HospitalInspections.org

Based on interview and record review, the facility failed to ensure that staff followed current standards of practice for patient safety, resulting in the use of an improper restraint technique for 1 (P-1) of ten patients sampled for Patient Rights.

Review of "Incident Report" dated 07/30/24 at 0946 revealed, "Patient agitated after doctor assessed abrasion to chest, patient then ran out of room, there was one staff in hallway. Staff did a one-person manual hold take down, STAT call [for assistance], staff received assistance to put patient in the restraint chair. No injury noted."

On 10/02/2024 during an interview with Director of Nursing Staff B and Assistant Nurse Executive Staff D, the pair were asked if the incident had been investigated. Staff B and D stated that "SHA" (State Hospital Administration) had concluded their investigation and had substantiated violation of "Failure to comply or enforce work rule # 2". Staff B and D confirmed that Staff E did not use a hold technique that was an approved Crisis Prevention and Intervention (CPI) technique (interventions staff are trained on to deescalate a patient before utilizing physical techniques) and therefore failed to follow protocol. Staff D stated that Recipient Rights had not concluded their investigation or any corrective actions at the time of survey exit, which was confirmed by Staff D at 1330 on 10/02/24.

On 10/01/2024 at 1045 during tour of the facility with Associate Director of Nursing (ADON) Staff F, Staff F was questioned if resident care associate (RCA) Staff E was working. Staff F stated that Staff E was on suspension. Staff F was questioned if he knew why Staff E was on suspension. Staff F stated that Recipient Rights has not completed their investigation of an incident between Staff E and P-1, and that Staff E would not return until they have completed their investigations. Staff F was asked if he knew of the event leading to Staff E's suspension. Staff F stated that "(P-1) came out of his room "hot" and that one guy tried to handle him. (Staff E) took him down. (Staff E) was not the target of (P-1), but Staff E took him down. (P-1) walks at a fast pace, almost a jog, (Staff E) tried to stop him, wrapped up his legs... and took him down. (Staff E) was suspended after that."

A review of security video from 07/30/24 at 0942 revealed that Staff E approached P-1's room with medical physician (Staff M) and a second RCA. The three staff leave the patient's doorway without entering and proceed down the hall away from the camera. RCA Staff E is seen trailing behind the other two and looks back over his shoulder briefly, toward P-1's room. Staff E next turns toward the camera and centers himself in the hallway, approximately 20 yards from the camera. P-1 is then seen ambulating quickly towards Staff E. Staff E is seen lowering his head and shoulders toward P-1 ' s waistline. Staff E connects his head and shoulders with P-1 ' s waistline and is seen quickly grabbing the back of P-1's knees and lifting his feet from the ground, while slightly driving P-1 forward. P-1's back appears to impact the floor. Three persons immediately perform a restraint hold on P-1 after he is on the floor.