HospitalInspections.org

Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to protect the rights of 1 patient (#1) of 3 patients reviewed for abuse.

The findings included:

During the survey it was found Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status, Alcohol Abuse, Failure to Thrive, Mild Diffuse Ataxia (impaired balance or coordination), Lethargy, and Disorientation. Further review revealed the patient was admitted to an inpatient unit with diagnoses of Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, Malnutrition, and Hard of Hearing. On 9/24/16 a Registered Nurse (RN #1) was called into the room of Patient #1 after the patient tried to stand and after the patient became agitated and was physically resistant. RN #1 and 3 patient care techs (PCT #1, #2, and #3) held the patient on the bed for an injection of Geodon (antipsychotic). RN #1 held the patient by the throat until the other staff members physically removed the RN's hand from the patient's throat. The staff did not report the incident promptly to the supervisor.

Interview with the Chief Nursing Officer, Accreditation Coordinator, Director of Acute Care & Women/Children, Risk Manager, and Quality Director on 10/19/16 at 9:50 AM, in the conference room, confirmed the facility failed to protect the rights of Patient #1 to be free of abuse and physical and chemical restraints; failed to obtain an order for restraints; failed to assess the patient's response to restraints.

During a telephone conference on 10/24/16 at 1:00 PM, the Chief Operating Officer, Chief Nursing Officer, Accreditation Coordinator, Quality Director, and Risk Manager were informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment or death) at 42 CFR PART 482.13 Condition of Participation, Patient Rights.

Please refer to:
A-145
A-159
A-160
A-168
A-188
A-199

Based on review of facility policy, medical record review, review of facility documentation, interview, review of personnel files, and observation, the facility failed to protect a patient from abuse; failed to report witnessed abuse; failed to document an assessment of the patient after the allegation of abuse; and failed to complete an occurrence report of abuse prior to the end of the shift for one patient (#1) of 3 patients reviewed for abuse.

The findings included:

Review of the facility's Abuse policy, revised 9/2015, revealed "...Patient Rights: Each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment...to be treated with respect and dignity at all times...All staff is educated on the signs and or symptoms of abuse. It is their obligation by law to report any type of suspicion or allegation of abuse of patients immediately to their supervisor/manager and risk management. The person with the most direct knowledge of the allegation will complete an occurrence report by the end of their shift..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. The patient was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of the medical record revealed the patient had many falls and a sitter was implemented for reduction of falls.

Medical record review of the Medication Administration Record (MAR) revealed Geodon (antipsychotic medication used to treat mood disorder, Bipolar disease, and Schizophrenia) 5 milligrams (mg) was ordered on 9/14/16 to be administered intramuscularly (IM) as needed (PRN) every 12 hours.

Medical record review of the Medication Administration Record (MAR) revealed a physician order dated 9/22/16 at 12:58 AM for Geodon 10 mg to be administered IM (intramuscular) every 4 hours as needed (PRN).

Review of the medical record for patient #1 revealed no documentation of an incident on 9/24/16 where the patient was physically restrained by facility staff. Further review revealed no documentation of an assessment of the patient on 9/24/16 before or after the incident at 4:05 AM. Continued review revealed the patient was not assessed until 9/24/16 at 8:26 AM (4 hours after the incident).

Review of the facility investigation revealed an e-mail dated 9/24/16 at 12:06 PM from the Administrative Supervisor (RN #4) to the Chief Nursing Officer (CNO), Human Resource Director, Risk Manager, Director of Acute Care/Women's & Children, and Clinical Leader #1. Continued review revealed "...Today we had (Registered Nurse #1)...accused by...coworkers of patient abuse. I have notified (RN #1) is suspended until further notice...and the coworkers who voiced concerns over alleged abuse has been notified to submit written statements..."

Review of the facility investigation revealed a witness statement by RN #1 dated 9/24/16. Continued review revealed "...I was called to [the room of patient #1] where the patient was trying to get out of bed. [Patient #1] was confused...the patient was angry and agitated, and when I asked the patient to get back into bed [the patient] cursed and threatened me. So patient care technician [PCT #2] was called to the room, [a person the patient liked in the past and was able to reason with the patient]...the patient continued to become angry and agitated, and cursed and threatened the staff, more help was called...[the nurse] was to give Geodon [antipsychotic medication]...When trying to get the patient back into the bed [the patient] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled...[the patient] back into bed. I lost my temper and found I had my hand at [the patient's] neck, and another of the staff told me to let go, so I did immediately. The Geodon was given and the patient calmed down. I admit I lost my temper, and am deeply sorry for doing so, but did not intend to hurt the patient..."

Review of a witness statement completed by PCT #3 dated 9/24/16 revealed the PCT was called to patient #1's room and entered the room to find the patient agitated and confused. Further review revealed the patient was surrounded by PCT #1, PCT #2, RN #1 and RN#2. Continued review revealed RN #2 was preparing to administer an injection and "...unfortunately we needed to hold the patient...[The patient] became more aggressive and threw a kick. At this point [RN#1] grabs the patient by the shoulder and throat and proceeds to choke the patient. [RN #1] was told to let go multiple times and did not let go until [PCT #2] grabbed [RN #1's] arm and pulled it away..."

Review of a witness statement completed by RN #2 dated 9/24/16 (the nurse assigned patient #1) revealed PCT #1 and #2 were trying to keep the patient from getting out of bed and the patient "...started to get aggravated. [PCT #1] called [RN #1] which made things worse because [RN #1] came in with a bad attitude and [Patient #1] was feeding off of that...[Patient #1] made a fist and was going to hit me. [PCT #2] grabbed [patient #1's] fist and [patient #1] tried to hit [PCT #3] with the other hand. [PCT #3] grabbed [the patient's] hand and [RN #1] threw [the patient] back onto the bed and held...shoulder down with...left hand and wrapped...right hand around...throat. I told [RN #1] multiple times to let go...[PCT #2] grabbed [RN #1's] arm and pried...hand off [the patient's] throat. [PCT#2] was also yelling at [RN #1] to let go of [the patient's] throat..."

Review of a witness statement completed by Patient Care Tech [PCT #1] dated 9/25/16 revealed PCT #1 was the assigned sitter to Patient #1 from 9/23/16 at 7:00 PM until 9/24/16 at 7:00 AM. Review of the statement revealed, "...At 0400 [4:00 AM] on September 24 my patient [patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way. I...called [named RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit PCT #2. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient [saw] it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 & #3] tried to keep...from getting up. The patient started kicking and punching staff members so we laid [the patient]...back down in the bed. [PCT #3] had...legs to keep from kicking...[PCT #2] and I had...arms and shoulders to keep...from hitting and coming back out of bed. [RN #1] had a hold of...neck with one hand and [PCT #2] told...to let go several times. [PCT #2] pushed [RN #1] hand off the patient's neck. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning..."

Review of a witness statement completed by PCT #2 dated 9/25/16 revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "...very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [the patient's] fist...[the patient] acted like [he] was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and [patient's] leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [Patient #1] shoulder with one hand and [the patient's] throat with the other. [RN #2] kept asking [RN #1] to please let go of [the patient's] throat...after [RN #2] asked three times I had to pry...hands off...Then [RN #2] gave...the shot and [Patient #1] started to calm down and [RN #1] left..."

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed when the incident occured the patient was in a low-boy bed and the ¼ side rails on the right side of the bed were in the raised position when he attempted to get out of bed. Continued interview revealed the patient woke up and stated he wanted to go to the bathroom, and the PCT "...offered [named patient) the urinal but he did not use it..." Further interview revealed the patient positioned self to the foot of the bed between the foot board and the bottom of the side rail. Continued interview revealed the PCT did not offer for the patient to stand and did not notify other staff of the patient's request to go to the bathroom. Further interview revealed the PCT recognized the handling of the Patient #1 by RN #1 was abuse. Continued interview confirmed PCT #1 did not report the witnessed abuse.

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "...I was coming from the nursing station and [RN #1] was two steps ahead of me. As I walked in the room [the patient] started cursing and yelling 'You're not going to stab me with that...needle'..." Continued interview revealed after RN #1 released the hand from the patient's neck "...I looked [the patient] over...I did not see any marks or bruising...I was upset...knew the protocol was to call the supervisor...I did not notify anyone of the abuse..."

Interview with PCT #2 on 10/13/16 at 9:25 AM, in the conference room, revealed at the time of the incident the patient was calm, sitting on the side of the bed near the footboard, but wanted to get up and leave. Further interview revealed the PCT was not able to redirect the patient. Continued interview revealed the patient "...was calm but just wanted to get up..." until the nurse came in with the syringe. Further interview revealed, "...When [RN #2] pulled the cap off the syringe, [Patient #1] drew back like...was going to hit [RN #1] so I held [the patient's] arm. [The patient] clearly did not want the shot. [Patient #1] drew back the other arm and [(PCT #1 and #3] held the arm down...kicked [PCT #3] and [the patient's] legs were held down..." Continued interview revealed the PCT recognized the handling of the patient by RN #1 was abuse. Futher interview revealed PCT #2 discussed the witnessed abuse with PCT #3 and RN #2 intermittently for the remainder of the shift and was in agreement to delay reporting of the abuse until after the shift to avoid RN #1 being aware they had reported the incident.

Interview with PCT #3 on 10/13/16 at 10:15 AM, in the conference room, revealed PCT #3 was called into patient #1's room by PCT #2 and was told the patient was "physical" with PCT #1. "...At that point I knew I was going to have to hold [Patient #1]..." Continued interview revealed when PCT #3 arrived there were 4 other employees in the room (PCT #1, PCT #2, RN #1, and RN #2). Further interview revealed the patient was "...agitated but not physical..." Continued interview revealed PCT #2 and PCT #3 made attempts to calm the patient but were unsuccessful. Further interview revealed "...We go to lay [Patient #1] down and [the patient] resisted. I held [the patient's] arm and then [the patient] kicked me in the shoulder then we [PCT #1 and #3] get his legs. [RN #1] was behind [the patient] and suddenly put one hand on [the patient's] shoulder and one on [the patient's] neck and slammed [the patient] on the bed..." Continued interview revealed the PCT recognized the handling of the patient by RN #1 was abuse and PCT#3 discussed RN #1's abusive action with PCT #2 and RN #2 throughout the shift. Further interview revealed PCT #3 was in agreement to delay reporting of the abuse until after the shift to prevent RN #1 from knowing they were reporting the incident. Continued interview revealed "...We were in shock; we decided since [RN #1] had calmed down we did not want to escalate the situation and risk anyone getting hurt..."

Interview with RN #3 on October 12, 2016 at 6:24 PM, in the conference room, revealed the nurse was not a witness to the incident. Continued interview revealed, "...I was standing in the hallway when [PCT #2] came up to me and I knew [PCT #2] was upset...I could see it in...face. The [PCT] told me [RN #1] choked [named patient]...I knew it was bad and should be reported..."

Interview with RN #1 on October 17, 2016 at 9:30 AM, in the lobby, revealed the sitter (PCT #1) called the nurse for assistance to get the patient back in bed. Continued interview revealed the patient was sitting on the side of the bed and the sitter did not tell the nurse the patient requested to go to the bathroom. Further interview revealed the nurse attempted to calm the patient but was unsuccessful so the nurse called PCT #2 who had been successful in previous attempts. Continued interview revealed when other staff arrived the nurse moved to the other side of the bed (the left side) behind the patient. Further interview revealed "...When [Patient #1] stood up, hitting and kicking, I tried to get [the patient] up in bed...[the patient] did not resist. I had my arms around [the patient] from behind...I tried to get around...shoulders. As soon as I heard I had my hand around [the patient's] neck I let go immediately. I was frustrated, but I was not angry...no one said anything to me until I got a call at home...woke me up to tell me I was accused of abuse and was suspended pending investigation..."

Interview with the Assistant Clinical Leader (ACL #1) on 10/12/16 at 4:45 PM, in the conference room, revealed the ACL received a telephone call from RN #3 on 9/24/16 around 8:00 AM and requested a meeting to discuss an incident regarding patient #1. Continued interview revealed ACL #1 met with RN #2, RN #3, PCT #2, and PCT #3 at 8:10 AM as requested. Further interview revealed the RNs and PCTs described the incident of Patient #1 getting aggressive, kicking, and hitting at the staff and described RN #1 held the patient down with one hand on the shoulder and one hand on the throat. Continued interview revealed ACL #1 was told by the 4 staff members they discussed the witnessed incident and recognized it was abuse "...but all agreed to wait until the shift was over to report the incident..." Further interview revealed ACL #1 reported the incident to the Administrative Supervisor on duty (RN #4) on 9/24/16 at 8:30 AM, the Clinical Leader (CL #1), and the patient's physician.

Interview with the attending physician (Physician #1) on 10/19/16 at 8:30 AM, in the conference room, revealed the physician was notified of the incident by the ACL #1 when the physician arrived on the inpatient unit the morning of 9/24/16, "...around 8 AM..." Continued interview revealed the physician was informed the patient was agitated earlier in the morning; received Geodon; and a staff member had hands on the patient's neck/throat. Further interview revealed the physician performed an evaluation of the patient and no bruising, redness, swelling, or marks were noted on the patient's neck or throat and the patient's behavior was "...no different from the usual behavior..."

Review of the personnel file and time card for RN #1 revealed RN #1 clocked out of the facility at 7:37 AM on 9/24/16 (3 hours after the abuse was witnessed) and was suspended on 9/24/16. Continued review revealed the RN was terminated from the facility on 9/26/16 after determination of "...actions that do not align with our values, policy or align with any other level of practice as a caregiver..."

Observation of Patient #1 on 10/18/16 at 8:15 PM, in his room, revealed the patient was lying in bed with the head of the bed up nearly 90 degrees. Further observation revealed a sitter was at the patient's bedside.

Interview with Patient #1 on 10/18/16 at 8:15 PM, in his room, revealed the patient was confused, disoriented, and answered questions with unrelated words. Further observation revealed the patient spoke in a very soft and slow manner.

Interview with the Chief Nursing Officer, Accreditation Coordinator, Director of Acute Care & Women/Children, Risk Manager, and Quality Director on October 19, 2016, at 9:50 AM, in the conference room, confirmed the facility failed to protect 1 patient (#1) from abuse, failed to immediately report abuse, and failed to document an assessment of the patient after the allegation of abuse.

Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to protect 1 patient (#1) from physical hold restraints of 3 patients reviewed.

The findings included:

Review of the facility's Restraint and Seclusion Policy, revised 7/2015, revealed "...Restraints will be used when clinically justified and when other alternatives are ineffective...any manual method, physical or mechanical device...equipment that immoblizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...physical restraints include hands on or manual holds...RN [Registered Nurse] may initiate application of restraint when less restrictive interventions have either been exhausted or have been determined to be ineffective to protect the patient...An order is still required and must be obtained immediately...when a restraint or seclusion is used for the management of violent and/or self-destructive behavior...the registered nurse immediately notifies the MD [Medical Doctor] or NP [Nurse Practitioner] to obtain an order..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. The patient was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of the medical record revealed the patient had many falls and a sitter was implemented for reduction of falls.

Review of the medical record for Patient #1 revealed no documentation of an incident on 9/24/16 where the patient was physically restrained by facility staff. Further medical record review revealed no documentation less restrictive interventions had been attempted prior to the use of physical restraints.

Review of the facility investigation revealed a witness statement was completed by RN #1 on 9/24/16. Continued review revealed "...I was called to [the room of patient #1] where the patient was trying to get out of bed...the patient was angry and agitated, and when I asked the patient to get back into bed [the patient] cursed and threatened me...patient care technician [PCT #2] was called to the room [a person the patient liked in the past and was able to reason with the patient]...the patient continued to become angry and agitated, and cursed and threatened the staff, more help was called [the nurse] was to give Geodon [antipsychotic medication]...When trying to get the patient back into the bed [the patient] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled [the patient]...back into bed..."

Review of a witness statement completed by PCT #3 dated 9/24/16 revealed the PCT was called to patient #1's room and entered the room to find the patient agitated and confused. Further review revealed the patient was surrounded by PCT #1, PCT #2, RN #1 and RN#2. Continued review revealed RN #2 was preparing to administer an injection and "...unfortunately we needed to hold the patient...[The patient] became more aggressive and threw a kick. At this point [RN#1] grabs the patient by the shoulder and throat and proceeds to choke the patient. [RN #1] was told to let go multiple times and did not let go until [PCT #2] grabbed [RN #1's] arm and pulled it away..."

Review of a witness statement completed by RN #2 dated 9/24/16 (the nurse assigned patient #1) revealed PCT #1 and #2 were trying to keep the patient from getting out of bed and the patient "...started to get aggravated. [PCT #1] called [RN #1] which made things worse because [RN #1] came in with a bad attitude and [Patient #1] was feeding off of that...[Patient #1] made a fist and was going to hit me. [PCT #2] grabbed [patient #1's] fist and [patient #1] tried to hit [PCT #3] with the other hand. [PCT #3] grabbed [the patient's] hand and [RN #1] threw [the patient] back onto the bed and held...shoulder down with...left hand and wrapped...right hand around...throat. I told [RN #1] multiple times to let go of...[PCT #2] grabbed [RN #1's] arm and pried...hand off [the patient's] throat. [PCT#2] was also yelling at [RN #1] to let go of [the patient's] throat..."

Review of a witness statement completed by Patient Care Tech (PCT #1) dated 9/25/16 revealed PCT #1 was the assigned sitter to Patient #1 from 9/23/16 at 7:00 PM until 9/24/16 at 7:00 AM. Review of the statement revealed, "...At 0400 [4:00 AM] on September 24 my patient [patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way. I...called [named RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit PCT #2. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient [saw] it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 & #3] tried to keep...from getting up. The patient started kicking and punching staff members so we laid [the patient]...back down in the bed. [PCT #3] had...legs to keep from kicking...[PCT #2] and I had...arms and shoulders to keep...from hitting and coming back out of bed. [RN #1] had a hold of...neck with one hand and [PCT #2] told...to let go several times. [PCT #2] pushed [RN #1] hand off the patient's neck. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning..."

Review of a witness statement completed by PCT #2 dated 9/25/16 revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "...very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [the patient's] ...[the patient] acted like he was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and [named patient's] leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [Patient #1] shoulder with one hand and [the patient's] throat with the other. [RN #2] kept asking [RN #1] to please let go of [the patient's] throat...after [RN #2] asked three times I had to pry...hands off...Then [RN #2] gave...the shot and [patient #1] started to calm down and [RN #1] left..."

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed when the incident occured the patient was in a low-boy bed and the ¼ side rails on the right side of the bed were in the raised position when he attempted to get out of bed. Continued interview revealed the patient woke up and stated he wanted to go to the bathroom, and the PCT "...offered [named patient) the urinal but he did not use it..." Further interview revealed the patient positioned self to the foot of the bed between the foot board and the bottom of the side rail. Continued interview revealed the PCT did not offer for the patient to stand and did not notify other staff of the patient's request to go to the bathroom.

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "...I was coming from the nursing station and [RN #1] was two steps ahead of me. As I walked in the room [the patient] started cursing and yelling 'You're not going to stab me with that...needle...'[PCT #2] grabbed the left wrist and [the patient] tried to hit the nurse with the other fist and [PCT #3] grabbed the right arm...the patient was sitting on the foot of the bed when [RN#1] comes in and stood behind [the patient] and laid [the patient] down suddenly on the bed and put the left hand on the patient's shoulder and the right hand on the patient's throat..." Continued interview confirmed the employees held the patient down for RN #3 to administer the antipsychotic medication and the Geodon was administered involuntarily. Further interview confirmed the nurse did not notify the physican after the patient required a physical hold for the administration of the medication.

Interview with PCT #2 on 10/13/16 at 9:25 AM, in the conference room, revealed at the time of the incident the patient was calm, sitting on the side of the bed near the footboard, but wanted to get up and leave. Further interview revealed the PCT was not able to redirect the patient. Continued interview revealed the patient "...was calm but just wanted to get up..." until the nurse came in with the syringe. Further interview revealed, "...When [RN #2] pulled the cap off the syringe, [Patient #1] drew back like...was going to hit [RN #1] so I held [the patient's] arm. [The patient] clearly did not want the shot. [Patient #1] drew back the other arm and [PCT #1 and #3] held the arm down...kicked [PCT #3] and [the patient's] legs were held down..." Continued interview revealed the the patient was held down in the bed until the nurse administered the medication.

Interview with PCT #3 on 10/13/16 at 10:15 AM, in the conference room, revealed PCT #3 was called into patient #1's room by PCT #2 and was told the patient was "physical" with PCT #1. "...At that point I knew I was going to have to hold [Patient #1]..." Continued interview revealed when PCT #3 arrived there were 4 other employees in the room (PCT #1, PCT #2, RN #1, and RN #2). Further interview revealed the patient was "...agitated but not physical..." Continued interview revealed PCT #2 and PCT #3 made attempts to calm the patient but were unsuccessful. Further interview revealed "...We go to lay [Patient #1] down and [the patient] resisted. I held [the patient's] arm and then [the patient] kicked me in the shoulder then we [PCT #1 and #3] get his legs. [RN #1] was behind [the patient] and suddenly put one hand on [the patient's] shoulder and one on [the patient's] neck and slammed [the patient] on the bed..." Continued interview the patient was held down in the bed for administration of the medication.

Interview with RN #1 on October 17, 2016 at 9:30 AM, in the lobby, revealed the sitter (PCT #1) called the nurse for assistance to get the patient back in bed. Continued interview revealed the patient was sitting on the side of the bed and the sitter did not tell the nurse the patient requested to go to the bathroom. Further interview revealed the nurse attempted to calm the patient but was unsuccessful so the nurse called PCT #2 who had been successful in previous attempts. Continued interview revealed when other staff arrived the nurse moved to the other side of the bed (the left side) behind the patient. Further interview revealed "...When [Patient #1] stood up, hitting and kicking, I tried to get [the patient]... up in bed...[the patient] did not resist. I had my arms around [the patient] from behind...I tried to get around...shoulders...I pulled [the patient] up and back in bed so [RN #2] could give the medication and to keep my staff safe..."

Interview with the Chief Nursing Officer, Accreditation Coordinator, Director of Acute Care & Women/Children, Risk Manager, and Quality Director on October 19, 2016, at 9:50 AM, in the conference room, confirmed the facility failed to protect the patient from physical restraints and failed to follow facility policy.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to protect the rights of 1 patient (#1) to be free from a chemical restraint of 3 patients reviewed.

The findings included:

Review of the facility's Restraint and Seclusion Policy revised 7/2015 revealed "...a Restraint is...a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition...chemical restraint...A drug or medication, when it is given involuntarily as a restriction to manage a patient's behavior or restrict the patient's freedom of movement and is NOT a standard treatment or dosage for the patient's condition...In emergency application situation, a RN may initiate application of restraint when less restrictive interventions have either been exhausted or have been determined to be ineffective to protect the patient and/or others. An order is still required and must be obtained immediately...When a restraint or seclusion is used for the management of violent and/or self-destructive behavior that jeopardizes safety, the registered nurse immediately notifies the Medical Doctor [MD] or Nurse Practitioner [NP] to obtain an order..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. The patient was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of the medical record revealed the patient had many falls and a sitter was implemented for reduction of falls.

Medical record review of the Medication Administration Record (MAR) revealed Geodon (antipsychotic medication used to treat mood disorder, Bipolar disease, and Schizophrenia) 5 milligrams (mg) was ordered on 9/14/16 to be administered intramuscularly (IM) as needed (PRN) every 12 hours.

Medical record review of the Medication Administration Record (MAR) revealed a physician order dated 9/22/16 at 12:58 AM for Geodon 10 mg to be administered IM (intramuscular) every 4 hours as needed (PRN).

Review of the facility investigation revealed a witness statement was Registered Nurse (RN #1) on 9/24/16. Continued review revealed "...I was called to [the room of patient #1] where the patient was trying to get out of bed. [Patient #1] was confused...the patient was angry and agitated and when I asked the patient to get back into bed [the patient] cursed and threatened me. So patient care technician [PCT #2] was called to the room [a person the patient liked in the past and was able to reason with the patient]...the patient continued to become angry and agitated, and cursed and threatened the staff, more help was called [the nurse] was to give Geodon [antipsychotic medication]...When trying to get the patient back into the bed [the patient] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled [the patient]...back into bed. I lost my temper and found I had my hand at [the patient's] neck, and another of the staff told me to let go, so I did immediately. The Geodon was given and the patient calmed down. I admit I lost my temper, and am deeply sorry for doing so, but did not intend to hurt the patient..."

Review of a witness statement completed by PCT #3 dated 9/24/16 revealed the PCT was called to patient #1's room and entered the room to find the patient agitated and confused. Further review revealed the patient was surrounded by PCT #1, PCT #2, RN #1 and RN#2. Continued review revealed RN #2 was preparing to administer an injection and "...unfortunately we needed to hold the patient...[The patient] became more aggressive and threw a kick. At this point [RN#1] grabs the patient by the shoulder and throat and proceeds to choke the patient.

Review of a witness statement completed by Patient Care Tech (PCT #1) dated 9/25/16 revealed PCT #1 was the assigned sitter to Patient #1 from 9/23/16 at 7:00 PM until 9/24/16 at 7:00 AM. Review of the statement revealed, "...At 0400 [4:00 AM] on September 24 my patient [patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way. I...called [named RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit PCT #2. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient [saw] it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 & #3] tried to keep...from getting up. The patient started kicking and punching staff members so we laid [the patient]...back down in the bed. [PCT #3] had...legs to keep from kicking...[PCT #2] and I had...arms and shoulders to keep...from hitting and coming back out of bed. [RN #1] had a hold of...neck with one hand and [PCT #2] told...to let go several times. [PCT #2] pushed [RN #1] hand off the patient's neck. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning..."

Review of a witness statement completed by PCT #2 dated 9/25/16 revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "...very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [the patient's] fist [the patient] acted like [he] was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and [patient's] leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [Patient #1] shoulder with one hand and [the patient's] throat with the other. [RN #2] kept asking [RN #1] to please let go of [the patient's] throat...after [RN #2] asked three times I had to pry...hands off...Then [RN #2] gave...the shot and [patient #1] started to calm down and [RN #1] left..."

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed when the incident occured the patient was in a low-boy bed and the ¼ side rails on the right side of the bed were in the raised position when he attempted to get out of bed. Continued interview revealed the patient woke up and stated he wanted to go to the bathroom...[PCT #1 and PCT #2] tried to keep [the patient] in the bed...[the patient] said 'I don't want to hit you but I will do what I have to do'...[the patient] got more agitated when...saw the syringe...[the patient] cursed and said 'I don't want that...don't come near me with that'..." Further interview reveale PCT #1 had been previously involved in holding the patient down for an injection because the patient "...fights it..."

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "...I was coming from the nursing station and [RN #1] was two steps ahead of me. [RN #1] had removed Geodon from [named medication dispensing system]...[RN #1] handed me the Geodon and I got it ready...outside the [patient's] room...As I walked in the room [the patient] started cursing and yelling 'You're not going to stab me with that...needle'...[PCT #2] grabbed the left wrist and [the patient] tried to hit me with the other fist and [PCT #3] grabbed the right arm...the patient was sitting on the foot of the bed when [RN #1] comes in and stood behind [the patient] and laid [the patient] down suddenly on the bed...put the left hand on the patient's shoulder and the right hand on the patient's throat while I administered the Geodon..." Continued interview confirmed the 4 employees held the patient down for RN #2 to administer the antipsychotic medication and the patient and demonstrated refusal of the medication. Further interview confirmed the Geodon was administered involuntarily.

Interview with PCT #2 on 10/13/16 at 9:25 AM, in the conference room, revealed at the time of the incident the patient was calm, sitting on the side of the bed near the footboard, but wanted to get up and leave. Further interview revealed the PCT was not able to redirect the patient. Continued interview revealed the patient "...was calm but just wanted to get up..." until the nurse came in with the syringe. Further interview revealed, "...When [RN #2] pulled the cap off the syringe, [Patient #1] drew back like...was going to hit [RN #1] so I held [the patient's] arm. [The patient] clearly did not want the shot. [Patient #1] drew back the other arm and [PCT #1 and #3] held the arm down...kicked [PCT #3] and [the patient's] legs were held down..."

Interview with PCT #3 on 10/13/16 at 10:15 AM, in the conference room, revealed PCT #3 was called into patient #1's room by PCT #2 and was told the patient was "physical" with PCT #1. "...At that point I knew I was going to have to hold [Patient #1]..." Continued interview revealed when PCT #3 arrived there were 4 other employees in the room (PCT #1, PCT #2, RN #1, and RN #2). Further interview revealed the patient was "...agitated but not physical..." Continued interview revealed PCT #2 and PCT #3 made attempts to calm the patient but were unsuccessful. Further interview revealed "...We go to lay [patient #1] down and [the patient] resisted. I held [the patient's] arm and then [the patient] kicked me in the shoulder then we [PCT #1 and #3] get his legs. [RN #1] was behind [the patient] and suddenly put one hand on [the patient's] shoulder and one on [the patient's] neck and slammed [the patient] on the bed...[the patient] repeatedly said 'get off me and get up'...[the patient] was held for the shot..."

Interview with RN #1 on October 17, 2016 at 9:30 AM, in the lobby, revealed the sitter (PCT #1) called the nurse for assistance to get the patient back in bed. Continued interview revealed the patient was sitting on the side of the bed and the sitter did not tell the nurse the patient requested to go to the bathroom. Further interview revealed the nurse attempted to calm the patient but was unsuccessful so the nurse called PCT #2 who had been successful in previous attempts. Continued interview revealed when other staff arrived the nurse moved to the other side of the bed (the left side) behind the patient. Further interview revealed "...When [Patient #1] stood up, hitting and kicking, I tried to get [the patient]...up in bed. [The patient] did not resist. I had my arms around [the patient] from behind...I tried to get around...shoulders..." Continued interview confirmed the nurse physically held the patient on the bed to allow the nurse to administer the medication after the patient verbalized refusal of the medication.

Interview with Patient #1 on 10/18/16 at 8:15 PM, in his room, revealed the patient was confused, disoriented, and answered questions with unrelated words. Further observation revealed the patient spoke in a very soft and slow manner.

Interview with the Chief Nursing Officer, Accreditation Coordinator, Director of Acute Care & Women/Children, Risk Manager, and Quality Director on October 19, 2016, at 9:50 AM, in the conference room, confirmed the facility failed to protect the rights of a patient to be free from chemical restraints.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to obtain an order for a restraint for 1 patient (#1) of 3 patients reviewed.

The findings included:

Review of the facility's Restraint and Seclusion Policy revised 7/15 revealed, "...G. Ordering and Face-to-Face Evaluation...In emergency application situation, a RN [Registered Nurse] may initiate application of restraint when less restrictive interventions have either been exhausted or have been determined to be ineffective to protect the patient and/or others. An order is still required and must be obtained immediately; not to exceed 1 hour from initiation." Continued review revealed, "8. The following guidelines regarding ordering and evaluation are specific to Violent/Self-destructive Restraints: a.When a restraint or seclusion is used for the management of violent and/or self-destructive behavior that jeopardizes safety, the registered nurse immediately notifies the MD [Medical Doctor] or NP [Nurse Practitioner] to obtain an order."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. The patient was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of the medical record revealed the patient had many falls and a sitter was implemented for reduction of falls.

Medical record review of the Medication Administration Record (MAR) revealed Geodon (antipsychotic medication used to treat mood disorder, Bipolar disease, and Schizophrenia) 5 milligrams (mg) was ordered on 9/14/16 to be administered intramuscularly (IM) as needed (PRN) every 12 hours.

Medical record review of the Medication Administration Record (MAR) revealed a physician order dated 9/22/16 at 12:58 AM for Geodon 10 mg to be administered IM (intramuscular) every 4 hours as needed (PRN).

Review of a facility investigation witness statement completed by RN #1, dated 9/24/16, revealed, "I was called to [the room of Patient #1] where the patient was trying to get out of bed. [Patient #1] was confused...was angry and agitated, and when I asked the patient to get back into bed [Patient #1] cursed and threatened me...more help was called and [RN #2] was to give Geodon. "When trying to get the patient back into the bed [Patient #1] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled...back into bed..." The Geodon was given and the patient calmed down.

Review of the witness statement completed by Patient Care Technician (PCT) #3, dated 9/24/16, revealed the PCT was called to Patient #1's room and entered the room to find the patient agitated and confused and was surrounded by PCT #1, PCT #2, RN #1 and RN #2. Continued review revealed RN #2 was preparing to administer an injection, and "unfortunately we needed to hold the patient...[The patient] became more aggressive and threw a kick. At this point [RN #1] grabbed the patient by the shoulder...and throat and proceeds to choke the patient. [RN #1] was told to let go multiple times and did not let go until [PCT #2] grabbed [RN #1's] arm and pulled it away..."

Review of the witness statement completed by RN #2 dated 9/24/16 (the nurse assigned to Patient #1) revealed PCT #1 and #2 were trying to keep Patient #1 from getting out of bed and the patient became aggravated. Patient #1 made a fist and was going to hit RN #2. PCT #1 grabbed the patient's fist and the patient tried to hit PCT #3 with the other hand. PCT #3 grabbed the patient's hand and RN #1 threw the patient back onto the bed and held the patient's shoulder down with the left hand and wrapped the right hand around the patient's throat.

Review of the witness statement completed by PCT #1 dated 9/25/16 revealed PCT #1 was assigned as a sitter to Patient #1 for the 9/23/16 7PM - 9/24/16 7AM shift. Review of the statement revealed, "At 0400 [4:00 AM] on September 24 my patient [Patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way...I...called [RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit PCT #2. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient (saw) it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 and #3] tried to keep [patient] from getting up. The patient started kicking and punching staff members so we laid [Patient #1] back down in the bed. [PCT #3] had [the patient's] legs to keep from kicking; [PCT #2] and I had [the patient's] arms and shoulders to keep [Patient #1] from hitting and coming back out of bed. [RN #1] had a hold of...neck with one hand. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [Patient #1] was calm for the rest of the morning."

Review of the witness statement completed by PCT #2 dated 9/25/16 revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "very agitated and drew back like [Patient #1] was going to hit [RN #2]. That's when I grabbed [the patient's] fist...[Patient #1] acted like...was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and...leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [patient #1's] shoulder with one hand and [the patient's] throat with the other...Then [RN #2] gave [Patient #1] the shot and [Patient #1] started to calm down..."

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed the patient was in a low bed and ¼ side rails were in the raised position when the patient was attempting to get out of bed. Continued interview revealed the patient woke up and wanted to go to the bathroom. Continued interview revealed PCT #1 and #2 "tried to keep [Patient #1] in the bed. [The patient said], 'I don't want to hit you but I will do what I have to do.'" Continued interview revealed the patient "got more agitated when...saw the syringe. [Patient #1] cursed and said, 'I don't want that; don't come near me with that.'" Continued interview revealed the PCT participated in holding the patient down on the bed to allow the nurse to administer the injection.

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "I was coming from the nursing station and [RN #1] was 2 steps ahead of me. [RN #1] had removed Geodon from the Omnicell [medication dispensing system]. [RN #1] handed me the Geodon and I got it ready at the med [medication] cart outside the patient's door. As I walked in the room [Patient #1] started cursing and yelling 'You're not going to stab me with that...needle'. [PCT #2] grabbed the left wrist and [the patient] tried to hit me with the other fist and [PCT #3] grabbed the right arm. The patient was sitting on the foot of the bed when [RN #1] comes in and stood behind [Patient #1] and laid [Patient #1] down suddenly on the bed and put the left hand on the patient's shoulder and the right hand on the patient's throat while I administered Geodon in [the patient's] left deltoid." Continued interview revealed RN #1, PCT #1, #2, and #3 held the patient down for RN #2 to administer the antipsychotic medication. Continued interview confirmed the Geodon was administered involuntarily. Continued interview confirmed the nurse did not call the physician prior to the physical hold, did not notify the physician after the physical restraint and administration of Geodon, and stated, "It never occurred to me to call the physician." Further interview confirmed the patient did not have an order for a restraint.

Interview with PCT #3 on 10/13/16 at 10:15 AM, in the conference room, revealed PCT #3 was called into Patient #1's room by PCT #2 and was told the patient was "physical" with PCT #1. "At that point I knew I was going to have to hold [Patient #1]." Continued interview revealed when PCT #3 arrived there were 4 other employees in the room (PCT #1, #2, RN #1, and #2). The patient was "agitated but not physical." Continued interview revealed PCT #2 and #3 made attempts to calm the patient but were unsuccessful. Continued interview revealed, "We go to lay [Patient #1] down and [the patient] resisted. I hold [the patient's] arm and then [the patient] kicked me in the shoulder then we [PCT #1 and #3] get his legs. [RN #1] was behind [Patient #1] and suddenly put one hand on [the patient's] shoulder and one on [the patient's] neck and slammed [the patient] on the bed." Continued interview revealed the patient repeatedly said, "Get off me; Get up." Further interview revealed RN #2 administered the shot while the patient was held in the bed.

Interview with RN #1 on 10/17/16 at 9:30 AM, in the lobby, revealed the sitter called RN #1 for assistance to get the patient back in bed. Continued interview revealed the nurse attempted to calm the patient but was unsuccessful so the nurse called PCT #2 who had been successful in attempts previously. Continued interview revealed when other staff came in, RN #1 moved to the other side of the bed (the left side) behind the patient. Continued interview revealed, "When [Patient #1] stood up, hitting and kicking, I tried to get [the patient] back and up in bed...I had my arms around [Patient #1] from behind...I tried to get around [the patient's] shoulders." Continued interview revealed RN #1 and 3 co-workers held the patient in the bed for the nurse to administer the medication. Continued interview revealed RN #1 heard the patient refuse the medication. Further interview revealed the RN #1 did not notify the physician after restraining Patient #1 and administering the Geodon.

Interview with the Chief Nursing Officer, Accreditation Coordinator, Quality Director, Risk Manager, and Director of Acute Care and Women/Children on October 19, 2016, at 9:50 AM, in the conference room, confirmed the facility failed to obtain an order to restrain Patient #1.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to document the patient's response to the applied restraint for 1 (#1) of 3 patients reviewed.

The findings included:

Review of the facility's Restraint and Seclusion Policy revised 7/15 revealed, "...The following documentation shall be included in the medical record: The Patient's condition or symptom(s) that justify the use of restraint. Any alternatives and/or strategies attempted. Type of restraint used. The patient's response to the intervention(s) used..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. Patient #1 was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Medical record review of the Medication Administration Record (MAR) revealed Geodon (an antipsychotic medication used to treat mood disorder, bipolar disease, and Schizophrenia) 5 milligrams (mg) was ordered on 9/14/16 to be administered intramuscularly (IM) as needed (PRN) every 12 hours.

Medical record review of the Medication Administration Record (MAR) revealed a physician order dated 9/22/16 at 12:58 AM for Geodon 10 mg to be administered IM (intramuscular) every 4 hours as needed (PRN). Further review revealed Registered Nurse (RN #2) administered the medication on 9/24/16 at 4:08 AM.

Review of a facility investigation witness statement completed by RN #1, dated 9/24/16, revealed, "I was called to [the room of patient #1] where the patient was trying to get out of bed. [Patient #1] was confused...was angry and agitated, and when I asked the patient to get back into bed [Patient #1] cursed and threatened me...the patient care technician [PCT #2] was called to the room. The patient continued to become angry and agitated, and cursed and threatened the staff. More help was called and [RN #2] was to give Geodon...when trying to get the patient back into the bed [Patient #1] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled...back into bed..." The Geodon was given and the patient calmed down.

Review of a witness statement completed by PCT #3, dated 9/24/16, revealed the PCT was called to Patient #1's room and entered the room to find the patient agitated and confused and surrounded by PCT #1, PCT #2, RN #1 and #2. Continued review revealed RN #2 prepared to administer an injection, and "unfortunately we needed to hold the patient...[Patient #1] became more aggressive and threw a kick. At this point [RN #1] grabbed the patient by the shoulder...and throat and proceeds to choke the patient. [RN #1] was told to let go multiple times and did not let go until [PCT #2] grabbed [RN #1's] arm and pulled it away..."

Review of the witness statement completed by RN #2 dated 9/24/16 (the nurse assigned patient #1) revealed PCT #1 and #2 were trying to keep the patient from getting out of bed and the patient became aggravated. Patient #1 made a fist and was going to hit RN #2. PCT #1 grabbed the patient's fist. PCT #3 grabbed the patient's hand and RN #1 threw the patient back onto the bed, held the patient's shoulder down with the left hand, and wrapped the right hand around the patient's throat.

Review of the witness statement completed by Patient Care Tech (PCT #1), dated 9/25/16 revealed PCT #1 was assigned as a sitter to Patient #1 for the 9/23/16 7PM - 9/24/16 7AM shift. Review of the statement revealed, "At 0400 [4:00 AM] on September 24 my patient [Patient #1] started to get out of bed. I asked...calmly to lay back down and [Patient #1] started to push me out of the way. I...called [RN #1] to help...Patient started to get more agitated and threatened to hit [PCT #2]. [PCT #2] called [PCT #3] to help. [PCT #3]) and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient (saw) it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 and #3] tried to keep [Patient #1] from getting up. The patient started kicking and punching staff members so we laid [the patient] back down in the bed. [PCT #3] had [the patient's] legs to keep from kicking; [PCT #2] and I had [the patient's] arms and shoulders to keep [the patient] from hitting and coming back out of bed. [RN #1] had a hold of [the patient's ] neck with one hand. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning."

Review of a witness statement completed by PCT #2, dated 9/25/16, revealed the patient was sitting at the foot of the bed attempting to get up, and when RN #2 entered the room with the syringe, the patient became "very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [the patient's] fist...[PCT #1 and #3] grabbed the patient's other arm and leg and was holding them down. [RN #1]] slammed [Patient #1]) on the bed and held the patient's shoulder with one hand and throat with the other." Continued review revealed RN #2 gave the patient the shot and "(Patient #1) started to calm down..."

Review of the electronic medical record for Patient #1 revealed no documentation of the incident on 9/24/16. Continued review revealed no documentation of an assessment of the patient on 9/24/16 after the incident at 4:05 AM. Further review revealed vital signs documented on 9/23/16 at 9:12 PM, and no other assessment or evaluation of the patient until 9/24/16 at 8:26 AM, four hours after the incident occurred.

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed the patient was in a low bed with ¼ side rails in the raised position when the patient was attempting to get out of bed. Continued interview revealed the patient woke up and wanted to go to the bathroom. Continued interview revealed PCT #1 and #2 "tried to keep [Patient #1] in the bed." Continued interview revealed the patient "got more agitated when [the patient] saw the syringe. [Patient #1] cursed and said, 'I don't want that; don't come near me with that.'" Continued interview revealed the PCT participated in holding the patient down on the bed to allow the nurse to administer the injection.

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "I was coming from the nursing station and [RN #1] was 2 steps ahead of me. [RN #1] had removed Geodon from the Omnicell [medication dispensing system]. [RN #1] handed me the Geodon and I got it ready at the med [medication] cart outside the patient's door. As I walked in the room [Patient #1] started cursing and yelling 'You're not going to stab me with that...needle'. [PCT #2] grabbed the left wrist...[PCT #3] grabbed the right arm. The patient was sitting on the foot of the bed when [RN #1] comes in and stood behind [Patient #1] and laid [Patient #1] down suddenly on the bed and put the left hand on the patient's shoulder and the right hand on the patient's throat while I administered Geodon in [the patient's] left deltoid." Continued interview revealed RN #1, PCT #1, #2, and #3 held the patient down for RN #2 to administer the antipsychotic medication. Continued interview confirmed the Geodon was administered involuntarily. Continued interview revealed the nurse "looked over" the patient after the hold was released, did not obtain vital signs; and did not perform an assessment of the impact of the restraints on the patient or an assessment of the patient's response.

Interview with PCT #3 on 10/13/16 at 10:15 AM, in the conference room, revealed PCT #3 was called into Patient #1's room by PCT #2 was told the patient was "physical" with PCT #1. "At that point I knew I was going to have to hold [Patient #1]." Continued interview revealed when PCT #3 arrived there were 4 other employees in the room (PCT #1, #2, and RN #1, #2); the patient was "agitated but not physical." Continued interview revealed PCT #2 and #3 made attempts to calm the patient but were unsuccessful. Continued interview revealed, "We go to lay [Patient #1] down and [the patient] resisted. I hold [the patient's] arm and then [the patient] kicked me in the shoulder then we [PCT #1 and #3] get his legs. [RN #1] was behind [Patient #1] and suddenly put one hand on [the patient's] shoulder and one on [the patient's] neck and 'slammed' [the patient] on the bed." Continued interview revealed the patient repeatedly said, "Get off me; Get up." Further interview revealed RN #2 administered the shot while the patient was held in the bed.

Interview with RN #1 on 10/17/16 at 9:30 AM, in the lobby, revealed the sitter called RN #1 for assistance to get the patient back in bed. Continued interview revealed the nurse attempted to calm the patient but was unsuccessful. Continued interview revealed when other staff came in RN #1 moved to the other side of the bed (the left side) behind the patient. Continued interview revealed, "When [Patient #1] stood up, hitting and kicking, I tried to get [the patient] back and up in bed...I had my arms around [the patient] from behind...I tried to get around [the patient's] shoulders." Continued interview revealed RN #1 and 3 co-workers held the patient in the bed for the nurse to administer the medication. Continued interview revealed RN #1 heard the patient refuse the medication.

Interview with the Chief Nursing Officer, Accreditation Coordinator, Quality Director, and Director of Acute Care and Women/Children on 10/18/16 at 12:00 PM, in the conference room, confirmed the facility failed to document the patient status after the restraints.

Based on review of facility policy, medical record review, facility investigation review, interview, and review of personnel files, the facility failed to ensure a restraint competency had been completed for 1 (PCT #1) employee of 6 employees reviewed.

The findings included:

Review of the facility's Restraint and Seclusion policy revised 7/15, revealed "...Staff providing direct care are required to have education, training, and demonstrate knowledge based on needs of the population..." Further review revealed Acute Care nurses and Patient Care Technicians (PCTs) were required to have education in orientation, annual competency with return demonstration and annual computer based learning. Ancillary staff who applied and removed restraints were required to have education in orientation and annual competency with return demonstration.

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. Patient #1 was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, and Malnutrition.

Review of a facility investigation statement dated 9/24/16, from Registered Nurse (RN) #2 (the nurse assigned patient #1) revealed PCT #1 and #2 were trying to keep Patient #1 from getting out of bed and the patient "started to get aggravated. [Patient #1] made a fist and was going to hit me [PCT #1] grabbed [the patient's] fist and [the patient] tried to hit [PCT #3] with the other hand. [PCT #3] grabbed [the patient's] hand and [RN #1] threw [the patient] back onto the bed and held [the patient's] shoulder down with...left hand and wrapped...right hand around [Patient #1's] throat..."

Review of a facility investigation witness statement by Patient Care Tech (PCT #1), dated 9/25/16, revealed, "At 0400 [4:00 AM] on September 24 my patient [Patient #1] started to get out of bed. I asked [the patient] calmly to lay back down and [the patient] started to push me out of the way. I...called [RN #1] to help...Patient started to get more agitated and threatened to hit [PCT #2]. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient (saw) it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 and #3] tried to keep [the patient] from getting up. The patient started kicking and punching staff members so we laid [the patient] back down in the bed. [PCT #3]) had [the patient's] legs to keep from kicking; [PCT #2] and I had [the patient's] arms and shoulders to keep [the patient] from hitting and coming back out of bed. [RN #1] had a hold of [the patient's] neck with one hand...[RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning."

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed the patient was in a low bed with ¼ side rails in the raised position when the patient was attempting to get out of bed. Continued interview revealed the patient woke up and wanted to go to the bathroom. Continued interview revealed PCT #1 and #2 "tried to keep [Patient #1] in the bed." Continued interview revealed the patient "got more agitated when [the patient] saw the syringe. [Patient #1] cursed and said, 'I don't want that; don't come near me with that.'" Continued interview revealed the PCT participated in holding the patient down on the bed to allow the nurse to administer the injection.

Review of personnel files revealed the date of hire for PCT #1 was 7/1/13. Continued review of the educational transcript revealed the PCT completed Restraint Application Return Demonstration on 2/20/15 and had not completed the Restraint Skills Competency Checklist.

Interview with the Clinical Leader of 2E Unit, the Human Resources Director, and the Accreditation Coordinator on 10/18/16 at 6:00 PM, confirmed the Restraint Skills Competency Checklist is an annual requirement and the facility failed to ensure the PCT completed the education.

Based on medical record review, review of facility documentation, and interview, the facility failed to provide nursing services to provide care to a patient based on the patient's assessment and needs for 1 patient (#1) of 3 patients reviewed for abuse.

The findings included:

During the survey it was found Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status, Alcohol Abuse, Failure to Thrive, Mild Diffuse Ataxia (impaired balance or coordination), Lethargy, and Disorientation. Further review revealed the patient was admitted to an inpatient unit with diagnoses of Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, Malnutrition, and Hard of Hearing. On 9/24/16 a Registered Nurse (RN #1) was called into the room of Patient #1 after the patient tried to stand and after the patient became agitated and was physically resistant. RN #1 and 3 patient care techs (PCT #1, #2, and #3) held the patient on the bed for an injection of Geodon (antipsychotic). The staff did not assess the patient to determine the needs of the patient before implementing a physical restraint and injection of an antipsychotic medication.

Refer to A-0395

Based on medical record review, facility investigation review, and interview, the facility failed to provide nursing services to assess and provide care to meet the needs of 1 patient (#1) of 3 patients reviewed.

The findings included:

Medical record review revealed patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. Patient #1 was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of a witness statement completed by Registered Nurse (RN #1), dated 9/24/16, revealed RN #1 "...was called to [the room of Patient #1] where the patient was trying to get out of bed. [Patient #1] was confused and had already fallen multiple times. The patient was angry and agitated, and when [RN #1] asked the patient to get back into bed; [the patient] cursed and threatened me. So [patient care technician (PCT #2)], a person the patient liked in the past and was able to reason with was called to the room. The patient continued to become angry and agitated, and cursed and threatened the staff; more help was called as [RN #2] was to give Geodon [antipsychotic medication]. When trying to get the patient back into the bed [the patient] began to punch and kick the other staff members and [RN #1] grabbed at [the patient's] shoulders and pulled [the patient] back into bed. I lost my temper and found I had my hand at [the patient's] neck, and another of the staff told me to let go, so I did immediately. The Geodon was given and the patient calmed down. I admit I lost my temper..."

Review of a witness statement completed by RN #2 the nurse assigned patient #1) dated 9/24/16, revealed PCT #1 and #2 were trying to keep the patient from getting out of bed and the patient "started to get aggravated. [PCT #1] called [RN #1] which made things worse because [RN #1] came in with a bad attitude and [Patient #1] was feeding off of that...[Patient #1] made a fist and was going to hit me. [PCT #1] grabbed [the patient's] fist and [the patient] tried to hit [PCT #3] with the other hand. [PCT #3] grabbed [the patient's] hand and [RN #1] threw [the patient] back onto the bed and held...shoulder down with...left hand and wrapped...right hand around [the patient's] throat. I told [RN #1] multiple times to let go of [the patient's] throat and [PCT #2] grabbed [RN #1's] arm and pried [RN #1's] hand off [the patient's] throat. [PCT#2] was also yelling at [RN #1] to let go of [the patient's] throat..."

Review of a witness statement completed by PCT #1, dated 9/25/16, revealed PCT #1 was assigned as a sitter to Patient #1 on the 9/23/16 7PM - 9/24/16 7AM shift. Review of the statement revealed, "At 0400 [4:00 AM] on September 24 my patient [Patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way. I...called [RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit [PCT #2]. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient (saw) it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 and #3] tried to keep [the patient] from getting up. The patient started kicking and punching staff members so we laid [the patient] back down in the bed. [PCT #3] had [the patient's] legs to keep from kicking; [PCT #2] and I had [the patient's] arms and shoulders to keep [the patient] from hitting and coming back out of bed. [RN #1] had a hold of [the patient's] neck with one hand and [PCT #2] told [RN #1] to let go several times. [PCT #2] pushed [RN #1's] hand off the patient's neck. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning."

Review of a witness statement completed by PCT #2, dated 9/25/16, revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [(the patient's] fist; [the patient] acted like [the patient] was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and...leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [Patient #1's] shoulder with one hand and [the patient's] throat with the other. [RN #2] kept asking [RN #1] to please let go of [the patient's] throat...after [RN #2] asked three times I had to pry [RN #1's] hands off...Then [RN #2] gave [the patient] the shot and [Patient #1] started to calm down and [RN #1] left."

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "I was coming from the nursing station and [RN #1] was 2 steps ahead of me. [RN #1] had removed Geodon from the Omnicell [medication dispensing system]. [RN #1] handed me the Geodon and I got it ready at the med [medication] cart outside the door. As I walked in the room [Patient #1] started cursing and yelling 'You're not going to stab me with that...needle'. [PCT #2] grabbed the left wrist and [Patient #1] tried to hit me with the other fist and [PCT #3] grabbed the right arm. The patient was sitting on the foot of the bed when [RN #1] comes in and stood behind [the patient] and laid [Patient #1] down suddenly on the bed and put the left hand on the patient's shoulder and the right hand on the patient's throat while I administered Geodon in (the patient's) left deltoid." Continued interview confirmed the 4 employees held the patient down for RN #2 to administer the antipsychotic medication; and the patient stated and demonstrated refusal of the medication. Continued interview confirmed the Geodon was administered involuntarily. Further interview confirmed RN #2 entered the room with the intent to administer the medication and the nurse did not perform an assessment to determine if other types of intervention were reasonable alternatives to a restraint or to determine if the patient had any unmet basic needs.

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed the patient was in a low bed with ¼ side rails in the raised position when he was attempting to get out of bed. Continued interview revealed the patient woke up and wanted to go to the bathroom and the PCT "offered [Patient #1] the urinal but [Patient #1] did not use it." Continued interview revealed the patient positioned self to the foot of the bed between the foot board and the bottom of the side rail. Continued interview revealed the patient "was dry" (continent of urine at the time). Continued interview revealed after the patient was administered the Geodon the patient received pericare for an episode of urinary incontinence; the patient was assisted to the bedside chair; and the bed linens were changed. Continued interview revealed the PCT did not offer the patient to stand to use the urinal and did not notify other staff of the patient's request to go to the bathroom.

Interview with RN #1 on 10/17/16 at 9:30 AM, in the lobby, revealed the patient was sitting on the side of the bed when the nurse entered in response to being called by PCT #1. Continued interview revealed the nurse attempted to calm the patient, was unsuccessful, so the nurse called PCT #2, who has been successful in attempts previously. Continued interview revealed when Patient #1 "stood up, hitting and kicking, I tried to get [patient] back and up in bed. [The patient] did not resist. I had my arms around...from behind...I tried to get around [the patient's] shoulders. I pulled [the patient] up and back in bed so [RN #2] could give the medication..." Continued interview revealed RN #1 was the charge nurse for the 7PM-7AM shift and did not ask the sitter (PCT #1) if the patient requested anything when making attempts to get out of bed. Further interview revealed RN #1 did not perform an assessment to determine if any unmet basic needs were present or if alternative interventions were reasonable.

Interview with the Accreditation Coordinator and the Director of Acute and Women and Children on 10/17/16 at 11:45 AM, in the conference room, confirmed the facility failed to provide nursing services to assess the patient's needs prior to interventions of chemical and physical restraints.

Based on review of facility policy, medical record review, review of facility documentation, interview, review of personnel files, and observation, the facility failed to protect a patient from abuse; failed to report witnessed abuse; failed to document an assessment of the patient after the allegation of abuse; and failed to complete an occurrence report of abuse prior to the end of the shift for one patient (#1) of 3 patients reviewed for abuse.

The findings included:

Review of the facility's Abuse policy, revised 9/2015, revealed "...Patient Rights: Each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment...to be treated with respect and dignity at all times...All staff is educated on the signs and or symptoms of abuse. It is their obligation by law to report any type of suspicion or allegation of abuse of patients immediately to their supervisor/manager and risk management. The person with the most direct knowledge of the allegation will complete an occurrence report by the end of their shift..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. The patient was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of the medical record revealed the patient had many falls and a sitter was implemented for reduction of falls.

Medical record review of the Medication Administration Record (MAR) revealed Geodon (antipsychotic medication used to treat mood disorder, Bipolar disease, and Schizophrenia) 5 milligrams (mg) was ordered on 9/14/16 to be administered intramuscularly (IM) as needed (PRN) every 12 hours.

Medical record review of the Medication Administration Record (MAR) revealed a physician order dated 9/22/16 at 12:58 AM for Geodon 10 mg to be administered IM (intramuscular) every 4 hours as needed (PRN).

Review of the medical record for patient #1 revealed no documentation of an incident on 9/24/16 where the patient was physically restrained by facility staff. Further review revealed no documentation of an assessment of the patient on 9/24/16 before or after the incident at 4:05 AM. Continued review revealed the patient was not assessed until 9/24/16 at 8:26 AM (4 hours after the incident).

Review of the facility investigation revealed an e-mail dated 9/24/16 at 12:06 PM from the Administrative Supervisor (RN #4) to the Chief Nursing Officer (CNO), Human Resource Director, Risk Manager, Director of Acute Care/Women's & Children, and Clinical Leader #1. Continued review revealed "...Today we had (Registered Nurse #1)...accused by...coworkers of patient abuse. I have notified (RN #1) is suspended until further notice...and the coworkers who voiced concerns over alleged abuse has been notified to submit written statements..."

Review of the facility investigation revealed a witness statement by RN #1 dated 9/24/16. Continued review revealed "...I was called to [the room of patient #1] where the patient was trying to get out of bed. [Patient #1] was confused...the patient was angry and agitated, and when I asked the patient to get back into bed [the patient] cursed and threatened me. So patient care technician [PCT #2] was called to the room, [a person the patient liked in the past and was able to reason with the patient]...the patient continued to become angry and agitated, and cursed and threatened the staff, more help was called...[the nurse] was to give Geodon [antipsychotic medication]...When trying to get the patient back into the bed [the patient] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled...[the patient] back into bed. I lost my temper and found I had my hand at [the patient's] neck, and another of the staff told me to let go, so I did immediately. The Geodon was given and the patient calmed down. I admit I lost my temper, and am deeply sorry for doing so, but did not intend to hurt the patient..."

Review of a witness statement completed by PCT #3 dated 9/24/16 revealed the PCT was called to patient #1's room and entered the room to find the patient agitated and confused. Further review revealed the patient was surrounded by PCT #1, PCT #2, RN #1 and RN#2. Continued review revealed RN #2 was preparing to administer an injection and "...unfortunately we needed to hold the patient...[The patient] became more aggressive and threw a kick. At this point [RN#1] grabs the patient by the shoulder and throat and proceeds to choke the patient. [RN #1] was told to let go multiple times and did not let go until [PCT #2] grabbed [RN #1's] arm and pulled it away..."

Review of a witness statement completed by RN #2 dated 9/24/16 (the nurse assigned patient #1) revealed PCT #1 and #2 were trying to keep the patient from getting out of bed and the patient "...started to get aggravated. [PCT #1] called [RN #1] which made things worse because [RN #1] came in with a bad attitude and [Patient #1] was feeding off of that...[Patient #1] made a fist and was going to hit me. [PCT #2] grabbed [patient #1's] fist and [patient #1] tried to hit [PCT #3] with the other hand. [PCT #3] grabbed [the patient's] hand and [RN #1] threw [the patient] back onto the bed and held...shoulder down with...left hand and wrapped...right hand around...throat. I told [RN #1] multiple times to let go...[PCT #2] grabbed [RN #1's] arm and pried...hand off [the patient's] throat. [PCT#2] was also yelling at [RN #1] to let go of [the patient's] throat..."

Review of a witness statement completed by Patient Care Tech [PCT #1] dated 9/25/16 revealed PCT #1 was the assigned sitter to Patient #1 from 9/23/16 at 7:00 PM until 9/24/16 at 7:00 AM. Review of the statement revealed, "...At 0400 [4:00 AM] on September 24 my patient [patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way. I...called [named RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit PCT #2. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient [saw] it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 & #3] tried to keep...from getting up. The patient started kicking and punching staff members so we laid [the patient]...back down in the bed. [PCT #3] had...legs to keep from kicking...[PCT #2] and I had...arms and shoulders to keep...from hitting and coming back out of bed. [RN #1] had a hold of...neck with one hand and [PCT #2] told...to let go several times. [PCT #2] pushed [RN #1] hand off the patient's neck. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning..."

Review of a witness statement completed by PCT #2 dated 9/25/16 revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "...very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [the patient's] fist...[the patient] acted like [he] was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and [patient's] leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [Patient #1] shoulder with one hand and [the patient's] throat with the other. [RN #2] kept asking [RN #1] to please let go of [the patient's] throat...after [RN #2] asked three times I had to pry...hands off...Then [RN #2] gave...the shot and [Patient #1] started to

Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to protect 1 patient (#1) from physical hold restraints of 3 patients reviewed.

The findings included:

Review of the facility's Restraint and Seclusion Policy, revised 7/2015, revealed "...Restraints will be used when clinically justified and when other alternatives are ineffective...any manual method, physical or mechanical device...equipment that immoblizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...physical restraints include hands on or manual holds...RN [Registered Nurse] may initiate application of restraint when less restrictive interventions have either been exhausted or have been determined to be ineffective to protect the patient...An order is still required and must be obtained immediately...when a restraint or seclusion is used for the management of violent and/or self-destructive behavior...the registered nurse immediately notifies the MD [Medical Doctor] or NP [Nurse Practitioner] to obtain an order..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. The patient was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of the medical record revealed the patient had many falls and a sitter was implemented for reduction of falls.

Review of the medical record for Patient #1 revealed no documentation of an incident on 9/24/16 where the patient was physically restrained by facility staff. Further medical record review revealed no documentation less restrictive interventions had been attempted prior to the use of physical restraints.

Review of the facility investigation revealed a witness statement was completed by RN #1 on 9/24/16. Continued review revealed "...I was called to [the room of patient #1] where the patient was trying to get out of bed...the patient was angry and agitated, and when I asked the patient to get back into bed [the patient] cursed and threatened me...patient care technician [PCT #2] was called to the room [a person the patient liked in the past and was able to reason with the patient]...the patient continued to become angry and agitated, and cursed and threatened the staff, more help was called [the nurse] was to give Geodon [antipsychotic medication]...When trying to get the patient back into the bed [the patient] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled [the patient]...back into bed..."

Review of a witness statement completed by PCT #3 dated 9/24/16 revealed the PCT was called to patient #1's room and entered the room to find the patient agitated and confused. Further review revealed the patient was surrounded by PCT #1, PCT #2, RN #1 and RN#2. Continued review revealed RN #2 was preparing to administer an injection and "...unfortunately we needed to hold the patient...[The patient] became more aggressive and threw a kick. At this point [RN#1] grabs the patient by the shoulder and throat and proceeds to choke the patient. [RN #1] was told to let go multiple times and did not let go until [PCT #2] grabbed [RN #1's] arm and pulled it away..."

Review of a witness statement completed by RN #2 dated 9/24/16 (the nurse assigned patient #1) revealed PCT #1 and #2 were trying to keep the patient from getting out of bed and the patient "...started to get aggravated. [PCT #1] called [RN #1] which made things worse because [RN #1] came in with a bad attitude and [Patient #1] was feeding off of that...[Patient #1] made a fist and was going to hit me. [PCT #2] grabbed [patient #1's] fist and [patient #1] tried to hit [PCT #3] with the other hand. [PCT #3] grabbed [the patient's] hand and [RN #1] threw [the patient] back onto the bed and held...shoulder down with...left hand and wrapped...right hand around...throat. I told [RN #1] multiple times to let go of...[PCT #2] grabbed [RN #1's] arm and pried...hand off [the patient's] throat. [PCT#2] was also yelling at [RN #1] to let go of [the patient's] throat..."

Review of a witness statement completed by Patient Care Tech (PCT #1) dated 9/25/16 revealed PCT #1 was the assigned sitter to Patient #1 from 9/23/16 at 7:00 PM until 9/24/16 at 7:00 AM. Review of the statement revealed, "...At 0400 [4:00 AM] on September 24 my patient [patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way. I...called [named RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit PCT #2. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient [saw] it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 & #3] tried to keep...from getting up. The patient started kicking and punching staff members so we laid [the patient]...back down in the bed. [PCT #3] had...legs to keep from kicking...[PCT #2] and I had...arms and shoulders to keep...from hitting and coming back out of bed. [RN #1] had a hold of...neck with one hand and [PCT #2] told...to let go several times. [PCT #2] pushed [RN #1] hand off the patient's neck. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning..."

Review of a witness statement completed by PCT #2 dated 9/25/16 revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "...very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [the patient's] ...[the patient] acted like he was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and [named patient's] leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [Patient #1] shoulder with one hand and [the patient's] throat with the other. [RN #2] kept asking [RN #1] to please let go of [the patient's] throat...after [RN #2] asked three times I had to pry...hands off...Then [RN #2] gave...the shot and [patient #1] started to calm down and [RN #1] left..."

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed when the incident occured the patient was in a low-boy bed and the ¼ side rails on the right side of the bed were in the raised position when he attempted to get out of bed. Continued interview revealed the patient woke up and stated he wanted to go to the bathroom, and the PCT "...offered [named patient) the urinal but he did not use it..." Further interview revealed the patient positioned self to the foot of the bed between the foot board and the bottom of the side rail. Continued interview revealed the PCT did not offer for the patient to stand and did not notify other staff of the patient's request to go to the bathroom.

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "...I was coming from the nursing station and [RN #1] was two steps ahead of me. As I walked in the room [the patient] started cursing and yelling 'You're not going to stab me with that...needle...'[PCT #2] grabbed the left wrist and [the patient] tried to hit the nurse with the other fist and [PCT #3] grabbed the right arm...the patient was sitting on the foot of the bed when [RN#1] comes in and stood behind [the patient] and laid [the patient] down suddenly on the bed and put the left hand on the patient's shoulder and the right hand on the pa

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to protect the rights of 1 patient (#1) to be free from a chemical restraint of 3 patients reviewed.

The findings included:

Review of the facility's Restraint and Seclusion Policy revised 7/2015 revealed "...a Restraint is...a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition...chemical restraint...A drug or medication, when it is given involuntarily as a restriction to manage a patient's behavior or restrict the patient's freedom of movement and is NOT a standard treatment or dosage for the patient's condition...In emergency application situation, a RN may initiate application of restraint when less restrictive interventions have either been exhausted or have been determined to be ineffective to protect the patient and/or others. An order is still required and must be obtained immediately...When a restraint or seclusion is used for the management of violent and/or self-destructive behavior that jeopardizes safety, the registered nurse immediately notifies the Medical Doctor [MD] or Nurse Practitioner [NP] to obtain an order..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. The patient was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of the medical record revealed the patient had many falls and a sitter was implemented for reduction of falls.

Medical record review of the Medication Administration Record (MAR) revealed Geodon (antipsychotic medication used to treat mood disorder, Bipolar disease, and Schizophrenia) 5 milligrams (mg) was ordered on 9/14/16 to be administered intramuscularly (IM) as needed (PRN) every 12 hours.

Medical record review of the Medication Administration Record (MAR) revealed a physician order dated 9/22/16 at 12:58 AM for Geodon 10 mg to be administered IM (intramuscular) every 4 hours as needed (PRN).

Review of the facility investigation revealed a witness statement was Registered Nurse (RN #1) on 9/24/16. Continued review revealed "...I was called to [the room of patient #1] where the patient was trying to get out of bed. [Patient #1] was confused...the patient was angry and agitated and when I asked the patient to get back into bed [the patient] cursed and threatened me. So patient care technician [PCT #2] was called to the room [a person the patient liked in the past and was able to reason with the patient]...the patient continued to become angry and agitated, and cursed and threatened the staff, more help was called [the nurse] was to give Geodon [antipsychotic medication]...When trying to get the patient back into the bed [the patient] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled [the patient]...back into bed. I lost my temper and found I had my hand at [the patient's] neck, and another of the staff told me to let go, so I did immediately. The Geodon was given and the patient calmed down. I admit I lost my temper, and am deeply sorry for doing so, but did not intend to hurt the patient..."

Review of a witness statement completed by PCT #3 dated 9/24/16 revealed the PCT was called to patient #1's room and entered the room to find the patient agitated and confused. Further review revealed the patient was surrounded by PCT #1, PCT #2, RN #1 and RN#2. Continued review revealed RN #2 was preparing to administer an injection and "...unfortunately we needed to hold the patient...[The patient] became more aggressive and threw a kick. At this point [RN#1] grabs the patient by the shoulder and throat and proceeds to choke the patient.

Review of a witness statement completed by Patient Care Tech (PCT #1) dated 9/25/16 revealed PCT #1 was the assigned sitter to Patient #1 from 9/23/16 at 7:00 PM until 9/24/16 at 7:00 AM. Review of the statement revealed, "...At 0400 [4:00 AM] on September 24 my patient [patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way. I...called [named RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit PCT #2. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient [saw] it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 & #3] tried to keep...from getting up. The patient started kicking and punching staff members so we laid [the patient]...back down in the bed. [PCT #3] had...legs to keep from kicking...[PCT #2] and I had...arms and shoulders to keep...from hitting and coming back out of bed. [RN #1] had a hold of...neck with one hand and [PCT #2] told...to let go several times. [PCT #2] pushed [RN #1] hand off the patient's neck. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning..."

Review of a witness statement completed by PCT #2 dated 9/25/16 revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "...very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [the patient's] fist [the patient] acted like [he] was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and [patient's] leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [Patient #1] shoulder with one hand and [the patient's] throat with the other. [RN #2] kept asking [RN #1] to please let go of [the patient's] throat...after [RN #2] asked three times I had to pry...hands off...Then [RN #2] gave...the shot and [patient #1] started to calm down and [RN #1] left..."

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed when the incident occured the patient was in a low-boy bed and the ¼ side rails on the right side of the bed were in the raised position when he attempted to get out of bed. Continued interview revealed the patient woke up and stated he wanted to go to the bathroom...[PCT #1 and PCT #2] tried to keep [the patient] in the bed...[the patient] said 'I don't want to hit you but I will do what I have to do'...[the patient] got more agitated when...saw the syringe...[the patient] cursed and said 'I don't want that...don't come near me with that'..." Further interview reveale PCT #1 had been previously involved in holding the patient down for an injection because the patient "...fights it..."

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "...I was coming from the nursing station and [RN #1] was two steps ahead of me. [RN #1] had removed Geodon from [named medication dispensing system]...[RN #1] handed me the Geodon and I got it ready...outside the [patient's] room...As I walked in the room [the patient] started cursing and yelling 'You're not going to stab me with that...needle'...[PCT #2] grabbed the left wrist and [the patient] tried to hit me with the other fist and [PCT #3] grabbed the right arm...the patient was sitting on the foot of the bed when [RN #1] comes in and stood behind [the patient] and laid [the patient] down suddenly on the bed...put the left hand on the patient's shoulder and the right hand on the patient's throat while I administered the Geodon..." Continu

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to obtain an order for a restraint for 1 patient (#1) of 3 patients reviewed.

The findings included:

Review of the facility's Restraint and Seclusion Policy revised 7/15 revealed, "...G. Ordering and Face-to-Face Evaluation...In emergency application situation, a RN [Registered Nurse] may initiate application of restraint when less restrictive interventions have either been exhausted or have been determined to be ineffective to protect the patient and/or others. An order is still required and must be obtained immediately; not to exceed 1 hour from initiation." Continued review revealed, "8. The following guidelines regarding ordering and evaluation are specific to Violent/Self-destructive Restraints: a.When a restraint or seclusion is used for the management of violent and/or self-destructive behavior that jeopardizes safety, the registered nurse immediately notifies the MD [Medical Doctor] or NP [Nurse Practitioner] to obtain an order."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. The patient was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of the medical record revealed the patient had many falls and a sitter was implemented for reduction of falls.

Medical record review of the Medication Administration Record (MAR) revealed Geodon (antipsychotic medication used to treat mood disorder, Bipolar disease, and Schizophrenia) 5 milligrams (mg) was ordered on 9/14/16 to be administered intramuscularly (IM) as needed (PRN) every 12 hours.

Medical record review of the Medication Administration Record (MAR) revealed a physician order dated 9/22/16 at 12:58 AM for Geodon 10 mg to be administered IM (intramuscular) every 4 hours as needed (PRN).

Review of a facility investigation witness statement completed by RN #1, dated 9/24/16, revealed, "I was called to [the room of Patient #1] where the patient was trying to get out of bed. [Patient #1] was confused...was angry and agitated, and when I asked the patient to get back into bed [Patient #1] cursed and threatened me...more help was called and [RN #2] was to give Geodon. "When trying to get the patient back into the bed [Patient #1] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled...back into bed..." The Geodon was given and the patient calmed down.

Review of the witness statement completed by Patient Care Technician (PCT) #3, dated 9/24/16, revealed the PCT was called to Patient #1's room and entered the room to find the patient agitated and confused and was surrounded by PCT #1, PCT #2, RN #1 and RN #2. Continued review revealed RN #2 was preparing to administer an injection, and "unfortunately we needed to hold the patient...[The patient] became more aggressive and threw a kick. At this point [RN #1] grabbed the patient by the shoulder...and throat and proceeds to choke the patient. [RN #1] was told to let go multiple times and did not let go until [PCT #2] grabbed [RN #1's] arm and pulled it away..."

Review of the witness statement completed by RN #2 dated 9/24/16 (the nurse assigned to Patient #1) revealed PCT #1 and #2 were trying to keep Patient #1 from getting out of bed and the patient became aggravated. Patient #1 made a fist and was going to hit RN #2. PCT #1 grabbed the patient's fist and the patient tried to hit PCT #3 with the other hand. PCT #3 grabbed the patient's hand and RN #1 threw the patient back onto the bed and held the patient's shoulder down with the left hand and wrapped the right hand around the patient's throat.

Review of the witness statement completed by PCT #1 dated 9/25/16 revealed PCT #1 was assigned as a sitter to Patient #1 for the 9/23/16 7PM - 9/24/16 7AM shift. Review of the statement revealed, "At 0400 [4:00 AM] on September 24 my patient [Patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way...I...called [RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit PCT #2. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient (saw) it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 and #3] tried to keep [patient] from getting up. The patient started kicking and punching staff members so we laid [Patient #1] back down in the bed. [PCT #3] had [the patient's] legs to keep from kicking; [PCT #2] and I had [the patient's] arms and shoulders to keep [Patient #1] from hitting and coming back out of bed. [RN #1] had a hold of...neck with one hand. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [Patient #1] was calm for the rest of the morning."

Review of the witness statement completed by PCT #2 dated 9/25/16 revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "very agitated and drew back like [Patient #1] was going to hit [RN #2]. That's when I grabbed [the patient's] fist...[Patient #1] acted like...was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and...leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [patient #1's] shoulder with one hand and [the patient's] throat with the other...Then [RN #2] gave [Patient #1] the shot and [Patient #1] started to calm down..."

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed the patient was in a low bed and ¼ side rails were in the raised position when the patient was attempting to get out of bed. Continued interview revealed the patient woke up and wanted to go to the bathroom. Continued interview revealed PCT #1 and #2 "tried to keep [Patient #1] in the bed. [The patient said], 'I don't want to hit you but I will do what I have to do.'" Continued interview revealed the patient "got more agitated when...saw the syringe. [Patient #1] cursed and said, 'I don't want that; don't come near me with that.'" Continued interview revealed the PCT participated in holding the patient down on the bed to allow the nurse to administer the injection.

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "I was coming from the nursing station and [RN #1] was 2 steps ahead of me. [RN #1] had removed Geodon from the Omnicell [medication dispensing system]. [RN #1] handed me the Geodon and I got it ready at the med [medication] cart outside the patient's door. As I walked in the room [Patient #1] started cursing and yelling 'You're not going to stab me with that...needle'. [PCT #2] grabbed the left wrist and [the patient] tried to hit me with the other fist and [PCT #3] grabbed the right arm. The patient was sitting on the foot of the bed when [RN #1] comes in and stood behind [Patient #1] and laid [Patient #1] down suddenly on the bed and put the left hand on the patient's shoulder and the right hand on the patient's throat while I administered Geodon in [the patient's] left deltoid." Continued interview revealed RN #1, PCT #1, #2, and #3 held the patient down for RN #2 to administer the antipsychotic medication. Continued interview confirmed the Geodon was administered involuntarily. Continued interview confirmed the nurse did not call the physician prior to the physical hold, did not notify the physician after the physical

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to document the patient's response to the applied restraint for 1 (#1) of 3 patients reviewed.

The findings included:

Review of the facility's Restraint and Seclusion Policy revised 7/15 revealed, "...The following documentation shall be included in the medical record: The Patient's condition or symptom(s) that justify the use of restraint. Any alternatives and/or strategies attempted. Type of restraint used. The patient's response to the intervention(s) used..."

Medical record review revealed Patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son, and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. Patient #1 was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Medical record review of the Medication Administration Record (MAR) revealed Geodon (an antipsychotic medication used to treat mood disorder, bipolar disease, and Schizophrenia) 5 milligrams (mg) was ordered on 9/14/16 to be administered intramuscularly (IM) as needed (PRN) every 12 hours.

Medical record review of the Medication Administration Record (MAR) revealed a physician order dated 9/22/16 at 12:58 AM for Geodon 10 mg to be administered IM (intramuscular) every 4 hours as needed (PRN). Further review revealed Registered Nurse (RN #2) administered the medication on 9/24/16 at 4:08 AM.

Review of a facility investigation witness statement completed by RN #1, dated 9/24/16, revealed, "I was called to [the room of patient #1] where the patient was trying to get out of bed. [Patient #1] was confused...was angry and agitated, and when I asked the patient to get back into bed [Patient #1] cursed and threatened me...the patient care technician [PCT #2] was called to the room. The patient continued to become angry and agitated, and cursed and threatened the staff. More help was called and [RN #2] was to give Geodon...when trying to get the patient back into the bed [Patient #1] began to punch and kick the other staff members and I grabbed at [the patient's] shoulders and pulled...back into bed..." The Geodon was given and the patient calmed down.

Review of a witness statement completed by PCT #3, dated 9/24/16, revealed the PCT was called to Patient #1's room and entered the room to find the patient agitated and confused and surrounded by PCT #1, PCT #2, RN #1 and #2. Continued review revealed RN #2 prepared to administer an injection, and "unfortunately we needed to hold the patient...[Patient #1] became more aggressive and threw a kick. At this point [RN #1] grabbed the patient by the shoulder...and throat and proceeds to choke the patient. [RN #1] was told to let go multiple times and did not let go until [PCT #2] grabbed [RN #1's] arm and pulled it away..."

Review of the witness statement completed by RN #2 dated 9/24/16 (the nurse assigned patient #1) revealed PCT #1 and #2 were trying to keep the patient from getting out of bed and the patient became aggravated. Patient #1 made a fist and was going to hit RN #2. PCT #1 grabbed the patient's fist. PCT #3 grabbed the patient's hand and RN #1 threw the patient back onto the bed, held the patient's shoulder down with the left hand, and wrapped the right hand around the patient's throat.

Review of the witness statement completed by Patient Care Tech (PCT #1), dated 9/25/16 revealed PCT #1 was assigned as a sitter to Patient #1 for the 9/23/16 7PM - 9/24/16 7AM shift. Review of the statement revealed, "At 0400 [4:00 AM] on September 24 my patient [Patient #1] started to get out of bed. I asked...calmly to lay back down and [Patient #1] started to push me out of the way. I...called [RN #1] to help...Patient started to get more agitated and threatened to hit [PCT #2]. [PCT #2] called [PCT #3] to help. [PCT #3]) and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient (saw) it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 and #3] tried to keep [Patient #1] from getting up. The patient started kicking and punching staff members so we laid [the patient] back down in the bed. [PCT #3] had [the patient's] legs to keep from kicking; [PCT #2] and I had [the patient's] arms and shoulders to keep [the patient] from hitting and coming back out of bed. [RN #1] had a hold of [the patient's ] neck with one hand. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning."

Review of a witness statement completed by PCT #2, dated 9/25/16, revealed the patient was sitting at the foot of the bed attempting to get up, and when RN #2 entered the room with the syringe, the patient became "very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [the patient's] fist...[PCT #1 and #3] grabbed the patient's other arm and leg and was holding them down. [RN #1]] slammed [Patient #1]) on the bed and held the patient's shoulder with one hand and throat with the other." Continued review revealed RN #2 gave the patient the shot and "(Patient #1) started to calm down..."

Review of the electronic medical record for Patient #1 revealed no documentation of the incident on 9/24/16. Continued review revealed no documentation of an assessment of the patient on 9/24/16 after the incident at 4:05 AM. Further review revealed vital signs documented on 9/23/16 at 9:12 PM, and no other assessment or evaluation of the patient until 9/24/16 at 8:26 AM, four hours after the incident occurred.

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed the patient was in a low bed with ¼ side rails in the raised position when the patient was attempting to get out of bed. Continued interview revealed the patient woke up and wanted to go to the bathroom. Continued interview revealed PCT #1 and #2 "tried to keep [Patient #1] in the bed." Continued interview revealed the patient "got more agitated when [the patient] saw the syringe. [Patient #1] cursed and said, 'I don't want that; don't come near me with that.'" Continued interview revealed the PCT participated in holding the patient down on the bed to allow the nurse to administer the injection.

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "I was coming from the nursing station and [RN #1] was 2 steps ahead of me. [RN #1] had removed Geodon from the Omnicell [medication dispensing system]. [RN #1] handed me the Geodon and I got it ready at the med [medication] cart outside the patient's door. As I walked in the room [Patient #1] started cursing and yelling 'You're not going to stab me with that...needle'. [PCT #2] grabbed the left wrist...[PCT #3] grabbed the right arm. The patient was sitting on the foot of the bed when [RN #1] comes in and stood behind [Patient #1] and laid [Patient #1] down suddenly on the bed and put the left hand on the patient's shoulder and the right hand on the patient's throat while I administered Geodon in [the patient's] left deltoid." Continued interview revealed RN #1, PCT #1, #2, and #3 held the patient down for RN #2 to administer the antipsychotic medication. Continued interview confirmed the Geodon was administered involuntarily. Continued interview revealed the nurse "looked over" the patient after the hold was released, did not obtain vital signs; and did not perform an assessment of the impact of the restraints on the patient or an assessment of the patient's response.

Interview with PCT #3 on 10/13/16 at 10:15 AM, in the conference room, revealed PCT #3 was called into Patient #1's room by PCT #2 was told the patient was

Based on medical record review, facility investigation review, and interview, the facility failed to provide nursing services to assess and provide care to meet the needs of 1 patient (#1) of 3 patients reviewed.

The findings included:

Medical record review revealed patient #1 presented to the Emergency Department (ED) via emergency medical service on 8/17/2016 with chief complaint of Altered Mental Status and Alcohol Abuse. Continued review revealed the patient presented with Failure to Thrive after the recent death of a son and had mild diffuse Ataxia (impaired balance or coordination), lethargy, and disorientation. Patient #1 was admitted with diagnoses including Wernicke Encephalopathy, Cerebellar Ataxia due to Alcoholism, Urinary Retention, and Malnutrition.

Review of a witness statement completed by Registered Nurse (RN #1), dated 9/24/16, revealed RN #1 "...was called to [the room of Patient #1] where the patient was trying to get out of bed. [Patient #1] was confused and had already fallen multiple times. The patient was angry and agitated, and when [RN #1] asked the patient to get back into bed; [the patient] cursed and threatened me. So [patient care technician (PCT #2)], a person the patient liked in the past and was able to reason with was called to the room. The patient continued to become angry and agitated, and cursed and threatened the staff; more help was called as [RN #2] was to give Geodon [antipsychotic medication]. When trying to get the patient back into the bed [the patient] began to punch and kick the other staff members and [RN #1] grabbed at [the patient's] shoulders and pulled [the patient] back into bed. I lost my temper and found I had my hand at [the patient's] neck, and another of the staff told me to let go, so I did immediately. The Geodon was given and the patient calmed down. I admit I lost my temper..."

Review of a witness statement completed by RN #2 the nurse assigned patient #1) dated 9/24/16, revealed PCT #1 and #2 were trying to keep the patient from getting out of bed and the patient "started to get aggravated. [PCT #1] called [RN #1] which made things worse because [RN #1] came in with a bad attitude and [Patient #1] was feeding off of that...[Patient #1] made a fist and was going to hit me. [PCT #1] grabbed [the patient's] fist and [the patient] tried to hit [PCT #3] with the other hand. [PCT #3] grabbed [the patient's] hand and [RN #1] threw [the patient] back onto the bed and held...shoulder down with...left hand and wrapped...right hand around [the patient's] throat. I told [RN #1] multiple times to let go of [the patient's] throat and [PCT #2] grabbed [RN #1's] arm and pried [RN #1's] hand off [the patient's] throat. [PCT#2] was also yelling at [RN #1] to let go of [the patient's] throat..."

Review of a witness statement completed by PCT #1, dated 9/25/16, revealed PCT #1 was assigned as a sitter to Patient #1 on the 9/23/16 7PM - 9/24/16 7AM shift. Review of the statement revealed, "At 0400 [4:00 AM] on September 24 my patient [Patient #1] started to get out of bed. I asked...calmly to lay back down and [the patient] started to push me out of the way. I...called [RN #1] to help...I asked [RN #1] to call [PCT #2] because the patient gets along well with [PCT #2]...Patient started to get more agitated and threatened to hit [PCT #2]. [PCT #2] called [PCT #3] to help. [PCT #3] and the patient's nurse [RN #2] showed up to help calm the patient down. [RN #2] had a syringe with medication to help calm the patient down. The patient (saw) it and began to get more agitated...threatened to hurt staff members. The patient started to climb out of bed and [PCT #2 and #3] tried to keep [the patient] from getting up. The patient started kicking and punching staff members so we laid [the patient] back down in the bed. [PCT #3] had [the patient's] legs to keep from kicking; [PCT #2] and I had [the patient's] arms and shoulders to keep [the patient] from hitting and coming back out of bed. [RN #1] had a hold of [the patient's] neck with one hand and [PCT #2] told [RN #1] to let go several times. [PCT #2] pushed [RN #1's] hand off the patient's neck. [RN #2] had the syringe to give the patient medicine. We finally talked the patient down once the medicine was given and [the patient] was calm for the rest of the morning."

Review of a witness statement completed by PCT #2, dated 9/25/16, revealed the patient was sitting at the foot of the bed attempting to get up; and when RN #2 entered the room with the syringe the patient became "very agitated and drew back like [the patient] was going to hit [RN #2]. That's when I grabbed [(the patient's] fist; [the patient] acted like [the patient] was going to hit [RN #2] with the other fist. [PCT #1 and #3] grabbed...other arm and...leg and was holding them down. Then [RN #1] slammed [Patient #1] on the bed and held [Patient #1's] shoulder with one hand and [the patient's] throat with the other. [RN #2] kept asking [RN #1] to please let go of [the patient's] throat...after [RN #2] asked three times I had to pry [RN #1's] hands off...Then [RN #2] gave [the patient] the shot and [Patient #1] started to calm down and [RN #1] left."

Interview with RN #2 on 10/13/16 at 8:40 AM, in the conference room, revealed, "I was coming from the nursing station and [RN #1] was 2 steps ahead of me. [RN #1] had removed Geodon from the Omnicell [medication dispensing system]. [RN #1] handed me the Geodon and I got it ready at the med [medication] cart outside the door. As I walked in the room [Patient #1] started cursing and yelling 'You're not going to stab me with that...needle'. [PCT #2] grabbed the left wrist and [Patient #1] tried to hit me with the other fist and [PCT #3] grabbed the right arm. The patient was sitting on the foot of the bed when [RN #1] comes in and stood behind [the patient] and laid [Patient #1] down suddenly on the bed and put the left hand on the patient's shoulder and the right hand on the patient's throat while I administered Geodon in (the patient's) left deltoid." Continued interview confirmed the 4 employees held the patient down for RN #2 to administer the antipsychotic medication; and the patient stated and demonstrated refusal of the medication. Continued interview confirmed the Geodon was administered involuntarily. Further interview confirmed RN #2 entered the room with the intent to administer the medication and the nurse did not perform an assessment to determine if other types of intervention were reasonable alternatives to a restraint or to determine if the patient had any unmet basic needs.

Interview with PCT #1 (assigned sitter) on 10/13/16 at 7:30 AM, in the conference room, revealed the patient was in a low bed with ¼ side rails in the raised position when he was attempting to get out of bed. Continued interview revealed the patient woke up and wanted to go to the bathroom and the PCT "offered [Patient #1] the urinal but [Patient #1] did not use it." Continued interview revealed the patient positioned self to the foot of the bed between the foot board and the bottom of the side rail. Continued interview revealed the patient "was dry" (continent of urine at the time). Continued interview revealed after the patient was administered the Geodon the patient received pericare for an episode of urinary incontinence; the patient was assisted to the bedside chair; and the bed linens were changed. Continued interview revealed the PCT did not offer the patient to stand to use the urinal and did not notify other staff of the patient's request to go to the bathroom.

Interview with RN #1 on 10/17/16 at 9:30 AM, in the lobby, revealed the patient was sitting on the side of the bed when the nurse entered in response to being called by PCT #1. Continued interview revealed the nurse attempted to calm the patient, was unsuccessful, so the nurse called PCT #2, who has been successful in attempts previously. Continued interview revealed when Patient #1 "stood up, hitting and kicking, I tried to get [patient] back and up in bed. [The patient] did not resist. I had my arms around...from behind...I tried to get around [the patient's] shoulders. I pull