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Based on observations, record reviews, and interviews, the hospital failed to ensure that patients in restraint holds in the hospital lodge received care and services in a responsible manner to ensure the safety of those patients restrained for 1 of 1 patient who died while in an inappropriate hold. (Patient 5)

The findings are:

Cross Reference to A 0043: The governance of the hospital failed to ensure the oversight and monitoring of patients in restraint holds receiving care in the hospital to ensure clear expectations for the patient ' s safety were established for 1 of 1 patients in an inappropriate hold who died. (Patient 5)


Cross Reference to A 0063: The hospital failed to promote and ensure the safety of 1 of 1 patient who died while in an inappropriate hold in the hospital's lodge with a potential to affect any restrained patient when crisis management, medical management, clinical leadership, and clinical assessments are not implemented during restraint interventions. (Patient 5)

Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the governance of the hospital failed to ensure the oversight and monitoring of patients in restraint holds receiving care in the hospital to ensure clear expectations for the patient ' s safety were established for 1 of 1 patients in an inappropriate hold who died. (Patient 5)

The findings are:

On 2/1/19 at 3:46 p.m., review of the hospital ' s video related to a restraint hold for Patient 5 that occurred on 1/22/2019 at approximately 10:40 AM per the date and time stamp on the video revealed:
1/22/2019 - 10:40 AM: Patient 5 ambulates in the hallway towards a room(atrium) with plexiglass windows. Patient 5 kicked at the bottom seal of plexiglass. A female staff member approached the patient and then walked away from the patient. Patient 5 turned a corner and started kicking the plexiglass windows on the other side of the room(atrium). A male staff member walked towards the patient and then left the patient who continued to kick the plexiglass windows. A male staff member walked into the nursing station which is also located on the hallway and the medication administration room is located in front of the nursing station. At 10:44 AM, the male staff member exited the nursing station and entered the medication administration room without closing the door. Patient 5 walked towards the medication room. The male staff member attempted to close the door to the medication administration room as Patient 5 attempted to open the door and enter the medication administration room. Patient 5 attempted to push the door to the medication room open while the male staff member attempted to close the door. Two (2) female staff members and 1 male staff member approached the patient from the patient's back and used their hands to grab the patient's jacket. Then, a fourth male staff member ran from behind the patient and grabbed the patient's neck and all of the staff members threw the patient to the floor. The patient was face down when all four staff members got on top of the patient. A glimpse of the patient showed the patient's head was covered by the jacket and half the patient's buttocks were in view. Physician 2 appeared in the hall way, approached the scene, looked, and then walked away from the scene. The male staff person that was in the medication room who was identified later as a Registered Nurse was observed on the patient also. Staff continued to cover the patient's body. Physician 2 exited the nurse station again, but then returned to the nurse station. The patient was not visible with all the bodies on the patient. There is no observed supervision by nursing, medical staff, or administrative staff during the restraint hold or any physical assessment for the patient's well being during the restraint hold.

At 10:48, the first Patient Safety Officer arrived and requested staff to get off the patient and move back. Multiple bystanders were in the hall way. The patient was on the floor on his stomach. Then, staff turned the patient, and when the patient was noticed to be unresponsive, started chest compressions. Staff members had an ambu bag but appeared to encounter difficulty in the operation of the ambu bag. At 10:50, a staff member brought a code cart to the scene. The code cart had an AED on top but the AED was later moved to the floor where it was observed throughout the code. The AED was not placed on the patient. At 10:52, staff appeared to try to get the ambu operational. At 10:54 AM, more and more bystanders appeared in the hallway. At 10:52, compressions were discontinued and then restarted.
At 11:01 AM, the Emergency Medical Transport Team arrived to the scene and instituted emergency management of the patient with oxygen, cardiac monitor, defibrillator, and transported the patient to the hospital where the patient was pronounced.

Based on record reviews and interviews, the hospital failed to promote and ensure the safety of 1 of 1 patient who died while in an inappropriate hold in the hospital's lodge with a potential to affect any restrained patient when crisis management, medical management, clinical leadership, and clinical assessments are not implemented during restraint interventions. (Patient 5)


The findings are:


On 2/1/19 at 3:46 p.m., review of the hospital ' s video related to a restraint hold for Patient 5 that occurred on 1/22/2019 at approximately 10:40 AM per the date and time stamp on the video revealed:
1/22/2019 - 10:40 AM: Patient 5 ambulates in the hallway towards a room(atrium) with plexiglass windows. Patient 5 kicked at the bottom seal of plexiglass. A female staff member approached the patient and then walked away from the patient. Patient 5 turned a corner and started kicking the plexiglass windows on the other side of the room(atrium). A male staff member walked towards the patient and then left the patient who continued to kick the plexiglass windows. A male staff member walked into the nursing station which is also located on the hallway and the medication administration room is located in front of the nursing station. At 10:44 AM, the male staff member exited the nursing station and entered the medication administration room without closing the door. Patient 5 walked towards the medication room. The male staff member attempted to close the door to the medication administration room as Patient 5 attempted to open the door and enter the medication administration room. Patient 5 attempted to push the door to the medication room open while the male staff member attempted to close the door. Two (2) female staff members and 1 male staff member approached the patient from the patient's back and used their hands to grab the patient's jacket. Then, a fourth male staff member ran from behind the patient and grabbed the patient's neck and all of the staff members threw the patient to the floor. The patient was face down when all four staff members got on top of the patient. A glimpse of the patient showed the patient's head was covered by the jacket and half the patient's buttocks were in view. Physician 2 appeared in the hall way, approached the scene, looked, and then walked away from the scene. The male staff person that was in the medication room who was identified later as a Registered Nurse was observed on the patient also. Staff continued to cover the patient's body. Physician 2 exited the nurse station again, but then returned to the nurse station. The patient was not visible with all the bodies on the patient. There is no observed supervision by nursing, medical staff, or administrative staff during the restraint hold or any physical assessment for the patient's well being during the restraint hold.

At 10:48, the first Patient Safety Officer arrived and requested staff to get off the patient and move back. Multiple bystanders were in the hall way. The patient was on the floor on his stomach. Then, staff turned the patient, and when the patient was noticed to be unresponsive, started chest compressions. Staff members had an ambu bag but appeared to encounter difficulty in the operation of the ambu bag. At 10:50, a staff member brought a code cart to the scene. The code cart had an AED on top but the AED was later moved to the floor where it was observed throughout the code. The AED was not placed on the patient. At 10:52, staff appeared to try to get the ambu operational. At 10:54 AM, more and more bystanders appeared in the hallway. At 10:52, compressions were discontinued and then restarted.
At 11:01 AM, the Emergency Medical Transport Team arrived to the scene and instituted emergency management of the patient with oxygen, cardiac monitor, defibrillator, and transported the patient to the hospital where the patient was pronounced.

Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure its staff followed the hospital's policies and procedures to ensure protection and promote safety for patients in restraints for 1 of 1 patient who died while in an inappropriate hold. (Patient 5)

The findings are:

Cross Reference to A 0144: The governance of the hospital failed to ensure the oversight and monitoring of patients restrained in the hospital's emergency department to ensure clear expectations for safety were established for 1 of 1 patients who died during an inappropriate hold in the hospital's lodge. (Patient 5 )

Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the governance of the hospital failed to ensure the oversight and monitoring of patients restrained in the hospital's emergency department to ensure clear expectations for safety were established for 1 of 1 patients who died during an inappropriate hold in the hospital's lodge. (Patient 5 )

The findings are:

On 2/1/19 at 3:46 p.m., review of the hospital ' s video related to a restraint hold for Patient 5 that occurred on 1/22/2019 at approximately 10:40 AM per the date and time stamp on the video revealed:
1/22/2019 - 10:40 AM: Patient 5 ambulates in the hallway towards a room(atrium) with plexiglass windows. Patient 5 kicked at the bottom seal of plexiglass. A female staff member approached the patient and then walked away from the patient. Patient 5 turned a corner and started kicking the plexiglass windows on the other side of the room(atrium). A male staff member walked towards the patient and then left the patient who continued to kick the plexiglass windows. A male staff member walked into the nursing station which is also located on the hallway and the medication administration room is located in front of the nursing station. At 10:44 AM, the male staff member exited the nursing station and entered the medication administration room without closing the door. Patient 5 walked towards the medication room. The male staff member attempted to close the door to the medication administration room as Patient 5 attempted to open the door and enter the medication administration room. Patient 5 attempted to push the door to the medication room open while the male staff member attempted to close the door. Two (2) female staff members and 1 male staff member approached the patient from the patient's back and used their hands to grab the patient's jacket. Then, a fourth male staff member ran from behind the patient and grabbed the patient's neck and all of the staff members threw the patient to the floor. The patient was face down when all four staff members got on top of the patient. A glimpse of the patient showed the patient's head was covered by the jacket and half the patient's buttocks were in view. Physician 2 appeared in the hall way, approached the scene, looked, and then walked away from the scene. The male staff person that was in the medication room who was identified later as a Registered Nurse was observed on the patient also. Staff continued to cover the patient's body. Physician 2 exited the nurse station again, but then returned to the nurse station. The patient was not visible with all the bodies on the patient. There is no observed supervision by nursing, medical staff, or administrative staff during the restraint hold or any physical assessment for the patient's well being during the restraint hold.

At 10:48, the first Patient Safety Officer arrived and requested staff to get off the patient and move back. Multiple bystanders were in the hall way. The patient was on the floor on his stomach. Then, staff turned the patient, and when the patient was noticed to be unresponsive, started chest compressions. Staff members had an ambu bag but appeared to encounter difficulty in the operation of the ambu bag. At 10:50, a staff member brought a code cart to the scene. The code cart had an AED on top but the AED was later moved to the floor where it was observed throughout the code. The AED was not placed on the patient. At 10:52, staff appeared to try to get the ambu operational. At 10:54 AM, more and more bystanders appeared in the hallway. At 10:52, compressions were discontinued and then restarted.
At 11:01 AM, the Emergency Medical Transport Team arrived to the scene and instituted emergency management of the patient with oxygen, cardiac monitor, defibrillator, and transported the patient to the hospital where the patient was pronounced.

Interviews
Registered Nurse 3
On 2/1/19 from 2:22 p.m. until 2:28 p.m., a telephone interview was conducted with Registered Nurse (RN) 3 who verified he/she was on duty in Lodge B on 01/22/19 on the 7:00 a.m. to 3:30 p.m. shift during the incident. RN 3 stated, "The patient was kicking the windows. I went in the med room to see if he had medication. I closed the med room door. The charge nurse attempted to enter the med room, and the patient was behind him. Some other staff came to help the charge nurse remove the patient. I closed the door to the medication room and drew up his medication. I came out to give him his medicine. They turned him over, and he was blue. There were so many people standing around, and I yelled out to call a code. I brought the crash cart and they had the AED on him. He had Benadryl and Thorazine ordered, but I couldn ' t ' find the Thorazine. Right after the girl started CPR, someone called a code." RN 3 reported when asked if he/she had administered the medication to the patient, "No, when they turned him over, he was blue." RN 3 verified the witness statement that he/she submitted on January 22, 2019.

Master of Social Work
On 2/1/19 from 2:39 p.m. until 2:55 p.m., a telephone interview was conducted with Medical Social Worker (MSW) 1 who verified that he/she was on duty in Lodge B on 01/22/19 during the incident. MSW 1 stated, "I don't remember the time, but myself, Mental Health Counselor (MHC) 1, Nurse Practitioner 1 and a Nurse Practitioner student were in the treatment room in Pod 2 at a table. The treatment team had discussed the patient's treatment and the patient was restricted and placed on white band. We all stayed there. He (patient) comes back to the door and MHC 1 gets up to talk to him. We heard him kicking on the windows, and I tried to talk to him. I told someone to call a code management. I don't know who made the first call. I had my cell phone in my hand. I called the number several times and couldn't get through. I called Public Safety at the nurse station. I saw the patient halfway through the door of the med room. The patient's arms appeared to be around the nurse's neck. I see him down on the ground. I held a leg and MHC 1 held a leg. The patient is aggressive, and we need help. We ushered patients to Pod 3. Behavioral Health Associate (BHA) 1 ran out the back door to find help. Public Safety Officers (PSO) came in and staff released the patient. I heard them call a code Blue. I had a panic attack that morning. I wrote my statement, but I don't know what I put in my statement. They called Code Management and Code Blue at the same time. The PSO was using his walkie talkie to call Code Blue. The surveyor questioned MSW 1 regarding the training received for restraints and/or holds, and MSW 1 stated, "We have BEST training. I think the most I got out of it was how to do when the patient attacks you. I know you can hold arms or legs. We were told, "You guys won't have to do anything because you can call Code Management." I have no clue how to restrain a patient in relation to patient attacking someone else. Ankles and feet, and arms and wrists can be restrained." MSW verified the witness statement that he/she submitted on Jan 22, 2019.

Behavioral Health Aide(BHA) 2
On 2/1/19 from 3:03 p.m. until 3:08 p.m., a telephone interview was conducted with BHA 2 who verified that he/she was on duty in Lodge B on 01/22/19 when the incident occurred. BHA 2 stated, "I got there at the last minute. He was attacking the nurse. He was already inside the med room. We all pulled him out of the room and escorted him to the ground and guided him to the ground and restrained him til PSO got there." BHA 2's witness statement dated 01/22/2019 was verified with him/her.

Physician 2
On 2/1/19 from 3:11 p.m. until 3:25 p.m., a telephone interview was conducted with Physician 2 who verified that he/she was in Lodge B on 1/22/19 during the incident. Physician 2 stated, "We had treatment team meeting that morning. The patient had an altercation with a peer the day before. The patient was given a different band. The patient left the room and was upset. He was banging on the windows. The Nurse Practitioner ordered a prn(as needed medication). He tried to enter the nurse station. The staff restrained him. I went to the nurse station to call PSO. I'm new, and I don't know who to call. I found an alternate number. They called a Code Management and the PSC came. The staff let the patient go, and he didn't move. Other patients were coming up, and they were getting agitated. I got on the floor and CPR(cardiopulmonary resuscitation) was started. I was trying to lead the code. Code Blue was called. The Ambu bag didn't have the correct attachment. The AED was attached, and we continued CPR. I'm not ACLS(Advanced Cardiac Life Support) trained. I bagged the patient and swapped out. There were other doctors and the NP there. The NP took over the bagging. I saw them restrain him. It was 4 people. Two on his arms and 2 on his legs." The surveyor asked if anyone monitored the patient while he was restrained. Physician 2 stated "No".
Physician 2 verified the witness statement submitted on January 22, 2019.

Mental Health Counselor(MHC) 1
On 2/1/19 from 3:26 p.m. until 3:35 p.m., a telephone interview was conducted with MHC 1 who verified that he/she was in Lodge B on 1/22/19 during the incident. MHC 1 stated, "The patient became agitated, and we tried to calm him down. We called Code Management. Someone said we can't call Code Management anymore. We called PSO, and the line was busy, busy. Another female ran out. The patient started fighting the nurse. Two (2) males put him on the ground. PSO came in. All they were doing were holding his legs and arms."
MHC 1 verified his/her witness statement submitted on Jan 22, 2019.

Registered Nurse(RN) 6
On 2/4/19, from 2:56 p.m. until 3:05 p.m., a telephone interview was conducted with RN 6 who verified that he/she was in Lodge B on duty on 1/22/19 on the 7:00 a.m. to 3:30 p.m. shift when the incident occurred. RN 6 stated, "Basically a patient tried to come after me into the med room. I walked to the med room, and the patient asked me, "Are you gonna give me a shot?" He tried to get in the room. He did not hit me, and he didn't raise his hands to hit me. I tried to push him out of the room. There were 2 other staff members on the other side of the door, and they took him to the ground. He did not hit his head. I held his arm. We called PSO, but couldn't get through to them. So another staff member ran out the door and got PSO and radioed to staff. Everyone started showing up. When the rest of PSO got there, he was turned over. We got the crash cart and started CPR. PSO called EMS from their radio." RN 6 verified the witness statement that he/she submitted on 1/22/2019.

Based on record reviews and interviews, the hospital failed to ensure its nurses followed the hospital's policies and procedures to promote safety for restrained patients in high risk problem prone areas in the hospital's lodge for 1 of 1 patient who died while in an inappropriate hold (Patient 5 ) and for failure to ensure the necessary


The findings are:


Cross Reference to A 0392: The hospital failed to ensure its nursing staff followed the hospital's policies for evaluating and assessing patients in restraints to ensure the safety of its patients for 1 of 1 patient restrained. (Patient 5)

Cross Reference to A 0395: Nursing Services failed to ensure its nursing staff provided the supervision necessary to protect and assess patients in crisis situations for 1 of 1 patients in restraints. (Patient 5 and 6)

Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the governance of the hospital failed to ensure nursing oversight and monitoring of patients restrained in the hospital's lodge to ensure clear expectations for safety were established for 1 of 1 patients who died during an inappropriate hold in the hospital's lodge (Patient 5), and failed to ensure the appropriate level of supervision was in place for 1 of 1 patient with suicidal ideations whose level of monitoring or other interventions were not appropriately implemented to ensure the patient's safety for 1 of 10 patient charts reviewed. (Patient 6)




The findings included:

Cross Reference to A 0144: The hospital's nursing services failed to ensure the necessary monitoring and supervision of a patient in a restraint hold in which the patient died and failed to institute the management of a code situation following the restraint hold episode. (Patient 5)

Patient 6
Patient 6 was admitted on 8/26/18. Record review from 1/29/19 - 2/1/19 revealed concerns related to incidents when the patient expressed suicidal ideation to a nurse on 10/17/19 at 9:00 PM. Review of a Nursing Progress Note dated 10/17/18 at 10:50 PM showed nurse notes documented at 9:00 PM, "Patient came to the Nurses Station and stated that s/he was thinking about hurting her/himself like s/he did before which is by tying something around her/his neck. I got her/him to express her/himself. S/he has a bandana around her/his head. It was removed and given to me by the patient to be placed at the Nurses Station. Will continue to monitor." There was nothing documented in the notes that the nurse notified anyone about the patient's report on 10/17/18 that s/he had been thinking about harming him/herself. A review of Special Treatment Procedure Logs for 10/17/18 revealed documentation by a behavioral health assistant on 10/17/19 at 9:00 PM that stated the patient was getting ready for bed. A 10/17/19 at 9:30 PM, Behavioral Health Assistant note showed the patient was sitting in the pod and hearing voices. There was no documentation that a search had been conducted to remove any possible ligature risks or potentially harmful items from the patient's access that evening/night shift after the patient's statement. According to the Special Treatment Procedure Log dated 10/18/18 at 8:30 AM, a "19" was documented. According to the codes listed on the Special Treatment Log, Code 19 meant a contraband check had been completed by the Certified Nursing Assistant (CNA). On 10/18/18 at 9:20 AM, the CNA documented, "Pt. (Patient) tried to choke her/himself with a neckband. Did a contraband check...". A Nursing Progress Note dated 10/18/18 at 3:56 PM revealed documentation dated 10/18/18 at 12:00 PM that read, "Staff reports pt (patient) was seen breathing heavy and asked what was wrong. It was discovered that the patient had a strap tied around her/his neck. The strap was immediately cut from her/his neck.

A Psychology/Counseling Note dated 10/17/18 at 2:43 PM documented a meeting with the patient on 10/16/18 at 10:16 AM. According to the note, the treatment team met with the patient to follow up on incidents in the last few days. "...(Patient 6) reported having suicidal ideation and had self-harmed by scratching her/himself...LPP explained the changes to medication by stopping some medications that could make her/him more restless." The note stated Patient 6 had overdosed on Depakote on 8/10/18 prior to admission to the hospital. The patient had a history of multiple suicide attempts, and wanted to die. According to the note, the patient had attempted to walk into traffic, cut wrists, overdosed on pills, and used a shoe string to choke her/himself.

Review of the nursing progress notes and the Special Treatment Procedure Log for 10/16/18 through 10/19/18 revealed the patient's supervision level had not been increased as a result of the suicidal incident with the patient having tied a strap around her/his neck. S/he had remained on Group Precautions (except for the times when s/he had been restrained or secluded) after the incident. A nursing note dated prior to the incident on 10/17/18 documented the patient was on Group Precautions before the incident happened, and a nursing note dated after the incident on 10/18/18 at 6:59 PM, revealed the patient remained on Group Precautions. According to the Special Treatment Procedure Log Documentation Guidelines, this meant the patient must be kept within line of sight at all times, with a 3:1 patient to staff ratio. Contraband checks would be documented, as well as observation and care every 30 minutes. Review of the policy, entitled, "Special Treatment Modalities/Observation Levels" dated June 2017 revealed that Group Precautions (GP) was for "Any patient whose uncontrolled behavior/condition could be detrimental to the milieu...(the patient) is assigned to an individual staff member and must remain within line of sight of staff at all times. The staff member may be responsible for up to three (3) patients...".

A review of the Unusual Occurrence Reports revealed that on 10/18/18 at 9:17 AM, "The patient was seen breathing heavy and asked what was wrong. It was discovered the patient had a strap tied around her/his neck. The strap was immediately cut from the patient's neck." According to the report, at the time of the occurrence, a Nurse Practitioner and the charge nurse (Registered Nurse #5) had been notified. In the report under section N, "(what was done to reduce the risk of reoccurrence):" was checked, Patient education, Enhanced staff observation for safety, and Attending Physician or designee consulted.

Interviews
Behavioral Health Assistant (BHA) 3
During an interview on 1/30/19 at 1:34 PM with RN 5 (charge nurse) and BHA 3, RN 5 could not recall for sure what the patient used to tie around his/her neck or how it had been obtained. RN 4, the Lodge Nurse Manager (who was also present), thought the patient used a strap from a craft activity that the patients had been doing. BHA 3, who was listed as a witness on the incident report, stated the patient used a string from his/her hoodie jacket. When asked if they had conducted a check of the patient's belongings/area for any types of ligature or items the patient could use to hurt him/herself after the incident had occurred, BHA 3 stated that s/he had, but didn't document this. According to the staff, the physician saw the patient that day, and staff had gone to the patient's room and removed shoe laces and took the strings out of any hoodies.

RN 4
During an interview on 2/1/19 at 3:04 PM, RN 4 verified the above nursing/practitioner notes after review of the notes. According to RN 4, the nurse taking care of Patient 6 should have called and notified the physician on the night of 10/17/18 after the patient had expressed a desire to hurt her/himself. After reviewing the Special Treatment Log documentation, s/he verified the patient's supervision level had not changed and the patient had remained on group precautions.

Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the governance of the hospital failed to ensure nursing oversight and monitoring of patients restrained in the hospital's lodge to ensure clear expectations for safety were established for 1 of 1 patients who died during an inappropriate hold in the hospital's lodge (Patient 5), and failed to ensure the appropriate level of supervision was in place for 1 of 1 patient with suicidal ideations whose level of monitoring or other interventions were not appropriately implemented to ensure the patient's safety for 1 of 10 patient charts reviewed. (Patient 6)


The findings are:


Patient 5
On 2/1/19 at 3:46 p.m., review of the hospital ' s video related to a restraint hold for Patient 5 that occurred on 1/22/2019 at approximately 10:40 AM per the date and time stamp on the video revealed:
1/22/2019 - 10:40 AM: Patient 5 ambulates in the hallway towards a room(atrium) with plexiglass windows. Patient 5 kicked at the bottom seal of plexiglass. A female staff member approached the patient and then walked away from the patient. Patient 5 turned a corner and started kicking the plexiglass windows on the other side of the room(atrium). A male staff member walked towards the patient and then left the patient who continued to kick the plexiglass windows. A male staff member walked into the nursing station which is also located on the hallway and the medication administration room is located in front of the nursing station. At 10:44 AM, the male staff member exited the nursing station and entered the medication administration room without closing the door. Patient 5 walked towards the medication room. The male staff member attempted to close the door to the medication administration room as Patient 5 attempted to open the door and enter the medication administration room. Patient 5 attempted to push the door to the medication room open while the male staff member attempted to close the door. Two (2) female staff members and 1 male staff member approached the patient from the patient's back and used their hands to grab the patient's jacket. Then, a fourth male staff member ran from behind the patient and grabbed the patient's neck and all of the staff members threw the patient to the floor. The patient was face down when all four staff members got on top of the patient. A glimpse of the patient showed the patient's head was covered by the jacket and half the patient's buttocks were in view. Physician 2 appeared in the hall way, approached the scene, looked, and then walked away from the scene. The male staff person that was in the medication room who was identified later as a Registered Nurse was observed on the patient also. Staff continued to cover the patient's body. Physician 2 exited the nurse station again, but then returned to the nurse station. The patient was not visible with all the bodies on the patient. There is no observed supervision by nursing, medical staff, or administrative staff during the restraint hold or any physical assessment for the patient's well being during the restraint hold.

At 10:48, the first Patient Safety Officer arrived and requested staff to get off the patient and move back. Multiple bystanders were in the hall way. The patient was on the floor on his stomach. Then, staff turned the patient, and when the patient was noticed to be unresponsive, started chest compressions. Staff members had an ambu bag but appeared to encounter difficulty in the operation of the ambu bag. At 10:50, a staff member brought a code cart to the scene. The code cart had an AED on top but the AED was later moved to the floor where it was observed throughout the code. The AED was not placed on the patient. At 10:52, staff appeared to try to get the ambu operational. At 10:54 AM, more and more bystanders appeared in the hallway. At 10:52, compressions were discontinued and then restarted.
At 11:01 AM, the Emergency Medical Transport Team arrived to the scene and instituted emergency management of the patient with oxygen, cardiac monitor, defibrillator, and transported the patient to the hospital where the patient was pronounced.

Interviews
Registered Nurse 3
On 2/1/19 from 2:22 p.m. until 2:28 p.m., a telephone interview was conducted with Registered Nurse (RN) 3 who verified he/she was on duty in Lodge B on 01/22/19 on the 7:00 a.m. to 3:30 p.m. shift during the incident. RN 3 stated, "The patient was kicking the windows. I went in the med room to see if he had medication. I closed the med room door. The charge nurse attempted to enter the med room, and the patient was behind him. Some other staff came to help the charge nurse remove the patient. I closed the door to the medication room and drew up his medication. I came out to give him his medicine. They turned him over, and he was blue. There were so many people standing around, and I yelled out to call a code. I brought the crash cart and they had the AED on him. He had Benadryl and Thorazine ordered, but I couldn ' t ' find the Thorazine. Right after the girl started CPR, someone called a code." RN 3 reported when asked if he/she had administered the medication to the patient, "No, when they turned him over, he was blue." RN 3 verified the witness statement that he/she submitted on January 22, 2019.

Master of Social Work
On 2/1/19 from 2:39 p.m. until 2:55 p.m., a telephone interview was conducted with Medical Social Worker (MSW) 1 who verified that he/she was on duty in Lodge B on 01/22/19 during the incident. MSW 1 stated, "I don't remember the time, but myself, Mental Health Counselor (MHC) 1, Nurse Practitioner 1 and a Nurse Practitioner student were in the treatment room in Pod 2 at a table. The treatment team had discussed the patient's treatment and the patient was restricted and placed on white band. We all stayed there. He (patient) comes back to the door and MHC 1 gets up to talk to him. We heard him kicking on the windows, and I tried to talk to him. I told someone to call a code management. I don't know who made the first call. I had my cell phone in my hand. I called the number several times and couldn't get through. I called Public Safety at the nurse station. I saw the patient halfway through the door of the med room. The patient's arms appeared to be around the nurse's neck. I see him down on the ground. I held a leg and MHC 1 held a leg. The patient is aggressive, and we need help. We ushered patients to Pod 3. Behavioral Health Associate (BHA) 1 ran out the back door to find help. Public Safety Officers (PSO) came in and staff released the patient. I heard them call a code Blue. I had a panic attack that morning. I wrote my statement, but I don't know what I put in my statement. They called Code Management and Code Blue at the same time. The PSO was using his walkie talkie to call Code Blue. The surveyor questioned MSW 1 regarding the training received for restraints and/or holds, and MSW 1 stated, "We have BEST training. I think the most I got out of it was how to do when the patient attacks you. I know you can hold arms or legs. We were told, "You guys won't have to do anything because you can call Code Management." I have no clue how to restrain a patient in relation to patient attacking someone else. Ankles and feet, and arms and wrists can be restrained." MSW verified the witness statement that he/she submitted on Jan 22, 2019.

Behavioral Health Aide(BHA) 2
On 2/1/19 from 3:03 p.m. until 3:08 p.m., a telephone interview was conducted with BHA 2 who verified that he/she was on duty in Lodge B on 01/22/19 when the incident occurred. BHA 2 stated, "I got there at the last minute. He was attacking the nurse. He was already inside the med room. We all pulled him out of the room and escorted him to the ground and guided him to the ground and restrained him til PSO got there." BHA 2's witness statement dated 01/22/2019 was verified with him/her.

Physician 2
On 2/1/19 from 3:11 p.m. until 3:25 p.m., a telephone interview was conducted with Physician 2 who verified that he/she was in Lodge B on 1/22/19 during the incident. Physician 2 stated, "We had treatment team meeting that morning. The patient had an altercation with a peer the day before. The patient was given a different band. The patient left the room and was upset. He was banging on the windows. The Nurse Practitioner ordered a prn(as needed medication). He tried to enter the nurse station. The staff restrained him. I went to the nurse station to call PSO. I'm new, and I don't know who to call. I found an alternate number. They called a Code Management and the PSC came. The staff let the patient go, and he didn't move. Other patients were coming up, and they were getting agitated. I got on the floor and CPR(cardiopulmonary resuscitation) was started. I was trying to lead the code. Code Blue was called. The Ambu bag didn't have the correct attachment. The AED was attached, and we continued CPR. I'm not ACLS(Advanced Cardiac Life Support) trained. I bagged the patient and swapped out. There were other doctors and the NP there. The NP took over the bagging. I saw them restrain him. It was 4 people. Two on his arms and 2 on his legs." The surveyor asked if anyone monitored the patient while he was restrained. Physician 2 stated "No".
Physician 2 verified the witness statement submitted on January 22, 2019.

Mental Health Counselor(MHC) 1
On 2/1/19 from 3:26 p.m. until 3:35 p.m., a telephone interview was conducted with MHC 1 who verified that he/she was in Lodge B on 1/22/19 during the incident. MHC 1 stated, "The patient became agitated, and we tried to calm him down. We called Code Management. Someone said we can't call Code Management anymore. We called PSO, and the line was busy, busy. Another female ran out. The patient started fighting the nurse. Two (2) males put him on the ground. PSO came in. All they were doing were holding his legs and arms."
MHC 1 verified his/her witness statement submitted on Jan 22, 2019.

Registered Nurse(RN) 6
On 2/4/19, from 2:56 p.m. until 3:05 p.m., a telephone interview was conducted with RN 6 who verified that he/she was in Lodge B on duty on 1/22/19 on the 7:00 a.m. to 3:30 p.m. shift when the incident occurred. RN 6 stated, "Basically a patient tried to come after me into the med room. I walked to the med room, and the patient asked me, "Are you gonna give me a shot?" He tried to get in the room. He did not hit me, and he didn't raise his hands to hit me. I tried to push him out of the room. There were 2 other staff members on the other side of the door, and they took him to the ground. He did not hit his head. I held his arm. We called PSO, but couldn't get through to them. So another staff member ran out the door and got PSO and radioed to staff. Everyone started showing up. When the rest of PSO got there, he was turned over. We got the crash cart and started CPR. PSO called EMS from their radio." RN 6 verified the witness statement that he/she submitted on 1/22/2019.

Patient 6
Patient 6 was admitted on 8/26/18. Record review from 1/29/19 - 2/1/19 revealed concerns related to incidents when the patient expressed suicidal ideation to a nurse on 10/17/19 at 9:00 PM. Review of a Nursing Progress Note dated 10/17/18 at 10:50 PM showed nurse notes documented at 9:00 PM, "Patient came to the Nurses Station and stated that s/he was thinking about hurting her/himself like s/he did before which is by tying something around her/his neck. I got her/him to express her/himself. S/he has a bandana around her/his head. It was removed and given to me by the patient to be placed at the Nurses Station. Will continue to monitor." There was nothing documented in the notes that the nurse notified anyone about the patient's report on 10/17/18 that s/he had been thinking about harming him/herself. A review of Special Treatment Procedure Logs for 10/17/18 revealed documentation by a behavioral health assistant on 10/17/19 at 9:00 PM that stated the patient was getting ready for bed. A 10/17/19 at 9:30 PM, Behavioral Health Assistant note showed the patient was sitting in the pod and hearing voices. There was no documentation that a search had been conducted to remove any possible ligature risks or potentially harmful items from the patient's access that evening/night shift after the patient's statement. According to the Special Treatment Procedure Log dated 10/18/18 at 8:30 AM, a "19" was documented. According to the codes listed on the Special Treatment Log, Code 19 meant a contraband check had been completed by the Certified Nursing Assistant (CNA). On 10/18/18 at 9:20 AM, the CNA documented, "Pt. (Patient) tried to choke her/himself with a neckband. Did a contraband check...". A Nursing Progress Note dated 10/18/18 at 3:56 PM revealed documentation dated 10/18/18 at 12:00 PM that read, "Staff reports pt (patient) was seen breathing heavy and asked what was wrong. It was discovered that the patient had a strap tied around her/his neck. The strap was immediately cut from her/his neck.

A Psychology/Counseling Note dated 10/17/18 at 2:43 PM documented a meeting with the patient on 10/16/18 at 10:16 AM. According to the note, the treatment team met with the patient to follow up on incidents in the last few days. "...(Patient 6) reported having suicidal ideation and had self-harmed by scratching her/himself...LPP explained the changes to medication by stopping some medications that could make her/him more restless." The note stated Patient 6 had overdosed on Depakote on 8/10/18 prior to admission to the hospital. The patient had a history of multiple suicide attempts, and wanted to die. According to the note, the patient had attempted to walk into traffic, cut wrists, overdosed on pills, and used a shoe string to choke her/himself.

Review of the nursing progress notes and the Special Treatment Procedure Log for 10/16/18 through 10/19/18 revealed the patient's supervision level had not been increased as a result of the suicidal incident with the patient having tied a strap around her/his neck. S/he had remained on Group Precautions (except for the times when s/he had been restrained or secluded) after the incident. A nursing note dated prior to the incident on 10/17/18 documented the patient was on Group Precautions before the incident happened, and a nursing note dated after the incident on 10/18/18 at 6:59 PM, revealed the patient remained on Group Precautions. According to the Special Treatment Procedure Log Documentation Guidelines, this meant the patient must be kept within line of sight at all times, with a 3:1 patient to staff ratio. Contraband checks would be documented, as well as observation and care every 30 minutes. Review of the policy, entitled, "Special Treatment Modalities/Observation Levels" dated June 2017 revealed that Group Precautions (GP) was for "Any patient whose uncontrolled behavior/condition could be detrimental to the milieu...(the patient) is assigned to an individual staff member and must remain within line of sight of staff at all times. The staff member may be responsible for up to three (3) patients...".

A review of the Unusual Occurrence Reports revealed that on 10/18/18 at 9:17 AM, "The patient was seen breathing heavy and asked what was wrong. It was discovered the patient had a strap tied around her/his neck. The strap was immediately cut from the patient's neck." According to the report, at the time of the occurrence, a Nurse Practitioner and the charge nurse (Registered Nurse #5) had been notified. In the report under section N, "(what was done to reduce the risk of reoccurrence):" was checked, Patient education, Enhanced staff observation for safety, and Attending Physician or designee consulted.

Interviews
Behavioral Health Assistant (BHA) 3
During an interview on 1/30/19 at 1:34 PM with RN 5 (charge nurse) and BHA 3, RN 5 could not recall for sure what the patient used to tie around his/her neck or how it had been obtained. RN 4, the Lodge Nurse Manager (who was also present), thought the patient used a strap from a craft activity that the patients had been doing. BHA 3, who was listed as a witness on the incident report, stated the patient used a string from his/her hoodie jacket. When asked if they had conducted a check of the patient's belongings/area for any types of ligature or items the patient could use to hurt him/herself after the incident had occurred, BHA 3 stated that s/he had, but didn't document this. According to the staff, the physician saw the patient that day, and staff had gone to the patient's room and removed shoe laces and took the strings out of any hoodies.

RN 4
During an interview on 2/1/19 at 3:04 PM, RN 4 verified the above nursing/practitioner notes after review of the notes. According to RN 4, the nurse taking care of Patient 6 should have called and notified the physician on the night of 10/17/18 after the patient had expressed a desire to hurt her/himself. After reviewing the Special Treatment Log documentation, s/he verified the patient's supervision level had not changed and the patient had remained on group precautions.