HospitalInspections.org

Based on review of facility video footage, staff interview, review of Medical Record #1 (MR1), and review of facility documents, it was determined the facility failed to ensure the patient's right to receive care in a safe setting (A0144), and failed to ensure patients are only restrained in the least restrictive manner necessary to ensure their immediate physical safety, in accordance with facility policy (A0154).

Based on staff interview, and review of facility video footage, Medical Record #1 (MR1), and facility documents, it was determined the facility failed to ensure the patient's right to receive care in a safe setting.

Findings include:

Reference: Facility policy titled "Patient Rights" (last reviewed 2021) states, " ... Personal Needs ... To receive care in a safe setting ... ."

On 4/4/24 at 10:15 AM, an entrance conference was conducted with Staff #1 (S1), Director of Standards and Regulatory, Staff #2 (S2), Chief Nursing Officer (CNO), and Staff #3, Manager of Standards and Regulatory. S1, S2, and S3 confirmed that an incident involving a security officer and an adolescent patient took place on 3/16/24 at approximately 2:12 PM.
Video footage of the incident that occurred on 3/16/24, was reviewed on the following dates and times: 4/4/24 at 2:08 PM, in the presence of Staff #5 (S5), Assistant Vice President of Operations, and Staff #28 (S28), Discharge Coordinator; 4/5/24 at 10:10 AM, in the presence of Staff #26 (S26), Sergeant of Security; and 4/8/24 at 9:45 AM, in the presence of Staff #27 (S27), Vice President of Quality, Safety, and Experience.

Review of video footage revealed the following:

1:21 PM: Patient #1 (P1) had a white sheet covering his/her shoulders and was accompanied by Staff #17 (S17), Security Officer, and Staff #18 (S18), Mental Health Associate (MHA). All three individuals were walking toward the classroom.

1:22 PM: P1 walked into the classroom with S17 and S18 walking behind him/her.

2:11 PM: P1 walked out of the classroom with a white sheet draped over his/her head. S17 and S18 walked behind him/her. P1 stopped to speak to individuals in the hallway (patients and visitors) and then continued to walk down the hallway toward the nurse's station. S17 and S18 continued to follow P1.

2:12 PM: P1 entered the nurse's station followed by S17 and S18. At this time, P1, S17, and S18 were out of the camera's view. S17 then walked backwards out of the nurse's station with his/her arms wrapped tightly around P1's forehead, neck, and shoulders, while dragging P1 across the hallway, toward Room #515. P1 was quickly kicking his/her legs back and forth, as he/she was being dragged into Room #515 by S17. S17 did not release his/her arms from the forehead, neck, and shoulders of P1, until P1 was inside Room #515.

2:13 PM: S17 walked out of Room #515, stood outside the room, and pointed toward the inside of the room. Staff #6 (S6), Security Lieutenant, arrived to Room #515. P1 exited the room and verbally engaged with S17. S6 stood between P1 and S17 and redirected S17 away from P1. S6 and P1 then walked into the nurse's station. P1 and S6 are not fully in the camera view at this time. S6 and P1 then walked out of the nurse's station and began walking toward the Day Room. S17 followed S6 and P1 as they were walking toward the Day Room, stopping in front of Room #515. Staff #22 (S22), Security Officer, arrived to the unit and verbally engaged with S17.

2:14 PM: Staff #21 (S21), Security Officer, arrived to the unit and stood with S17 and S22. P1 was verbally engaging with S6 and pointing towards S17, S21, and S22. S19 (Registered Nurse) and S20 (Registered Nurse) were verbally engaging with P1. S17 walked toward the nurse's station.

2:15 PM: S19, S20, and S21 were in the Day Room verbally engaging with P1. P1 was sitting in a chair.

2:18 PM: S17 left the unit.

The findings of the video footage were confirmed by the following staff on the following days:

4/4/24: S5 confirmed on the video footage, the identity of staff and the events observed, that took place on 3/16/24 from 2:11 PM to 2:13 PM.

4/5/24: S26 confirmed the identity of staff observed on the video footage and the events that took place on 3/16/24, beginning at approximately 2:12 PM.

4/8/24: S27 confirmed the identity of staff observed on the video footage and the events that took place on 3/16/24, from 1:21 PM to approximately 2:49 PM.

Review of MR1, on 4/5/24 at 2:10 PM, revealed the following:

A Physician assessment, documented on 3/16/24 at 2:51 PM, states, " ... [P1] has three abrasions on [his/her] face and neck related to the recent altercation and has pain in the neck as a result ... ."

A Nursing progress note documented on 3/16/24 at 6:44 PM states, " ... Security guard then grabbed pt (patient) face ... Pt walked out of room hyperventilating and crying... Pediatrician evaluated patient, who had three scratches on [his/her] temple, jaw, and back of neck ... ."

During an interview on 4/5/24 at 11:17 AM, Staff #26 (S26), Security Sergeant, stated he/she viewed the video footage of the incident which took place on 3/16/24. S26 stated the physical restraint technique used by S17 on P1 is not in compliance with "Best Training" (de-escalation and restraint training given to all security, emergency department, and behavioral health unit staff).

During an interview on 4/5/24 at 12:23 PM, S22 confirmed the restraint technique used by S17 on P1 is not in compliance with "Best Training."

Based on staff interview, review of video footage, Medical Record #1 (MR1), and facility policies and procedures, it was determined the facility failed to ensure patients are only restrained in the least restrictive manner necessary to ensure their immediate physical safety, in accordance with facility policy.

Findings include:

Reference #1: Facility policy titled "Restraints" (effective 2022) states, "Recognizing that all patients have the right to freedom from restraint of any form and that use of restraint can only be utilized to ensure the immediate physical safety of the patient, the staff, or others it is the philosophy of [Name of facility] that the use of restraint will: a. Only be utilized when they are clinically appropriate and adequately justified to protect the patient, staff, or others. b. Utilize the least restrictive and most effective method of restraint ... d. Never used as a means of coercion, discipline, convenience, or retaliation ... . "

Reference #2: Facility policy titled, "Restraints-Violent and Non-Violent Self Destructive" (effective 2022) states, "... Physical Holding: Holding a patient in a manner that restricts the patient's movement against the patient's will is considered a restraint. This includes holds that physically restrain a patient by holding them for limited period to control their behavior ... With the exception of an emergency situation a patient should not be restrained until being seen and evaluated by a LIP [Licensed Independent Practitioner] ... De-escalation: ... staff members will attempt de-escalation techniques designed to help the patient regain control of behaviors ... ."

On 4/4/24 at 10:15 AM, an entrance conference was conducted with S1, S2, and S3. S1, S2, and S3 confirmed an incident involving a security officer and an adolescent patient took place on 3/16/24 at approximately 2:12 PM. Video footage of the incident occurring on 3/16/24 was reviewed by the surveyor, on 4/4/24 at 2:08 PM, 4/5/24 at 10:10 AM, and 4/8/24 at 9:45 AM, and revealed the following:

1:21 PM: P1 had a white sheet covering his/her shoulders and was accompanied by S17 (Security Officer) and S18 (MHA). All three individuals were walking towards the classroom.

1:22 PM: P1 walked into the classroom with S17 and S18 walking behind him/her.

2:11 PM: P1 walked out of the classroom with a white sheet draped over his/her head. S17 and S18 walked behind him/her. P1 stopped to speak to individuals in the hallway (patients and visitors) and then continued to walk down the hallway towards the nurse's station. S17 and S18 continued to follow P1.

2:12 PM: P1 entered the nurse's station followed by S17 and S18. At this time, P1, S17, and S18 were out of the camera's view. S17 then walked backwards out of the nurse's station with his/her arms wrapped around P1's forehead, neck, and shoulders, while pulling P1 towards Room #515. P1 was kicking his/her legs as he/she was being pulled down the corridor, into Room #515 by S17.

2:13 PM: S17 walked out of Room #515, stood outside the room, and points toward the inside of the room. S6 (Security Lieutenant) arrived to Room #515. P1 exited the room and verbally engaged with S17. S6 stood between P1 and S17, redirecting S17 away from P1. S6 and P1 then walked into the nurse's station. P1 and S6 are not fully in the camera view at this time. S6 and P1 then walked out of the nurse's station and began walking toward the Day Room. S17 followed S6 and P1 as they were walking toward the Day Room, stopping in front of Room #515. S22 (Security Officer) arrived to the unit and verbally engaged with S17.

2:14 PM: S21 (Security Officer) arrived to the unit and stood with S17 and S22. P1 was verbally engaging with S6 and pointing towards S17, S21, and S22. S19 (Registered Nurse) and S20 (Registered Nurse) were also verbally engaging with P1. S17 walked towards the nurse's station.

2:15 PM: S19, S20, and S21 were in the Day Room verbally engaging with P1.

2:18 PM: S17 exited the unit.

Review of MR1 on 4/5/24 at 2:10 PM revealed the following:

Physician assessment documented on 3/16/24 at 2:51 PM states, " ... [P1] has three abrasions on [his/her] face and neck related to the recent altercation and has pain in the neck as a result ... ."

Nursing progress note documented on 3/16/24 at 6:44 PM states, " ... Security guard then grabbed pt (patient) face ... Pediatrician evaluated patient, who had three scratches on [his/her] temple, jaw, and back of neck ... ."

During an interview on 4/5/24 at 11:17 AM, S26 stated he/she viewed the video footage of the incident which took place on 3/16/24. S26 stated that the physical restraint technique used by S17 on P1 is not in compliance with the facility's "Best Training" (de-escalation and restraint training given to all security, emergency department, and behavioral health unit staff).

During an interview on 4/5/24 at 11:30 AM, S6 (Security Lieutenant) stated the physical restraint technique used by S17 on P1 was not in compliance with the facility's "Best Training."

During an interview on 4/5/24 at 12:23 PM, S22 confirmed that the restraint technique used by S17 on P1 is not in compliance with the facility's "Best Training."