HospitalInspections.org

Based on document review, observation of video, policy review and staff interview it was determined the hospital failed to ensure care was provided in a safe setting (see A 144), failed to ensure patient #1 and patient #2 were kept free from abuse (see A 145) and failed to ensure patient #1 and patient #2 were kept free from use of restraints as punishment (See tag A 154).

A. An Immediate Jeopardy to Patient Rights and Nursing Services was called on 4/6/21 at 12:30 p.m. because of the hospital failed to ensure patient #1 was kept free of harm and abuse. The Nursing Supervisor failed to follow the hospital's policy on abuse reporting and restraint policy, failed to remove the alleged abuser from patient care and failed to notify the physician when the patient was placed in a hold/restraint resulting in injury.

B. Harm or Potential Harm: Patient #1 had to be transported to the Emergency Room and ultimately taken to surgery for a spiral fracture she received during the inappropriate hold by the Behavioral Health Technician (BHT). The Nursing Supervisor failing to follow policy and instructing support staff to follow policy could lead to the potential harm of another patient.

C. Immediacy: The hospital needs to take immediate corrective action to ensure all staff is trained in appropriate holding/restraining techniques to ensure no further harm will come to a patient of this hospital. The hospital needs to take immediate action to ensure the Nursing Supervisor and all staff is trained on how to follow the restraint/seclusion policy and abuse reporting policy.

D. An immediate plan of correction was received and sent to the State agency Program Manager. The IJ was abated on 4/6/21 at 4:02 p.m.

Based on video review, chart review and staff interview it was determined the hospital failed to ensure staff followed their own restraint policy. This failure led to an improper restraint being used by Behavioral Health Technician (BHT) #1 placing patients #1 and 2 in improper holds that required both patients to be transferred to a local emergency room (ER) and ultimately leading to patient #1 having emergency surgery for a spiral fracture of her right upper arm.

Findings include:

1. A review of the video of the injury to patient #1 on 4/4/21 was reviewed with the Director of Risk and Quality on 4/5/21 at 2:06 p.m. During the video you can visualize patient #1 coming on the hall with other patients. The other patients leave, leaving only patient # 1 with BHT #1. Patient #1 makes no move towards the BHT when the BHT grabs patient #1 at 4:42:03 p.m.; he then takes the patient face first into the wall at 4:42:07 p.m. The BHT is then seen twisting the right arm behind her back and slamming her face down on the floor at 4:42:17 p.m. At this time, you can see the BHT pull patient #1's right arm up and twisting the arm. At 4:42:28 p.m. other patients come into the hallway attempting to get the BHT to let the patient up by jumping on him. At 4:42:34 p.m. the BHT throws patient #2 to the ground. At 4:42:35 p.m. the Registered Nurse (RN) and other staff can be seen attempting to get the situation under control. At 4:44:17 p.m. patient #1 was let out of the hold. At 4:44:56 p.m. BHT #1 can be visualized placing patient #2 in a hold.

2. An interview was conducted with the Director of Quality and Risk on 4/5/21 at approximately 1:00 p.m. He stated he was made aware of the incident involving patient #1 this morning. He stated, "We reviewed the video this morning and realized it was more than a restraint." He stated they suspended BHT #1 pending the investigation. He contacted the police and had reported the incident to Child Protective Services (CPS).

3. A telephone interview was conducted with the on-call physician on 4/6/21 at approximately 9:05 a.m. He stated he was made aware that the patient had been in an altercation with another patient on Saturday evening. He stated on Sunday he was told a patient punched a wall and had possibly broken her arm and needed to be sent out for further evaluation. He stated he gave an order to transfer the patient to the ER. When questioned if he was aware of the restraint/hold of patient #1 and the altercation with BHT #1 he stated, "I was not notified about a restraint or the altercation with BHT #1. When asked about the restraint for patient #2 he was not aware of the restraint used on her. He stated the staff called him later that evening to tell him patient #1 would need emergency surgery either Sunday or Monday. He stated it was his expectation that if any hold or restraint was used on a patient that he would be notified as soon as possible.

4. A review of the hospital document entitled 'Progress Note' dated 4/4/21 at 9:49 p.m. states, "Later in the evening staff called me saying that pt. hit wall and might have broken arm. She was sent to ED (Emergency Department), staff was informed pt. requires emergency surgery today or tomorrow morning." The note was signed by the on-call physician.

5. On 4/4/21 the patient was hitting and kicking a BHT during an altercation on the unit. A review of video dated 4/4/21 revealed the BHT threw patient #2 to the ground. She was then placed in a hold and placed on the ground. She stated her arm was hurt during the hold. A review of the medical record revealed there was not an order for a hold. The physician was notified, and the patient was transferred to Women's and Children's Hospital ER for evaluation. The patient was cleared medically. The staff member who accompanied patient #2 to the hospital ER was asked to leave the room while the physician spoke with the patient. The ER physician decided to admit the patient until social workers could arrive and become involved. The patient was discharged from Highland Hospital. She was readmitted to Highland Hospital on 4/5/21.

6. An interview was conducted with RN #1 on 4/6/21 at 11:00 p.m. She stated that she just started at the facility on March 15, 2021. She stated, "This was my third day off orientation. I had one day of orientation on Tween Unit. I told the scheduler I was not comfortable with working the Tween Unit because I hadn't really had orientation. She said she would put another strong nurse with me to help me but the nurse that was supposed to be working with me that day called in. I was the only nurse and had three (3) BHT's working with me. The kids were already aggravated because of an issue that had happened on Saturday. They were already antsy during shift change and it started to go downhill from there. I tried to keep all the kids on one side of the hall so they could be more easily monitored. One of the kids shoved a lunch cart into the door of the other hall and opened it up and some of the kids went back over to that side of the hall. BHT #1 was over there monitoring them. I had another patient acting up that I needed to give a PRN (as needed) medication to, so I called for one of the nurses from the Children's unit 2 East to come over and help me. The other nurse came over and we went into a room to give the PRN medication when heard a loud bang and lots of screaming coming out of the hallway and told the other BHT to call for help. The first view I had was patient #1 with BHT #1 restraining her with her arm behind her back there were other patients on the back of BHT #1. Patient #1 was screaming 'I commit to safety; I commit to safety.' The other kids were screaming 'he's hurting her'. I told the BHT to let her go." She stated it was basically a riot. BHT #1 restrained patient #2 a few minutes later. She stated, "We could not get the kids under control. There was not enough staff to keep them under control, so I called for the police to come and assist. I sent the BHT off the floor to give the kids a little while to calm down and I could hear the kids saying they were going to jump BHT #1 when he came back on the unit. I decided to send the BHT to the other Children's Unit and bring the male BHT from there over to the Tween Unit." When questioned if BHT #1 had used an appropriate hold on patient #1 and patient #2 she stated, "No! You are never supposed to hold a patient the way he held them." RN #1 stated that she never spoke or saw the Nursing Supervisor on the unit during her whole shift even when the police came to the unit. She stated there was not an order put in for the restraints that were used on patient #1 or patient #2. She stated she called the physician and informed him the patient needed sent out for her arm injury. She stated after the incident one (1) of the BHT's walked out and the other BHT was sent to the hospital with the patient. RN #1 stated, "The CEO (Chief Executive Officer) had to come in and work the unit because we didn't have enough staff."

7. A review of the hospital document entitled 'Nursing Shift Note' dated 4/5/21 at 12:21 a.m. and signed by RN #1 states, "special entry: patient slammed into the door, breaking into the other side of the hallway. BHT stated he went to escort her back onto the other side but patient "became aggressive" and refused to cooperate. BHT then tried to place patient into a hold but patient resisted, BHT placed her on the ground. While the patient was on the ground in a hold, the BHT twisted her arm behind her back. Patient committed to safety, complained of arm pain and nurse told BHT to release her. Patient then got into a sitting position and continued to complain and cry of arm pain. An ambulance was called, and patient was transferred to women's and children's via ambulance, Patient was discharged from highland hospital and admitted to General CAMC hospital."

8. A review of the hospital document entitled 'Behavioral Health - Patient Observation Sheet' dated 4/4/21 at 12:00 a.m. shows patient #1 had all fifteen (15) minute checks as ordered by the physician. The times on the sheet at 16:36 (4:36 p.m.) lists the patient's behavior as calm. The next three fifteen (15) minute entry's timed for 17:09 (5:09 p.m.), 17:13 (5:13 p.m.) and 17:22 (5:22 p.m.) are completed by BHT #1 and have the patient documented as being calm. The alleged abuser continued to be in direct contact with the patient after the alleged abuse occurred.

9. An interview was conducted with RN #2 on 4/6/21 at approximately 11:50 a.m. She stated, "I got a call from the RN on the Tween Unit saying she needed some help, she had a kid that was escalating, and she needed help getting him medicated. I was familiar with the patient, so I went over to help. When I walked on the unit it was calm. We walked into a room to medicate the patient because it was an IM injection and all of a sudden you could hear screaming and yelling. There was a teenage boy saying, 'We are going to riot.' All I could see was the BHT had a kid in a hold. As soon as I saw patient #1's arm I knew she had to be sent out. Her arm was obviously broken." When asked if the Nursing Supervisor responded to the incident, she stated, "No, not even after she was made aware of the patient's injury. She never came to or called the floor that I am aware of."

10. A review of the hospital document entitled 'Abuse Reporting,' last revised 4/18, states, "Physical signs indicating abuse (bruises, broken bones, etc.). The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member will complete a CPS/APS Reporting form."

11. A review of the hospital document entitled 'Restraint/Seclusion Policy' states, "Regardless of duration of the restraint, the physician, PA (Physician Assistant) or RN must make a face-to-face evaluation of the patient within 1 hour of initiation of the order and document the evaluation of the Restraint/Seclusion/Safety Packet. The physician must "authenticate" a telephone restraint/seclusion order with their signature, date, and time within 24 hours. The treating physician or on-call physician must be consulted as soon as possible when a PA or RN does the face-to-face evaluation." The policy further states, "If the patient is exhibiting unsafe behavior, (i.e., hitting the wall, banging their head) 2-3 staff will enter the room and implement a physical restraint to obtain maximum control without injury to the patient while additional staff is summoned." Patient #2 was a fourteen (14) year old female admitted to Highland Hospital on 3/29/21 with a diagnosis of Unspecified Mood Disorder and Oppositional Defiant Disorder (ODD). She was having suicidal ideations. She had been discharged from the facility on 3/23/21. She had a history of substance abuse and numerous inpatient hospitalizations.

12. An interview was conducted with the Director of Quality and Risk and the Corporate Director of Quality and Compliance on 4/6/21 at approximately 12:10 p.m. During the interview they concurred that there was no order for the restraint of patient #1 and patient #2, BHT #1 did not perform a proper restraint on patient #1 or patient #2, the restraint ultimately led to the spiral fracture of patient #1 that required emergency surgery and the hospital failed to ensure BHT #1 was removed from patient care after the alleged abuse of patient #1 and patient #2. They concurred that nursing did not follow policy and procedure and the Nursing Supervisor did not follow her job description.

Based on video review, staff interview and document review it was determined the hospital failed to ensure two (2) patients on the Tween Unit were kept free from harm and abuse (patient #1 and #2). The failure of staff to follow hospital policy led to patient #1 and patient #2 being sent to the emergency room (ER) for injuries received during an altercation with Behavioral Health Technician (BHT) #1. The altercation led to patient #1 requiring emergency surgery for a spiral fracture of her right upper arm.

Findings include:

1. A review of the video of the injury to patient #1 on 4/4/21 was reviewed with the Director of Risk and Quality on 4/5/21 at 2:06 p.m. During the video you can visualize patient #1 coming on the hall with other patients. The other patients leave, leaving only patient # 1 with BHT #1. Patient #1 makes no move towards the BHT when the BHT grabs patient #1 at 4:42:03 p.m.; he then takes the patient face first into the wall at 4:42:07 p.m. The BHT is then seen twisting the right arm behind her back and slamming her face down on the floor at 4:42:17 p.m. At this time, you can see the BHT pull patient #1's right arm up and twisting the arm. At 4:42:28 p.m. other patients come into the hallway attempting to get the BHT to let the patient up by jumping on him. At 4:42:34 p.m. the BHT throws patient #2 to the ground. At 4:42:35 p.m. the Registered Nurse (RN) and other staff can be seen attempting to get the situation under control. At 4:44:17 p.m. patient #1 was let out of the hold. At 4:44:56 p.m. BHT #1 can be visualized placing patient #2 in a hold.

2. An interview was conducted with the Director of Quality and Risk on 4/5/21 at approximately 1:00 p.m. He stated he was made aware of the incident involving patient #1 this morning. He stated, "We reviewed the video this morning and realized it was more than a restraint." He stated they suspended BHT #1 pending the investigation. He contacted the police and had reported the incident to Child Protective Services (CPS).

3. A telephone interview was conducted with the on-call physician on 4/6/21 at approximately 9:05 a.m. He stated he was made aware that the patient had been in an altercation with another patient on Saturday evening. He stated on Sunday he was told a patient punched a wall and had possibly broken her arm and needed to be sent out for further evaluation. He stated he gave an order to transfer the patient to the ER. When questioned if he was aware of the restraint/hold of patient #1 and the altercation with BHT #1 he stated, "I was not notified about a restraint or the altercation with BHT #1. When asked about the restraint for patient #2 he was not aware of the restraint used on her. He stated the staff called him later that evening to tell him patient #1 would need emergency surgery either Sunday or Monday. He stated it was his expectation that if any hold or restraint was used on a patient that he would be notified as soon as possible.

4. A review of the hospital document entitled 'Progress Note' dated 4/4/21 at 9:49 p.m. states, "Later in the evening staff called me saying that pt. hit wall and might have broken arm. She was sent to ED (Emergency Department), staff was informed pt. requires emergency surgery today or tomorrow morning." The note was signed by the on-call physician.

5. On 4/4/21 the patient was hitting and kicking a BHT during an altercation on the unit. A review of video dated 4/4/21 revealed the BHT threw patient #2 to the ground. She was then placed in a hold and placed on the ground. She stated her arm was hurt during the hold. A review of the medical record revealed there was not an order for a hold. The physician was notified, and the patient was transferred to Women's and Children's Hospital ER for evaluation. The patient was cleared medically. The staff member who accompanied patient #2 to the hospital ER was asked to leave the room while the physician spoke with the patient. The ER physician decided to admit the patient until social workers could arrive and become involved. The patient was discharged from Highland Hospital. She was readmitted to Highland Hospital on 4/5/21.

6. An interview was conducted with RN #1 on 4/6/21 at 11:00 p.m. She stated that she just started at the facility on March 15, 2021. She stated, "This was my third day off orientation. I had one day of orientation on tween unit. I told the scheduler I was not comfortable with working the Tween Unit because I hadn't really had orientation. She said she would put another strong nurse with me to help me but the nurse that was supposed to be working with me that day called in. I was the only nurse and had three (3) BHT's working with me. The kids were already aggravated because of an issue that had happened on Saturday. They were already antsy during shift change and it started to go downhill from there. I tried to keep all the kids on one side of the hall so they could be more easily monitored. One of the kids shoved a lunch cart into the door of the other hall and opened it up and some of the kids went back over to that side of the hall. BHT #1 was over there monitoring them. I had another patient acting up that I needed to give a PRN (as needed) medication to, so I called for one of the nurses from the Children's unit 2 East to come over and help me. The other nurse came over and we went into a room to give the PRN medication when heard a loud bang and lots of screaming coming out of the hallway and told the other BHT to call for help. The first view I had was patient #1 with BHT #1 restraining her with her arm behind her back there were other patients on the back of BHT #1. Patient #1 was screaming 'I commit to safety; I commit to safety.' The other kids were screaming 'he's hurting her'. I told the BHT to let her go." She stated it was basically a riot. BHT #1 restrained patient #2 a few minutes later. She stated, "We could not get the kids under control. There was not enough staff to keep them under control, so I called for the police to come and assist. I sent the BHT off the floor to give the kids a little while to calm down and I could hear the kids saying they were going to jump BHT #1 when he came back on the unit. I decided to send the BHT to the other Children's Unit and bring the male BHT from there over to the Tween Unit." When questioned if BHT #1 had used an appropriate hold on patient #1 and patient #2 she stated, "No! You are never supposed to hold a patient the way he held them." RN #1 stated that she never spoke or saw the Nursing Supervisor on the unit during her whole shift even when the police came to the unit. She stated there was not an order put in for the restraints that were used on patient #1 or patient #2. She stated she called the physician and informed him the patient needed sent out for her arm injury. She stated after the incident one (1) of the BHT's walked out and the other BHT was sent to the hospital with the patient. RN #1 stated, "The CEO (Chief Executive Officer) had to come in and work the unit because we didn't have enough staff."

7. A review of the hospital document entitled 'Nursing Shift Note' dated 4/5/21 at 12:21 a.m. and signed by RN #1 states, "special entry: patient slammed into the door, breaking into the other side of the hallway. BHT stated he went to escort her back onto the other side but patient "became aggressive" and refused to cooperate. BHT then tried to place patient into a hold but patient resisted, BHT placed her on the ground. While the patient was on the ground in a hold, the BHT twisted her arm behind her back. Patient committed to safety, complained of arm pain and nurse told BHT to release her. Patient then got into a sitting position and continued to complain and cry of arm pain. An ambulance was called, and patient was transferred to women's and children's via ambulance, Patient was discharged from highland hospital and admitted to General CAMC hospital."

8. A review of the hospital document entitled 'Behavioral Health - Patient Observation Sheet' dated 4/4/21 at 12:00 a.m. shows patient #1 had all fifteen (15) minute checks as ordered by the physician. The times on the sheet at 16:36 (4:36 p.m.) lists the patient's behavior as calm. The next three fifteen (15) minute entry's timed for 17:09 (5:09 p.m.), 17:13 (5:13 p.m.) and 17:22 (5:22 p.m.) are completed by BHT #1 and have the patient documented as being calm. The alleged abuser continued to be in direct contact with the patient after the alleged abuse occurred.

9. An interview was conducted with RN #2 on 4/6/21 at approximately 11:50 a.m. She stated, "I got a call from the RN on the Tween Unit saying she needed some help, she had a kid that was escalating, and she needed help getting him medicated. I was familiar with the patient, so I went over to help. When I walked on the unit it was calm. We walked into a room to medicate the patient because it was an IM injection and all of a sudden you could hear screaming and yelling. There was a teenage boy saying, 'We are going to riot.' All I could see was the BHT had a kid in a hold. As soon as I saw patient #1's arm I knew she had to be sent out. Her arm was obviously broken." When asked if the Nursing Supervisor responded to the incident, she stated, "No, not even after she was made aware of the patient's injury. She never came to or called the floor that I am aware of."

10. A review of the hospital document entitled 'Abuse Reporting,' last revised 4/18, states, "Physical signs indicating abuse (bruises, broken bones, etc.). The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member will complete a CPS/APS Reporting form."

11. A review of the hospital document entitled 'Restraint/Seclusion Policy' states, "Regardless of duration of the restraint, the physician, PA (Physician Assistant) or RN must make a face-to-face evaluation of the patient within 1 hour of initiation of the order and document the evaluation of the Restraint/Seclusion/Safety Packet. The physician must "authenticate" a telephone restraint/seclusion order with their signature, date, and time within 24 hours. The treating physician or on-call physician must be consulted as soon as possible when a PA or RN does the face-to-face evaluation." The policy further states, "If the patient is exhibiting unsafe behavior, (i.e., hitting the wall, banging their head) 2-3 staff will enter the room and implement a physical restraint to obtain maximum control without injury to the patient while additional staff is summoned." Patient #2 was a fourteen (14) year old female admitted to Highland Hospital on 3/29/21 with a diagnosis of Unspecified Mood Disorder and Oppositional Defiant Disorder (ODD). She was having suicidal ideations. She had been discharged from the facility on 3/23/21. She had a history of substance abuse and numerous inpatient hospitalizations.

12. An interview was conducted with the Director of Quality and Risk and the Corporate Director of Quality and Compliance on 4/6/21 at approximately 12:10 p.m. During the interview they concurred that there was no order for the restraint of patient #1 and patient #2, BHT #1 did not perform a proper restraint on patient #1 or patient #2, the restraint ultimately led to the spiral fracture of patient #1 that required emergency surgery and the hospital failed to ensure BHT #1 was removed from patient care after the alleged abuse of patient #1 and patient #2. They concurred that nursing did not follow policy and procedure and the Nursing Supervisor did not follow her job description.

Based on video review, staff interview and document review it was determined the hospital used an improper restraint on two (2) patients on the Tween Unit (patient #1 and 2). This failure led to Behavioral Health Technician (BHT) #1 causing injury to the patients and leading to them being transferred by ambulance to a local emergency room (ER). The injury to patient #1 required emergency surgery to repair a spiral fracture of her upper right arm.

Findings include:

1. A review of the video of the injury to patient #1 on 4/4/21 was reviewed with the Director of Risk and Quality on 4/5/21 at 2:06 p.m. During the video you can visualize patient #1 coming on the hall with other patients. The other patients leave, leaving only patient # 1 with BHT #1. Patient #1 makes no move towards the BHT when the BHT grabs patient #1 at 4:42:03 p.m.; he then takes the patient face first into the wall at 4:42:07 p.m. The BHT is then seen twisting the right arm behind her back and slamming her face down on the floor at 4:42:17 p.m. At this time, you can see the BHT pull patient #1's right arm up and twisting the arm. At 4:42:28 p.m. other patients come into the hallway attempting to get the BHT to let the patient up by jumping on him. At 4:42:34 p.m. the BHT throws patient #2 to the ground. At 4:42:35 p.m. the Registered Nurse (RN) and other staff can be seen attempting to get the situation under control. At 4:44:17 p.m. patient #1 was let out of the hold. At 4:44:56 p.m. BHT #1 can be visualized placing patient #2 in a hold.

2. An interview was conducted with the Director of Quality and Risk on 4/5/21 at approximately 1:00 p.m. He stated he was made aware of the incident involving patient #1 this morning. He stated, "We reviewed the video this morning and realized it was more than a restraint." He stated they suspended BHT #1 pending the investigation. He contacted the police and had reported the incident to Child Protective Services (CPS).

3. A telephone interview was conducted with the on-call physician on 4/6/21 at approximately 9:05 a.m. He stated he was made aware that the patient had been in an altercation with another patient on Saturday evening. He stated on Sunday he was told a patient punched a wall and had possibly broken her arm and needed to be sent out for further evaluation. He stated he gave an order to transfer the patient to the ER. When questioned if he was aware of the restraint/hold of patient #1 and the altercation with BHT #1 he stated, "I was not notified about a restraint or the altercation with BHT #1. When asked about the restraint for patient #2 he was not aware of the restraint used on her. He stated the staff called him later that evening to tell him patient #1 would need emergency surgery either Sunday or Monday. He stated it was his expectation that if any hold or restraint was used on a patient that he would be notified as soon as possible.

4. A review of the hospital document entitled 'Progress Note' dated 4/4/21 at 9:49 p.m. states, "Later in the evening staff called me saying that pt. hit wall and might have broken arm. She was sent to ED (Emergency Department), staff was informed pt. requires emergency surgery today or tomorrow morning." The note was signed by the on-call physician.

5. On 4/4/21 the patient was hitting and kicking a BHT during an altercation on the unit. A review of video dated 4/4/21 revealed the BHT threw patient #2 to the ground. She was then placed in a hold and placed on the ground. She stated her arm was hurt during the hold. A review of the medical record revealed there was not an order for a hold. The physician was notified, and the patient was transferred to Women's and Children's Hospital ER for evaluation. The patient was cleared medically. The staff member who accompanied patient #2 to the hospital ER was asked to leave the room while the physician spoke with the patient. The ER physician decided to admit the patient until social workers could arrive and become involved. The patient was discharged from Highland Hospital. She was readmitted to Highland Hospital on 4/5/21.

6. An interview was conducted with RN #1 on 4/6/21 at 11:00 p.m. She stated that she just started at the facility on March 15, 2021. She stated, "This was my third day off orientation. I had one day of orientation on Tween Unit. I told the scheduler I was not comfortable with working the Tween Unit because I hadn't really had orientation. She said she would put another strong nurse with me to help me but the nurse that was supposed to be working with me that day called in. I was the only nurse and had three (3) BHT's working with me. The kids were already aggravated because of an issue that had happened on Saturday. They were already antsy during shift change and it started to go downhill from there. I tried to keep all the kids on one side of the hall so they could be more easily monitored. One of the kids shoved a lunch cart into the door of the other hall and opened it up and some of the kids went back over to that side of the hall. BHT #1 was over there monitoring them. I had another patient acting up that I needed to give a PRN (as needed) medication to, so I called for one of the nurses from the Children's unit 2 East to come over and help me. The other nurse came over and we went into a room to give the PRN medication when heard a loud bang and lots of screaming coming out of the hallway and told the other BHT to call for help. The first view I had was patient #1 with BHT #1 restraining her with her arm behind her back there were other patients on the back of BHT #1. Patient #1 was screaming 'I commit to safety; I commit to safety.' The other kids were screaming 'he's hurting her'. I told the BHT to let her go." She stated it was basically a riot. BHT #1 restrained patient #2 a few minutes later. She stated, "We could not get the kids under control. There was not enough staff to keep them under control, so I called for the police to come and assist. I sent the BHT off the floor to give the kids a little while to calm down and I could hear the kids saying they were going to jump BHT #1 when he came back on the unit. I decided to send the BHT to the other Children's Unit and bring the male BHT from there over to the Tween Unit." When questioned if BHT #1 had used an appropriate hold on patient #1 and patient #2 she stated, "No! You are never supposed to hold a patient the way he held them." RN #1 stated that she never spoke or saw the Nursing Supervisor on the unit during her whole shift even when the police came to the unit. She stated there was not an order put in for the restraints that were used on patient #1 or patient #2. She stated she called the physician and informed him the patient needed sent out for her arm injury. She stated after the incident one (1) of the BHT's walked out and the other BHT was sent to the hospital with the patient. RN #1 stated, "The CEO (Chief Executive Officer) had to come in and work the unit because we didn't have enough staff."

7. A review of the hospital document entitled 'Nursing Shift Note' dated 4/5/21 at 12:21 a.m. and signed by RN #1 states, "special entry: patient slammed into the door, breaking into the other side of the hallway. BHT stated he went to escort her back onto the other side but patient "became aggressive" and refused to cooperate. BHT then tried to place patient into a hold but patient resisted, BHT placed her on the ground. While the patient was on the ground in a hold, the BHT twisted her arm behind her back. Patient committed to safety, complained of arm pain and nurse told BHT to release her. Patient then got into a sitting position and continued to complain and cry of arm pain. An ambulance was called, and patient was transferred to women's and children's via ambulance, Patient was discharged from highland hospital and admitted to General CAMC hospital."

8. A review of the hospital document entitled 'Behavioral Health - Patient Observation Sheet' dated 4/4/21 at 12:00 a.m. shows patient #1 had all fifteen (15) minute checks as ordered by the physician. The times on the sheet at 16:36 (4:36 p.m.) lists the patient's behavior as calm. The next three fifteen (15) minute entry's timed for 17:09 (5:09 p.m.), 17:13 (5:13 p.m.) and 17:22 (5:22 p.m.) are completed by BHT #1 and have the patient documented as being calm. The alleged abuser continued to be in direct contact with the patient after the alleged abuse occurred.

9. An interview was conducted with RN #2 on 4/6/21 at approximately 11:50 a.m. She stated, "I got a call from the RN on the Tween Unit saying she needed some help, she had a kid that was escalating, and she needed help getting him medicated. I was familiar with the patient, so I went over to help. When I walked on the unit it was calm. We walked into a room to medicate the patient because it was an IM injection and all of a sudden you could hear screaming and yelling. There was a teenage boy saying, 'We are going to riot.' All I could see was the BHT had a kid in a hold. As soon as I saw patient #1's arm I knew she had to be sent out. Her arm was obviously broken." When asked if the Nursing Supervisor responded to the incident, she stated, "No, not even after she was made aware of the patient's injury. She never came to or called the floor that I am aware of."

10. A review of the hospital document entitled 'Abuse Reporting,' last revised 4/18, states, "Physical signs indicating abuse (bruises, broken bones, etc.). The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member will complete a CPS/APS Reporting form."

11. A review of the hospital document entitled 'Restraint/Seclusion Policy' states, "Regardless of duration of the restraint, the physician, PA (Physician Assistant) or RN must make a face-to-face evaluation of the patient within 1 hour of initiation of the order and document the evaluation of the Restraint/Seclusion/Safety Packet. The physician must "authenticate" a telephone restraint/seclusion order with their signature, date, and time within 24 hours. The treating physician or on-call physician must be consulted as soon as possible when a PA or RN does the face-to-face evaluation." The policy further states, "If the patient is exhibiting unsafe behavior, (i.e., hitting the wall, banging their head) 2-3 staff will enter the room and implement a physical restraint to obtain maximum control without injury to the patient while additional staff is summoned." Patient #2 was a fourteen (14) year old female admitted to Highland Hospital on 3/29/21 with a diagnosis of Unspecified Mood Disorder and Oppositional Defiant Disorder (ODD). She was having suicidal ideations. She had been discharged from the facility on 3/23/21. She had a history of substance abuse and numerous inpatient hospitalizations.

12. An interview was conducted with the Director of Quality and Risk and the Corporate Director of Quality and Compliance on 4/6/21 at approximately 12:10 p.m. During the interview they concurred that there was no order for the restraint of patient #1 and patient #2, BHT #1 did not perform a proper restraint on patient #1 or patient #2, the restraint ultimately led to the spiral fracture of patient #1 that required emergency surgery and the hospital failed to ensure BHT #1 was removed from patient care after the alleged abuse of patient #1 and patient #2. They concurred that nursing did not follow policy and procedure and the Nursing Supervisor did not follow her job description.

Based on video review, document review and staff interview it was determined the Nursing Supervisor failed to ensure staff adequately supervised patients on the Tween Unit (see A 392), failed to ensure nursing personnel had the competence to care for psychiatric patients on the Tween Unit (see A 397) and failed to ensure nursing personnel followed hospital policy and procedure (see A 398).

Based on document review, video review and staff interview it was determined the hospital failed to ensure the Tween Unit was adequately staffed and supervised to ensure patient safety. This failure led to Behavioral Health Technician (BHT) #1 using inappropriate restraints on two (2) patients on the Tween Unit (patient #1 and 2). The inappropriate restraint led to both patients being transferred to an emergency room (ER) for injuries received during the altercation with the BHT and ultimately leading to patient #1 having emergency surgery on her right upper arm for a spiral fracture.

Findings include:

1. A review of the video of the injury to patient #1 on 4/4/21 was reviewed with the Director of Risk and Quality on 4/5/21 at 2:06 p.m. During the video you can visualize patient #1 coming on the hall with other patients. The other patients leave, leaving only patient # 1 with BHT #1. Patient #1 makes no move towards the BHT when the BHT grabs patient #1 at 4:42:03 p.m.; he then takes the patient face first into the wall at 4:42:07 p.m. The BHT is then seen twisting the right arm behind her back and slamming her face down on the floor at 4:42:17 p.m. At this time, you can see the BHT pull patient #1's right arm up and twisting the arm. At 4:42:28 p.m. other patients come into the hallway attempting to get the BHT to let the patient up by jumping on him. At 4:42:34 p.m. the BHT throws patient #2 to the ground. At 4:42:35 p.m. the Registered Nurse (RN) and other staff can be seen attempting to get the situation under control. At 4:44:17 p.m. patient #1 was let out of the hold. At 4:44:56 p.m. BHT #1 can be visualized placing patient #2 in a hold.

2. An interview was conducted with the Director of Quality and Risk on 4/5/21 at approximately 1:00 p.m. He stated he was made aware of the incident involving patient #1 this morning. He stated, "We reviewed the video this morning and realized it was more than a restraint." He stated they suspended BHT #1 pending the investigation. He contacted the police and had reported the incident to Child Protective Services (CPS).

3. A telephone interview was conducted with the on-call physician on 4/6/21 at approximately 9:05 a.m. He stated he was made aware that the patient had been in an altercation with another patient on Saturday evening. He stated on Sunday he was told a patient punched a wall and had possibly broken her arm and needed to be sent out for further evaluation. He stated he gave an order to transfer the patient to the ER. When questioned if he was aware of the restraint/hold of patient #1 and the altercation with BHT #1 he stated, "I was not notified about a restraint or the altercation with BHT #1. When asked about the restraint for patient #2 he was not aware of the restraint used on her. He stated the staff called him later that evening to tell him patient #1 would need emergency surgery either Sunday or Monday. He stated it was his expectation that if any hold or restraint was used on a patient that he would be notified as soon as possible.

4. A review of the hospital document entitled 'Progress Note' dated 4/4/21 at 9:49 p.m. states, "Later in the evening staff called me saying that pt. hit wall and might have broken arm. She was sent to ED (Emergency Department), staff was informed pt. requires emergency surgery today or tomorrow morning." The note was signed by the on-call physician.

5. A telephone interview was conducted with the Nursing Supervisor on 4/6/21 at approximately 9:45 a.m. She stated she is on modified duty and does not report to codes on the Tween Unit. She said the call came at 4:34 p.m. and she was in admissions doing a screening. She said she texted the Administrator on call. When asked if she ever responded to the code called, she stated, "No, I am on modified duty. I thought it was handled."

6. A review of the hospital document entitled 'Highland Hospital Job Description Nursing Supervisor,' updated 12/19/18, states under the paragraph listed as 'Physical Demands: Participates as necessary in the physical restraint of patients, responds appropriately to rapidly escalating patient situations, and adapts to the many carried resultant physical posturing as learned in mandatory training.'

7. An interview was conducted with RN #1 on 4/6/21 at 11:00 p.m. She stated that she just started at the facility on March 15, 2021. She stated, "This was my third day off orientation. I had one day of orientation on Tween Unit. I told the scheduler I was not comfortable with working the Tween Unit because I hadn't really had orientation. She said she would put another strong nurse with me to help me but the nurse that was supposed to be working with me that day called in. I was the only nurse and had three (3) BHT's working with me. The kids were already aggravated because of an issue that had happened on Saturday. They were already antsy during shift change and it started to go downhill from there. I tried to keep all the kids on one side of the hall so they could be more easily monitored. One of the kids shoved a lunch cart into the door of the other hall and opened it up and some of the kids went back over to that side of the hall. BHT #1 was over there monitoring them. I had another patient acting up that I needed to give a PRN (as needed) medication to, so I called for one of the nurses from the Children's unit 2 East to come over and help me. The other nurse came over and we went into a room to give the PRN medication when heard a loud bang and lots of screaming coming out of the hallway and told the other BHT to call for help. The first view I had was patient #1 with BHT #1 restraining her with her arm behind her back there were other patients on the back of BHT #1. Patient #1 was screaming 'I commit to safety; I commit to safety.' The other kids were screaming 'he's hurting her'. I told the BHT to let her go." She stated it was basically a riot. BHT #1 restrained patient #2 a few minutes later. She stated, "We could not get the kids under control. There was not enough staff to keep them under control, so I called for the police to come and assist. I sent the BHT off the floor to give the kids a little while to calm down and I could hear the kids saying they were going to jump BHT #1 when he came back on the unit. I decided to send the BHT to the other Children's Unit and bring the male BHT from there over to the Tween Unit." When questioned if BHT #1 had used an appropriate hold on patient #1 and patient #2 she stated, "No! You are never supposed to hold a patient the way he held them." RN #1 stated that she never spoke or saw the Nursing Supervisor on the unit during her whole shift even when the police came to the unit. She stated there was not an order put in for the restraints that were used on patient #1 or patient #2. She stated she called the physician and informed him the patient needed sent out for her arm injury. She stated after the incident one (1) of the BHT's walked out and the other BHT was sent to the hospital with the patient. RN #1 stated, "The CEO (Chief Executive Officer) had to come in and work the unit because we didn't have enough staff."

8. A review of the hospital document entitled 'Nursing Shift Note' dated 4/5/21 at 12:21 a.m. and signed by RN #1 states, "special entry: patient slammed into the door, breaking into the other side of the hallway. BHT stated he went to escort her back onto the other side but patient "became aggressive" and refused to cooperate. BHT then tried to place patient into a hold but patient resisted, BHT placed her on the ground. While the patient was on the ground in a hold, the BHT twisted her arm behind her back. Patient committed to safety, complained of arm pain and nurse told BHT to release her. Patient then got into a sitting position and continued to complain and cry of arm pain. An ambulance was called, and patient was transferred to women's and children's via ambulance, Patient was discharged from highland hospital and admitted to General CAMC hospital."

9. A review of the hospital document entitled 'Behavioral Health - Patient Observation Sheet' dated 4/4/21 at 12:00 a.m. shows patient #1 had all fifteen (15) minute checks as ordered by the physician. The times on the sheet at 16:36 (4:36 p.m.) lists the patient's behavior as calm. The next three fifteen (15) minute entry's timed for 17:09 (5:09 p.m.), 17:13 (5:13 p.m.) and 17:22 (5:22 p.m.) are completed by BHT #1 and have the patient documented as being calm. The alleged abuser continued to be in direct contact with the patient after the alleged abuse occurred.

10. An interview was conducted with RN #2 on 4/6/21 at approximately 11:50 a.m. She stated, "I got a call from the RN on the Tween Unit saying she needed some help, she had a kid that was escalating, and she needed help getting him medicated. I was familiar with the patient, so I went over to help. When I walked on the unit it was calm. We walked into a room to medicate the patient because it was an IM injection and all of a sudden you could hear screaming and yelling. There was a teenage boy saying, 'We are going to riot.' All I could see was the BHT had a kid in a hold. As soon as I saw patient #1's arm I knew she had to be sent out. Her arm was obviously broken." When asked if the Nursing Supervisor responded to the incident, she stated, "No, not even after she was made aware of the patient's injury. She never came to or called the floor that I am aware of."

11. On 4/4/21 the patient was hitting and kicking a Behavioral Health Technician (BHT) during an altercation on the unit. A review of video dated 4/4/21 revealed the BHT threw patient #2 to the ground. She was then placed in a hold and placed on the ground. She stated her arm was hurt during the hold. A review of the medical record revealed there was not an order for a hold. The physician was notified, and the patient was transferred to Women's and Children's Hospital ER for evaluation. The patient was cleared medically. The staff member who accompanied Patient #2 to the hospital ER was asked to leave the room while the physician spoke with the patient. The ER physician decided to admit the patient until social workers could arrive and become involved. The patient was discharged from Highland Hospital. She was readmitted to Highland Hospital on 4/5/21.

12. An interview was held with the Interim Director of Nursing (DON) on 4/6/21 at approximately 3:35 p.m. She stated it was her expectation that the Nursing Supervisor respond to the unit if a code is called unless she was staffing another unit. If she were staffing another unit, she would expect the Nursing Supervisor to call the nurse on the unit directly or assist in any way she could.

13. A review of the staffing for the Tween Unit revealed one (1) RN and three (3) BHT's for the 3-11 p.m. shift on 4/4/21 for eighteen Tween patients between the ages of thirteen (13) to seventeen (17) years of age.

14. A review of the hospital document entitled 'Abuse Reporting,' last revised 4/18, states, "Physical signs indicating abuse (bruises, broken bones, etc.). The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member will complete a CPS/APS Reporting form."

15. A review of the hospital document entitled 'Restraint/Seclusion Policy' states, "Regardless of duration of the restraint, the physician, PA (Physician Assistant) or RN must make a face-to-face evaluation of the patient within 1 hour of initiation of the order and document the evaluation of the Restraint/Seclusion/Safety Packet. The physician must "authenticate" a telephone restraint/seclusion order with their signature, date, and time within 24 hours. The treating physician or on-call physician must be consulted as soon as possible when a PA or RN does the face-to-face evaluation." The policy further states, "If the patient is exhibiting unsafe behavior, (i.e., hitting the wall, banging their head) 2-3 staff will enter the room and implement a physical restraint to obtain maximum control without injury to the patient while additional staff is summoned." Patient #2 was a fourteen (14) year old female admitted to Highland Hospital on 3/29/21 with a diagnosis of Unspecified Mood Disorder and Oppositional Defiant Disorder (ODD). She was having suicidal ideations. She had been discharged from the facility on 3/23/21. She had a history of substance abuse and numerous inpatient hospitalizations.

16. A review of the hospital document entitled 'Emergency Medical Care Transfer,' last revised 1/17, states "Print a copy of patient's latest lab work results, (Medication Administration Record) MAR showing all medications that patient has received in the past twenty-four (24) hours, EKG when available, copy of transfer order, check box with Highland Hospital billing number on it, and an Advanced Directive Acknowledgement form. Send these items with the patient to the emergency room staff along with a completed Interagency Transfer Sheet."

17. An interview was conducted with the Director of Quality and Risk and the Corporate Director of Quality and Compliance on 4/6/21 at approximately 12:10 p.m. During the interview they concurred that there was no order for the restraint of patient #1 and patient #2, BHT #1 did not perform a proper restraint on patient #1 or patient #2, the restraint ultimately led to the spiral fracture of patient #1 that required emergency surgery and the hospital failed to ensure BHT #1 was removed from patient care after the alleged abuse of patient #1 and patient #2. They concurred that nursing did not follow policy and procedure and the Nursing Supervisor did not follow her job description.

Based on video review, document review and staff interview it was determined the hospital failed to ensure the Nursing Supervisor was competent to follow nursing policy and procedure and supervise the care of patients as required by her job description. This failure led to the injury of two (2) patients (patient #1 and 2) during an altercation with Behavioral Health Technician (BHT) #1. The altercation led to the need for the patients to be transferred to a local emergency room (ER) where patient #1 had to ultimately have emergency surgery for a spiral fracture of the right upper arm.

Findings include:

1. A review of the video of the injury to patient #1 on 4/4/21 was reviewed with the Director of Risk and Quality on 4/5/21 at 2:06 p.m. During the video you can visualize patient #1 coming on the hall with other patients. The other patients leave, leaving only patient # 1 with BHT #1. Patient #1 makes no move towards the BHT when the BHT grabs patient #1 at 4:42:03 p.m.; he then takes the patient face first into the wall at 4:42:07 p.m. The BHT is then seen twisting the right arm behind her back and slamming her face down on the floor at 4:42:17 p.m. At this time, you can see the BHT pull patient #1's right arm up and twisting the arm. At 4:42:28 p.m. other patients come into the hallway attempting to get the BHT to let the patient up by jumping on him. At 4:42:34 p.m. the BHT throws patient #2 to the ground. At 4:42:35 p.m. the Registered Nurse (RN) and other staff can be seen attempting to get the situation under control. At 4:44:17 p.m. patient #1 was let out of the hold. At 4:44:56 p.m. BHT #1 can be visualized placing patient #2 in a hold.

2. An interview was conducted with the Director of Quality and Risk on 4/5/21 at approximately 1:00 p.m. He stated he was made aware of the incident involving patient #1 this morning. He stated, "We reviewed the video this morning and realized it was more than a restraint." He stated they suspended BHT #1 pending the investigation. He contacted the police and had reported the incident to Child Protective Services (CPS).

3. A telephone interview was conducted with the on-call physician on 4/6/21 at approximately 9:05 a.m. He stated he was made aware that the patient had been in an altercation with another patient on Saturday evening. He stated on Sunday he was told a patient punched a wall and had possibly broken her arm and needed to be sent out for further evaluation. He stated he gave an order to transfer the patient to the ER. When questioned if he was aware of the restraint/hold of patient #1 and the altercation with BHT #1 he stated, "I was not notified about a restraint or the altercation with BHT #1. When asked about the restraint for patient #2 he was not aware of the restraint used on her. He stated the staff called him later that evening to tell him patient #1 would need emergency surgery either Sunday or Monday. He stated it was his expectation that if any hold or restraint was used on a patient that he would be notified as soon as possible.

4. A review of the hospital document entitled 'Progress Note' dated 4/4/21 at 9:49 p.m. states, "Later in the evening staff called me saying that pt. hit wall and might have broken arm. She was sent to ED (Emergency Department), staff was informed pt. requires emergency surgery today or tomorrow morning." The note was signed by the on-call physician.

5. A telephone interview was conducted with the Nursing Supervisor on 4/6/21 at approximately 9:45 a.m. She stated she is on modified duty and does not report to codes on the Tween Unit. She said the call came at 4:34 p.m. and she was in admissions doing a screening. She said she texted the Administrator on call. When asked if she ever responded to the code called, she stated, "No, I am on modified duty. I thought it was handled."

6. A review of the hospital document entitled 'Highland Hospital Job Description Nursing Supervisor,' updated 12/19/18, states under the paragraph listed as 'Physical Demands: Participates as necessary in the physical restraint of patients, responds appropriately to rapidly escalating patient situations, and adapts to the many carried resultant physical posturing as learned in mandatory training.'

7. An interview was conducted with RN #1 on 4/6/21 at 11:00 p.m. She stated that she just started at the facility on March 15, 2021. She stated, "This was my third day off orientation. I had one day of orientation on Tween Unit. I told the scheduler I was not comfortable with working the Tween Unit because I hadn't really had orientation. She said she would put another strong nurse with me to help me but the nurse that was supposed to be working with me that day called in. I was the only nurse and had three (3) BHT's working with me. The kids were already aggravated because of an issue that had happened on Saturday. They were already antsy during shift change and it started to go downhill from there. I tried to keep all the kids on one side of the hall so they could be more easily monitored. One of the kids shoved a lunch cart into the door of the other hall and opened it up and some of the kids went back over to that side of the hall. BHT #1 was over there monitoring them. I had another patient acting up that I needed to give a PRN (as needed) medication to, so I called for one of the nurses from the Children's unit 2 East to come over and help me. The other nurse came over and we went into a room to give the PRN medication when heard a loud bang and lots of screaming coming out of the hallway and told the other BHT to call for help. The first view I had was patient #1 with BHT #1 restraining her with her arm behind her back there were other patients on the back of BHT #1. Patient #1 was screaming 'I commit to safety; I commit to safety.' The other kids were screaming 'he's hurting her'. I told the BHT to let her go." She stated it was basically a riot. BHT #1 restrained patient #2 a few minutes later. She stated, "We could not get the kids under control. There was not enough staff to keep them under control, so I called for the police to come and assist. I sent the BHT off the floor to give the kids a little while to calm down and I could hear the kids saying they were going to jump BHT #1 when he came back on the unit. I decided to send the BHT to the other Children's Unit and bring the male BHT from there over to the Tween Unit." When questioned if BHT #1 had used an appropriate hold on patient #1 and patient #2 she stated, "No! You are never supposed to hold a patient the way he held them." RN #1 stated that she never spoke or saw the Nursing Supervisor on the unit during her whole shift even when the police came to the unit. She stated there was not an order put in for the restraints that were used on patient #1 or patient #2. She stated she called the physician and informed him the patient needed sent out for her arm injury. She stated after the incident one (1) of the BHT's walked out and the other BHT was sent to the hospital with the patient. RN #1 stated, "The CEO (Chief Executive Officer) had to come in and work the unit because we didn't have enough staff."

8. A review of the hospital document entitled 'Nursing Shift Note' dated 4/5/21 at 12:21 a.m. and signed by RN #1 states, "special entry: patient slammed into the door, breaking into the other side of the hallway. BHT stated he went to escort her back onto the other side but patient "became aggressive" and refused to cooperate. BHT then tried to place patient into a hold but patient resisted, BHT placed her on the ground. While the patient was on the ground in a hold, the BHT twisted her arm behind her back. Patient committed to safety, complained of arm pain and nurse told BHT to release her. Patient then got into a sitting position and continued to complain and cry of arm pain. An ambulance was called, and patient was transferred to women's and children's via ambulance, Patient was discharged from highland hospital and admitted to General CAMC hospital."

9. A review of the hospital document entitled 'Behavioral Health - Patient Observation Sheet' dated 4/4/21 at 12:00 a.m. shows patient #1 had all fifteen (15) minute checks as ordered by the physician. The times on the sheet at 16:36 (4:36 p.m.) lists the patient's behavior as calm. The next three fifteen (15) minute entry's timed for 17:09 (5:09 p.m.), 17:13 (5:13 p.m.) and 17:22 (5:22 p.m.) are completed by BHT #1 and have the patient documented as being calm. The alleged abuser continued to be in direct contact with the patient after the alleged abuse occurred.

10. An interview was conducted with RN #2 on 4/6/21 at approximately 11:50 a.m. She stated, "I got a call from the RN on the Tween Unit saying she needed some help, she had a kid that was escalating, and she needed help getting him medicated. I was familiar with the patient, so I went over to help. When I walked on the unit it was calm. We walked into a room to medicate the patient because it was an IM injection and all of a sudden you could hear screaming and yelling. There was a teenage boy saying, 'We are going to riot.' All I could see was the BHT had a kid in a hold. As soon as I saw patient #1's arm I knew she had to be sent out. Her arm was obviously broken." When asked if the Nursing Supervisor responded to the incident, she stated, "No, not even after she was made aware of the patient's injury. She never came to or called the floor that I am aware of."

11. On 4/4/21 the patient was hitting and kicking a Behavioral Health Technician (BHT) during an altercation on the unit. A review of video dated 4/4/21 revealed the BHT threw patient #2 to the ground. She was then placed in a hold and placed on the ground. She stated her arm was hurt during the hold. A review of the medical record revealed there was not an order for a hold. The physician was notified, and the patient was transferred to Women's and Children's Hospital ER for evaluation. The patient was cleared medically. The staff member who accompanied Patient #2 to the hospital ER was asked to leave the room while the physician spoke with the patient. The ER physician decided to admit the patient until social workers could arrive and become involved. The patient was discharged from Highland Hospital. She was readmitted to Highland Hospital on 4/5/21.

12. An interview was held with the Interim Director of Nursing (DON) on 4/6/21 at approximately 3:35 p.m. She stated it was her expectation that the Nursing Supervisor respond to the unit if a code is called unless she was staffing another unit. If she were staffing another unit, she would expect the Nursing Supervisor to call the nurse on the unit directly or assist in any way she could.

13. A review of the staffing for the Tween Unit revealed one (1) RN and three (3) BHT's for the 3-11 p.m. shift on 4/4/21 for eighteen Tween patients between the ages of thirteen (13) to seventeen (17) years of age.

14. A review of the hospital document entitled 'Abuse Reporting,' last revised 4/18, states, "Physical signs indicating abuse (bruises, broken bones, etc.). The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member will complete a CPS/APS Reporting form."

15. A review of the hospital document entitled 'Restraint/Seclusion Policy' states, "Regardless of duration of the restraint, the physician, PA (Physician Assistant) or RN must make a face-to-face evaluation of the patient within 1 hour of initiation of the order and document the evaluation of the Restraint/Seclusion/Safety Packet. The physician must "authenticate" a telephone restraint/seclusion order with their signature, date, and time within 24 hours. The treating physician or on-call physician must be consulted as soon as possible when a PA or RN does the face-to-face evaluation." The policy further states, "If the patient is exhibiting unsafe behavior, (i.e., hitting the wall, banging their head) 2-3 staff will enter the room and implement a physical restraint to obtain maximum control without injury to the patient while additional staff is summoned." Patient #2 was a fourteen (14) year old female admitted to Highland Hospital on 3/29/21 with a diagnosis of Unspecified Mood Disorder and Oppositional Defiant Disorder (ODD). She was having suicidal ideations. She had been discharged from the facility on 3/23/21. She had a history of substance abuse and numerous inpatient hospitalizations.

16. A review of the hospital document entitled 'Emergency Medical Care Transfer,' last revised 1/17, states "Print a copy of patient's latest lab work results, (Medication Administration Record) MAR showing all medications that patient has received in the past twenty-four (24) hours, EKG when available, copy of transfer order, check box with Highland Hospital billing number on it, and an Advanced Directive Acknowledgement form. Send these items with the patient to the emergency room staff along with a completed Interagency Transfer Sheet."

17. An interview was conducted with the Director of Quality and Risk and the Corporate Director of Quality and Compliance on 4/6/21 at approximately 12:10 p.m. During the interview they concurred that there was no order for the restraint of patient #1 and patient #2, BHT #1 did not perform a proper restraint on patient #1 or patient #2, the restraint ultimately led to the spiral fracture of patient #1 that required emergency surgery and the hospital failed to ensure BHT #1 was removed from patient care after the alleged abuse of patient #1 and patient #2. They concurred that nursing did not follow policy and procedure and the Nursing Supervisor did not follow her job description.

Based on video review, document review, and staff interview it was determined the nursing supervisor failed to ensure nursing personnel followed the hospitals policy and procedures. This failure led to the injury of two (2) patients (patient # 1 and # 2) during an improper restraint used by Behavioral Health Technician (BHT) # 1. The improper restraint led to the hospitalization of both patients and ultimately led to patient # 1 having emergency surgery for a spiral fracture of the right upper arm.

Findings include:

1. A review of the video of the injury to patient #1 on 4/4/21 was reviewed with the Director of Risk and Quality on 4/5/21 at 2:06 p.m. During the video you can visualize patient #1 coming on the hall with other patients. The other patients leave, leaving only patient # 1 with BHT #1. Patient #1 makes no move towards the BHT when the BHT grabs patient #1 at 4:42:03 p.m.; he then takes the patient face first into the wall at 4:42:07 p.m. The BHT is then seen twisting the right arm behind her back and slamming her face down on the floor at 4:42:17 p.m. At this time, you can see the BHT pull patient #1's right arm up and twisting the arm. At 4:42:28 p.m. other patients come into the hallway attempting to get the BHT to let the patient up by jumping on him. At 4:42:34 p.m. the BHT throws patient #2 to the ground. At 4:42:35 p.m. the Registered Nurse (RN) and other staff can be seen attempting to get the situation under control. At 4:44:17 p.m. patient #1 was let out of the hold. At 4:44:56 p.m. BHT #1 can be visualized placing patient #2 in a hold.

2. An interview was conducted with the Director of Quality and Risk on 4/5/21 at approximately 1:00 p.m. He stated he was made aware of the incident involving patient #1 this morning. He stated, "We reviewed the video this morning and realized it was more than a restraint." He stated they suspended BHT #1 pending the investigation. He contacted the police and had reported the incident to Child Protective Services (CPS).

3. A telephone interview was conducted with the on-call physician on 4/6/21 at approximately 9:05 a.m. He stated he was made aware that the patient had been in an altercation with another patient on Saturday evening. He stated on Sunday he was told a patient punched a wall and had possibly broken her arm and needed to be sent out for further evaluation. He stated he gave an order to transfer the patient to the ER. When questioned if he was aware of the restraint/hold of patient #1 and the altercation with BHT #1 he stated, "I was not notified about a restraint or the altercation with BHT #1. When asked about the restraint for patient #2 he was not aware of the restraint used on her. He stated the staff called him later that evening to tell him patient #1 would need emergency surgery either Sunday or Monday. He stated it was his expectation that if any hold or restraint was used on a patient that he would be notified as soon as possible.

4. A review of the hospital document entitled 'Progress Note' dated 4/4/21 at 9:49 p.m. states, "Later in the evening staff called me saying that pt. hit wall and might have broken arm. She was sent to ED (Emergency Department), staff was informed pt. requires emergency surgery today or tomorrow morning." The note was signed by the on-call physician.

5. A telephone interview was conducted with the Nursing Supervisor on 4/6/21 at approximately 9:45 a.m. She stated she is on modified duty and does not report to codes on the Tween Unit. She said the call came at 4:34 p.m. and she was in admissions doing a screening. She said she texted the Administrator on call. When asked if she ever responded to the code called, she stated, "No, I am on modified duty. I thought it was handled."

6. A review of the hospital document entitled 'Highland Hospital Job Description Nursing Supervisor,' updated 12/19/18, states under the paragraph listed as 'Physical Demands: Participates as necessary in the physical restraint of patients, responds appropriately to rapidly escalating patient situations, and adapts to the many carried resultant physical posturing as learned in mandatory training.'

7. An interview was conducted with RN #1 on 4/6/21 at 11:00 p.m. She stated that she just started at the facility on March 15, 2021. She stated, "This was my third day off orientation. I had one day of orientation on Tween Unit. I told the scheduler I was not comfortable with working the Tween Unit because I hadn't really had orientation. She said she would put another strong nurse with me to help me but the nurse that was supposed to be working with me that day called in. I was the only nurse and had three (3) BHT's working with me. The kids were already aggravated because of an issue that had happened on Saturday. They were already antsy during shift change and it started to go downhill from there. I tried to keep all the kids on one side of the hall so they could be more easily monitored. One of the kids shoved a lunch cart into the door of the other hall and opened it up and some of the kids went back over to that side of the hall. BHT #1 was over there monitoring them. I had another patient acting up that I needed to give a PRN (as needed) medication to, so I called for one of the nurses from the Children's unit 2 East to come over and help me. The other nurse came over and we went into a room to give the PRN medication when heard a loud bang and lots of screaming coming out of the hallway and told the other BHT to call for help. The first view I had was patient #1 with BHT #1 restraining her with her arm behind her back there were other patients on the back of BHT #1. Patient #1 was screaming 'I commit to safety; I commit to safety.' The other kids were screaming 'he's hurting her'. I told the BHT to let her go." She stated it was basically a riot. BHT #1 restrained patient #2 a few minutes later. She stated, "We could not get the kids under control. There was not enough staff to keep them under control, so I called for the police to come and assist. I sent the BHT off the floor to give the kids a little while to calm down and I could hear the kids saying they were going to jump BHT #1 when he came back on the unit. I decided to send the BHT to the other Children's Unit and bring the male BHT from there over to the Tween Unit." When questioned if BHT #1 had used an appropriate hold on patient #1 and patient #2 she stated, "No! You are never supposed to hold a patient the way he held them." RN #1 stated that she never spoke or saw the Nursing Supervisor on the unit during her whole shift even when the police came to the unit. She stated there was not an order put in for the restraints that were used on patient #1 or patient #2. She stated she called the physician and informed him the patient needed sent out for her arm injury. She stated after the incident one (1) of the BHT's walked out and the other BHT was sent to the hospital with the patient. RN #1 stated, "The CEO (Chief Executive Officer) had to come in and work the unit because we didn't have enough staff."

8. A review of the hospital document entitled 'Nursing Shift Note' dated 4/5/21 at 12:21 a.m. and signed by RN #1 states, "special entry: patient slammed into the door, breaking into the other side of the hallway. BHT stated he went to escort her back onto the other side but patient "became aggressive" and refused to cooperate. BHT then tried to place patient into a hold but patient resisted, BHT placed her on the ground. While the patient was on the ground in a hold, the BHT twisted her arm behind her back. Patient committed to safety, complained of arm pain and nurse told BHT to release her. Patient then got into a sitting position and continued to complain and cry of arm pain. An ambulance was called, and patient was transferred to women's and children's via ambulance, Patient was discharged from highland hospital and admitted to General CAMC hospital."

9. A review of the hospital document entitled 'Behavioral Health - Patient Observation Sheet' dated 4/4/21 at 12:00 a.m. shows patient #1 had all fifteen (15) minute checks as ordered by the physician. The times on the sheet at 16:36 (4:36 p.m.) lists the patient's behavior as calm. The next three fifteen (15) minute entry's timed for 17:09 (5:09 p.m.), 17:13 (5:13 p.m.) and 17:22 (5:22 p.m.) are completed by BHT #1 and have the patient documented as being calm. The alleged abuser continued to be in direct contact with the patient after the alleged abuse occurred.

10. An interview was conducted with RN #2 on 4/6/21 at approximately 11:50 a.m. She stated, "I got a call from the RN on the Tween Unit saying she needed some help, she had a kid that was escalating, and she needed help getting him medicated. I was familiar with the patient, so I went over to help. When I walked on the unit it was calm. We walked into a room to medicate the patient because it was an IM injection and all of a sudden you could hear screaming and yelling. There was a teenage boy saying, 'We are going to riot.' All I could see was the BHT had a kid in a hold. As soon as I saw patient #1's arm I knew she had to be sent out. Her arm was obviously broken." When asked if the Nursing Supervisor responded to the incident, she stated, "No, not even after she was made aware of the patient's injury. She never came to or called the floor that I am aware of."

11. On 4/4/21 the patient was hitting and kicking a Behavioral Health Technician (BHT) during an altercation on the unit. A review of video dated 4/4/21 revealed the BHT threw patient #2 to the ground. She was then placed in a hold and placed on the ground. She stated her arm was hurt during the hold. A review of the medical record revealed there was not an order for a hold. The physician was notified, and the patient was transferred to Women's and Children's Hospital ER for evaluation. The patient was cleared medically. The staff member who accompanied Patient #2 to the hospital ER was asked to leave the room while the physician spoke with the patient. The ER physician decided to admit the patient until social workers could arrive and become involved. The patient was discharged from Highland Hospital. She was readmitted to Highland Hospital on 4/5/21.

12. An interview was held with the Interim Director of Nursing (DON) on 4/6/21 at approximately 3:35 p.m. She stated it was her expectation that the Nursing Supervisor respond to the unit if a code is called unless she was staffing another unit. If she were staffing another unit, she would expect the Nursing Supervisor to call the nurse on the unit directly or assist in any way she could.

13. A review of the staffing for the Tween Unit revealed one (1) RN and three (3) BHT's for the 3-11 p.m. shift on 4/4/21 for eighteen Tween patients between the ages of thirteen (13) to seventeen (17) years of age.

14. A review of the hospital document entitled 'Abuse Reporting,' last revised 4/18, states, "Physical signs indicating abuse (bruises, broken bones, etc.). The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. The staff member will complete a CPS/APS Reporting form."

15. A review of the hospital document entitled 'Restraint/Seclusion Policy' states, "Regardless of duration of the restraint, the physician, PA (Physician Assistant) or RN must make a face-to-face evaluation of the patient within 1 hour of initiation of the order and document the evaluation of the Restraint/Seclusion/Safety Packet. The physician must "authenticate" a telephone restraint/seclusion order with their signature, date, and time within 24 hours. The treating physician or on-call physician must be consulted as soon as possible when a PA or RN does the face-to-face evaluation." The policy further states, "If the patient is exhibiting unsafe behavior, (i.e., hitting the wall, banging their head) 2-3 staff will enter the room and implement a physical restraint to obtain maximum control without injury to the patient while additional staff is summoned." Patient #2 was a fourteen (14) year old female admitted to Highland Hospital on 3/29/21 with a diagnosis of Unspecified Mood Disorder and Oppositional Defiant Disorder (ODD). She was having suicidal ideations. She had been discharged from the facility on 3/23/21. She had a history of substance abuse and numerous inpatient hospitalizations.

16. A review of the hospital document entitled 'Emergency Medical Care Transfer,' last revised 1/17, states "Print a copy of patient's latest lab work results, (Medication Administration Record) MAR showing all medications that patient has received in the past twenty-four (24) hours, EKG when available, copy of transfer order, check box with Highland Hospital billing number on it, and an Advanced Directive Acknowledgement form. Send these items with the patient to the emergency room staff along with a completed Interagency Transfer Sheet."

17. An interview was conducted with the Director of Quality and Risk and the Corporate Director of Quality and Compliance on 4/6/21 at approximately 12:10 p.m. During the interview they concurred that there was no order for the restraint of patient #1 and patient #2, BHT #1 did not perform a proper restraint on patient #1 or patient #2, the restraint ultimately led to the spiral fracture of patient #1 that required emergency surgery and the hospital failed to ensure BHT #1 was removed from patient care after the alleged abuse of patient #1 and patient #2. They concurred that nursing did not follow policy and procedure and the Nursing Supervisor did not follow her job description.