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Based on review of facility policy, medical record review, review of a digital video recording and interviews, the facility failed to promote the right to be free from abuse and harassment for one patient (Patient #1) of 14 patients reviewed.

The findings included:

Patient #1 was admitted to the hospital on 2/6/2023 with diagnoses that included Autism Spectrum Disorder, Bipolar Disorder, and Depression. On 2/10/2023 the patient was exhibiting angry and aggressive behaviors in the cafeteria area and was taken to a seclusion room to lower his stimulation and decrease audience to his behavior. On 2/10/2023 at approximately 7:10 PM a male employee grabbed the patient around his neck from behind in what appeared to be a choke hold. This abuse was unwitnessed but was recorded on a digital video in the seclusion room. The video revealed (at minute 10:37) the male employee grabbed Patient #1 from behind, in a choke hold, with his forearm around the patient's neck. The employee held the choke hold for 8 seconds (released at minute 10:45). Patient #1 reported the incident to the Patient Advocate on 2/12/2023. The Patient Advocate reported the alleged abuse to the Chief Nursing Officer who suspended the accused employee and initiated an investigation into the incident. Patient #1 remained in the facility until he was discharged to a Residential Treatment Facility on 2/24/2023.

Refer to A-0145

Based on review of facility policy, medical record review, review of a digital video recording and interviews, the facility failed to protect one patient (Patient #1) from physical abuse of 14 patients reviewed.

The findings included:

Review of the facility policy titled, "Restraint and Seclusion" dated 6/1/2018 revealed, "...It is the policy of Erlanger Behavioral Health Hospital that all patients have the right to be free from physical or mental abuse..."

Medical record review revealed Patient #1 was admitted to the hospital on 2/6/2023 with diagnoses that included Autism Spectrum Disorder, Bipolar Disorder, and Depression.

Review of the History and Physical Exam dated 2/7/2023 at 10:49 AM revealed, "...I said I was going to kill everyone at my other facility and got kicked out...male presents from [outside hospital] for SI/HI [suicidal and homicidal ideation] and outbursts of behavior. He was in residential treatment facility but due to behavior was told he had to leave and could not come back..."

Medical record review of a Psychiatry Progress Note dated 2/10/2023 at 7:40 AM revealed, "...Patient is found pacing in the hallway...He is anxious for discharge today. Reports ongoing depression and anxiety which he rates as a 5/10 in severity today. He does report continued suicidal ideation but that they are not as severe this morning. He denies current HI, SIB and AVH [Homicidal Ideation, Self-Injurious Behaviors, and Audio-Visual Hallucinations]. States some feelings of irritability..."

Medical record review of a Physician's Order dated 2/10/2023 at 7:21 PM revealed, "...Physical Restraint - Adult per orders, Request Type: Now, Purpose: Threat to Immediate Physical Safety of Others...Duration of 4 hours for adults 18 years and older..."

Medical record review of a Progress Note dated 2/10/2023 at 7:30 PM revealed, "...The patient became angry and started screaming and cursing in the cafeteria...He was taken to the seclusion room to decrease the audience...Zyprexa [antipsychotic medication used to treat agitation, schizophrenia, bipolar and other psychosis] 10 mg [milligrams] and Ativan [an antianxiety medication] 2 mg IM [injection into the muscle] after several attempts to redirect..."

Medical record review of a discharge summary dated 2/24/2023 at 8:09 AM revealed, "...attended groups and worked to develop positive coping skills to manage mood and enhance reality testing...worked with the assigned social worker to develop a safety plan and ensure access to outpatient resources...reports improved mood...is actively denying suicidal/homicidal thoughts...in good spirits on the day of discharge..." Continued review revealed the patient was discharged to a residential treatment facility on 2/24/2023.

A digital video recording of the seclusion room on the Thought Unit, was provided on 3/21/2023 by the Director of Risk Management. The Director of Risk Management identified it as a video recorded on 2/10/2023 starting at approximately 7:00 PM. The Director of Risk Management stated the date on the video (2/11/2023) was incorrect and the correct date was 2/10/2023. Review of the video revealed a patient identified by the Director of Risk Management as Patient #1 and Behavioral Health Associate #1 (BHA #1/the male employee accused of abusing the patient) entered the seclusion room. Continued review revealed there was no audio/sound available, but the patient and BHA #1 can be seen having an animated conversation. Continued review revealed at minute 10:37 (on the video time counter) Patient #1 turned his back and was walking away from BHA #1, when it was observed BHA #1 grabbed the patient in a choke hold from behind. BHA #1 had his forearm around the front of Patient #1's neck in an obvious chokehold. BHA #1 held the chokehold for 8 seconds and released the patient at minute 10:45. Continued review of the video showed Patient #1 stood facing BHA #1 and held his hand to his neck. The patient could be seen talking animatedly to BHA #1 and then walked around the seclusion room waving his arms about. Continued review revealed two nurses came in and gave Patient #1 an injection in his left arm at minute 21:20 on the video. Patient #1 was observed on the video lying or sitting in the floor of the seclusion room until the recording ended at minute 30:00.

During an interview with the facility's Patient Advocate on 3/20/2023 at 2:47 PM in the Administration conference room, the Patient Advocate stated Patient #1 reported to her on 2/12/2023 that he had been physically abused by BHA #1. The Patient Advocate stated the patient told her he had been choked by BHA #1 on the night of 2/11/2023. The Patient Advocate stated she immediately reported the allegation of abuse to the Chief Nursing Officer (CNO) who was the Administrator on Call on 2/12/2023.

Interview with the Director of Risk Management on 3/20/2023 at 4:00 PM confirmed BHA #1 had physically abused Patient #1 by choking him from behind on 2/10/2023 at approximately 7:30 PM. Continued interview revealed the facility was not aware of the abuse until Patient #1 reported the abuse to the Patient Advocate on 2/12/2023 (exact time unknown) in the late afternoon. Continued interview revealed the Patient Advocate immediately reported the allegation to the CNO on 2/12/2023. Continued interview revealed the Director of Risk Management and the CNO began to investigate the allegations on the morning of 2/13/2023 and observed the digital video recording of BHA #1 physically abusing Patient #1 on 2/10/2023 in a seclusion room on the Thought Unit (the facility's Acute Psychiatric Unit). Continued interview revealed the staff working on the Thought Unit were educated on abuse after this event, but staff on the other 3 units had not been educated on abuse after the event.

Interview with the CNO was completed on 3/21/2023 at 11:30 AM in the Administration Conference Room. The CNO stated she had been notified of the alleged abuse on 2/12/2023 and she was uncertain of the exact time but it was in the evening after BHA #1 had already left the facility. The CNO confirmed she suspended BHA #1 and he was informed he would not be back to work until the investigation was completed. Continued interview revealed on 2/13/2023 the CNO notified the Director of Risk Management of the allegations and they both began to investigate the allegations. Continue interview revealed the CNO reviewed the video recording of the seclusion room for 2/10/2023 and observed a recording of BHA #1 physically abusing Patient #1 by physically choking him. Continued interview revealed BHA #1 never returned to the facility and was terminated on 2/15/2023. Continued interview revealed the staff working on the Thought Unit were educated on abuse after this event, but staff on the other 3 units had not been educated on abuse after the event.

Interview with Registered Nurse (RN) #1 was completed in the Administration Conference Room on 3/21/2023 at 11:50 AM. RN #1 stated she remembered Patient #1 was being very aggressive and verbally assaultive on 2/10/23 at approximately 7:00 PM. RN #1 stated it was around dinner and the patient was yelling, cursing, and threatening staff verbally. Continued interview revealed the patient was getting very loud with his threats and curses so she asked BHA #1 to escort the patient to the seclusion room where it was quiet and there was not an audience or stimulation for Patient #1. RN #1 stated the patient volunteered to go to the seclusion room and was not forced there by anyone. RN #1 stated they often used the seclusion room as a quiet room for agitated patients that do not need to be secluded but need less visual and auditory stimulation. RN #1 stated when used for this the door of the seclusion room is not closed, and staff maintain 1:1 supervision for the patient's safety. RN #1 stated the patient was being very aggressive verbally and making threatening gestures, so she contacted the provider for an order for seclusion. RN #1 stated she obtained an order for seclusion for Patient #1 while the BHA was trying to deescalate the patient's behavior.

Interview with RN #2 was completed in the Administration Conference Room on 3/21/2023 at 12:17 PM. RN #2 stated she remembered Patient #1 being very aggressive and unruly after dinner on 2/10/2023. RN #2 stated the patient was loudly yelling curses and threats towards staff and resisted efforts to be redirected. Continued interview revealed RN #2 observed the patient demonstrating self-harm by hitting his head on a wall in the hallway. RN #2 stated she did not see the patient escorted to the seclusion room but knew that they used it for a quiet area to deescalate patients sometimes. RN #2 stated she witnessed RN #1 obtain an order for Patient #1 to be put in seclusion after dinner on 2/10/2023.