HospitalInspections.org

46901

Based on record review, interview, and observation, the facility failed to meet the Condition of Participation (CoP) for the patients right to be free from harm, abuse, neglect, and harassment by failing to comply with the requirements as evidenced by the following:

A. The facility failed to ensure the patients' right to receive care in a safe setting, and to be free from harm, abuse, neglect, and harassment, by not adhering to facility implemented trainings, procedures, and policies. Refer to 0144.

Based on record review and interview the facility failed to maintain a process for patients to be informed of contact information for Department of Health (DOH) Complaints for all patients receiving treatment in the psychiatric unit of the facility. This failed practice can lead to patient's not being informed of the process for entering a complaint/grievance, can lead to repeat complaint issues and can lead to patient harm.

The findings are:
A. Record review of facility's policy titled, "Patient Rights and Responsibilities" dated 10/18/22 confirms under section titled "Procedure":
a. #3 The patient rights information contains information for patients on how to file a grievance or complaint with [facility]. See [facility]Board of Trustees Patient Grievance Policy.
b. #4 [Facility] will include New Mexico Mental Health Code for patient rights and responsibilities requirements.

B. Record review of facility's "Patient Admission Packet" for Psychiatric Emergency Services dated 05/03/17 does not contain the correct contact information for Department of Health Complaints.

C. On 10/19/22 during interview with Staff (S3) (Regulatory Manager) who confirmed, "I thought it was in there, that information needs to be updated."

46901


Based on record review, interview, and observation the facility failed to protect the patients' rights to receive care in a safe setting, and to be free from abuse and harassment for 1 patient (P1) of 10 (P1-P10) patients reviewed. This failed practice led to assault of a pediatric patient, inappropriate use of force, intimidation, and escalation of a pediatric patient, inappropriate use of a physical restraint/carry, psychosocial harm, and physical harm.
The findings are:

A. Record review of Facilities policy titled "Patient Rights and Responsibilities" dated 03/09/2022, revealed page 1 para 1, "The [name of facility] informs patient, or when appropriate a patient's representative, of the patient's rights ... All patients will be informed of, and (sic) provided a copy of the patient rights and responsibilities handout upon inpatient admission to a hospital inpatient unit ... [name of applicable unit within facility] will include New Mexico Mental Health Code for patient rights and responsibilities requirements."

B. Record review of Facilities admission packet titled "Notice of Privacy Practices" dated 05/03/2017, shows no notice of the patients right to be free from all forms of abuse, neglect, or harassment.

C. Observation of facilities video recording of incident dated 06/06/2022 11:01-11:19 pm, revealed:

1. On 06/06/2022 at 11:01 pm, P1 enters through "Sally Port" (a secured, controlled entryway to an enclosure, in this case an outdoor area that is used for ambulance, security, police or otherwise emergent admission of patients) outer perimeter door accompanied by two police officers [PO]. P1's hands are restrained behind back with police issued handcuffs upon entrance. P1 walks enclosed area and stands with back against wall in corner farthest from Sally Port door and door leading to unit. P1 stands with feet square and slightly leaned back in this location from 11:01 pm to 11:08 pm when patient attempts to move away from PO1 for 4-5 feet. PO1 and PO2 retrieve P1 by both arms and attempt to seat patient in plastic chair, P1 slips from chair and regains standing position in same location and stance prior to attempt to flee. P1 stands in this location with PO1 and PO2 at either side until 11:11 pm.
2. On 06/06/2022 at11:09 pm Security opens Sally Port door to allow access to 2 additional Police Officers; there are now 4 police officers, 2 security officers and no Healthcare Professionals in Sally Port with P1. Three of the Police Officers surround P1 as P1 is standing in corner of Sally Port.
3. On 06/06/2022 at 11:10 pm, facilities video recording of [name of unit] hallway revealed assembly of Crisis Response Team (CRT) (a designated team of staff assigned to emergently respond to situations of immediate clinical concern such as aggressive or self-harming individuals), to include 6 Mental Health Technicians (MHT), 2 Registered Nurses (RN), and the Medical Doctor (MD). At 11:11 pm, CRT exits toward Sally Port and P1.
4. On 06/06/2022 at 11:11 pm, personnel present in Sally Port to address P1 includes 6 MHT's, 4 police officers, 2 security officers, 2 RN's and 1 MD, to total 15 personnel. 13 personnel surround P1 in corner. RN1 advances toward P1 with syringe in gloved left hand. RN1 attempts to grab P1's right arm for administration of intramuscular (IM) injection. P1 pulls arm away and begins to struggle as RN makes second attempt to administer injection, Crisis Response Team and personnel advance on P1.
5. On 06/06/2022 at 11:11 pm P1 is lifted off the ground and carried face up by all four extremities by the Crisis Response Team and PO's into unit and placed supine (lying on back with face up) on restraint specialized bed (a bed that is made entirely of hard plastic with built in hooks to secure restraints to) in patient room. P1's hands continue to be restrained behind P1's back and P1 visibly yells out as P1's body weight is placed onto the handcuffs. MHT1 and MHT2 begin to secure P1's legs to bed using designated nylon restraints.
6. On 06/06/2022 at 11:12 pm RN1 enters room, prepares site and administers IM injection (refer to finding O) into P1's anterior right thigh. PO1 and PO2 sit patient up and begin to remove handcuffs from P1 at 11:12 pm. At this time there are 3 MHT's, 3 Police Officers, and 1 RN in the patient room.
7. On 06/06/2022 at 11:13 pm, P1's bilateral lower extremities are secured with restraints, P1's right upper arm is physically restrained by MHT2, Patient continues to struggle as MHT1 attempts to secure P1's left wrist with nylon restraint.
8. On 06/06/2022 at 11:13:32 pm MHT1 makes sudden aggressive advancement toward P1's face, upon withdraw from this action, MHT1 is observed gripping P1's left chest with MHT1's right hand in a pinching manner, P1's chest pulled back from the pinch as P1 visibly yells out.
9. On 06/06/2022 at 11:13 pm, spit guard is placed over P1's head by MHT3. All PO officers' leave from patient room and unit.

D. Observation of facilities video recording of incident dated 06/06/2022 11:01 pm -11:19 pm, revealed at 11:11 pm P1's hands continue to be restrained behind P1's back and P1 visibly yells out as P1's body weight is placed onto the handcuffs.
1. Refer to finding C (5) regarding restraint.

E. Observation of facilities video recording of incident dated 06/06/2022 11:01 pm -11:19 pm, revealed at 11:13:32 pm MHT1 makes sudden aggressive advancement toward P1's face, upon withdraw from this action, MHT1 is observed gripping P1's left chest with MHT1's right hand in a pinching manner, P1's chest pulled back from the pinch as P1 visibly yells out.
1. Refer to finding C (8) regarding physical assault.

F. Refer to tag A-0167 regarding unsafe and inappropriate use of force, intimidation, escalation, and use of restraint/carry.

Based on record review, interview, and observation, the facility failed to protect the patients' right to safe and appropriate restraint techniques as determined by hospital policy for 1 patient (P1) of 10 (P1-P10) patients reviewed. This failed practice led to inappropriate use of force, escalation of a patient, and the unsafe and inappropriate use of a physical restraint/carry.
The findings are:

A. Observation of facilities video recording of incident dated 06/06/2022 11:01-11:19 pm, revealed:
1. On 06/06/2022 at 11:01 pm, P1 enters through "Sally Port" (a secured, controlled entryway to an enclosure, in this case an outdoor area that is used for ambulance, security, police or otherwise emergent admission of patients) outer perimeter door accompanied by two police officers [PO]. P1's hands are restrained behind back with police issued handcuffs upon entrance. P1 walks enclosed area and stands with back against wall in corner farthest from Sally Port door and door leading to unit. P1 stands with feet square and slightly leaned back in this location from 11:01 pm to 11:08 pm when patient attempts to move away from PO1 for 4-5 feet. PO1 and PO2 retrieve P1 by both arms and attempt to seat patient in plastic chair, P1 slips from chair and regains standing position in same location and stance prior to attempt to flee. P1 stands in this location with PO1 and PO2 at either side until 11:11 pm.
2. On 06/06/2022 at11:09 pm Security opens Sally Port door to allow access to 2 additional Police Officers; there are now 4 police officers, 2 security officers and no Healthcare Professionals in Sally Port with P1. Three of the Police Officers surround P1 as P1 is standing in corner of Sally Port.
3. On 06/06/2022 at 11:10 pm, facilities video recording of [name of unit] hallway revealed assembly of Crisis Response Team (CRT) (a designated team of staff assigned to emergently respond to situations of immediate clinical concern such as aggressive or self-harming individuals), to include 6 Mental Health Technicians (MHT), 2 Registered Nurses (RN), and the Medical Doctor (MD). At 11:11 pm, CRT exits toward Sally Port and P1.
4. On 06/06/2022 at 11:11 pm, personnel present in Sally Port to address P1 includes 6 MHT's, 4 police officers, 2 security officers, 2 RN's and 1 MD, to total 15 personnel. 13 personnel surround P1 in corner. RN1 advances toward P1 with syringe in gloved left hand. RN1 attempts to grab P1's right arm for administration of intramuscular (IM) injection. P1 pulls arm away and begins to struggle as RN makes second attempt to administer injection, Crisis Response Team and personnel advance on P1.
5. On 06/06/2022 at 11:11 pm P1 is lifted off the ground and carried face up by all four extremities by the Crisis Response Team and PO's into unit and placed supine (lying on back with face up) on restraint specialized bed (a bed that is made entirely of hard plastic with built in hooks to secure restraints to) in patient room. P1's hands continue to be restrained behind P1's back and P1 visibly yells out as P1's body weight is placed onto the handcuffs. MHT1 and MHT2 begin to secure P1's legs to bed using designated nylon restraints.
6. On 06/06/2022 at 11:12 pm RN1 enters room, prepares site and administers IM injection (refer to finding O) into P1's anterior right thigh. PO1 and PO2 sit patient up and begin to remove handcuffs from P1 at 11:12 pm. At this time there are 3 MHT's, 3 Police Officers, and 1 RN in the patient room.
7. On 06/06/2022 at 11:13 pm, P1's bilateral lower extremities are secured with restraints, P1's right upper arm is physically restrained by MHT2, Patient continues to struggle as MHT1 attempts to secure P1's left wrist with nylon restraint.
8. On 06/06/2022 at 11:13:32 pm MHT1 makes sudden aggressive advancement toward P1's face, upon withdraw from this action, MHT1 is observed gripping P1's left chest with MHT1's right hand in a pinching manner, P1's chest pulled back from the pinch as P1 visibly yells out.
9. On 06/06/2022 at 11:13 pm, spit guard is placed over P1's head by MHT3. All PO officers' leave from patient room and unit.

Inappropriate Escalation of a Patient:
B. In an interview with Staff (S11), MHT on 10/20/2022 at 8:05 am, S11 states, "It all happened at once ... the patient was scared. He lifted his leg because he was scared ... It was very unorganized, a lot of people involved. Because [P1] is a child we should have been calmer, more patient."

C. Record review of facilities policy titled "Panic and Crisis Alarm Use in Behavioral Health" dated 08/21/2022, revealed page 2 para 2:
1. "Begin verbal intervention de-escalation techniques.
2. If patient becomes combative, security Officers will only use the amount of force that is objectively reasonable to safely restrain the patient from harming his/her self [sic]or others.
3. Patient should be transferred to behavior restraints as soon as reasonably possible when handcuffs are utilized ...
4. Crisis team members should step away from the incident ..."

D. Observation of Facilities video recording of incident dated 06/06/2022 11:01 pm -11:19 pm, revealed P1 remains in police issued handcuffs from 11:01 pm -11:12 pm, a total of eleven minutes after arrival to facility.

E. Observation of Facilities video recording of incident dated 06/06/2022 11:01 pm -11:19 pm, revealed no attempt to initiate removal of handcuffs as soon as reasonably possible by security or healthcare staff and prior to escalation of patient behavior.

F. Record review of Facilities implemented training program titled "Management of Aggressive Behavior (MOAB)" dated 1993, revision date January 2021, revealed page 12, "Of the five methods of communication; non-verbal is the most critical to understand because approximately 90% of all communication is nonverbal ... Non-verbal communication (or body language) revealed the inner most thoughts that are often referred to as: anxiety, fear, apprehension, hunches, intuition, gut feeling ... In reading non-verbal communications, we need to rely on a cluster of signals rather than only one signal ..."

G. Record review of Facilities implemented training program titled "MOAB" dated 1993, revision date January 2021, revealed page 37:
1. "Signals to Watch For and Understand ...
i. Legs/Stance ...
1. Shifting weight back = usually defensive
2. Weight equal on both feet = usually not aggressive
ii. Leaning the body ...
1. Leaning the body slightly back indicates defensiveness or fear or both ...
2. Three stages of conflict and management:
i. Anxiety: a noticeable change in behavior. An involuntary reaction or response to something that happens.
1. Recognizing anxiety:
a. head down ...
b. Eye contact is minimal ...
c. Talking is minimal ...
d. Appears confused ...
ii. Anxiety triggers:
1. Your body language
2. Third party ...
3. Cornering ...
4. Fear of injury
iii. Managing the individual's anxiety
1. Proper space
2. Supportive eye communications
3. Supportive gestures and postures
4. Supportive facial expressions
5. Empathic listening
6. Supportive verbal communications
7. Supportive stance ...

H. Record review of Facilities implemented training program titled "MOAB" dated 1993, revision date January 2021, revealed page 59, "Emotional Confrontation Triggers ...
1. Being endangered
2. Physical threat ...
3. Threat to self-esteem or dignity"

I. Observation of facilities video recording of incident dated 06/06/2022 11:01 pm-11:19 pm, revealed P1 remains in Sally Port from 11:01 pm to 11:11 pm without signs of aggressive or self-harming behavior prior to attempt to administer chemical restraint.

J. In an interview with S14, MHT on 10/20/2022 at 8:20 am, S14 states, "He didn't want a shot. staff wanted to sit him down in a chair and he didn't want to. The patient was picked up, I'm not sure why ... The patient was taken into the room with restraints, and he was still in handcuffs. There were way too many people ... about 15, way too many people."

K. Record review of P1, "Nursing Notes" dated 06/07/2022 at 7:53 am, documents, "Patient was given Thorazine (a medication under the drug class of antipsychotics, used in this application to calm hyperexcitable, disruptive or combative behavior in children) 50 mg (milligrams) at 2350 (11:50 pm) 6/6/22 and 0015 (12:15 am) 6/7/22," signed by registered nurse (RN).

L. Observation of facilities video recording of incident dated 06/06/2022 11:01 pm-11:19 pm, shows no attempt of least restrictive or de-escalation techniques implemented by staff prior to administration of chemical restraint to P1.

Inappropriate Use of Force and Intimidation:
M. Record review of facilities implemented training program titled "Management Of Aggressive Behavior (MOAB)" dated 1993, revision date January 2021, revealed page 73-74:
a. "We have a tendency to corner individuals, but we are often unaware that we are doing it. We frequently hear people say, 'he went out of control for no apparent reason.' The reason was that the individual was cornered which triggered the aggressive reaction. It is difficult to calm people down once cornered. Their focus is not on what you are saying, but rather on their cornered state. Cornering increases your risk of injury ...
b. Surround Cornering Mistake: several persons form a circle or semicircle around an individual. This is an attempt to show force by using a team. Violent confrontations often occur when this tactic is used. Injury rates have been high for both sides ...
c. To avoid a cornering mistake, the proper technique involves only one contact person with others standing at least eight to ten feet away."

N. Record review of facilities implemented training program titled "MOAB" dated 1993, revision date January 2021, revealed page 73: "When cornering individuals, they have three options:
1. Resist
2. Submit
3. Flee."

O. Refer to finding A (4) regarding restraints and finding N.

P. Observation of Facilities video recording of incident dated 06/06/2022 11:01 pm -11:19 pm, revealed P1 was kept in handcuffs from time of entrance onto facility grounds at 11:01 pm until they were removed inside patient room after 4-person carry and initiation of 4-point restraints at 11:12 pm.

Q. Observation of facilities video recording of incident dated 06/06/2022 11:01 pm -11:19 pm, revealed no visible attempt to de-escalate P1 prior to use of force and intimidation.

R. Record review of facilities implemented training program titled "MOAB" dated 1993, revision date January 2021, shows no restraint or hold requiring more than 2 trained staff.

S. Record review of facilities implemented training program titled "MOAB" dated 1993, revision date January 2021, shows no restraint or hold that instructs the use of lifting a patient off the ground.

T. In an interview with S11, Mental Health Technician (MHT) on 10/20/2022 at 8:05 am, S11 states "it was very disorganized, lots of people involved ... In my experience with the Crisis Team is 6 people, there is usually a supervisor, a RN and security will help sometimes. Everyone has a role but in this case there were probably 6 other people present who shouldn't have been there (Police officers), there were too many people. We usually have steps to follow and it goes a lot better."

U. In an interview with S14, MHT on 10/20/2022 at 8:20 am, S14 states "There were too many people in the room. Like 3 police officers, 2 nurses and 2 MHTs in a very small room. We (Crisis Response Team) had to back out and the 2 techs took care of the restraints. I feel they handled him rough, he was handcuffed, and they were holding him down rough ... There was so many people there ... at least 3 police officers, the Crisis Team that is 6 staff plus three other staff, one security person and 3 nurses, about 15 people, way too many people."

Inappropriate Use of Restraint/Carry:
V. Observation of facilities video recording of incident dated 06/06/2022 11:01 pm -11:19 pm revealed, at 11:11 pm P1 is lifted off the ground and carried face up by all four extremities by the Crisis Response Team and PO into unit and placed supine on restraint specialized bed.

W. In an interview with S11, Mental Health Technician (MHT) on 10/20/2022 at 8:05 am, S11 states "it was very disorganized, lots of people involved ... In my experience with the Crisis Team is 6 people, there is usually a supervisor, a RN and security will help sometimes. Everyone has a role but in this case there were probably 6 other people present who shouldn't have been there (Police officers), there were too many people. We usually have steps to follow and it goes a lot better."

X. In an interview with S14, MHT on 10/20/2022 at 8:20 am, S14 states "There were too many people in the room. Like 3 police officers, 2 nurses and 2 MHTs in a very small room. We (Crisis Response Team) had to back out and the 2 techs took care of the restraints. I feel they handled him rough, he was handcuffed, and they were holding him down rough ... There was so many people there ... at least 3 police officers, the Crisis Team that is 6 staff plus three other staff, one security person and 3 nurses, about 15 people, way too many people."

Y. Observation of facilities video recording of incident dated 06/06/2022 11:01 pm -11:19 pm, shows no attempt of least restrictive methods or de-escalation techniques employed by staff prior to initiation of physical restraint to P1.

Z. Observation of facilities video recording of incident dated 06/06/2022 11:01 pm - 11:19 pm, shows no evidence of P1 aggressive (e.g., kicking, hitting, spitting) or self-harming behavior prior to initiation of physical restraint/carry and initiation of 4-point restraint.

AA. Refer to tag A-0144 regarding patient harm, inappropriate use of force and intimidation.

Based on record review and interview, the facility failed to write and implement a policy to address initial treatment in the Psychiatric Emergency Room, when the patient is brought in by police, or in otherwise restrained custody for all patients in the facility. This failed practice may lead to patient neglect, unnecessary restraint, unnecessary use of force, and patient harm.

The findings are:
A. In an interview with Staff (S9), Director of Behavioral Health (DBH) on 10/21/2022 at 10:30 am, when asked to provide a policy addressing how patients are accepted from police custody, S9 states that there is not currently a policy addressing this.

B. Record review of facilities policy titled, "Panic and Crisis Alarm Use in Behavioral Health" dated 08/21/2020, revealed page 2 para 2, "Security's Role in Patient Management ... Patient should be transferred to behavior restraints as soon as reasonably possible when handcuffs are utilized."

C. Record review of facilities policies and procedures shows no policy to address appropriate procedures on the assumption of care when a patient is brought in by police, or in otherwise restrained custody.

D. Refer to Tag A-0144 regarding patient harm.

F. Refer to Tag A-0167 regarding unsafe restraint.