HospitalInspections.org

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Based on record review and interview, the facility failed to meet the Condition of Participation of Patient Right's according to CFR 482.13. The facility failed to protect and promote each patient's rights which had the potential to place all patients (based on a census of 72) at risk for exposure to verbal and physical abuse and prohibited physical hold techniques used during escalated emergencies. Findings:

1. The facility failed to ensure a patient's right to receive care in a safe setting was maintained for 3 patients (#'s 1, 15, and 32), out of 7 patients reviewed. Specifically, the facility failed to: 1) Re-educated one Psychiatric Nursing Assistant (PNA) (#6) who was identified to use incorrect physical hold techniques during an incident on 12/4/23 when physically restraining an escalated patient (#1); 2) Identify, correct, and/or report PNA #6's use of incorrect physical hold techniques during an incident on 12/11/23 when physically restraining an escalated patient (#15); and 3) Protect other patients after the 12/11/23 incident, which resulted in PNA #6's continued use of incorrect physical hold techniques during an incident on 12/13/23 when physically restraining an escalated patient (#32). (Refer to A-144).

2. The facility failed to ensure a patient's right to be free from all forms of abuse or harassment were upheld for 1 patient (#15), out of 7 patients reviewed. This failed practice exposed this patient to verbal and physical abuse, intimidation, and retaliation which instigated an escalation and a crisis event which resulted in physical restraint. (Refer to A-145).
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Based on record review and interview, the facility failed to ensure a patient's right to receive care in a safe setting was maintained for 3 patients (#'s 1, 15, and 32), out of 7 patients reviewed. Specifically, the facility failed to:

1) Re-educated one Psychiatric Nursing Assistant (PNA) (#6) who was identified to use incorrect physical hold techniques during an incident on 12/4/23 when physically restraining an escalated patient (#1);

2) Identify, correct, and/or report PNA #6's use of incorrect physical hold techniques during an incident on 12/11/23 when physically restraining an escalated patient (#15); and

3) Protect other patients after the 12/11/23 incident, which resulted in PNA #6's continued use of incorrect physical hold techniques during an incident on 12/13/23 when physically restraining an escalated patient (#32).

These failed practices resulted in these patients having prohibited hold techniques inflicted on them during emergency brief manual holds (physical restraint used to control a patient's arms and movements for safety) when escalated, which increased the risk of asphyxiation, and had the potential to place all patients (based on a census of 72) at risk for inappropriate hold techniques during an escalated incident. Findings:

Incident on 12/4/23

Patient #1

Record review on 12/29/23 and 1/3/24 revealed Patient #1 was admitted to the facility with diagnoses that included Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and Reactive Attachment Disorder (RAD - a condition where a child doesn't form health emotional bonds and has trouble managing their emotions). Further review revealed Patient #1 had a history of self-harm behavior.

Review of the facility's video recording on 1/3/24 at 9:29 AM, of an incident that occurred on 12/4/23, revealed Patient #1 was escalated and had attempted to use a cinder block from the greenhouse to hit himself/herself on the forehead repeatedly. A brief manual hold was initiated by Therapist #9. Further review revealed PNA #6 entered the greenhouse to assist Therapist #9 and took over the hold. PNA #6 was observed to place his/her arms over and around Patient #1's upper arms from behind. Patient #1 slipped out of the hold, sat on the ground and attempted to hit the staff. PNA #6 was observed to kneel directly behind and slightly above Patient #1 and placed his/her arms around Patient #1 in the same fashion as before. PNA #6 applied pressure with his/her chest to the back of Patient #1's upper shoulder/neck area, and pushed forward and down from above, forcing Patient #1's head down towards his/her chest. PNA #6 held this position, which had the potential to restrict Patient #1's airway and limit his/her ability to take a full breath, which increased the risk of asphyxia, until more help arrived to assist.

Review of the facility's "Camera Review Tool" (a form used by the facility to review video recordings of incidents), dated 12/7/23, and competed by Advanced Mandt Instructor #3, revealed: " ... The patient [#1] is being restrained in a seated position with staff [PNA #6] [on top]/behind [him/her] from [3:35 PM] to [3:37 PM] ..." In the "Areas for Improvement, Education Identified and/or Positive Feedback" section of the tool, it was documented: "Unsafe dangers/risk of positional asphyxiation."

During an interview on 1/3/24 at 9:45 AM, Advanced Mandt Instructor #4 stated the over arm technique used by PNA #6 during the 12/4/23 incident was not an approved Mandt technique and that the exertion of Patient #1's head in a downward, forward position increased the risk of asphyxia.

During an interview on 1/3/24 at 9:52 AM, Advanced Mandt Instructor #3 stated PNA #6 had not been re-educated on the use of prohibited practices used during the 12/4/23 incident.

Incident on 12/11/23

Patient #15

Record review on 12/29/23 and 1/3/24 revealed Patient #15 was admitted to the facility with diagnoses that included autism spectrum disorder and attention deficit hyperactivity disorder (ADHD). Further review revealed Patient #15 was also diagnosed with Smith-Magenis syndrome (a developmental disorder that affects behavior, emotion, and learning processes. Major features of this condition include behavioral problems, mild to moderate intellectual disability and delayed speech and language skills).

Review of the facility's video recording on 1/3/24 at 9:29 AM, of an incident on 12/11/23, revealed Patient #15 was escalated and placed in a brief manual hold by PNA #6. It was observed that Patient #15 had dropped his/her weight while in the hold to sit and then lay down on his/her back on the ground. PNA #6 was observed to position Patient #15 onto his/her right side, placed Patient #15's left arm across his/her chest, and positioned himself/herself over Patient #15's body. While PNA #6's chest area was positioned over and very close to Patient #15's left shoulder, he/she placed his/her right forearm across Patient #15's left jaw line/upper neck area and applied pressure to keep Patient #15's head down on the floor. Once he/she removed his/her forearm, PNA #6 was further observed to place his/her hand on Patient #15's forehead to keep Patient #15's head on the floor.

Further review of the video recording revealed three other staff members were present during this incident, PNA #16, PNA #53, and Licensed Nurse (LN) #2. No one corrected, or later reported, PNA #6's use of this prohibited technique during the restraint episode.

During an interview on 12/29/23 at 10:18 AM, the Quality Director stated PNA #6's use of his/her forearm and hand to hold down Patient #15's head was not an approved Mandt techniques and was a danger to the patient's safety. When asked how the facility ensured brief manual holds, and any other more restrictive intervention (like a mechanical restraint or seclusion), were conducted safely, the Quality Director stated that when an incident occurred an Unusual Occurrence Report (UOR) was submitted the same day. The Nursing Shift Supervisor (NSS) would have briefly reviewed the video recording of the incident to ensure correct action from the staff was taken, which included Mandt techniques. The next day, or later in the week, Risk Management would have conducted a more in-depth camera review, using the "Camera Review Tool" form, to look at the incident from interactions just prior to and then through the closure of the incident.

When asked about the 12/11/23 incident's UOR review by the NSS on the same day, the Quality Director stated NSS #72 had not completed the UOR review, to include the video review, prior to leaving for the day on 12/11/23. The Quality Director further stated the UOR remained on the NSS's desk, through the NSS's weekend, until 12/14/23 when Risk Management received it and completed their camera review.

The Quality Director further stated that if a NSS had observed anything concerning from their initial camera reviews, on any UOR incident, they would have alerted leadership of the concern. If there was a safety concern, the staff involved would have been placed on administrative leave until the investigation was completed. Because the 12/11/23 camera review was not completed until 12/14/23 (three days later), and because PNA #6's behavior wasn't reported, PNA #6's verbal and physical abuse was discovered late. PNA #6 was placed on administrative leave on 12/14/23 until the investigation was completed, and when concerns were substantiated, PNA #6 was terminated on 12/14/23.

Review of the facility's "Camera Review Tool," dated 12/14/23, and competed by Advanced Mandt Instructor #3, revealed: " ... During this brief manual restraint, [PNA #6] is observed to use a prohibited practice restraint by placing [his/her] forearm/elbow forcibly on patient [#15's] left jaw/neck area at [1:34 PM] and restraining [him/her] in this manner for 27 seconds until [1:36 PM]. [PNA #6] also presses [patient #15's] head to the floor by placing [his/her] hand on [his/her] forehead for 30 seconds ..."

During an interview on 12/29/23 at 3:20 PM, the Quality Director, the Assistant Director of Nursing, and Advanced Mandt Instructor #5 all agreed that none of the staff present corrected, or later reported, PNA #6's inappropriate hold technique during the 12/11/23 brief manual hold.

Incident on 12/13/23 (one day before PNA #6 was placed on administrative leave)

Patient #32

Record review on 12/29/23 and 1/3/24 revealed Patient #32 was admitted to the facility with a diagnosis of autism spectrum disorder. Further review revealed Patient #32's level of observation, for safety, revealed he/she was on close observation, 2nd degree (one patient has one staff member assigned to continuously observe them at all times). He/she had a history of being dangerous to others and exhibiting unpredictable behaviors.

Review of the facility's video recording on 12/29/23 at 3:30 PM, of an incident on 12/13/23, revealed Patient #32 was quickly pacing up and down the unit hallway and flapping his/her hands constantly (this was a form of stimming, self-stimulation, behavior that could be triggered by excitement, nervousness, or fidgeting). Patient #32 was observed to impulsively strike out at staff when medications were offered to help calm him/her. Further observation revealed a two-person escort was attempted by PNA #6, who restrained the left arm, and PNA #41, who restrained the right arm.

Patient #32 was observed to drop his/her weight and sit on the floor. Both PNA's knelt and PNA #6 positioned himself/herself behind and over Patient #32, while PNA #41 remained on Patient #32's right side, all the while both continuing to restrain Patient #32's arms.

PNA #6, while still restraining Patient #32's left arm with his/her left hand, brought his/her right arm up and over Patient #32's right shoulder close to the neck, and then down in front of Patient #32's chest area. With his/her chest, PNA #6 exerted pressure to the back of Patient #32's upper shoulder/neck area and pushed forward and down over Patient #32, forcing his/her head down towards his/her chest. PNA #6 held this position, which had the potential to restrict Patient #32's airway and limit his/her ability to take a full breath, increasing the risk of asphyxia.

As this incident had occurred, two other PNAs (#21 and #80) stood by to assist if needed. Further observation revealed none of the other PNAs present corrected, or later reported, PNA #6's inappropriate hold technique.

During an interview on 12/29/23 at 3:32 PM, Advanced Mandt Instructor #5 stated an arm around or near a patient's neck, in any fashion, was a prohibited technique. He/she also stated that putting weight on and then leaning a patient forward was prohibited as well because it increased the risk of asphyxia.

Review of the facility's Mandt Instructor manual "The Mandt System Instructor Manual Building Healthy Relationships since 1975 Curriculum 2.0," dated 1975 - 2022, revealed: " ... Prohibited Practices ... The Mandt System prohibits these practices ... Pressure or weight on chest, lungs, sternum, diaphragm, back, or upper abdomen ... can results in immediate asphyxiation and death ...Any manual restraint that maintains a person on the floor in any position (prone, supine, side-lying) ... the risks of using such restraints are outweighed by any benefits at this level of training ... Any technique that involves substantial risk of injury. If a practice is not on this list, and you believe it could result in harm or injury, don't do it!.."

Review of the facility's "Patient Rights from The Joint Commission and The Center for Medicare and Medicaid Services," dated 11/1/21, revealed: "Psychiatric hospital by the Joint commission will honor and promote the following patient rights and standards ... Patients will be treated in a dignified and respectful manner that supports his or her dignity ... As a Participant of the Medicaid and Medicare, the facility agrees to protect and promote each of the rights listed below ... to receive care in a safe setting ... to safe implementation of restraint or seclusion by trained staff ..."
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Based on record review and interview, the facility failed to ensure a patient's right to be free from all forms of abuse or harassment were upheld for 1 patient (#15), out of 7 patients reviewed. This failed practice exposed this patient to verbal and physical abuse, intimidation, and retaliation which instigated an escalation and a crisis event which resulted in physical restraint. Findings:

Patient #15

Record review on 12/29/23 and 1/3/24 revealed Patient #15 was admitted to the facility with diagnoses that included autism spectrum disorder and attention deficit hyperactivity disorder (ADHD). Further review revealed Patient #15 was also diagnosed with Smith-Magenis syndrome (a developmental disorder that affects behavior, emotion, and learning processes. Major features of this condition include behavioral problems, mild to moderate intellectual disability and delayed speech and language skills).

Review of Patient #15's behavior plan "Working with [Patient #15]," undated, revealed: "Things to remember: [Patient #15] has a genetic disorder that affects many aspects of [his/her] cognitive and physical functioning. [His/her] functioning level is comparable to that of a 2-year-old. [Patient #15] shifts from calm and happy to elevated and aggressive rapidly. [He/she] also lacks the skills and ability to self-regulate [calm self down]. [Patient #15] values [his/her] space and privacy ... Tips for staff: Remind yourself "[Patient #15] can't" don't get stuck thinking "[Patient #15] won't." Be calm in times of stress with [Patient #15] even when you need to be firm ... Use a neutral/positive tone of voice. Focus on what [Patient #15] CAN do. Reduce stimulation (light, people, and noise) when [Patient #15] is escalating ..."

Review of Patient #15's level of observation, for safety, revealed he/she was on close observation, 3rd degree in the milieu (one patient has two staff members assigned to continuously observe them at all times) and 2nd degree in the bed area (one patient has one staff member assigned to continuously observe them at all times). Further observation revealed: "staff to disengage when pt [patient] becomes elevated (may monitor outside of room from window)."

Incident on 12/11/23

Review of the facility's video recording on 12/29/23 at 10:18 AM, of an incident involving Patient #15, on 12/11/23, revealed:

- 1:19 PM - Patient #15 was in the facility's gym with two Psychiatric Nursing Assistants (PNAs) #6 and #8. There were no other patients in the gym.

- 1:29 PM - Patient #15 was observed to attempt to go pick up a ball, PNA #6 was observed to kick the ball away from Patient #15's reach. Patient #15 chased after the ball saying, "give it to me." Patient #15 started to escalate and said "fuck you sissy" to PNA #8 who was not engaged with Patient #15 at the time. PNA #6 immediately said, "Let's go - oak room [this is a seclusion room]. Now, oak room. Let's go, you ain't going to be no bully around me." Patient #15 walked away from PNA #6 and went to the other side of the gym. Patient #15, continued to focus on PNA #8 and told PNA #8 to leave the gym. PNA #6 stated, "[he's/she's] not going nowhere you're just going to the oak room." Patient #15 was observed to chant for PNA #8 to leave the gym, while still being on the other side the gym. PNA #6 tossed a ball away that he/she had been bouncing, advanced towards Patient #15 and stated: "Yeah, come on that's it I'm taking you straight to the oak room." As PNA #6 continued to advance towards Patient #15, he/she stated: "Let's go, we'll go straight to the oak room. Can't wait." PNA #6 observed to say "you're a bully" twice.

- 1:30 PM: Patient #15 started to pace in the gym, still focused on PNA #8. PNA #6 started to confront Patient #15, "Let's go bully, you don't bully [him/her]." PNA #6 confronted Patient #15 "pick me" and attempted to escort Patient #15 from the gym to the unit. Patient #15 dropped to the floor to sit and PNA #6 stated, "Oh no, I'm gonna fight with you, let's go to oak room." Patient #15 started crawling on the floor, PNA #6 was observed to be following him/her as he/she crawled and stood over Patient #15 challenging him/her saying, "Me and you, I'll put you in a hold let's go to the oak room, what's up?" PNA #6 was observed to attempt to pick Patient #15 up off the floor several times by grasping Patient #15's underarms, to attempt to escort him/her out of the gym, Patient #15 continued to drop or reposition himself/herself on the floor. PNA #6 observed to say, "Let's go, stand up." With a raised voice, PNA #6 stated, "Stand up I'll fight you! Pick me! I'm just going to put you in a hold. You're rude!"

- 1:31 PM: Patient #15 was observed to escalate from this interaction. Patient #15 started to spit on the gym floor, screaming, and banging her head/face on the gym floor. Patient #15 started to crawl toward PNA #8, who was not engaged with Patient #15 at all. PNA #6 was observed to continue to mirror Patient #15's movement, turn patient physically to divert him/her away from PNA #8, and all the while continuing to verbally abuse Patient #15, "I'm not playing with you;" "you're being a bully;" "let's go, get up;" "let's go bully;" and "come on bully get up, let's go."

- 1:32 PM: Patient #15 continuing to escalate from PNA #6's behavior and attempted to kick PNA #6. PNA #6 picked Patient #15 up off the floor by his/her underarms saying, "we are going to the oak room, I promise you."

Further observation revealed PNA #6 escorted Patient #15 back to the unit, at which time Patient #15 refused to walk to the oak room and dropped to the floor. This resulted in a brief manual hold initiated by PNA #6. PNA #6 was observed to position Patient #15 onto his/her right side, placed Patient #15's left arm across his/her chest, and positioned himself/herself over Patient #15's body. While PNA #6's chest area was positioned over and very close to Patient #15's left shoulder, he/she placed his/her right forearm across Patient #15's left jaw line/upper neck area and applied pressure to keep Patient #15's head down on the floor. Once he/she removed his/her forearm, PNA #6 is further observed to place his/her hand on Patient #15's forehead to keep Patient #15's head on the floor. From here, Patient #15 was placed on a gurney, taken to the oak room, and placed in mechanical 5-point restraints (mechanical restraints placed on both wrists, both ankles, and a strap across the chest area).

Review of the facility's "Camera Review Tool," dated 12/27/23, and completed by Advanced Mandt Instructor #3, revealed: " ... Video review shows multiple instances of verbal and physical abuse directed toward patient [#15] from [PNA #6] ... [PNA #6] is antagonistic and verbally abusive towards the patient as evidenced by [his/her] body language and positioning, the tone and volume of [his/her] voice, and the actual words directed towards the patient. [PNA #6] is heard on the video to make comments such as "Do you need the oak room?" when no observable danger to self or others behavior is displayed by [Patient #15] ..."

Further review of the "Camera Review Tool" identified the inappropriate hold techniques used by PNA #6 during the brief manual hold: " ... During this brief manual restraint, [PNA #6] is observed to use a prohibited practice restraint by placing [his/her] forearm/elbow forcibly on patient [#15's] left jaw/neck area at [1:34 PM] and restraining [him/her] in this manner for 27 seconds until [1:36 PM]. [PNA #6] also presses [patient #15's] head to the floor by placing [his/her] hand on [his/her] forehead for 30 seconds ..."

During an interview on 12/29/23 at 10:18 AM, the Assistant Director of Nursing (ADON) and Quality Director stated both PNA #6 and #8 had radios and could have called for assistance but did not. The ADON and Quality Director stated that they determined, based on their independent review of the 12/11/23 incident, that PNA #6 had not used approved de-escalation techniques and was verbally and physically abusive towards Patient #15. The Quality Director further stated that Patient #15's behavior plan was not followed and PNA #6's behavior escalated Patient #15 to the point of requiring physical intervention.

The ADON and Quality Director agreed that PNA #8 had not attempted to disengage PNA #6 from this inappropriate behavior, nor did PNA #8 report PNA #6's inappropriate behavior to leadership.

When asked how the facility ensured brief manual holds, and any other more restrictive intervention (like a mechanical restraint or seclusion), were conducted safely, the Quality Director stated that when an incident occurred an Unusual Occurrence Report (UOR) was submitted the same day. The Nursing Shift Supervisor (NSS) would have briefly reviewed the video recording of the incident to ensure correct action from the staff was taken, which included Mandt techniques. The next day, or later in the week, Risk Management would have conducted a more in-depth camera review, using the "Camera Review Tool" form, to look at the incident from interactions just prior to and then through the closure of the incident.

When asked about the 12/11/23 incident's UOR review by the NSS on the same day, the Quality Director stated NSS #72 had not completed the UOR review, to include the video review, prior to leaving for the day on 12/11/23. The Quality Director further stated the UOR remained on the NSS's desk, through the NSS's weekend, until 12/14/23 when Risk Management received it and completed their camera review.

The Quality Director further stated that if a NSS had observed anything concerning from their initial camera reviews, on any UOR incident, they would have alerted leadership of the concern. If there was a safety concern, the staff involved would have been placed on administrative leave until the investigation was completed. Because the 12/11/23 camera review was not completed until 12/14/23 (three days later), and because PNA #6's behavior wasn't reported, PNA #6's verbal and physical abuse was discovered late. PNA #6 was placed on administrative leave on 12/14/23 until the investigation was completed, and when concerns were substantiated, PNA #6 was terminated on 12/14/23.


Review of the facility's Mandt Instructor manual "The Mandt System Instructor Manual Building Healthy Relationships since 1975 Curriculum 2.0," dated 1975 - 2022, revealed: " ... Staff have a tremendous power to affect the behavior of the people with and for whom they work. It is the staff's personal approach that creates the climate where they work. The staff's emotions and attitudes are in the words they say, the way they say them ... Staff may have situations where it was their overreaction that caused a situation to escalate into a crisis event ..."

Review of the facility's Mandt Instructor manual "The Mandt System Instructor Manual Building Healthy Relationships since 1975 Curriculum 2.0," dated 1975 - 2022, revealed: " ... Prohibited Practices ... The Mandt System prohibits these practices ... Pressure or weight on chest, lungs, sternum, diaphragm, back, or upper abdomen ... can results in immediate asphyxiation and death ...Any manual restraint that maintains a person on the floor in any position (prone, supine, side-lying) ... the risks of using such restraints are outweighed by any benefits at this level of training ... Any technique that involves substantial risk of injury. If a practice is not on this list, and you believe it could result in harm or injury, don't do it!.."

Review of the facility's "Patient Rights from The Joint Commission and The Center for Medicare and Medicaid Services," dated 11/1/21, revealed: "Psychiatric hospital by the Joint commission will honor and promote the following patient rights and standards ... Patients will be treated in a dignified and respectful manner that supports his or her dignity ... Patients have the right to be free from neglect, exploitation, and verbal, mental[,] physical, and sexual abuse ... As a Participant of the Medicaid and Medicare, the facility agrees to protect and promote each of the rights listed below ... to receive care in a safe setting ... to be free from harassment, physical or mental abuse, or corporal punishment ... to be free from restraints or seclusion of any form imposed as a means of coercion discipline, convenience, or retaliation by staff ... to safe implementation of restraint or seclusion by trained staff ..."
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