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Based on staff interviews, review of investigative statements, review of records, review of policy and procedures, and review of training material, the facility failed to fulfill the patient's right to be free from all forms of abuse or harassment, failed to ensure all patients have the right to be free from the inappropriate use of physical restraint, and failed to ensure a physical restraint was safely implemented. 1. The facility failed to ensure Patient (P)1 was free from all forms of abuse or harassment as evidenced by P1 being abused by Mental Health Specialist (MHS) 3. The facility also failed to identify and investigate a previous occurrence of possible abuse by MHS3 toward another patient (refer to A-0145). 2. The facility failed to ensure P1's right to be free from the inappropriate use of physical restraint and failed to ensure that P1's physical restraint was safely implemented as MHS3 did not follow protocol for a physical hold, there was no order obtained for the physical hold, and that staff members did not ensure that no pressure was applied to P1's body or chest (refer to A-0154, A-0165). The cumulative effect of these problems resulted in the hospital's failure to protect and promote this patient's rights.

Based on staff interviews, review of investigative statements, review of records, review of policy and procedures, and review of training material, the facility failed to fulfill the patient's right to be free from all forms of abuse or harassment as evidenced by Patient (P) 1 being abused by Mental Health Specialist (MHS) 3, and the failure of the facility to identify and investigate a previous occurrence of possible abuse by MHS3 toward another patient.

Findings Include:

During an interview with the Director of Patient Care (DIR) on 08/28/20 at 10:43 AM, DIR revealed that the facility was currently investigating a recent abuse allegation of MHS3 toward P1. DIR also stated that the facility has reported this to other state authorities as well.

A review of P1's medical record revealed that P1 was admitted with a diagnoses of Schizophrenia, Substance use disorder. P1 has a history of violence, aggressive behavior, un-predictable behaviors, auditory hallucinations, delusional, and has been moved to different nursing units because of aggressive behaviors. According to the nursing progress notes, on 08/21/20 at 05:35 PM, P1 punched P2 for no apparent reason. Staff attempted to re-direct P1, but P1 refused to listen, started posturing, and went to punch MHS staff to assault them. P1 was very aggressive and was looking for a fight. The unit was cleared and a Code Green was initiated. The physician was called and approved the order for restraints and as needed (prn) medication. P1 was successfully put to the chair restraint and took the prn medication. P1 was also complaining of a headache, and was given medication for pain. "Upon assessment I and my supervisor noted red discoloration and scratches on patient's neck".

A review of P2's medical record revealed that P2 complained of pain after the incident, was treated with medication and was transferred to another nursing unit.

An interview, on 08/28/20 at 01:45 PM, with the Shift Supervisor (Supvr) and review of Supervisor's written statement showed that P1 was tackled down to the ground and held by two staff members; MHS2 and MHS3. MHS 3 was noted to be sitting on P1's chest and MHS3's hands was wrapped around P1's neck with both thumbs pressing the throat. Supvr told MHS3 to get away and tried pulling MHS3 off but MHS 3 was saying "don't touch me". MHS3 released his hands but then started to slap P1's face while saying "you fucka don't you ever do that to me again!". About fifteen seconds later, MHS3 again was seen with hands around P1's neck with both thumbs pressing the throat. At this time, P1 was noted to have redness to eyes and face, and could barely talk. Supvr yelled saying "please please stop" and successfully pushed MHS 3 away. Supvr instructed MHS 3 to go to another unit, but later MHS3 returned to P1, pointed to P1's face and slightly slapped P1 and said "Don't you ever do that to me!". This time, MHS3 was separated from P1. Supvr assessed P1 who expressed pain to head and throat, mild redness noted to throat area and redness to right shoulder.

During an interview, on 08/31/20 at 10:14 AM, with Charge Nurse (CN1), and review of CN1's written statement, CN1 revealed that P1 was transferred three times to different nursing units with the latest incident of P1 being assaultive to female staff. CN1 stated that upon responding to the Code Green and arriving to the unit, CN1 noticed that P1 was on the ground and MHS3 was on top putting so much pressure. CN1 heard Supvr yelling at MHS3, trying to redirect MHS3 to get off P1.

An interview, on 08/31/20 at 11:29 AM, with Charge Nurse (CN2), and review of CN2's written statement revealed that P1 did not show any signs of aggressive and/or assaultive behavior leading up to the time of the incident. CN2 observed P1 punched P2 at 05:35 PM for no apparent reason. CN2 tried to re-direct P1 but P1 refused to listen, started posturing, and then was noted to have punched MHS3 on the face and head. MHS3 became very aggressive and fought back to P1. The unit was cleared and Code Green was called. CN2 heard MHS3 say to P1 "Don't ever dare to punch me" and CN2 noticed that MHS3 was upset and wanted to fight back. P1 was tackled down to the ground and was held by MHS2 and MHS3. CN2 noted that MSH3 was elbowing, slapping the face, and choking P1 because MSH3 was angry. Other support staff arrived and P1 was successfully put in the restraint chair.

An interview, on 08/31/20 at 12:22 PM, with MHS2 and review of MHS2's written statement revealed that P1 was pacing around the unit and then turned around and punched P2 for no reason. Staff tried to talk to P1 but P1 attacked MHS3 instead. P1 punched and kicked MHS3, then was taken down by MHS3 and held down by MHS3 and MHS2. Two other patients also came to help hold down P1. MHS2 stated that P1 was very angry, violent, fighting back, trying to bite, head butt, and kick both MHS3 and MHS2. It took a while for help to arrive, the Code Green was called, and when help came P1 was placed in the restraint chair and then placed in the quiet room. In addition during this interview, MHS2 revealed an occurrence that happened one to two months ago where another patient was initially taken down by MHS3 and then held down by other staff for medication. MHS2 stated that staff was talking to this patient, but the patient was loud, threatening, and not cooperative. Then, all of sudden MHS3, by himself, jumped in and took down this patient and surprised the rest of the staff. MHS3 got on top of this patient and had his hands wrapped around the patient's neck as if to choke this patient. MHS3 was told to get off and did. MHS2 stated that this occurrence was discussed and that MHS3 was spoken to during a debriefing of the event.

During an inquiry with DIR on 08/31/20 at 01:08 PM, DIR said that MHS3 has had no prior infractions and did not show any signs of violence and/or abuse prior to the occurrence being investigated. DIR stated that staff receives initial Non-violent Crisis Intervention (CPI) training and maintains ongoing CPI training on an annual basis. DIR acknowledged that at no time, does CPI training teach anyone to be positioned on top of the patient's chest. DIR also stated that based on staff statements for this case, the allegations of abuse appeared to be substantiated.

A review of the Patient Rights and Responsibilities stated the following: Patient Rights; A humane environment. To be treated with respect, dignity, and to be free from verbal and physical abuse, harassment, and reprisal. As mentioned before, the facility failed to fulfill the Patient's Right to be free from all forms of abuse.

Review of facility policy on Abuse and Neglect (Duty to Report) stated the following: Purpose; To define the procedures necessary for reporting a patient's allegation of staff's indication of possible physical, emotional, or sexual abuse, or of neglect that may have occurred prior to the patient's admission to the hospital, while the patient is staying at the hospital, while the patient is on an approved pass from the hospital, or may occur in the reasonably foreseeable future. Policy; It is policy of Sutter Health Kahi Mohala ("Kahi Mohala") to ensure compliance with Hawaii's regulations regarding the reporting of a reasonable, good faith belief that a child, adolescent, or vulnerable adult has been subject to abuse or neglect. As previously mentioned, the facility failed to identify, investigate, and/or report a recent occurrence of possible abuse by MHS3 toward another patient.

A review of the workbook on CPI, stated the following: Understanding the Risks of Physical Restraints; No physical intervention is free of risks. Physical restraint should only be used as a last resort, with the least amount of restriction when an individual poses an immediate or imminent threat to harm. Even when physical intervention has been identified as an appropriate response to manage a prevailing risk associated with an individual's behavior, it is your responsibility to understand the potential risks and adverse impacts physical interventions may have on both the individual and staff involved ...

Based on interviews with staff members, review of the facility's policy and procedures and investigative statements by staff members, the facility failed to ensure all patients have the right to be free from inappropriate use of physical restraint.

Findings include:

Adult Protective Services (APS) submitted an "Adult Abuse & Neglect Case Report" to the Office of Health Care Assurance via facsimile on 08/26/20 at 12:34 PM. APS received a complaint on 08/25/20 at noon of an allegation of abuse. On 08/21/20 at 05:30 PM, Patient (P)1 went over to P2 and hit him. Staff members, Mental Health Specialist (MHS)3 and MHS2 attempted to intervene. P1 was agitated and reportedly wanting to fight. P1 chased staff members on the unit. MHS3 put P1 on the ground (supine) and sat atop the patient's chest. MHS3 reportedly slapped P1's face, slapped his elbow and choked the patient. Code green was alerted to request assistance from other units.

On 08/28/20 at 01:45 PM an interview was conducted with the Shift Supervisor (Supvr) regarding the incident. Supvr reported on 08/21/20 at approximately 05:35 PM she responded to a code green (behavior crisis alert on the unit (Mokihana A). Upon arrival, Supvr observed P1 on the ground with MHS3 on top of the patient's chest. MHS3's hands were wrapped around P1's neck and pressing the patient's throat. Supvr called MHS3 by name, asked him what he was doing, and she pulled at his shirt to get his attention. Supvr instructed MHS3 to get off the patient. Supvr moved on to help re-direct the other patients on the unit to go into their rooms. Supvr went back to MHS3 and P1, MHS3 reported released his hands from patient's neck. More staff arrived to assist as P1 was still aggressive (one staff to each extremity: right and left leg and right and left arm). MHS3 began slapping the patient, P1 was noted to be "really physically aggressive". Supvr recalled MHS2 sitting on the patient's lower extremities.

Supvr left and upon return observed MHS3 choking the patient, both hands around neck with his thumbs pressing into the patient's neck. P1 was red and could hardly talk. Supvr pushed MHS3 away and went to assess the patient. MHS3 was redirected and walked away from the situation to retrieve his belongings to transfer to another unit. MHS3 reported walked by P1 and stated "you fucka don't you ever do that to me" and slightly slapped the resident.

P1 would not contract for safety and having thoughts of hurting others. Eventually P1 was agreeable to get into a chair restraint. While getting into the chair P1 continued to express homicidal ideations. On assessment, P1 reported pain level of 10/10. Tylenol was provided. P1 assessed with discoloration to the throat and bruising to the right shoulder. An as needed (prn) Olanzapine orally disintegrating tablet (ODT) was given. P1 was taken to the quiet room and provided 1:1 supervision. Assessment of the patient was done every 15 minutes.

Supvr reported debriefing was done with MHS3 and MHS2. MHS3 informed the Supvr that being cornered by P1 was traumatic and after being punched, P1 felt he needed to protect himself and put the patient down. P1 reported to Supvr this was the first time he was assaulted by a patient and was "triggered". Supvr reported MHS3 is a good worker in all codes, and MHS3 was remorseful about what happened.

Inquired how long was MHS3 atop the patient with hands around P1's neck. Supvr was unable to provide a time estimation. However, upon Supvr's arrival to the unit, MHS3 was already atop P1 with hands around the neck. Supvr attempted to get MHS3 off the patient. Supvr went to attend to the other patients. When the Supvr returned, MHS3 and P1 in the same position. Supvr attempted to redirect staff, unsuccessful. Supvr left and when upon return, P1 was already red and could barely talk.

Further queried what should have been done. Supvr reported there was limited options; however, based on CPI protocol, staff members should continue to talk with the resident to de-escalate the situation. Physical restraining is the last resort and the facility stresses the importance of "Nurture Heart" approach. The Supvr noted P1 is very unpredictable and had a history of "going after a female float" staff member.

Supvr reported at the time of the incident, there were 16 patients on the unit, one nurse and two MHS on schedule (MHS3 was a float at that time).

Charge Nurse (CN)2 was interviewed on 08/31/20 at 11:29 AM. CN2 was the charge nurse on the day of the event. CN2 recalled he saw P1 punch another patient. At this time, P1 was "feisty" and looking for a fight. CN2 pressed button to call for support. P1 was approaching other patients but they were "trapped" from going into their rooms (P1 was by the nurse's station). CN2 reportedly observed P1 go to MHS3 and hit him, support arrived, and CN2 tried to redirect MHS3. CN2 stated that MHS3 was not instructed to physically restrain P1. CN2 could not recall how MHS3 got P1 to the ground.

When Supvr arrived, CN2 was instructed to call the doctor. At that time, CN2 observed MHS3 atop P1 and Supvr trying to redirect MHS3.

Inquired what is the CN's role in these situations. CN2 responded to contact the doctor to get prn order for medication and try to help to control the situation. CN2 reported that this was the first code green that he/she experienced. Further queried what are staff members to do in response to being hit by a patient. CN2 stated that you are not allowed to fight back, in the training staff member should wait for support team to arrive, the more in number you can control the situation better. CN2 shared this was a bad code and he/she was unable to get MHS3 off the patient and was unable to redirect the staff member. CN2 noted MHS3 was feisty and posturing too.

MHS2 was interviewed on 08/31/20 at 12:22 PM. MHS2 was working with MHS3 at the time of the incident. MHS2 recalled after dinner, P1 ate his dinner then started pacing on the unit and without saying a word, walked over and hit P2. MHS2 attempted to intervene and MHS3 was approaching. P1 kicked MHS2. MHS3 ended up backing up, hit the wall and was corned by P1. P1 punched MHS3 in the face, MHS3 tried to duck, then hugged (put arms around resident) and they both fell to the ground. P1 reported was punching MHS3. At this time MHS2 attempted to grab the patient's hand, whilst P1 was head butt and bite staff. MHS3 got on top of P1. MHS2 asked the nurse to call a code green.

Inquired whether MHS3 was seen with hands around P1's neck or whether MHS3 attempted to hit the patient. MHS2 stated he/she didn't see, but heard someone saying, "enough already, get up, get up" and MHS2 heard that MHS3 was choking the patient. Further queried when are staff allowed to put hands on patients, the response was when the Charge Nurse calls it and the charge Nurse did not call it in. MHS2 further stated, my personal knowledge is you are not supposed to get on top of the patient.

MHS2 was asked how long did this event last? MHS2 responded it was a long time before anybody else responded from the time MHS3 brought the patient to the ground. Best guess was five minutes.

Charge Nurse (CN)1 was interviewed on 08/31/20 at 10:14 AM. CN1 reportedly responded to the code green. Upon arrival saw somebody on the floor and somebody on top. CN1 recalls hearing the Supvr yelling MHS3's name and telling MHS3 to stop. CN1 went to assist CN2 at the nursing station to obtain prn medication order. CN1 saw the Supvr attempting to get MHS3 off P1, however, MHS3 yelled at Supvr not to touch him/her. CN1 observed MHS3 and MHS2 atop P1 with MHS3 being on P1's upper extremities and MHS2 on P1's lower extremities.

CN1 reported it is not common for staff members to get patients on the ground and get on top of them. Inquired how long before MHS3 got off P1, CN1 reported until P1 was not resisting anymore. Staff were able to transfer the patient to the chair at 06:15 PM. CN1 could not recall seeing any of MHS3's action, only that he/she was on P1 and he/she did not see where the staff members hands were.

On 08/31/20 at 02:22 PM interview was done with the Director of Patient Care (DIR). Inquired what interventions are staff members trained to utilize in this situation. The DIR reported the priority is to block and move. If blocking does not work, then you run, noting every situation is different and depends on how the patient responds. Staff members are trained to use a non-violent crisis intervention (CPI) hold which typically immobilizes the patient and at times the patient may lose balance and will end up on the floor. Inquired whether putting your arms around the patient's torso as they are standing is part of the CPI training, the DIR responded that is not a technique employed in CPI training. The DIR further commented that it was unfortunate that this happened.

A review of staff members' written statement found no discrepancy with the information provided during the staff interviews.

The facility's policy and procedure entitled "Seclusion and Restraint" was reviewed. The procedure for restraint application notes, the facility teaches CPI-approved supportive holds and when a patient demonstrates imminent danger to themselves or other a Licensed Independent Practitioner (LIP) order will be obtained for a CPI supportive hold. Also noted if a patient bends their knees and takes themselves to the ground and the LIP determines a restraint is necessary, staff may restrain the patient by holding their ankles and wrists against the ground in supine position. Notably, staff will take special care to be certain that no pressure is applied across the patient's body or chest areas (staff will continuously assess that the patient's breathing is not compromised).

Based on staff interviews, the facility failed to ensure a physical restraint was safely implemented as a staff member did not follow the protocol for a physical hold, there was no order obtained for physical hold and the staff members did not ensure no pressure was applied across the patient's body or chest.

Findings include:

Cross reference to A-0154.

On 08/21/20 at approximately 05:30 PM there was an incident of Patient (P)1 striking another patient. The two Mental Health Specialists (MHS) on duty responded to the incident. P1 became violent, reportedly kicking, head butting and biting MHS2 and MHS3. P1 chased the two MHS staff members around the unit, cornering them against the wall. MHS3 reportedly wrapped his arms around the patient's torso and they ended up on the ground.

The nurse Shift Supervisor (Supvr) was interviewed on 08/28/20 at 01:45 PM. Supvr reported upon arrival to the unit, MHS3 was observed to be sitting atop P1's upper body with hands around the patient's neck and pressing in with thumbs. Supvr attempted to redirect MHS3; however, was unsuccessful. Supvr reported, the patient's face became red and could barely speak. On examination, P1 reported pain level of 10/10 and was administered acetaminophen. P1 was also assessed to have discoloration to the throat and a bruise to the right shoulder.

Interview and review of the Charge Nurse (CN)2 statements found that the two staff members (MHS2 and MHS3) put P1 on the floor without instruction by CN2. During the interview with MHS2 on 08/31/20 at 12:22 PM, MHS2 was asked when do you do hands on? MHS2 replied when the CN calls it and confirmed the CN on duty (CN2) "did not call it in". MHS2 also confirmed during physical restraint, staff are not supposed to get on top of the patient when they are supine on the ground.

The facility's policy and procedure entitled "Seclusion and Restraint" was reviewed. The procedure for restraint application notes, the facility teaches CPI-approved supportive holds and when a patient demonstrates imminent danger to themselves or other a Licensed Independent Practitioner (LIP) an order will be obtained for a CPI supportive hold. Also noted if a patient bends their knees and takes themselves to the ground and the LIP determines a restraint is necessary, staff may restrain the patient by holding their ankles and wrists against the ground in supine position. Notably, staff will take special care to be certain that no pressure is applied across the patient's body or chest areas (staff will continuously assess that the patient's breathing is not compromised).