HospitalInspections.org

Based on policy review, Participant Workbook Nonviolent Crisis Intervention Foundation Course review, medical record review, video recording review, and staff interview, the hospital's Governing Body failed to provide oversight and have systems in place to ensure protection of patient's rights for behavioral health patients.

The findings included:

1. The hospital staff failed to ensure restraints were implemented in a safe manner, utilizing approved techniques for 2 of 3 restraints reviewed (Patient #3 and Patient #4).

~cross refer to 482.13. Patient's Rights: Tag 0167

Based on policy review, Participant Workbook Nonviolent Crisis Intervention Foundation Course review, medical record review, video recording review, and staff interview, the hospital staff failed to protect and promote patient's rights by failing to ensure restraints were implemented in a safe manner, utilizing approved techniques.

The findings included:

1. The hospital staff failed to ensure restraints were implemented in a safe manner, utilizing approved techniques for 2 of 3 restraints reviewed (Patient #3 and Patient #4).

~cross refer to 482.13. Patient's Rights: Tag 0167

Based on policy review, Participant Workbook Nonviolent Crisis Intervention Foundation Course, medical record review, video recording review, and staff interview, hospital staff failed to ensure restraints were implemented in a safe manner, utilizing approved techniques for 2 of 3 restraints reviewed (Patient #4 and Patient #3).

The findings included:

Review of the "Management of Assaultive-Combative Patients Policy" effective 10/2020 revealed, " ... In the event a patient escalates and becomes assaultive/combative, all safety measures shall be provided to the patient, other patients, and staff with the least restrictive interventions possible based on the level of acuity and patient needs ...1. In the event a patient escalates and requires intervention, the staff will assess the situation and call for assistance as needed. 2. If the staff available cannot contain the situation, a Code [used to summon additional staff for assistance] will be paged on the intercom. 3. Talk to the patient and attempt to de-escalate verbally if possible. Do not attempt to approach patient until adequate help is available. ..."

Review of the "Seclusion and Restraint" policy effective 3/2021 revealed " ...CPI [Crisis Prevention Institute: international training organization that specializes nonviolent crisis intervention training] Transport Patients will be transported via transitional hold only by the use of CPI approved hold known as 'CPI Transport' requiring 2 staff controlling patient actions while standing or walking ... Physical Restraint = (CPI Team Control) A CPI Team Control shall be limited to the minimum amount of time necessary to safely bring the patient under control ... The use of CPI Team Control shall be subject to the following requirements ... * The weight of the staff shall be placed to the side, rather than on top of the individual. No restraint shall allow staff to straddle or bear weight on the individual's torso while applying the restraint, i.e., no downward pressure may be applied that may compromise the individual's ability to breathe. * No restraint/CPI Team Control shall allow the individual's hands or arms to be under or behind his/her head or body. The arms must be at the individual's side. No restraint shall obstruct the patient's vision, airway, impair breathing, or ability to communicate. * The Hospital prohibits the use of prone [face-down] restraint ... If physical restraint is indicated, two (2) CPI trained staff must participate in the physical hold application ..."

Review of the "Seclusion and Restraint Requirements for Staff Training and Competency" last revised 03/2021 revealed, " ... During the first 30 days of employment, all staff are assigned to attend the behavioral management certification course and then annually for renewal. (CPI) ... The CPI Team Control Position is used to manage individuals who have become dangerous to themselves or others. Two staff members hold the individual as the auxiliary team member(s) continually assess the safety of all involved and assist, if needed ... The (aka transitional hold) will allow the safe movement of an individual who is beginning to regain control ... It is not recommended to transport an individual who is struggling. If necessary, return to the CPI Team Control Position if the individual's and/or staff's safety is at risk ..."

Review of the policy revealed a physical restraint at this facility is defined as a two person physical hold to manage dangerous behaviors.

Review of the "Participant Workbook Nonviolent Crisis Intervention Foundation Course" (CPI), copywrite 2015, reprinted 2019, revealed potential risks associated with the use of physical interventions as, "Psychosocial Injury ... Soft Tissue Injury including injury to skin, muscles, ligaments, and tendons; Articular or Bone Injury including injury to joints and bones; Respiratory Restriction including compromise to airway, bellows mechanism, and gaseous exchange which results in respiratory crisis or failure; Cardiovascular Compromise including compromise to the heart and peripheral vascular system. ..."

1. Closed medical record review on 04/12/2021 of Patient #4 revealed a 31 year-old male patient that was admitted under involuntary commitment on 03/04/2021 at 2305 with unresolved psychosis and a history of schizophrenia. Review of the record revealed the patient was manic on arrival. Review of the physician's Comprehensive Psychiatric Evaluation dated 03/05/2021 at 1050 revealed the patient was having auditory and visual hallucinations, believing the TV was speaking to him. Review of the notes recorded the patient had a history of aggression toward family members and staff. Review of a restraint record (Restraint #1) revealed the patient was placed in a physical restraint on 03/05/2021 at 0300 and released at 0317. Review of the nursing notes recorded on 03/05/2021 at 0340 revealed the patient was admitted to the Meadows Unit and shortly after arrival was running across the unit and into other patient's rooms. Review of the note revealed the patient was jumping on a bed in a patient's room while the patient was sleeping and fell and hit his mouth on the floor. Review revealed the patient stood up and tried to fight the staff. Review revealed attempts at redirection were unsuccessful and the patient was placed in a physical restraint at 0300. Review revealed the patient was escorted to his room and released at 0317. Review of the patient's medical record revealed the patient was placed in a physical restraint (Restraint #2) on 03/5/2021 at 0610 and released at 0625 when he was placed in seclusion and released at 0700. Review of a nursing note (not timed) recorded the patient came out of his room after receiving medications (antipsychotic medications), went into other patients rooms and attacked the staff. Review of the note revealed the patient was not able to be redirected and was placed in a physical restraint and given additional antipsychotic medication. Review of the note revealed the patient "was not calm and was transported to the seclusion room." Review of restraint documentation revealed the patient was placed in a physical restraint (Restraint #3) at 0712 and released at 0713 when he was transported to the seclusion room. Review revealed the patient was released from seclusion at 0803. Review of the restraint paperwork recorded the patient "ran out of the seclusion room, jumping, trying to open doors, pushing and throwing furniture. CPI transport to seclusion room. Released hold." Review of nursing notes recorded the patient was in the day room during this restrictive intervention. Review of the one hour face to face assessment documented at 0808 recorded the patient had bruising and redness to his back and bilateral arms. Review revealed the patient was on 1:1 precautions (one staff member within arms length of the patient at all times) due to elopement risk when he was released. Review of a "Seclusion and staff Debriefing" form recorded that correct CPI techniques were maintained at all times. Further review revealed two identified staff injuries listed as "multiple scratches." Review of restraint documentation revealed the patient was placed in a physical restraint (Restraint #4) on 03/05/2021 at 1735 and released at 1857. Review revealed the patient was placed in the hold due to "running into female patients room and having to be stopped from jumping on their bed." Review of a summary of events documented by a nurse at 1755 recorded the female patients were escorted out of the room and Patient #4 was placed in a physical restraint on the floor. Review of the notes recorded that the patient fought and tried to attack staff during the restrictive intervention. Review revealed the "Patient had bruising on both upper arms from four previous holds throughout the day." Review revealed two staff members involved with the physical restraint sustained injuries during this restrictive intervention. The injuries were listed as one staff member had a knee injury and one staff member had bruising on upper arms. Review of a late entry nursing note documented on 03/05/2021 at 1945 recorded "Staff involved in restraint had bruising to arms, chest and legs. (staff name) had shoulder pain/strain following restraint. (staff name) had swelling to right knee and limited motion." Review of the record revealed the patient received antipsychotic medications during the restrictive intervention and was continuing to fight. Review of a transfer form documented by a nurse on 03/05/2021 at 1832 that recorded a physician's order on 03/05/2021 at 1825 to transfer the patient to an acute care emergency department. Review of the transfer form recorded, "Pt (patient) yelling; screaming. Psychosis. Agitated. Combative. Attempting to attack others. No labs available as pt was new admit and labs not collected yet. In need of medical clearance. Was walk-in. Pt has required 4 physical restraints and IM (intramuscular) meds have been ineffective. ..." Review revealed the patient was transported via ambulance to an acute hospital emergency department for a medical workup at 1857. Review revealed the patient returned to the facility on 03/06/2021 at 1220 and had no further restrictive interventions after he returned. The patient improved and was discharged home on 03/18/2021.

Interview on 04/12/2021 at 1055 with Staff #3 revealed he was the facility's CPI and restraint trainer. Interview revealed the facility did not use any type of mechanical restraints. Interview revealed all physical restraints done at the facility were done by staff physically holding a patient. Interview revealed all clinical staff were taught in class that two persons were required for a controlled hold. Interview revealed staff are taught to utilize CPI deescalation and restraint techniques used at the facility.

Review of video recording of Patient #4's restrictive interventions on 03/05/2021 was conducted with the Director of Quality on 04/09/2021 beginning at 1245, with Restraint #4 reviewed at 1630. It was noted that camera times were not consistent with documented times in the patient's medical record. Review of portions of the video recording was conducted on 04/12/2021 at 1055 with Staff #3 who was a CPI (non violent crisis intervention/restraint trainer).

Review of a video recording of Restraint #1 of Patient #4 on 03/05/2021 revealed the documented physical restraint occurred in a patient room and the restraint intervention was unable to be seen on video.

Review of a video recording of Restraint #2 revealed on 03/05/2021 at 06:20:53 Patient #4 was lying on the floor. One staff had two hands on the patient's left arm at the wrist area. Another staff member had two hands on the patient's right wrist area. The patient is face up when another staff member lifted his upper torso up and off the floor. A staff member had his hands on the patient's right lower leg and another staff member had his hands on the patient's left lower leg (now five staff carrying the patient). The patient's lower body was turned to the right side such that the patient's body was twisted. At 06:21:00 the patient was carried to the seclusion room with staff holding his bilateral arms at the wrist area and legs supported with the staff's hands under the back of the patient's knee and ankle areas. Another staff member had his arms under the patient's back. During transport the patient was seen kicking and wiggling his body. Review of the video showed the staff reached the doorway of the seclusion and the video recording ended at 06:21:10.

Interview on 04/12/2021 at 1055 with Staff #3 during review of the video recording revealed a patient should never be lifted off the ground when transporting a patient. Interview revealed Restraint #2 was not an approved CPI technique for transport of a patient. Staff #3 stated the transport of Patient #4 was "definitely not safe for the patient at all. There is a risk of dropping the patient, pulling the patient's limbs and it is not safe for staff. The staff should have done a two person transport never lifting the patient's legs. If the patient refused to transport, the team should have set the patient in a chair or on the floor in a hold until he was ready to walk to the seclusion room."

Review of a video recording of Restraint #3 revealed Patient #4 ran out of the seclusion ante room on 03/05/2021 at 07:11:54 into the unit day room area. Observation of the area revealed chairs and furniture with patients sitting in the day room. At 07:11:56 PCA (patient care assistant) #1 had his left hand on Patient #4's right wrist and the right hand of PCA #1 was on the patient's left shoulder while they were facing each other. Six patients were seen sitting in the day room area with another staff member talking with the patients in the day room area. The video review revealed PCA #1 and the patient remained with hands in a hold position with their feet moving around the day room area. The PCA and patient continued to face each other as they moved around the room. At 07:12:02 PCA #1 had the patient against a wall with his hands on the patient's arms. Review revealed 5 patients and one staff member remained in the day room area. Review revealed the patient was struggling to get free. At 07:12:10 PCA #1 and Patient #4 remained stationary against the wall. The PCA had his right hand on the patient's elbow and his left hand located on the patient's shoulder. At 07:12:12 RN #2 came through the door to the day room area running toward the patient and PCA #1. At 07:12:14 PCA #1 was standing face to face with the patient. PCA #1 had his left hand on the patient's right shoulder and his right hand on the patient's left elbow. The patient was standing with his legs spread apart. At 07:12:14 RN #2 squatted behind the patient and put his right hand on the patient's left knee and his left hand on the patient's left ankle. RN #2 pulled the patient's left leg upward with the patient's knee toward RN #2's chest. At 07:12:15 the patient's right heel was off the floor and the patient had twisted his body away from PCA #1 and toward RN #2. The PCA had his left hand on the patient's left shoulder and his right hand on the patient's wrist. The RN had the patient's left leg pulling it toward the RN. The RN straightened the patient's leg and was holding it against the RN's chest. The patient's body was twisted. At 07:12:16 the RN was pulling the patient's leg behind the patient. The patient's leg was stretched, and the patient was twisted. PCA#1 continued to have his hands on the patient, with the patient's back to the PCA. The RN released the patient's leg. At 07:12:17 the patient went to the floor. RN #2 grabbed the patient's shirt above the right shoulder with his hand. At 07:12:18 PCA #1's hands were off the patient. The patient had his feet and buttocks on the floor. RN #2 was pulling at the patient's shirt. At 07:12:21 the patient was crawling toward a round wooden table in the day room area. The RN was squatted behind the patient and grabbed the patient from behind. The RN wrapped his arms behind the patient from behind in a bear hug manner. The patient placed his right hand on the round table. PCA #1 remained hands off. At 07:12:22 the patient flipped the table over. PCA #1 and RN #4 were approaching the patient and RN #2. RN #2 and PCA #1 were trying to hold the patient. The patient remained on the floor. RN #2 remained behind the patient and had his right hand on the patient's right shoulder. PCA #1 had his hands on the patient's legs. At 07:12:24 RN #4 used her foot to scoot the round table out of the way. The patient grabbed a chair leg. At 07:12:25 the patient was squatted on the floor holding the bottom of a chair leg. RN #2 had his right arm bent at the elbow with his hand around the patient's upper chest area. The RN's body was touching the back side of the patient's body. PCA #1's hands were off the patient. At 07:12:25 the patient was trying to flip the chair. RN #4 was holding the top of the chair with the patient holding the bottom of the chair. RN #2 was behind the patient with his right arm bent at the elbow and his arm is around the patient's neck in a choke hold manner. PCA #1 remained with hands off. At 07:12:26 the patient flipped the chair over and began to rise up. RN #2 remained behind the patient with his right arm located around the patient's neck. RN #2 had his left hand holding the patient's left arm just below the elbow. At 07:12:28 the patient was rising from the floor. RN #2 was behind the patient with his arm remaining around the patient's neck. PCA #1 had his left hand on the patient's right wrist. At 07:12:30 the patient was standing. RN #2 had his arm around the patient's neck and was holding the patient's left arm. PCA #1 was holding the patient's right wrist. At 07:12:31 RN #2 was pulling the patient backward. RN #2 had his right hand on the patient's neck. The patient's head was to the side turned away from the RN. RN #4 was removing the patient's fingers from the chair bottom. PCA #1 was holding the patient's right wrist with his left hand and stabilizing the bottom of the chair with his right hand. At 07:12:32 RN #2 continued to have his arm around the patient's neck as the patient was seen rocking back and forth. At 07:12:36 Staff #3 (CPI/restraint trainer) arrived. The patient's head was not able to be seen on the video. Staff was observed moving furniture out of the area. At 07:12:40 Staff #3 and PCA #1 had the patient in a physical restraint with hands on each side of the patient. The patient was standing bent over with his head toward the floor between the two staff members. The patient remained in a two person hold as they move off camera at 07:12:53.

Interview on 04/12/2021 at 1055 with Staff #3 during review of the video recording revealed he had heard a Code 100 (behavioral response requiring emergency assistance) and responded to the code (Restraint #3 for Patient #4). He stated when he arrived, he saw a chair was turned over and 2 or 3 staff members were around the patient. He reported he saw RN #2 with his arm around the patient's neck and he asked him to remove his arm. Staff #3 stated he reminded RN #2 to "always remember, not the neck. He (RN #2) said he knew." The staff member stated the patient was very psychotic and strong. Staff #3 stated he would have given Patient #4 space to pace and removed the other patients and dangerous objects (furniture) from the area. Staff #3 reported two persons are required for a controlled physical hold. He stated it was not appropriate for PCA #1 to attempt to touch the patient on his own. The staff were calling for assistance and other staff were removing the patients from the area. Staff #3 stated when RN #2 grabbed the patient's leg it was not an approved or appropriate CPI technique. Staff #3 stated "He should have approached and secured the patient's right side and arm." Staff #3 stated the arm around the patient's neck was not an approved CPI technique and that it could have resulted in suppressing the patient's ability to breathe. The staff member stated, "I told him to remove his arm from around the patient's neck." Interview revealed CPI training included risks of inappropriate physical holds. He stated "I believe it was reactionary. He should have waited for assistance."

Review of a video recording of Restraint #4 on 03/05/2021 revealed Patient #4 was located in a patient room during the documented restrictive intervention. The restrictive intervention was not able to be viewed as it was off camera. Review of the video recording revealed the patient was transported out of the facility by EMS (ambulance) stretcher at 18:58:04. Review of the video revealed the patient was transported via EMS on a stretcher with his legs, arms and body secured with stretcher straps.

Interview on 04/12/2021 at 1300 with PCA #1 revealed he remembered Patient #4. Interview with the staff member revealed he was just coming on duty when he heard a Code 100 called and he responded. He reported that Patient #4 was on the floor and trying to fight staff. The staff member stated a nurse said to take the patient to the seclusion room and "we carried him to the seclusion room." PCA #1 stated they usually did a "control walk" meaning two staff member have the patient in a controlled hold and walk the patient to the seclusion room. The staff member stated he was fighting so they carried him to the seclusion room. PCA #1 stated "He (Patient #4) was kicking on the way." PCA #1 reported his knee "popped" during the transport and continued to hurt through the remainder of the day. Interview revealed he was monitoring the patient in seclusion and when the patient was released from seclusion, the patient came out fast. PCA #1 stated "I grabbed his shirt. I thought he was going to attack another patient. I know I wasn't supposed to do that but wanted to prevent an injury to another patient. I should have just let him go. We are trained if the patient is not harming someone, let him go and wait." PCA #1 stated that when RN #2 came in he let the patient go. He stated the maneuver to raise the patient's leg and the arm around the patient's neck were not approved CPI techniques. Interview revealed the PCA got scratched and was bleeding behind the back of his head during the restraint intervention. He stated he was not aware of the injury at the time it occurred.

Telephone interview with RN #4 revealed she remembered Patient #4. Interview revealed she was involved with Restraint #3. Interview revealed the nurse was getting report when the code was called and she came to assist. The nurse reported the patient was actively psychotic. She stated he was talking and breathing, and vital signs were not able to be taken because it was not safe. RN #4 stated she saw RN #2 had his arm around the patient neck. The nurse stated "I don't think he realized where his arm was. We needed more people to do the restraint. It takes more than one person to do a hold safely. The patient was using wrestling maneuvers. We have to do CPI." Interview revealed the arm around the patient's neck is not an approved CPI technique.

Telephone interview on 04/12/2021 at 1720 with RN #2 revealed he remember Patient #4. Interview revealed he was present during Restraint #2 for Patient #4. Interview revealed the patient was fighting staff and needed to be taken to the seclusion room. Interview revealed he wasn't aware that the five person carry was not an approved CPI technique. The nurse stated no one spoke to him about that transport. Interview revealed RN #2 was involved with Restrain #3. Interview revealed the staff member heard the code call and responded. RN #2 stated "I grabbed his leg to try and hold him. At the moment, I didn't know of another way to hold him because not all people were there yet. I tried to hold him until the people came. I was hurt from the prior restraint, had pain in my back. I didn't intend to hold his neck. I meant to hold his chest and arm. I didn't realize I was holding him in a choke hold. I was trying to get my hands around his waist. Other people came and I had no more energy. I could not hold him anymore. (Staff #3) came to help. He took over. I was exhausted. It happened really fast."

In summary, staff failed to apply approved and safe restraint techniques on March 5, 2021. Patient #4 was transported by staff carrying the patient using a non-approved technique as evidenced by Restraint #2. Facility staff then lifted the patient's leg upward and away from his body, followed by placing an arm around the patient's neck as evidenced by Restraint #3. The observed techniques used were not approved CPI techniques and subjected the patient and staff to injury and harm.



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2. Closed medical record review on 04/07/2021 of Patient #3 revealed a 28-year-old male patient who was admitted under involuntary commitment (IVC) on 03/30/2021 with psychosis, aggressive behavior, command hallucinations (reported hearing voices telling him to harm himself and others) and a history of schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings), and non-compliance with medications. Review of the "Screening Assessment", dated 03/30/2021 at 1510 by the Licensed Clinical Mental Health Counselor Associate (LCMHCA), revealed the patient "assaulted security guard" in the Emergency Department at Hospital B prior to transfer and admission to Hospital A. Review of the Psychiatric Evaluation, dated 03/31/2021 at 0832, revealed the patient had not slept in days, "yelling and talking to voices in his head" prior to admission, was having command auditory hallucinations, "telling him to hurt himself" and stated, 'I was feeling suicidal and homicidal.' Review of restraint record notes by RN #6 revealed the patient was placed in a physical restraint on 04/02/2021 at 1938 and released at 1948 (10 minutes) ..."Clinical Assessment/Progress Note" on 04/02/2021 at 2025 revealed, "Patient struck nurse [RN #6] in temple with a closed fist punch. Patient squared up and tried to box nurse and was restrained by RN and Tech [technician] on ground until staff arrived patient was escorted into chair where he received his IM injections." Review of "Alternative Interventions Attempted by Staff Prior to Initiation of Seclusion/Restraint/Emergency Medications" revealed "Therapeutic limit setting, Active listening, Verbal support/redirection, 1:1 Verbal interaction, Reduced stimuli" were unsuccessful, and the patient was placed in a "Physical Restraint" at 1938. Further review of the "Alternative Interventions" revealed "Thorazine [antipsychotic used to treat psychosis] 400 mg IM [milligrams intramuscular], Benadryl [antihistamine used to treat allergies] 50 mg IM and Ativan [benzodiazepine: used to treat agitation and anxiety] 2 mg IM" was administered at 1943 escorted to his room and released from the physical restraint without further incident. Review revealed attempts at redirection were unsuccessful and Review revealed a "Patient Management Plan" was developed on 04/02/2020 at 1540 which provided staff direction on how to manage the patient's psychosis and unpredictable behavior. Review no other restraints were noted, and the patient was discharged home on 04/06/2021 at 0915.

Review of a video recording of Patient #3's restrictive intervention on 04/02/2021 was conducted with the Director of Quality and Risk on 04/07/2021 at 1350. Review of portions of the video recording was conducted on 04/12/2021 at 1055 with the facility's CPI (Crisis Prevention Intervention: non-violent and crisis intervention skills)/restraint trainer.

Review of the video recording on 04/07/2021 at 1350 revealed on 04/02/2021 at 7:22:30, Patient #3 was standing at the nurses' station, talking with RN #8 and PCA #9, when RN #6 walked up to the nurses' station, beside the patient and was physically assaulted at 07:22:37. Review revealed the RN #6 stepped away from the patient at 07:22:38 and attempted to block the patient's blows with his arms. The patient turned to RN #6 and positioned himself into a boxing stance and swung again at the nurse. RN #6 stepped to the side and reached to block the patient's blow and attempted to secure the patient's arm. Review of the video recording revealed that as the patient turned away at 07:22:39, RN #6 continued to attempt to physically restrain the patient, by himself, via repeated attempts to secure the patient's arms behind his back. Review revealed the patient tripped over a chair 07:22:40 and both the nurse and patient went to the floor at 07:22:41. Once on the floor, the patient's upper body was in the face-down position, while his lower body was twisted at the waist to the left side. The nurse was observed positioned with one leg on one side and one leg on the other side at the patient's waist, at 07:22:44 with his left hand on the patient's head, holding it to the side on the floor, until another staff member arrived to assist with the hold at 07:22:48 and straightened the patients lower legs out, placing the patient in a full face-down position. The nurse repositioned himself to the patient's right side at 07:23:04, securing the patients arms behind his back as he repositioned himself at 07:23:06 and placed both knees on the patient's back at 07:23:12. The nurse's knees remained on the patient's back until additional help arrived at 07:24:10 and the patient was assisted onto his back at 07:24:28. Review revealed the patient was assisted to a standing position at 7:27:59; assisted to a chair at 7:28:09, where he received IM medications; and was assisted to his room at 7:40:52.

Interview on 04/06/2021 at 1730 with RN #8 revealed she was at the nurses' station on 04/02/2021 talking with Patient #3 when he assaulted RN #6. Interview revealed Patient #3 was being monitored within line of sight by PCA #12 and had been moved to one side of the unit on 03/30/2021, which had been blocked via a closed door, with one other patient (Patient #18), to decrease stimuli and to prevent further patient assaults. Interview revealed the patient was standing at the nursing station talking with RN #8 and PCA #9, requesting Ativan, when RN #6 came out of Patient #18's room and walked up to the nursing station, told Patient #3 he was not getting Ativan, and was assaulted.

Interview with the Director of Quality and Risk (DQR) on 04/07/2021 at 1350 during review of the video recording of the restraint, revealed the restraint application was not safe and that the nurse should have "disengaged until helped arrived ... it was not safe at all," she said. Interview revealed the video recording of the physical restraint involving RN #6 was reviewed "this morning" by the Director of Human Resources (DHR); Chief Executive Officer (CEO); and DQR and that the nurse was placed on suspension "with recommendation for termination" for failure to implement CPI principles and techniques during the physical restraint.

Interview with the facility's CPI/restraint trainer on 04/08/2021 at 1055, during review of the video recording, revealed the nurse used "totally inappropriate technique" during the physical restraint. "Arms behind the back, prone [face-down] on the ground and knees on the back, are not appropriate at all ... Many things could happen and none of them good."

Interview on 04/13/2021 at 1553 with RN #10 revealed he responded to the help call on 04/02/2021. Interview revealed when he arrived to the unit, he noted the patient "on his stomach with his hands being held behind his back by [RN #6]." Interview revealed the nurse said, "Let me get one arm and you get the other ... I saw him [RN #6] holding his hand behind his back and that is not an approved CPI hold ... The patient was not resisting at the time of my arrival."

In summary, staff failed to apply approved and safe restraint techniques on 04/02/2021 at 1938 when RN #6 failed to implement approved CPI principles and techniques during a physical restraint by positioning himself with one leg on one side of the patient's waist and one leg on the other side at the patient's waist, securing the patient's arms behind his back, and by restraining the patient in a face-down position. The observed techniques used subjected the patient and staff to the potential for injury and harm.

NC00175497; NC00175685; NC00175630; NC00176120; NC00176149