HospitalInspections.org

Based on hospital policy and procedure review, medical record review, job description review, document review, video review, and staff interviews, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights and an organized nursing service to ensure the safety of patients.

The findings include:

1. The staff failed to promote and protect patients' rights by failing to prevent abuse of an adolescent patient that was forcibly and inappropriately restrained by hospital staff.

~ cross refer to 482.13 Patient Rights' Condition: Tag 0115.

2. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care.

~ cross refer to 482.23 Nursing Services Condition: Tag 0385.

Based on hospital policy and procedure review, medical record review, document review, video review, and staff interviews, the staff failed to promote and protect patients' rights by failing to prevent abuse of an adolescent patient that was forcibly and inappropriately restrained by hospital staff.

The findings include:

1. The staff failed to prevent abuse of a 12 year-old youth forcibly restrained by hospital staff for 1 of 1 patients (#13).

~cross refer to 482.13(c)(3) Patients' Rights Standard: Tag 0145

2. The staff failed to use the least restrictive restraint for 1 of 3 restrained patients (#13).

~cross refer to 482.13 (e)(3) Patients' Rights Standard: Tag 0165

3. The staff failed to ensure appropriate restraint technique was used during a restraint for 1 of 3 patients (#13).

~cross refer to 482.13 (e)(4)(ii) Patients' Rights Standard: Tag 0167

4. The staff failed to obtain a physician order for restraints for 2 of 3 restrained patients (#13 and #4).

~cross refer to 482.13 (e)(5) Patients' Rights Standard: Tag 0168

5. The staff failed to release a patient from restraints at the earliest time identified for 1 of 3 restrained patients (#4).

~cross refer to 482.13 (e)(9) Patients' Rights Standard: Tag 0174

6. Tthe staff failed to monitor a patient while in restraints for 1 of 3 restrained patients (#4).

~cross refer to 482.13 (e)(10) Patients' Rights Standard: Tag 0175

Based on hospital policy and procedure review, medical record review, document review, video review, and staff interviews, the staff failed to prevent abuse of a 12 year-old youth forcibly restrained by hospital staff for 1 of 1 patients (#13).

The findings include:

Review of the hospital's policy "Restraint/Seclusion" revision date of 02/2012 revealed "It is the policy of (facility name) to support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The patient has the right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing."

Review of hospital's policy "Patient Rights and Restrictions of Patient Rights" revised 12/2012 revealed "Patient Rights:...Without limitations, patients shall be entitled to: a. considerate, respectful, human care and treatment...c. to be treated with human dignity and in an environment that contributes to a positive self-image...t. receive treatment in the least restrictive setting within the facility necessary to accomplishes the treatment goals...w. the right not to be subjected to any harsh or unusual treatment".

Review of the hospital's policy "Abuse/Neglect Reporting" revised 09/11/2008 revealed "POLICY: (Facility) will insure that all allegations of abuse, neglect and/or exploitation are reported to all appropriate agencies. This will include reports of alleged abuse to patients prior to admission, staff to patient abuse, or patient to patient abuse....B. Staff to patient abuse: 1. any staff member who witnesses or suspects an incident of abuse must report the situation to their supervisor. The supervisor will, in turn, report the situation to the Risk Manager. 2. The Risk Manager will investigate the situation according to procedure. Legal authorities and Health Care Registry will be notified as appropriate. 3. Administrative actions will be taken according to policy." Review of the policy revealed no definition of 'abuse'.

Closed Medical Record review for patient #13 revealed a 12 year old male admitted to the adolescent unit on 04/16/2013 with a diagnosis of Suicidal risk with history of ADHD (attention deficit hyperactive disorder) and Asthma. Record review revealed he was admitted to the facility with IVC (involuntary commitment) after attempting to hang himself from a flag pole and stabbing himself with a pencil. Further review of the chart revealed "Height 4'7" and weight 80 (pounds)". Further review of the chart revealed a physician order on 04/25/2013 at 1100 "0930 Snack - 2 pieces of fruit and goldfish with routine 0930 snack and with 1930 routine snack add 2 pieces of fruit and goldfish." Review of the Dietary Requisition Sheet on 04/25/2013 revealed a request for patient #13 "**other Extra Snack for AM snack and 7:30 pm snack - 2 pieces of fruit and bag of gold fish for each snack".

Review of a "Restrictive Intervention Flow Sheet" dated 04/26/2013 at 1930 revealed "emergency intervention order/initiation:...4/26/13 at 2030...physical restraint. Maximum time 15 min (minutes)...Clinical Justification for Intervention: per report "out of control" "threatening, cursing, walking toward mental health tech". Order received from : (Physician name) at Date: 04/26/13 Time: 1600 (4 hr and 30 minutes before initiation of the restraint)....Order authentication: (Physician signature) Date: 04/26/13 Time 1800 (2 hours and 30 minutes before initiation of the restraint); ...RN Signature: (signature) Date: 04/29/13 (no time documented) (3 days after the initiation of the restraint)... Termination/Post Intervention: Time of termination (no time documented). Attending physician notified of intervention: Yes; Date/Time: 04/29/13 (no time documented) (3 days after the restraint). Patient/Staff Debriefing: Date/Time: 04/26/2013 (no time is documented). Staff's perception of events/factors leading to intervention: uncomfortable. Could anything have been handled differently?...Yes. Were patient's well-being, psychological comfort and right to privacy maintained? No, explain: behavior of staff was inappropriate. Was any trauma suffered by patient: Yes, ..if yes describe counseling provided: therapeutic discussion of events leading up to incident and incident itself...RN signature (house supervisor) Date/Time 04/26/13 (at) 21 (time not completed)." Continued review of the chart reveals no documenation of a restraint, seclusion, or altercation. Interview on 05/03/2013 at 1550 with the primary nurse (RN #1) revealed the Restraint Intervention form was completed on Monday 04/29/2013 (3 days after an abuse incident) and the nurses notes does not address the use of a restraint, seclusion or altercation with the staff.

Interview on 05/02/2013 at 1555 with administrative staff revealed "On 04/26/2013 around 2030 or 2100 we had an incident where a MHT (Mental Health Technician #1) had an altercation with a patient (#13). The MHT was a large man, weighing around 250 pounds, and the patient was a small 12 year old boy who weighed about 65 pounds. Around 2030 or 2100 in the evening the snacks had been provided in the Day Room at the end of the (male) hall. The patient (#13) routinely received two snacks and he had received one of the snacks but the MHT was withholding the second snack because he didn't feel the patient had earned it because of his behavior. We (administrative staff) watched the surveillance videos which show the child was active, running around and kept returning to the MHT trying to get his second snack. The situation escalated; the child picks up a chair and throws it toward the MHT; a few minutes after that the MHT grabs the patient by the arm and takes him to the floor pinning him to the floor and against the wall. You can see on the video what looks like the MHT using his knees to pin the patient to the floor; the patient is struggling to get loose while in a prone position. The MHT takes his whole opened hand and pushes the patient's face against the floor and the MHT's hand slips off the patients' face to the neck briefly. The MHT manually lifted the patient to his feet. The MHT's left hand had the patients' left arm with the MHT's rights hand on the patient's waist band of his pants at his back and drags the patient to the seclusion room. Once in the seclusion room (RN #2) in the medication room arrives after hearing the noise and the MHT leaves the seclusion room. At that point the patient reports the abuse to (RN #2). Within minutes (RN #1 - primary nurse) arrives in seclusion area. (RN #1) then notified the house supervisor who immediately met with the staff to investigate the allegation. The house supervisor said the patient had informed the staff that (MHT #1) had body slammed him, choked him, and threw him up against the wall and pushed him into the quiet room, he was crying and telling them it was all on tape. The patient stated the incident started because he was trying to get a snack that he had previously been refused to have. Per the staff the patient was normally allowed to have 2 snacks. He had been given one snack but he was wanting his second snack. (RN #1) had informed the house supervisor that she witnessed (MHT #1) dragging and pulling the patient by the arm and clearly running the patient into the wall. (RN #1) said the patient was yelling and screaming. (RN #1) had not been informed of what was happening until she saw the patient being pulled up the hallway by (MHT #1). (RN #2) reported to the house supervisor that she was in the medication room and heard a child yelling and screaming (from the quiet/seclusion room) and heard a man's voice say 'what do you think about your B**** A** now'. (RN #2) stated when she heard that she stepped from the medication room to the seclusion area and saw pt. (#13) sitting on the bed crying and (MHT #1) standing in the doorway. (RN #2) stated she stared at (MHT #1) and he just turned and left the seclusion area. The house supervisor after interviewing the staff concluded (MHT #1) had restrained the patient inappropriately and forcibly taken him to the seclusion room. The house supervisor (RN) talked with pt (#13). The house supervisor suspected an abuse situation and called the administrator on-call and the DON (director of nursing) to report the events and was advised to suspend MHT immediately pending outcome of the investigation. (MHT #1) was sent home. The patient was allowed to leave the seclusion room. We (administrative staff) began our formal investigation on 04/29/2013. We reviewed the video recording of the activities on the unit and interviewed the staff working including (MHT #1). The video clearly identifies patient (#13) being by definition abused by (MHT #1). The video showed (MHT #1) taking the patient to the floor with an inappropriate restraint, his open hand covering the patient's face and then slipping to the patient's neck, and then forcibly dragging the patient up the hallway by the waist of his pants and his (the ptients) left arm and placing him in the seclusion room barricading the door with his body so the patient could not leave. The areas of concern that we identified were 1. the treatment of the patient which we saw as abuse; 2. Failure to use CPI (nonviolent crisis intervention) training: a. the RN did not initiate the hold/restraint per policy; b. the RN was not involved at all in the restraint; c. a one man hold was used which is not supported with our model; d. MHT placed the patient in a prone position which is not appropriate; e. the MHT used his knees to hold the patient down on the floor and his hand was over the patients face and near his neck which are inappropriate techniques and not supported by our model of restraints; 3. the lack of RN supervision and documentation; and 4. the RN's failure to recognize potential abuse situation from the MHT... Based upon these findings on 04/30/2013 we did a self reporting to the DHSR (Division of Health Service Regulation) and HCPR (Health Care Personnel Registry). The DHSR returned my call on 05/01/2013 at 0829 to take detailed information of the complaint ". Continued interview revealed that multiple attempts were made to contact the patient's mother and finally reached her on 04/29/2013 to report the incident."

Review of the video, Camera #10, of the males back hallway on 05/02/2013 at 1700 revealed on 04/26/2013 at 20:26 MHT #1 with his open hand on the patient's (#13) back maneuvers the patient to the dayroom at the end of the male hallway; at 20:28 patient #13 is running up and down the hallway to and from the nurses station; at 20:29 the patient is at the back hallway and trying to reach a brown paper bag MHT #1 has placed at his workstation and the MHT #1 moves the bag out of the patient's reach; patient #13 gets down off the chair then throws the chair down the hallway toward direction (MHT #1) is standing; MHT #1 returns the chair to its' original place; 20:31:09 MHT #1 and Pt #13 are in the back hallway facing each other with 12-14 inches between them. Video revealed that MHT #1 has both of his hands placed on his hips; 20:31:20 MHT #1 extends his right hand to motion toward an open door leading to the back dayroom, closing the door (door dividing the male hallway, between the nursing station and the day room area) ; 20:31:37 MHT #1 and pt #13 remain in the hallway. At 20:32:01 the video revealed MHT #1 and patient (#13) engaged in shoving each other; 20:32:06 MHT #1 and patient #13 have hands on each other in a struggle; during the struggle the MHT #1 pushes the patient to the floor in the back hallway near the wall. The two continue to struggle while on the floor with the patient kicking, wiggling and turning side to side trying to get out of the hold. The MHT #1 has both hands on the patient. The left hand is holding the patient's arms across his body and the MHT #1's right hand is used to push against the side of the patient's face toward the floor. The patient continues to try to pull his head away but the MHT#1 continues to push on the side of the patient's face and at one point his hand slips down toward the patient's throat. The MHT #1's body is straddling the patient around his hip area, pinning him to the floor. At 20:32:52 the patient continues to struggle, wiggle, kick and jerk against the MHT #1's hold until he maneuvers to a prone position. At 20:33:31 the MHT #1 continues to hold the patient down with his left knee at the patient's hip and back area and his right knee on the floor. He has one hand on the patient's back near the shoulder blades and the other hand on the patient's head holding it down while the patient continues to jerk his head back and forth. At 20:34:00 the MHT #1 releases the patient and he stands up. The patient attempts to walk away from the MHT #1 but the MHT #1, with his left hand, grabs the patient by his left arm. The MHT #1 has his right hand at the patient's back pulling up on the waist band of the patient's pants. The video revealed the MHT #1 is pulling the patient up the hallway by the arm and waist band of his pants and the patient's feet are intermittently on and off the floor as he is pulled and pushed up the hallway by the MHT #1. Review of the video camera #4 of the seclusion/quiet room revealed at 20:34:38 the MHT #1 pushes the patient into the quiet/seclusion room. The patient sits on the bed in the quiet/seclusion room; 20:34:46 the MHT #1 is standing in front of the quiet/seclusion room door preventing the patient from leaving the room; 20:34:50 the patient is sitting on the bed and appears to be coughing. Video revealed that while the patient is sitting he is leaning over looking toward the floor. Review of video camera #8 of the anteroom of the seclusion area revealed at 20:37:44 the patient is standing at the quiet room door. The MHT #1 is standing adjacent to the patient and at times blocking the doorway to the seclusion room with his body; RN #2 (medication nurse) appears/enters the quiet/seclusion room area from the medication room; 20:39:24 the patient is talking to RN #2 (medication nurse). The patient walks out of the quiet/seclusion room toward RN #2 and extends his arm to knock an "object" out of her hand; 20:39:46 the MHT #1 exits the quiet room area; 20:40:00 RN #1 (patient's primary nurse) enters the quiet room area and attempts to speak with the patient (8 minutes after the altercation between MHT #1 and patient #13 started).

Interview on 05/03/2013 at 1507 with RN#2 (medication RN) revealed she was working on 04/26/2013 at the time of the incident. She revealed she "had worked day shift (7-3pm) and had agreed to stay over and help on the evening shift because they were getting 4 admissions (new patients). Around 2000 or 2030 I was preparing to pass the 2100 medications...I was in the medication room when I heard a patient voice escalating and getting very loud. The medication room has two doors; one leads to the nurses station and the other opens into the anteroom of the seclusion room. The patient was cursing loudly and screaming...then I heard the door on the boys side seclusion/quiet room open and shut...the patient was crying and coughing and he was still cursing. I thought maybe the primary nurse who was at the nurse station doing documentation was involved or aware of what was going on. Then I heard a male voice say 'What do you think about your B**** A** now'. I stopped what I was doing and quickly opened the door and saw (MHT #1) leaning against the door to the boys hallway (the door between the hallway and the seclusion anteroom). The patient (#13) was standing in the seclusion doorway crying and coughing. I went immediately to him and he was so mad he kept saying 'He (MHT #1) called me a B****, he grabbed my shirt collar and his hand hit me in the chin. It's all on camera and you won't do S*** about it'. This is the second time since January this patient has been here and he doesn't usually scream and yell. He (pt #13) was screaming and yelling and just kept coughing. I told him we will see what's on the camera and we will do something about it. (Name) (MHT #1) left without saying a word. I got the medicine cup because I had just pulled his 2100 medications and offered them to him thinking it might calm him down but he just slapped them out of my hand. The primary nurse (RN #1) entered the seclusion area from the boys side. She (RN #1) bent down to talk with the patient; I asked her if she had the situation now, she said yes so I went back to passing my medications. I had no idea anything was going on until I heard the male voice in the anteroom of the seclusion room. We had nothing in shift report that indicated the patient (#13) was having any issues that day. Patient was ordered extra snacks by the physician because he was always hungry. The MHT usually distributes the snacks that are delivered from the kitchen. We never withhold snacks because of the child's behavior... When I heard (name) (patient #13) coughing and the door slam I knew he (MHT #1) who is about 6'4" had been too rough with that child....my definition of abuse and what our training has taught us is any action above and beyond what it takes to control the situation...powering over the child and excessive force is abuse. There is also verbal abuse...based upon what the patient was saying and how he was acting, yes he (MHT #1) had abused this child. Definitely verbal abuse when he (MHT #1) said 'B**** A**'...what we are suppose to do if abuse is suspected is remove the child from the situation and make them safe, then report it to the primary nurse and/or supervisor... I told the House Supervisor what I saw and that (name) (MHT #1) was blocking the doorway and the patient wasn't free to leave. The patient never stepped over the threshold of the doorway to the seclusion room."

Interview on 05/03/2013 at 1550 with RN #1 revealed she was working on 04/26/2013 and was the primary nurse for patient #13, "I was sitting at the desk, I heard yelling down the hallway, I looked down there, and about middle of the hallway, (name) (MHT #1) had the patient by the arm & shoulder raised up in the air. (Name) (MHT #1) was pulling the patient who was yelling, screaming, and cursing coming towards the nurses desk where I was sitting. The patient was not coming down the hallway willingly. I stood up when they were walking down the hall so I could see what was going on. When I turned I saw (Name) (MHT #1) dragging the patient and then shove him against the wall. They made it up to the corner, they turned left to the door leading into the seclusion room and I saw (Name) (MHT #1) push the patient into the seclusion room. He purposefully pushed him, like he was sending a message...when I arrived in the seclusion area the patient was sitting on the bed and (Name) (MHT #1) was just standing there. I guess the patient could have left because the door wasn't closed or locked but I don't think (Name) (MHT#1) would have allowed him to leave. The patient was cursing and screaming and yelling the whole time I was with him. I couldn't understand what he was saying he was screaming so much...I stood there maybe a minute or so...(Name) (MHT #1) turned and left and went back to the day room...the patient told me that (Name) (MHT #1) had put him on the ground and put his (MHT #1) knees on his back. I tried to console him but he started to scream and yell 'he (MHT #1) can't do that to me'. He (the patient) freely walked out (of the seclusion room). He (pt #13) was complaining of his arm hurting so I got an ice pack and put on it. I did not see scratches on his arm, just redness. He wanted to talk to his mom or grandma so I helped him try to call them since I wanted to talk with her too but he was not able to reach either of them by phone. When I first saw what was going on and before I left the nurses station to go to the seclusion room I had already called the nursing supervisor and requested he come immediately. When I first looked up and saw (Name) (MHT #1) coming down the hall with the patient I thought oh my God, he might be hurting him (patient #13). He (MHT #1) was not using appropriate technique for restraining, he'd left all the other children alone, he had a walkie talkie and could have and should have called for help. I didn't have a chance to intervene. By the time I was aware of what was going on I recognized how inappropriate (Name) (MHT #1) was treating the patient and it would need to be addressed. The definition of abuse is when I see someone pulling a child against their will, hurting them verbally or physically, this is abuse. And this was a situation of abusing a child. I did not call (physician name) on 04/26/3013. As far as I know the physician didn't know about the incident until Monday (04/29/2013). As the RN my responsibility is for the supervision of care."

Interview on 05/03/2013 at 1715 via phone with MHT #2 revealed she was working the evening of 04/26/2013. The staff member stated "one of my male patients was provoking ( patient #13). I saw (Name) (MHT #1) talking to (Name) (patient #13) and blocking him from coming up my hallway but I thought he was trying to keep him from coming up my hallway. When I looked in my peripheral vision I saw (Name) (MHT #1) close the double door which I thought was to separate the two boys. Then I heard someone mumbling. The next thing I knew (Name) (MHT #1) holding the boy (patient #13) down then saw him escorting him up the hallway to the seclusion room...I looked at (Name) (RN #1) with a look of what's going on and she got up from behind the desk and I went back to watching the boys I was assigned to cause I felt like the nurse was going to handle it. I knew it was not protocol that (Name) (MHT #1) restrained the patient without the RN order. All the MHT's have walkie talkies and Code White (need for help) is to be called over the walkie talkie. I felt like the situation was out of control when the double doors were shut. I heard arguing before the double doors closed. I had a big concern when I saw what was going on as he was coming down the hallway. I heard the patient say 'he sat on me'. I realized he must have put a hold on the patient and sitting on the patient is inappropriate that would be some kind of abuse...If we suspect abuse we are to report it to our immediate supervisor. I wasn't sure at the time if the child was just yelling and screaming...(Name) (MHT #1) is a big guy and (Name) (patient #13) is a really small guy. I think he didn't ask for help because (Name) (patient #13) was so small and he felt he didn't need help."

Interview on 05/03/2013 at 1855 with the CPI (non violent crisis intervention) instructor revealed "our policy, what we teach is you do not engage in a one person restraint and it is trained during annual CPI training which we just had March 22 & 23, 2013, which all of the staff working that evening had attended. He (MHT #1) should have called for another staff member to tap him out (switch) because he needed to remove himself from the situation. He has a walkie talkie and could have asked for help, or get a nurse or call the nursing supervisor all via the walkie talkie. He should have called a Code White which all crisis responders would have responded when the child threw the chair down the hall..."

Interview on 05/03/2013 at 1930 with the RN, House Supervisor revealed he was on duty the evening of 04/26/2013 when he "received a call from (Name (RN #1) approximately 2045 requesting him to come immediately to the adolescent unit because she had a problem with (Name) (MHT #1) and (Name) (patient #13). She told me there had been a verbal confrontation. I went immediately and by the time I arrived the patient was not in seclusion but had gone back to the day room on his end of the hall. (Name) (MHT #1) was also back down that hallway. Everything had calmed down. (Name) (RN#1) shared with me that a verbal confrontation between (Name) (MHT #1) and (patient #13) had occurred and while (Name) (MHT #1) was taking the patient to the seclusion room he had hit him with the door. I talked with the staff and (Name) (RN #1) felt (Name) (MHT #1) had purposefully shoved the patient into the door while taking him to the seclusion room. (Name) (MHT #2) said she was not comfortable with what had occurred especially after the door in the hallway was shut. She said she had large boys on her end of the hallway and wasn't comfortable leaving them to go see what was going on with (Name) (MHT #1) and (Name) (patient #13). I spoke with (Name) (RN #2) who informed me the patient had been coughing like someone who had been choked and his shirt was stretched out. I didn't do an assessment but I did talk to the patient and didn't see any obvious injuries. Based on the information I received after interviewing (Name) (MHT #1) and the staff I notified the administrator on call and the DON (Director of Nursing) and was directed to suspend (Name) (MHT #1) pending an investigation. I do not know if the physician or the parents were notified, I would expect the primary nurse to do this."

Review of the Nursing Supervisors documentation of events dated 04/26/2013 revealed "(MHT #1) stated that the patient had been verbally harassing him and threatening to hit him and kept "coming at me". (MHT #1) indicated that he continues to use his hand to back the patient away but that he continued his harassment. (MHT #1) then stated the patient picked up a chair and threw it at him. (MHT #1) said that he responded by pushing the chair against the wall. The patient continued to harass him and so he "took him to the floor". I asked (Name)(MHT #1) why did he do this because this was not the way we handle patients and he stated that he didn't know that. I pointed out to (MHT #1) in CPI training he was taught not to take patients to the floor and that if you did go to the floor the patient must be released. He said, "Oh, I let him up" I asked "did you hold him down on the floor?" (MHT #1) responded "yes"... He said he then "physically restrained him and escorted him to the seclusion room" ... "by the arm"..."

Based on hospital policy and procedure review, medical record review, hospital document review, video review, and staff interviews the staff failed to use the least restrictive restraint for 1 of 3 restrained patients (#13).

The findings include:

Review of the hospital's policy "Restraint/Seclusion" revision date of 02/2012 revealed "It is the policy of (facility name) to support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. ... Less Restrictive Measures: measures which modify the environment, enhance interpersonal interaction, or provide treatment so as to minimize or eliminate the problems/behaviors which place the patient at risk. Examples of less restrictive measures include, but are not limited to: 1. Verbal interventions such as talking quietly with the patient; 2. Environmental intervention through reduction of stimuli causing irritation; 3. Relaxation techniques; 4. Physical activity; 5. Pain control; 6. Psychoactive medications; 7. Reality Orientation; 8. Quiet time; 9. Time out/time away..."

Review of hospital's policy "Patient Rights and Restrictions of Patient Rights", revised 12/2012 revealed, "Patient Rights:...Without limitations, patients shall be entitled to: ...t. receive treatment in the least restrictive setting within the facility necessary to accomplishes the treatment goals...w. the right not to be subjected to any harsh or unusual treatment".

Closed Medical Record review for patient #13 revealed a 12 year old male admitted to the adolescent unit on 04/16/2013 with a diagnosis of Suicidal risk with history of ADHD (attention deficit hyperactive disorder) and Asthma. Record review revealed he was admitted to the facility with IVC (involuntary commitment) after attempting to hang himself from a flag pole and stabbing himself with a pencil. Review of a "Restrictive Intervention Flow Sheet" on 04/26/2013 at 1930 revealed "emergency intervention order/initiation:...4/26/13 at 2030...physical restraint. Maximum time 15 min (minutes)...Clinical Justification for Intervention: per report "out of control" "threatening, cursing walking toward mental health tech". Less Restrictive Interventions Attempted: verbal de-escalation/redirection; time out/time away; 1:1 processing Order received from : (Physician name) at Date: 04/26/13 Time: 1600 (4 hr and 30 minutes before initiation of the order)....Order authentication: (Physician signature) Date: 04/26/13 Time 1800 (2 hours and 30 minutes before initiation of the restraint); ...RN Signature: (signature) Date: 04/29/13 (no time documented) (3 days after the initiation of the restraint)... Termination/Post Intervention: Time of termination (no time documented). Attending physician notified of intervention: Yes; Date/Time: 04/29/13 (no time documented) (3 days after the restraint). Patient/Staff Debriefing: Date/Time: 04/26/2013 (no time is documented). Staff's perception of events/factors leading to intervention: uncomfortable. Could anything have been handled differently?...Yes. Were patient's well-being, psychological comfort and right to privacy maintained? No, explain: behavior of staff was inappropriate. Was any trauma suffered by patient: Yes, ..if yes describe counseling provided: therapeutic discussion of events leading up to incident and incident itself...RN signature (house supervisor) Date/Time 04/26/13 (at) 21 (time not completed)." Continued review of the chart reveals no documenation of a restraint. Interview on 05/03/2013 at 1550 with the primary nurse (RN #1) revealed the Restraint Intervention form was completed on Monday 04/29/2013 (3 days after the incident) and there is no documentation of the restraint in the nurses notes.

Interview on 05/02/2013 at 1555 with administrative staff revealed "On 04/26/2013 around 2030 or 2100 we had an incident where a MHT (Mental Health Technician) had an altercation with a patient (#13). (MHT #1) was a large man, weighing around 250 pounds, and the patient was a small 12 year old who weighed about 65 pounds. We (administrative staff) reviewed the surveillance video that revealed the young man runnning up and down the halls and to the nurses station... at one point he throws a chair... the MHT (#1) escorts him back to his room...the MHT (#1) grabs the patient by the arm and takes him to the floor pinning him to the floor and against the wall. You can see on the video what looks like (Name) (MHT#1) using his knees to pin the patient to the floor; the patient is struggling to get loose while in a prone position....The areas of concern that we identified were...(MHT #1) had ample opportunity to call for assistance when it was apparent the situation was escalating...as the child become more agitated (MHT #1) could have requested someone relief him (switch places with him)...the RN failed to intervene and supervise the situation...we do not use a one man restraint in our facility...he should have called for help and excused himself from the situation and allowed someone else to de-escalate the child..."

Review of the video, Camera #10, of the males back hallway on 05/02/2013 at 1700 revealed on 04/26/2013 ...at 20:26 the MHT #1 with his open hand on the patient's (#13) back maneuvers the patient to the dayroom at the end of the male hallway; at 20:28 patient #13 is running up and down the hallway to and from the nurses station; at 20:29 the patient is at the back hallway and trying to reach a brown paper bag the MHT #1 has placed at his workstation and the MHT #1 moves the bag out of the patient's reach; patient #13 gets down off the chair then throws the chair down the hallway toward direction (MHT #1) is standing; MHT #1 returns the chair to its' original place; 20:30:49 MHT #1 and patient #13 are both standing in the back hallway; facing each other; 20:31:20 MHT #1 extends his right hand to motion toward an open door leading to the back dayroom, closing the door that divides the male hallway; 20:32:01 the video revealed MHT #1 and patient (#13) engaged in shoving each other; 20:32:06 MHT #1 and patient have hands on each other in a struggle; during the struggle the MHT #1 pushes the patient to the floor in the back hallway near the wall. The two continue to struggle while on the floor with the patient kicking, wiggling and turning side to side trying to get out of the hold. The MHT #1 has both hands on the patient. The left hand is holding the patient's arms across his body and the MHT#1's right hand is used to push against the side of the patient's face toward the floor. The patient continues to try to pull his head away but the MHT #1 continues to push on the side of the patient's face and at one point his hand slips down toward the patient's throat. The MHT #1's body is straddling the patient around his hip area, pinning him to the floor. At 20:32:52 the patient continues to struggle, wiggle, kick and jerk against the MHT#1's hold until he maneuvers to a prone position. At 20:33:31 the MHT #1 continues to hold the patient down with his left knee at the the patient's hip and back area and his right knee on the floor. He has one hand on the patient's back near the shoulder blades and the other hand on the patient's head holding it down while the patient continues to jerk his head back and forth. At 20:34:00 the MHT #1 releases the patient and stands up. The patient attempts to walk away from the MHT #1 but the MHT #1, with his left hand, grabs the patient by his left arm. The MHT #1 has his right hand at the patient's back pulling up on the waist band of the patient's pants. The video revealed the MHT #1 is pulling the patient up the hallway by the arm and waist band of his pants and the patient's feet are intermittently on and off the floor as he is pulled and pushed up the hallway by the MHT #1...

Interview on 05/03/2013 at 1507 with RN #2 revealed she was working the evening of 04/26/2013 She revealed "...I was in the medication room when I heard a patient voice escalating and getting very loud...The patient was cursing loudly and screaming...then I heard the door on the boys side seclusion/quiet room open and shut...the patient was crying and coughing and he was still cursing...I stopped what I was doing and quickly opened the door and saw (MHT #1) leaning against the door to the boys hallway (the door between the hallway and the seclusion anteroom). The patient (#13) was standing in the seclusion doorway crying and coughing. I went immediately to him and he was so mad he kept saying 'He (MHT #1) called me a (expletive), he grabbed my shirt collar and his hand hit me in the chin. It's all on camera and you won't do (expletive) about it'...When I heard (patient #13) coughing and the door slam I knew he (MHT #1) who is about 6'4" had been to rough with that child...the MHT (MHT #1) was blocking the doorway and the patient wasn't free to leave."

Interview on 05/03/2013 at 1550 with RN #1 revealed she was working the evening of 04/26/2013 and was the primary nurse for patient #13, "...I was sitting at the desk, I heard yelling down the hallway, I looked down there, and about middle of the hallway, the MHT(MHT #1) had the patient by the arm & shoulder raised up in the air. (MHT #1) was pulling the patient who was yelling, screaming, and cursing coming towards the nurses desk where I was sitting. The patient was not coming down the hallway willingly. I stood up when they were walking down the hall so I could see what was going on when I turned I saw (MHT #1) dragging the patient and then shove him against the wall. They made it up to the corner, they turned left to the door leading into the seclusion room and I saw (MHT #1) push the patient into the seclusion room. He purposefully pushed him, like he was sending a message...He (patient #13) was complaining of his arm hurting so I got an ice pack and put on it. I did not see scratches on his arm just redness...When I first looked up and saw (MHT #1) coming down the hall with the patient (#13) I thought oh my God, he might be hurting him (patient #13). He (MHT #1) was not using appropriate technique for restraining, he had a walkie talkie and could have and should have called for help." Interview confirmed the staff failed to use the least restrictive interventions for this patient's behavior.

Interview on 05/03/2013 at 1715 via phone with MHT #2 revealed she was working the evening of 04/26/2013 "one of my male patients was provoking patient #13. I saw (MHT #1) talking to (patient #13) and blocking him from coming up my hallway but I thought he was trying to keep him from coming up my hallway. When I looked in my peripheral vision I saw (MHT #1) close the double door which I thought was to separate the two boys. Then I heard some one mumbling. The next thing I knew (MHT #1) holding the boy (patient #13) down then saw him escorting him up the hallway to the seclusion room... I knew it was not protocol that (MHT #1) restrained the patient without the RN order...I heard the patient say 'he sat on me'. I realized he (MHT #1) must have put a hold on the patient ...(MHT #1) is a big guy and (patient #13) is a really small guy. He should have called for help..."

Interview on 05/03/2013 at 1855 with the CPI (non violent crisis intervention) instructor revealed "our policy and what we teach is you do not engage in a one person restraint...We teach verbal de-escalation that is/should be used before ever resorting to a restraint. We teach the use of the CPI team control position which requires 3 staff. Two staff members to hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist, if needed (page 15 of the CPI manual). We also teach the CPI transport position (page 16 of CPI manual) to safely move an individual from one place to another. We do not teach take downs (taking patient to the floor). Once the patient is back in control and being escorted back to their room then we teach the handoff - control position (page 14 CPI Children's Control position). He (MHT #1) should have called for another staff member to tap him out (switch) because he needed to remove himself from the situation. He has a walkie talkies and could have asked for help, or get a nurse or call the nursing supervisor all via the walkie talkie. He should have called a Code White which all crisis responders would have responded when the child threw the chair down the hall..." Interview confirmed the staff failed to use the least restrictive interventions for this patient's behavior.

Review of the Nursing Supervisors documentation of events dated 04/26/2013 revealed "The patient (#13) continued to harass (MHT #1) and so he (MHT #1) 'took him (patient #13) to the floor'. I asked (MHT #1) why did he do this because this was not the way we handle patients and he stated that he didn't know that. I pointed out to (MHT #1) in CPI training he was taught not to take patients to the floor and that if you did go to the floor the patient must be released. He said, 'Oh, I let him up' I asked 'did you hold him down on the floor?' (MHT #1) responded 'yes'... He said he then 'physically restrained him and escorted him to the seclusion room' ... 'by the arm'...".

Based on medical record review, hospital document review, video review, and staff interviews the staff failed to ensure appropriate restraint technique was used during a restraint for 1 of 3 patients (#13).

The findings include:

Interview on 05/03/2013 at 1855 with the CPI (non violent crisis intervention) instructor revealed "our policy and what we teach the use of the CPI team control position which requires 3 staff. Two staff members to hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist, if needed (page 15 of the CPI manual). We also teach the CPI transport position (page 16 of CPI manual) to safely move an individual from one place to another. We do not teach take downs (taking patient to the floor). Once the patient is back in control and being escorted back to their room then we teach the handoff - control position (page 14 CPI Children's Control position). He (MHT #1) should have called for another staff member to tap him out (switch) because he needed to remove himself from the situation. He has a walkie talkies and could have asked for help, or go get him a nurse call the nursing supervisor all via the walkie talkie. He should have called a Code White which all crisis responders would have responded when the child threw the chair down the hall. We honestly had no reason to suspect MHT #1 would lose control this way. He had compliments from his patient. We just hate this incident happened and this child was subjected to this."

Closed Medical Record review for patient #13 revealed a 12 year old male admitted to the adolescent unit on 04/16/2013 with a diagnosis of Suicidal risk with history of ADHD (attention deficit hyperactive disorder) and Asthma. Record review revealed He was admitted to the facility with IVC (involuntary commitment) after attempting to hang himself from a flag pole and stabbing himself with a pencil. Review of the "Restrictive Intervention Flow Sheet" on 04/26/2013 at 1930 revealed "emergency intervention order/initiation:...4/26/13 at 2030...physical restraint. Maximum time 15 min (minutes)...Clinical Justification for Intervention: per report "out of control" "threatening, cursing walking toward mental health tech". Less Restrictive Interventions Attempted: verbal de-escalation/redirection; time out/time away; 1:1 processing Order received from : (Physician name) at Date: 04/26/13 Time: 1600 (4 hr and 30 minutes before initiation of the order)....Order authentication: (Physician signature) Date: 04/26/13 Time 1800 (2 hours and 30 minutes before initiation of the restraint); ...RN Signature: (signature) Date: 04/29/13 (no time documented) (3 days after the initiation of the restraint)... Termination/Post Intervention: Time of termination (no time documented). Attending physician notified of intervention: Yes; Date/Time: 04/29/13 (no time documented) (3 days after the restraint). Patient/Staff Debriefing: Date/Time: 04/26/2013 (no time is documented). Staff's perception of events/factors leading to intervention: uncomfortable. Could anything have been handled differently?...Yes. Were patient's well-being, psychological comfort and right to privacy maintained? No, explain: behavior of staff was inappropriate. Was any trauma suffered by patient: Yes, ..if yes describe counseling provided: therapeutic discussion of events leading up to incident and incident itself...RN signature (house supervisor) Date/Time 04/26/13 21 (no time documented)." Interview on 05/03/2013 at 1550 with the primary nurse (RN #1) revealed the Restraint Intervention form was completed on Monday 04/29/2013 (3 days after the incident) and the nurses notes does not address the use of a restraint or seclusion.

Interview on 05/02/2013 at 1555 with administrative staff revealed "On 04/26/2013 around 2030 or 2100 we had an incident where a MHT (Mental Health Technician) had an altercation with a patient (pt) (#13). The MHT was a large man, weighing around 250 pounds, and the patient was a small 12 year old who weighed about 65 pounds. ...the MHT grabs the patient by the arm and takes him to the floor pinning him to the floor and against the wall. You can see on the video what looks like the MHT using his knees to pin the patient to the floor; the patient is struggling to get lose while in a prone position. The MHT takes his whole opened hand and pushing the patient's face against the floor. It appears on the video the MHT's hand slips off the patients' face to the neck briefly. The MHT manually lifted the patient to his feet. The MHT's left hand had the patients left arm with the MHT's rights hand on the patient's waistband of his pants at his back and drags the patient to the seclusion room...The house supervisor said the patient had informed the staff that MHT had body slammed him, choked him, and threw him up against the wall and pushed him into the quiet room, he was crying and telling them it was all on tape... The house supervisor after interviewing the staff concluded the MHT had restrained the patient inappropriately and forcibly taken the patient to the seclusion room. We (the administrative staff ) reviewed the video recording of the activities on the unit and interviewed the staff working including MHT. The video showed MHT taking the patient (#13) to the floor with an inappropriate restraint, his open hand covering the patient's face and then slipping to the patient's neck, and then forcibly dragging the patient up the hallway by the waste of his pants and his (the patients) left arm and placing him in the seclusion room barricading the door with his body so the patient could not leave...He was not using restraint techniques taught in our CPI training..."

Review of the video on 05/02/2013 at 1700 revealed on 04/26/2013 at 20:26 the MHT #1 maneuvers the pt #13 to the dayroom at the end of the male hallway; ...20:32:01 the MHT and patient engaged in shoving each other; 20:32:06 MHT #1 and patient have hands on each other in a struggle; during the struggle the MHT #1 pushes the patient to the floor in the back hallway near the wall. The two continue to struggle while on the floor with the patient kicking, wiggling and turning side to side trying to get out of the hold. The MHT #1 has both hands on the patient. The left hand is holding the patient's arms across his body and the MHT #1's right hand is used to push against the side of the patient's face toward the floor. The patient continues to try to pull his head away but the MHT#1 continues to push on the side of the patient's face and at one point his hand slips down toward the patient's throat. The MHT #1's body is straddling the patient around his hip area, pinning him to the floor. At 20:32:52 the patient continues to struggle, wiggle, kick and jerk against the MHT #1's hold until he maneuvers to a prone position. At 20:33:31 the MHT #1 continues to hold the patient down with his left knee at the the patient's hip and back area and his right knee on the floor. He has one hand on the patient's back near the shoulder blades and the other hand on the patient's head holding it down while the patient continues to jerk his head back and forth. At 20:34:00 the MHT #1 releases the patient and he stands up. The patient attempts to walk away from the MHT #1 but the MHT #1, with his left hand, grabs the patient by his left arm. The MHT #1 has his right hand at the patient's back pulling up on the waistband of the patient's pants. The video revealed the MHT #1 is pulling the patient up the hallway by the arm and waistband of his pants and the patient's feet are intermittently on and off the floor as he is pulled and pushed up the hallway by the MHT #1.

Interview on 05/03/2013 at 1550 with RN #1 revealed she was working on 04/26/2013 and was the primary nurse for (patient #13), "I was sitting at the desk, I heard yelling down the hallway, I looked down there, and about middle of the hallway, (MHT #1) had the patient by the arm & shoulder raised up in the air. (MHT #1) was pulling the patient who was yelling, screaming, and cursing coming towards the nurses desk where I was sitting. The patient was not coming down the hallway willingly...I saw (MHT #1) dragging the patient and then shove him against the wall...the patient told me that (MHT #1) had put him on the ground and put his (MHT#1) knees on his back...When I first looked up and saw (MHT #1) coming down the hall with the patient I thought oh my God, he might be hurting him (patient #13). He (MHT #1) was not using appropriate technique for restraining,.."

Interview on 05/03/2013 at 1715 via phone with MHT #2 revealed she was working the evening of 04/26/2013 "one of my male patients was provoking patient #13. I saw MHT #1 talking to patient #13 and blocking him from coming up my hallway...The next thing I knew (MHT #1) holding the boy (patient #13) down then saw him escorting him up the hallway to the seclusion room...I knew it was not protocol that (MHT #1) restrained the patient by himself and without the RN order...I heard the patient say 'he sat on me'. I realized he must have put a hold on the patient and sitting on the patient is inappropriate ...(MHT #1) is a big guy and (patient #13) is a really small guy..."

Review of the Nursing Supervisor's documentation of events dated 04/26/2013 revealed "...The patient (#13) continued to harass him (MHT #1) and so he 'took him to the floor'. I asked (MHT #1) why did he do this because this was not the way we handle patients and he stated that he didn't know that. I pointed out to (MHT #1) in CPI training he was taught not to take patients to the floor and that if you did go to the floor the patient must be released. He said, 'Oh, I let him up' I asked 'did you hold him down on the floor?' (MHT #1) responded 'yes'... He said he then 'physically restrained him and escorted him to the seclusion room' ... 'by the arm'..."

Based on hospital policy and procedure review, medical record review, hospital document review, video review, and staff interviews the staff failed to obtain a physician order for restraints for 2 of 3 restrainied patients (#13 & #4).

The findings include:

Review of the hospital's policy "Restraint/Seclusion" revision date of 02/2012 revealed "...5.0 Physician Orders, Consultation, and Evaluation: 5.1 Restraint or seclusion shall be used in emergency situations only and requires an order from a physician...5.1.1 in the absence of a physician/authorized LIP (licensed independent practitioner), the registered nurse may authorize the initiation of restraint or seclusion in an emergency 5.1.2 The physician/LIP must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated. 5.1.3 Telephone/verbal orders for restraint/seclusion may be received and recorded by an RN. 5.1.4 The physician shall authenticate the telephone/verbal order within 24 hours. 5.2 The physician's orders for use of restraint or seclusion will be recorded in the medical record and include the following: 5.2.1 reason for using restraint/seclusion..5.2.2 time limits not to exceed...2 hours for children and adolescents ages 9 to 17...5.2.5 the nurse receiving the (restraint) order, the physician giving the (restraint) order, and the nurses transcribing the (restraint) orders, with appropriate dates and times..."

1. Closed Medical Record review for patient #13 revealed a 12 year old male admitted on 04/16/2013 to the adolescent unit with a diagnosis of Suicidal risk with history of ADHD (attention deficit hyperactive disorder) and Asthma. Continued review of the "Restrictive Intervention Flow Sheet" on 04/26/2013 at 1930 revealed "emergency intervention order/initiation:...4/26/13 at 2030...physical restraint. Maximum time 15 min (minutes)...Clinical Justification for Intervention: per report "out of control" "threatening, cursing walking toward mental health tech". Less Restrictive Interventions Attempted: verbal de-escalation/redirection; time out/time away; 1:1 processing Order received from : (Physician name) at Date: 04/26/13 Time: 1600 (4 hr and 30 minutes before initiation of the order)....Order authentication: (Physician signature) Date: 04/26/13 Time 1800 (2 hours and 30 minutes before initiation of the restraint); ...RN Signature: (signature) Date: 04/29/13 (no time documented) (3 days after the initiation of the restraint)... Termination/Post Intervention: Time of termination (no time documented). Attending physician notified of intervention: Yes; Date/Time: 04/29/13 (no time documented) (3 days after the restraint)." Interview on 05/03/2013 at 1550 with the primary nurse (RN #1) revealed the Restraint Intervention form was completed on Monday 04/29/2013 (3 days after the incident) and the nurses notes does not address the use of a restraint, seclusion or altercation with the staff.

Review of the Nursing flowsheet/progress record on 04/26/2013 at 2100 revealed "Pt (patient) has been labile easily agitated by peers. He provoked peers frequently then would cuss at them as well as threaten them. Pt was escorted to the open seclusion room to facilitate him calming down. Pt. refused PRN's (as needed medications). He was able to calm with staff intervention." (No documentation of a restraint/seclusion or altercation with the staff)

Interview on 05/02/2013 at 1555 with administrative staff revealed "On 04/26/2013 around 2030 or 2100 we had an incident where a MHT (Mental Health Technician) had an altercation with a patient (#13). The MHT (#1) physcially restrained the patient (#13)...a. the RN did not initiate the hold/restraint per policy, b. the RN was not involved at all in the restraint...in the absence of a physician the RN must initiate and order the restraint, this was not done."

Interview on 05/03/2013 at 1550 with RN #1 revealed she was working on 04/26/2013 and was the primary nurse for patient #13, "I was sitting at the desk, I heard yelling down the hallway, I looked down there, and about middle of the hallway, (MHT #1) had the patient by the arm & shoulder raised up in the air. (MHT #1) was pulling the patient who was yelling, screaming, and cursing coming towards the nurses desk where I was sitting. The patient was not coming down the hallway willingly...Yes this was a restraint and the (MHT #1) should have called for help. He did not have an order to restrain the patient. A (registered) nurse can initiate the restraint in an emergency but I wasn't even aware of what was going on..." The nurse stated "I did not call (physician name) on 04/26/3013. As far as I know the physician didn't know about the incident until Monday (04/29/2013)."

2. Closed Medical record review for patient #4 revealed a 13 year old female admitted on 11/12/2012 to the adolescent unit with diagnosis of suicidal ideation , mood disorder, borderline and borderline personality traits. Continued review revealed a nurses note on 11/17/2012 "the patient tried to barricade herself in the room. 1300 patient then begin to hit head on the quiet room wall. Staff processed with patient and patient agreed to take med (medication) to help her calm down. Minutes later patient begin to hit her head on the wall again. patient had to be physically removed by staff and became more agitated patient was given med by IM (intramuscular) injection. Patient calmed down about 30 minutes later..." Continued review of the chart revealed no restraint/seclusion order form on the chart and no physician order for a restraint.

Interview on 05/02/2013 at 1217 with RN #3 revealed "a physical restraint is when you actually put hands on the patient...what I mean by my notes on 11/17/2012 is that two staff members picked her up and physically carried the patient (#4) to the seclusion room. This is a restraint and should have had a physician order but I do not see one on the chart. I do not see documentation of the restraint in the chart. There is no restraint/seclusion order/record for this date (11/17/2012) in the chart. Even if the restraint is just one minute hold you should notify the physican for an order. Interview confirmed there was no physician order for the restraint.

Based on hospital policy and procedure review, medical record review, hospital document review, and staff interviews the staff failed to release a patient from restraints at the earliest time identified for 1 of 3 restrained patients (#4).

The findings include:

Review of the hospital's policy "Restraint/Seclusion" revision date of 02/2012 revealed "It is the policy of (facility name) to support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which tere is an imminent risk of a patient physically harming him/herself or others...Discontinuation of Restraint/Seclusion: ...the goal is to discontinue restraint or seclusion as soon as the patient meets the behavioral criteria for release...6.2.1 Trial releases of restraint/seclusion are not allowed...6.3 Behavioral criteria for discontinuation of restraint or seclusion may include: 6.3.1 Absence of self-injurious behavior; 6.3.2 Absence of aggressive/violent/threatening behavior....11.0 Nursing standards during the use of restraints: ...11.3.6 Readiness for discontinuation of restraint or seclusion; ... 16.0 Documentation of use of restraint/seclusion: The use of the restraint/seclusion will be thoroughly documented in the patient's medical record...16.3 Documentation of each episode of restraint/seclusion includes:...16.3.6. Behavioral criteria for discontinuation of restraint/seclusion; ...16.3.10: every 15 minute assessments of the patient's status...16.3.14 Time of initiation and termination of restraint/seclusion."

Closed Medical record review for patient #4 revealed a 13 year old female admitted on 11/12/2012 to the adolescent unit with diagnosis of suicidal ideation , mood disorder, and borderline personality traits. Continued medical record review revealed a restraint order for 11/18/2013 at 1820 initated by RN#3. Record review revealed Type of intervention was a physical restraint for 5 minutes; a mechanical restraint for one hour and seclusion for one hour with a behavioral justification of "banging head on the wall". Documentation by the RN on 11/18/2012 at 1925 identifies the type of intervention as "mechanical restraint" Record review revealed an RN assessment was documented on 11/18/2012 at 1850 with a description of behavior "calm - 22 (quiet)" (30 minutes after restraint initiated); at 1905 behavior is "calm - 22 (quiet) (45 minutes after the restraint was initiated); 1920 behavior is "calm, 22 (quiet)" (1 hour after restraint initiated); at 1935 behavior is calm & comm (communicating) (1 hour and 15 minutes after the restraint was initiated), 22 (quiet); and at 1950 the behavior is "calm & communicating, 22 (quiet)". Continued review of the nurse's documentation revealed the termination/post intervention time was 1945 (1 hr and 25 minutes after the initiation of the restraint and 55 minutes after the first documentation that the patient was calm and quiet).

Interview on 05/02/2013 at 1217 with RN #3 revealed "to be released from restraints once the behavior no longer requires a restraint, no danger, we are to remove the restraint as soon as possible...there's no reason I left her in restraints that long except I knew (pt #4) and knew as soon as as we released her (from the restraint) she would possibly act out again...the policy is when they are calm remove restraints as soon as possible. There are no notes that indicate she (pt #4) was still disruptive or banging her head and we should have released her from the restraints earlier when she had calmed down." Interview confirmed Patient #4 was not released from restraints at the earliest time identified.

Based on hospital policy and procedure review, medical record review, hospital document review, and staff interviews the staff failed to monitor a patient while in restraints for 1 of 3 restrained patients (#4).

The findings include:

Review of the hospital's policy "Restraint/Seclusion" revision date of 02/2012 revealed...11.0 Nursing standards during the use of restraints: ...11.3 The patient shall be assessed every 15 minutes while in restraint/seclusion by the RN. The assessment includes, as appropriate: 11.3.1 signs of any injury associated with the use of restraint/seclusion; 11.3.2 Nutrition/hydration; 11.3.3 Vital signs; 11.3.4 Hygiene and elimination; 11.3.5 Physical and psychological status and comfort; 11.3.6 Readiness for discontinuation of restraint or seclusion; 11.3.7 circulation and skin condition... 16.0 Documentation of use of restraint/seclusion: The use of the restraint/seclusion will be thoroughly documented in the patient's medical record...16.3 Documentation of each episode of restraint/seclusion includes:...16.3.12. 15 minute assessments of the patient's status..16.3.14 Time of initiation and termination of restraint/seclusion."

Closed Medical record review for patient #4 revealed a 13 year old female admitted on 11/12/2012 to the adolescent unit with diagnosis of suicidal ideation , mood disorder, and borderline personality traits. Continued review revealed a nurses note on 11/17/2012 "the patient tried to barricade herself in the room. 1300 patient then begin to hit head on the quiet room wall. Staff processed with patient and patient agreed to take med (medication) to help her calm down. Minutes later patient begin to hit her head on the wall again. Patient had to be physically removed by staff and became more agitated patient was given med by IM (intramuscular) injection. Patient calmed down about 30 minutes later..." Continued review of the chart revealed no documentation of restraint/seclusion monitoring and assessment every 15 minutes as required by the policy and procedure.

Interview on 05/02/2013 at 1217 with RN #3 revealed "a physical restraint is when you actually put hands on the patient...what I mean by my notes on 11/17/2012 is that two staff members picked her up and physically carried the patient (#4) to the seclusion room. This is a restraint...I do not see documentation of the restraint in the chart. There is no restraint/seclusion order/record for this date (11/17/2012) in the chart. There is no documentation of the monitoring and assessing of the patient while she was in restraints on 11/17/2012." Interview confirmed there was no documentation of monitoring and assessment of patient #4 while in restraints on 11/17/2012.

Based on hospital policy and procedure review, medical record review, job description review, hospital document review, video review, and staff interviews, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care.

The findings include:

The nursing staff failed to evaluate and supervise the nursing care of patients by failing to supervise and prevent staff to patient abuse of a 12 year old patient forcibly restrained by hospital staff (Patient #13).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

Based on job description review, hospital policy and procedure review, medical record review, video review, and staff interviews, the nursing staff failed to evaluate and supervise the nursing care of patients by failing to supervise and prevent abuse of a 12 year old patient forcibly restrained by hospital staff (Patient #13).

The findings include:

Review of the (Hospital name) Nursing Services Job Description revised, 02/2013 revealed, Position Summary: "The nurse is responsible for the delivery of quality nursing care for all patients on the Adolescent and Adult Inpatient Units. The nurse is in charge of the unit activities for each shift, supervising the Mental Health Technicians working on the unit...and overall responsibility for ensuring a safe and therapeutic environment for patients and staff on their assigned unit."

Review of the hospital's policy "Restraint/Seclusion" revision date of 02/2012 revealed "It is the policy of (facility name) to support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The patient has the right to be free from restraint/seclusion imposed as a means of punishment, discipline, or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing... Patients in restraints/seclusion will be closely monitored and evaluated and immediately assisted if a potentially dangerous situation exists, i.e. choking, seizure, etc. (Hospital name) does not permit the use of prone or "face down" therapeutic holds ...DEFINITION: Physical Restraints: The application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely (also named therapeutic hold, protective hold, or manual restraint) ...Section 11.0, Nursing standards during the use of restraints: ...article 11.2 ...Any patient in a physical (manual) restraint will have a staff person who is not participating in the hold observing him/her for any signs of distress or incorrect holding procedures. Any patient placed in seclusion will be continuously observed by staff standing immediately outside the seclusion room ...Section 13.0 ...Application of Physical Restraints: Physical restraints (holds) may only be done using techniques trained through the aggression management program. In no case may a patient be taken to the floor or held in a prone position."

Closed record review of Patient #13 revealed a 12 year old male was admitted under IVC (involuntary commitment) petition on 04/16/2013 to the adolescent unit after complaining of "hearing voices telling him to kill himself" and kill/hurt others as well as stabbing himself with a pencil at school and attempting to hang himself with the flagpole chain. Record review revealed Patient #13's diagnoses include Suicidal ideation, Psychosis (delusional thinking), mood disorder versus ADHD (attention deficit hyperactivity disorder), and asthma. Further medical record review revealed the patient's physical exam was within normal limits; height 55 inches and weight 79.8 pounds. Review of the patient's record revealed a history of multiple past admissions for suicidal ideation. Review revealed a physician order on 04/25/2013 at 1100 "0930 Snack - 2 pieces of fruit and goldfish with routine 0930 snack and with 1930 routine snack add 2 pieces of fruit and goldfish." Review of the Dietary Requisition Sheet on 04/25/2013 revealed a request for patient #13 "**other Extra Snack for AM snack and 730 pm snack - 2 pieces of fruit and bag of gold fish for each snack".
Review of Patient #13's MAR (medication administration record) dated 04/26/2013 revealed 0930 snack-2 pieces of fruit and goldfish with routine 0930 snack and with 1930
routine snack add 2 pieces of fruit and goldfish.

Review of a video recording, Camera #10, of the males back hallway on 05/02/2013 at 1700 revealed on 04/26/2013 at 20:26 MHT #1 (mental health technician) with his open hand on the patient's (#13) back maneuvers the patient to the dayroom at the end of the male hallway; at 20:28 patient #13 is running up and down the hallway to and from the nurses station; at 20:29 the patient is at the back hallway and trying to reach a brown paper bag MHT #1 has placed at his workstation and the MHT #1 moves the bag out of the patient's reach; patient #13 gets down off the chair then throws the chair down the hallway toward direction (MHT #1) is standing; MHT #1 returns the chair to its' original place; 20:31:09 MHT #1 and Pt #13 are in the back hallway facing each other with 12-14 inches between them. Video revealed that MHT #1 has both of his hands placed on his hips; 20:31:20 MHT #1 extends his right hand to motion toward an open door leading to the back dayroom, closing the door (door dividing the male hallway, between the nursing station and the day room area) ; 20:31:37 MHT #1 and pt #13 remain in the hallway. At 20:32:01 the video revealed MHT #1 and patient (#13) engaged in shoving each other; 20:32:06 MHT #1 and patient #13 have hands on each other in a struggle; during the struggle the MHT #1 pushes the patient to the floor in the back hallway near the wall. The two continue to struggle while on the floor with the patient kicking, wiggling and turning side to side trying to get out of the hold. The MHT #1 has both hands on the patient. The left hand is holding the patient's arms across his body and the MHT #1's right hand is used to push against the side of the patient's face toward the floor. The patient continues to try to pull his head away but the MHT#1 continues to push on the side of the patient's face and at one point his hand slips down toward the patient's throat. The MHT #1's body is straddling the patient around his hip area, pinning him to the floor. At 20:32:52 the patient continues to struggle, wiggle, kick and jerk against the MHT #1's hold until he maneuvers to a prone position. At 20:33:31 the MHT #1 continues to hold the patient down with his left knee at the patient's hip and back area and his right knee on the floor. He has one hand on the patient's back near the shoulder blades and the other hand on the patient's head holding it down while the patient continues to jerk his head back and forth. At 20:34:00 the MHT #1 releases the patient and he stands up. The patient attempts to walk away from the MHT #1 but the MHT #1, with his left hand, grabs the patient by his left arm. The MHT #1 has his right hand at the patient's back pulling up on the waist band of the patient's pants. The video revealed the MHT #1 is pulling the patient up the hallway by the arm and waist band of his pants and the patient's feet are intermittently on and off the floor as he is pulled and pushed up the hallway by the MHT #1. Review of the video camera #4 of the seclusion/quiet room revealed at 20:34:38 the MHT #1 pushes the patient into the quiet/seclusion room. The patient sits on the bed in the quiet/seclusion room; 20:34:46 the MHT #1 is standing in front of the quiet/seclusion room door preventing the patient from leaving the room; 20:34:50 the patient is sitting on the bed and appears to be coughing. Video revealed that while the patient is sitting he is leaning over looking toward the floor. Review of video camera #8 of the anteroom of the seclusion area revealed at 20:37:44 the patient is standing at the quiet room door. The MHT #1 is standing adjacent to the patient and at times blocking the doorway to the seclusion room with his body; RN #2 (medication nurse) appears/enters the quiet/seclusion room area from the medication room; 20:39:24 the patient is talking to RN #2 (medication nurse). The patient walks out of the quiet/seclusion room toward RN #2 and extends his arm to knock an "object" out of her hand; 20:39:46 the MHT #1 exits the quiet room area; 20:40:00 RN #1 (patient's primary nurse) enters the quiet room area and attempts to speak with the patient.

Interview on 05/03/2013 at 1715 via phone with MHT #2 revealed she was working the evening of 04/26/2013. The staff member stated "one of my male patients was provoking (patient #13). I saw (MHT #1) talking to (patient #13) and blocking him from coming up my hallway but I thought he was trying to keep him from coming up my hallway. When I looked in my peripheral vision I saw (MHT #1) close the double door which I thought was to separate the two boys. Then I heard someone mumbling. The next thing I knew (MHT #1) holding the boy (patient #13) down then saw him escorting him up the hallway to the seclusion room...I looked at (RN #1) with a look of what's going on and she got up from behind the desk and I went back to watching the boys I was assigned to cause I felt like the nurse was going to handle it. I knew it was not protocol that (MHT #1) restrained the patient without the RN order. All the MHT's have walkie talkies and Code White (need for help) is to be called over the walkie talkie. I felt like the situation was out of control when the double doors were shut. I heard arguing before the double doors closed. I had a big concern when I saw what was going on as he was coming down the hallway. I heard the patient say 'he sat on me'. I realized he must have put a hold on the patient and sitting on the patient is inappropriate that would be some kind of abuse...If we suspect abuse we are to report it to our immediate supervisor. I wasn't sure at the time if the child was just yelling and screaming...(MHT #1) is a big guy and (patient #13) is a really small guy. I think he didn't ask for help because (patient #13) was so small and he felt he didn't need help."

Interview on 05/03/2013 at 1507 with RN#2 (medication RN) revealed she was working on 04/26/2013 at the time of the incident. She revealed she "had worked day shift (7-3pm) and had agreed to stay over and help on the evening shift because they were getting 4 admissions (new patients). Around 2000 or 2030 I was preparing to pass the 2100 medications...I was in the medication room when I heard a patient voice escalating and getting very loud. The medication room has two doors; one leads to the nurses station and the other opens into the anteroom of the seclusion room. The patient was cursing loudly and screaming...then I heard the door on the boys side seclusion/quiet room open and shut...the patient was crying and coughing and he was still cursing. I thought maybe the primary nurse who was at the nurse station doing documentation was involved or aware of what was going on. Then I heard a male voice say 'What do you think about your B**** A** now'. I stopped what I was doing and quickly opened the door and saw (MHT #1) leaning against the door to the boys hallway (the door between the hallway and the seclusion anteroom). The patient (#13) was standing in the seclusion doorway crying and coughing. I went immediately to him and he was so mad he kept saying 'He (MHT #1) called me a B****, he grabbed my shirt collar and his hand hit me in the chin. It's all on camera and you won't do S*** about it'. This is the second time since January this patient has been here and he doesn't usually scream and yell. He (pt #13) was screaming and yelling and just kept coughing. I told him we will see what's on the camera and we will do something about it. (Name) (MHT #1) left without saying a word. I got the medicine cup because I had just pulled his 2100 medications and offered them to him thinking it might calm him down but he just slapped them out of my hand. The primary nurse (RN #1) entered the seclusion area from the boys side. She (RN #1) bent down to talk with the patient; I asked her if she had the situation now, she said yes so I went back to passing my medications. I had no idea anything was going on until I heard the male voice in the anteroom of the seclusion room. We had nothing in shift report that indicated the patient (#13) was having any issues that day. Patient was ordered extra snacks by the physician because he was always hungry. The MHT usually distributes the snacks that are delivered from the kitchen. We never withhold snacks because of the child's behavior... When I heard (name) (patient #13) coughing and the door slam I knew he (MHT #1) who is about 6'4" had been too rough with that child....my definition of abuse and what our training has taught us is any action above and beyond what it takes to control the situation...powering over the child and excessive force is abuse. There is also verbal abuse...based upon what the patient was saying and how he was acting, yes he (MHT #1) had abused this child. Definitely verbal abuse when he (MHT #1) said 'B**** A**'...what we are suppose to do if abuse is suspected is remove the child from the situation and make them safe, then report it to the primary nurse and/or supervisor... I told the House Supervisor what I saw and that (MHT #1) was blocking the doorway and the patient wasn't free to leave. The patient never stepped over the threshold of the doorway to the seclusion room."

Interview on 05/03/2013 at 1550 with RN #1 revealed she was working on 04/26/2013 and was the primary nurse for patient #13, "I was sitting at the desk, I heard yelling down the hallway, I looked down there, and about middle of the hallway, (MHT #1) had the patient by the arm & shoulder raised up in the air. (MHT #1) was pulling the patient who was yelling, screaming, and cursing coming towards the nurses desk where I was sitting. The patient was not coming down the hallway willingly. I stood up when they were walking down the hall so I could see what was going on. When I turned I saw (MHT #1) dragging the patient and then shove him against the wall. They made it up to the corner, they turned left to the door leading into the seclusion room and I saw (MHT #1) push the patient into the seclusion room. He purposefully pushed him, like he was sending a message...when I arrived in the seclusion area the patient was sitting on the bed and (MHT #1) was just standing there. I guess the patient could have left because the door wasn't closed or locked but I don't think (MHT#1) would have allowed him to leave. The patient was cursing and screaming and yelling the whole time I was with him. I couldn't understand what he was saying he was screaming so much...I stood there maybe a minute or so...(MHT #1) turned and left and went back to the day room...the patient told me that (MHT #1) had put him on the ground and put his (MHT #1) knees on his back. I tried to console him but he started to scream and yell 'he (MHT #1) can't do that to me'. He (the patient) freely walked out (of the seclusion room). He (pt #13) was complaining of his arm hurting so I got an ice pack and put on it. I did not see scratches on his arm, just redness. He wanted to talk to his mom or grandma so I helped him try to call them since I wanted to talk with her too but he was not able to reach either of them by phone. When I first saw what was going on and before I left the nurses station to go to the seclusion room I had already called the nursing supervisor and requested he come immediately. When I first looked up and saw (MHT #1) coming down the hall with the patient I thought oh my God, he might be hurting him (patient #13). He (MHT #1) was not using appropriate technique for restraining, he'd left all the other children alone, he had a walkie talkie and could have and should have called for help. I didn't have a chance to intervene. By the time I was aware of what was going on I recognized how inappropriate (MHT #1) was treating the patient and it would need to be addressed. The definition of abuse is when I see someone pulling a child against their will, hurting them verbally or physically, this is abuse. And this was a situation of abusing a child. I did not call (physician name) on 04/26/3013. As far as I know the physician didn't know about the incident until Monday (04/29/2013). As the RN my responsibility is for the supervision of care." Interview with the nurse revealed she was not aware that Patient #13 had not received his second snack on 04/26/2013. The nurse further stated "I am rarely able to leave our glass bubble (nursing station). We have 18 patients with one nurse. (RN #2) stayed over but she said she wasn't helping with the new admissions until her day shift charting was done. I had four admissions."

Interview on 05/03/2013 at 1930 with the House Supervisor revealed he was on duty the evening of 04/26/2013 when he "received a call from (RN #)1 at approximately 2045 requesting him to come immediately to the adolescent unit because she had a problem with (MHT #1) and (Patient #13). Interview revealed, "(RN #1) shared with me that a verbal confrontation between (MHT #1) and (Patient #13) had occurred and while (MHT #1) was taking the patient to the seclusion room he had hit him with the door." Interview revealed, "I talked with the staff and (RN #1) felt (MHT #1) had purposefully shoved the patient into the door while taking him to the seclusion room." Interview revealed House Supervisor spoke with RN #2 who "informed me the patient had been coughing like someone who had been choked and his shirt was stretched out." Interview revealed," I didn't do an assessment but I did talk to the patient and didn't see any obvious injuries. Based on the information I received after interviewing (MHT #1) and the staff I notified the administrator on call and the DON and was directed to suspend (MHT #1) and complete an investigation." Interview revealed, "I do not know if the physician or the parents were notified." Interview revealed the House Supervisor would expect the nurse to do this. Interview revealed it was the House Supervisor's expectation that the RN supervise the care of all patients and supervise the MHTs care of the patients.

Interview on 05/02/2013 at 1555 with administrative staff revealed "On 04/26/2013 around 2030 or 2100 we had an incident where a MHT (Mental Health Technician) had an altercation with a patient (#13). The MHT was a large man, weighing around 250 pounds, and the patient was a small 12 year old boy who weighed about 65 pounds. Around 2030 or 2100 in the evening the snacks had been provided in the Day Room at the end of the (male) hall. The patient (#13) routinely received two snacks and he had received one of the snacks but the MHT was withholding the second snack because he didn't feel the patient had earned it because of his behavior. We (administrative staff) watched the surveillance videos which show the child was active, running around and kept returning to the MHT trying to get his second snack. The situation escalated; the child picks up a chair and throws it toward the MHT; a few minutes after that the MHT grabs the patient by the arm and takes him to the floor pinning him to the floor and against the wall. You can see on the video what looks like the MHT using his knees to pin the patient to the floor; the patient is struggling to get loose while in a prone position. The MHT takes his whole opened hand and pushes the patient's face against the floor and the MHT's hand slips off the patients' face to the neck briefly. The MHT manually lifted the patient to his feet. The MHT's left hand had the patients' left arm with the MHT's rights hand on the patient's waist band of his pants at his back and drags the patient to the seclusion room. Once in the seclusion room (RN #2) in the medication room arrives after hearing the noise and (MHT#1) leaves the seclusion room. At that point the patient reports the abuse to (RN #2). Within minutes (RN #1 - primary nurse) arrives in seclusion area. (RN #1) then notified the house supervisor who immediately met with the staff to investigate the allegation. The house supervisor said the patient had informed the staff that (MHT #1) had body slammed him, choked him, and threw him up against the wall and pushed him into the quiet room, he was crying and telling them it was all on tape. The patient stated the incident started because he was trying to get a snack that he had previously been refused to have. Per the staff the patient was normally allowed to have 2 snacks. He had been given one snack but he was wanting his second snack. (RN #1) had informed the house supervisor that she witnessed (MHT #1) dragging and pulling the patient by the arm and clearly running the patient into the wall. (RN #1) said the patient was yelling and screaming. (RN #1) had not been informed of what was happening until she saw the patient being pulled up the hallway by (MHT #1). (RN #2) reported to the house supervisor that she was in the medication room and heard a child yelling and screaming (from the quiet/seclusion room) and heard a man's voice say 'what do you think about your B**** A** now'. (RN #2) stated when she heard that she stepped from the medication room to the seclusion area and saw pt. (#13) sitting on the bed crying and (MHT #1) standing in the doorway. (RN #2) stated she stared at (MHT #1) and he just turned and left the seclusion area. The house supervisor after interviewing the staff concluded (MHT #1) had restrained the patient inappropriately and forcibly taken him to the seclusion room. The house supervisor (RN) talked with pt (#13). The house supervisor suspected an abuse situation and called the administrator on-call and the DON (director of nursing) to report the events and was advised to suspend (MHT #1) immediately pending outcome of the investigation. (MHT #1) was sent home. The patient was allowed to leave the seclusion room. We (administrative staff) began our formal investigation on 04/29/2013. We reviewed the video recording of the activities on the unit and interviewed the staff working including (MHT #1). The video clearly identifies patient (#13) being by definition abused by (MHT #1). The video showed (MHT #1) taking the patient to the floor with an inappropriate restraint, his open hand covering the patient's face and then slipping to the patient's neck, and then forcibly dragging the patient up the hallway by the waist of his pants and his (the patients) left arm and placing him in the seclusion room barricading the door with his body so the patient could not leave. The areas of concern that we identified were 1. the treatment of the patient which we saw as abuse; 2. Failure to use CPI (nonviolent crisis intervention) training: a. the RN did not initiate the hold/restraint per policy; b. the RN was not involved at all in the restraint; c. a one man hold was used which is not supported with our model; d. MHT placed the patient in a prone position which is not appropriate; e. the MHT used his knees to hold the patient down on the floor and his hand was over the patients face and near his neck which are inappropriate techniques and not supported by our model of restraints; 3. the lack of RN supervision and documentation; and 4. the RN's failure to recognize potential abuse situation from the MHT..."