biting. She was then carried to a restraint room and placed in restraints. Patient #11 was discharged on 04/18/19.

Review of the facility's internal investigation of Staff G's statement, dated 04/17/19 at 6:17 PM, showed that:
- Patient #11 started to hit the shower walls.
- Staff G left to retrieve medication to help the patient to calm down.
- While she was in the nursing station, security brought the patient out of the bathroom and attempted to walk her down to seclusion room.
- Security and the patient fell to the floor.
- The patient was brought to the restraint room by security and nursing staff.
- Patient#11 was place in restraints.

During an interview on 05/29/19 at 4:30 PM, Staff W, Registered Nurse (RN), stated the following:
- Staff G, requested help with Patient #11 in the shower.
- Staff W was the high ranking clinical staff member and should of been in charge.
- Multiple staff were talking to Patient #11, which was causing confusion.
- Staff W knew what to do, but other staff were interfering.
- The interfering caused Patient #11 to continue to escalate, which he instructed staff to restrain the patient.
- The staff should of left her alone.

During an interview on 05/30/19 at 8:47 AM, Staff DD, Chief Nurse Executive, stated that an RN should be in charge of a patient at all times. Staff should use the least restrictive method to control the behaviors of the patient that promoted a safe environment.