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Based on observation, interview, video recording, and policy review the hospital failed to ensure that:
- Three staff members were immediately removed from patient care after allegations of abuse were reported for two discharged patients (#4 and #9) of two allegations of abuse reviewed; (A-0145)
- Staff appropriately followed Mandt (an approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others) training and utilized appropriate techniques during a restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) for one patient (#4) of one restraint reviewed; (A-0145)
- The internal policy for investigation of abuse was followed, performed timely and thoroughly investigated, and recognized the need for house wide education after allegations of abuse were reported for two discharged patients (#4 and #9) of two abuse investigations reviewed. (A-0145)

These deficient practices resulted in the hospital's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The hospital census was 26.

Based on interview, record review, policy review, and video recording review, the hospital failed to ensure staff:
- Immediately removed three staff members from patient care after allegations of abuse were reported for two discharged patients (#4 and #9) of two allegations of abuse reviewed;
- Appropriately followed Mandt (an approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others) training and utilized appropriate techniques during a restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) for one patient (#4) of one restraint reviewed; and
- Followed their policy for investigation of abuse, performed timely and thorough investigations, and recognized the need for house wide education after allegations of abuse were reported for two discharged patients (#4 and 9) of two abuse investigations reviewed.
These failures had the potential to place all patients at risk for abuse and their overall safety. The hospital census was 26.

Findings included:

Review of the hospital's policy titled, "Abuse and Neglect," dated 01/21/21 showed that:
- The hospital would protect patients from abuse during investigations of any allegations of abuse or neglect.
- A potential abuse or neglect allegation would immediately result in the employee being removed from the patient care area.
- Any staff member that witnessed potential abuse must notify the charge nurse, house supervisor, director of nursing, patient advocate, risk manager, or other member of the administration team immediately. This was so that the staff member could be removed from the unit pending an investigation.
- All investigations would be conducted in a timely manner.

Review of the hospital's policy titled, "Abuse or Neglect Investigations," dated 08/01/11, showed that:
- The staff were to report any suspicion of abuse or neglect immediately to the Executive Director during normal business hours or Administrator on Call (AOC) after hours.
- The AOC would determine what other internal notifications would be made.
- The staff were to complete an Incident Report regarding the suspected abuse or neglect.

Review of the hospital's policy titled, "Emergency Safety Interventions," dated 09/22/20, showed that:
- Physical restraint or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) must not result in harm or injury to the patient.
- All direct care staff are trained in Mandt and will follow the procedures outlined in their manual and training.
- Staff who are not currently Mandt certified shall not be allowed to participate in the restraint procedures.
- Physical restraint shall not restrict respiratory movements or other vital functions.
- The sole purpose of seclusion is to prevent physical harm to the patient and/or staff.
- Seclusion will not be used in a manner that causes physical discomfort, harm, or pain to the patient.

1. Record review of Patient #4's medical record showed that:
- He was a 12 year old boy admitted on 12/23/21, transferred from another hospital for hitting his foster mom, and weighed 88 pounds.
- His past medical history included Severe Sexual trauma, Attention Deficit Hyperactivity Disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), Chronic Major Depressive Disorder (a long period of feeling worried or empty with a loss of interest in activities once enjoyed), oppositional defiant disorder (ODD, a disorder marked by defiant and disobedient behavior to authority figures).
- His current medications were Vistaril (a medication used to treat anxiety, vomiting, itching, and allergies), Melatonin (a hormone used to treat sleep disorders), Abilify (a medication used along with an antidepressant), Lamictal (a medication used to delay mood episodes), and Guanfacine (a medication used to treat ADHD).
- The emergency safety intervention documentation, after the restraint and seclusion, showed that the patient had ecchymosis to his right back and right lateral chest, right neck abrasion, and right forearm bruise caused by a self-inflicted bite mark.

Review of the video recording of A Pod East dated 12/26/21 showed that:
- At 2:04 PM, Patient #4 entered his room and staff talked with him at the door.
- At 2:06 PM, Patient #4 shut his door and Staff H, Mental Health Technician (MHT), opened it and entered his room.
- At 2:09 PM, Staff O, MHT, arrived at the door and entered the room.
- At 2:12 PM, Staff L, Registered Nurse (RN), Charge Nurse, and Staff O, MHT, stood in the doorway and the patient was not in view of the camera. Items of clothing, bedding, and towels were seen thrown from the room into the hallway.
- At 2:19 PM, Staff O, MHT entered the room and Staff L, RN remained at the door. Staff K, RN, House Supervisor, came to the door and then walked to the nurses' station.
- At 2:25 PM, Staff K, RN, House Supervisor and Staff L, RN stood in the doorway.
- At 2:26 PM, Staff P, MHT, arrived and entered the patient's room, while Staff O, MHT, was in the patient's room with Staff I, MHT
- At 2:27 PM, Staff J, RN, and Staff K, RN, House Supervisor, entered the patient's room and Staff L, RN, returned and entered the patient's room.
- At 2:28 PM, Staff K, RN, House Supervisor, left the room and entered a room across the hall.
- At 2:29 PM, All staff exit the patients' room with Patient #4 and entered B Pod West. Patient #4 was escorted down the hallway. Staff O, MHT, was on Patient #4's right side, Staff I, MHT, was on the left side, and Staff P, MHT, was behind patient with one hand on his back. Patient #4 walked down the hallway with bare feet and his feet appeared to have slid back and forth as he was escorted by staff.
- At 2:29:30 PM, Patient #4 was taken into the seclusion room by Staff I, MHT, and Staff O, MHT.
- At 2:29:47 PM, Staff O, MHT, positioned himself behind Patient #4, and wrapped his arms crisscrossed around the front of Patient #4. Staff O's back was against the back wall of the seclusion room and together they slide down to sit on the floor. Patient #4 was sitting on the floor between Staff O's legs. All the staff except Staff O, MHT, and Patient #4 exited the seclusion room. Staff O continued to hold Patient #4. Patient #4 squirmed, turned and appeared to have bit Staff O's right inner thigh. Staff P, MHT, Staff I, MHT, Staff J, RN and Staff L, RN, entered the seclusion room to assist Staff O, MHT.
- At 2:30 PM, Patient #4 attempted to bite Staff J, RN. Staff J placed her hand on Patient #4's forehead and held his right arm. Staff P, MHT, held the patients left arm. Staff I, MHT, held the patients ankles. Staff L, RN was bent over observing. Staff P, MHT, placed her right hand behind Patient #4's head. The patient squirmed and Staff P, MHT, readjusted her right hand under and on the left side of Patient #4's jaw. Staff J, RN, laid across Patient #4's legs and on top of Staff O, MHT. Staff O's legs appear to support Staff J, RN. Staff L, RN, held Patient #4's left leg, and Staff I, MHT, held Patient #4's right leg.
- At 2:31 PM, Patient #4 moved his head around with an open mouth, and leaned toward Staff J, RN, and Staff P, MHT. The patient forcefully banged the back of his head four times on Staff O, MHT's chest and snapped his mouth shut at Staff P, MHT.
- At 2:31:35 Staff P, MHT positioned her right hand on the left side of the patient's neck with her fingers on the back of his neck and her thumb appeared to have pressed against the patient's throat underneath the chin directly below the patient's ear lobe.
- At 2:32 PM, Staff P, MHT, had her right hand behind Patient #4's head, and Staff P's left hand was cupping the bottom of Patient #4's jaw with his jaw in the space between Staff P's thumb and index finger with the lower portion of her hand/fingers appeared to have been positioned across the patient's throat and her thumb appeared to have pressed just under his jaw line. (possible pressure point)
- At 2:35 PM, Staff I, MHT, released Patient #4's ankles and opened the seclusion room door. The patient squirmed and Staff I returned to the floor and held Patient #4's ankles.
- At 2:37 PM, Patient #4's right arm was prepped and medication was injected by Staff K, RN, House Supervisor. Staff P, MHT appeared to have placed her hand, lengthwise, across the patient's throat. Patient #4's face appeared to be red and he was crying.
- At 2:38:20 PM Patient #4 arched his back and Staff P, MHT released her positioning of her left hand. The patient's facial redness remained.
- At 2:38:21 PM, Staff O, MHT, Staff J, RN, Staff L, RN, Staff P, MHT, and Staff I, MHT, continued to hold Patient #4 as he continued to arch his back. Staff P, MHT, held her hands on Patient #4, with her hands positioned on each side of his head/neck near the patients' ears and jaws, while Staff J, RN, laid across the legs, the ankles were held by Staff I, MHT, and the patient's arms were held by Staff O, MHT, and Staff L, RN.
- At 2:39:30 PM, Patient #4 grabbed his own shirt with his left hand, Staff L, RN, grabbed the patients' wrist, and jerked his arm away multiple times. The patient squirmed and slammed his head against the chest of Staff O, MHT.
- At 2:41 PM, Patient #4 attempted to bite Staff P, MHT, and squirmed.
- At 2:42 PM, Staff K, RN, House Supervisor, exited the room.
- At 2:43:16 PM Staff K, RN, House Supervisor, returned to the seclusion room and cut Patient #4's shirt off down the right side.
- At 2:43:57 PM, Patient #4 was released from the hold. The patient placed his hands around his own neck.
- At 2:44 PM, Patient #4 hits Staff O, MHT, and Staff P, MHT. Staff O and Staff I, MHT, assisted Staff P, MHT, by blocking Patient #4 from Staff P. All the staff attempted to leave the seclusion room. Patient #4 attempted to follow the staff and escape the seclusion room. Staff O, MHT, attempted to close the seclusion room door, as Patient #4 blocked the door from closing with his foot. Staff I and Staff O attempted to move the patient away from the door as Patient #4 kicked from a sitting position on floor. All staff attempted to leave and close the seclusion door again, as Patient #4 quickly positioned his body in the doorway as the door was being closed. Patient #4 sits outside the doorway. Two female staff take Patient #4 by under the arms and pulled him backwards inside the seclusion room. Patient #4 attempted to bite multiple times, shoved the female staff back, and attempted to exit the seclusion room.
- At 2:45:05 PM, Staff O, MHT, stopped Patient #4 from exiting and takes him to the back of the room as the female staff exit the room. Staff O attempts to exit the seclusion room. Patient #4 ran toward the exit.
- At 2:45:06 PM, Staff O, MHT, placed his hand near Patient #4 clavicles/neck and pushed the patient backward. The patient attempted to exit the room as the door was closing. Staff O, MHT, opened the doorway, Patient #4 dropped to the floor to lay down and placed his feet in the doorway to keep the door open.
- At 2:45:25 PM, Staff O, MHT, and Staff K, RN, House Supervisor, spoke to Patient #4 as the patient had his feet on the door.
- At 2:45:45 PM, Staff O, MHT, picked up Patient #4 and took him to the back corner of the seclusion room. The patient crawled on the floor toward the exit as Staff O held Patient #4 back. Staff O backed up toward the exit while closing the seclusion room door. Patient #4 placed his right arm in the doorway and moved his body to keep the door open. Staff O moved Patient #4 back and quickly exited while closing the door. Patient #4 grabbed the door with his hand.
- At 2:45:58 PM, Patient #4's right fingers appear to be shut in door. Patient #4 attempted to stick his hands in the door opening as the door was closing. The patient used his hand in the door and his foot on wall to pull the door.
- At 2:46 PM, Patient #4's hand was shut in door. The patient pulled his hand back, shook it, and appeared to yell.
- At 2:49 PM, Patient #4 laid down on the seclusion room floor.
- At 3:06 PM, Patient #4 continued to lay on the seclusion room floor by himself while staff remained outside the door.
- At 3:11 PM, the seclusion door was opened by Staff K, RN, House Supervisor.
- At 3:12 PM, Patient #4 exited the seclusion room.
- At 3:13 PM, Patient #4 was escorted back to Pod A.

Review of the hospital provided Mandt training manual, dated 2017, showed that:
- The emphasis of training is to minimize duration, minimize frequency, and minimize the intensity of the restraint.
- The maximum time an individual could be restrained in the Mandt system is three minutes and one minute ideally; and to use the minimum amount of force.
- A restraint response that indicates distress can be redness or bruising.
- The use of restraint has been shown to traumatize children.
- The use of pressure points and use of any technique that puts a person off balance, are both prohibited practices.
- Any manual restraint that maintains a person on the floor in any position, is prohibited in the Mandt system.

The hospital staff that were involved and whom witnessed inappropriate Mandt techniques used on Patient #4 failed to intervene and ensure his safety when they witnessed and overheard Staff P, MHT verbalize that she was utilizing a pressure point maneuver and witnessed Staff O, MHT initiate a physical hold that continued on the floor and lasted longer than three minutes. Mandt training specifically trained staff that no hold should be performed on the floor or for a period of time longer than three minutes. Staff K, RN, House Supervisor and/or Staff L, Charge Nurse also failed to intervene to ensure the safety of the patient as part of their supervisory role.

During a concurrent interview and video review of the restraint/seclusion with Patient #4 on 01/12/22 at 2:52 PM, Staff Q, Mandt Instructor, stated that:
- Staff O, MHT, did not use an approved Mandt hold during the restraint on 12/26/21.
- During Mandt training, there was no portion of the program that taught the use of pressure points and Staff P, MHT did not use an approved Mandt hold.
- He did not teach the ground hold during Mandt.

The techniques that staff used were not part of Mandt training as Staff Q verified with his review of the video recording. As part of the internal investigation, Staff Q was not interviewed or asked to review the video for his opinion if the techniques used were appropriate and/or were part of the Mandt training.

Review of the time cards and post event education sheets provided by the hospital showed that Staff P, MHT, worked on 12/27/21, 12/30/21 and then terminated on 12/30/21; and Staff O, MHT, worked on 12/27/21 and 12/28/21 when he was suspended, and then terminated on 12/31/21.

Staff P, MHT, and Staff O, MHT, continued to work and care for patients after the allegations of abuse had been reported to leadership staff.

Review of the personnel record for Staff L, RN, showed that she had no current Mandt training.

Review of the personnel records for Staff I, MHT, Staff J, RN, Staff K, RN, Staff O, MHT, and Staff P, MHT, showed that these staff had been trained in Mandt within the last year. Mandt training was required on a yearly basis.

During a telephone interview on 01/14/22 at 1:40 PM, Staff J, RN, stated that:
- She heard Staff O, MHT, tell Staff P, MHT, to move her hands away from Patient #4's neck.
- She told Staff P, MHT, to move her hands away from Patient #4's neck, and Staff P said, "I'm fine, I'm not applying pressure except the pressure point under the chin."
- Staff K, RN, House Supervisor, told Staff P, MHT, to move her hands but Staff P did not move her hands.
- She heard Staff P, MHT, say "I'm not applying pressure, the patient is."
- A forceful push from Staff O, MHT, prior to closing the door, was not acceptable.

During a telephone interview on 01/14/22 at 1:00 PM, Staff K, RN, House Supervisor, stated that:
- She saw Staff P, MHT, with her hands around Patient #4's neck from behind and above in the seclusion room.
- She told Staff P to move her hands and Staff P replied, "I don't have him tight." "I have the pressure point under the chin."
- She heard Staff J, RN, also ask Staff P to move her hands away from Patient #4's neck.

Staff Q, Mandt Instructor, had not viewed the video prior to the review on 01/12/22 and had not been asked by leadership if any techniques used were in accordance with the Mandt training.

During an interview on 01/12/22 at 11:05 AM, Staff A, Director of Nursing (DON), stated that:
- She found out about the incident the next morning on 12/27/21, when two RN's felt they needed to notify her about the MHT who refused to stop holding Patient #4's neck.
- Staff P, MHT, did not follow directions given by the nurses during the restraint when she had her hands on Patient #4's neck.
- Staff O, MHT, should not have pushed Patient #4 back into the seclusion room.
- She reviewed the video of the incident from 12/26/21 with each individual involved and provided education on a one to one basis based on the discussion with the individual.
- There was no formal documentation of what was discussed with each individual.
- Staff L, RN, did not have proper Mandt training and should not have been involved in the hold with Patient #4. Staff L signed paperwork that she would not participate in any holds until she received Mandt training.

During a telephone interview on 01/20/22 at 8:30 AM, Staff P, MHT, stated that:
- She had worked for months before she received Mandt training.
- The Mandt training she received was very short and Staff O, MHT, was her trainer.
- She had her hand behind Patient #4's head and her fingers were on the area where your jaw would clench, during the restraint in the seclusion room.
- No one ever asked her to tap out or reposition her hands.
- Her hand behind his head was to prevent him from head butting Staff O, MHT.
- She was talking to Patient #4 the whole time he was in the seclusion room.
- The rough part was when the staff were trying to leave the room and the patient tried to get out, his fingers were in the door, and Staff O, MHT, pushed the patient back into the room.

During an interview on 01/12/22 at 12:02 PM, Staff M, MHT stated that she had not received any education after the event on 12/26/21.

During an interview on 01/12/22 at 2:00 PM, Staff H, MHT stated that she had not received any education after the incident on 12/26/21.

During an interview on 01/11/22 at 5:05 PM, Staff D, Human Resource Director, stated that only the staff that were involved in the incident received education after the event.

Review of the time cards and post event education sheets provided by the hospital showed that:
- Staff J, RN, worked on 12/27/21 and was not educated until 01/05/22.
- Staff I, MHT, worked on 12/27/21, 12/28/21, 12/29/21, 01/01/22, 01/02/22, 01/03/22, 01/07/22 and was not educated until 01/07/22.
- Staff K, RN, worked on 12/27/21, 12/31/21, 01/04/22, 01/05/22 and was not educated until 01/05/22.
- Staff L, RN, worked on 12/27/21,12/30/21, 12/31/21, 01/04/22, 01/05/22 and was not educated until 01/05/22.

The hospital failed to remove staff that abused a patient; failed to investigate in a timely manner after an allegation of abuse had been made; and failed to provide house wide education to staff about abuse to prevent further abuse to patients during restraint and seclusion.

2. Record review of Patient #9's medical record showed that he was a 12 year old female, (patient preferred to be referred to as a male), who was admitted to the hospital on 05/05/21 for thoughts of suicide (to cause one's own death) after he had ran away from home. He had a previous history of chronic major depressive disorder and Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock). Patient #9 was discharged on 05/27/21 at 10:38 AM.

Review of hospital document titled, "Incident Notification Report," showed date of incident as 05/20/21 with report date of 05/21/21 by Staff O, MHT regarding Patient #9. The report showed the category of the incident was sexual allegations of misconduct between a staff member and a patient. An attached shift note by Staff O documented that Patient #9 had informed him that Staff S, MHT had touched his breasts and that Staff S placed her hand high on his thigh while he was trying to sleep.

Review of the hospital's internal investigation document titled, "Interview with Staff S, MHT", dated 05/21/21 showed the following:
- Staff S was asked how it had gone with the one to one (1:1, continuous visual contact with close physical proximity) with Patient #9.
- Staff S replied that it had gone well that the patient was scared at where he would go after his discharge.
- Staff S was asked if there was a need to provide physical interaction with the patient.
- Staff S replied that the patient had asked her to pat his arm while he went to sleep. The patient had informed her that the water was too cold to shower so she told him to wash at the sink that it would help him sleep.
- Staff S reported that she washed his face and arms and told him to wash the rest of his body.
- Staff S was asked if the patient was upset during her shift and she replied no only when he asked her to adopt him and she told him that she could not that he then got mad.
- On 05/24/21 Staff S, MHT was informed that she would be removed from the schedule pending results of the investigation.

Review of an untitled hospital document from the internal investigation showed documentation of an interview with the roommate of Patient #9. The roommate was asked if Staff S, MHT had been Patient #9's 1:1 staff and the roommate replied yes. When asked how she felt about Staff S she replied that she was very nice and that made her feel comfortable, and she had not heard of nor did she witness anything inappropriate from Staff S to Patient #9.

Review of an untitled hospital document from the internal investigation showed the following:
- 1:1 supervision requires staff to be within arm's length of the patient.
- Cultural differences may have a role in the perception of the event.
- Provide training to staff how touch can be perceived by members of other cultures as well as individuals that experience trauma.
- Current onboarding orientation training is in the process of being updated and improved.
- Training on touch will be included in this revision of training.
- Education will be provided to current staff during their next monthly meeting.

Although requested no evidence was provided that staff had received education as stated within the hospital's internal investigation.

Review of Staff S, MHT's timecard showed the following shifts worked:
- 05/20/21 3:15 PM to 11:00 PM;
- 05/21/21 3:00 PM to 11:00 PM;
- 05/22/21 3:00 PM to 11:15 PM;
- 05/23/21 2:45 PM to 11:00 PM; and
- 05/24/21 3:00 PM to 3:45 PM.

Staff S, MHT was interviewed by the hospital on 05/21/21 in regards to the allegations by Patient #9 of sexual abuse. Staff S completed her eight hour shift on 05/21/21 and worked two eight hours shifts over the next two days.

During an interview on 01/18/22 at 11:25 AM, Staff S, MHT stated that:
- She remembered taking care of Patient #9 and the interview with the hospital administrative staff regarding the allegations made by the patient.
- She would never do anything to harm a child, she had children of her own, loved kids and was currently in nursing school to become a nurse.
- She was from the Philippines and that she loved her job.
- After she had been interviewed by the hospital administrative staff she returned to work the next day and worked a few more days before she was informed that she would be suspended until they completed the investigation.
- After her suspension she "just went back to work" and did not receive any education regarding appropriate touching or re-education on abuse and neglect.
- She resigned in 07/2021 to return to nursing school.

During an interview on 01/12/22 at 9:50 AM, Staff C, Quality and Risk Director stated that she had interviewed Staff S and the roommate of Patient #9. She stated that Patient #9 was discharged the following day.

Review of Patient #9's demographic sheet from the medical record showed that Patient #9 was discharged on 05/27/21, six days after the date of the reported allegations.

The allegations of sexual misconduct against Staff S, MHT were reported by Patient #9 on 05/21/21. Patient #9's roommate was interviewed along with Staff S, MHT on 05/21/21. Staff S completed her eight hour shift on 05/21/21, following her interview and worked two eight hours shifts over the next two days. The hospital failed to immediately remove Staff S from patient care and failed to do a thorough investigation as Patient #9 was never interviewed by the hospital in regards to the sexual allegations he made against Staff S, MHT.




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