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Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. The Governing Body failed to ensure the facility's policies and procedures were implemented to protect and promote patient rights, prevent physical abuse, and provide care in a safe setting for two (2) of ten (10) sampled patients, Patient #1 and #9.

Refer to A 144, A 145, and A 397.

Based on interview, record review, and policy review, it was determined the Governing Body failed to ensure the Chief Administrative Executive Officer (CAO) of the facility was responsible for the conduct of the facility. The facility's Governing Body and CAO failed to ensure patients were free from abuse by failing to ensure Nursing Staff on the Behavioral Health Unit used safe approved physical management technique when involuntarily administering injections for two (2) of ten (10) sampled patients, Patients #1 and #9. Record review and interview revealed the facility failed to ensure the facility's policies and procedures prohibiting abuse were implemented, failed to move an alleged perpetrator immediately from patient care, failed to report one (1) incident of alleged abuse (Patient #9) to the appropriate State Agency, and failed to thoroughly investigate the abuse.

The findings include:

Review of the facility's Organizational Structure, Board of Trustees, undated, revealed the Quality, Clinical Services, Patient Safety, and Value Board Committee reported to the Full Board.

Review of the facility's Instructor Manual for Crisis Prevention Intervention (CPI) for nonviolent crisis intervention, dated 2012, revealed the goal of staff when intervening with persons to address behavior that may escalate into a disruptive or violent incident, was to provide for the care, welfare, safety, and security of all involved. The manual's introduction to the personal safety techniques stated the education was not intended as a self-defense course, rather to protect staff and acting-out individuals from injury. Staff was instructed to be especially careful not to use their own bodies in ways that restrict a restrained person's ability to breathe. This included sitting or lying across a person's back. Multiple safe physical intervention methods were described. Choke holds, pushing, pinning, and or bear hug tackles were not recommended or listed as safe techniques.

Review of the facility's Techniques for Effective Aggression Management (TEAM) essentials workbook, dated 2015, revealed a comprehensive overview of the aggression cycle in healthcare settings, verbal de-escalation, and other non-physical management of aggressive behaviors and identification of behavior control methods. There was no specific guidance for safe physical holds, restraint, or management of out of control patients. The advanced module indicated to remain seven (7) feet away from aggressive patients and taught staff to distract, disengage, defend by deflection, escape, avoid, and to defend self from ground level. There were descriptions of safe one-person and two-person escort positioning. The pushing and/or bear hug tackling toward preferred patient position were not recommended or listed as safe techniques.

Review of the facility's policy, Abuse and Neglect, effective 08/01/17, revealed Health Care providers were responsible for assisting patients in situations where abuse/neglect was suspected or reported. Identified/suspected cases of abuse/neglect involving vulnerable adults must be reported to the appropriate authorities by the individual who suspected or received the complaint of abuse/neglect. Those making the report were legally protected. Failure to report a case in which there was knowledge or reasonable suspicion of abuse, neglect, or exploitation to the appropriate agency violated the law. Patients had the right to be free from all forms of abuse or harassment during admission in the facility.

The policy further revealed in protecting patients from abuse, the facility would adhere to the following: Prevention - including analysis of the physical environment to detect any factors that might make abuse/neglect more likely to occur, such as secluded areas and deployment of staff in sufficient numbers to meet the patient's healthcare needs. Screening - persons with a record of abuse or neglect shall not be hired or retained as employees. Identification - maintenance of proactive approach to identify events or occurrences that might constitute or contribute to abuse or neglect. Training - through orientation and on-going training, all employees were provided with information regarding abuse and neglect, related reporting requirements, prevention, intervention, and detection. Protection - patients would be protected from abuse during investigation of any allegation of abuse, neglect, or harassment, this included moving the patient to a safe location, re-assigning staff members, or placing the involved staff member on Administrative leave pending completion of the investigation. An objective investigation would be performed in a thorough and timely manner. When informed of abuse by an employee, Administration would be notified immediately. A Patient Safety Report (PSR) would be completed and entered into the system and Human Resources (HR) would be notified. The initial investigation to determine if an alleged incident occurred would be conducted by the Manager and Human Resources. Written statements would be obtained from the complainant, alleged perpetrator, and all witnesses. Any possible signs of abuse (e.g., bruises, bumps, scratches) would be documented. The appropriate authority, Adult Protective Services (APS) or Child Protective Services (CPS), would be notified. Respond - all incidents of abuse, neglect, or harassment would be reported and analyzed, followed by appropriate corrective, remedial, or disciplinary action in accordance with applicable state or federal laws or regulations.

Staff interview and record review revealed on two (2) separate occasions, 10/24/17 and 01/30/18, Security staff reported MHA #1 used potentially harmful, unnecessary force while physically managing patients on the behavioral health unit (Patient #1 and Patient #9). MHA #1 was not removed from patient care and one incident was not reported to the Department of Community Based Services (DCBS), per the facility's policy and State law. Neither incident was thoroughly investigated. (Refer to A 145)

Review of personnel records revealed Security Guard (SG) #1, Registered Nurse (RN) #4, Security Supervisor, Mental Health Associate (MHA) #1, SG #2, RN #8, MHA #3, MHA #2, Licensed Practical Nurse (LPN) #1 and the Administrative Assistant all had TEAM training and Abuse and Neglect training timely.

Interview with the Nurse Manager, on 03/28/18 at 4:30 PM, revealed she had RN #5 and RN #6 auditing seclusion and restraint occurrences by chart review. She stated she was a frequent presence on the unit, but "eyes on" safe management technique audits were not done.

Interview with the Security Director, on 03/28/18 at 1:32 PM, revealed he was spearheading the facility's transition from CPI to TEAM safe physical management technique. He stated TEAM was specific to healthcare settings and taught more de-escalation than hands on. He stated CPI had been dormant, as far as training, for over a year. He stated the transition was slow, but going well and all staff performed "eyes on" physical competencies to finish the course. He stated the education was mandatory for Security staff and the Psychiatric unit staff and was being phased in elsewhere. He stated there were no ongoing competency checks or audits outside the initial training.

Interview with the Director of Accreditation and Medical Staff, on 03/28/18 at 3:20 PM, revealed the Incorporated Company was the parent company of the facility and many other units. The oversight for the entire system was provided by the Board of Trustees who appointed and managed the Chief Executive Officer (CEO). She further explained the operations of the facility were overseen by the Chief Administrative Officer (CAO), who was part of the Executive Leadership Team.

Interview with the System Assistant Vice President and Patient Safety Officer, the Vice President of Finance and Operations, and the Chief Administrative Officer (CAO), on 03/28/18 at 4:00 PM, revealed the System Assistant Vice President and Patient Safety Officer was part of the Quality, Clinical Services, Patient Safety, and Value Board Committee who reported quarterly aggregate safety data to the full Board. She stated the Board of Directors was very engaged with facility safety.

The Vice President of Finance and Operations stated he was responsible for patient safety at the facility. He monitored patient safety by ensuring the multiple safety meetings every day included all unit and departmental input. He stated leadership conducted safety rounds weekly, which included the Behavioral Health Unit. He stated if abuse occurred, security staff would be called, and he assumed staff was following the abuse policy for those cases. He stated he was confident the educational programs cascaded to prepare staff for safety issues and reporting.

The CAO stated he oversaw the facility and was invested in the success of their Security, who provided services to all of the downtown facilities. The facility had spent hundreds of thousands of dollars on security in the last six (6) months. He explained the Security Director submitted safety reports on safety to him. He stated all the reports he received were aggregated data, not specific event details.

Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to provide care in a safe setting, failed to ensure patients were free from abuse and protected from further abuse, and failed to thoroughly investigate allegations of abuse for one (2) of ten (10) sampled patients, Patient #1 and #9. Two (2) incidents of alleged abuse occurred on the Adult Behavioral Health Unit involving the same Mental Health Associate (MHA), MHA #1.


Refer to A 144 and A 145.

Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to provide care in a safe setting for two (2) of ten (10) sampled patients, Patient #1 and #9.

On 01/30/18, Patient #1 required a medication injection for aggressive behavior displayed on the unit. The patient sat on his/her bed while MHA #1 took the patient's wrists in his/her hands and applied a significant amount of force. Patient #1 quickly escalated in response and broke free form the hold. MHA #1 lunged forward onto Patient #1 pinning him/her on the bed with his right knee on the patient's chest and his left knee on the patient's right bicep. The Security Manager/Supervisor repositioned Patient #1's left arm for comfort and Security Guard (SG) #1 and #3 held the patient's legs while Registered Nurse (RN) #4 gave the injection.

On 10/24/17, Patient #9 yelled, cussed, and threatened staff in opposition to a facility transfer. Security staff and MHA #1 held Patient #9 face down on the bed and an involuntary shot was administered. Upon release, Patient #9 swung at nursing staff and MHA #1 blocked the swing and pushed the patient toward the bed by grabbing the patient's throat. Patient #9 went down sideways on the bed, it rolled backward and hit the wall, and Patient #9's head hit the wall. Patient #9 was held to the bed by MHA #1 until security pulled him off.

The findings include:

Review of the facility's system-wide policy, Patient Rights, effective 08/25/17, revealed the facility supported the rights of each patient and was committed to ensuring the protection of those rights in its provision of care, treatment, and services...the patient had the right to considerate, respectful care at all times and under all circumstances, with recognition of personal dignity and respect. The policy further revealed patients had the right to a safe and secure environment safeguarded by clinical personnel and security staff.

Review of the facility's Instructor Manual for Crisis Prevention Institute (CPI) for nonviolent crisis intervention, dated 2012, revealed the goal of staff when intervening with persons to address behavior that may escalate into a disruptive or violent incident was to provide for the care, welfare, safety, and security of all involved. Power struggles, threats and overreaction was not to be used in verbal interventions. Empathic listening, including offering nonjudgmental attention, rational detachment, and a consistent professional attitude was encouraged. The manual's introduction to the personal safety techniques stated the education was not intended as a self-defense course, rather to protect staff and acting-out individuals from injury. Staff was instructed to be especially careful not to use their own bodies in ways that restrict a restrained person's ability to breathe. This included sitting or lying across a person's back. Multiple safe physical intervention methods were described; however, choke holds, pushing, pinning, and or bear hug tackles were not recommended or listed as safe techniques.

Review of the facility's Techniques for Effective Aggression Management (TEAM) essentials workbook, dated 2015, revealed a comprehensive overview of the aggression cycle in healthcare settings, verbal de-escalation, and other non-physical management of aggressive behaviors and identification of behavior control methods. There was no specific guidance for safe physical holds, restraint or management of out of control patients. The advanced module indicated to remain seven (7) feet away from aggressive patients and taught staff to distract, disengage, defend by deflection, escape, avoid, and to defend self from ground level. There were descriptions of safe one-person and two-person escort positioning. Pushing and/or bear hug tackling toward preferred patient position were not recommended or listed as safe techniques.

1. Review of Patient #1's closed clinical revealed the patient was admitted to the Behavioral Health unit on 01/30/18, following an evaluation in the Emergency Department (ED). Review of the History and Physical revealed the patient was brought in by his/her parents because the patient stopped taking medication and had been getting progressively worse, was delusional, bizarre, and fixated on the apocalypse. Patient #1 was increasingly aggressive at home and had threatened to kill his/her family to get help. Patient #1 was admitted on a seventy-two hour (72) hold for safety, stabilization, and medication management. Patient #1 was placed on aggression precautions.

Review of a Patient Safety Report (PSR), dated 01/30/18 by Securing Guard (SG) #3, revealed on 01/30/18 at approximately 5:00 PM, SG #3 responded to the Adult Psychiatric Unit of the facility to assist staff with a disorderly patient. Upon arrival, SG #3 found Patient #1 verbally resisting staff about returning to his/her room. SG #1 arrived and when Patient #1 noticed both SGs, the patient began walking to his/her bedroom while remaining verbally abusive. The Security Supervisor joined the SGs on the way to the patient's room and when they arrived, the patient was on his/her bed facing the door and MHA #1 took the patient's wrists in his/her hands to protect Registered Nurse (RN) #4 while she attempted to give the patient a shot. Per the PSR, MHA #1 appeared to apply a significant amount of force even though the patient did not appear to be resisting. The patient became agitated with the amount of pressure applied to his/her wrists and attempted to free himself/herself. MHA #1 lunged forward onto Patient #1, pinning him/her on the bed with MHA #1's right knee on the patient's chest and his left knee on the patient's right bicep, then adjusted his position to the left of the bed to maintain the patient's right arm. While MHA #1 moved, the Security Supervisor repositioned Patient #1's left arm for comfort, and SG #1 and #3 held the patient's legs while RN #4 gave the shot in his/her left arm. Patient #1 remained verbally aggressive while staff stood by for protection, after a few minutes, all units cleared with no further incident. The PSR was reviewed by the Security Supervisor on 02/19/18.

Interview with RN #4, on 03/26/18 at 3:26 PM, via telephone, revealed she remembered the 01/30/18 event and was the nurse assigned to Patient #1. She recalled Patient #1 yelling, cursing, and throwing water at patients and staff. Patient #1 went back to his/her room for the injection and began to settle down and then he/she swung at MHA #1. MHA #1 grabbed one arm and she grabbed the other. She stated there was no inappropriate behavior from MHA #1. She stated she had no issues with MHA #1, he had excellent rapport with patients.

Continued interview with RN #4, on 03/27/18 at 3:26 PM, revealed she normally had safe physical management training (CPI) in January, but attended TEAM in February. She was unsure which techniques were used with Patient #1, but stated it was easier to safely control a patient when they were flat on the bed.

Interview with the Security Supervisor, on 03/20/18 at 3:50 PM, revealed he recently had TEAM training and Crisis Prevention Institute (CPI) training. He stated he recalled responding to the unit on 01/30/18 and SG #1 and SG #3 were already present. MHA #1 had his hands on Patient #1's wrists and the patient asked for him to loosen his grip. The patient then pulled his/her hands out and MHA #1 got the patient in the upper chest throat area and pushed him/her to the bed. MHA #1 pushed the patient to the bed and was on top of the patient, as the patient was lying flat. MHA #1's knees were on the bed and his hands on Patient #1's chest. Security Supervisor stated MHA #1 did not need to put his knee in the patient's bicep; he did not use the safe positioning staff was taught. After, Patient #1 got up and said he/she was going to the TV room and MHA #1 told him/her he/she needed to remain in the room and calm down. MHA #1 then guided the patient back to the room with his hand on the small of the patient's back and when inside the room, MHA #1 put his hands on Patient #1's chest and used his full body to take the patient to the bed. He continued and stated he was unsure if the use of force was necessary, but every situation was different. He stated holding hands at the wrists was standard protocol, but if a patient resists they should be repositioned. The initial takedown that MHA #1 used looked like a "chokehold" and staff did not do that at the facility. MHA #1's knee to the patient's bicep was also unnecessary, as there was more than enough staff there to control the situation. He stated after the event, he notified his Director about the hands to the neck/throat and knee to bicep.

Interview with MHA #1, on 03/20/18 at 4:15 PM, revealed he received CPI training about five (5) years ago and learned to control aggressive patients. He stated TEAM training was new and he told the Supervisor of Security in class that it would not work for the unit and he found the TEAM method useless. He revealed the TEAM training taught staff to push away and run if patients were aggressive, and that would not work on the Psychiatric unit. He further stated he was a retired police officer and would go to any length to keep staff safe; he would do anything necessary to protect himself and to make sure his nurses were okay. MHA #1 further stated he preferred to use CPI physical management methods and his personal experience as a retired police officer. He revealed he worked on 01/30/18 and remembered the incident with Patient #1. He stated the Assistant Nurse Manager texted him the next day and told him security had complained on him. He wrote a statement and took it in to HR. He stated he hurt his knee during the altercation with Patient #1 and was off on medical leave. He described abuse as any verbal, physical, or emotional action against a coworker or patient. He revealed Patient #1 was attacking people so it was not abuse; he was helping him/her not hurt himself/herself or someone else.

Interview with the Assistant Unit Manager, on 03/27/18 at 3:50 PM, revealed MHA #1's knee to Patient #1's bicep was not an approved safety maneuver.

Interview with the Nurse Manager, on 03/20/18 at 1:30 PM, revealed Security thought there was excessive force used on Patient #1's arm; however, nursing staff stated Security had little to no involvement in the incident with Patient #1.

Interview with the Director of Security, Safety, and Emergency Preparedness, on 03/20/18 at 1:15 PM, revealed his recollection of the 01/30/18 event was the guards were concerned with MHA #1's physical management technique. Continued interview at 4:00 PM, revealed there were times when staff reverted to muscle memory when pushed to fight mode and did not use approved physical management techniques.

2. Review of Patient #9's closed clinical record revealed the patient presented voluntarily to the ED on 10/16/17, and requested a Psychiatric evaluation and drug test. Examination revealed Patient #9 exhibited fast-talking and actions, bizarre behavior, and inability to concentrate. He/she was admitted to the Behavioral Health unit for safety and stabilization, with diagnoses which included Bipolar Disorder, Psychosis, and Post Traumatic Stress Disorder (PTSD-acting out while flashing back to personal trauma).

Review of the Physician Discharge Summary, dated 10/24/17, revealed Patient #9 needed longer-term treatment than the facility could provide so a seventy-two (72) hour hold was obtained and discharge to another facility was arranged.

Review of a Nursing Note by Licensed Practical Nurse (LPN) #1, dated 10/24/17 at 9:17 AM, revealed "Patient #9 instructed was being transferred to another facility, became elevated, loud, and agitated, Haldol and Ativan were given IM, Security called, patient became more aggressive and agitated, staff and Security assisted, patient attempted to hit this nurse in the jaw, patient swung and just missed, after ten (10) minutes patient less agitated and transferred to another facility."

Interview with LPN #1, on 03/26/18 at 1:29 PM, revealed she remembered the 10/24/17 event when Patient #9 became agitated and "went off" because of the pending transfer. She stated when patients became belligerent; it was her job to give the patient something to calm them down. She could not recall any specifics about her actions because the event was too long ago. She stated it was her job to give the shot, not hold the patient. She stated she had no concerns about physical holds with unit staff or Security staff.

Interview with MHA #1, on 03/20/18 at 4:15 PM, revealed on 10/24/17, Patient #9 got a shot, tried to punch the nurse, and he pushed the patient on to the bed and Security filed a report. Additional interview with MHA #1, on 03/27/18 at 2:25 PM, revealed Patient #9 threw a punch at LPN #1 and he grabbed the patient's upper body, not sure exactly where, and put the patient on the bed. He stated the old hospital bed in that room had brakes that were problematic and patients could unlock them. He stated the bed was about a foot from the wall and chained to the floor, but the chain was not taut. He stated he guessed Patient #9 hit the wall as he came at the patient crossways on the bed. He stated CPI taught staff to get patients horizontal because they were easier to manage when flat.

Interview with SG #2, 03/26/18 at 10:10 AM, revealed he had TEAM and CPI training, which was for physical management. He revealed on 10/24/17, he and MHA #1 took hold of Patient #9's upper body and the patient resisted. The force was increased to get the patient to the bed and when the patient was placed on the bed face down, the unsecured bed rolled into the wall and both the bed and Patient #9's head hit the wall. He, MHA #1, SG #4 and RN #2 held Patient #9 while LPN #1 gave and injection. Patient #9 screamed obscenities and remained combative during the entirety of the physical hold. Following the injection, all staff released the hold and Patient #9 leapt from the bed and made an aggressive gesture toward LPN #1, nearly striking her. MHA #1 blocked the strike by lunging toward Patient #9, grabbed the patient's right arm and throat, and pushed the patient in the direction of the bed, which was done with such force the patient's upper torso was forced into the wall and Patient #9 again hit his/her head. Following the incident, he submitted a PSR and was asked to write a statement for his Manager. He considered the actions of MHA #1 as abusive and reported them to his supervisor.

Interview with the Security Director, on 03/28/18 at 1:32 PM, revealed he spoke with SG #2 regarding the 10/24/17 PSR and SG #2 clarified two issues in the PSR, which concerned him, the throat choke and taking Patient #9 to the floor, as they were not safe physical management techniques.

Interview with RN #2, on 03/26/18 at 1:01 PM, revealed he was trained in CPI in April 2017 and scheduled to do TEAM this month. He worked 10/24/17 and remembered the incident involving Patient #9. He stated LPN #1 told Patient #9 he/she would be transferred to another facility and redirected to him/her to their room for a shot. Security staff was called and he stood at the patient's door and observed LPN #1 at the foot of the bed with MHA #1 and two (2) to three (3) Security guards also present. RN #2 stated he did not have a clear view of the patient. He stated he saw Patient #9 make a posturing advance toward LPN #1, was not sure if it was before or after the shot, and MHA #1 was the only staff who acted quickly enough to keep LPN #1 from getting hit. He further stated MHA #1 grabbed the Patient #9's shoulders, turned the patient's body toward him and when he put him/her on the bed, his/her shoulders went back toward the wall. The bed was unlocked and it rolled into the wall and the patient hit their head on the wall. RN #2 stated he heard the bed hit the wall as it was chained to the floor, and the chains rattled before it hit the wall. He remembered Security staff told MHA #1 to let Patient #9 go and one Security staff put his hands on MHA #1's shoulders to prompt him. He further stated MHA #1 matched the force of the patient and it was not excessive.

Interview with the Director of Patient Care Services, on 03/20/18 at 1:45 PM, revealed she ensured her Nurse Manager and staff implemented appropriate CPI and TEAM technique by validating techniques when she rounded. She stated she did not have a rounding schedule, nor had she intentionally observed any patient physical managements.

Interview with the Vice President Patient Care Services/Chief Nursing Officer (CNO), on 03/28/18 at 2:45 PM, revealed she had been in her position since November. She stated staff completed safety competencies at hire and annually thereafter. She stated facility administration was currently assessing which units would most benefit from TEAM training, as it offered healthcare specific technique. The TEAM approach taught how to approach care in a non-threatening manner, specific words to avoid, how to manage body language, and de-escalation. She stated all staff who was educated with TEAM received both classroom and hands on instruction. Staff had to perform hands on competency check offs to complete the education. The CNO stated she wanted her team to be consistent in their approach to safe physical management, across the board.

Interview, on 03/28/18 at 4:00 PM, with the Vice President of Finance and Operations revealed he was over safety and he monitored safety by ensuring departments reported issues on their units during daily meetings. Leadership followed unit schedules and conducted safety rounds weekly.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure patients were free from abuse, allegations of abuse were investigated, and patients were protected from further abuse for two (2) of ten (10) sampled patients, Patient #1 and Patient #9.

Two (2) incidents of alleged abuse occurred on the Adult Behavioral Health Unit involving the same Mental Health Associate, (MHA) #1.

On 01/30/18, Patient #1 required a medication injection for aggressive behavior displayed on the unit. The patient sat on his/her bed while MHA #1 took the patient's wrists in his/her hands and applied a significant amount of force. Patient #1 quickly escalated in response and broke free from the hold. MHA #1 lunged forward onto Patient #1 pinning him/her on the bed with his right knee on the patient's chest and his left knee on the patient's right bicep. The Security Manager/Supervisor repositioned Patient #1's left arm for comfort and Security Guard (SG) #1 and #3 held the patients legs while Registered Nurse (RN) #4 gave the injection.

On 10/24/17, Patient #9 yelled, cussed, and threatened staff in opposition to a facility transfer. Security staff and MHA #1 held Patient #9 face down on the bed and an involuntary shot was administered. Upon release, Patient #9 swung at nursing staff and MHA #1 blocked the swing and pushed the patient toward the bed by grabbing the patient's throat. Patient #9 went down sideways on the bed, it rolled backward and hit the wall, and Patient #9's head hit the wall. Patient #9 was held to the bed by MHA #1 until security pulled him off.

The facility did not remove MHA #1 from patient care in either instance and the 10/24/17 incident was not reported to the Department of Community Based Services (DCBS), per State law and facility policy. The facility unsubstantiated the allegations of abuse; however, interviews with staff and Administration revealed a thorough investigation was not completed. Per interview, they could not recall the process, time, place, or persons who investigated and unsubstantiated these allegations of abuse.

The findings include:

Review of the facility's system-wide policy, Patient Rights, effective 08/25/17, revealed the facility supported the rights of each patient and was committed to ensuring the protection of those rights in its provision of care, treatment, and services. The policy revealed patients had the right to be free from abuse and harassment and entitled to a safe and secure environment safeguarded by clinical personnel and security staff.

Review of the facility's policy, Abuse and Neglect, effective 08/01/17, revealed Health Care providers were responsible for assisting patients in situations where abuse/neglect was suspected or reported. Identified/suspected cases of abuse/neglect involving vulnerable adults must be reported to the appropriate authorities by the individual who suspected or received the complaint of abuse/neglect. Those making the report were legally protected. Failure to report a case in which there was knowledge or reasonable suspicion of abuse, neglect, or exploitation to the appropriate agency violated the law. Patients had the right to be free from all forms of abuse or harassment during admission in the facility.

The policy further revealed in protecting patients from abuse, the facility would adhere to the following: Prevention - including analysis of the physical environment to detect any factors that might make abuse/neglect more likely to occur, such as secluded areas and deployment of staff in sufficient numbers to meet the patient's healthcare needs. Screening - persons with a record of abuse or neglect shall not be hired or retained as employees. Identification - maintenance of proactive approach to identify events or occurrences that might constitute or contribute to abuse or neglect. Training - through orientation and on-going training, all employees were provided with information regarding abuse and neglect, related reporting requirements, prevention, intervention, and detection. Protection - patients would be protected from abuse during investigation of any allegation of abuse, neglect, or harassment, this included moving the patient to a safe location, re-assigning staff members, or placing the involved staff member on Administrative leave pending completion of the investigation. An objective investigation would be performed in a thorough and timely manner. When informed of abuse by an employee, Administration would be notified immediately. A Patient Safety Report (PSR) would be completed and entered into the system and Human Resources (HR) would be notified. The initial investigation to determine if an alleged incident occurred would be conducted by the Manager and Human Resources. Written statements would be obtained from the complainant, alleged perpetrator, and all witnesses. Any possible signs of abuse (e.g., bruises, bumps, scratches) would be documented. The appropriate authority, Adult Protective Services (APS) or Child Protective Services (CPS), would be notified. Respond - all incidents of abuse, neglect, or harassment would be reported and analyzed, followed by appropriate corrective, remedial, or disciplinary action in accordance with applicable state or federal laws or regulations.

1. Review of Patient #1's closed clinical revealed the patient was admitted to the Behavioral Health unit on 01/30/18, following an evaluation in the Emergency Department (ED). Review of the History and Physical revealed the patient was brought in by his/her parents because the patient stopped taking medication and had been getting progressively worse, was delusional, bizarre, and fixated on the apocalypse. Patient #1 was increasingly aggressive at home and had threatened to kill his/her family to get help. Patient #1 was admitted on a seventy-two hour (72) hold for safety, stabilization, and medication management. Patient #1 was placed on aggression precautions.

Review of a Patient Safety Report (PSR), dated 01/30/18 by Securing Guard (SG) #3, revealed on 01/30/18 at approximately 5:00 PM, SG #3 responded to the Adult Psychiatric Unit of the facility to assist staff with a disorderly patient. Upon arrival, SG #3 found Patient #1 verbally resisting staff about returning to his/her room. SG #1 arrived and when Patient #1 noticed both SGs, the patient began walking to his/her bedroom while remaining verbally abusive. The Security Supervisor joined the SGs on the way to the patient's room and when they arrived, the patient was on his/her bed facing the door and MHA #1 took the patient's wrists in his/her hands to protect Registered Nurse (RN) #4 while she attempted to give the patient a shot. Per the PSR, MHA #1 appeared to apply a significant amount of force even though the patient did not appear to be resisting. The patient became agitated with the amount of pressure applied to his/her wrists and attempted to free himself/herself. MHA #1 lunged forward onto Patient #1, pinning him/her on the bed with MHA #1's right knee on the patient's chest and his left knee on the patient's right bicep, then adjusted his position to the left of the bed to maintain the patient's right arm. While MHA #1 moved, the Security Supervisor repositioned Patient #1's left arm for comfort, and SG #1 and #3 held the patient's legs while RN #4 gave the shot in his/her left arm. Patient #1 remained verbally aggressive while staff stood by for protection, after a few minutes, all units cleared with no further incident. The PSR was reviewed by the Security Supervisor on 02/19/18.

Review of a DCBS (aka Adult Protective Services) report revealed the facility notified the State Agency of the allegation of physical abuse on 01/30/18 at 9:21 PM. The reporting source stated he/she believed Patient #1 would have complied if staff had not put his hands around Patient #1's throat and tackled him/her.

Review of a Nursing Note, dated 01/30/18 at 9:00 PM, revealed the House Manager noted Security staff contacted Adult Protective Services (APS) regarding an incident between the patient and a MHA, and all leadership and risk management had been notified.

Review of a Nursing Note, dated 01/30/18 at 10:46 PM by RN #4, revealed Patient #1 was agitated at the beginning of the shift, demanded the radio be turned up, accused staff of being mean and called them "a bunch of bitches", and threw a cup of water into the nurses' station. Security staff was called to the unit for assistance and Patient #1 had to be escorted to his/her room. Staff held Patient #1's arm to prevent him/her from hitting the nurse, which angered the patient and he/she began swinging at MHA #1. Security staff intervened to prevent injury and the patient was given an injection of Haldol (antipsychotic) and Ativan (sedative) Intramuscularly (IM) at 4:57 PM. Patient #1 continued to make sarcastic comments about staff/unit rules.

Review of RN #4's Statement, written 01/31/18 at 11:31 AM, referred to Patient #1's medical record for a review of Patient #1's behavior, which led to an injection and the need for security staff. She was present in Patient #1's room when the patient tried to punch MHA #1 in the stomach. MHA #1 grabbed one of the patient's arms and she grabbed the other to prevent staff injury and gave the injection for agitation. She witnessed no inappropriate actions or mishandling from any staff. Two (2) SGs were present in the room at the time. Her statement was e-mailed to the Assistant Unit Manager at the time it was written.

Interview with RN #4, on 03/26/18 at 3:26 PM, via telephone, revealed she remembered the 01/30/18 event and was the nurse assigned to Patient #1. She recalled Patient #1 yelling, cursing, and throwing water at patients and staff. Patient #1 went back to his/her room for the injection and began to settle down and then he/she swung at MHA #1. MHA #1 grabbed one arm and she grabbed the other. She stated normally, staff called security for back up when there was a patient with the potential for violence. Security staff responded but remained in the hallway, none of them went into the room. Following review of her Nursing Note, she stated at the time she was in Patient #1's room, there were no other people in the room. Per interview, Security was never in the room and she was not sure why she put that in the note. She further stated the note sounded like someone else was with her and MHA #1, but she could not remember. She stated there was no inappropriate behavior from MHA #1. Following the injection, Patient #1 immediately calmed down, and after a few more minutes came back to the lounge and turned off the TV. Patient #1 turned over a cup of water sitting on the table and then went to his/her room on his/her own. She stated she had no issues with MHA #1, he had excellent rapport with patients. She stated she spoke with the Employee Relations Manager about the matter back in January, and told her if MHA #1 had not been there, someone would have gotten hurt.

Continued interview with RN #4, on 03/27/18 at 3:26 PM, revealed MHA #1 had a rapport with Patient #1 but was unable to calm the patient. Security staff was called because sometimes a show of force was calming to patients. She pulled up the injection and went to Patient #1's room and the patient was calmly sitting on the side of the bed. She did not remember anyone else in the room, but she had her back to the door. Patient #1 suddenly became agitated and swung at MHA #1. She stated she got the patient's right arm, MHA #1 got the left, and then they pulled Patient #1 flat to the bed.

Review of SG #1's statement, dated 01/30/18 at 5:43 PM, revealed on 01/30/18, SG #3, the Security Supervisor, and SG #1 were present with MHA #1 in Patient #1's room. The patient was slightly agitated and stated MHA #1 was holding his/her hands too hard and asked him to loosen his grip and when MHA #1 did not loosen his grip, the patient pulled away to get his/her hands free. MHA #1 leapt onto the patient placing his hands around the patient's throat, his knees to the patient's chest and stomach, and slammed the patient into the bed. MHA #1 then shifted his legs to where his knees were on Patient #1's right bicep, SG #3 secured the patient's legs, and the Security Supervisor assisted with his/her left arm to stable for the shot. Following the shot, Patient #1 was released and stated he/she wanted to go watch TV and staff informed the patient he/she had to remain in his/her room. The patient exited the room and MHA #1 grabbed the patient's left arm telling the patient to return to his/her room. As the patient was walking back to the room, he/she called MHA #1 a "bitch" and MHA #1 tackled the patient to the bed. Security staff was not involved in the situation. His statement was e-mailed to the Employee Relations Manager, the Security Manager, and the Security Director at the time it was written.

Interview with SG #1, on 03/20/18 at 2:23 PM, revealed Security staff was called to assist with Patient #1. After the patient and staff went into the patient's room for the injection, the patient sat on the bed and MHA #1 held the patient's hands. SG #1 stated the patient asked MHA #1 to release his grip some and MHA #1 told the patient he was not going to do anything the patient asked. The patient pulled his/her hands up and MHA #1 leapt onto the patient and put his knee on the patient's chest and into the bed. The patient and MHA #1 argued, another SG grabbed the patient's legs and MHA #1 moved and had a knee in the patient's chest and a knee in on the patient's right arm. According the SG #1, after the injection was given, the patient got up and wanted to leave but the nurse and MHA #1 told him/her to stay in the room until the medicine took effect. However, Patient #1 walked by them and MHA #1 "bear hugged" the patient and "tackled him/her to the bed" and then MHA #1 stood in the doorway to ensure the patient did not get up and leave.

Review of the Security Supervisor's statement, dated 01/30/18 at 5:49 PM, revealed he arrived as Patient #1 was escorted to his/her room. He entered the room with SG #1 and #3. The patient was seated on the bed and MHA #1 was holding the patient's arms at the wrists. Patient #1 asked MHA #1 to loosen his grip, he did not, and Patient #1 pulled his/her arms away. MHA #1 then pushed the patient to the bed with his hands on the patient's upper chest and throat area, and when Security had control of his/her left arm and legs, the MHA had his knee in the patient's right bicep. The Security Supervisor took over the left arm, moved it to a safe position on bed, and advised the patient the nurse was giving him/her a shot. RN #4 asked Patient #1 to relax his/her arm and he/she did. After the shot, staff released the holds and the patient became upset again. MHA #1 walked Patient #1 back to his/her room and again pushed the patient to the bed. The whole time the patient was calling everyone in the room names and MHA #1 was talking back to the patient in an aggressive manor. His statement was e-mailed to the Employee Relations Manager, the Security Manager, and the Security Director at the time it was written.

Interview with the Security Supervisor, on 03/20/18 at 3:50 PM, revealed he recalled responding to the unit on 01/30/18 and SG #1 and #3 were already present. He described Patient #1 walking to the room calmly while verbally resisting the shot and sat on the edge of the bed. He stated he was in the doorway and RN #4, MHA #1, and SG #1 and #3 were in Patient #1's room. MHA #1 had his hands on Patient #1's wrists and the patient asked for him to loosen his grip. The patient then pulled his/her hands out and MHA #1 got the patient in the upper chest throat area and pushed him/her to the bed. MHA #1 pushed the patient to the bed and was on top of the patient, as the patient was lying flat. MHA #1's knees were on the bed and his hands on Patient #1's chest. He stated the SGs got the patient's legs and MHA #1 put his knee in the patient's right bicep. RN #4 had the patient's left arm. He stated he told the patient they were repositioning his/her arm for an injection, the patient agreed, and injection was given. After, Patient #1 got up and said he/she was going to the TV room and MHA #1 told him/her he/she needed to remain in the room and calm down. MHA #1 then guided the patient back to the room with his hand on the small of the patient's back and when inside the room, MHA #1 put his hands on Patient #1's chest and used his full body to take the patient to the bed. He continued and stated he was unsure if the use of force was necessary, but every situation was different. He stated holding hands at the wrists was standard protocol, but if a patient resists they should be repositioned. The initial takedown that MHA #1 used looked like a "chokehold" and staff did not do that at the facility. MHA #1's knee to the patient's bicep was also unnecessary, as there was more than enough staff there to control the situation. He stated after the event, he notified his Director about the hands to the neck/throat and knee to bicep. He also notified Risk Management, submitted a PSR, and reported the incident to APS as instructed.

Review of MHA #1's statement, dated 02/01/18, revealed on 01/30/18, Patient #1 was focused on the TV and radio. After MHA #1 told the patient he was not allowed to touch the TV, MHA #1 tried to calm the patient unsuccessfully. Patient #1 threatened the nurse and the MHA, and threw a cup of water at the Administrative Assistant causing charts and the computer to become wet. Security staff was called for assistance with an involuntary IM injection. MHA #1 approached Patient #1 asked the patient to walk to his/her room for medication administration to calm him/her and Patient #1 said "F--k you," and refused to go. MHA #1 responded, "we can do this the easy way or the hard way." Patient #1 stated, "the hard way" and MHA #1 motioned to Security to approach. Patient #1 walked willingly to the room and requested the IM be given in the arm and sat on the bed while MHA #1 told him/her their hands would be held. Patient #1 moved and raised his/her hands to MHA #1's chest and at that time, MHA #1 laid the patient back into the bed and placed his weight on Patient #1's arm when he/she resisted. Security staff secured his/her legs. Following the injection, staff released Patient #1 and as the patient exited the room, he/she pulled a pen from the Administrative Assistants hand and MHA #1 grabbed Patient #1 from the back and placed the patient on the bed while telling him/her to let go of the pen. MHA #1 let go of Patient #1 when the pen was recovered. MHA #1 remained in the room with Patient #1 for about seven (7) minutes.

Interview with MHA #1, on 03/20/18 at 4:15 PM, revealed he worked on 01/30/18 and remembered the incident with Patient #1. He stated in response to Patient #1's aggression, nursing staff decided to prepare a shot and they called Security staff. He told Patient #1, staff was going to give him/her some medicine the easy way or the hard way. Patient #1 walked to the room voluntarily and sat on the bed and he held Patient #1's hands for safety. Patient #1 stated MHA #1 was squeezing too hard and broke free and MHA #1 pushed Patient #1 to the bed using both his hands and his body weight. He stated his legs were squished between the wall and the bed so his knees were on the bed and when Patient #1 resisted, he put his knee into Patient #1's right arm. Security staff held the patient's other limbs. He further stated the shot was given while the patient struggled and when he pulled back, Patient #1 ran out of room. MHA #1 stated he caught the patient in the hallway and redirected the patient to go back to bed and relax. As the patient walked back to the room, he/she took a pen from the Administrative Assistant's hand. MHA #1 stated he was concerned Patient #1 was dangerous with a pen; however, he stated Patient #1 did not make any threatening gestures with it. He stated he "bear hugged" the patient from behind and took the patient down and told the patient to let go of the pen multiple times, until the patient let go. He stated RN #4 checked on the patient and said the patient could come out. MHA #1 stated his physical management was not abusive because he did not punch, bite, or kick Patient #1 and the patient did not "get anyone" with the pen. He stated after the incident with Patient #1, he continued to work and finished his shift.

Review of MHA #1's timecard, dated 01/01/18 to 03/30/18, revealed he worked from 6:45 AM to 7:30 PM on 01/30/18.

Review of the 01/30/18 Adult Psychiatry Safety/Activity Flowsheet revealed MHA #1 continued to care for Patient #1 and others following the allegation of abuse. He documented he rounded on Patient #1 from 5:30 PM until 7:30 PM.

Interview with the Assistant Unit Manager, on 03/27/18 at 3:50 PM, revealed she was not in the building when the 01/30/18 event occurred. She stated MHA #1 finished his shift on 01/30/18, went to Human Resources (HR) the next day, and gave his statement. Her only concern with the statement was the claim that Security staff did not assist with Patient #1. She did not see any other statements and was not sure who and what process was used to determine the allegation of abuse was unsubstantiated.

Interview with the Nurse Manager, on 03/20/18 at 1:30 PM, revealed she was not in the building when the 01/30/18 event occurred. She stated the Employee Relations Manager called her at home that evening and they discussed the report and she contacted her supervisor. She reported she talked with RN #4 and she stated she did not send MHA #1 home. She relayed the Employee Relations Manager was supposed to collect statements but since she was not at the facility at the time of the occurrence, she could not be sure. She stated she was involved in the investigation but was also off work for some of it. She thought the Security Manager had some involvement with the investigation. She stated Security thought there was excessive force used on Patient #1's arm and nursing staff stated Security had little to no involvement in the incident with Patient #1.

Interview with the Security Director, on 03/20/18 at 1:15 PM, revealed he was called by his Security Supervisor immediately following the 01/30/18 allegation of abuse. The Security Supervisor reported he observed MHA #1 abusing Patient #1, via a choke hold. He contacted Risk Management who gave him specific instructions to submit a PSR, report allegation of abuse to APS, and have SG #1 and #3 email their statements. He reported he forwarded the statements and the other information to the Employee Relations Manager and the Risk Manager. He stated he was not briefed on the outcome of either allegation and stated since the alleged perpetrator was employed by another department, he figured it was none of his business.

Interview with Director of Patient Care Services, on 03/28/18 at 3:11 PM, by telephone revealed she was notified of the 01/30/18 alleged abuse and did not participate in the investigation. Per interview, she thought the Employee Relations Manager did interviews and the follow-up investigation. She stated she recalled some emails regarding the event but did not review them closely. She also stated HR was responsible to make the decision whether an allegation was valid or not and the Nurse Manager would be involved too.

A meeting held on 03/20/18 at 12:52 PM, with the following Administrative staff in attendance: Unit Manager, Director of Patient Care Services, Human Resources Manager, Employee Relations Manager, Director of Accreditation and Medical Staff, System Director of Security, and Safety and Emergency Preparedness, revealed they were unclear regarding who led the facility's internal investigation, and who interviewed the involved employees. The group consensus was the employee statements were so different, abuse could not be substantiated.

2. Review of Patient #9's closed clinical record revealed the patient presented voluntarily to the ED on 10/16/17, and requested a Psychiatric evaluation and drug test. Examination revealed Patient #9 exhibited fast-talking and actions, bizarre behavior, and inability to concentrate. He/she was admitted to the Behavioral Health unit for safety and stabilization, with diagnoses which included Bipolar Disorder, Psychosis, and Post Traumatic Stress Disorder (PTSD-acting out while flashing back to personal trauma).

Review of the Physician Discharge Summary, dated 10/24/17, revealed Patient #9 needed longer-term treatment than the facility could provide so a seventy-two (72) hour hold was obtained and discharge to another facility was arranged.

Review of a Nursing Note by Licensed Practical Nurse (LPN) #1, dated 10/24/17 at 9:17 AM, revealed "Patient #9 instructed was being transferred to another facility, became elevated, loud, and agitated, Haldol and Ativan were given IM, Security called, patient became more aggressive and agitated, staff and Security assisted, patient attempted to hit this nurse in the jaw, patient swung and just missed, after ten (10) minutes patient less agitated and transferred to another facility."

Review of a statement submitted by LPN #1, dated 10/25/17, revealed on 10/24/17, she tried to calm Patient #9 after informing the patient of discharge. When the patient became louder, she informed the patient an injection would be necessary. Security staff was called to assist staff with patient management. Patient #9 was redirected to his/her room and was yelling and fighting in the room, so staff and security staff assisted the patient to the bed. LPN #1 administered the injection and as she prepared to exit the room, Patient #9 swung at her and MHA #1 blocked the attempted strike by grabbing the patient's shoulders. Patient #9 and MHA #1 fell onto the bed and the bed moved. LPN #1 exited the room.

Interview with LPN #1, on 03/26/18 at 1:29 PM, revealed she had abuse and neglect training on the computer annually. She remembered the 10/24/17 event when Patient #9 became agitated and "went off" because of the pending transfer. She stated when patients became belligerent; it was her job to give the patient something to calm them down. She could not recall any specifics about her actions because the event was too long ago. She stated it was her job to give the shot, not hold the patient. She stated she had no concerns about physical holds with unit staff or Security staff.

Review of SG #2, #4, and MHA #1's statements regarding the 10/24/17 event involving Patient #9 revealed Security staff was called to the unit at 8:45 AM to assist with Patient #9. Upon entering the room, the patient became belligerent and backed into a corner with fists up, squatting to the floor. MHA #1 and SG #2 took hold of Patient #9's upper body and the patient resisted. The force was increased to get the patient to the bed and when the patient was placed on the bed face down, the unsecured bed rolled into the wall and both the bed and Patient #9's head hit the wall. MHA #1, SG #2 and #4 and RN #2 held Patient #9 while LPN #1 gave and injection. Patient #9 screamed obscenities and remained combative during the entirety of the physical hold. Following the injection, all staff released the hold and Patient #9 leapt from the bed and made an aggressive gesture toward LPN #1, nearly striking her, and screamed "you f--king b--ch, I am going to kill you." MHT #1 blocked the strike by lunging toward Patient #9, grabbed the patient's right arm and throat, and pushed the patient in the direction of the bed, which was done with such force the patient's upper torso was forced into the wall and Patient #9 again hit his/her head. MHT #1 remained on the bed with the patient, his hand remained on the patients throat while yelling "you will not assault our staff." SG #2 and #4 pulled MHA #1 from Patient #9. MHA #1 did not resist and he walked to the doorway. The SGs cleared the area and discussed the need for a report to be filed.

Interview with MHA #1, on 03/20/18 at 4:15 PM, revealed on 10/24/17, Patient #9 got a shot, tried to punch the nurse, and he pushed the patient on to the bed and Security filed a report. Additional interview with MHA #1, on 03/27/18 at 2:25 PM, revealed Patient #9 threw a punch at LPN #1 and he grabbed the patient's upper body, not sure exactly where, and put the patient on the bed. He stated the old hospital bed in that room had brakes that were problematic and patients could unlock them. MHA #1 stated he finished his shift following the incident and the unit management called him the next day and asked him to provide a statement. He recalled he was contacted and told the complaint was cleared because he did not do anything wrong. He could not remember who called him and he returned to work.

Interview with SG #2, 03/26/18 at 10:10 AM, revealed he had Abuse and Neglect education at orientation and annually thereafter. His interview corroborated the statement and additionally he added he was in clear view of MHA #1 and Patient #9, with all other staff present behind him during the altercation. Following the incident, he submitted a PSR and was asked to write a statement for his Manager. He considered the actions of MHA #1 as abusive and reported them to his supervisor, he stated he knew he could call APS too but did not believe it was necessary. He stated he was not involved in any further discussion of the incident.

Interview with RN #2, on 03/26/18 at 1:01 PM, revealed he worked 10/24/17 and remembered the incident involving Patient #9. He stated LPN #1 told Patient #9 he/she would be transferred to another facility and redirected to him/her to their room for a shot. Security staff was called and he stood at the patient's door and observed LPN #1 at the foot of the bed with MHA #1 and two (2) to three (3) Security guards also present. RN #2 stated he did not have a clear view of the patient. He stated he saw Patient #9 make a posturing advance toward LPN #1, was not sure if it was before or after the shot, and MHA #1 was the only staff who acted quickly enough to keep LPN #1 from getting hit. He further stated MHA #1 grabbed Patient #9's shoulders, turned the patient's body toward him and when he put him/her on the bed, his/her shoulders went back toward the wall. The bed was unlocked and it rolled into the wall and the patient hit their head on the wall. RN #2 stated he heard the bed hit the wall as it was chained to the floor, and the chains rattled before it hit the wall. He could not recall if anyone assessed the patient for injury. He remembered Security staff told MHA #1 to let Patient #9 go and one Security staff put his hands on MHA #1's shoulders to prompt him. He further stated MHA #1 matched the force of the patient and it was not excessive. Lastly, he stated LPN #1 was a senior citizen and staff tended to be a little more protective of her and other women on the unit during those types of situations.

Interview with the Assistant Manager, on 03/27/18 at 3:50 PM, revealed she was on vacation when the allegation of abuse concerning Patient #9 occurred on 10/24/17. She stated her Nurse Manager had taken statements and she was told Security recanted their allegation and the incident was resolved.

Interview with the Nurse Manager, on 03/20/18 at 2:05 PM, revealed the incident, which involved alleged abuse by MHA #1 on 10/24/17, had been resolved when Security retracted his statement. She did not know who made the decision.

However, continued interview with SG #2, 03/26/18 at 10:10 AM, revealed he clarified his statement to both the Security Manager/Supervisor and Director, and did not recant his statement.

Interview with the Security Manager, on 03/27/18 at 4:13 PM, revealed she spoke with SG #2 to seek clarity regarding the PSR he submitted of the 10/24/17 allegation of abuse, as it did not line up with some of the other statements. She stated ultimately, the matter was turned over to HR. She stated she remembered they concluded the witnesses all saw the event from different angles in the room, which affected their perception of the event. She reported she did not interview the other witnesses and assumed HR interviewed the other witnesses. She offered no further explanation or resolution regarding the event. She stated she thought no wrongdoing was disc

Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to ensure nursing staff used safe physical management techniques and assessed patients for injuries following allegations of abuse for two (2) of ten (10) sampled patients, Patient #1 and #9.

Refer to A 397.

Based on interview, record review, review of facility policies, and review of staff training records, it was determined the facility failed to ensure safe competent care was provided during physical management for two (2) of ten (10) sampled patients, Patient #1 and #9.

Patient #1 was admitted with a seventy-two hour (72) hold for safety, stabilization, and medication management. On 01/30/18, during a physical hold for an involuntary injection, Patient #1 broke free and Mental Health Associate (MHA) #1 lunged forward, grabbed the patient's throat and pinned the patient on the bed with his right knee on the patient's chest and his left knee on the patient's right bicep. He then adjusted his position to the left of the bed and maintained the patient's right arm, with his knee in the patient's bicep.

Patient #9 was admitted to the Behavioral Health unit on 10/16/17 for safety and stabilization; a seventy-two (72) hour hold was obtained and discharge to another facility was arranged. On 10/24/17, prior to transfer, during a physical hold for an involuntary injection, Patient #9 attempted to punch Licensed Practical Nurse (LPN) #1 and MHA #1 blocked the punch by grabbing Patient #9's shoulder and taking the patient to the bed by the throat. Patient #9 hit his/her head on the wall and MHA #1 was pulled off the patient by Security staff.

The findings include:

Review of the Adult Psychiatric policy for Behavioral Management, dated 12/07/11, revealed a cognitive behavioral management approach to care was utilized with patients with emotional disorders. Corporal punishment, conditioning, and aversion therapy were never used. Staff used the least restrictive methods first when intervening in behaviors such as: invading other's personal space, provoking others, minor threatening or agitation, name-calling ...unless the behavior presented a danger to the patient or others then positive teaching techniques would be used. Choices were offered, alternative behaviors in the form of redirection, substitution, or distraction. Limits or consequences stated in positive terms. Staff were taught to repeat, reinforce, encourage, praise, restate, and repeat. Patients needed clearly stated messages presented as facts, not criticism. When patients were unable to respond to those interventions they may need to be removed or to remove themselves from the milieu to refocus, time out could be offered. This could be used in response to direct aggression. Time out offered an opportunity for the patient for privacy and to calm themselves in a neutral environment away from external stimuli. If the patient became increasingly out-of-control and a danger to self or others, not responding to less restrictive interventions, staff responded immediately by use of more directive and restrictive interventions.

Review of the facility's Instructor Manual for Crisis Prevention Institute (CPI) for nonviolent crisis intervention, dated 2012, revealed the goal of staff when intervening with persons to address behavior that may escalate into a disruptive or violent incident was to provide for the care, welfare, safety, and security of all involved. Limit setting was described as a verbal technique when a person was offered choices and consequences, both clear, simple, reasonable and enforceable. Power struggles, threats and overreaction was not to be used in verbal interventions. Empathic listening, including offering nonjudgmental attention, rational detachment, and a consistent professional attitude was encouraged. The manual's introduction to the personal safety techniques stated the education was not intended as a self-defense course, rather to protect staff and acting-out individuals from injury. Staff was instructed to be especially careful not to use their own bodies in ways that restrict a restrained person's ability to breathe. This included sitting or lying across a person's back. Team members who were involved in crisis intervention must go through a debriefing process when the crisis was over. Multiple safe physical intervention methods were described; however, choke holds, pushing, pinning, and or bear hug tackles were not recommended or listed as safe techniques.

Review of the facility's Techniques for Effective Aggression Management (TEAM) essentials workbook, dated 2015, revealed a comprehensive overview of the aggression cycle in healthcare settings, verbal de-escalation, and other non-physical management of aggressive behaviors and identification of behavior control methods. There was no specific guidance for safe physical holds, restraint or management of out of control patients. The advanced module indicated to remain seven (7) feet away from aggressive patients and taught staff to distract, disengage, defend by deflection, escape, avoid, and to defend self from ground level. There were descriptions of safe one-person and two-person escort positioning. Pushing and/or bear hug tackling toward preferred patient position were not recommended or listed as safe techniques.

1. Review of Patient #1's clinical record revealed the patient was admitted to the facility's Psychiatric unit on 01/30/18. Review of the History and Physical revealed the patient stopped taking medication and had been getting progressively worse and was delusional, bizarre, and fixated on the apocalypse. Patient #1 was increasingly aggressive at home and had threatened to kill his/her family to get help. Patient #1 was admitted, with a seventy-two hour (72) hold, for safety, stabilization and medication management. Patient #1 was placed on aggression precautions.

Review of a Nursing Note, dated 01/30/18 at 10:46 PM, revealed Patient #1 was agitated at the beginning of the shift, accused staff of being mean and called them "a bunch of bitches", and threw a cup of water into the nurses' station. Security staff was called to the unit for assistance and Patient #1 had to be escorted to his/her room. Staff held Patient #1's arm to prevent him/her from hitting the nurse, which angered the patient and he/she began swinging at MHA #1. Security staff intervened to prevent injury and the patient was given an injection of Haldol (antipsychotic) and Ativan (sedative) Intramuscularly (IM) at 4:57 PM. Patient #1 continued to make sarcastic comments about staff/unit rules.

Review of a facility Patient Safety Report (PSR), submitted by Security Guard (SG) #3, dated 01/30/18, revealed at approximately 5:00 PM on 01/30/18, Security staff responded to the Adult Psychiatric Unit and assisted with a "disorderly" Patient #1. Patient #1 walked to his/her bedroom while verbally abusive and sat on the bed and MHA #1 took his/her wrists in his/her hands and applied a significant amount of force compared to no resistance from the patient. Patient #1 quickly escalated in response and broke free form the hold. MHA #1 lunged forward onto Patient #1 pinning him/her on the bed with his right knee on the patient's chest and his left knee on the patient's right bicep. He then adjusted his position to the left of the bed and maintained the patient's right arm and the Security Supervisor repositioned Patient #1's left arm for comfort and SG #1 and #3 held the patient's legs while RN #4 gave the shot in his/her left arm and the hold was released. The PSR was checked by the Security Supervisor on 02/19/18.

Interview with RN #4, on 03/27/18 at 3:26 PM, revealed she received annual Abuse/Neglect training and normally had safe physical management training (CPI) in January, but attended TEAM this February. She was unsure which techniques were used with Patient #1, but stated it was easier to safely control a patient when they were flat on the bed. She pulled up the injection and went to Patient #1's room and the patient was calmly sitting on the side of the bed. She did not remember anyone else in the room, but she had her back to the door. Patient #1 suddenly became agitated and swung at MHA #1. She stated she got the patient's right arm, MHA #1 got the left, and then they pulled Patient #1 flat to the bed.

2. Review of the Physician Discharge Summary for Patient #9, dated 10/24/17, revealed Patient #9 was admitted to the Behavioral Health unit on 10/16/17 for safety and stabilization and the diagnoses included Bipolar Disorder, Psychosis, and Post Traumatic Stress Disorder (PTSD - acting out while flashing back to personal trauma). The treatment team determined Patient #9 needed longer-term treatment than the facility could provide so a seventy-two (72) hour hold was obtained and discharge to another facility was arranged.

Review of SG #2, #4, and MHA #1's statements regarding a 10/24/17 allegation of abuse revealed Security staff responded to the Adult Psychiatric Unit at 8:45 AM to assist with Patient #9. The patient was "belligerent" and backed into a corner and assumed a threatening posture. MHA #1 and SG #2 took hold of Patient #9's upper body while the patient resisted. They increased their force to get the patient to the bed and when the patient was placed on the bed face down, the unsecured bed rolled into the wall and both the bed and Patient #9's head hit the wall. MHA #1, SG #2 and #4 and RN #2 held Patient #9 and LPN #1 gave the injection. Patient #9 screamed obscenities and remained combative. All staff released the hold and Patient #9 leapt up, made an aggressive gesture toward LPN #1 and nearly struck her, and screamed "you f--king b--ch, I am going to kill you." MHT #1 blocked the strike, lunged toward Patient #9, grabbed his/her right arm and throat and pushed in the direction of the bed. Patient #9's upper torso and head hit the wall. MHT #1 remained on the bed with Patient #9, his hands on the his/her throat. while he yelled "you will not assault our staff." SG #2 and #4 pulled MHA #1 off Patient #9 and MHA #1 walked to the doorway. SG #2 and #4 cleared the area.

Review of a Nursing Note entered by LPN #1, on 10/24/19 at 9:17 AM revealed, "Patient #9 instructed was being transferred to another facility, became elevated, loud, and agitated, and Haldol and Ativan were given IM. Security called, patient became more aggressive and agitated, staff and Security assisted, patient attempted to hit this nurse in the jaw, patient swung and just missed, after ten (10) minutes patient less agitated and transferred to another facility."

Interview with LPN #1, on 03/26/18 at 1:29 PM, revealed she had abuse and neglect training on the computer annually. She stated she remembered the 10/24/17 event and could not recall any specifics about her actions because the event was too long ago. She stated it was her job to give the shot, not hold the patient. She stated she had no concerns about physical holds with unit staff or Security staff.

Interview with RN #2, on 03/26/18 at 1:01 PM, revealed he was trained in CPI in April 2017 and scheduled to do TEAM this month. He worked 10/24/17 and remembered the incident involving Patient #9. He stated he saw Patient #9 make a posturing advance toward LPN #1, was not sure if it was before or after the shot, and MHA #1 was the only staff who acted quickly enough to keep LPN #1 from getting hit. He further stated MHA #1 grabbed the Patient #9's shoulders, turned the patient's body toward him and when he put him/her on the bed, his/her shoulders went back toward the wall. The bed was unlocked and it rolled into the wall and the patient hit their head on the wall. He could not recall if anyone assessed the patient for injury. He remembered Security staff told MHA #1 to let Patient #9 go and one Security staff put his hands on MHA #1's shoulders to prompt him.

Interview with MHA #1, on 03/20/18 at 4:15 PM, revealed he received training on CPI and TEAM. He found the TEAM method useless and preferred to use physical management methods he learned with CPI and his personal experience as a retired police officer. Regarding Patient #9, he stated the patient got a shot, tried to punch the nurse, and he pushed the patient onto the bed and Security filed a report.

Additional interview with MHA #1, on 03/27/18 at 2:25 PM, revealed Patient #9 threw a punch at LPN #1 and he grabbed the patient's upper body, not sure exactly where, and put the patient on the bed. He stated he guessed Patient #9 would have hit the wall as he went at the patient crossways on the bed. He stated CPI taught staff to get patients horizontal, they were easier to manage when flat. He further stated CPI did not teach staff how to prevent someone from getting punched. MHA #1 stated he felt competent in his ability to safely manage patients as he had CPI training and was a retired police officer.

Interview with the Vice President Patient Care Services/Chief Nursing Officer (CNO), on 03/28/18 at 2:45 PM, revealed all staff completed safety competencies at hire and annually thereafter. She stated facility administration was currently assessing which units would most benefit from TEAM training, as it offered healthcare specific technique. She stated the TEAM approach taught how to approach care in a non-threatening manner, specific words to avoid, how to manage body language and de-escalation. She stated all staff who was educated with TEAM received both classroom and hands on instruction. Staff had to perform hands on competency check offs to complete the education. She stated she wanted her team to be consistent in their approach to safe physical management, across the board.

Review of personnel records revealed SG #1, RN #4, Security Supervisor, MHA #1, SG #2, RN #8, MHA #3, MHA #2, LPN #1 and the Administrative Assistant all had TEAM training and Abuse and Neglect training timely.

Interview with the Nurse Manager, on 03/28/18 at 4:30 PM, revealed she was a frequent presence on the unit but "eyes on" safe management technique audits were not done.

Interview with the Security Director, on 03/28/18 at 1:32 PM, revealed he was spearheading the facility transition from CPI to TEAM safe physical management technique. He stated TEAM was specific to healthcare settings and taught more de-escalation than hands on. He stated that CPI had been dormant, as far as training, for over a year. He stated the transition was going slow, but well and all staff performed "eyes on" physical competencies to finish the course. He stated the education was mandatory for Security staff and the Psychiatric unit staff and was being phased in elsewhere. He stated there were no ongoing competency checks or audits outside the initial training.

Interview with Director of Quality and Clinical Effectiveness, on 03/27/18 at 3:25 PM, revealed the facility continued to watch for trends in safety and when identified, created an action plan. She stated following the last Survey Agency visit, the fifteen (15) minute rounding checks were placed, documentation was continually validated, and videos were viewed to ensure documentation was accurate.