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Based on document review, observation and interview, the facility failed to ensure a patient was free from abuse, failed to report an occurrence of patient abuse by a staff member to government agencies within 24 hours of the abuse, facility nursing staff implemented restraint or seclusion without a provider order for 1 of 10 medical records reviewed. (P4); and failed to ensure all direct patient care staff members held a current Handle with Care and/or restraint/seclusion certification for 8 of 15 personnel files reviewed. (N3 [Registered Nurse], N4 [Licensed Practical Nurse], MHT6 [Mental Health Tech], MHT7 [Mental Health Tech], MHT8 [Mental Health Tech], MHT9 [Mental Health Tech], MHT10 [Mental Health Tech], MHT11 [Mental Health Tech])

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review, observation and interview, facility nursing staff failed to complete direct visual contact with assigned patients during patient observation rounding visual for 1 of 10 medical records reviewed. (P1)

Findings include:


1. Facility policy titled, Level of Observation, PolicyStat ID 15820401, last revised 11/2018, indicated under PROCEDURE: 5. Every 15 Minute Observations. Staff will observe patient and document on the Patient Observation record q 15 minutes. Staff will make direct visual contact with their assigned patients and confirm they are in no danger or distress.

2. Review of P1's MR indicated the patient was 41 y/o (year/old) admitted to facility from 8/22/24-8/23/24, with diagnoses including but not limited to delusions, schizophrenia, and methamphetamine use disorder. Patient Observation documentation dated 8/23/24 indicated MHT5 (Mental Health Technician) charted P1 being in the courtyard from 5:30 pm -7:00 pm then as in his/her room at 7:15 pm, MHT4 (Mental Health Technician) documented P1 as being in the courtyard at 7:30 pm and 7:45 pm. No other patient observation checks were documented as completed for P1 after 7:45 pm on 8/23/24.

3. MR for P4 lacked documentation related to the incident that occurred on 8/29/24 that included MHT1 (Mental Health Tech) abusing P4.

4. P1 was listed on the incident report log on 8/23/24 for an elopement from the facility. On 8/23/24 at approximately 6:45 pm P1 climbed a tree in the courtyard while he/she was unsupervised by facility staff members during a smoke break. P1 was found by law enforcement at a local hospital with a fracture injury related to the elopement. Since this event all trees in that courtyard have had their limbs trimmed to a non-reachable height.

5. In interview on 10/2/24 at approximately 11:30 am with A2 ( Director of Risk Management) confirmed N1 (Registered Nurse) did not follow restraint/seclusion/hand with care training and was suspended until retrained. Confirmed a provider should have been notified of the abuse that resulted in injury but was not, confirmed skin assessment with wound documentation should have been charted in P4's medical record but was not. MHT4 and MHT5 did not make direct visual contact with their assigned P1 during observation rounding while in the courtyard but should have.

Based on document review, observation and interview, the facility failed to ensure patient was free from abuse and failed to report an occurrence of patient abuse by a staff member to G1 (Government Agency) and G3 (Government Agency) within 24 hours of the abuse for 1 of 10 medical records reviewed. (P4).

Findings include:

1. Facility policy titled, Patient Rights and Responsibilities, PolicyStat ID 15601140, last revised 03/2017, indicated under Adult Patient Rights: 7. You will be free from mental or physical abuse, and from chemical and physical restraints except those restraints authorized in writing by the physician when necessary for your protection or the protection of others. When restraints are necessary, they will be applied under the direction of a physician

2. Facility policy titled, Abuse Assessment and Reporting, PolicyStat ID 15678512, last revised 02/2020, by indicated under PROCEDURE: Suspected abuse/neglect occurred while receiving services at H1: 4. If the suspected abuse is reported abuse or neglect occurs to an adult while an inpatient, the report must be called to G1. 6. G3 shall be contacted within 24 hours by Risk Manager is designee if the alleged or reported abuse or neglect occurred on any acute inpatient unit. The report should be called or faxed (using D3 Incident Report) to the G3.

3. Medical Record review for P4 lacked documentation of patient abuse by MHT1 (Mental Health Technician) that occurred on 8/29/24.

4. Facility Incident log indicated on 8/29/24, P4 was listed for aggression by staff (MHT1) towards patient. P4 came out his/her room and staff tried to redirect to his/her room. According to the filed incident report, while being redirected the patient ran into his/her door causing an injury that required first aid. When assessed by the practitioner on 8/30/24 the patient was sent out for assessment and treatment of a puncture wound. An update entered by A2 (Director of Risk Management) indicated video footage of the incident was reviewed, and it was determined that staff (MHT1) aggressively moved the patient down the hallway, causing the patient to fall at one point and when the patient got up, staff (MHT1) continued to aggressively move the patient and appeared to push the patient into his/her room.

5. Video footage review on 10/2/24 at approximately 11:30 am with A2, this writer observed the following:
a. 8/29/24 at approximately 11:22 pm P4 can been seen walking naked towards and entering the day room.
b. 8/29/24 at approximately 11:22 pm P4, N1 (Registered Nurse) and MHT1 can be seen in the day room.
c. 8/29/24 at approximately 11:23 pm MHT1 can be seen violently shoving P4 multiple times with both hands out of the day room door and down the unit hallway towards the patient's room. While in the unit hallway MHT1 can be seen violently shoving P4 to the floor with both hands, then MHT picked P4 up with both hands under his/her posterior underarms then P4 went into his/her room. MHT1 remained present close to or within the patient's doorway.
d. 8/29/24 at approximately 11:23:34 pm P4 attempts to exit his/her room and was met by MHT1 who then violently shoved with both hands P4 back into his/her room. MHT1 can be seen entering P4 room during these actions.
e. 8/29/24 at approximately 11:23:48 pm MHT1 can be seen exiting the patient's room and signaling for help.
f. 8/29/24 at approximately 11:24 pm N1 enters P1's room/doorway for approximately 20 seconds but does not appear to be keeping the patient from leaving.
g. The incident footage ends at 11:24 pm on 8/29/24 and this writer is unable to determine when first aid was rendered to the patient after the abuse.

6. In interview on 10/2/24 at approximately 11:30 am, A2 confirmed P4 was physically abused by MHT1 on 8/29/24 and should not have been, and a critical incident report was not filed but should have been with G3 nor was there notification to G1 after the discover of patient abuse until 10/1/2

7. In telephone interview on 10/8/24 at approximately 11:45 am with MHT2 (Mental Health Tech) confirmed P4 was naked, MHT1 pushed the patient hard into his/her room door causing an injury with bleeding and bruising. MHT2 also confirmed that employees are not allowed and/or trained to push or shove patients, patient abuse is not common at H1, and nursing staff was notified to come help the injured P4.

Based on document review and interview, facility nursing staff implemented restraint or seclusion without a provider order for 1 of 10 medical records reviewed. (P4)

Findings include:

1. Facility policy titled, Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion-Adult (Seclusion Restraint), PolicyStat ID 15286480, last revised 05/2024, indicated under PROCEDURE: C. Physician Orders, Consultation, and Evaluation. 1. Restraint or seclusion shall be used in emergency situations only and requires an order from a physician. Prior to initiation of restraint or seclusion, the physician and nurse will be aware of any considerations that should be taken based upon the initial assessment completed at the time of admission.

2. Review of P4 medical record indicated patient was placed in seclusion by N1 (Registered Nurse) on 8/29/2024. MR (medical record) lacked a provider order for seclusion.

3. Personnel file reviewed for N1 indicated current year required education and/or competencies including Handle with Care initial training and recertifications, completed facility and unit orientation. Status change documentation dated 9/10/24 indicated a discussion was had of the performance concerns and policy violations which have been seen including not redirecting MHT1 (Mental Health Technician) who pushed a patient, participating in physically stopping a patient from leaving their room thus doing a seclusion without a physician's order.

4. In interview on 10/2/24 at approximately 11:30 am A2 (Director of Risk Management) confirmed N1 did not, but should have, followed restraint/seclusion/hand with care training when placing P4 in seclusion, and is suspended until retrained.

Based on document review, observation and interview, the facility failed to ensure all direct patient care staff members held a current Handle with Care and/or restraint/seclusion certification for 8 of 15 personnel files reviewed. (N3 [Registered Nurse], N4 [Licensed Practical Nurse], MHT6 [Mental Health Tech], MHT7 [Mental Health Tech], MHT8 [Mental Health Tech], MHT9 [Mental Health Tech], MHT10 [Mental Health Tech], MHT11 [Mental Health Tech])

Findings include:

1. Facility policy titled, Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion-Adult (Seclusion Restraint), PolicyStat ID 15286480, last revised 05/2024, indicated under PROCEDURE: N. Staff Training and Competence Assessment: Medical Staff, direct care staff, and RNs/PAs are oriented to the standards for the use of restraint/seclusion. Direct care staff and PAs are required to attend a nationally recognized physical/aggression management training program and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment and care of a patient in restrains or seclusion. Physician and other LIPs authorized to order restraint of seclusion must have a working knowledge of the facility's policy regarding the use of restraint/seclusion. Nurses and PAs authorized to conduct the one-hour face-to-face evaluation will receive additional training and demonstrate competency to conduct both a physical and behavioral assessment of the patient. All records documenting completion of training and competency demonstration will be maintained in staff personnel filed or credential files.

2. Personnel file(s) were reviewed for N3 (Registered Nurse), N4 (Licensed Practical Nurse), MHT6 (Mental Health Tech), MHT7 (Mental Health Tech), MHT8 (Mental Health Tech), MHT9 (Mental Health Tech), MHT10 (Mental Health Tech), MHT11 (Mental Health Tech) indicated an expired Handle with Care certifications.

3. In interview on 10/2/24 at approximately 11:45 am with A3 (Chief Operating Officer) confirmed employees without current Handle with Care certifications were allowed to work in direct patient care while expired and should not have been. These employees should have been suspended until recertified but were not.

Based on document review and interview, facility nursing staff failed to notify a provider of a patient's change in condition for 1 of 10 medical records reviewed. (P4).

Findings include:

1. Facility policy titled, Changes in Patient's Condition, PolicyStat ID 15820433, last revised 05/2024, indicated under PROCEDURE: Clinical Staff/ Nurse: When the clinical nursing staff identify symptoms in a patient that constitute a medical risk/acute change of condition they will proceed with the following steps: a. Assess whether the patients' condition requires emergent action (transfer to medical facility emergency room) or whether the condition can wait until the nurse can consult with the medical staff. b. If the condition is emergent the clinical staff will provide immediate first aid and/or CPR and call for emergency transport. c. Charge Nurse or RN designee will call the attending physician or medical consultant immediately to provide and update and obtain necessary orders. (If medical consultant is called first due to an urgent medical condition, the attending physician must also be notified as soon as possible.

2. MR review for P4 lacked documentation of physician notification of P4's injury sustained on 8/29/24 at approximately 11:22 pm as a result of patient abuse by MHT1 (Mental Health Tech).

3. Facility Incident log indicated on 8/29/24, P4 was listed for aggression by staff (MHT1) towards patient. P4 came out of his/her room and staff tried to redirect to his/her room. According to the filed incident report the while being redirected the patient ran into his/her door causing an injury that required first aid. When assessed by the practitioner on 8/30/24 the patient was sent out for assessment and treatment of a puncture wound. An update entered by A2 (Director of Risk Management) indicated video footage of the incident was reviewed, and it was determined that staff (MHT1) aggressively moved the patient down the hallway, causing the patient to fall at one point and when the patient got up, staff (MHT1) continued to aggressively move the patient and appeared to push the patient into his/her room. A critical incident report was not filed with G3 (Government Agency) nor was there notification to G2 (Government Agency) related this incident of patient abuse by a staff member until 10/1/24 at 4:42 pm. No notification to P4's family was made due to the patient being involuntarily committed by a judge to facility to regain his/her competency to stand trial. An investigation timeline provided by A2 is as follows:
a. 8/29/24- 11:15 pm incident occurred.
b. 8/30/24 - Reviewed incident report originally documented in morning administrative/safety meeting (AKA [Also Known As] Flash). Incident reported as an accidental patient injury.
c. 8/30/24 - Patient sent to local emergency room for treatment after seeing practitioner. P4 received stitches to his/her puncture wound.
d. 9/3/24 - A2 received health services compliance hotline call. Video footage reviewed. MHT1 was suspended pending full investigation.
e. 9/4/24 - MHT1 was interviewed in person by facility human resources.
f. 9/6/24 - N1 was interviewed by telephone by facility human resources. N1 (Registered Nurse) suspended pending in person interview on 9/10/24. MHT1 terminated.
g. 9/10/24 - Facility human resources and nursing leadership interviewed N1. N1 suspended rending re-education and review of corrective action documentation scheduled for 9/16/24.
h. 9/16/24 - A2 interviews MHT2. N1 rescheduled training for 9/23/24.
i. 9/24/24 - N1 cancels training stating he/she might be available on 9/30/24.
j. 9/30/24 - N1 does not complete training. N1 remains suspended.

4. In interview on 10/2/24 at approximately 11:30 am, A2 confirmed a provider should have been notified of the abuse that resulted in P4 injury, but was not.